Health History
A nurse is providing feedback to a colleague after observing the colleague's interview of a newly admitted client. Which of the following would the nurse identify as an example of a closed-ended question or statement?
1) “Tell me about your relationship with your children?”
2)“Tell me what you eat in a normal day?”
3)“Are you allergic to any medications?”
4)“What is your typical day like?”
“Are you allergic to any medications?”
Closed-ended questions ask for specific information that can be answered with one or two words. Asking about the relationship, what the client eats in a normal day, and what the client's typical day is like are examples of open-ended questions that elicit information about the client's feelings and perceptions.
The sinoatrial node of the heart is located on the
1)anterior wall of the left atrium.
2)anterior wall of the right atrium.
3)upper intraventricular system.
4) posterior wall of the right atrium.
The sinoatrial (SA) node (or sinus node) is located on the posterior wall of the right atrium near the junction of the superior and inferior vena cava.
The nursing instructor teaches students the most accurate location to auscultate the right middle lobe of the lung is where?
1) Anterior
2) Posterior
3) Laterally
4) Medially
The right middle lobe is best auscultated using the anterior approach. Only a small portion an be auscultated laterally.
A client is told by another care provider that his liver was enlarged. Although the client is a lifelong smoker with a history of emphysema, the client has never used drugs or alcohol, nor does the client have any knowledge of liver disease. Upon examination by the nurse, a liver edge is palpable 4 cm below the costal arch. Which intervention would provide the most relevant information to determine liver status at this time?
1) Check an ultrasound of the liver.
2) Obtain a hepatitis panel.
3) Determine liver span by percussion.
4) Assess the client for signs of jaundice.
Determine liver span by percussion.
A liver edge palpable this far below the costal arch should not be ignored. Ultrasound, laboratory investigation, and assessing for jaundice are reasonable actions if the liver is actually enlarged. The client has developed emphysema with flattening of the diaphragms. This pushes a normal sized liver below the costal arch so that it appears to be enlarged. A liver span should be determined by percussing down the chest wall until dullness is heard. A measurement is then made between this point and lower border of the liver to determine its span. Percussion is the only way to assess liver size on examination, and in this case saved the client much inconvenience and expense.
A 20-year-old comatose high school student arrives at the emergency room. His friends have accompanied him and report that they have been shooting up heroin tonight and think their friend may have had too much. The client is unconscious and cannot protect his airway so he is intubated. His heart rate is 60 and he is breathing through the ventilator. He is not posturing and he does not respond to a sternal rub. On neurological examination with a penlight, what type of pupils is the examiner likely to see in this comatose client?
1) Pinpoint
2) Large
3) Asymmetrical
4) Irregularly shaped
Pinpoint
Narcotics and cholinergics cause very small pupils. Reactions to light can be appreciated with a magnifying glass.
The nurse is reviewing the medical record before meeting a new client. In which phase of the interview process is the nurse working?
1)working
2)termination
3)introduction
4)pre-interview
Pre Interview
In the pre-interview stage the medical record is reviewed to help set the stage for a smooth interview. In the working phase, the client information is collected. In the termination phase, important points are summarized and the plan of care is developed. In the introduction phase the client is greeted and rapport is established.
Which technique would be most appropriate to use when examining the jugular venous pulse?
1)Inspect the suprasternal notch or around the clavicles.
2)Have the client sit up at a 90-degree angle.
3)Have the client look straight ahead with chin slightly lifted.
4)Perform the exam with the client in a supine position.
Perform the exam with the client in a supine position
When assessing the jugular venous pulse, the client should be supine with the torso elevated 30 to 45 degrees with the head and torso on the same plane. The client turns his head slightly to the left and the nurse shines a tangential light source onto the neck to increase visualization of pulsations as well as shadows. The nurse inspects the sternal notch or area around the clavicles for pulsations.
The nurse is planning to percuss the chest of an adult male client for diaphragmatic excursion. The nurse should begin the assessment by
1) asking the client to take a deep breath and hold it.
2) percussing upward from the base of the lungs.
3) percussing downward until the tone changes to resonance.
4) asking the client to exhale forcefully and hold his breath.
asking the client to exhale forcefully and hold his breath.
Explanation
When percussing for diaphragmatic excursion ask the client to exhale forcefully and hold the breath.
A client reports that he has been experiencing diarrhea for the past week. What question by the nurse will assist in determining if this client is truly experiencing an alteration in bowel pattern?
1)"What is the consistency of your stools??"
2)"How many times a day are you having a bowel movement?"
3)"Do you have a bowel movement every day?"
4) "Have you changed your food intake this week?"
"How many times a day are you having a bowel movement?"
Diarrhea is defined as frequency of bowel movements producing unformed or liquid stools. To determine if the client is truly experiencing diarrhea, the nurse should ask about how many times a day the client is having a bowel movement. The other important question is how many times a day does the client normally have a bowel movement. The consistency will not tell the nurse whether this is normal or abnormal. Asking about food intake will give information about whether the client has tried to treat the problem.
The nurse in the health care clinic is performing a neurological assessment and is testing the motor function of cranial nerve V (trigeminal nerve). Which technique would the nurse implement to test the motor function of this nerve?
1) Ask the client to puff out the cheeks.
2) Separate the client's jaw by pushing down on the chin.
3) Place a small amount of sugar on the client's tongue and ask them to identify the taste.
4) Ask the client to rotate the head forcibly against resistance applied to the side of his or her chin.
Separate chin from jaw
Rationale, Strategy, Tip
Rationale:
The motor function (muscles of mastication) of cranial nerve V (trigeminal nerve) is assessed by palpating the temporal and masseter muscles as the person clenches the teeth. The muscles would feel equally strong on both sides. The nurse would try to separate the client's jaws by pushing down on the chin; normally, the jaws cannot be separated. Asking the client to puff out the cheeks tests the facial nerve. Placing an object on the client's tongue tests sense of taste and the sensory function of the facial nerve. Checking for equal strength by asking the person to rotate the head forcibly against resistance applied to the side of the client's chin assesses cranial nerve XI, the spinal accessory nerve.
What information aids the nurse in assessing possible biases in the data collected in the health history?
1)Ethnicity of client
2)Gender of client
3)Source of information
4)Socioeconomic status of the client
Source of information
Designating the source helps the nurse and reader assess the type of information provided and possible biases.
When learning about hereditary variability, the student would learn that what ethnic group has the highest number of premature deaths due to heart disease?
1)Native American
2)Pacific Islanders
3)African American
4)Hispanic
The number of premature deaths from heart disease (i.e., younger than 65 years of age) is greatest among American Indians or Alaska Natives and lowest among Caucasians.
A nursing student is performing a respiratory assessment on an adult client and is assessing for tactile fremitus. Which action by the nursing student indicates a need for further teaching?
1)Palpating over the lung apices in the supraclavicular area
2)Asking the client to repeat the word ninety-nine during palpation
3) Palpating over the breast tissue to assess and compare vibrations from one side to the other
4)Comparing vibrations from one side to the other as the client repeats the word ninety-nine
Palpating over the breast tissue to assess and compare vibrations from one side to the other
When assessing for tactile fremitus, the nurse would begin palpating over the lung apices in the supraclavicular area. The nurse would compare vibrations from one side to the other as the client repeats the word ninety-nine.
Client Needs: Health Promotion and Maintenance
Clinical Judgment/Cognitive Skill(s): Evaluate Outcomes
Cognitive Ability: Evaluating
Content Area: Health Assessment/Physical Exam: Thorax and Lungs
Integrated Process: Teaching and Learning
Priority Concepts: Clinical Judgment, Health Promotion
Strategies: Comparable or Alike Options, Negative Event Query, Strategic Words
During the abdominal examination, a nurse performs deep palpation in the left lower quadrant. At this point, the client reports pain. This test is positive for which sign?
1) Rovsing's
2) Obturator
3) Psoas
4) Murphy's
Rovsing’s sign involves pain caused by deep palpation in the left lower quadrant.
The obturator sign involves pain in the right lower quadrant as a result of the nurse flexing the client’s hip and rotating the leg externally and internally while supporting the client’s right knee and ankle.
Psoas sign involves pain in the right lower quadrant on hyperextension of the client’s right leg and indicates appendicitis.
Murphy’s sign is for assessment of cholecystitis and is elicited by pressing the fingers at the client’s right costal margin and telling the client to inhale.
A client cannot differentiate between sharp/dull pain sensations when a nurse tests with a safety pin. What is an appropriate action by the nurse?
1) Determine the ability to differentiate hot/cold temperatures
2) Try another object and test only the upper dermatomes
3) Determine the ability to differentiate hot/cold temperatures
If a client cannot correctly differentiate between sharp/dull pain sensations then the nurse should test for temperature sensation. Temperature and pain sensations travel in the lateral spinothalamic tract, so temperature is only tested if pain sensation is altered. If a client cannot feel pain, they are unlikely to feel a lighter touch. Striking a tuning fork and placing it on the top of one foot test vibratory sensation, not pain or touch.
Nurses weave the individualization of the client interview through all aspects of the encounter. The nurse should avoid assuming that clients follow cultural beliefs. In place of making this assumption, what should a nurse do?
1)Assess the degree to which the client perceives the cultural beliefs
2)Assess how acculturated the client is
3)Know the mores of the culture
4)Know his or her own cultural beliefs
Assess the degree to which the client perceives the cultural beliefs
The nurse should avoid assuming clients follow cultural beliefs and assess the degree to which each individual perceives those beliefs. Knowing the mores of the culture and the nurse's own cultural beliefs are important, but do not answer the question at hand. The nurse would have difficulty assessing how acculturated the client is within the client's cultural beliefs.
During chest auscultation, the nurse is assessing the client for the presence of a murmur of aortic regurgitation. How will the nurse proceed with the exam?
1) Ask the client to sit up, lean forward, and exhale.
2)Use the bell of the stethoscope and listen at the apex of the heart.
3)Ask the client to assume a left lateral position.
4)Have the client hold a deep breath and elevate the head of the bed 45 degrees.
Ask the client to sit up, lean forward, and exhale.
To assess for the presence of aortic regurgitation, the nurse will ask the client to sit up, lean forward, and exhale. The diaphragm of the stethoscope should be used instead of the bell. The left lateral position may be used to auscultate for an S3 or S4 heart sound or a murmur of mitral stenosis, not aortic regurgitation. The client should not hold a deep breath during the exam. Having the head of the bed elevated 45 degrees may be used for observing the jugular venous pulse, not for auscultating for aortic regurgitation.
A nurse assesses the respiration pattern on a client who arrives in the emergency department due to an overdose of narcotics. The nurse notes the respirations are decreased in rate and depth, and have an irregular pattern. How should the nurse document this finding?
1)Cheyne-Stokes respiration
2)Biot's respiration
3)Hypoventilation
4) Bradypnea
Hypoventilation
Hypoventilation is decreased rate, decreased depth, and irregular pattern of respiration. A client with regular pattern characterized by alternating periods of deep rapid breathing followed by periods of apnea has Cheyne-Stokes respiration. A client with irregular pattern characterized by varying depth and rate of respirations followed by periods of apnea has Biot's respiration. A client with bradypnea may have a regular respiration rate of less than 10/min.
What causes the characteristic features of coffee-ground emesis?
1)Digested blood
2) Decreased peristalsis
3) Active bleeding
4) Irritated intestinal lining
Coffee-ground emesis is digested blood; bloody emesis is an active bleed with undigested blood. Green emesis usually results from reduced peristalsis with irritation.
A 37-year-old insurance agent comes to the office with a report of trembling hands. She says that for the past 3 months when she tries to use her hands to fix her hair or cook they shake badly. She says she doesn't feel particularly nervous when this occurs, but she worries that other people will think she has an anxiety or alcohol disorder. She admits to having some recent fatigue, trouble with vision, and difficulty maintaining bladder control. Her past medical history is remarkable for hypothyroidism. Her mother has lupus and her father is healthy. She has an older brother with type 1 diabetes. She is married with three children. She denies tobacco, alcohol, or drug use. On examination, when she tries to reach for a pencil to fill out the health form, she has obvious tremors in her dominant hand. What type of tremor is most likely?
1) Intention tremor
2) Postural tremor
3) Resting tremor
Intention tremors are absent at rest or in a postural position and only occur with intentional movement of the hands. This is seen in cerebellar disease (stroke or alcohol use) or in multiple sclerosis. This client's tremor, fatigue, bladder problems, and visual problems suggest multiple sclerosis.
A 34-year-old man has come to the clinic to establish care. His chief complaint is that “my skin feels sour, so sour” and he fidgets continuously during the interview. How should the clinician best respond to this statement?
1)Initiate a focused integumentary assessment.
2)Tell the client that the clinician has concerns regarding the client's cognition and orientation.
3)Redirect the conversation to include components of a mental status examination.
4)Explain to the client that his complaint is phrased in an unusual way and that the clinician wants to assess for neurological health problems.
Redirect the conversation to include components of a mental status examination.
A bizarre description of a problem may prompt suspicions of a neurological or psychiatric health problem and is best addressed by steering the interview toward a mental status assessment.
Which characteristic of the apical pulse should a nurse expect to find in the client diagnosed with left ventricular hypertrophy?
1)Displaced
2)Diminished
3)Bounding
4)Normal
Displaced
The nurse should expect to find a displaced apical pulse for a client with left ventricular hypertrophy. In ventricular hypertrophy, the apical pulse may be larger than 1 to 2 cm, displaced, more forceful, or of longer duration. Bounding apical pulse is not a characteristic of ventricular hypertrophy.
A 37-year-old man presents at the emergency department complaining that he is having trouble breathing. What would the nurse prioritize in this client's acute assessment
1) Inspecting the oral mucosa
2)Performing full lung function testing
3) Assessing oral temperature
4) Assessing pulse
Pulse
If a client has acute shortness of breath, immediately assess respiratory and pulse rates, blood pressure, and oxygen saturation.
A client is admitted to a health care facility with new onset of abdominal pain, fatigue, and low back pain. The client relates a 10-year history of high blood pressure. When auscultating the client's abdomen for bowel sounds, what other assessment should the nurse perform at this time?
1) Inspect the abdomen for color, shape, and symmetry
2) Obtain a complete set of vital signs and pain assessment
3) Listen with the bell of the stethoscope for vascular sounds
4) Observe for evidence of increased abdominal girth
3) Listen with the bell of the stethoscope for vascular sounds
A client with a history of hypertension is at risk for bruits over any of the vascular areas on the abdomen such as renal artery, iliac artery, or femoral artery. The bell of the stethoscope is used for this assessment since bruits are low-pitched murmur-like sounds. Inspection of the abdomen should be performed before auscultation. Vital signs are part of the general survey and are usually the first hands on assessment of a client. measuring abdominal girth is done if the nurse observes a distended abdomen or there are other signs of fluid retention within the abdomen.
A client is admitted to the health care facility with new onset of right-sided paralysis, slurred speech, and lethargy. A nurse obtains in the history that the client has uncontrolled hypertension and smokes 2 packs of cigarettes a day. Which nursing diagnosis is priority for the client upon admission?
1) Risk for Aspiration
2) Unilateral Neglect
3) Impaired Verbal Communication
4) Risk for Altered Skin Integrity
Due to the client's decreased mental status and slurred speech, he is at greatest risk for aspiration. Measures must be implemented by the nurse to prevent aspiration, such as NPO, elevating the head of bed, and assessment of lung sounds. Impaired Verbal Communication is a psychosocial issue, and physiologic problems take precedence over mental health at this point in time. Unilateral neglect is not as much of a priority as is the risk for aspiration. There is no indication that there is a risk for altered skin integrity.