Exam 7: Health Assessment

The nurse assesses the oral mucosa for pathological color changes.Which finding does the nurse expect to see in the patient's mouth,and why does the nurse expect to find it?

The nurse assesses an adult patient with a cardiopulmonary illness and hears a grating sound over the lower lateral lung during inspiration that does not clear with coughing.What would the nurse most likely document as a result of the assessment findings?

The nurse is preparing to auscultate the pulmonic area.At which site should the nurse place the stethoscope?

The nurse assesses the adult patient's spine.Which expected finding does the nurse identify about the patient's alignment and posture?

The nurse observes yellow sclerae while assessing the patient's eyes.What does the nurse look for to validate this finding?

The nurse is listening to the patient's lungs.Which information should the nurse use to document normal patient lung sounds?

The school nurse alerts parents to observe for chickenpox.Which clinical indicator does the nurse instruct the parents to observe for chickenpox?

How often should the nurse perform a general assessment of the patient?

The patient has an irregular,elevated,localized area of edema on the left forearm.Which term should the nurse use when documenting?

The nurse documents the patient's swollen lower extremities and measures the depth of a 4-mm indentation made 1 minute ago.Which is the best description for the nurse to use to describe the patient's lower extremities?

The nurse assesses the patient with altered musculoskeletal function.Which is the best reason supporting the nurse's motive for asking probing questions?

The nurse is performing a neuromuscular assessment.Which method should the nurse use to evaluate muscle strength?

A male patient with back pain asks why the nurse needs so many details about his history.What is the most effective response by the nurse?

The nurse is performing a cardiovascular assessment at the fifth intercostal space at the midclavicular line.What would the nurse be attempting to check?

The nurse assesses the patient's lungs to find high-pitched musical sounds on inspiration and expiration.Which description does the nurse use to document the findings?

The nurse is performing a neurological assessment.Which patient behaviors demonstrate a level of consciousness within normal limits?

A patient has the following intake: a cup of oatmeal,a half cup of ice,3 ounces of apple juice,and 6 ounces of coffee.What is the total intake the nurse should document on the intake portion?

The nurse begins to assess the patient's respiratory system.Which assessment by the nurse best determines the patient's diaphragmatic excursion?

The nurse is assessing an older patient and finds the heart rate to be 62 and irregular.Suddenly the patient complains of dizziness and "feeling faint." Which action should the nurse take next?

The nurse is teaching a nursing student the correct technique for assessing an apical pulse.Which method when used by the student demonstrates she knows the correct location to take an adult patient's apical pulse?