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?
Comprehensive
Ongoing partial assessment
Focused assessment
Emergency assessment
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?
Are you able to dress yourself?
Do you have a history of smoking?
What is the problem for which you are seeking care?
Do you prepare your own meals?
Do you manage your own finances?
Whom do you rely on for support?
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?
Ask the patient to sit about 3 feet away facing the nurse
Keep a penlight about one foot from the patient's face and move it slowly through the cardinal positions
Move a pen light in a circular motion in front of the patient's eyes
Ask the patient to cover one eye with a hand or index card
Which actions will the nurse perform when using the technique of palpation during the physical assessment of a patient?
The nurse compares the patient's bilateral body parts for symmetry
The nurse takes a patient's pulse
The nurse touches a patient's skin to test for tugor
The nurse checks a patient's lymph nodes for swelling
The nurse taps a patient's body to check the organs
The nurse uses a stethoscope to listen to a patient's heart sounds
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?
Jaundice
Cyanosis
Erythema
Pallor
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?
Macule
Patch
Plaque
Nodule
Bulla
Pustule
A patient's visual acuity is assessed as 20/40 in both eyes using the Snellen chart. The nurse interprets this finding as
The patient can see twice as well as normal
The patient has double vision
The patient has less than normal vision
The patient has normal vision
When assessing a patient's breath sounds, the nurse hears a high-pitched continuous sound. What type of breath sound would the nurse document?
Rhonchi
Crackles
Stridor
Wheezes
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.
Localizing to pain
Flexion response to pain
Extension response to pain
No response to pain
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
Adventitious breath sounds
Bronchovesicular breath sounds
Vesicular breath sounds
Bronchial sounds
A nurse is assessing a patient's yese for accommodation. What actions would the nurse perform during this test?
Bring a penlight from the side of the patient's face and briefly shine the light on the pupil
Hold a forefinger, a pencil, or other straight object about 10 to 15 cm (4" to 6") from the bridge of the patient's nose.
Hold a finger about 6" to 8" from the bridge of the patient's nose
Darken the room
Ask the patient to look straight ahead
Ask the patient to first look at a close object, then at a distant object, then back to the close object
A nurse is palpating the breast of a woman during an assessment. Which technique is performed correctly?
The nurse starts at the tail of Spence and moves in increasing smaller circles
The nurse uses the palms of the hands to gently compress the breast tissue against the chest wall
The nurse works in a counterclockwise direction and palpates from the periphery toward the areola
The nurse starts at the inner edge of the breast and palpates up and down the breast
During a physical assessment, a nurse inspects a patient's abdomen. What assessment technique would the nurse perform next?
Percussion
Palpation
Auscultation
Whichever is more comfortable for the patient
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?
Awake and alert
Lethargic
Stuporous
Comatose
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?
Olfactory
Optic
Facial
Vagus
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?
Percussion of tympanic sounds over the intestines
auscultation of a bruit
percussion of dull sounds over the right upper quadrant
auscultation of peristalsis sounds
A nursing student is getting ready to palpate a client's peripheral pulses. Which of the following pulses should be included?
Radial
Posterior tibial
Brachial
Popliteal
Femoral
Dorsalis pedis
A grating feel and noise with joint movement, particularly in the temperomandibular joint is called what?
crepitus
fremitus
inflammation
arthritis
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?
Decrease color and peripheral vision
Increase adaptation to light and dark
Entropion and/or ectropion
A blue ring around the cornea (arcus senilis)
Impaired conductive hearing
A nurse auscultates the right carotid artery in an older adult client and identifies a bruit. What does this assessment finding mean?
Normal
Inflamed
Dissecting
Distended
What respiratory sound indicates an upper airway obstruction?
Fremitus
Dyspnea
Wheeze
When performing an abdominal assessment, the nurse uses a different order of techniques than with other systems. Which of the following represents this order?
Inspection, auscultation, percussion, palpation
palpation, percussion, inspection, auscultation
percussion, auscultation, inspection, palpation
Inspection, palpation, percussion, auscultation
Which of the following senses is used when the nurse performs the inspection phase of assessments?
smell
taste
hearing
touch
sight
You are palpating a client's precordium. Which of the following is an expected clinical finding?
Palpable heave over the pulmonic area
Palpable vibration over the right sternal border
Palpable pulsation over the right mitral area
Palpable thrill over the aortic area
