Exam 8: Health Assessment

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

The nurse assesses a possible melanoma on the patient's skin.Which characteristic does the lesion have that is consistent with a melanoma?

The nurse is assessing the temperature of the lower legs.Which method should the nurse use to best assess the patient's skin temperature subjectively?

Which aspect of obtaining health information can the nurse delegate to nursing assistive personnel (NAP)?

The nurse assesses peripheral perfusion.Which does the nurse find in a patient with arterial insufficiency?

The nurse is preparing to assess the patient's abdomen.Nursing care is appropriate if which maneuver is seen?

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

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

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

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

The nurse admitted a patient with clear lungs and 2 days later has rhonchi in the left lung.Which should the nurse implement next?

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

The nurse assesses the patient admitted with constipation.Which assessment finding warrants further investigation?

The nurse assesses the pupils of an older patient.What unexpected finding might the nurse identify about the patient's pupils?

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

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 is assessing an older patient and finds the heart rate to be 52 beats per minute and irregular.Suddenly the patient complains of dizziness and "feeling faint." Which action does the nurse take next?

The nurse admits the patient with mild chest pain from the emergency department.Which should the nurse implement first to gain patient cooperation during a physical assessment?