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Terms in this set (88)
The nurse is performing a thoracic Barrel chest
assessment on a client with chronic
asthma and hyperinflation of the lungs.
Which finding should be expected for this
client?
The nurse is assessing bowel soundsNote the character and frequency of bowel sounds for a
hospitalized client. The nurse has heard bowel sounds in the right upper quadrant. What action
should the nurse take next?
During inspection of a client's mouth and Document an intact gag reflex.
pharynx, the nurse places a tongue blade
on the back of the tongue which causes
the client to gag. After removing the
tongue blade, what action should the
nurse take?
When teaching a client how to perform a Upper outer quadrant.
monthly breast selfassessment, the nurse
should tell the client that it is most
important to assess which part of the
breast more closely for changes?
The nurse is assessing a postmenopausal A waist circumference is greater than 35 inches in women puts you at higher risk for
client who has a BMI of 32. The client has type 2 diabetes and heart disease."
a chest measurement of 42 inches, waist
measurement of 45 inches, and hip
measurement of 50 inches. What
important message should the nurse
explain to the client to promote health
promotion?
The nurse performs a physical assessment Height reduction of 1.5 inches.
on an older female client. Which change
from the prior exam may be an indication
of osteoporosis?
, While conducting an interview to obtain a Sit quietly to allow the client to respond comfortably.
health history, the nurse notices that the
client pauses frequently and looks at the
nurse expectantly. Which response is best
for the nurse to provide?
A client is in the clinical for a yearlyAsk the client to urinate before beginning the examination. physical
examination. Which action should the nurse take when preparing to examine the client's abdomen?
Which respiratory condition
shouldBradypnea. the nurse document after
measuring a respiratory rate of 8
breaths/minute?
Measure the apical pulse and compare it to the peripheral pulse.
Which procedure should the nurse use to
assessfor a pulse deficit? *A pulse deficit is a palpable difference between the apical pulse at the point of
maximal impulse and the radial pulse palpated at the wrist.
A client has been diagnosed with Dull, thud-like.
bilateral lower lobe atelectasis. What
percussion sound should the nurse
expect to hear when percussing over the
client's lower lobes?
A client is being assessed upon admission Inspect the hair and skin.
to the medical-surgical unit. The nurse is
preparing to complete a head-to-toe
assessment and will begin at the head of
the client. Which technique should the
nurse use to begin the assessment?
The nurse is assessing a healthy youngDeep palpation above and to the left of the umbilicus.
adult during an annual physical
examination. Which assessment
technique should the nurse implement
when palpating the abdominal aorta?
The nurse is conducting a family history Document at least 3 generations of the client's family medical history.
as part of the assessment interview.
Which action should the nurse take to
ensure that sufficient information about
the client's blood relatives is obtained?
The nurse is testing the client's shoulders Range of 90 degrees when the hands are placed at the small of the back.
for range of motion. What should the
nurse document to record normal
internal rotation?