Health Assessments Module 3 Flashcards
In what client situations would a comprehensive assessment be performed?
On initial evaluation by the home health nurse
What type of assessment is complaints of chest pain?
Focused
What type of assessment is “the patient is found lying on the floor and is unresponsive”?
emergency
What type of assessment is “on arrival in the surgery holding area of the operating room”?
10 min or focused
The nurse would place information about the client’s concern that his illness is threatening his job security in which functional health pattern?
Role-relationship
Which situation would require the nurse to obtain a focused assessment?
A previously identified problem needs reassessment
What type of assessment can the nurse perform when a client denies a current health problem?
10 minute
What type of assessment can the nurse perform when a baseline health maintenance examination is required?
comprehensive
What type of assessment can the nurse perform when an emergency problem is identified during physical examination?
emergency
What action should the nurse take to increase the likelihood of obtaining quality data when doing a complete physical examination?
Provide adequate lighting and a comfortably warm room for the interview and physical examination
The nurse selects what equipment to test for a patellar reflex?
percussion hammer
What do you use a stethoscope for?
ausculatation
To perform the proper evaluation of client’s gait, the nurse should place the client in which position?
Standing
To administer a suppository or enema, what position should you place the patient in?
Sim’s
Which of the following would palpation as an assessment technique be used by the nurse to obtain data? SATA
A. Pitting edema B. Cyanosis of the lips C. Hyperactive peristalsis D. Cool, clammy skin E. Normal blood flow to the arteries
A
D
E
The nurse prepares to conduct a general survey on an adult client. Which assessment is performed first while the nurse initiates the nurse-client relationship?
Appearance and behavior
The nurse selects which of the following as the highest priority diagnosis for a 70 y/o male client with an absence of hair on the lower left leg?
A. Imbalanced nutrition: Less than body requirements
B. Risk for infection
C. Deficient fluid volume
D. Impaired peripheral tissue perfusion
D b/c absence of hair is arterial not venous
An inspection of the lower extremities is being performed. The presence of venous return impairment is suspected if the nurse observes what?
A. Cooler skin temperatures
B. Diminished pulses
C. Brown pigmentation
D. Numbness and tingling sensation
C - Brown pigmentation
Cooler skin temperature is an indication of what?
Pallor
Diminished pulses are an indication of what?
Pulselessness
Numbness and tingling sensation is an indication of what?
Paresthesia
What should the nurse use when palpating an edematous area on a client?
A. Dorsal aspect of the hand
B. Palmar surface of the hand
C. Pads of the fingers
D. Fingertips
C - Pads of the fingers
The nurse uses the dorsal aspect of the hand to check for _____________________.
temperature
The nurse uses the palmar surface of the hand to check for ____________________.
vibration in the lungs; called tactile fremitus
The nurse pinches the skin under the clavicle or on the forearm to check for ___________.
skin turgor
In assessing for jaundice, what area should the nurse specifically look on a client with dark skin?
A. Dorsal surface of the hands
B. Buccal mucosa
C. Ear lobe
D. Sclera
D - Sclera (the white outer layer of the eyeball)
In assessing for cyanosis, what area should the nurse specifically look on a client with dark skin?
Buccal mucosa
When the client is unable to detect a wisp of cotton touching his left cheek, the nurse interprets the finding as an abnormality of which cranial nerve?
V - Trigeminal
Which of the following symptoms would occur in a client with a retinal detachment?
Flashing lights and floaters
When the client has ptosis, the nurse interprets the finding as an abnormality of which cranial nerve?
III
What is the disease of the eye when you have loss of central vision?
macular degeneration
What is the disease of the eye when you have blurred vision?
cataracts
Which situation makes the nurse suspect the client has macular degeneration?
A. An automobile accident did not see the car in the next lane
B. The cake tasted funny because the client could not read the recipe
C. The client has been wearing mismatched clothes and socks
D. The client ran a stoplight and hit a pedestrian walking in the crosswalk
D
A is glaucoma
B cataracts
C color blindness
The client’s vision is tested with a Snellen’s chart. The results of the tests are documented as 20/60. The nurses interprets this as:
The client can read only at a distance of 20 ft what a client with a normal vision can read at 60 ft
CN III (Oculomotor) would be assessed using which method?
Check pupil for reaction to light and accommodation
CN II (Optic) would be assessed using which methods?
Inspection with an ophthalmoscope
Testing vision with Snellen chart
Comparing the patient visual fields with nurse’s own
In order to examine the ocular mobility of a client who recently experienced a stroke, the nurse should examine which of the following cranial nerves? SATA
A. CN II (Optic) B. CN III (Oculomotor) C. CN IV (Trochlear) D. CN V (Trigeminal) E. CN VI (Abducens)
B
C
E
The nurse is assessing a client who has a “pinpoint” pupil size and the pupils do not constrict when the light is shown on the eye. Which should the nurse document?
A. Pupillary response poor
B. Pupils one (1 mm) equal and non-reactive to light
C. Pupils two (2 mm) to three (3 mm) and non-constrictive to light
D. Pupils are barely open and don’t constrict to light
B
The student nurse asks the nurse, “Which type of hearing loss involves damage to the cochlea?”
Sensorineural hearing loss
Which statement made by the client indicates an understanding of how the nurse will perform the Romberg test?
A. “You want to bend over so you can inspect my spine for curvature”
B. “I need to touch my toes without bending my knees if possible.”
C. “I am going to walk five to six steps on my toes only, then on my heels only.”
D. “You want me to stand with my feet together and eyes closed for a short time.”
D
Rationale:
A. This is checking for scoliosis
B. Checking for ROM
C. Test for balance or coordination
The nurse is assessing the client’s cranial nerves. Which assessment data indicate cranial nerve I is intact?
A. The client can identify cold and hot on the face
B. The client does not have any tongue tremor
C. The client has not ptosis of the eyelids
D. The client is able to identify a peppermint smell
D
Rationale:
A. CN V
B. CN XII
C. CN III
The nurse is assessing the client’s cranial nerves. Which assessment data indicate cranial nerve I is intact?
A. The client can identify cold and hot on the face
B. The client does not have any tongue tremor
C. The client has not ptosis of the eyelids
D. The client is able to identify a peppermint smell
D
Rationale:
A. CN V
B. CN XII
C. CN III
Which assessment technique should the nurse use to assess the client’s facial nerve?
A. Have the client identify different smells
B. Have the client discriminate between sugar and salt
C. Have the client read the Snellen chart
D. Have the client say “ah” to assess the rise of the uvula
B
Rationale:
A. CN I
C. CN II
D. CN IX-X
During examination of a client’s neck with the bell of the stethoscope, the nurse identifies a carotid bruit. When are bruits audible in the neck?
When the carotid artery is partially occluded
A client with a GCS of 3 is most likely to exhibit what behavior?
No response to verbal or pain stimuli
A student nurse is working with a client who has asthma. The primary nurse tells the student that wheezes can be heard on auscultation. What should the student expect to hear?
High-pitched whistling sounds
What type of normal breath sounds are found at the site of the trachea?
Tubular/Bronchial
Where will the nurse hear bronchovesicular sounds?
Bronchioles
Where will the nurse hear vesicular sounds?
Alveoli
What sounds do crackles make and what area will you hear them?
Coarse crackles and bubbling
Hear them in the vesicular area
What does friction rub sound like when auscultating the lungs?
Dry, grating noises
What does rhonchi sound like?
Loud, low-pitched rumbling
The nurse is auscultating the client’s lungs and notes that bronchovesicular sounds as:
medium-pitched, hollow sounds with inspiration equaling expiration
The nurse is auscultating the client’s lungs and notes that bronchial sounds as:
loud, high-pitched, hollow sounds with expiration longer than inspiration
sounds created by air moving through large upper airways
The nurse is auscultating the client’s lungs and notes that vesicular sounds as:
soft, breezy, low-pitched sounds with longer inspiration
While auscultating the client’s lungs, the nurse hears loud, bubbly sounds during inspiration that did not disappear after the client coughed. Which finding should the nurse document from the lung assessment?
A. Rhonchi
B. Crackles
C. Wheeze
D. Friction Rub
B
Rationale:
Crackles don’t disappear with coughing
The nurse is observing the student nurse perform respiratory assessment on a client. Which action by the student nurse requires the nurse to intervene?
A. The student stands at a midline position behind the client observing for position of the spine and scapula
B. The student palpates the thoracic muscles for masses
C. The student places the bell of the stethoscope on the anterior wall to auscultate for breath sounds
D. The student places the palm of the hand over the intercostal spaces and asks the client to say “99”.
C
Rationale:
You use the diaphragm when you auscultate for breath sounds.
How does the nurses assess the client’s chest expansion?
Place the thumbs at the midline of the lower chest
Rationale:
Respiratory excursion
A nurse is assessing a client’s bilateral pulses for symmetry. Which pulse site should NOT be assessed on both sides of the body at the same time?
Carotid
A nurse is preparing to auscultate a client’s chest. In which area should the nurse listen to evaluate the client’s mitral valve?
Fifth left intercostal space along the midclavicular line
A nurse is preparing to auscultate a client’s chest. In which area should the nurse listen to evaluate the client’s aortic valve?
Second right intercostal space
A nurse is preparing to auscultate a client’s chest. In which area should the nurse listen to evaluate the client’s Erb’s Point?
Third left intercostal space
The student nurse is seeking assistance in hearing the client’s abnormal heart sounds. What should the nurse tell the student to do for a more effective assessment?
Use the bell of the stethoscope with the client leaning forward or on the left side
A nurse must assess for the presence of bowel sounds. Which technique should the nurse employ to obtain accurate results when auscultating the client’s abdomen?
A. Listen for several minutes in each quadrant of the abdomen
B. Place a warmed stethoscope on the surface of the abdomen
C. Perform auscultation before palpation of the abdomen.
D. Start at the left lower quadrant of the abdomen.
C
When grading muscle strength, the nurse records a score of 3/5, which indicates:
Active movement against gravity, but against no resistance
Full range of motion with gravity is Fair
When do you check for lumps on the breasts?
After menstruation
