Basic Physical Assessment

A client tells a nurse that he has a rash on his back and right flank. The nurse observes elevated, round, blisterlike lesions filled with clear fluid. When documenting the findings, what medical term should the nurse use to describe these lesions?

• Pustules

• Papules

• Plaque

• Vesicles

A client comes to the clinic for a routine checkup. To assess the client's gag reflex, the nurse should use which method?

• Place a tongue blade on the front of the tongue and ask the client to say "ah."

• Place a tongue blade lightly on the posterior aspect of the pharynx.

• Place a tongue blade on the middle of the tongue and ask the client to cough.

• Place a tongue blade on the uvula.

A nurse is auscultating a client's chest. How can the nurse differentiate a pleural friction rub from other abnormal breath sounds?

• A rub occurs only during expiration and produces a light, popping, musical noise.

• A rub occurs only during inspiration and the nurse may hear it anywhere.

• A rub occurs during both inspiration and expiration and produces a squeaking or grating sound.

• A rub occurs only during inspiration and clears with coughing.

During assessment, a nurse auscultates for a client's breath sounds. Auscultation provides which type of data?

• Subjective

• Objective

• Secondary source

• Medical

A nurse is taking a client's blood pressure and fails to recognize an auscultatory gap. What should the nurse do to avoid recording an erroneously low systolic blood pressure?

• Have the client lie down while she takes his blood pressure.

• Inflate the cuff to at least 200 mm Hg.

• Take blood pressure readings in both of the client's arms.

• Inflate the cuff at least another 30 mm Hg after she can't palpate the radial pulse.

When palpating the bladder of an adult client, a nurse should identify which finding as normal?

• A soft, smooth bladder

• A hard, rough bladder

• A nonpalpable bladder

• A palpable bladder located 3″ to 5″ (7.5 to 12.7 cm) above the symphysis pubis

A client undergoes a total abdominal hysterectomy. When assessing the client 10 hours later, the nurse identifies which finding as an early sign of shock?

• Confusion

• Pale, warm, dry skin

• Heart rate of 110 beats/minute

• Urine output of 30 ml/hour

A nurse prepares to assess a client who has just been admitted to the health care facility. During assessment, the nurse performs which activity?

• Collects data

• Formulates nursing diagnoses

• Develops a care plan

• Writes client outcomes

A nurse correctly identifies which items as belonging to the dorsal cavity?

• Mediastinum

• Mouth

• Vertebral canal

• Reproductive organs

A nurse reviews the arterial blood gas (ABG) values of a client admitted with pneumonia: pH, 7.51; PaCO2, 28 mm Hg; PaO2, 70 mm Hg; and HCO3–, 24 mEq/L. What do these values indicate?

• Metabolic acidosis

• Metabolic alkalosis

• Respiratory acidosis

• Respiratory alkalosis

When obtaining a client's history, a nurse develops a genogram. What is the purpose of developing a genogram?

• To identify genetic and familial health problems

• To identify previously undetected diseases and disorders

• To identify the client's reason for seeking care

• To identify the client's chronic health problems

A nurse conducts a test for Romberg's sign. What is the correct procedure for this test?

• Have the client stand with feet together and arms at his sides and try to balance. Have the client first do this with his eyes open and then with his eyes closed.

• Instruct the client to walk across the room on his heels and to return walking on his toes.

• Ask the client to touch the thumb of one hand to each finger on that hand and then do the same thing using the other hand.

• Instruct the client to lie on his back and slowly slide his heel down the shin of the opposite leg, from the knee to the ankle.

The ear canal of an infant or young child:

• Slants upward.

• Slants downward.

• Is horizontal.

• Slants backward.

A nurse measures a client's temperature at 102° F. What is the equivalent Centigrade temperature?

• 38.9° C

• 39° C

• 40.1° C

• 47° C

A nurse is conducting a physical assessment on an obese 17-year-old who has asked for information about gastric bypass surgery. Which statement best describes informed consent as it applies to this situation?

• Providing the adolescent with information about the procedure implies informed consent.

• The nurse should inform the adolescent that he may sign a consent form for the surgical procedure if a parent cosigns the form.

• The nurse should inform the adolescent that, in most states, only parents may give consent for a minor's medical care.

• The nurse may provide the adolescent's legal guardian with information regarding the procedure.

A nurse is assessing a client who may be in the early stages of dehydration. Early manifestations of dehydration include:

• Coma or seizures.

• Sunken eyeballs and poor skin turgor.

• Increased heart rate with hypotension.

• Thirst or irritability.

A nurse is palpating a client's pulse on the inner aspect of his ankle, below the medial malleolus. Which pulse is the nurse assessing?

• Brachial

• Femoral

• Posterior tibial

• Dorsalis pedis

A nurse is assessing a client who has a rash on his chest and upper arms. Which questions should the nurse ask in order to gain more information about the client's rash? Select all that apply.

• When did the rash start?

• Are you allergic to any medications, foods, or pollen?

• How old are you?

• What have you been using to treat the rash?

• Have you recently traveled outside the country?

• Do you smoke cigarettes or drink alcohol?

A nurse uses a stethoscope to auscultate a client's chest. Which statement about a stethoscope with a bell and diaphragm is true?

• The bell detects high-pitched sounds best.

• The diaphragm detects high-pitched sounds best.

• The bell detects thrills best.

• The diaphragm detects low-pitched sounds best.

A client, age 75, is admitted to the facility. Because of the client's age, the nurse should modify the assessment by:

• Shortening it.

• Speaking in a loud voice.

• Addressing the client by his first name.

• Allowing extra time for the assessment.

A nurse is caring for a client who is exhibiting signs and symptoms characteristic of a myocardial infarction (MI). Which statement describes priorities the nurse should establish while performing the physical assessment?

• Assess the client's level of pain and administer prescribed analgesics.

• Assess the client's level of anxiety and provide emotional support.

• Prepare the client for pulmonary artery catheterization.

• Ensure that the client's family is kept informed of his status.

A nurse is teaching a client who will soon be discharged how to change a sterile dressing on his right leg. During the teaching session, the nurse notices redness, swelling, and induration at the wound site. What do these signs suggest?

• Infection

• Dehiscence

• Hemorrhage

• Evisceration

Two days after undergoing a total abdominal hysterectomy, a client complains of left calf pain. Venography reveals deep vein thrombosis (DVT). When assessing this client, the nurse is likely to detect:

• Pallor and coolness of the left foot.

• A decrease in the left pedal pulse.

• Loss of hair on the lower portion of the left leg.

• Left calf circumference 1" (2.5 cm) larger than the right.

A mother comes to the clinic with her 5-year-old son who is complaining of a fever and sore throat. The nurse documents the client's tonsils as 3+. This rating means they're:

• Barely visible outside the tonsillar pillar.

• Midway between the tonsillar pillar and the uvula.

• Touching the uvula.

• Touching each other.

When a nurse enters a client's room, the client complains that she's spitting up blood when she coughs. The nurse takes a quick health history that includes:

• The history of the present problem, medications, review of systems, and recent major operations.

• The history of the present problem, allergies, medications, and recent major operations.

• The history of the present problem, medications, family history, psychosocial history, and review of systems.

• The history of the present problem, allergies, medications, review of systems, and recent major operations.

A nurse is conducting a physical assessment on an adolescent who doesn't want her parents informed that she had an abortion in the past. Which statement best describes the information security measures the nurse can implement in this situation?

• Respect the adolescent's wishes and maintain her confidentiality.

• Because the adolescent is a minor, inform her parents about her medical history.

• Discussing the adolescent's medical history with her parents and thoroughly document it in the medical record.

• Before agreeing to maintain confidentiality, determine whether the adolescent is an emancipated minor.

When testing a client's pupils for accommodation, a nurse should interpret which findings as normal?

• Constriction and divergence

• Dilation and convergence

• Constriction and convergence

• Dilation and divergence

At 8 a.m., a nurse assesses a client who's scheduled for surgery at 10 a.m. During the assessment, the nurse detects dyspnea, a nonproductive cough, and back pain. What should the nurse do next?

• Check to see that the client had a chest X-ray the previous day as ordered.

• Check the client's serum electrolyte levels and complete blood count (CBC).

• Immediately notify the physician of these findings.

• Sign the preoperative checklist for this client.

A client is admitted to the hospital with pneumonia. He has a history of Parkinson's disease, which his family says is worsening. Which assessment should the nurse expect?

• Impaired speech

• Muscle flaccidity

• Pleasant and smiling demeanor

• Tremors in the fingers that increase with purposeful movement

A client comes to the clinic for diagnostic allergy testing. The nurse understands that intradermal injections are used for such testing based on which principle?

• Intradermal injection is less painful.

• Intradermal drugs are easier to administer.

• Intradermal drugs diffuse more rapidly.

• Intradermal drugs diffuse more slowly.

A client with a spinal cord injury says he has difficulty recognizing the symptoms of urinary tract infection (UTI). Which symptom is an early sign of UTI in a client with a spinal cord injury?

• Lower back pain

• Burning sensation on urination

• Frequency of urination

• Fever and change in urine clarity

When inspecting a client's skin, a nurse finds a circumscribed elevated area filled with serous fluid. What term should the nurse use to document this finding?

• Macule

• Papule

• Vesicle

• Pustule

A nurse prepares to palpate a client's maxillary sinuses. For this procedure, where should the nurse place her hands?

• On the bridge of the client's nose

• Below the client's eyebrows

• Below the client's cheekbones

• Over the client's temporal area

A nurse can auscultate for heart sounds more easily if the client is:

• Supine.

• On his right side.

• Holding his breath.

• Leaning forward.

A client with fever, weight loss, and watery diarrhea is being admitted to the facility. While assessing the client, a nurse inspects the client's abdomen and notices that it's slightly concave. Additional assessment should proceed in which order?

• Auscultation, percussion, and palpation

• Palpation, percussion, and auscultation

• Percussion, palpation, and auscultation

• Palpation, auscultation, and percussion

A nurse is performing a preoperative assessment. Which client statement should alert her to the presence of risk factors for postoperative complications?

• I haven't been able to eat anything solid for the past 2 days.

• I've never had surgery before.

• I had an operation 2 years ago, and I don't want to have another one.

• I've cut my smoking down from two packs to one pack per day.

A nurse is obtaining the health history of a client whose background differs from her own. To develop culturally acceptable strategies for nursing care, the nurse should assess which client factor?

• Marital status

• Cultural influences

• Financial resources

• Community involvement

To evaluate a client's reason for seeking care, a nurse performs deep palpation. What is the nurse assessing?

• Skin turgor

• Hydration

• Organs

• Temperature

A 10-year-old child with rheumatic fever must have his heart rate measured while he's awake and while he's sleeping. Why are two readings necessary?

• To obtain a heart rate that isn't affected by medication

• To eliminate interference from the jerky movements of chorea

• To ensure that the child can't consciously raise or lower his heart rate

• To compensate for activity's effects on the child's heart rate

A nurse is caring for a client with herpes zoster. Place the pathophysiologic changes associated with the client's disorder in the proper sequence.1. Fever, malaise, and red nodules develop.2. Pain, itching, and paresthesia develop3. Vesicles crust and scab.4. Residual antibodies mobilize but are effective.5. Vesicles with clear fluid or pus appear.6. Varicella-zoster virus is reactivated.

When percussing a client's chest, the nurse should expect to hear:

• Hyperresonance.

• Tympany.

• Resonance.

• Dullness.

What is a common source of airway obstruction in an unconscious client?

• A foreign object

• Saliva or mucus

• The tongue

• Edema

A nurse is caring for a client who has experienced an acute exacerbation of Crohn's disease. Which statement best indicates that the disease process is under control?

• The client exhibits signs of adequate GI perfusion.

• The client expresses positive feelings about himself.

• The client verbalizes a manageable level of discomfort.

• The client maintains skin integrity.

A nurse is assessing a postoperative client. Which information should the nurse document as subjective data?

• Vital signs

• Laboratory test results

• Client's descriptions of pain

• Electrocardiograms (ECGs)

A nurse measures a client's apical pulse rate and compares it with his radial pulse rate. The differential between these two pulses is called:

• The pulse pressure.

• The pulse deficit.

• The pulse rhythm.

• Pulsus regularis.

A nurse determines that a client has 20/40 vision. Which statement about this client's vision is true?

• The client can read the entire vision chart at a distance of 40′ (12 m).

• The client can read from a distance of 20′ (6 m) what a person with normal vision can read at a distance of 40′.

• The client can read the vision chart from a distance of 20′ with the right eye and from 40′ with the left eye.

• The client can read at a distance of 30′ (9 m) what a person with normal vision can read at a distance of 40′.

A nurse is assessing a client's abdomen. Which finding should the nurse report as abnormal?

• Dullness over the liver

• Bowel sounds occurring every 10 seconds

• Shifting dullness over the abdomen

• Vascular sound over the renal arteries

To help assess a client's cerebral function, a nurse should ask:

• Have you noticed a change in your memory?

• Have you noticed a change in your muscle strength?

• Have you had any problems with coordination?

• Have you had any problems with your eyes?