The nurse is performing a thoracic assessment on a client with chronic asthma and hyperinflation of the lungs. Which finding should be expected for this
... [Show More] client?
Barrel chest
The nurse is assessing bowel sounds for a hospitalized client. The nurse has heard bowel sounds in the right upper quadrant. What action should the nurse take next?
Note the character and frequency of bowel sounds
During inspection of a client's mouth and 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?
Document an intact gag reflex.
When teaching a client how to perform a monthly breast self-assessment, the nurse should tell the client that it is most important to assess which part of the breast more closely for changes?
Upper outer quadrant.
The nurse is assessing a postmenopausal client who has a BMI of 32. The client has 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?
A waist circumference is greater than 35 inches in women puts you at higher risk for type 2 diabetes and heart disease."
The nurse performs a physical assessment on an older female client. Which change from the prior exam may be an indication of osteoporosis?
Height reduction of 1.5 inches.
While conducting an interview to obtain a 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?
Sit quietly to allow the client to respond comfortably.
A client is in the clinical for a yearly physical examination. Which action should the nurse take when preparing to examine the client's abdomen?
Ask the client to urinate before beginning the examination.
Which respiratory condition should the nurse document after measuring a respiratory rate of 8 breaths/minute?
Bradypnea.
Which procedure should the nurse use to assessfor a pulse deficit?
Measure the apical pulse and compare it to the peripheral pulse.
*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 bilateral lower lobe atelectasis. What percussion sound should the nurse expect to hear when percussing over the client's lower lobes?
Dull, thud-like.
A client is being assessed upon admission 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?
Inspect the hair and skin. [Show Less]