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Questions and Answers
What is the most appropriate action for assessing the femoral pulse in an obese patient?
What is the most appropriate action for assessing the femoral pulse in an obese patient?
- Ask the patient to bend his or her knees to the side in a froglike position. (correct)
- Have the patient assume a prone position.
- Press firmly against the bone with the patient in a semi-Fowler position.
- Listen with a stethoscope for pulsations because it is very difficult to palpate the pulse in an obese person.
What sound indicates arterial flow when using a Doppler ultrasonic stethoscope?
What sound indicates arterial flow when using a Doppler ultrasonic stethoscope?
- Swishing, whooshing sound (correct)
- Steady, even, flowing sound
- Low humming sound
- Regular 'lub, dub' pattern
What does a '2+' reading of the radial pulse indicate?
What does a '2+' reading of the radial pulse indicate?
- Normal (correct)
- Weak
- Absent
- Bounding
Which statement best describes the purpose of a functional assessment?
Which statement best describes the purpose of a functional assessment?
During a functional assessment on an 82-year-old patient who recently had a stroke, which question would be most important to ask?
During a functional assessment on an 82-year-old patient who recently had a stroke, which question would be most important to ask?
Which questions are appropriate to ask the parents during a developmental history for a 5-year-old child? (Select all that apply)
Which questions are appropriate to ask the parents during a developmental history for a 5-year-old child? (Select all that apply)
During an examination, the nurse can assess mental status by which activity?
During an examination, the nurse can assess mental status by which activity?
As the nurse begins the mental status portion of an assessment on a 75-year-old man, what should the nurse expect?
As the nurse begins the mental status portion of an assessment on a 75-year-old man, what should the nurse expect?
Which statement is true regarding the mental status examination?
Which statement is true regarding the mental status examination?
Which question should the nurse ask to assess a patient's affect during a mental status examination?
Which question should the nurse ask to assess a patient's affect during a mental status examination?
Which question by the nurse best assesses a person's judgment during a mental status assessment?
Which question by the nurse best assesses a person's judgment during a mental status assessment?
Which statement about the assessment of mental status is true?
Which statement about the assessment of mental status is true?
When performing a physical assessment, which technique will the nurse always use first?
When performing a physical assessment, which technique will the nurse always use first?
What is the best technique to assess a patient's skin temperature?
What is the best technique to assess a patient's skin temperature?
How should the nurse proceed when preparing to assess a patient's abdomen by palpation?
How should the nurse proceed when preparing to assess a patient's abdomen by palpation?
In which situation would the nurse use bimanual palpation technique?
In which situation would the nurse use bimanual palpation technique?
When percussing over the liver, a nurse notices a dull sound. What should the nurse consider?
When percussing over the liver, a nurse notices a dull sound. What should the nurse consider?
What is the best action if the nurse is unable to palpate the right radial pulse on a patient?
What is the best action if the nurse is unable to palpate the right radial pulse on a patient?
Which statement describes the most appropriate action a nurse should take when performing a physical examination?
Which statement describes the most appropriate action a nurse should take when performing a physical examination?
When should the nurse elicit the Moro reflex during an infant examination?
When should the nurse elicit the Moro reflex during an infant examination?
What should the nurse do first when examining a 6-month-old infant who is sleeping?
What should the nurse do first when examining a 6-month-old infant who is sleeping?
Which assessment findings would be considered normal for an 80-year-old male patient?
Which assessment findings would be considered normal for an 80-year-old male patient?
Regarding the strength of a pulse, the nurse recalls that it:
Regarding the strength of a pulse, the nurse recalls that it:
Which question should the nurse ask to assess the quality of a patient's pain?
Which question should the nurse ask to assess the quality of a patient's pain?
What concern exists regarding the nutritional status of a 68-year-old woman complaining of constipation?
What concern exists regarding the nutritional status of a 68-year-old woman complaining of constipation?
Why is it important for the nurse to ask a patient about medications during a nutritional assessment?
Why is it important for the nurse to ask a patient about medications during a nutritional assessment?
Which factor is most likely to affect the nutritional status of an elderly person?
Which factor is most likely to affect the nutritional status of an elderly person?
What type of hearing loss occurs with aging?
What type of hearing loss occurs with aging?
What symptom indicates tinnitus?
What symptom indicates tinnitus?
Which changes in hearing occur with aging? (Select all that apply)
Which changes in hearing occur with aging? (Select all that apply)
The left lung consists of how many lobes?
The left lung consists of how many lobes?
What are expected assessment findings in a normal adult lung? (Select all that apply)
What are expected assessment findings in a normal adult lung? (Select all that apply)
What should the nurse assess for when a patient reports being awakened from sleep with shortness of breath?
What should the nurse assess for when a patient reports being awakened from sleep with shortness of breath?
Where is tactile fremitus felt most intensely?
Where is tactile fremitus felt most intensely?
What causes tactile fremitus?
What causes tactile fremitus?
Which statement is true regarding note-taking during an interview?
Which statement is true regarding note-taking during an interview?
What type of breath sounds are normally heard over the posterior lower lobes?
What type of breath sounds are normally heard over the posterior lower lobes?
What does dullness in percussion indicate?
What does dullness in percussion indicate?
Which verbal skill is used when the nurse states, 'You mentioned shortness of breath. Tell me more about that'?
Which verbal skill is used when the nurse states, 'You mentioned shortness of breath. Tell me more about that'?
The question, 'You don't smoke, drink, or take drugs, do you?' is an example of:
The question, 'You don't smoke, drink, or take drugs, do you?' is an example of:
What indicates fine crackles in auscultation?
What indicates fine crackles in auscultation?
If bronchophony is present, what condition should the nurse assess for?
If bronchophony is present, what condition should the nurse assess for?
What does a change in a parent's posture from an open position to a closed position suggest?
What does a change in a parent's posture from an open position to a closed position suggest?
What technique would be most beneficial in communicating with a patient with a hearing impairment?
What technique would be most beneficial in communicating with a patient with a hearing impairment?
What adventitious sound is produced by air passing through narrowed bronchioles?
What adventitious sound is produced by air passing through narrowed bronchioles?
Which interpreter choice is the most appropriate for a female patient who does not speak English well?
Which interpreter choice is the most appropriate for a female patient who does not speak English well?
What indicates asthma based on assessment findings?
What indicates asthma based on assessment findings?
Which statements regarding open-ended questions are true? (Select all that apply)
Which statements regarding open-ended questions are true? (Select all that apply)
How should a nurse auscultate breath sounds?
How should a nurse auscultate breath sounds?
What is the best use of a computer during an interview in an outpatient clinic?
What is the best use of a computer during an interview in an outpatient clinic?
What does the coarse, crackling sensation over the skin indicate?
What does the coarse, crackling sensation over the skin indicate?
What indicates atelectatic crackles?
What indicates atelectatic crackles?
What action is appropriate when the nurse notices a patient handling a small charm?
What action is appropriate when the nurse notices a patient handling a small charm?
How do many Mexican-Americans perceive coughing, sweating, and diarrhea?
How do many Mexican-Americans perceive coughing, sweating, and diarrhea?
Which normal finding indicates that voice sounds are muffled during assessment?
Which normal finding indicates that voice sounds are muffled during assessment?
What does a blowing, swishing sound over the carotid artery indicate?
What does a blowing, swishing sound over the carotid artery indicate?
In Asian cultures, what does the yin/yang theory reflect?
In Asian cultures, what does the yin/yang theory reflect?
What is the likely belief of an individual with a magicoreligious perspective on illness?
What is the likely belief of an individual with a magicoreligious perspective on illness?
Where is the apical impulse normally palpated?
Where is the apical impulse normally palpated?
What is the correct technique for auscultating heart sounds?
What is the correct technique for auscultating heart sounds?
When seeking help with diabetes, what might an American Indian consider?
When seeking help with diabetes, what might an American Indian consider?
What would a culturally sensitive nurse do for a Mexican-American woman with traditional beliefs?
What would a culturally sensitive nurse do for a Mexican-American woman with traditional beliefs?
Regarding the apical impulse, which statement is true?
Regarding the apical impulse, which statement is true?
Which statement is true regarding pain?
Which statement is true regarding pain?
What normal physiologic change is associated with aging?
What normal physiologic change is associated with aging?
What does the 'profile sign' help detect?
What does the 'profile sign' help detect?
Why might working with children from different cultural perspectives be challenging?
Why might working with children from different cultural perspectives be challenging?
If the ulnar pulses are not palpable but capillary refill is normal, what should the nurse do next?
If the ulnar pulses are not palpable but capillary refill is normal, what should the nurse do next?
What is the most appropriate question to assess cultural beliefs with an elderly American Indian patient?
What is the most appropriate question to assess cultural beliefs with an elderly American Indian patient?
What component should be included in a cultural assessment?
What component should be included in a cultural assessment?
When evaluating the reliability of a patient's responses, which statement is correct?
When evaluating the reliability of a patient's responses, which statement is correct?
What note would be most accurate for a patient denying childhood illnesses?
What note would be most accurate for a patient denying childhood illnesses?
What would be an appropriate response to a mother regarding her child's earache?
What would be an appropriate response to a mother regarding her child's earache?
What information should the nurse collect before a 5-year-old's tonsil procedure?
What information should the nurse collect before a 5-year-old's tonsil procedure?
When evaluating the mid-upper arm circumference and triceps skinfold of an 82-year-old man, which is important for the nurse to remember?
When evaluating the mid-upper arm circumference and triceps skinfold of an 82-year-old man, which is important for the nurse to remember?
The nurse needs to perform anthropometric measures of an 80-year-old man who is confined to a wheelchair. Which of the following is true?
The nurse needs to perform anthropometric measures of an 80-year-old man who is confined to a wheelchair. Which of the following is true?
The nurse is performing a nutritional assessment on an 80-year-old patient. The nurse knows that physiological changes that directly affect the nutritional status of the elderly include:
The nurse is performing a nutritional assessment on an 80-year-old patient. The nurse knows that physiological changes that directly affect the nutritional status of the elderly include:
The nurse keeps in mind that a thorough skin assessment is very important because the skin holds information about a person's:
The nurse keeps in mind that a thorough skin assessment is very important because the skin holds information about a person's:
A patient tells the nurse that he has noticed that one of his moles has started to burn and bleed. What additional finding would the nurse be concerned with?
A patient tells the nurse that he has noticed that one of his moles has started to burn and bleed. What additional finding would the nurse be concerned with?
An elderly woman is brought to the emergency department after being found lying on the kitchen floor for 2 days, and she is extremely dehydrated. What would the nurse expect to see upon examination?
An elderly woman is brought to the emergency department after being found lying on the kitchen floor for 2 days, and she is extremely dehydrated. What would the nurse expect to see upon examination?
A 65-year-old man with emphysema and bronchitis has come to the clinic for a follow-up appointment. On assessment, the nurse might expect to see which assessment finding?
A 65-year-old man with emphysema and bronchitis has come to the clinic for a follow-up appointment. On assessment, the nurse might expect to see which assessment finding?
The nurse has discovered decreased skin turgor in a patient. This is an expected finding in which of these conditions?
The nurse has discovered decreased skin turgor in a patient. This is an expected finding in which of these conditions?
A 40-year-old woman reports a change in mole size, accompanied by color changes, itching, burning, and bleeding over the past month. The nurse would:
A 40-year-old woman reports a change in mole size, accompanied by color changes, itching, burning, and bleeding over the past month. The nurse would:
The nurse is assessing for clubbing of the fingernails and would expect to find:
The nurse is assessing for clubbing of the fingernails and would expect to find:
A patient has been admitted for severe psoriasis. The nurse can expect to see what finding in the patient's fingernails?
A patient has been admitted for severe psoriasis. The nurse can expect to see what finding in the patient's fingernails?
The nurse suspects that a patient has hyperthyroidism and laboratory data indicate that the patient's thyroxine and tri-iodothyronine hormone levels are elevated. Which of these findings would the nurse most likely find on examination?
The nurse suspects that a patient has hyperthyroidism and laboratory data indicate that the patient's thyroxine and tri-iodothyronine hormone levels are elevated. Which of these findings would the nurse most likely find on examination?
During an examination, what assessment finding would Paget's disease indicate?
During an examination, what assessment finding would Paget's disease indicate?
A woman comes to the clinic with puffy eyes, coarse dry hair and eyebrows. The nurse will assess for signs of:
A woman comes to the clinic with puffy eyes, coarse dry hair and eyebrows. The nurse will assess for signs of:
The physician reports that a patient with a neck tumor has a tracheal shift. What does this indicate?
The physician reports that a patient with a neck tumor has a tracheal shift. What does this indicate?
During an assessment of an infant, the nurse notes that the fontanels are depressed and sunken. What condition does this suggest?
During an assessment of an infant, the nurse notes that the fontanels are depressed and sunken. What condition does this suggest?
The nurse is performing an assessment on a 7-year-old child with symptoms of chronic allergies. What characteristic findings might be observed?
The nurse is performing an assessment on a 7-year-old child with symptoms of chronic allergies. What characteristic findings might be observed?
A mother asks when her newborn infant's eyesight will be developed. What should the nurse reply?
A mother asks when her newborn infant's eyesight will be developed. What should the nurse reply?
During an eye assessment on an 80-year-old patient, which finding is considered abnormal?
During an eye assessment on an 80-year-old patient, which finding is considered abnormal?
The nurse notices periorbital edema when assessing a 70-year-old patient. What should the nurse do next?
The nurse notices periorbital edema when assessing a 70-year-old patient. What should the nurse do next?
After a boxing match, a patient presents with a swollen eye and concerns about possible retinal damage. What are signs of retinal detachment?
After a boxing match, a patient presents with a swollen eye and concerns about possible retinal damage. What are signs of retinal detachment?
A 68-year-old woman struggles with reading and has some loss of central vision. What does this suggest?
A 68-year-old woman struggles with reading and has some loss of central vision. What does this suggest?
An ophthalmic examination reveals papilledema. What does this finding indicate?
An ophthalmic examination reveals papilledema. What does this finding indicate?
During an examination, a patient states she was diagnosed with open-angle glaucoma 2 years ago. Which characteristics should the nurse assess?
During an examination, a patient states she was diagnosed with open-angle glaucoma 2 years ago. Which characteristics should the nurse assess?
The nurse is taking the history of a patient who may have a perforated eardrum. What is an important question to ask?
The nurse is taking the history of a patient who may have a perforated eardrum. What is an important question to ask?
During an ear examination of an 80-year-old patient, which finding would be considered normal?
During an ear examination of an 80-year-old patient, which finding would be considered normal?
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Study Notes
Note-Taking in Nursing Interviews
- Note-taking can disrupt the observation of patients' nonverbal cues and their narrative flow.
- It is important to maintain eye contact and focus on the patient to enhance their sense of importance.
Verbal Skills in Health Assessments
- Open-ended questions are used to encourage detailed responses from patients about specific issues, facilitating in-depth exploration of topics.
Question Bias in Health History
- Leading questions can influence patient responses, potentially forcing them to conform to perceived expectations.
Nonverbal Cues in Parent-Child Interviews
- Changes in posture, such as crossing arms, may indicate discomfort with the topic being discussed, signaling a need for sensitivity in the conversation.
Communicating with Hearing-Impaired Patients
- It's essential to understand preferred communication methods, such as sign language or lip reading, to ensure effective interaction.
Language Barriers in Assessments
- Utilize simple language free from medical jargon when questioning patients with language barriers, focusing on direct and clear inquiries.
Choosing an Interpreter
- Prioritize trained interpreters who are familiar with medical terminology for effective communication with patients who have language difficulties.
Utilization of Open-Ended Questions
- Open-ended questions enhance patient self-expression and build rapport, leading to richer narrative responses.
Efficient Use of Technology in Interviews
- Data should be recorded after fully exploring a patient’s narrative to avoid distractions and maintain engagement; the patient should be able to see the monitor to promote transparency.
Cultural Significance of Personal Items
- Inquire about meaningful objects, like charms, to understand their cultural significance and enhance the therapeutic relationship.
Cultural Perspectives on Health
- Recognize that beliefs about symptoms may differ across cultures, with some viewing certain symptoms as normal rather than indicative of illness.
Yin/Yang Beliefs and Health
- Health in cultures embracing the yin/yang philosophy is perceived as a balance of all aspects of life, focusing on holistic well-being.
Magicoreligious Perspective on Illness
- Illness is often viewed as a consequence of supernatural forces rather than biological factors.
Seeking Holistic Healing
- Patients from diverse cultural backgrounds may seek additional support from traditional healers, highlighting the need for culturally competent care.
Culturally Sensitive Nursing
- Assess cultural beliefs of patients, respecting their preferences for spiritual and traditional healing methods in conjunction with biomedical care.
Variability in Pain Perception
- Pain expression varies by culture; nurses should anticipate different responses based on individual and cultural backgrounds.
Spiritual Needs in Children
- Children’s spiritual needs are influenced by their developmental stages and family context, necessitating sensitive handling during health assessments.
Initiating Cultural Assessments
- Open-ended questions about spiritual beliefs facilitate a better understanding of the cultural context that shapes a patient's health perspectives.
Components of Cultural Assessment
- Include health-related beliefs and practices as key components in a cultural assessment to personalize patient care.
Evaluating Patient Reliability
- A patient is deemed reliable if they consistently provide information, emphasizing the importance of careful evaluation in nursing assessments.
Documenting Childhood Illnesses Accurately
- Ensure accurate documentation of past illnesses by specifically naming conditions to avoid ambiguity in patient history.
Addressing Pain in Children
- Engage parents to describe signs of pain in very young children to obtain accurate assessments before clinical examination.
Preoperative Assessments in Pediatric Patients
- Reactions to past hospitalizations are crucial to tailor preparatory interventions for children undergoing procedures.
Purpose of Functional Assessments
- Functional assessments focus on how well individuals manage daily life, aiding in identification of support needs and care planning.
Importance of Daily Activities Assessment in Elderly
- Questions about daily activities, such as dressing, are vital in evaluating functional independence, especially after health events like strokes.
Developmental History in Pediatric Assessments
- Collecting appropriate developmental history aids in evaluating childhood milestones and identifying potential concerns.### Developmental Assessment Questions
- Appropriate developmental questions include abilities like tying shoelaces and telling time.
- Nutritional-related questions cover junk food intake and vitamins; food allergies are not part of developmental history.
Mental Status Assessment Techniques
- Mental status is assessed by observing behaviors, not direct examination like physical signs.
- Age does not significantly affect general knowledge, but response time does slow.
- Basic mental status information is often adequately gathered during health history interviews.
Assessing Affect and Judgment
- To assess affect, asking "How do you feel today?" is effective.
- Assessing judgment can be done by inquiring about future plans post-discharge.
Overall Mental Status Examination
- Full mental status examinations may not be necessary; context from health history is often sufficient.
- A dull sound during liver percussion is considered normal.
- The best technique to check skin temperature is the dorsal surface of the hand.
Palpation Techniques
- Light palpation should be done first during abdominal assessments.
- Bimanual palpation is appropriate for kidneys and uterus, while general tenderness should be evaluated last.
Safety and Infection Control
- Hand washing is crucial before and after every patient interaction to prevent infection transmission.
Examination of Infants
- The Moro reflex should be elicited at the examination's end as it may distress the infant.
- Auscultation of respiratory systems is best done while the infant is asleep.
Aging and Nutritional Assessment
- Kyphosis and knee/hip flexion are normal postural changes in the elderly.
- Living alone on a fixed income impacts elderly nutritional status.
Anthropometric Measurements
- Weight measures may be hard to interpret in older adults due to varied normal ranges.
- Accurate height measurements might be challenging in elderly patients due to osteoporosis.
Physiological Changes in the Elderly
- Slowed gastrointestinal motility significantly affects nutritional status.
- Changes in skin may provide insights into circulatory status.
Skin Assessment and Danger Signs
- Important signs for pigmented lesions include asymmetry, border irregularity, color variation, and diameter over 6 mm.
- A patient with a bleeding, burning mole should raise concerns regarding color variation.
Emergency Situations
- In cases of extreme dehydration in elderly patients, thorough skin assessment is vital for identifying circulatory issues.### Dehydration and Mucous Membranes
- Dry mucous membranes and cracked lips are signs of dehydration.
- Dehydration results in parched lips and dry mucous membranes.
Clubbing of Nails
- Clubbing of the nails is associated with pulmonary diseases, including emphysema and bronchitis.
- The nail base feels spongy, with an angle of 180 degrees or greater, indicating clubbing.
Skin Turgor
- Decreased skin turgor is typically an expected finding in severe dehydration.
- Severe weight loss can also result in decreased skin turgor.
Suspected Melanoma
- Changes in a mole’s size, color, or texture, including itching, burning, and bleeding, warrant suspicion of melanoma.
- The ABCD criteria for melanoma: Asymmetry, Border irregularity, Color variation, Diameter changes.
Assessment Findings for Various Conditions
- Decreased skin turgor indicates severe dehydration.
- Paget's disease may result in symptoms such as headache, vertigo, tinnitus, and deafness.
- Myxedema, associated with hypothyroidism, leads to puffiness and coarse hair.
Tracheal Shift
- A tracheal shift to the unaffected side can indicate conditions like an aortic aneurysm, tumor, or pneumothorax.
Depressed Fontanels in Infants
- Depressed and sunken fontanels suggest dehydration, not rickets or increased intracranial pressure.
Chronic Allergy Symptoms
- Chronic allergies may show signs like a transverse nasal crease, dark shadows under the eyes, and changes in eyelid creasing.
Infant Eye Development
- By 3 months, infants typically develop coordinated eye movements and can fixate on objects.
Normal Findings in Aging Eyes
- Unequal pupillary responses to light in an elderly patient is abnormal; constriction should still be symmetric.
Periorbital Edema
- Periorbital edema in older adults may indicate systemic issues such as heart failure or renal failures, rather than infections like blepharitis.
Retinal Detachment Signs
- Shadowing or diminished vision, particularly in one quadrant, indicates potential retinal detachment.
Macular Degeneration Indicators
- Loss of central vision with intact peripheral vision suggests the possibility of macular degeneration, a common cause of blindness.
Papilledema
- Papilledema is indicative of increased intracranial pressure; it’s characterized by optic disc elevation and blurred margins.
Open-Angle Glaucoma Characteristics
- Open-angle glaucoma typically has few symptoms; vision loss begins in peripheral vision and can lead to tunnel vision in late stages.
Perforated Eardrum Inquiry
- Assessing the relationship between ear pain and discharge is crucial for diagnosing a suspected perforated eardrum.
Normal Ear Examination Findings in Older Adults
- High-tone frequency loss is common in older adults; the eardrum may appear thicker and more opaque with age.
Tinnitus Recognition
- Tinnitus is the perception of ringing, buzzing, or crackling sounds in the ears, often associated with ear disorders.
Tactile Fremitus Assessment
- Tactile fremitus should feel most intense between the scapulae; pronounced alternate findings over the lung fields may indicate underlying issues.
Palpable Vibrations
- Tactile fremitus results from sounds from the larynx transmitted through the lungs to the chest wall; it is a clinical indicator of lung health.
Vesicular Breath Sounds
- Normal lung assessment reveals vesicular breath sounds over the posterior lower lobes, characterized by low-pitched, softer sounds with longer inspiration.
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