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Health Assessment LAB Mrs. Davids is a 55-year-old patient who presents with complaints of spots in her nails. As the health care provider, you know that the components of a nail examination include: * clubbing, pitting, and grooving. texture, toughness, and translucency shape, surface, and circulation. contour, consistency, and color. A dark band is a normal finding on the nails of: * dark-skinned people. children. elderly people. pregnant women. The nurse auscultates the thorax and lungs and hears coarse gurgling sounds on expiration. The nurse would describe these sounds as: * Adventitious breath sounds Bronchovesicular breath sounds Vesicular breath sounds Bronchial sounds The home health nurse visits a male client to provide wound care and finds the client lethargic and confused. His wife states he fell down the stairs 2 hours ago. The nurse should * Send him to the emergency room for evaluation Reassure the client’s wife that the symptoms are transient Instruct the client’s wife to call the doctor if his symptoms become worse Place a call to the client’s health care provider for instructions Which of the following is the best position for the client to assume if the back is to be examined by the nurse? * Sitting Prone Standing Side lying An individual with functional scoliosis will demonstrate which of the following? * A lateral spinal curvature that remains at less than 20 degrees A lateral spinal curvature that remains visible in the standing and bending position A lateral spinal curvature that is visible in the standing position but disappears when the individual bends over A lateral spinal curvature that affects either the thoracic area or the lumbar area but not both When performing a physical assessment, the technique the nurse will always use first is: * auscultation inspection. palpation. percussion. When assessing a patient’s eyes, which instrument would the nurse use to visualize the retina? * Otoscope Ophthalmoscope Tuning fork Stethoscope When examining a middle-aged man’s scalp and hair, which of the following would not be regarded normal findings?Choose all that apply. * Lice receding hair line thinning hair alopecia Rectal examination is done with a client in what position? * Dorsal recumbent Lithotomy Supine Sims position When using an otoscope to assess the tympanic membrane of an adult, the nurse straightens the ear canal by gently pulling the pinna in which direction? * In any direction Down and forward Up and back Away from the examiner A high school nurse observes a 14 year-old female rubbing her scalp excessively in the gym. The most appropriate course of action for the nurse to do is: * Contact the female’s parents about your observations. Request a private evaluation of the female’s scalp from her parents. Contact the student’s physician Observe the hairline and scalp for possible signs of lice. Rectal examination is done with a client in what position? * Supine Lithotomy Sims position Dorsal recumbent When assessing heart sounds, the nurse understands that the sounds heard reflect which of the following? * Blood flflow through the heart Closure of the heart valves Blood moving into the heart from the aorta Contraction of the cardiac muscle A nurse obtained a client’s pulse and found the rate to be above normal. The nurse document this findings as: * Arrythmia Tachycardia Hyper pyrexia Tachypnea During a physical examination, what tools would be required to evaluate cranial nerves 9 and 10? * A pen light An ophthalmoscope A cotton ball A tongue depressor and flashlight When palpating the breast of a woman during an assessment, the nurse would divide the breast into which of the following? * Halves Quadrants Entire breast tissue Bilateral comparison Skin temperature is best assessed with the: * palm of the hand. back of the hand fingertips. wrist. Which technique would a nurse use to assess skin turgor? * Use a special type of lighting Indent area with fifingertips Touch the area to detect moisture Lightly pinch a fold of skin In assessing the client’s chest, which position best show chest expansion as well as its movements? * Sidelying Supine Prone Sitting What is the name of the nerve you are doing an assessment on if you assess the six cardinal fields of gaze with the emphasis on superior rectus, inferior rectus, inferior oblique and the medial rectus? * Glossopharyngeal Olfactory Optic oculomotor The best position for any procedure that involves vaginal and cervical examination is * Side lying Lithotomy Supine Dorsal recumbent The best method of evaluating the amount of peripheral edema is: * Measuring the intake and output Weighing the client daily Measuring the extremity Checking for pitting What would the nurse be able to tell just by looking at the way the client enters the room? signs of illness, well nourished gait and posture gender and age dress and signs of illness The charge nurse examines a patient’s abdomen.Which method of examination should the nurse utilize first? * Percussion Palpation Auscultation Inspection While performing a physical examination on a newborn, which assessment should be reported to the physician? * Head circumference of 40 cm Heart rate of 160 and respirations of 40 Acrocyanosis and edema of the scalp Chest circumference of 32 cm What is the first thing a nurse should do before palpating a patient’s scalp? * go ahead and inspect the client’s scalp ask the client how their hair feels go right ahead and palpate client’s scalp with bare hands. preform hand hygiene If your patient has a skin rash, you should ask specific questions to determine whether either of the patient’s parents has a history of: * allergies. emphysema. Kaposi’s sarcoma. impetigo Which term would the nurse use to document pain at one site that is perceived in other site? * Referred pain Intractable pain Phantom pain Aftermath of pain A client who is admitted with an above-the-knee amputation tells the nurse that his foot hurts and itches. Which response by the nurse indicates understanding of phantom limb pain? * “The pain is psychological because your foot is no longer there.” “The pain is due to peripheral nervous system interruptions. I will get you some pain medication.” “The pain and itching are due to the infection you had before the surgery.” “The pain will go away in a few days.” The nurse uses a stethoscope to auscultate a male patient’s chest. Which statement about a stethoscope with a bell and diaphragm is true? * The diaphragm detects low-pitched sounds best The diaphragm detects high-pitched sounds best The bell detects high-pitched sounds best The bell detects thrills best After inspecting a patient’s abdomen, which technique would the nurse do next? * Percussion Whichever the patient agrees to Auscultation Palpation A pregnant woman is most likely to demonstrate which of the following alterations in her posture, which is directly related to her pregnancy? * List Scoliosis Lordosis Kyphosis While conducting a physical assessment, the nurse uses the bell of the stethoscope to hear which type of sounds? * Lung sounds Heart sounds Tympanic sounds Bowel sounds Which of the following assessments about general appearance would be considered normal nursing observations? * client is well groomed client appears well-nourished all of the above dress is appropriate for the season no visible signs of illness noted Measure the leg circumference of a client with bipedal edema is best done in what position? * Dorsal recumbent Sitting Supine Standing Which pain theory provides the greatest information to nurses when planning pain reduction interventions? * Central-control theory Specificity theory Gate-control theory Pattern theory As you assess your patient, you note clubbed fingers. This is a sign of: * hypoxia. malnutrition. allergic reaction bacterial infection. Which of the following behaviors demonstrates proper pain adaptation in a client? The client reports pain reduction with decreased activity. The client denies the existence of any pain. The client distracts himself during pain episodes. The client reports no need for family support. Which of the following is the first sign of dehydration? * Thirst Tachycardia Poor skin turgor Restlessness

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