Question 1

Which disorder(s)might limit a patient's visual field? Select all that apply.
A) Diabetes
B) Advanced glaucoma
C) Peripheral vascular disease
D) Cataracts
E) Macular degeneration

Accepted Answer

The answer of Which disorder(s)might limit a patient's visual field?...

Question 2

The nurse applies resistance to the top of the client's foot and asks him to pull his toes toward his knee.The nurse observes active motion against some,but not against full,resistance.How should the nurse document this finding?
A) 5: Normal
B) 4: Slight weakness
C) 3: Weakness
D) 2: Poor ROM

Accepted Answer

This finding indicates slight weakness, which corresponds to a score of 4 on the muscle strength scale. The client is able to move against some resistance but not full resistance, indicating some degree of weakness. A score of 5 would be normal, indicating full motion against resistance. A score of 3 would indicate weakness with limited motion, and a score of 2 would indicate poor range of motion with no resistance.

Question 3

The nurse obtains vital signs for a 56-year-old patient who underwent surgery yesterday.Which finding(s)require(s)further assessment? Select all that apply.
A) Blood pressure 110/64 mm Hg
B) Pulse rate 118 beats/minute
C) Respiratory rate 35 breaths/minute
D) Oral temperature 98.6°F (37°C)
E) Pulse oximetry reading 94% on room air

Accepted Answer

A pulse rate of 118 beats/minute and a respiratory rate of 35 breaths/minute are both higher than the normal range and require further assessment. A high pulse rate could indicate pain, anxiety, or a cardiovascular or respiratory problem. A high respiratory rate could indicate underlying respiratory distress or hypoxia. The other vital signs are within normal ranges.

Question 4

The nurse prepares to complete a focused physical assessment on a client with a chronic health problem.What should the nurse explain to the client as being the purpose of this assessment? Select all that apply.
A) Adds data to the database
B) Examines all body systems
C) Focuses on one body system
D) Focuses on a particular body part
E) Includes a health history interview

Accepted Answer

The answer of The nurse prepares to complete a focused...

Question 5

A client asks why the nurse needs so much time to complete a physical assessment.What should the nurse explain as the purposes for this type of assessment? Select all that apply.
A) Obtain baseline data
B) Identify nursing diagnoses
C) Screen for health problems
D) Evaluate teaching provided
E) Monitor previously identified problems

Accepted Answer

A physical assessment is a comprehensive evaluation of a patient's health status that helps nurses gather baseline data, identify nursing diagnoses, screen for health problems, and monitor previously identified issues. These processes help nurses develop an effective care plan that promotes optimal health outcomes. Therefore, a thorough physical assessment is crucial for providing holistic patient care. However, physical assessment does not evaluate teaching provided.

Quiz 21: Physical Assessment

Which disorder(s) might limit a patient's visual field? Select all that apply.

The nurse applies resistance to the top of the client's foot and asks him to pull his toes toward his knee.The nurse observes active motion against some,but not against full,resistance.How should the nurse document this finding?

The nurse obtains vital signs for a 56-year-old patient who underwent surgery yesterday.Which finding(s) require(s) further assessment? Select all that apply.

The nurse prepares to complete a focused physical assessment on a client with a chronic health problem.What should the nurse explain to the client as being the purpose of this assessment? Select all that apply.

A client asks why the nurse needs so much time to complete a physical assessment.What should the nurse explain as the purposes for this type of assessment? Select all that apply.