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Cards In This Set
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A nurse examining the lungs of a patient percusses over the anterior thorax using the proper sequence. This technique helps to identify:
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Density and location of lungs
Density and location of lungs
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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?
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Client hears vibrations in the affected ear
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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.
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V
VII IX |
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Which of the following statements accurately represents a characteristic of the third or fourth heart sound?
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S3 is considered normal in children and young adults and abnormal in middle-aged and older adults.
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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
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Avoid a position change that requires turning
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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?
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Bronchophony
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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
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To obtain data about an adult patient's sexuality and reproductive pattern, the nurse should ask the patient
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“Has anything changed your sexual performance?”
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How would a nurse assess a patient for pupillary accommodation?
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Patient states, "I feel winded all of the time and yesterday I started spitting up a lot of phlegm." (always exact wording from patient)
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A nurse assesses a patient for blood pressure. Which of the following techniques would be used for this assessment? Palpation, Inspection, Auscultation, Percussion
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Auscultation
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Following auscultation of a patient's heart, the nurse documents grade III murmur. What are the characteristics of this type of murmur?
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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.)
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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?
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Inspect and palpate the supraclavicular area.
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A nurse auscultates the right carotid artery in an elderly client and identifies a bruit. What does this assessment finding mean?
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It is distended
(Bruits occur when the artery is partially obstructed or distended, which prevents blood flow from moving straight through the vessel) |
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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?
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Prone
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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?
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Partially obstructed blood flow through a valve opening
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