Essential Components of Nursing Care
5. Identifying responses to care, compar- ing actual outcomes to expected out-
comes, analyzing factors that affected outcomes, and modifying the plan of care if necessary are all part of the Evaluation step of the Nursing Process.
CHAPTER4 NURSINGPROCESS 165
2779_Ch04_155-230.qxd 8/10/11 5:54 PM Page 165
Physical Assessment
KEYWORDS
The following words include nursing/medical terminology, concepts, principles, and information relevant to content specifically addressed in the chapter or associated with topics presented in it.
English dictionaries, nursing textbooks, and medical dictionaries, such as Taber’s Cyclopedic Med- ical Dictionary, are resources that can be used to expand your knowledge and understanding of these words and related information.
Afebrile Asymptomatic
Autonomic nervous system Barrel chest
Blood pressure:
Auscultatory gap Korotkoff’s sounds Pulse pressure Systolic/diastolic Body weight
Borborygmi (bowel sounds) Breathing:
Costal (thoracic)
Diaphragmatic (abdominal) Patterns:
Biot
Cheyne-Stokes Eupnea Kussmaul Rate:
Apnea Bradypnea Tachypnea Breath sounds:
Adventitious:
Crackles (rales) Gurgles (rhonchi) Pleural friction rub Stridor
Wheeze Expected:
Bronchial Bronchovesicular Vesicular Capillary refill
Circadian rhythms, Diurnal variations Clubbing
Cognitive impairment:
Confusion Delirium
Data:
Objective, Subjective Primary source of Secondary source of Ecchymosis
Edema:
Dependent Sacral Erythema Exacerbation
Fever (pyrexia), stages of:
Onset (chill) Course (plateau)
Defervescence (flush, fever abatement) General Adaptation Syndrome
Heart rate:
Bradycardia
Irregular rhythm (dysrhythmia) Pulse deficit
Tachycardia Hirsutism Hyperemia Hypertension Hypotension Hypovolemic shock Jaundice
Lesions Lethargy
Level of consciousness Local Adaptation Syndrome Malaise
Memory:
Long term Short term Mental status Mobility:
Balance Gait Posture Strength 2779_Ch04_155-230.qxd 8/10/11 5:54 PM Page 166
CHAPTER4 PHYSICALASSESSMENT 167 Neurovascular assessment
Orientation to time, place, person Orthostatic hypotension
Pain assessment scales:
Numerical scales
Wong-Baker FACES Rating Scale Parasympathetic nervous system Physical assessment:
Auscultation Inspection Palpation Percussion Pruritus Pulse sites:
Apical Brachial Carotid
Femoral Pedal Popliteal Posterior tibial Temporal Tibial Remission Shivering
Sympathetic nervous system Tremor
Temperature sites:
Axillary Oral Rectal Tympanic Turgor Urticaria
QUESTIONS
1. The nurse is assessing a patient’s bilateral pulses for symmetry. Which pulse site should not be assessed on both sides of the body at the same time?
1. Radial 2. Carotid 3. Femoral 4. Brachial
2. A nurse is caring for a patient who is experiencing an increase in signs and symptoms associated with multiple sclerosis. Which term best describes a recurrence of signs and symptoms associated with a chronic disease?
1. Variance 2. Remission 3. Adaptation 4. Exacerbation
3. A nurse in the clinic must obtain the vital signs of each patient before being assessed by the practitioner. Which characteristic indicates that the nurse should take the patient’s temperature via the rectal route?
1. Mouth breather 2. History of vomiting
3. Intolerance of the semi-Fowler position 4. Seven-year-old child level of intelligence
4. A patient with hypertension is given discharge instructions to take the blood pressure every day. The nurse is evaluating a family member taking the patient’s blood pressure as part of the patient’s discharge teaching plan. Which behavior indicates to the nurse that the family member needs additional teaching?
1. Places the diaphragm of the stethoscope over the brachial artery 2. Applies the center of the bladder of the cuff directly over an artery
3. Releases the valve on the manometer so that the gauge drops 10 mm Hg per heartbeat
4. Inserts the 2 earpieces of the stethoscope into the ears so that they tilt slightly forward
2779_Ch04_155-230.qxd 8/10/11 5:54 PM Page 167
5. A patient has a serious vitamin K deficiency. For which clinical manifestation should the nurse assess this patient?
1. Bone pain 2. Skin lesions 3. Bleeding gums 4. Muscle weakness
6. The nurse identifies that a patient with a fever has warm skin. What is an additional sign that confirms the defervescence (flush) phase of a fever?
1. Sweating 2. Shivering
3. Cyanotic nail beds 4. Goosebumps on the skin
7. When evaluating the vital signs of a group of patients the nurse takes into considera- tion the circadian rhythm of body temperature. At what time of day is body tempera- ture usually at its lowest?
1. 4 PM–6 PM 2. 4 AM–6 AM 3. 8 PM–10 PM 4. 8 AM–10 AM
8. Which method of examination is being used when the nurse’s hands are used to assess the temperature of a patient’s skin?
1. Palpation 2. Inspection 3. Percussion 4. Observation
9. The nurse must assess for the presence of bowel sounds in a postoperative patient.
The nurse should auscultate the patient’s abdomen:
1. For several minutes in each quadrant 2. Starting at the left lower quadrant 3. Using a warmed stethoscope 4. Before palpation
10. Which assessment requires the nurse to assess the patient further?
1. 18-year-old woman with a pulse rate of 140 after riding 2 miles on an exercise bike
2. 50-year-old man with a BP of 112/60 on awakening in the morning 3. 65-year-old man with a respiratory rate of 10
4. 40-year-old woman with a pulse of 88
11. The nurse is interviewing a newly admitted patient. Which patient statement indicates the onset of a fever? “I feel:
1. Cold.”
2. Warm.”
3. Sweaty.”
4. Thirsty.”
12. The nurse is monitoring the status of postoperative patients. Which vital sign that changes first indicates that a postoperative patient has internal bleeding?
1. Body temperature 2. Blood pressure 3. Pulse pressure 4. Heart rate
168 FUNDAMENTALSSUCCESS: A Q & A REVIEWAPPLYINGCRITICALTHINKING TOTESTTAKING 2779_Ch04_155-230.qxd 8/10/11 5:54 PM Page 168
13. A patient has had a 101°F fever for the past 24 hours. How often should the nurse monitor this patient’s temperature?
1. Every 2 hours 2. Every 4 hours 3. Every 6 hours 4. Every 8 hours
14. The nurse is unable to palpate a patient’s brachial pulse. Which pulse should the nurse assess to determine adequate brachial blood flow in this patient?
1. Radial 2. Carotid 3. Femoral 4. Popliteal
15. Which of the following can cause urine to appear red?
1. Beets 2. Strawberries 3. Cherry Jell-O 4. Red food dye
16. The nurse is assessing a patient’s heart rate by palpating the carotid artery. What is the most important thing the nurse should do when assessing a pulse at this site?
1. Monitor for a full minute 2. Palpate just below the ear
3. Press gently when palpating the site 4. Massage the site before assessing for rate
17. The nurse obtains the blood pressure of several adults. What blood pressure result causes the most concern?
1. 102/70 2. 140/90 3. 125/85 4. 118/75
18. The nurse is planning care for a patient who has an intolerance to activity. What is the first assessment that should be made by the nurse?
1. Range of motion 2. Pattern of vital signs
3. Impact on functional health patterns 4. Influence on the other family members
19. The nurse concludes that a patient has inadequate nutrition. Which patient adaptation supports this conclusion?
1. Presence of surface papillae on the tongue 2. Reddish-pink mucous membranes
3. Cachectic appearance 4. Shiny eyes
20. The nurse must take a patient’s rectal temperature. What should the nurse do?
1. Take the temperature for 5 minutes 2. Wear gloves throughout the procedure 3. Place the patient in the right lateral position 4. Insert the thermometer 2 inches into the rectum
21. Which usually is unrelated to a nursing physical assessment?
1. Posture and gait 2. Balance and strength 3. Hygiene and grooming 4. Blood and urine values
CHAPTER4 PHYSICALASSESSMENT 169
2779_Ch04_155-230.qxd 8/10/11 5:54 PM Page 169
22. The patient has a temperature of 102°F and reports feeling thirsty. Which additional sign should the nurse expect during the febrile stage of a fever?
1. Restlessness with confusion 2. Decreased respiratory rate 3. Profuse perspiration 4. Pale, cold skin
23. The nurse is performing a psychosocial assessment. Which assessment should be identified as a subtle indicator of depression?
1. Unkempt appearance 2. Anxious behavior 3. Tense posture 4. Crying
24. The nurse in the emergency department is caring for a patient who is diagnosed with hypothermia. The presence of which factor in the patient’s history may have precipitated this condition?
1. Heat stroke 2. Inability to sweat 3. Excessive exercise 4. High alcohol intake
25. A patient has lost approximately 2 units of blood during a vaginal delivery. For which response to this blood loss should the nurse assess this patient?
1. Increased urinary output 2. Rapid, shallow breathing 3. Hypertension
4. Bradypnea
26. Which is common to the collection of specimens for culture and sensitivity tests regardless of their source?
1. A preservative media must be used 2. Two specimens should be obtained 3. Surgical asepsis must be maintained 4. A morning specimen should be collected
27. A patient’s vital signs are: oral temperature 99°F, pulse 88 beats per minute with a regular rhythm, respirations 16 breaths per minute and deep, and blood pressure 180/110 mm Hg. Which sign should cause the most concern?
1. Pulse 2. Respirations 3. Temperature 4. Blood pressure
28. A patient is admitted to the emergency department with difficulty breathing. Which patient response identified by the nurse causes the most concern?
1. Low pulse oximetry 2. Wheezing on expiration 3. Shortness of breath on exertion 4. Using accessory muscles of respiration
29. The nurse is assessing a postoperative patient for signs of hemorrhage. Which clinical manifestation is most indicative of shock?
1. Hyperemia 2. Hypotension 3. Irregular pulse 4. Slow respirations
170 FUNDAMENTALSSUCCESS: A Q & A REVIEWAPPLYINGCRITICALTHINKING TOTESTTAKING 2779_Ch04_155-230.qxd 8/10/11 5:54 PM Page 170
30. When evaluating the vital signs of a group of patients the nurse takes into considera- tion the circadian rhythm of body temperature. At what time of day is body tempera- ture usually is at its highest?
1. 12 AM–2 AM 2. 6 AM–8 AM 3. 4 PM–6 PM 4. 8 PM–10 PM
31. Which physical examination method should the nurse use when assessing for borborygmi?
1. Palpation 2. Inspection 3. Percussion 4. Auscultation
32. The nurse plans to take a patient’s radial pulse. Which method of examination should be used by the nurse?
1. Palpation 2. Inspection 3. Percussion 4. Auscultation
33. Which nursing action is common to all instruments when taking a temperature?
1. Identify that the reading is below 96°F before insertion 2. Wash with cool soap and water after use
3. Place a disposable sheath over the probe 4. Ensure that the instrument is clean
34. The nurse concludes that a patient is experiencing hyperthermia. Which assessment precipitated this conclusion?
1. Mental confusion 2. Increased appetite
3. Rectal temperature of 101°F 4. Heart rate of 50 beats per minute
35. The nurse in the emergency department is engaging in an initial assessment of a patient. Which assessment takes priority?
1. Blood pressure 2. Airway clearance 3. Breathing pattern 4. Circulatory status
36. The nurse is obtaining a patient’s blood pressure. Which information is most important for the nurse to document?
1. Staff member who took the blood pressure
2. Patient’s tolerance to having the blood pressure taken
3. Position of the patient if the patient is not in a sitting position 4. Difference between the palpated and auscultated systolic readings
37. The nurse is teaching a cancer prevention community health class. Which recom- mended cancer screening guideline for asymptomatic people not at risk for cancer should the nurse include?
1. Pap smear annually for females 13 years of age and older 2. Mammogram annually for women 30 years of age and older 3. Prostate-specific antigen yearly for men 30 years of age and older 4. Sigmoidoscopy every 5 years for patients 50 years of age and older
CHAPTER4 PHYSICALASSESSMENT 171
2779_Ch04_155-230.qxd 8/10/11 5:54 PM Page 171
38. The nurse considers that body heat production is increased by:
1. Vasodilation 2. Evaporation 3. Shivering 4. Radiation
39. A patient is admitted with a tentative diagnosis of myasthenia gravis. The practi- tioner prescribes edrophonium (Tensilon) 2 mg to be administered intravenously.
After no reaction the practitioner orders 8 mg to be administered intravenously. The expected response is an improvement in muscle weakness confirming the diagnosis of myasthenia gravis. However, within 30 seconds after administration of the 8 mg of Tensilon, the patient experiences a cholinergic reaction with increased muscle weak- ness, bradycardia, diaphoresis, and hypotension. The physician orders atropine sulfate 1 mg to be administered intravenously STAT. The vial of atropine sulfate indicates 0.5 mg/mL. Calculate how many milliliters of atropine sulfate the nurse should administer intravenously. Record your answer using a whole number.
Answer: mL.
40. Place an X (on the drawing) over the site that is used most often by the nurse for as- sessing a patient’s heart rate.
172 FUNDAMENTALSSUCCESS: A Q & A REVIEWAPPLYINGCRITICALTHINKING TOTESTTAKING 2779_Ch04_155-230.qxd 8/10/11 5:54 PM Page 172
ANSWERS AND RATIONALES
be opened to allow the gauge to drop 2 to 3 mm Hg per heartbeat.
4. This ensures that the openings in the ear- pieces of the stethoscope are facing toward the ear canal for uninterrupted transmission of sounds.
5. 1. A deficiency in vitamin D, not vitamin K, causes bone pain associated with osteoporosis.
2. Vitamin K deficiency is not associated with skin lesions. Ascorbic acid (vitamin C) defi- ciency causes small skin hemorrhages and delays wound healing. Riboflavin (vitamin B2) deficiency causes lip lesions, seborrheic der- matitis, and scrotal and vulval skin changes.
3. A disruption in the clotting mechanism