Health Assessment (30)

Question 1

Which is a normal finding on auscultation of the lungs?

1. ) Tympany over the right upper lobe
2. ) Resonance over the left upper lobe
3. ) Hyperresonance over the left lower lobe
4. ) Dullness above the left 10th intercostal space

Answer 1

2.) Resonance over the left upper lobe

Resonance is a normal sound over the lung. Tympany would be heard over the stomach (air filled) (option 1), hyperresonance is never a normal finding (option 3), and dullness would be heard below (not above) the 10th intercostal space (option 4).

Question 2

The nurse positions the client sitting upright during palpation of which area?

1. ) Abdomen
2. ) Genitals
3. ) Breast
4. ) Head and neck

Answer 2

4.) Head and neck

The client should sit for examination of the head and neck. For palpation of the abdomen (option 1), genitals (option 2), and breast (option 3), the client should be supine.

Question 3

After auscultating the abdomen, the nurse should report which finding to the primary care provider?

1. ) Bruit over the aorta
2. ) Absence of bowel sounds for 60 seconds
3. ) Continuous bowel sounds over the ileocecal valve
4. ) A completely irregular pattern of bowel sounds

Answer 3

1.) Bruit over the aorta

A bruit suggests abnormal turbulence in the aorta, and the primary care provider must be notified. For absence of bowel sounds to be considered abnormal, they must be silent for 3 to 5 minutes (option 2). Continuous bowel sounds are normally heard over the ileocecal valve following meals (option 3). Bowel sounds are more commonly irregular than they are regular (option 4).

Question 4

If unable to locate the client’s popliteal pulse during a routine examination, what should the nurse do next?

1. ) Check for a pedal pulse.
2. ) Check for a femoral pulse.
3. ) Take the client’s blood pressure on that thigh.
4. ) Ask another nurse to try to locate the pulse.

Answer 4

1.) Check for a pedal pulse.

If a pedal pulse, which is more distal than the popliteal, is present, then adequate arterial circulation to the leg is present even though the popliteal artery has not been located. Presence of a femoral pulse would not provide confirmation that arterial flow exists below that point (option 2). Taking a thigh BP requires locating the popliteal pulse (option 3). Because the purpose of finding the popliteal pulse is to provide information about arterial circulation to the leg, checking the distal pulse before requesting assistance from another nurse is appropriate (option 4).

Question 5

Which of the following is an expected finding during assessment of the older adult?

1. ) Facial hair that becomes finer and softer
2. ) Decreased peripheral, color, and night vision
3. ) Increased sensitivity to odors
4. ) An irregular respiratory rate and rhythm at rest

Answer 5

2.) Decreased peripheral, color, and night vision

Visual acuity often lessens with age. Facial hair is likely to become coarser, not finer (option 1). The sense of smell becomes less, rather than more acute (option 3). The respiratory rate and rhythm is regular at rest (option 4). However, both may change quickly with activity and be slow to return to the resting level.

Question 6

List five aspects of the skin that the nurse assesses during a routine examination.

Answer 6

1. ) color
2. ) turgor
3. ) temperature
4. ) moisture
5. ) lesions
6. ) odor
7. ) edema

Question 7

If the client reports loss of short-term memory, the nurse would assess this using which one of the following?

1. ) Have the client repeat a series of three numbers, increasing to eight if possible.
2. ) Have the client describe his or her childhood illnesses.
3. ) Ask the client to describe how he or she arrived at this location.
4. ) Ask the client to count backward from 100 subtracting seven each time.

Answer 7

3.) Ask the client to describe how he or she arrived at this location.

Recent memory includes events of the current day. Recalling a series of numbers tests immediate recall (option 1). Recalling childhood events tests remote (long-term) memory (option 2), and subtracting backwards from 100 tests attention span and calculation skills (option 4).

Question 8

Refer back to Figure 30–14. If the client can accurately read only the top three lines, what would be an appropriate nursing diagnosis?

1. Deficient Knowledge
2. Impaired Memory
3. Ineffective Tissue Perfusion
4. Risk for Injury

Answer 8

4. Risk for Injury

If the client can only read the first three lines, vision is impaired and could lead to falls or other injuries. This impaired vision is not related to deficient knowledge (option 1) or memory (option 2) and may or may not be related to circulation (option 3).

Question 9

To palpate lymph nodes, the nurse uses which technique?

1,) Use the flat of all four fingers in a vertical and then side-to-side motion.

2. ) Use the back of the hand and feel for temperature variation between the right and left sides.
3. ) Use the pads of two fingers in a circular motion.
4. ) Compress the nodes between the index fingers of both hands.

Answer 9

3.) Use the pads of two fingers in a circular motion.

Use the pads of two fingers and a gentle rotating motion over the nodes. None of the other options is proper palpation of lymph nodes.

Question 10

For a client whose assessment of the musculoskeletal system is normal, which does the nurse check on the medical record? (Select all that apply.)

1. ) Atrophied 6.) Flaccid
2. ) Contractured 7.) Hypertrophied
3. ) Crepitation 8.) Spastic
4. ) Equal 9.) Symmetrical
5. ) Firm 10,) Tremor

Answer 10

Equal, symmetrical, and firm