Health Assessment I Review

What is mydriasis?

Crackles are associated with fluid. True or false.

What is a modifiable risk factor to educate a client on for lung disease, cancer, and myocardial infarction?

When speaking with a client, you notice they are not giving you eye contact. What does the nurse suspect?

A postoperative knee surgery client arrives crying and restless to the floor. What is the next step?

A child comes in crying, tugging on their ear, and has had poor sleep. What should the nurse suspect?

Barrel Chest (AP 1:1) is seen in a client who has what?

Client is vomiting and constant diarrhea for 2 days. On assessment: skin turgor is tenting & dry oral mucosa. Cause?

What is one of the first things you do as an RN upon entering the room?

What percussion findings might you find on a client with bilateral lobe pneumonia?

A client's body mass index (BMI) is 32. What category is this?

A client has 20/40 vision. What is the next step for the nurse?

RN assesses: ascites, jaundice, swelling, malnutrition, and hepatic encephalopathy. What does RN suspect is the cause?

What can cause bradycardia?

A client has bronchitis. What adventitious sounds will the nurse most likely auscultate?

Why should clients with heart failure be on a low sodium diet?

The RN auscultates a murmur over the 2nd intercostal space, right sternal border. What valve is associated?

What data is subjective?

Where do you auscultate the area associated with the tricuspid valve?

A child has been screaming & crying for 20 minutes. What adventitious breath sounds might the RN hear?

Client puts on a shirt that was washed at moms. They develop urticaria, erythema, and pruritis. What does RN suspect?

RN administers IV fentanyl & checks client 2 hours later: breathing 3/min & non-responsive. What should have been done?

A dark skinned client complains of pain, tenderness, and swelling in their LLE. What is one way to assess the color?

A client informs RN she has gained 5 lbs in a week, swelling in her feet, & feels her neck is bulging. What's going on?

SBAR is used for what situation?

A client has conductive hearing loss. Which of the following could be a potential cause?

What can assist a hard of hearing (HOH) client when doing discharge education with them?

What is true about tinea corporis?

A patient has a hemoglobin of 5 (low). What might you observe?

Arterial Blood is oxygenated blood. True or false.

What can develop w/a child if strep isn't treated posbly causing fever, tender joints, cardiomegaly, murmur, tachycardia

A nurse just palpated a client's pulse on top of the foot. This would be charted under what location?

A client's oxygen saturation is 91% on room air. You asses their pulse ox is on correctly. What would be the next step?

RN comes in and assesses the client's carotids using pressure for 20 seconds simultaneously. What might she observe?

What is true about a stage III pressure ulcer?

Assessment: tactile fremitus increased, chest expansion decreased, dull percussion, crackles. What does the RN suspect?

What quick test can you do to check the blood flow to the fingers?

Hypoxemia is a decrease of oxygen in the blood. What symptoms can be seen with hypoxia?

A trauma client is lethargic, vomiting, tachycardia, LBP, Hgb went from 11 to 6.2. What would the HCP most likely order?

A client is agitated, tachycardic, & dilated pupils. Friend says "he took something at a party". What does RN suspect?

Client is intubated in ICU & wife went home. A woman who states is sister calls for info but not in system. RN should:

Infants & children have same vital sign ranges as adults. True or false.

What can cause unequal chest expansion?

Which question is open-ended?

Subjective data: what you as RN observe by inspecting, palpating, percussing, and auscultating during phys. asesmt. T/F?

A waist circumference ≥35 inches in women and ≥40 inches in men:

RN observes new circumoral cyanosis, and confusion. Which of the following actions should the nurse take first?

Causes of a 1+ pulse?

Mom brings in 2YO after a fall. x-ray shows multiple old rib fractures. You still need child's info. What is next step?

Which pulse is counted by listening directly to the heart at 5th ICS L/MCL?