Case Study Fundamentals - Health & Physical Assessment Questions and Answers

Case Study Fundamentals - Health & Physical Assessment Questions and Answers Which action would the nurse implement when a client is receiving total parenteral nutrition (TPN)? Select all that apply. One, some, or all responses may be correct. Assess hydration Ensure rapid delivery of each infusion Monitor weight daily Infuse using an electric pump Reassess vital signs every 4 hours Discard any solution after 24 hours Check the expiration date before administration Utilize peripheral IV for administration Assess hydration Monitor weight daily Infuse using an electric pump Reassess vital signs every 4 hours Discard any solution after 24 hours Check the expiration date before administration Rationale: It is important for the nurse to monitor hydration and weight to ensure that the client is receiving the correct amount of nutrition and fluids. An electric or smart pump is always used to infuse TPN to avoid too rapid of an infusion or a delay in administration. Vital signs would be monitored every 4 hours, as this may be an indicator of TPN complications. TPN would not be administered if it was expired, and any solution left after 24 hours would be discarded. TPN is usually administered continuously over 24 hours, or sometimes it is administered over 12-14 hours while the client sleeps. A rapid infusion of TPN causes blood glucose levels to go up and predisposes the client for hyperglycemic crisis. TPN should not be administered into a peripheral IV because of its high osmolality. TPN should only be administered via a centrally placed catheter. The nurse is performing a breast assessment. Which statement made by the client indicates the risk of breast cancer? Select all that apply. I had a late onset of menarche." "My first child was born when I was 32." "I noticed a slight discharge from a nipple." "I perform breast self-examinations frequently." "I consume two to four glasses of alcohol a day." "My provider prescribed hormone replacement therapy (HRT)" "I am going to turn 60 years old next week." "My new diet is not helping me with my obesity very much." - "My first child was born when I was 32." - "I noticed a slight discharge from a nipple." - "I consume two to four glasses of alcohol a day." - "My provider prescribed hormone replacement therapy (HRT)" - "My new diet is not helping me with my obesity very much." Rationale: Clients who gave birth to a first child after the age of 30 are at a risk of breast cancer. Discharge from the nipple may indicate an early symptom of breast cancer. Consuming two to four glasses of alcohol daily may also increase the risk of breast cancer. The use of HRT containing estrogen and progestin increases the risk of breast cancer. Another risk factor is obesity. An early, not late, onset of menarche is a risk factor for breast cancer. Performing breast self-examinations frequently may help identify the early stages of breast cancer. The risk of breast cancer progressively increases after an individual turns 65 years old. A client with a history of cardiac dysrhythmias is admitted to the hospital due to a fluid volume deficit caused by a pulmonary infection. Which physiologic change would the nurse expect with this client? Select the 3 findings that the nurse would expect. Respiratory rate of 12 breaths/minute Blood pressure of 135/80 mm Hg Oxygen saturation of 100% Temporal temperature of 101.2°F (38.4°C) Radial pulse rate of 72 and irregular Pain of 6 of 10 with coughing Temporal temperature of 101.2°F (38.4°C) Radial pulse rate of 72 and irregular Pain of 6 of 10 with coughing Rationale: The normal temperature range is 96.8°F (36°C) to 100.4°F (38°C); temperature is often elevated with any type of infection. Cardiac dysrhythmias are associated with a pulse deficit in which the radial pulse would be irregular; reassessment would not be required. Pleural pain associated with cough is expected with a pulmonary infection. In pulmonary infections, the respiratory rate would more likely be elevated than at the low end of normal. In fluid volume deficit, the blood pressure may be decreased. If oxygen saturation was changed with this client, it would be decreased, whereas 100% is at the high end of normal. A respiratory rate of 12 breaths/minute, a blood pressure of 135/80 mm Hg, and an oxygen saturation of 100% would not be considered physiologic changes expected with this client. The nurse expects a client with an elevated temperature to exhibit which indicators of pyrexia? Select all that apply. One, some, or all responses may be correct. Dyspnea Increased appetite Flushed face Precordial pain Increased pulse rate Increased blood pressure General lethargy Chills Flushed face Increased pulse rate General lethargy Chills Rationale: Increased body heat dilates blood vessels, causing a flushed face. The pulse rate increases to meet increased tissue demands for oxygen in the febrile state. The client with a fever may demonstrate general lethargy or report chills. Fever may not cause difficulty breathing. Appetite will be decreased, not increased in the presence of a fever. Precordial pain is not related to fever. Blood pressure is not expected to increase with fever. A 50-year-old client is diagnosed with chronic obstructive pulmonary disease (COPD). The clinical data on admission are as follows: a heart rate of 86 beats/min, a blood pressure of 142/82 mm Hg, a respiratory rate of 32 breaths/min, a tympanic temperature 98.2°F (36.8°C), oxygen saturation of 88%, and general discomfort with pain 2 out of 10. Which vital signs obtained by the nurse indicate an improvement in condition? Select the 3 findings that indicate client improvement. Radial pulse: 88 beats/min Temperature: 98.6°F (37°C) Respiratory rate: 14 breaths/min Blood pressure: 110/70 mm Hg Oxygen saturation: 92% Pain of 2 out of 10 Respiratory rate: 14 breaths/min Blood pressure: 110/70 mm Hg Oxygen saturation: 92% Rationale: The respiratory rate in older adults ranges from 12 to 20 breaths/min, and this range may be elevated in clients with chronic obstructive pulmonary disease (COPD). Thus, a rate decrease to 14 breaths/min indicates a positive outcome, as it is within normal range. COPD may also cause high blood pressure. Thus, a blood pressure of 110/70 mm Hg obtained during therapy indicates a positive outcome. The normal oxygen saturation rate should be 95% to 100%. An oxygen saturation increase from 88% to 92% indicates a positive outcome of the therapy. The radial pulse is slightly elevated but relatively unchanged, which does not demonstrate an improvement in condition. A body temperature reading of 98.6°F (37°C), is considered normal and not a sign of COPD. A pain score of 2 out of 10 does not indicate a positive or negative outcome and is not a sign of COPD. The nurse considers an assessment technique to test the client for median nerve compression. The nurse performs the _____ by_______ Tinel sign by tapping the client's wrist with index finger Rationale: The nurse would perform the Tinel sign by tapping the client's wrist with index finger. A positive Tinel sign (tingling sensation from wrist to hand) is indicative of median nerve compression or carpal tunnel syndrome. The repetitive work of being a secretary and the history of hypothyroidism make this client prone to carpal tunnel syndrome. While the Phalen test can also be used for assessment of median nerve compression, the correct technique is placing both client's wrists in a fully palmar-flexed position with the dorsal surfaces pressed together for 1 minute, not pulling the tibia anteriorly while stabilizing the femur. Pulling the tibia anteriorly while stabilizing the femur is the Lachman test, which assesses the anterior cruciate ligament for injury or tear, not the median nerve. The Neer test assesses for a rotator cuff tear or injury, not for median nerve compression, and is performed by depressing the scapula and flexing the client's arm up to 150 degrees. The Bulge sign is performed by stroking the medial side of the knee and then the lateral side to assess effusion/fluid in the knee, not for median nerve compression. The nurse assesses the abdomen using the following sequence: the nurse will first Inspect venous return patterns them auscultate bowel sounds followed by percussing liver borders and ending with palpating liver border in right costal margin Rationale: The nurse incorporates liver assessments because the client is exhibiting signs of liver disease from alcohol drinking. For each assessment finding, click to indicate whether findings from this client's assessment are generally associated with heart failure, cirrhosis, or cholecystitis with cholelithiasis. Rounded abdomen with bulging flanks Yellow discoloration of skin Edema in the lower extremities Unable to walk to mailbox with fatigue Nausea HF: Edema in the lower extremities, fatigue, nausea Cirrhosis: Rounded abdomen with bulging flanks, yellow discoloration of skin, edema in the lower extremities, unable to walk to mailbox with fatigue, nausea Cholcystitis: Yellow discoloration of skin, Nausea Patient has ascities. The nurse plans to perform the following assessments: Murphy sign Iliopsoas muscle test CV angle tenderness Fluid wave Linea nigra Sister Mary Joseph's nodule Mcburney sign Shifting dullness Abdominal girth Obturator test Fluid wave Shifting dullness Abdominal girth Rationale: Since the client has cirrhosis with ascites, the nurse would assess fluid wave, shifting dullness, and abdominal girth. A fluid wave is present when the nurse can feel the impulse in the other flank area. As the ascites fluid resettles from gravity when the client is side-lying, the dullness shifts to the dependent side, indicating shifting dullness. Because of the excess fluid, the nurse would measure abdominal girth. Iliopsoas muscle test involves manipulation of the iliopsoas muscle to test for appendicitis, not cirrhosis and ascites. Costovertebral angle tenderness is tested in the back area and indicates kidney inflammation, not cirrhosis and ascites. Linea nigra is a darkened midline that occurs in pregnancy, not cirrhosis and ascites. Sister Mary Joseph's nodule is a painful umbilical mass from intraabdominal malignancy, not from cirrhosis and ascites. McBurney sign is rebound tenderness and sharp pain when McBurney point is palpated and is associated with appendicitis, not cirrhosis and ascites. Obturator test is irritation of the obturator muscle through manipulation of the leg, indicating a ruptured appendix, not cirrhosis and ascites. Murphy sign is abrupt cessation of inspiration upon gallbladder palpation, indicating cholecystitis, not cirrhosis and ascites. What are the equipments and techniques needed for: Fluid wave Shifting dullness Abdominal girth Fluid wave - Equipment: 3 hands(nurse & another person's) - Technique: Tap one side of abdomen w/ fingertips Shifting dullness: - Equipment: Nurse's hands - Technique: Place pt on side lying position Abdominal girth: - Equipment: tape measure - Technique: Use same marked area every time The client becomes confused and the nurse suspects the client is declining. Which assessment finding would indicate the client is not progressing as expected? Select all that apply. Asterixis Fetor hepaticus Negative Babinski sign Low-protein intake Decreased ammonia level Hyperreflexia Coherent Alcohol Anonymous attendance Esophageal varices development Consumption of potassium rich foods Asterixis Fetor hepaticus Hyperreflexia Esophageal varices development Consumption of potassium rich foods The assessment findings that indicate the client is not progressing as expected includes asterixis, fetor hepaticus, hyperreflexia, esophageal varices development, and consumption of potassium-rich foods. Asterixis is hand flapping, a sign of hepatic encephalopathy (a complication of cirrhosis). Fetor hepaticus is musty, sweet breath, characteristic of hepatic encephalopathy. Hyperreflexia occurs in Stage III of hepatic encephalopathy. Esophageal varices indicate the client is declining; esophageal varices can lead to bleeding and should not develop. Consumption of potassium rich foods indicates the client is declining because the client is taking spironolactone, a potassium-sparing diuretic; intake of potassium rich foods can lead to hyperkalemia and worsen his condition. All the other assessment findings indicate the client is improving. A negative Babinski sign is a neurological finding that indicates improvement; a positive Babinski sign can indicate hepatic encephalopathy. The client should have a low-protein intake; a high-protein intake can lead to hepatic encephalopathy. A decreased ammonia level indicates improvement; an elevated ammonia level can indicate hepatic encephalopathy. Coherent indicates the client is improving; mental confusion and inability to concentrate or think indicates hepatic encephalopathy. Attendance at Alcohol Anonymous indicates improvement; the client must abstain from alcohol.