Download Nursing Assessment Exam Study Guide: General Survey, Head-to-Toe, and Focused Assessments and more Exams Nursing in PDF only on Docsity!
N5451 Skills Lab Module 3. Assessment Exam
Study Guide A+ Graded
The nurse is beginning a general survey on a client who is being admitted to the hospital for abdominal pain. After identifying the client, which components would the nurse include in the general survey? Select all that apply. - ANSWER Does the person's body structure match the stated age? Are there any tubes, lines, or drains? Does the client appear to be alert? Is the client's color appropriate for ethnicity? After identifying the client, a general survey is completed by observing general appearance including whether the client is wearing oxygen, has an IV or other lines, the demeanor and behavior, body structure, BMI, and vital signs. This is then followed by a brief, generalized assessment from head to toe with the addition of in depth targeted assessments as needed, based on the client.
When performing a general survey assessment, how would the nurse assess the client's orientation? Select all that apply. - ANSWER Request the client states his or her name. Query about today's date and season. Question where the client is now. When assessing for the client's orientation, the nurse should assess the client for person, place, time, and situation. Asking about allergies and medications are not included in orientation.
A nurse is preparing to perform a general survey of a client. What equipment would the nurse require to perform this assessment? Select all that apply. - ANSWER Sphygmomanometer Stethoscope Tape measure Standing scale The general survey should include vital signs, which require a sphygmomanometer, as well as a height, weight, and BMI, which require a standing scale and a tape measure. A glucometer is not necessary to perform a general survey, it but could be used later during the physical assessment. A Doppler is not indicated unless the nurse was unable to palpate a pulse in a normal manner.
The nurse is performing a general survey on a client who is being admitted to the medical unit with abdominal pain. Which components would the nurse assess during the general survey? Select all that apply. - ANSWER Ask client for today's date and time Observe the client's gait Assess the client's vital signs The general survey is a precursor to any in-depth focused physical assessment. The general survey provides initial information about the client's overall demeanor, orientation, vital signs, appearance, gait, and behavior and can indicate the need for further targeted assessments. Evaluating the client's bowel pattern and palpating the entire abdomen would fall under the targeted abdominal assessment.
The nurse is caring for a client who is reporting throat pain, fever, and difficulty swallowing. Which technique should the nurse use to palpate the client's lymph nodes for enlargement or tenderness? - ANSWER Use gentle pressure, a circular manner, and palpate with bilateral finger pads to compare both sides. The nurse should use the
finger pads, in slow circular motions, comparing both sides to feel for any enlargement, tenderness, and mobility. The nurse should never use firm pressure nor pinch each node, because these cause discomfort to the client. The nurse should always compare both sides to look for asymmetry or differences.
The nurse is completing head and neck assessments on four different older adult clients in a long-term care facility. Which findings would the nurse promptly report to the health care provider for further testing? Select all that apply. - ANSWER Obvious turbulence upon auscultation of the bilateral carotid arteries New, mild, left sided facial droop upon inspection of the client's face Right pupil that is slightly misshapen and is not constricting with light Obvious turbulence upon auscultation indicates a bilateral bruit and carotid stenosis. New one-sided facial droop may indicate a recent cerebrovascular accident, and a right pupil that is slightly misshapen and is not constricting with light may indicate a cataract or other neurological issue. All require further testing. A small, nontender, soft, moveable node on the right the neck upon palpation as well as a symmetrical and mobile skull with no nodules or enlargement on palpation are normal findings.
The nurse is performing morning assessments on the medical-surgical unit. Which clients are most likely to have palpable lymph nodes in the neck? Select all that apply. - ANSWER Woman, 62, with chronic bronchitis Man, 67, with aspiration pneumonia Lymph nodes are usually palpable due to acute or frequent infection. Lymph nodes are not usually palpable with disease or pathology like dehydration, heart failure, or anemia.
An intensive care nurse is caring for a client who sustained a head injury from a motor vehicle accident. During the morning assessment, the nurse notices the following change: pupils were equal, but now the right pupil is fully dilated and nonreactive, and the left pupil is 3 mm and reacts to light. What is the nurse's priority action? - ANSWER Notify the health care provider immediately Decreased or absent pupillary response and uneven pupil dilation indicate blindness or increased cranial pressure and serious brain damage. The nurse would notify the health care provider immediately, because this is a critical change in condition. The nurse should not wait for 1 hour to reassess, because the client's condition will continue to deteriorate and brain damage could increase. Monitoring the client's breathing is important, but not the nurse's priority concern. Repositioning the client will not help to reduce the cranial pressure.
The emergency room nurse is conducting a focused thorax and lung assessment on a client reporting chest pain, cough, and dyspnea. Which assessment findings indicate the need for further assessment? Select all that apply. - ANSWER Observed the client have a moist cough with production of yellow sputum Auscultated low pitched, bubbling sounds during inspiration in right upper lobe High pitched popping sounds (crackles) and a productive cough for yellow sputum require further assessment to determine a possible pneumonia. All other findings are normal and do not need further assessment.
The nurse is conducting the initial thorax and lung assessment of a client with pneumonia. What would the nurse do first? - ANSWER Inspect the skin, bones, and muscles of the entire posterior thorax. Inspection is always done first and provides the
physical assessment of the abdomen, lateral Sims is used for enema insertion. A drape or blanket should not be removed but be used to cover all parts not being assessed to provide as much privacy as possible.
The nurse is conducting an initial assessment of the abdomen. When checking for vascular sounds in the abdomen, what should the nurse do? Select all that apply. - ANSWER Evaluate the aortic region of the abdomen first. Expose only the region of the client being assessed. Assess the lower region of the abdomen last. When assessing the abdomen for vascular sounds, the nurse should use the bell, not the diaphragm of the stethoscope, expose only the region being assessed, and go from top to bottom in the artery areas. Listening for growling sounds would be assessing for Borborygmi, which is a bowel, not vascular sound.
The emergency room nurse is caring for a client reporting severe right lower quadrant pain that had started as milder pain near the umbilicus. Vital signs include a fever of 38.6°C (101.5°F), pulse 92 bpm, respirations 24 breath/min, and blood pressure 136/ mm Hg. What should the nurse do next? Select all that apply. - ANSWER Begin an OR checklist Keep the client NPO Cleanse the abdomen with chlorhexidine The nurse would suspect acute appendicitis due to the pain location and vital signs. Thus, the client wound need to remain NPO and be immediately prepared for surgery, which includes applying the chlorhexidine cleanser to the abdomen and beginning an OR checklist. There is no need for a tap water enema or an antiemetic, because nausea or constipation are not mentioned in the assessment findings.
The medical-surgical nurse is caring for a client admitted with gastroenteritis. Which assessment finding would indicate that the nurse should contact the health care provider? - ANSWER Whooshing sound at the top of the abdomen near the aorta Whooshing sound at the top of the abdomen near the aorta may indicate an aneurysm or arterial stenosis and needs further assessment by the health care provider Loud gurgling in all four quadrants is normal with the expected increased motility of gastroenteritis and is called Borborygmi. The liver spans for about 6 to 12 cm and would be percussed as dull sounds at the right midclavicular line. Diffuse abdominal tenderness on palpation and cramping is common with gastroenteritis.
The nurse on a telemetry unit is performing morning assessments on the clients. Upon auscultation of an adult client's heart sounds, the nurse notes a scratchy, high-pitched sandpaper sound. How should the nurse document this sound? - ANSWER Pericardial friction rub Pericardial friction rub is a high pitched, scratchy sound usually found with an inflamed pericardium. Midsystolic click is an extra heart sound usually found with mitral valve prolapsed not associated with a scratchy noise. Inspiratory stridor is not a heart sound and is associated with an obstructed airway and often with respiratory infections such as croup. Benign murmur is a swooshing sound that is usually developmental and outgrown with aging.
A client with a history of congestive heart failure comes to the cardiac wellness clinic reporting "frequent awakening from sleep due to shortness of breath." Which action by the nurse is most appropriate? - ANSWER Assess for other signs and symptoms of paroxysmal nocturnal dyspnea. Paroxysmal nocturnal dyspnea is awakening from sleep with dyspnea (shortness of breath) and needing to be upright to achieve comfort. There is no assessment indication for nor a prescription for orthostatic vital signs. The nurse should not tell the client to take a sleeping pill nor tell that the dyspnea will subside in a few days; further assessment would be needed.
The telemetry nurse is conducting an initial cardiac assessment on a client admitted with chest pain and coronary artery disease (CAD). What should the nurse do first? - ANSWER Examine the client's chest for any visible pulsations. The initial step in any assessment is inspection, so the nurse should examine the client's chest for any visible pulsations. The other actions are all part of the cardiac assessment, but they should be performed after inspection.
The nurse is caring for a client who was recently admitted to the cardiac care unit after open-heart surgery. The current assessment by the nurse reveals +0 pedal pulse on the left foot and +2 pedal pulse on the right foot. What should the nurse do first? - ANSWER Notify the health care provider of this abnormal finding. An absent pulse after cardiac surgery is not normal. This finding needs to be reported to the health care provider, because it could indicate a thromboembolic obstruction. Elevating the right leg is not necessary, because there is a normal pulse in the right leg. It would not be appropriate to reassess in one hour, and absent pulse is not normal. Applying heat will not solve the problem of an absent pedal pulse.
A nurse is caring for a client who has a right femur fracture that is currently in traction. The client has a prescription for hourly circulatory assessment. Which nursing assessment findings should be reported to the health care provider? Select all that apply. - ANSWER Numbness and tingling to the right leg Edema and coolness to the right calf Right capillary refill of 4 seconds The nurse should report any neurovascular or circulatory compromise immediately to the health care provider. Reportable findings would include coolness, paleness, diminished pulse, impaired sensation such as numbness or tingling, muscle paralysis or extreme pain to the affected extremity. Pink color and warmth to the right calf is a normal finding and does not need reported to the health care provider. Pedal pulses +2 bilaterally is a normal pulse and does not need reported to the health care provider.
The nurse is to assess the cranial nerves of a client admitted with a recent cerebral vascular accident. What is the nurse evaluating when assessing the motor function of the glossopharyngeal nerve? - ANSWER Capability to swallow. The motor function of the glossopharyngeal nerve is swallowing motion. Presence of a gag reflex is tested in motor function of the vagus nerve. Ability to taste is the sensory function of the glossopharyngeal nerve. Lateral jaw movements are the motor function of the trigeminal nerve.
The nurse is performing a cranial nerve assessment on a client admitted with head trauma who is alert and oriented. Which actions should the nurse perform to assess cranial nerve V? Select all that apply. - ANSWER Touch a cotton ball to the client's forehead, cheek, and jaw bilaterally. Palpate the masseter and temporal muscles with the client's teeth clenched. When assessing cranial nerve V, touching the face with a cotton ball assesses facial sensory function, and palpating the masseter and temporal muscles assesses motor function. Asking the client to raise eyebrows, puff out cheeks, and smile; or taste foods is assessing cranial nerve VII. The corneal reflex should only be assessed in an unconscious client.
The nurse is conducting an initial cranial nerve assessment of a client with meningioma of the sphenoid ridge. Which actions should the nurse perform to assess cranial nerve I? Select all that apply. - ANSWER Test each nostril independently. Examine the client's ability to smell.
The emergency room nurse is caring for a client reporting dizziness and headache with identified nystagmus. Which cranial nerves would the nurse plan to assess? Select all that apply. - ANSWER Cranial nerve III, Cranial nerve IV, Cranial nerve VI
The nurse is to assess the cranial nerves of a client admitted with a suspected tumor of the sternocleidomastoid muscle. When assessing the motor function of the spinal accessory nerve, what is the nurse evaluating? - ANSWER Ability to rotate the head
The nurse is conducting a focused musculoskeletal and peripheral vascular assessment on a client. What should the nurse do first? - ANSWER Examine range of motion
The gerontologic nurse is assessing the muscles of an older adult client. Which muscle components are the most important for the nurse to assess with this client? Select all that apply. - ANSWER Contour, pain, range of motion, and symmetry; tone strength,
size, and tenderness
A nurse is conducting a peripheral vascular assessment on a client admitted with congestive heart failure. The nurse notes an 8-mm deep depression in the skin after pressing that remains for a prolonged period on both legs. How should the nurse document this finding? - ANSWER 4+ pitting edema
The nurse working on the rehabilitation unit is examining the shoulder of a client during a detailed muscloskeletal assessment. Which four motions should be included during this examination? - ANSWER Forward flexion, internal rotation, abduction, and external rotation
The nurse is preparing to conduct a 10-minute head-to-toe assessment on a client admitted with pneumonia. What should the nurse do first? - ANSWER Complete a general inspection.
The nurse is planning to assess an older adult client admitted with abdominal pain. Which special considerations are important to contemplate when assessing the older adult client? Select all that apply. - ANSWER Short term memory may diminish with age; Presence of heart sound S4 is considered normal; Older adults take longer to perform certain actions
An emergency room nurse is conducting a quick head-to-toe assessment of a client reporting flu-like symptoms. What pulse grade would the nurse document if the client's radial pulses were "full, easy to palpate, and cannot be obliterated"? - ANSWER + pulse
The nurse is completing a quick head-to-toe assessment on a client admitted with right-sided heart failure. Which body parts should be examined for peripheral edema? Select all that apply. - ANSWER Hands, Sacrum, Feet
