Deck 21: Physical Assessment

Question 1

The nurse is performing a physical assessment on an older adult client.Which is the best reason for the nurse to ask this client about experiences with constipation?

A)Older adult clients are known to overuse laxatives, which creates problems with constipation.
B)Older adult clients frequently have difficulty having a bowel movement while hospitalized.
C)In older adult clients, the rectal sphincter has lost elasticity and the sensation of urgency is decreased.
D)Older adult clients commonly experience slower intestinal peristalsis, creating issues with constipation.

Answer 1

Older adult clients commonly experience slower intestinal peristalsis, creating issues with constipation.

Question 2

The nurse provides care for a client who is one day postoperative.The client reports nausea and is refusing to eat.The nurse assesses the client by auscultating the abdomen.Which cause will the nurse suspect if assessment reveals hypoactive bowel sounds?

A)Peritonitis
B)Obstruction
C)Anesthesia
D)Paralytic ileus

Answer 2

Anesthesia

Question 3

The nurse is performing an assessment of the client's eyes, and tells the client, "Focus on my pencil and follow it as I move it away from you and then back toward you." Which specific function is the nurse assessing?

A)Anisocoric pupil response
B)Accommodation response
C)Consensual pupil reflex
D)Direct pupil response

Answer 3

Accommodation response

Question 4

The nurse is leading orientation for a newly hired nurse.The newly hired nurse states, "I worry about getting all the information documented after an assessment.How do I remember everything?" Which advice by the orienting nurse will be most helpful?

A)"Document in the same order you gather data by working from head to toe."
B)"It is always best to write everything down as you go and reference it later."
C)"Just start with the information you remember and then try to recall the rest."
D)"If you forget any specific information, just go back and assess the client again."

Question 5

The nurse performs a physical assessment on a client who is just admitted for left lower-lobe pneumonia.The client describes experiencing an unproductive cough.Which assessment finding will support the nurse's suspicion of consolidation in the left lower lobe?

A)Scattered rales
B)Absent breath sounds
C)Stridor with expiration
D)Rhonchi cleared by coughing

Question 6

The charge nurse notes a client's blood pressure at 8:00 a.m.was 124/80 mm Hg.It is now 12:00 p.m., and the client's blood pressure is 152/94 mm Hg.Which suggestion about the plan of care will the charge nurse make to the newly hired nurse?

A)The client's blood pressure should be rechecked in 15 minutes.
B)Any abnormal findings should be rechecked within 8 hours.
C)Because the blood pressure has become elevated, it should be rechecked in 1 to 2 hours.
D)Continue the current 4-hour assessment to determine if a pattern is being established.

Question 7

The nurse uses the five techniques for obtaining objective data when performing the physical assessment of a client.Which technique provides assessment information through the use of the nurse's hands?

A)Palpation
B)Auscultation
C)Observation
D)Olfaction

Question 8

The nurse documents that the client is eupneic in regard to the client's respiratory status.Which interpretation of the nurse's documentation is correct?

A)Breathing requires the use of costal, sternal, and sub-clavicular muscles.
B)Respirations are very shallow and at a rate between 8 and 12 per minute.
C)Client is using thoracic muscles to breathe at 20 to 24 breaths per minute.
D)Respiratory function is normal in depth and rate with abdominal muscle use.

Question 9

During a staff education meeting, the nurse explains that it is important to use four senses (sight, touch, hearing, and smell)to determine whether a client is exhibiting signs of illness or injury.Which description defines the assessment findings from these methods?

A)Subjective
B)Measurable
C)Reported by the client
D)Hidden

Question 10

The nurse plans additional time to build a relationship and establish rapport with a client admitted for surgery.Which is the most important reason for the nurse to promote this level of familiarity?

A)The client may not be willing to fully cooperate with the nurse otherwise.
B)The nurse can use the relationship to assure the client cooperates after surgery.
C)The client feels more relaxed if the nurse is perceived a friend.
D)The nurse understands the importance of establishing feelings of trust from the client.

Question 11

The nurse is admitting a client diagnosed with congestive heart failure.Although the client is sitting in a semi-Fowler position, the nurse is unable to auscultate distinct heart tones.Which action should the nurse perform first?

A)Document that the heart tones are muffled.
B)Count the radial pulse and document it as the heart rate.
C)Assist the client to lean forward and toward the left side.
D)Report the findings to the admitting physician.

Question 12

The nurse wakes the client during evening shift for a focused assessment.The client, trying to rest, tells the nurse, "I really need to sleep.Can you tell me why you need to wake me up so often?" Which response by the nurse explains the purpose of the assessment?

A)"Most clients don't understand the schedule we keep in the hospital."
B)"I understand your frustration, but this has been ordered by your physician."
C)"I do a head-to-toe assessment so that I can determine if there are any changes in your condition."
D)"Because you were just started on a medicine, I need to check your blood pressure more frequently."

Question 13

The nurse is assessing the feet of an adult client who is hospitalized with uncontrolled diabetes mellitus.Assessment findings indicate an absence of cuts, cracks, or blisters.The client states, "I don't have as much feeling in my feet as I used to." Which condition does the nurse correctly identify for this client?

A)Paresthesia
B)Infection
C)Lentigines
D)Necrosis

Question 14

The nurse is performing an initial physical assessment on a client.Which sequence does the nurse apply to correctly assess a client's abdomen?

A)Inspection, palpation, and auscultation
B)Palpation, inspection, and auscultation
C)Palpation, auscultation, and inspection
D)Inspection, auscultation, and palpation

Question 15

After completing the initial head-to-toe shift assessment, the nurse determines that no changes are needed in the client's plan of care.Which evaluation process supports the nurse's decision?

A)Using the knowledge that the client received a comprehensive health assessment
B)Reviewing the effectiveness of previously initiated nursing interventions
C)Referring to the facility's general plan of client care for the current shift
D)Recognizing that the client may be discharged from the hospital during this shift

Question 16

The nurse is providing care for a female client who was admitted due to a stroke.The client becomes frustrated because of an inability to respond verbally to the nurse's questions.Which terminology should the nurse use to document this complication?

A)Dysphasic
B)Dysphagic
C)Aphasic
D)Dyspneic

Question 17

The nurse is performing a physical assessment at the change of shift on an older adult client.Assessment indicates a breathing rate of 30 breaths per minute, breath sounds are clear to auscultation in all five lobes, and the client denies dyspnea.Which finding does the nurse expect with assessment of the client's capillary refill?

A)Nail beds dusky, capillary refill 10 seconds
B)Nail beds cyanotic, capillary refill 4 seconds
C)Nail beds pink, capillary refill 5 seconds
D)Nail beds blanched, capillary refill 3 seconds

Question 18

The initial assessment of a client admitted with a gastrointestinal inflammatory disease reveals that the client has hyperactive bowel sounds.The follow-up assessment indicates that the bowel sounds are still hyperactive, but are now audible without a stethoscope.Which documentation will the nurse make on the client's medical record?

A)"Low-pitched bowel sounds"
B)"Borborygmus noted"
C)"High-pitched bowel sounds"
D)"Hyperactive bowel sounds"

Question 19

The nurse performs a focused assessment.Which condition will provide the best information through the use of percussion?

A)Hyper-inflated lungs
B)An enlarged heart
C)Cardiac arrhythmia
D)Rebound tenderness

Question 20

The nurse who is performing a physical assessment is preparing to auscultate breath sounds.Which position is most favorable position for performing the assessment of breath sounds?

A)Supine position
B)Low Fowler position
C)Semi-Fowler position
D)High Fowler position

Question 21

The charge nurse is presenting recently licensed nurses with information about the importance of accurately assessing and documenting clients' heart sounds.Which information does the charge nurse determine to include in the presentation? Select all that apply.

A)To listen to and compare the intervals between the heartbeats
B)To compare the radial and apical pulses simultaneously
C)To document "distinct" if both heart tones are clearly heard
D)To listen to the apical pulse for a full 30 seconds
E)To document the rate for the apical pulse

Question 22

The nurse documents that a client has halitosis.Which conditions can the presence of halitosis indicate to the nurse? Select all that apply.

A)Stomach problems
B)Sinus infection
C)Leukemia
D)Poor hygiene
E)Pernicious anemia

Question 23

When positioning a client to listen to breath sounds, the nurse is correctly aware that which lobe can only be heard by anterior or lateral auscultation? Select all that apply.

A)Left upper lobe
B)Left lower lobe
C)Right upper lobe
D)Right middle lobe

Question 24

A client is admitted with long-standing chronic obstructive pulmonary disease (COPD)and is at risk for respiratory failure.Every 4 hours, the nurse performs a focused respiratory assessment.Which assessment action will the nurse include during each reassessment? Select all that apply.

A)Neck vein distention
B)Color of nail beds
C)Presence of sternal retractions
D)Temperature of extremities
E)SpO₂

Question 25

The nurse is performing a focused assessment of the client's cardiovascular system every 4 hours.Which specific assessment will the nurse include? Select all that apply.

A)Skin color, moisture, and temperature
B)Blood pressure
C)Use of accessory muscles
D)Strength and equality of peripheral pulses
E)Capillary refill of extremities