Deck 26: Assessment

Question 1

When performing a client's nursing health history,the nurse should place the primary focus on which areas?

A)functional health patterns,alterations in lifestyle,and responses to changes in health status
B)health teaching needs
C)objective data,which will aid in the diagnosis of the illness
D)symptoms and progression of disease or injury

Answer 1

functional health patterns,alterations in lifestyle,and responses to changes in health status

Question 2

The MOST appropriate time for a nurse to complete the initial nursing assessment of a client admitted to a health care facility is:

A)prior to admission by the office or clinic nurse
B)within 8 hours of admission
C)after the first 24 hours or the acute phase of health care has passed
D)just before the client's discharge to home or to a rehabilitation center

Answer 2

within 8 hours of admission

Question 3

A 95-year-old client has the following vital signs: oral T 98.6 degrees Fahrenheit,P 84 with a regular irregularity,R 18,and BP 140/86.What additional nursing assessment should be done at this time?

A)count apical pulse for 1 minute
B)count carotid pulse
C)full respiratory system assessment
D)positional blood pressure readings

Answer 3

count apical pulse for 1 minute

Question 4

Which of these concepts is MOST important for a nurse to use throughout the physical assessment of a client?

A)identifying oneself
B)providing privacy
C)turning off the television and radio
D)using natural light whenever possible

Question 5

Which of these respiratory assessments would be normal for a 24-year-old client?

A)exhibits costal,sternal,and subclavicular retractions with nasal flaring at a rate of 28 per minute,and complains of shortness of breath
B)exhibits very shallow respirations at a rate of 8 per minute
C)uses abdominal muscles at a rate of 12 per minute,without complaints of dizziness
D)uses thoracic muscles at a rate of 18 per minute

Question 6

The nurse is preparing to assess a client's carotid pulse.Which of these techniques would be MOST appropriate to use?

A)Apply light pressure to only one artery at a time.
B)Apply heavy pressure to one artery and then the other,and compare their forces.
C)Press forcefully on both arteries at the same time.
D)Press lightly on both arteries at the same time to compare the rates.

Question 7

In developing a nursing plan of care for a client who has a venous access device,which of these notations is essential to include?

A)"Do not measure blood pressure on the involved side."
B)"Maintain accurate measurement of intake and output at all times."
C)"Provide assistance with activities of daily living."
D)"Require a family member to remain with the client overnight to ensure assistance."

Question 8

A client's pulse pressure should be between how many mmHg?

A)10 and 20
B)30 and 40
C)50 and 60
D)70 and 80

Question 9

After noting that a client has a pulse deficit,what action should the nurse take next?

A)Document this finding.
B)Instruct the client to report for weekly reevaluations by the nurse.
C)Report this finding to the physician.
D)Teach the client how to check pulses at home.

Question 10

When percussing over the client's liver area,the nurse hears a low-pitched,thudlike sound.What is this normal finding called?

A)ascites
B)dullness
C)flatness
D)tympany

Question 11

The nurse is preparing a client with inflamed hemorrhoids for a rectal examination by the health care provider.In which position should the client be placed?

A)dorsal recumbent
B)prone
C)Sims'
D)supine

Question 12

What is the rationale for using the head-to-toe format when performing a physical examination?

A)It is systematic and thorough.
B)Nurses do not use the medical model of physical assessment.
C)The body systems format is difficult to remember.
D)Most clients prefer it.

Question 13

How should a beginning nursing student perform deep palpation of a client's liver?

A)by applying short jabs to the area with the palm
B)by exerting slight pressure over the area with the fingertips
C)by placing the heels of both hands over the area and pressing downward
D)only under an instructor's supervision

Question 14

A client complains of dizziness when moving from a reclining position to a standing position.Which of these assessments will provide the nurse with the MOST pertinent data about the client's symptoms?

A)respiratory pattern
B)temperature
C)positional blood pressures
D)radial and carotid pulses

Question 15

A nurse observes a client's lips and nail beds are cyanotic,which means that there is:

A)pale skin coloration
B)buildup of bile pigment in the skin
C)decreased oxygen supply to the area
D)increased redness to the skin

Question 16

The client is admitted in an emergency situation.The nurse is aware that the client's health history should be obtained:

A)after the emergency has passed
B)while the client is undergoing medical treatment for the emergency
C)before the physical assessment,as is usually done
D)within the physical examination

Question 17

A client complains of numbness,tingling,and coldness of the left leg.The nurse observes that the skin appears pale and is cool to touch.What assessment should be obtained next?

A)Ask the client when symptoms were noted and during what type of activity.
B)Notify health care provider of the findings immediately.
C)Obtain a detailed nursing health history while conducting the initial comprehensive physical examination.
D)Palpate and record the femoral,popliteal,posterior tibial,and dorsalis pedis pulses.

Question 18

In addition to demographic information and client and family medical history,a client's health history should contain which of these data?

A)type of health insurance coverage
B)reason for seeking health care and perception of health status
C)recent diagnostic tests performed
D)completion of advance directives

Question 19

A client is admitted with third-degree burns over the front and back upper half of the body.When conducting a nursing physical examination of the client,the nurse must assess blood pressure at which artery?

A)dorsalis pedis
B)popliteal
C)posterior tibial
D)radial

Question 20

An 84-year-old male client is admitted for severe dyspnea.Which nursing intervention should the nurse perform initially?

A)Administer humidified oxygen via mask at 8 liters per minute while performing the health history and physical assessment.
B)Notify the health care provider of the client's condition immediately.
C)Place the client in Fowler's or a forward-leaning position over a padded,raised overbed table with arms and head resting on the table.
D)Start intravenous normal saline solution at a "keep vein open" rate for the anticipated administration of emergency medications.

Question 21

When assessing a client's breath sounds,the nurse hears high-pitched,whistling sounds during both inhalation and exhalation.These breath sounds are called:

A)crackles
B)pleural friction rubs
C)sibilant wheezes
D)sonorous wheezes

Question 22

When a client has an order for "daily weight," when should the nurse weigh the client?

A)after breakfast each morning
B)at the same time each morning,on the same scale,wearing the same type of clothing
C)at the staff's convenience between the hours of 7 A.M.and 7 P.M.on the unit scales
D)before bedtime each evening

Question 23

When assessing a client's abdomen,a nurse notes pain when depressing and releasing fingertip pressure in the right lower quadrant.How should this finding be documented?

A)"borborygmi present"
B)"rebound tenderness"
C)"separation of the rectus abdominis muscle in the RLQ"
D)"tympany present"

Question 24

The client's upper extremity strength is assessed as normal when a handshake reveals which of the following?

A)Both hands are equal.
B)The dominant hand is stronger.
C)The nondominant hand is stronger.
D)Neither hand is stronger,because one hand will always dominate.

Question 25

When assessing the client's abdomen,a nurse hears high-pitched,loud,and rushing sounds with and without a stethoscope.These sounds are called:

A)borborygmi
B)dullness
C)flatness
D)tympany

Question 26

Height and weight measurements are essential at every health care visit for clients in all age groups because these measurements:

A)document that basic client evaluation has been done
B)provide data related to maturational level
C)indicate the need for diagnostic follow-up
D)signal possible onset of alterations that may indicate illness

Question 27

Convert between Fahrenheit and Celsius temperatures.
36.5 degrees Celsius

Question 28

A mother called the physician's office,reporting that her son had a temperature of 102.6 degrees Fahrenheit.The nurse is to record the information as a Celsius temperature.What should the nurse document?

Question 29

When performing a client's breast assessment,the nurse notes all of these findings.Which one indicates something is abnormal?

A)a slight difference in the size of the breasts
B)discharge from the right nipple
C)smooth skin that is even in color
D)symmetrical shape and color of the nipples and areolae

Question 30

A client is grimacing and with fists clenched states,"I'm in excruciating pain." Which of these entries indicates correct documentation of the client's affect?

A)"Client is angry."
B)"Client is in a hostile mood."
C)"Client states,'I'm in excruciating pain.' Grimacing,clenched fists noted."
D)"Client is uncooperative during the assessment process."

Question 31

When assessing a client's breath sounds,the nurse hears low-pitched snoring sounds that are louder on exhalation.These breath sounds are called:

A)crackles
B)pleural friction rubs
C)sibilant wheezes
D)sonorous wheezes

Question 32

The nurse is testing the patency of a client's nostrils.The MOST appropriate steps to take would be:

A)Ask the client to sniff while closing off each nostril in turn.
B)Inspect the inner membranes and septum with a nasal scope.
C)Instill normal saline drops into each naris,and observe the oropharynx for drainage.
D)Pass an oxygen tube into both sides of the nasopharynx.

Question 33

When a nurse asks a client to focus on an object in the distance and then move her gaze to a nearby object,what process is the nurse assessing?

A)accommodation
B)direct light reflex
C)pupil shape test
D)pupil size test

Question 34

A client's blood pressure readings have shown great variation since admission.Which of these actions should the nurse take next?

A)Assume the findings reflect the client's medical condition.
B)Determine whether the blood pressure cuff being used is the correct size for this client.
C)Report findings to the health care provider.
D)Review the medications ordered and the administration schedule to determine any effect on blood pressure.

Question 35

In which sequence should the nurse perform a client's abdominal assessment to obtain the MOST accurate data?

A)auscultation,inspection,palpation,percussion
B)inspection,auscultation,percussion,palpation
C)palpation,inspection,percussion,auscultation
D)percussion,palpation,auscultation,inspection

Question 36

When the skin of the anterior chest stays pinched for a few seconds during a client's admission assessment,how should this finding be documented?

A)"dehydrated"
B)"fair hydration"
C)"loose skin-turgor"
D)"normal hydration"

Question 37

When completing a health history on a client,the nurse needs to include which of the following? (Select all that apply. )

A)date of birth
B)religious preferences
C)blood pressure
D)last bowel movement
E)herbal use
F)home environment

Question 38

While assessing a client's mucous membranes of the lips and mouth,the nurse notes a smell like ammonia.This abnormal breath odor is associated with which of the following disease processes?

A)abscesses or gum disease of advanced tooth decay
B)ketoacidosis of diabetes or malnourishment
C)nitrogen breakdown of liver diseases
D)urea buildup of end-stage renal failure

Question 39

During auscultation of all four quadrants of a client's abdomen,the nurse hears 20 or more bowel sounds per minute.How should this finding be documented?

A)"bowel sounds absent"
B)"bowel sounds active"
C)"bowel sounds hyperactive"
D)"bowel sounds hypoactive"