CHAP 21 Physical assessment Flashcards by Gucci Lions

A nurse has been assigned to care for a patient who has been on the medical unit for 3 days with a clinical
diagnosis of uncontrolled hypertension (HTN). What type of physical assessment should the nurse perform
upon starting the shift?

Initial head-to-toe assessment
(A nurse beginning a shift should perform an initial head-to-toe
assessment looking at all body systems.)

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An unlicensed assistive personnel (UAP) has recorded vital signs on the patient’s record. In reviewing the
information, the nurse finds a documented temperature of 102.2°F (39°C). What is the next action that the
nurse should take?

Administer Tylenol.
(Because the patient is febrile, the nurse should administer Tylenol,
which is antipyretic medication)

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A nursing instructor is observing a nursing student perform a physical assessment on a simulation mannequin.
Which observation warrants immediate action by the nursing instructor?

Palpated abdomen before listening to bowel sounds
( when conducting an abdominal assessment, auscultation comes before
palpation and percussion so that bowel sounds are not altered.)

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A charge nurse notes a patient’s blood pressure at 8:00 a.m. was 124/80 mm Hg. It is now 12:00 p.m., and the
patient’s blood pressure is 152/94 mm Hg. Which suggestion about the plan of care should the charge nurse
make to the graduate nurse?

Because the blood pressure has become elevated, it should be rechecked in 1 to 2 hours.

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A nurse is monitoring a 58-year-old patient who is receiving diuretic therapy. Which assessment finding
would the nurse interpret as being most significant?

Weight gain of 2 pounds
(Because the patient is on diuretic therapy, a weight gain is considered to
be significant.)

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A nurse has obtained vital signs on an 82-year-old patient admitted for urinary tract infection. Which finding
warrants immediate intervention?

Presence S3 heart sound
(S3 heart (ventricular gallop) sound indicates a cardiac
concern and requires further assessment

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A nurse performs a focused assessment. Which condition provides the best information through the use of
percussion?

Hyperinflated lungs
(Performing percussion over the lung fields in patients with
hyperinflated lungs will yield a long, loud, low-pitched, hyper-resonant sound)

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A nurse is assessing the patient’s respiratory system. Which finding is consistent with normal respiratory
function?

Equal thoracic excursion

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A nurse is performing a physical assessment at the change of shift on an older adult patient. Assessment
indicates a breathing rate of 30 breaths per minute, breath sounds are clear to auscultation in all five lobes,
and the patient denies dyspnea. Which finding would the nurse expect with assessment of the patient’s
capillary refill?

Nail beds pink, capillary refill 5 seconds
(pink nail beds and capillary refill of 5 seconds
are normal and expected for this older adult patient)

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A nurse performing an assessment of the patient’s eyes tells the patient, “Focus on my pencil and follow it as
I move it away from you and then back toward you.” Which specific function is the nurse assessing?

Accommodation response

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nurse provides care for a patient who is 1 day postoperative. The patient reports nausea and is refusing to
eat. The nurse assesses the patient by auscultating the abdomen. Which cause would the nurse suspect if
assessment reveals hypoactive bowel sounds

Anesthesia

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A nurse is monitoring a patient who has decreased urinary output despite being on continuous intravenous
therapy and drinking fluids. Which assessment should the nurse identify as being a potential cause of this
finding

Abdomen slightly distended

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A nurse is assessing a patient’s skin and notes a bronzed appearance. The patient denies going out into the
sun. How should the nurse document this finding?

Bronzing

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A nurse is preparing to document findings of edema for a patient who has bilateral swelling of both feet up to
the level of the ankle. There is prolonged indentation after the nurse touches the area, which lasts several
minutes. How should the nurse document this finding?

3+ pitting edema of the feet to ankle bilaterally

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A nurse is preparing to perform a neurological examination on a 65-year-old patient during an annual office
visit. Which of the following indicates a normal finding based on the patient’s age?

Inability to distinguish certain tones or voices

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A nurse is providing care for a patient who was admitted due to a stroke. The patient becomes frustrated
because of an inability to respond verbally to the nurse’s questions. Which terminology should the nurse use
to document this complication?

Aphasic

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A nurse who is performing a physical assessment is preparing to auscultate breath sounds. Which position is
most favorable for performing the assessment of breath sounds?

High Fowler’s position

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A nurse performs a physical assessment on a patient who has just been admitted for left lower-lobe
pneumonia. The patient describes having an unproductive cough. Which assessment finding supports the
nurse’s suspicion of consolidation in the left lower lobe?

Absent breath sounds

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A nurse is monitoring the results of a patient’s Glasgow Coma Scale who is being assessed after a motor
vehicle accident (MVA). Based on the documentation, the score has decreased from 13 to 10. What is the best
nursing action?

Contact the health-care provider (HCP)

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A nurse is assessing a patient’s respiratory status and notes periods of apnea alternating with several deep
breaths. What priority action should the nurse take?

Call a rapid response.

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A nurse enters the patient’s room and observes a drooped right eyelid. Which assessment should the nurse
perform next?

Obtain BP reading

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A nurse is assessing an older patient’s eyes. Which findings are consistent with aging changes in the older
patient? Select all that apply.

Opaque white ring around cornea
Smooth conjunctiva

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A nurse is assessing a patient’s eyes using a penlight. Which findings indicate that consensual reflex is
normal? Select all that apply.

Pupillary constriction in response to light
Simultaneous pupillary response
Pupils returning to same size after light stimuli

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A nurse is performing a focused assessment of the patient’s cardiovascular system every 4 hours. Which
specific assessment would the nurse include? Select all that apply.

Skin color, moisture, and temperature
Blood pressure
Strength and equality of peripheral pulses
Capillary refill of extremities

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A patient is admitted with long-standing chronic obstructive pulmonary disease (COPD) and is at risk for respiratory failure. Every 4 hours, the nurse performs a focused respiratory assessment. Which assessment action should the nurse include during each reassessment? Select all that apply.

2. Color of nail beds 3. Presence of sternal retractions 5. SpO2

The nurse is reassessing a patient and begins assessing the patient's head and neck. Which action does the nurse perform first?

Check the patients skin color

The nurse is performing a focused assessment at the beginning of the shift on a patient diagnosed with pneumonia. Which patient assessment is least informative for the nurse?

Skin color and warmth

The nurse is preparing to reassess a patient's neurological status. Which reason is why the nurse verbally explains the assessment process to a patient who is comatose?

The sense of hearing still may be present

The nurse is providing care for a patient who suddenly develops abdominal pain at a level of 7 on a scale of 0 to 10. Which resource will the nurse use to assist in evaluating the patient's condition?

The physical assessment notes acquired at the time of the physical (this shows baseline for comparison to current findings)

The nurse is providing care for a patient from a culture whose members are modest and sensitive about being touched. Which statement by the nurse reflects cultural respect for this patient?

May I place my hands under your clothing and touch your abdomen

The nurse is reassessing a patient admitted to the hospital. When inspecting the patient's mouth, the nurse notes that the patient has no teeth. The patient states, "I have dentures but they hurt my mouth so I didn't even bring them." What is the nurse’s best response?

Seek an order for a mechanically soft diet

During the reassessment of a patient's lungs, the patient states, "I have been coughing up stuff that is kind of foamy and pink in color." Which patient diagnosis does the nurse anticipate?

Congestive heart failure

The nurse at a pediatric clinic is preparing to weigh an infant. Which action by the nurse will interfere with acquiring an accurate weight?

Placing a cover on the scale after the scale is calibrated

The nurse in an adult clinic is assessing a patient who is being admitted. Which assessment of the patient's general appearance indicates physical distress?

Breathing through the mouth

The nurse provides care for multiple patients in an acute care setting. Which patient is likely to require a daily weight assessment? Select all that apply.

- PT being treated for general edema -PT with a history of heart disease -PT on fluid restrictions for kidney disease

The nurse at a summer camp provides care for a camper who falls and is injured during a hike. The nurse has no medical equipment available. Which assessment process is the nurse likely to use? Select all that apply.

-Critical thinking for safest way to monitor -Visual inspection for injury location -Auditory skills for what pt. is subjectively feeling -Visualization for any external bleeding

The nurse is preparing to review the physical assessment performed on a newly admitted patient. Which definition is inaccurate?

It provides guidelines for decisions about medical treatment

The new graduate nurse states, "I am always fearful that I will forget part of the physical assessment process." Which is the best response by the experienced nurse?

Start at the top and move downward to the toes, then arms and legs

The nurse is preparing to interview an older adult patient. Which assessment is most important for the nurse to perform before the interview?

LOC

The nurse enters a patient's room and discovers the patient sitting on the side of the bed and leaning forward over the bedside table. Which condition does the nurse suspect?

Orthpnea

The nurse is reassessing an patient admitted to the hospital. Which nonverbal behavior by the patient requires further clarification by the nurse?

The patient grimaces and pulls away when palpating

The nurse is preparing to perform a head-to-toe assessment on a patient. Which step will the nurse perform first?

Gather all the necessary equipment

The licensed practical nurse/licensed vocational nurse (LPN/LVN) reviews the registered nurse's (RN's) assessment notes on a newly admitted patient. Which assessment finding will requires clarification from the RN?

The level of pain voiced by the patient during abdominal palpation.

The nurse is aware that the neurological assessment of a patient includes vital sign evaluation. Which vital signs are related to functions of the central nervous system? Select all that apply.

-Temperature -Pulse rate -Respiratory rate -Blood pressure

The nurse is reviewing a comprehensive assessment on a new patient. Which objective information does the nurse associate with the patient's physical examination?

The patients pain response to palpation of a growth

The nurse works in a medical clinic and is preparing for the health provider to assess a patient’s ears and nose. The use of which equipment will be anticipated? Select all that apply.

-Check the otoscope for functioning light bulb -Ensure availability for speculum covers

The nurse is admitting a patient to a long-term care facility. Which describes the reasoning to perform a physical assessment during admission? Select all that apply.

-It provides a baseline -Used to identify real and potential problems -Used to evaluate effectiveness of interventions -It provides historical information on body parts

The nurse works in the newborn nursery. What is the correct order when obtaining a newborn's weight and height? Place the options in the correct order. All options must be used.

1. Balance scale 2.Remove clothing 3.Lay in cradle of scale 4.gently extend leg at the knee and hip and mark the head and foot 5. Weigh newborn and provide 1-2 inch safety

The nurse is reassessing a patient's apical pulse prior to the administration of cardiac medication. Which action by the nurse is not appropriate?

Listening to the posterior aspect of the thoracic activity

The process of inspection begins when the nurse enters the room. Which can the nurse identify solely through the process of inspection? Select all that apply.

The patient needs assistance with personal care

When assessing a patient's eyes, the nurse can shine a light into one of the patient's eyes and both pupils should have a rapid constriction that is simultaneous and equal. What best describes this reaction?

Consensual reflex

Which olfaction assessment is most common among medical health-care providers?

The odor of acetone on breath of diabetes mellitus

The nurse is preparing to reassess a patient's initial shift assessment. Which physical assessment technique is least likely to be used by the nurse?

Percussion

The nurse conducts an admission assessment for a patient. Which information is included in the health interview portion of the assessment? Select all that apply.

-Med history -Personal identity -Allergies -Details on current condition

The nurse is preparing to reassess a patient at the beginning of the shift. Which assessment by the nurse requires equipment?

Inspection of tympanic membrane (requires otoscope)

The nurse is reviewing the admission notes for a newly admitted patient. Which assessment finding is recognized as a subjective symptom of the patient's condition?

The pt reports muscle tenderness and fever

The nurse is reassessing a patient. List the steps in the correct order when conducting an assessment.

1. Neuro 2.Cardiovascular 3.Respiratory 4.Integumentary 5.Gastro 6.Skeletal

The licensed practical nurse/licensed vocational nurse (LPN/LVN) is reassessing an assigned patient. Which assessment requires the LPN/LVN to use palpation?

To reassess dependent edema

The nurse is working in a clinic that focuses on the care of patients with respiratory conditions. Which adventitious breath sounds will the nurse recognize as causing the concern? Select all that apply.

-Rhonchi that sounds like snoring or gurgling -Stridor present in a toddler

The nurse is caring for a patient scheduled for surgery to amputate gangrenous toes from the left foot. During the shift assessment, the nurse checks pedal pulses, skin color and warmth, and the level of pain. Which finding would prompt the nurse to perform an additional assessment?

PTs right lower leg and ankle are swollen

CHAP 21 Physical assessment Flashcards

(60 cards)