Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
29 Cards in this Set
- Front
- Back
- 3rd side (hint)
|
A nurse is performing a physical assessment for an older adult client who recently had a hip replacement. In what position would the nurse place this client to examine the hip joint? |
Prone
In the prone position, the client lies flat on the abdomen with the head turned to one side, which enables the nurse to assess the hip joint and posterior thorax. The Sims position is used to assess the vagina or rectum. The dorsal recumbent position and the supine position are used to assess the head, neck, anterior thorax and lungs, heart, breasts, extremities, and peripheral pulses. |
|
|
|
A nurse is caring for a 44-year-old female who had a left total hip arthroplasty 3 days ago. Her postoperative course has been uneventful except for a urinary tract infection that developed yesterday for which she is receiving cefaclor 500 mg PO bid. The client tells the nurse that the backs of her legs and buttocks are "itching like crazy." Which action should the nurse take first? |
Inspect the area of itchy skin.
Inspecting the back of the client's legs and buttocks is the first step in determining the nature of the client's problem. Checking the chart for known allergies and reviewing the medical history and medication record may provide helpful information, but assessing the skin gives firsthand information about the problem. |
|
|
|
A 33-year-old male client returns to the medical-surgical unit following a thyroidectomy. Which assessment finding requires an immediate intervention by the nurse? |
The client makes noises when he breathes.
Noisy respirations are a sign of a narrowed airway that could be caused by postoperative bleeding or edema. This finding requires an immediate intervention. Reports of thirst after being NPO for at least 8 hours before surgery and pain at the surgical site are expected findings. Feeling sleepy from the anesthesia is an expected outcome. |
|
|
|
The nurse detects a weak, thready pulse found from a client palpating peripheral pulses. What condition does the nurse suspect the client is experiencing? |
Decreased cardiac output
Abnormal findings when assessing the peripheral pulses include an absent, weak, thready pulse (which may indicate a decreased cardiac output), a forceful or bounding pulse (seen in hypertension and circulatory fluid overload), and an asymmetric pulse (related to impaired circulation). Inflammation of a vein would not result in a weak or thready pulse. Impaired kidney function would not be related to the decrease in amplitude of peripheral pulses. |
|
|
|
The nurse has performed a Romberg test in the context of a client's neurologic assessment. The client has failed the test. The nurse should consequently identify what nursing diagnosis? |
Risk for Falls
Romberg test assesses balance; an unsuccessful test constitutes a likely risk for falls. This test does not relate to the client's cognition. |
|
|
|
A grating feel and noise with joint movement, particularly in the temporomandibular joint, is called what? |
Crepitus or crepitation
Problems with the temporomandibular joint include pain or a grating feeling called crepitus. |
|
|
|
A grating feel and noise with joint movement, particularly in the temporomandibular joint, is called what? |
Crepitus or crepitation
Problems with the temporomandibular joint include pain or a grating feeling called crepitus. |
|
|
|
A nurse auscultates the right carotid artery in an older adult client and identifies a bruit. What does this assessment finding mean? |
It is distended
Bruits occur when the artery is partially obstructed or distended, which prevents blood flow from moving straight through the vessel. |
|
|
|
A grating feel and noise with joint movement, particularly in the temporomandibular joint, is called what? |
Crepitus or crepitation
Problems with the temporomandibular joint include pain or a grating feeling called crepitus. |
|
|
|
A nurse auscultates the right carotid artery in an older adult client and identifies a bruit. What does this assessment finding mean? |
It is distended
Bruits occur when the artery is partially obstructed or distended, which prevents blood flow from moving straight through the vessel. |
|
|
|
A 57-year-old client is admitted to the medical unit with a 3-day history of sharp, nonradiating epigastric pain and vomiting. The client denies seeing blood in the stool. When assessing this client's abdomen, what assessment technique would the nurse perform last? |
Palpatation
The sequence of techniques used to assess the abdomen is inspection, auscultation, percussion, and palpation. Percussion and palpation are done after auscultation because they stimulate bowel sounds. |
|
|
|
Mr. Martinez is a 55-year-old male who was brought to the emergency department (ED). He reports abdominal pain in his right lower quadrant (RLQ) and nausea without vomiting. The nurse performs a physical assessment on the client and documents the following: Neurologic status: awake and alert; Cardiovascular: radial pulses 90, bounding, and equal; Skin: warm and dry; Respirations: 24 and regular; Gastrointestinal: abdominal pain with rebound tenderness in RLQ; Musculoskeletal: sitting up in bed with knees bent. Identify which findings involved the assessment technique of palpation. Select all that apply. |
Gastrointestinal: abdominal pain with rebound tenderness in RLQ Cardiovascular: radial pulses 90, bounding, and equal
Skin: warm and dry
Palpation involves the sense of touch. The hands and fingers are sensitive tools and can assess skin temperature, turgor, texture, and moisture, as well as vibrations, pulsations, and shapes within the body. Neurologic assessment findings of awake and alert, respirations of 24 and regular, and musculoskeletal assessment of the client observed sitting up in bed with knees bent are examples of inspection.
|
|
|
|
Palpation is the use of hands and fingers to gather information through touch. Different parts of the hand are more suitable for different tactile sensations. Which part of the hand is best for sensing temperature? |
the dorsum
The skin over the dorsum of the hand is sensitive to temperature because it is thin and its nerve density is great. The palm of the hand is sensitive to vibration and is useful in locating a vibration associated with a heart murmur. The fingertips are concentrated with nerve endings and can sense fine difference in texture and consistency. The knuckles are not used in palpation. |
|
|
|
The Glasgow Coma Scale is a standardized assessment tool for a person's level of consciousness. Which client would this scale not be appropriate for? |
a client in the Intensive Care Unit for acute pancreatitis asking for pain medications
Although acute pancreatitis can be fatal if the client is asking for pain medications, she is at the very least alert. Clients who are being treated for a stroke, brain tumor, or who are recovering from brain surgery need to be monitored closely for level of consciousness. |
|
|
|
The Glasgow Coma Scale is a standardized assessment tool for a person's level of consciousness. Which client would this scale not be appropriate for? |
a client in the Intensive Care Unit for acute pancreatitis asking for pain medications
Although acute pancreatitis can be fatal if the client is asking for pain medications, she is at the very least alert. Clients who are being treated for a stroke, brain tumor, or who are recovering from brain surgery need to be monitored closely for level of consciousness. |
|
|
|
A nurse is preparing to auscultate a client’s abdomen for the presence of bowel sounds. Which is the appropriate action of the nurse? |
Warm the diaphragm of the stethoscope.
|
Client comfort is essential when performing an assessment, especially when the assessment involves touching the client. To promote maximum client comfort, equipment should be warmed prior to touching the client. This assessment is done while the client is in the supine position, not the sitting position. Since physical assessment typically takes place while clients are undressed (or wearing only a loose examination gown), they generally appreciate being covered with a drape to provide modesty. The abdomen is always inspected and then auscultated (in that sequence) before using palpation or percussion techniques. Touching or manipulating the abdomen can alter bowel sounds, thus producing invalid findings.
|
|
|
The Glasgow Coma Scale is a standardized assessment tool for a person's level of consciousness. Which client would this scale not be appropriate for? |
a client in the Intensive Care Unit for acute pancreatitis asking for pain medications
Although acute pancreatitis can be fatal if the client is asking for pain medications, she is at the very least alert. Clients who are being treated for a stroke, brain tumor, or who are recovering from brain surgery need to be monitored closely for level of consciousness. |
|
|
|
A nurse is preparing to auscultate a client’s abdomen for the presence of bowel sounds. Which is the appropriate action of the nurse? |
Warm the diaphragm of the stethoscope.
|
Client comfort is essential when performing an assessment, especially when the assessment involves touching the client. To promote maximum client comfort, equipment should be warmed prior to touching the client. This assessment is done while the client is in the supine position, not the sitting position. Since physical assessment typically takes place while clients are undressed (or wearing only a loose examination gown), they generally appreciate being covered with a drape to provide modesty. The abdomen is always inspected and then auscultated (in that sequence) before using palpation or percussion techniques. Touching or manipulating the abdomen can alter bowel sounds, thus producing invalid findings.
|
|
|
The nurse is performing an initial admission assessment from a client. What subjective data gathered from the client will the nurse document? Select all that apply. |
Reports of abdominal pain of 4 on a 0 to 10 point scale The client states, "I feel nauseated." Client informs the nurse there is a floater in the left eye
Subjective data includes any reports or information that the client gives. These include: Reports of abdominal pain of 4 on a 0 to 10 point scale, The client states, "I feel nauseated", and the client informs the nurse there is a floater in the left eye. Objective data is assessment data that are gathered by the nurse and are inspected, palpated, percussed, or auscultated by the health care team. |
|
|
|
The nurse needs to obtain an admission weight for a client diagnosed with end-stage lung cancer. To obtain the client’s weight, what should the nurse do first? |
Assess the client’s ability to stand or sit.
The nurse must first assess the client’s ability to sit, stand, or lie still to identify the appropriate type of scale to use. Evaluating pain or presence of lines would be done after identifying the type of scale to use. If a portable bed scale is indicated, the nurse would place a cover over the sling of the bed scale.
|
|
|
|
The nurse is assessing the glossopharyngeal nerve on a client diagnosed with a cerebrovascular accident. Which action should the nurse take? |
Elicit a gag reflex
The motor function of the glossopharyngeal nerve can be tested eliciting a gag reflex by placing a tongue depressor on the back of the tongue and having the client move the tongue from side to side. Having the client open the mouth against resistance tests motor supply. Lightly touching with different sensations or palpating the jaw muscles while opened and clenched will test the trigeminal nerve (CN V). |
|
|
|
The nurse is preparing to do a focused assessment of the abdomen on a client following an abdominal hysterectomy. Which intervention is most important for the nurse to do prior to the physical assessment? |
Ask the client to empty her bladder.
Before palpating or percussing the abdomen, the client should empty their bladder to avoid discomfort or pressure during the examination. The only equipment used during the assessment of the abdomen is a stethoscope and the nurse’s hands. Both can be warmed with the hands at the time of use. The client should be placed in a flat position with the arms at the sides. It is not necessary to obtain height and weight prior to the assessment. |
|
|
|
Mrs. Harris was admitted to the psychiatric unit 3 days ago with a diagnosis of major depressive disorder. The client answers assessment questions with barely audible "yes" or "no" responses and tells the nurse that she has been depressed for a long time. She wants the door closed and the curtains drawn to darken her room. She refuses visitors, eats only 25% of her meals, and tells the nurse that the food makes her nauseous. The nurse observes the client biting her fingernails. She cries often and sleeps a lot. The nurse documents which client actions as objective assessment data? Select all that apply. |
The client answers questions in a barely audible voice. The client bites her fingernails. The client eats 25% of her meals. The client sleeps a lot.
Objective data are directly observed or elicited through physical examination techniques. Observing that the client talks in a low voice, does not eat all her food, sleeps a lot, and bites her fingernails is a means of attaining objective findings. Subjective data are experienced or known only by the client (e.g., pain and nausea) and are gathered by verbal report. |
|
|
|
A nurse is teaching a young female client about breast cancer prevention. The client, who has no family history or other elevated risk of breast cancer, asks at what age she needs to begin having mammograms. What is the nurse’s best response? |
"According to the American and Canadian Cancer Societies, your first mammogram should be done at age 40 and then yearly after that."
Often during a physical assessment, clients indicate a desire for more health information. To help establish a trusting relationship and provide accurate teaching, the nurse’s best response is to educate the client on the American Cancer Society or Canadian Cancer Society guidelines, which state that the first mammogram should be done at age 40 and then yearly. After providing that information to the client, questions on family history of breast or ovarian cancer are appropriate. |
|
|
|
The nurse is performing an assessment for a 12-months-old child and observes pronation of the child's feet. The parent asks the nurse what is wrong with the child's feet. What is the best response by the nurse? |
"This is an age-related variation for the child and should go away after about 30 months."
Pronation of the feet in children between 12 and 30 months of age is a common age-related variation. This usually disappears after the 30th month. A referral to the pediatric orthopedic clinic or health care provider is not a necessary intervention at this time. Serial casting is used for children born with clubfoot, which is not the case with this child. |
|
|
|
The nurse has finished assessing a newly admitted 6-month-old Native American/First Nations client. Which clinical findings should be immediately reported to the health care provider? |
circumoral cyanosis when the client is at rest
Circumoral cyanosis, a condition of bluish or grayish skin around the mouth, may indicate inadequate oxygenation, and thus should be reported immediately to the health care provider. Mongolian spot is a common variation of hyperpigmentation in newborns of African, Turkish, Asian, Native American/First Nations, and Hispanic heritage. It is a harmless blue-black to purple macular area of hyperpigmentation that is usually located at the sacrum or buttocks, but sometimes occurs on the abdomen, thighs, shoulders, or arms. The anterior fontanel bulging when the client cries and the abdomen appearing large in relation to the pelvis are normal findings. |
|
|
|
Which components are included in the integumentary system? Select all that apply. |
Skin Hair Nails Sweat glands
|
|
|
|
A client is being treated for chronic obstructive pulmonary disease. The nurse auscultates the client's lungs following a period of coughing. The findings of this assessment are an example of: |
objective data
Objective data can be directly observed or measured, such as vital signs or appearance. The results of auscultation are considered to be objective because they do not depend on the client's subjective description. Baseline data is obtained on first contact with the client. |
|
|
|
The nurse is completing the admission assessment on a client with a diagnosis of peripheral arterial disease (PAD). Which assessment finding is most significant? |
An absent popliteal pulse
Priority assessments address the ABCs. Absence of a pulse (circulation) is a significant finding, which without intervention could lead to loss of limb. The other listed integumentary changes do not pose a short-term threat, even though they are clinically significant. |
|
