PrepU: Taylor - Ch. 25 \"Assessments\"

Total Flash Cards » 18
 
1. 

A nurse examining the lungs of a patient percusses over the anterior thorax using the proper sequence. This technique helps to identify:

 

Density and location of lungs
Density and location of lungs

 
2. 

A nurse is conducting an auditory assessment of an older adult with a conductive hearing loss. The nurse performs the Weber test. Which finding would the nurse expect to assess in this client?

 

Client hears vibrations in the affected ear

 
3. 

A nurse is assessing the cranial nerves of a client who is recovering from Bell's palsy. Which of the following cranial nerves are important for the coordination of facial movement and reflex activity? Select all that apply.

 

V
VII
IX

 
4. 

Which of the following statements accurately represents a characteristic of the third or fourth heart sound?

 

S3 is considered normal in children and young adults and abnormal in middle-aged and older adults.

 
5. 

A client states during the interview that he has pain in his lower back. He states it is a 10 on a scale of 1 to 10 when he is asked to turn. The nurse should

 

Avoid a position change that requires turning

 
6. 

A nurse is auscultating a client's chest and notices adventitious breath sounds. The nurse suspects atelectasis and asks the client to repeat the word "ninety-nine." The nurse hears the sound louder and more clearly than normal. The nurse documents this as which of the following?

 

Bronchophony

 
7. 


Health assessment is the systematic collection of objective data that are directly observed or elicited through examination techniques, such as inspection, palpation, percussion and auscultation. T/F?

 

False.... also subjective data

 
8. 

To obtain data about an adult patient's sexuality and reproductive pattern, the nurse should ask the patient

 

“Has anything changed your sexual performance?”

 
9. 

How would a nurse assess a patient for pupillary accommodation?

 

Patient states, "I feel winded all of the time and yesterday I started spitting up a lot of phlegm." (always exact wording from patient)

 
10. 

A nurse assesses a patient for blood pressure. Which of the following techniques would be used for this assessment? Palpation, Inspection, Auscultation, Percussion

 

Auscultation

 
11. 

Following auscultation of a patient's heart, the nurse documents grade III murmur. What are the characteristics of this type of murmur?

 

A moderately loud murmur
(A grade I murmur = faint / grade II is a faint murmur but one that can be easily detected; grade III is a moderately loud murmur; grade IV is a very loud murmur that is usually associated with a thrill sound; grade V is an extremely loud murmur; and grade VI is an exceptionally loud murmur that can be heard while the stethoscope is lifted off the skin.)

 
12. 

A nurse is performing a head and neck assessment of a patient suspected of having leukemia. How would the nurse detect enlarged lymph nodes commonly associated with this disease?

 

Inspect and palpate the supraclavicular area.

 
13. 

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

 

It is distended
(Bruits occur when the artery is partially obstructed or distended, which prevents blood flow from moving straight through the vessel)

 
14. 

A nurse is performing a physical assessment of an 85-year-old woman who recently had a hip replacement. In what position would the nurse place this patient to examine the hip joint?

 

Prone

 
15. 

A nurse is performing a cardiac assessment. While auscultating the chest, the nurse hears swishing sounds through the stethoscope, resembling systolic murmurs. Which of the following would the nurse suspect?

 

Partially obstructed blood flow through a valve opening

 
16. 

During an assessment of the cranial nerves, the nurse asks the patient to smile, frown, wrinkle the forehead, and puff out the cheeks. What nerve is being tested by this action?

 

Cranial nerve VII

 
17. 

A nurse is conducting an auditory assessment of an older adult with a conductive hearing loss. The nurse performs the Weber test. Which finding would the nurse expect to assess in this client?

 

Client hears vibrations in the affected ear

 
18. 

A nurse examining the lungs of a patient percusses over the anterior thorax using the proper sequence. This technique helps to identify:

 

Density and location of lungs