Unit 1: Ch. 20 Health History and Physical Assessment Flashcards
Objective data can be gathered from the patient during which aspects of the physical assessment process? (Select all that apply.)
a. Patient interview
b. Health history
c. General survey
d. Physical examination
e. Laboratory testing
Answers: a, b, c, d, e
Objective data consist of observed information or signs that can be collected during all stages of the physical assessment process. Even while the patient is answering questions, providing subjective data or symptom information, the nurse observes for physical signs of abnormalities or impairment.
Which sequence best identifies the order in which the nurse should complete an abdominal assessment?
a. Inspection, palpation, percussion, auscultation
b. Auscultation, inspection, palpation, percussion
c. Auscultation, palpation, percussion, inspection
d. Inspection, auscultation, palpation, percussion
Answer: d
Assessment of the abdominal cavity requires auscultation to immediately follow inspection, before palpation or percussion, to avoid stimulating the bowel and eliciting inaccurate assessment results.
During examination of a patient’s neck with the bell of the stethoscope, the nurse identifies a carotid bruit. When are bruits audible in the neck?
a. When jugular vein distention is present
b. During normal examination of the neck
c. When the carotid artery is partially occluded
d. With complete occlusion of both carotid arteries
Answer: c
A bruit indicates blood flow turbulence and occurs with partial occlusion of a carotid artery by atherosclerosis. Bruits are not associated with jugular vein distention and are an abnormal assessment finding. Bruits will not be heard if the artery is 100% occluded or if the artery blood flow is normal, without partial obstruction.
A nurse is preparing to auscultate a patient’s chest. In which area should the nurse listen to evaluate the patient’s aortic valve?
a. Second right intercostal space
b. Third left intercostal space above the nipple line
c. Fifth right intercostal space
d. Fifth left intercostal space along the midclavicular line
Answer: a
The second intercostal space on the right is the auscultation point for the aortic valve. The ventricles and pulmonic valve are located on the left. The point of maximal impulse (PMI) over the mitral valve is located between the left fourth or fifth intercostal spaces along the midclavicular line.
Which assessment finding would be most important to document in a patient with known liver disease who has a distended, taut abdomen?
a. Abdominal girth
b. Dentition condition
c. Benign cardiac murmurs
d. Daily ambulatory distance
Answer: a
Increasing abdominal girth may be due to ascites, which is potentially life-threatening and could cause respiratory arrest if the ascitic fluid is not drained. Dentition condition and benign murmurs are not directly associated with liver disease. The patient’s condition may affect ambulatory distance; however, it is not the most important assessment finding listed.
The nurse notes the presence of ptosis when assessing an adult patient’s eyes. Which potential cause would be considered of most concern, requiring further evaluation as soon as possible?
a. Loss of skin elasticity
b. Levator muscle weakness
c. Congenital ocular abnormality
d. Oculomotor cranial nerve III paralysis
Answer: d
Oculomotor nerve paralysis may indicate the presence of a larger neurologic problem that requires further investigation as soon as possible. Loss of skin elasticity and muscle weakness may be due to aging, and congenital ptosis does not require immediate attention in an adult.
Which action by a patient with a family history of macular degeneration would demonstrate use of a prevention strategy that has been found to help prevent deterioration of the macula? (Select all that apply.)
a. Using medicated eyedrops
b. Wearing sunglasses when outside
c. Taking vitamin B6 and B12 supplements
d. Minimizing dietary intake of antioxidants
Answer: b, c
Taking dietary supplements, including vitamins E, C, B6, B12, beta carotene, zinc oxide, and copper, has been found to limit the development and severity of macular degeneration. Wearing sunglasses outside is another important recommended prevention strategy. Using medicated eyedrops and avoiding dietary antioxidants are not indicated in the prevention of macular deterioration.
The nurse begins the assessment of patient breath sounds and notes diminished breath sounds at the base of the right lung. What action should the nurse take next?
a. Refer the patient for a chest x-ray.
b. Listen to the base of the patient’s left lung.
c. Notify the patient’s primary care provider.
d. Palpate the patient’s lung fields bilaterally.
Answer: b
When auscultating a patient’s lungs, the nurse should follow a pattern that compares lung fields side to side in each area, making listening to the base of the patient’s left lung the next step for this nurse to take. Referring the patient for an x-ray, palpating the patient’s lung fields, and notifying the patient’s physician might be indicated later depending on the outcome of the full respiratory assessment.
What actions should the nurse take to assess whether a patient with a left above-the-knee amputation has adequate lower extremity circulation to the stump? (Select all that apply.)
a. Palpate the stump for warmth.
b. Assess pedal pulses bilaterally.
c. Evaluate the left popliteal pulse rate.
d. Inspect the stump and right leg for color.
e. Check the left femoral pulse for strength.
Answers: a, d, e
Palpating the stump for warmth and observing the stump and right leg for color will help evaluate the effectiveness of the patient’s circulation in the left leg. Comparing the appearance of one limb with that of its counterpart is an essential part of the assessment. Assessing the patient’s left femoral pulse is critical because it is the closest peripheral pulse to the site of the amputation. The patient has only right popliteal and pedal pulses because of the left above-the-knee amputation, making bilateral popliteal and pedal pulse assessment impossible.
A client who does not speak English arrives at the triage desk in the emergency department and states to the nurse that an interpreter is needed. Which is the BEST action for the nurse to take?
a. Have one of the client’s family members interpret.
b. Page an interpreter from the hospital’s interpreter services.
c. Have the triage receptionist who speaks the client’s language interpret.
d. Obtain a translation dictionary in the client’s language and attempt to triage the client.
b. Page an interpreter from the hospital’s interpreter services.
The nurse is performing a neurological assessment on a client and notes a positive Romberg’s test. The nurse makes the determination based on which observation?
a. An involuntary rhythmic, rapid twitching of the eyeballs.
b. A dorsiflexion of the great toe with fanning of the other toes.
c. A significant sway when the client stands erect with feet together, arms at the sides, and the eyes closed.
d. A lack of normal sense of position when the client is unable to return extended fingers to a point of reference.
c. A significant sway when the client stands erect with feet together, arms at the sides, and the eyes closed.
The nurse notes documentation that a client is exhibiting Cheyne-Strokes respirations. Om assessment of the client, the nurse would expect to note which finding?
a. Rhythmic respirations with periods of apnea.
b. Regular rapid and deep, sustained respirations.
c. Totally irregular respirations in rhythm and depth.
d. Irregular respirations with pauses at the end of inspiration and expiration.
