Objective.
During the interview portio of the health assessment, a nurse notes the person's posture, physical appearance, and ability to converse. How
... [Show More] should the nurse document these findings?
A round smooth mass that slides between the fingers
As a part of a routine health assessment, the nurse assesses the kidneys as part of the abdominal assessment. Which assessment finding should the nurse conclude is normal when palpating the client's right kidney?
Upper outer quadrant.
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?
Gland is not palpable
The nurse is completing a physical exam on an adult client. Which thyroid finding is considered normal?
4th intercostal space, right midclavicular line. Correct
The nurse is assessing a client's middle lung lobe. What is the best location for the nurse to place a stethoscope diaphragm to hear normal lung sounds in this lobe?
Document a normal finding.
While performing a head-to-toe assessment, the nurse assesses the client's pupillary accommodation. During the second portion of the test, the nurse notes that the client's pupils constrict and there is convergence of the axes of the eyes. What action should the nurse implement next?
A consensual response in the opposite eye.
The nurse is performing a head-to-toe assessment on a client. The nurse is assessing the client's pupillary light reflex by first darkening the room and asking the person to gaze into the distance. Then, the nurse advances a light toward one eye from the client's side. What would the nurse expect to see at this time?
Inspect the scalp looking for nits
A client presents with a rash along the occipital area of the hairline and reports intense itching. How should the nurse begin the objective part of the examination?
Have you had sudden and severe pain in the toes or feet?
A client has come to the clinic for a routine health assessment. What is the best assessment question for the nurse to ask a client after observing tophi on the client's ear cartilage?
Measure bilateral ankle circumference with a non-stretchable tape measure.
How should the nurse assess for lower extremity edema in a client who has been diagnosed with heart failure?
Seek the assistance of a healthcare team member who speaks the client's preferred language.
The nurse is conducting an interview with a client who speaks limited English. What action should the nurse implement?
Ask whether the client has been in a foreign country recently.
A client reports a recent onset of nausea and vomiting. What subjective information is important for the nurse to ascertain?
Document at least 3 generations of the client's family medical history. Correct
The nurse is conducting a family history as part of the assessment interview. Which action should the nurse take to ensure that sufficient information about the client's blood relatives is obtained? [Show Less]