Chapter 25: Health Assessment

A home health care nurse takes the vital signs of a patient who is receiving supplemental oxygen at home for chronic obstructive pulmonary disease (COPD). This is the nurse's fourth visit to the patient's home. The nurse records the data collected on the patient's chart. What type of assessment has this nurse performed?

A nurse caring for patients in a long-term care facility is performing a functional assessment of a new patient. Which questions would the nurse ask?

A nurse is assessing a patient's eyes for extraocular movements. Which actions correctly describes a step the nurse would take when performing this test?

Which actions will the nurse perform when using the technique of palpation during the physical assessment of a patient?

When inspecting the skin of a patient who has cirrhosis of the liver, the nurse notes that the skin has a yellow tint. What would the nurse document related to this finding?

After inspecting the skin of a patient, the nurse documents the presence of a skin lesion as a palpable solid mass measured at 1cm. What types of skin lesions might this describe?

A patient's visual acuity is assessed as 20/40 in both eyes using the Snellen chart. The nurse interprets this finding as

When assessing a patient's breath sounds, the nurse hears a high-pitched continuous sound. What type of breath sound would the nurse document?

A nurse is using the FOUR Coma Scale to assess the neurologic status of a patient following surgery to remove a brain tumor. The nurse rates the patient as M2 for motor response. What condition does this number represent.

A nurse auscultates the thorax and lungs and hears coarse, low-pitched, continuous sounds on expiration. When the patient coughs, the sound clear up somewhat. The nurse would document these sounds as

A nurse is assessing a patient's yese for accommodation. What actions would the nurse perform during this test?

A nurse is palpating the breast of a woman during an assessment. Which technique is performed correctly?

During a physical assessment, a nurse inspects a patient's abdomen. What assessment technique would the nurse perform next?

A nurse is assessing the level of consciousness of a patient who sustained a head injury in a motor vehicle accident. The nurse notes that the patient appears drowsy most of the time but makes spontaneous movements. The nurse is able to wake the patient by gently shaking him and calling his name. What level of consciousness would the nurse document?

A nurse is conducting an assessment of a patient's cranial nerves. The nurse asks the patient to raise the eyebrows, smile, and show the teeth to assess which cranial nerve?

The acute care nurse is assessing a newly admitted client's abdomen. Which of the following findings would indicate the need to contact the primary care provider?

A nursing student is getting ready to palpate a client's peripheral pulses. Which of the following pulses should be included?

A grating feel and noise with joint movement, particularly in the temperomandibular joint is called what?

A nurse performing physical assessments of residents in a long-term care facility describes to the student nurse common head and neck variations in the older adult. Which of the following accurately defines these variations?

A nurse auscultates the right carotid artery in an older adult client and identifies a bruit. What does this assessment finding mean?

What respiratory sound indicates an upper airway obstruction?

When performing an abdominal assessment, the nurse uses a different order of techniques than with other systems. Which of the following represents this order?

Which of the following senses is used when the nurse performs the inspection phase of assessments?

You are palpating a client's precordium. Which of the following is an expected clinical finding?