Exam 2: NR302 / NR 302 (New 2026/2027 Update) Health Assessment I |Verified Questions and Answers| 100% Correct | A Grade -Chamberlain

Exam 2: NR302 / NR 302 (New 2026/2027 Update) Health Assessment I |Verified Questions and Answers| 100% Correct | A Grade -Chamberlain Q. When examining the eye, the nurse notices that the patients eyelid margins approximate completely. The nurse recognizes that this assessment finding: ANSWER Is expected - The palpebral fissure is the elliptical open space between the eyelids, and, when closed, the lid margins approximate completely, which is a normal finding. Q. During ocular examinations, the nurse keeps in mind that movement of the extraocular muscles is: Stimulated by CNs III, IV, and VI ANSWER - Movement of the extraocular muscles is stimulated by three CNs: III, IV, and VI. Q. The nurse is performing an external eye examination. Which statement regarding the outer layer of the eye is true? ANSWER The outer layer of the eye is very sensitive to touch. - The cornea and the sclera make up the outer layer of the eye. The cornea is very sensitive to touch. The middle layer, the choroid, has dark pigmentation to prevent light from reflecting internally. The trigeminal nerve (CN V) and the facial nerve (CN VII) are stimulated when the outer surface of the eye is stimulated. The retina, in the inner layer of the eye, is where light waves are changed into nerve impulses. Q. When examining a patients eyes, the nurse recalls that stimulation of the sympathetic branch of the autonomic nervous system: ANSWER Elevates the eyelid and dilates pupil Q. The nurse is reviewing causes of increased intraocular pressure. Which of these factors determines intraocular pressure? ANSWER Amount of aqueous produced resistance to its outflow at the angle of the anterior chamber Q. The nurse is conducting a visual examination. Which of these statements regarding visual pathways and visual fields is true? ANSWER The image formed on the retina is upside down and reversed from its actual appearance in the outside world. Q. The nurse is testing a patients visual accommodation, which refers to which action? ANSWER Pupillary constriction when looking at a near object Q. A patient has a normal pupillary light reflex. The nurse recognizes that this reflex indicates that: ANSWER Constriction of both pupils occurs in response to bright light. Q. A mother asks when her newborn infants eyesight will be developed. The nurse should reply: ANSWER By approximately 3 months of age, infants develop more coordinated eye movements and can fixate on an object. Q. The nurse is reviewing in age-related changes in the eye for a class. Which of these physiologic changes is responsible for presbyopia? ANSWER Loss of lens elasticity - The lens loses elasticity and decreases its ability to change shape to accommodate for near vision. This condition is called presbyopia Q. Which of these assessment findings would the nurse expect to see when examining the eyes of a black patient? ANSWER Dark retinal background Q. A 52-year-old patient describes the presence of occasional floaters or spots moving in front of his eyes. The nurse should: ANSWER Know that floaters are usually insignificant and are caused by condensed vitreous fibers. Q. The nurse is preparing to assess the visual acuity of a 16-year-old patient. How should the nurse proceed? ANSWER Use the Snellen chart positioned 20 feet away from the patient. Q. A patients vision is recorded as 20/30 when the Snellen eye chart is used. The nurse interprets these results to indicate that: ANSWER The patient can read at 20 feet what a person with normal vision can read at 30 feet. Q. A patient is unable to read even the largest letters on the Snellen chart. The nurse should take which action next? ANSWER Shorten the distance between the patient and the chart until the letters are seen, and record that distance Q. A patients vision is recorded as 20/80 in each eye. The nurse interprets this finding to mean that the patient: ANSWER Has poor vision Q. When performing the corneal light reflex assessment, the nurse notes that the light is reflected at 2 o'clock in each eye. The nurse should: ANSWER Consider this a normal finding Q. The nurse is performing the diagnostic positions test. Normal findings would be which of these results? ANSWER Parallel movement of both eyes Q. During an assessment of the sclera of a black patient, the nurse would consider which of these an expected finding? ANSWER Presence of small brown macules on the sclera Q. A 60-year-old man is at the clinic for an eye examination. The nurse suspects that he has ptosis of one eye. How should the nurse check for this? ANSWER Observe the distance between the palpebral fissures. Q. During an examination of the eye, the nurse would expect what normal finding when assessing the lacrimal apparatus? ANSWER Absence of drainage from the puncta when pressing against the inner orbital rim Q. When assessing the pupillary light reflex, the nurse should use which technique? ANSWER Shine a light across the pupil from the side, and observe for direct and consensual pupillary constriction. Q. The nurse is assessing a patients eyes for the accommodation response and would expect to see which normal finding? ANSWER Convergence of the axes of the eyes Q. In using the ophthalmoscope to assess a patients eyes, the nurse notices a red glow in the patients pupils. On the basis of this finding, the nurse would: ANSWER Consider the red glow a normal reflection of the ophthalmoscope light off the inner retina. Q. The nurse is examining a patients retina with an ophthalmoscope. Which finding is considered normal? ANSWER Optic disc that is a yellow-orange color Q. A 2-week-old infant can fixate on an object but cannot follow a light or bright toy. The nurse would: ANSWER Consider this a normal finding Q. The nurse is assessing color vision of a male child. Which statement is correct? The nurse should: ANSWER Test for color vision screening at the Childs 2-year checkup Q. The nurse is performing an eye-screening clinic at a daycare center. When examining a 2-year-old child, the nurse suspects that the child has a lazy eye and should: ANSWER Test for strabismus by performing the corneal light reflex test Q. The nurse is performing an eye assessment on an 80-year-old patient. Which of these findings is considered abnormal? ANSWER Unequal pupillary constriction in response to light Q. The nurse notices the presence of periorbital edema when performing an eye assessment on a 70-year-old patient. The nurse should: ANSWER Ask the patient if he or she has a history of heart failure. Q. When a light is directed across the iris of a patients eye from the temporal side, the nurse is assessing for: ANSWER Presence of shadows, which may indicate glaucoma. Q. In a patient who has anisocoria, the nurse would expect to observe: ANSWER Pupils of unequal size. Q. A patient comes to the emergency department after a boxing match, and his left eye is swollen almost shut. He has bruises on his face and neck. He says he is worried because he cant see well from his left eye. The physician suspects retinal damage. The nurse recognizes that signs of retinal detachment include: ANSWER Shadow or diminished vision in one quadrant or one half of the visual field. Q. A patient comes into the clinic complaining of pain in her right eye. On examination, the nurse sees a pustule at the lid margin that is painful to touch, red, and swollen. The nurse recognizes that this is a ANSWER Hordeolum (stye) Q. A 68-year-old woman is in the eye clinic for a checkup. She tells the nurse that she has been having trouble reading the paper, sewing, and even seeing the faces of her grandchildren. On examination, the nurse notes that she has some loss of central vision but her peripheral vision is normal. These findings suggest that she may have: ANSWER Macular degeneration Q. A patient comes into the emergency department after an accident at work. A machine blew dust into his eyes, and he was not wearing safety glasses. The nurse examines his corneas by shining a light from the side across the cornea. What findings would suggest that he has suffered a corneal abrasion? ANSWER Shattered look to the light rays reflecting off the cornea. An ophthalmic examination reveals papilledema. The nurse is aware that this finding indicates: Increased intracranial pressure During a physical education class, a student is hit in the eye with the end of a baseball bat. When examined in the emergency department, the nurse notices the presence of blood in the anterior chamber of the eye. This finding indicates the presence of: Hyphema During an assessment, the nurse notices that an older adult patient has tears rolling down his face from his left eye. Closer examination shows that the lower lid is loose and rolling outward. The patient complains of his eye feeling dry and itchy. Which action by the nurse is correct? Assessing for other signs of ectropion During an examination, a patient states that she was diagnosed with open-angle glaucoma 2 years ago. The nurse assesses for characteristics of open-angle glaucoma. Which of these are characteristics of open-angle glaucoma?Select all that apply. - Patient experiences tunnel vision in the late stages. - Vision loss begins with peripheral vision. - Virtually no symptoms are exhibited. The nurse needs to pull the portion of the ear that consists of movable cartilage and skin down and back when administering eardrops. This portion of the ear is called the: Auricle The nurse is examining a patients ears and notices cerumen in the external canal. Which of these statements about cerumen is correct? The purpose of cerumen is to protect and lubricate the ear When examining the ear with an otoscope, the nurse notes that the tympanic membrane should appear: Pearly gray and slightly concave The nurse is reviewing the structures of the ear. Which of these statements concerning the eustachian tube is true? It helps equalize air pressure on both sides of the tympanic membrane. A patient with a middle ear infection asks the nurse, What does the middle ear do? The nurse responds by telling the patient that the middle ear functions to: Conduct vibrations of sounds to the inner ear. The nurse is reviewing the function of the cranial nerves (CNs). Which CN is responsible for conducting nerve impulses to the brain from the organ of Corti? VIII The nurse is assessing a patient who may have hearing loss. Which of these statements is true concerning air conduction? Air conduction is the normal pathway for hearing A patient has been shown to have a sensorineural hearing loss. During the assessment, it would be important for the nurse to: Ask the patient what medications he is currently taking During an interview, the patient states he has the sensation that everything around him is spinning. The nurse recognizes that the portion of the ear responsible for this sensation is the: Labyrinth A patient in her first trimester of pregnancy is diagnosed with rubella. Which of these statements is correct regarding the significance of this in relation to the infants hearing? Rubella can damage the infants organ of Corti, which will impair hearing. The mother of a 2-year-old is concerned because her son has had three ear infections in the past year. What would be an appropriate response by the nurse Your sons eustachian tube is shorter and wider than yours because of his age, which allows for infections to develop more easily. A 31-year-old patient tells the nurse that he has noticed a progressive loss in his hearing. He says that it does seem to help when people speak louder or if he turns up the volume of a television or radio. The most likely cause of his hearing loss is: Otosclerosis A 70-year-old patient tells the nurse that he has noticed that he is having trouble hearing, especially in large groups. He says that he cant always tell where the sound is coming from and the words often sound mixed up. What might the nurse suspect as the cause for this change? Nerve degeneration in the inner ear During an assessment of a 20-year-old Asian patient, the nurse notices that he has dry, flaky cerumen in his canal. What is the significance of this finding? This finding: Is a normal finding, and no further follow-up is necessary. The nurse is taking the history of a patient who may have a perforated eardrum. What would be an important question in this situation? Is there any relationship between the ear pain and the discharge you mentioned? A 31-year-old patient tells the nurse that he has noticed pain in his left ear when people speak loudly to him. The nurse knows that this finding: Is a characteristic of recruitment While discussing the history of a 6-month-old infant, the mother tells the nurse that she took a significant amount of aspirin while she was pregnant. What question would the nurse want to include in the history? Does your baby seem to startle with loud noises? The nurse is performing an otoscopic examination on an adult. Which of these actions is correct? Pulling the pinna up and back before inserting the speculum The nurse is assessing a 16-year-old patient who has suffered head injuries from a recent motor vehicle accident. Which of these statements indicates the most important reason for assessing for any drainage from the ear canal? Bloody or clear watery drainage can indicate a basal skull fracture In performing a voice test to assess hearing, which of these actions would the nurse perform? Whisper a set of random numbers and letters, and then ask the patient to repeat them. In performing an examination of a 3-year-old child with a suspected ear infection, the nurse would: Perform the otoscopic examination at the end of the assessment. The nurse is preparing to perform an otoscopic examination of a newborn infant. Which statement is true regarding this examination? The normal membrane may appear thick and opaque The nurse assesses the hearing of a 7-month-old by clapping hands. What is the expected response? The infant: Turns his or her head to localize the sound The nurse is performing an ear examination of an 80-year-old patient. Which of these findings would be considered normal? High-tone frequency loss An assessment of a 23-year-old patient reveals the following: an auricle that is tender and reddish-blue in color with small vesicles. The nurse would need to know additional information that includes which of these? Any prolonged exposure to extreme cold While performing the otoscopic examination of a 3-year-old boy who has been pulling on his left ear, the nurse finds that his left tympanic membrane is bright red and that the light reflex is not visible. The nurse interprets these findings to indicate a(n): Acute otitis media The mother of a 2-year-old toddler is concerned about the upcoming placement of tympanostomy tubes in her sons ears. The nurse would include which of these statements in the teaching plan? The purpose of the tubes is to decrease the pressure and allow for drainage. In an individual with otitis externa, which of these signs would the nurse expect to find on assessment? Enlarged superficial cervical nodes When performing an otoscopic examination of a 5-year-old child with a history of chronic ear infections, the nurse sees that his right tympanic membrane is amber-yellow in color and that air bubbles are visible behind the tympanic membrane. The child reports occasional hearing loss and a popping sound with swallowing. The preliminary analysis based on this information is that the child: Most likely has serous otitis media. The nurse is performing an assessment on a 65-year-old man. He reports a crusty nodule behind the pinna. It intermittently bleeds and has not healed over the past 6 months. On physical assessment, the nurse finds an ulcerated crusted nodule with an indurated base. The preliminary analysis in this situation is that this: Could be a potential carcinoma, and the patient should be referred for a biopsy The nurse suspects that a patient has otitis media. Early signs of otitis media include which of these findings of the tympanic membrane? Hypomobility The nurse is performing a middle ear assessment on a 15-year-old patient who has had a history of chronic ear infections. When examining the right tympanic membrane, the nurse sees the presence of dense white patches. The tympanic membrane is otherwise unremarkable. It is pearly, with the light reflex at 5 oclock and landmarks visible. The nurse should: Know that these are scars caused from frequent ear infections. The nurse is preparing to do an otoscopic examination on a 2-year-old child. Which one of these reflects the correct procedure? Pulling the pinna down The nurse is conducting a child safety class for new mothers. Which factor places young children at risk for ear infections? Passive cigarette smoke During an otoscopic examination, the nurse notices an area of black and white dots on the tympanic membrane and the ear canal wall. What does this finding suggest? Yeast or fungal infection A 17-year-old student is a swimmer on her high schools swim team. She has had three bouts of otitis externa this season and wants to know what to do to prevent it. The nurse instructs her to: Use rubbing alcohol or 2% acetic acid eardrops after every swim. During an examination, the patient states he is hearing a buzzing sound and says that it is driving me crazy! The nurse recognizes that this symptom indicates: Objective Vertigo A patient has been admitted after an accident at work. During the assessment, the patient is having trouble hearing and states, I dont know what the matter is. All of a sudden, I cant hear you out of my left ear! What should the nurse do next? Notify the patients health care provider The nurse is testing the hearing of a 78-year-old man and is reminded of the changes in hearing that occur with aging that include which of the following? Select all that apply. - Progression of hearing loss is slow - The aging person may find it harder to hear consonants than vowels. - Sounds may be garbled and difficult to localize The primary purpose of the ciliated mucous membrane in the nose is to: Filter out dust and bacteria The projections in the nasal cavity that increase the surface area are called the: Turbinates The nurse is reviewing the development of the newborn infant. Regarding the sinuses, which statement is true in relation to a newborn infant? Maxillary and ethmoid sinuses are the only sinuses present at birth The tissue that connects the tongue to the floor of the mouth is the: Frenulum The salivary gland that is the largest and located in the cheek in front of the ear is the_____ gland. Parotid In assessing the tonsils of a 30 year old, the nurse notices that they are involuted, granular in appearance, and appear to have deep crypts. What is correct response to these findings? No response is needed; this appearance is normal for tonsils The nurse is obtaining a health history on a 3-month-old infant. During the interview, the mother states, I think she is getting her first tooth because she has started drooling a lot. The nurses best response would be: She is just starting to salivate and hasn't learned to swallow the saliva The nurse is assessing an 80-year-old patient. Which of these findings would be expected for this patient? Decreased ability to identify odors The nurse is performing an oral assessment on a 40-year-old Black patient and notices the presence of a 1 cm, nontender, grayish-white lesion on the left buccal mucosa. Which one of these statements is true? This lesion is: Leukoedema and is common in dark-pigmented persons While obtaining a health history, a patient tells the nurse that he has frequent nosebleeds and asks the best way to get them to stop. What would be the nurses best response? Sit up with your head tilted forward and pinch your nose. A 92-year-old patient has had a stroke. The right side of his face is drooping. The nurse might also suspect which of these assessment findings? Dysphagia While obtaining a health history from the mother of a 1-year-old child, the nurse notices that the baby has had a bottle in his mouth the entire time. The mother states, It makes a great pacifier. The best response by the nurse would be: Prolonged use of a bottle can increase the risk for tooth decay and ear infections. A 72-year-old patient has a history of hypertension and chronic lung disease. An important question for the nurse to include in the health history would be: Have you noticed any dryness in your mouth? The nurse is using an otoscope to assess the nasal cavity. Which of these techniques is correct? Avoiding touching the nasal septum with the speculum The nurse is performing an assessment on a 21-year-old patient and notices that his nasal mucosa appears pale, gray, and swollen. What would be the most appropriate question to ask the patient? Are you aware of having any allergies? The nurse is palpating the sinus areas. If the findings are normal, then the patient should report which sensation? Firm pressure During an oral assessment of a 30-year-old Black patient, the nurse notices bluish lips and a dark line along the gingival margin. What action would the nurse perform in response to this finding? Proceed with the assessment, knowing that this appearance is a normal finding. During an assessment of a 20-year-old patient with a 3-day history of nausea and vomiting, the nurse notices dry mucosa and deep vertical fissures in the tongue. These findings are reflective of: Dehydration A 32-year-old woman is at the clinic for little white bumps in my mouth. During the assessment, the nurse notes that she has a 0.5 cm white, nontender papule under her tongue and one on the mucosa of her right cheek. What would the nurse tell the patient? These bumps are Fordyce granules, which are sebaceous cysts and are not a serious condition. A 10 year old is at the clinic for a sore throat that has lasted 6 days. Which of these findings would be consistent with an acute infection? Tonsils 3+/1-4+ with large white spots Immediately after birth, the nurse is unable to suction the nares of a newborn. An attempt is made to pass a catheter through both nasal cavities with no success. What should the nurse do next? Recognize that this situation requires immediate intervention. The nurse notices that the mother of a 2-year-old boy brings him into the clinic quite frequently for various injuries and suspects there may be some child abuse involved. During an inspection of his mouth, the nurse should look for: Bruising on the buccal mucosa or gums. The nurse is assessing a 3 year old for drainage from the nose. On assessment, a purulent drainage that has a very foul odor is noted from the left naris and no drainage is observed from the right naris. The child is afebrile with no other symptoms. What should the nurse do next? Perform an otoscopic examination of the left nares. During an assessment of a 26 year old at the clinic for a spot on my lip I think is cancer, the nurse notices a group of clear vesicles with an erythematous base around them located at the lip-skin border. The patient mentions that she just returned from Hawaii. What would be the most appropriate response by the nurse? Tell the patient that these vesicles are indicative of herpes simplex I or cold sores and that they will heal in 4 to 10 days. While performing an assessment of the mouth, the nurse notices that the patient has a 1-cm ulceration that is crusted with an elevated border and located on the outer third of the lower lip. What other information would be most important for the nurse to assess? When the patient first noticed the lesion A pregnant woman states that she is concerned about her gums because she has noticed they are swollen and have started bleeding. What would be an appropriate response by the nurse? Swollen and bleeding gums can be caused by the change in hormonal balance in your system during pregnancy A 40-year-old patient who has just finished chemotherapy for breast cancer tells the nurse that she is concerned about her mouth. During the assessment the nurse finds areas of buccal mucosa that are raw and red with some bleeding, as well as other areas that have a white, cheesy coating. The nurse recognizes that this abnormality is: candidiasis The nurse is assessing a patient in the hospital who has received numerous antibiotics and notices that his tongue appears to be black and hairy. In response to his concern, what would the nurse say? Black, hairy tongue is a fungal infection caused by all the antibiotics you have received. The nurse is assessing a patient with a history of intravenous drug abuse. In assessing his mouth, the nurse notices a dark red confluent macule on the hard palate. This could be an early sign of: Acquired immunodeficiency syndrome (AIDS). A mother brings her 4-month-old infant to the clinic with concerns regarding a small pad in the middle of the upper lip that has been there since 1 month of age. The infant has no health problems. On physical examination, the nurse notices a 0.5-cm, fleshy, elevated area in the middle of the upper lip. No evidence of inflammation or drainage is observed. What would the nurse tell this mother? This elevated area is a sucking tubercle caused from the friction of breastfeeding or bottle-feeding and is normal. A mother is concerned because her 18-month-old toddler has 12 teeth. She is wondering if this is normal for a child of this age. The nurses best response would be: This is a normal number of teeth for an 18 month old. When examining the mouth of an older patient, the nurse recognizes which finding is due to the aging process? Tongue that looks smoother in appearance When examining the nares of a 45-year-old patient who has complaints of rhinorrhea, itching of the nose and eyes, and sneezing, the nurse notices the following: pale turbinates, swelling of the turbinates, and clear rhinorrhea. Which of these conditions is most likely the cause? Allergic rhinitis When assessing the tongue of an adult, the nurse knows that an abnormal finding would be: Smooth glossy dorsal surface. The nurse is performing an assessment. Which of these findings would cause the greatest concern? Ulceration on the side of the tongue with rolled edges A patient has been diagnosed with strep throat. The nurse is aware that without treatment, which complication may occur? Rheumatic fever During a checkup, a 22-year-old woman tells the nurse that she uses an over-the-counter nasal spray because of her allergies. She also states that it does not work as well as it used to when she first started using it. The best response by the nurse would be: Using these nasal medications irritates the lining of the nose and may cause rebound swelling. During an oral examination of a 4-year-old Native-American child, the nurse notices that her uvula is partially split. Which of these statements is accurate? A bifid uvula may occur in some Native-American groups. A patient comes into the clinic complaining of facial pain, fever, and malaise. On examination, the nurse notes swollen turbinates and purulent discharge from the nose. The patient also complains of a dull, throbbing pain in his cheeks and teeth on the right side and pain when the nurse palpates the areas. The nurse recognizes that this patient has: Maxillary sinusitis A woman who is in the second trimester of pregnancy mentions that she has had more nosebleeds than ever since she became pregnant. The nurse recognizes that this is a result of: Increased vascularity in the upper respiratory tract as a result of the pregnancy. The nurse is teaching a health class to high-school boys. When discussing the topic of using smokeless tobacco (SLT), which of these statements are accurate? Select all that apply. - Using SLT has been associated with a greater risk of oral cancer than smoking. - Pain is rarely an early sign of oral cancer. - Tooth decay is another risk of SLT because of the use of sugar as a sweetener. During an assessment, a patient mentions that I just cant smell like I used to. I can barely smell the roses in my garden. Why is that? For which possible causes of changes in the sense of smell will the nurse assess? Select all that apply. - Cigarette smoking - Chronic allergies - Aging Which of these statements is true regarding the vertebra prominens? The vertebra prominens is: The spinous process of C7 When performing a respiratory assessment on a patient, the nurse notices a costal angle of approximately 90 degrees. This characteristic is: A normal finding in a healthy adult. When assessing a patients lungs, the nurse recalls that the left lung: Consists of two lobes. Which statement about the apices of the lungs is true? The apices of the lungs: Extend 3 to 4 cm above the inner third of the clavicles During an examination of the anterior thorax, the nurse is aware that the trachea bifurcates anteriorly at the: Sternal angle During an assessment, the nurse knows that expected assessment findings in the normal adult lung include the presence of: Muffled voice sounds and symmetric tactile fremitus. The primary muscles of respiration include the: Diaphragm and intercostals. A 65-year-old patient with a history of heart failure comes to the clinic with complaints of being awakened from sleep with shortness of breath. Which action by the nurse is most appropriate? Assessing for other signs and symptoms of paroxysmal nocturnal dyspnea When assessing tactile fremitus, the nurse recalls that it is normal to feel tactile fremitus most intensely over which location? Between the scapulae The nurse is reviewing the technique of palpating for tactile fremitus with a new graduate. Which statement by the graduate nurse reflects a correct understanding of tactile fremitus? Tactile fremitus: Is caused by sounds generated from the larynx. During percussion, the nurse knows that a dull percussion note elicited over a lung lobe most likely results from: Increased density of lung tissue. The nurse is observing the auscultation technique of another nurse. The correct method to use when progressing from one auscultatory site on the thorax to another is _______ comparison. side-to-side When auscultating the lungs of an adult patient, the nurse notes that low-pitched, soft breath sounds are heard over the posterior lower lobes, with inspiration being longer than expiration. The nurse interprets that these sounds are: Vesicular breath sounds and normal in that location. The nurse is auscultating the chest in an adult. Which technique is correct? Firmly holding the diaphragm of the stethoscope against the chest The nurse is percussing over the lungs of a patient with pneumonia. The nurse knows that percussion over an area of atelectasis in the lungs will reveal: Dullness During auscultation of the lungs, the nurse expects decreased breath sounds to be heard in which situation? When the bronchial tree is obstructed The nurse knows that a normal finding when assessing the respiratory system of an older adult is: Decreased mobility of the thorax. A mother brings her 3-month-old infant to the clinic for evaluation of a cold. She tells the nurse that he has had a runny nose for a week. When performing the physical assessment, the nurse notes that the child has nasal flaring and sternal and intercostal retractions. The nurses next action should be to: Recognize that these are serious signs, and contact the physician. When assessing the respiratory system of a 4-year-old child, which of these findings would the nurse expect? Presence of bronchovesicular breath sounds in the peripheral lung fields When inspecting the anterior chest of an adult, the nurse should include which assessment? Shape and configuration of the chest wall The nurse knows that auscultation of fine crackles would most likely be noticed in: The immediate newborn period. During an assessment of an adult, the nurse has noted unequal chest expansion and recognizes that this occurs in which situation? When part of the lung is obstructed or collapsed During auscultation of the lungs of an adult patient, the nurse notices the presence of bronchophony. The nurse should assess for signs of which condition? Pulmonary consolidation The nurse is reviewing the characteristics of breath sounds. Which statement about bronchovesicular breath sounds is true? Bronchovesicular breath sounds are: Expected near the major airways. The nurse is listening to the breath sounds of a patient with severe asthma. Air passing through narrowed bronchioles would produce which of these adventitious sounds? Wheezes A patient has a long history of chronic obstructive pulmonary disease (COPD). During the assessment, the nurse will most likely observe which of these? Anteroposterior-to-transverse diameter ratio of 1:1 A teenage patient comes to the emergency department with complaints of an inability to breathe and a sharp pain in the left side of his chest. The assessment findings include cyanosis, tachypnea, tracheal deviation to the right, decreased tactile fremitus on the left, hyperresonance on the left, and decreased breath sounds on the left. The nurse interprets that these assessment findings are consistent with: Pneumothorax An adult patient with a history of allergies comes to the clinic complaining of wheezing and difficulty in breathing when working in his yard. The assessment findings include tachypnea, the use of accessory neck muscles, prolonged expiration, intercostal retractions, decreased breath sounds, and expiratory wheezes. The nurse interprets that these assessment findings are consistent with: Asthma The nurse is assessing the lungs of an older adult. Which of these changes are normal in the respiratory system of the older adult? Lungs are less elastic and distensible, which decreases their ability to collapse and recoil A woman in her 26th week of pregnancy states that she is not really short of breath but feels that she is aware of her breathing and the need to breathe. What is the nurses best reply? What you are experiencing is normal. Some women may interpret this as shortness of breath, but it is a normal finding and nothing is wrong. A 35-year-old recent immigrant is being seen in the clinic for complaints of a cough that is associated with rust-colored sputum, low-grade afternoon fevers, and night sweats for the past 2 months. The nurses preliminary analysis, based on this history, is that this patient may be suffering from: Tuberculosis A 70-year-old patient is being seen in the clinic for severe exacerbation of his heart failure. Which of these findings is the nurse most likely to observe in this patient? Shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, and ankle edema A patient comes to the clinic complaining of a cough that is worse at night but not as bad during the day. The nurse recognizes that this cough may indicate: Postnasal drip or sinusitis During a morning assessment, the nurse notices that the patients sputum is frothy and pink. Which condition could this finding indicate? Pulmonary edema During auscultation of breath sounds, the nurse should correctly use the stethoscope in which of the following ways? Listening to at least one full respiration in each location A patient has been admitted to the emergency department with a possible medical diagnosis of pulmonary embolism. The nurse expects to see which assessment findings related to this condition? Chest pain that is worse on deep inspiration and dyspnea During palpation of the anterior chest wall, the nurse notices a coarse, crackling sensation over the skin surface. On the basis of these findings, the nurse suspects: Crepitus The nurse is auscultating the lungs of a patient who had been sleeping and notices short, popping, crackling sounds that stop after a few breaths. The nurse recognizes that these breath sounds are: Atelectatic crackles that do not have a pathologic cause. A patient has been admitted to the emergency department for a suspected drug overdose. His respirations are shallow, with an irregular pattern, with a rate of 12 respirations per minute. The nurse interprets this respiration pattern as which of the following? Hypoventilation A patient with pleuritis has been admitted to the hospital and complains of pain with breathing. What other key assessment finding would the nurse expect to find upon auscultation? Friction rub The nurse is assessing voice sounds during a respiratory assessment. Which of these findings indicates a normal assessment? Select all that apply. - Voice sounds are faint, muffled, and almost inaudible when the patient whispers one, two, three in a very soft voice. - When the patient speaks in a normal voice, the examiner can hear a sound but cannot exactly distinguish what is being said. - As the patient says a long ee-ee-ee sound, the examiner also hears a long ee-ee-ee sound The sac that surrounds and protects the heart is called the: Pericardium The direction of blood flow through the heart is best described by which of these? Right atrium right ventricle pulmonary artery lungs pulmonary vein left atrium left ventricle The nurse is reviewing the anatomy and physiologic functioning of the heart. Which statement best describes what is meant by atrial kick? The atria contract toward the end of diastole and push the remaining blood into the ventricles. When listening to heart sounds, the nurse knows the valve closures that can be heard best at the base of the heart are: Aortic and Pulmonic Which of these statements describes the closure of the valves in a normal cardiac cycle? The tricuspid valve closes slightly later than the mitral valve. The component of the conduction system referred to as the pacemaker of the heart is the: Sinoatrial (SA) node. The electrical stimulus of the cardiac cycle follows which sequence? AV node SA node bundle of His bundle branches The findings from an assessment of a 70-year-old patient with swelling in his ankles include jugular venous pulsations 5 cm above the sternal angle when the head of his bed is elevated 45 degrees. The nurse knows that this finding indicates: Elevated pressure related to heart failure. When assessing a newborn infant who is 5 minutes old, the nurse knows which of these statements to be true? Blood can flow into the left side of the heart through an opening in the atrial septum. A 25-year-old woman in her fifth month of pregnancy has a blood pressure of 100/70 mm Hg. In reviewing her previous examination, the nurse notes that her blood pressure in her second month was 124/80 mm Hg. In evaluating this change, what does the nurse know to be true? This decline in blood pressure is the result of peripheral vasodilatation and is an expected change. In assessing a 70-year-old man, the nurse finds the following: blood pressure 140/100 mm Hg; heart rate 104 beats per minute and slightly irregular; and the split S2 heart sound. Which of these findings can be explained by expected hemodynamic changes related to age? Increase in systolic blood pressure A 45-year-old man is in the clinic for a routine physical examination. During the recording of his health history, the patient states that he has been having difficulty sleeping. Ill be sleeping great, and then I wake up and feel like I cant get my breath. The nurses best response to this would be: Do you have any history of problems with your heart? In assessing a patients major risk factors for heart disease, which would the nurse want to include when taking a history? Smoking, hypertension, obesity, diabetes, and high cholesterol The mother of a 3-month-old infant states that her baby has not been gaining weight. With further questioning, the nurse finds that the infant falls asleep after nursing and wakes up after a short time, hungry again. What other information would the nurse want to have? Presence of dyspnea or diaphoresis when sucking In assessing the carotid arteries of an older patient with cardiovascular disease, the nurse would: Listen with the bell of the stethoscope to assess for bruits. During an assessment of a 68-year-old man with a recent onset of right-sided weakness, the nurse hears a blowing, swishing sound with the bell of the stethoscope over the left carotid artery. This finding would indicate: Blood flow turbulence. During an inspection of the precordium of an adult patient, the nurse notices the chest moving in a forceful manner along the sternal border. This finding most likely suggests a(n): Enlargement of the right ventricle. During an assessment of a healthy adult, where would the nurse expect to palpate the apical impulse? Fifth left intercostal space at the midclavicular line The nurse is examining a patient who has possible cardiac enlargement. Which statement about percussion of the heart is true? Studies show that percussed cardiac borders do not correlate well with the true cardiac border. The nurse is preparing to auscultate for heart sounds. Which technique is correct? Listening by inching the stethoscope in a rough Z pattern, from the base of the heart across and down, then over to the apex While counting the apical pulse on a 16-year-old patient, the nurse notices an irregular rhythm. His rate speeds up on inspiration and slows on expiration. What would be the nurses response? No further response is needed because sinus arrhythmia can occur normally. When listening to heart sounds, the nurse knows that the S1: Coincides with the carotid artery pulse. During the cardiac auscultation, the nurse hears a sound immediately occurring after the S2 at the second left intercostal space. To further assess this sound, what should the nurse do? Watch the patients respirations while listening for the effect on the sound Which of these findings would the nurse expect to notice during a cardiac assessment on a 4-year-old child? Murmur at the second left intercostal space when supine While auscultating heart sounds on a 7-year-old child for a routine physical examination, the nurse hears an S3, a soft murmur at the left midsternal border, and a venous hum when the child is standing. What would be a correct interpretation of these findings? These findings can all be normal in a child. During the precordial assessment on an patient who is 8 months pregnant, the nurse palpates the apical impulse at the fourth left intercostal space lateral to the midclavicular line. This finding would indicate: Displacement of the heart from elevation of the diaphragm In assessing for an S4 heart sound with a stethoscope, the nurse would listen with the: Bell of the stethoscope at the apex with the patient in the left lateral position. A 70-year-old patient with a history of hypertension has a blood pressure of 180/100 mm Hg and a heart rate of 90 beats per minute. The nurse hears an extra heart sound at the apex immediately before the S1. The sound is heard only with the bell of the stethoscope while the patient is in the left lateral position. With these findings and the patients history, the nurse knows that this extra heart sound is most likely a(n): Atrial gallop The nurse is performing a cardiac assessment on a 65-year-old patient 3 days after her myocardial infarction (MI). Heart sounds are normal when she is supine, but when she is sitting and leaning forward, the nurse hears a high-pitched, scratchy sound with the diaphragm of the stethoscope at the apex. It disappears on inspiration. The nurse suspects: Inflammation of the precordium. The mother of a 10-month-old infant tells the nurse that she has noticed that her son becomes blue when he is crying and that the frequency of this is increasing. He is also not crawling yet. During the examination the nurse palpates a thrill at the left lower sternal border and auscultates a loud systolic murmur in the same area. What would be the most likely cause of these findings? Tetralogy of Fallot A 30-year-old woman with a history of mitral valve problems states that she has been very tired. She has started waking up at night and feels like her heart is pounding. During the assessment, the nurse palpates a thrill and lift at the fifth left intercostal space midclavicular line. In the same area, the nurse also auscultates a blowing, swishing sound right after the S1. These findings would be most consistent with: Mitral regurgitation. During a cardiac assessment on a 38-year-old patient in the hospital for chest pain, the nurse finds the following: jugular vein pulsations 4 cm above the sternal angle when the patient is elevated at 45 degrees, blood pressure 98/60 mm Hg, heart rate 130 beats per minute, ankle edema, difficulty breathing when supine, and an S3 on auscultation. Which of these conditions best explains the cause of these findings? Heart failure The nurse knows that normal splitting of the S2 is associated with: inspiration During a cardiovascular assessment, the nurse knows that a thrill is: Vibration that is palpable. During a cardiovascular assessment, the nurse knows that an S4 heart sound is: Heard at the end of ventricular diastole. During an assessment, the nurse notes that the patients apical impulse is laterally displaced and is palpable over a wide area. This finding indicates: Volume overload, as in heart failure When the nurse is auscultating the carotid artery for bruits, which of these statements reflects the correct technique? While lightly applying the bell of the stethoscope over the carotid artery and listening, the patient is asked to take a breath, exhale, and briefly hold it. The nurse is preparing for a class on risk factors for hypertension and reviews recent statistics. Which racial group has the highest prevalence of hypertension in the world? Blacks The nurse is assessing a patient with possible cardiomyopathy and assesses the hepatojugular reflux. If heart failure is present, then the nurse should recognize which finding while pushing on the right upper quadrant of the patients abdomen, just below the rib cage? The jugular veins will remain elevated as long as pressure on the abdomen is maintained. The nurse is assessing the apical pulse of a 3-month-old infant and finds that the heart rate is 135 beats per minute. The nurse interprets this result as: Normal for this age The nurse is presenting a class on risk factors for cardiovascular disease. Which of these are considered modifiable risk factors for MI? Select all that apply. - Abnormal lipids - Smoking - Hypertension - Diabetes The nurse is preparing to assess a 55-year-old female. Which of the following will the nurse do first? Inspection Percussion Palpation Auscultation Inspection Inspection always precedes the other assessment skills and is never rushed. The order of assessment techniques is: inspection, palpation, percussion, and auscultation, except when assessing the abdomen, where the techniques are inspection, auscultation, percussion, and palpation. Nursing Process: Planning Cognitive Level: Comprehension Client Need: Physiological Integrity A client comes into the clinic with the complaint of swollen ankles. The nurse will utilize which assessment technique to find out more information about this complaint? Inspection Percussion Palpation Auscultation Palpation Palpation is the use of touch to assess specific body characteristics, which include size, shape, location, mobility, position, vibration, temperature, texture, moisture, tenderness, and edema. Palpating the ankle will give the nurse information about tenderness, temperature, mobility, and edema characteristics. Visual inspection is also included in the assessment of the ankles, but palpation will yield the most information. Percussion and auscultation are not techniques used to assess the ankles. Nursing Process: Assessment Cognitive Level: Synthesis Client Need: Physiological Integrity A client comes into the clinic with acute right lower quadrant abdominal pain. During the abdominal assessment of this client, the nurse realizes that: This area should be palpated first. This area should be palpated last. This area should be assessed using deep palpation techniques. This area should not be palpated. This area should be palpated last. Known-painful areas of the body are usually the last areas to be palpated. Deep palpation should be used with caution, especially if one suspects that there is inflammation, peritonitis, or ectopic pregnancy. The area should be assessed using light to moderate palpation. Nursing Process: Planning Cognitive Level: Application Client Need: Physiological Integrity The nurse is preparing to assess a client with flank pain and discomfort and pink-tinged urine. Which of the following assessment techniques would be appropriate for the nurse to use? Direct percussion Reflexive percussion Indirect percussion Blunt percussion Blunt percussion Blunt percussion is used for assessing pain and tenderness in the gallbladder, liver, and kidneys. With blunt percussion, the palm of the nondominant hand is flat against the body and a closed fist is used to strike the hand on the body. Direct percussion is tapping the body directly to examine the sinuses or the thorax of an infant. Reflexive percussion is not an assessment technique. Indirect percussion is the most common method used to produce sounds within the body. To perform indirect percussion, the middle finger of the nondominant hand is placed firmly over the area being examined. The middle finger of the dominant hand quickly strikes the middle finger of the nondominant hand, producing vibrations and a sound. Nursing Process: Assessment Cognitive Level: Application Client Need: Physiological Integrity During the percussion of a client's abdomen, the nurse hears a loud, high-pitched, drumlike tone. The nurse would document this sound as being: Resonance Hyperresonance Tympany Flatness Tympany Tympany is a loud, high-pitched, drumlike tone of medium duration commonly heard over the stomach or intestines. Resonance is a loud, low-pitched sound heard over the lungs. Hyperresonance is a loud, long sound heard when air is trapped in the lungs. Flatness is a soft, short sound heard over solid tissue such as bone. Nursing Process: Assessment Cognitive Level: Comprehension Client Need: Physiological Integrity After auscultating the bowel sounds of a client, the nurse realizes the sounds were long. Which of the following would be appropriate for the nurse to use to document this finding? Intensity Pitch Duration Quality Duration Duration refers to the length of time of the produced sound. This time frame ranges from very short to very long with variation in between. Intensity refers to the softness or loudness of the sound. Pitch refers to the number of vibrations of sound per second. Quality refers to the overtones produced by the vibration such as clear, hollow, muffled, or dull. Nursing Process: Evaluation Cognitive Level: Knowledge Category: Physiological Integrity The nurse is preparing to use a stethoscope while assessing a client. The bell is going to be placed on the client. Which of the following would the nurse assess with the bell of the stethoscope? Heart murmur Lung sounds Normal heart sounds Abdominal sounds Heart murmur The bell detects low-frequency sounds such as heart murmurs. Lung sounds, normal heart sounds, and abdominal sounds are all considered high-pitched sounds and would be assessed using the diaphragm of the stethoscope. Nursing Process: Assessment Cognitive Level: Application Client Need: Physiological Integrity A client complaining of a sore elbow is being assessed by the nurse. Which of the following would help the nurse assess this client? Skin-fold calipers Goniometer Penlight Reflex hammer Goniometer A goniometer measures the degree of joint flexion and extension. Skin-fold calipers are used to determine body fat. A penlight is used to examine the pupils, mouth, and pharynx. A reflex hammer is used to assess deep tendon reflexes. Nursing Process: Implementation Cognitive Level: Comprehension Category: Physiological Integrity A client with lower-extremity edema comes into the clinic. During the assessment, the nurse is unable to palpate the client's pedal pulses. Which of the following would be appropriate for the nurse to do? Nothing. Use a blood pressure cuff around the client's calf in efforts to feel the pulse. Use a tourniquet around the calf and then palpate the pulse. Use a Doppler to listen to the pulse. Use a Doppler to listen to the pulse. A Doppler uses ultrasonic waves to detect sounds that are difficult to hear with a regular stethoscope such as peripheral pulses. Doing nothing is not appropriate in this situation since the nurse needs to assess circulation to the affected area. Placing a blood pressure cuff or tourniquet around the calf will likely make the edema worse and pulses even more difficult to palpate. Nursing Process: Assessment Cognitive Level: Application Category: Physiological Integrity During a physical assessment, the nurse notices several small scabs along the inner aspects of both of the client's lower extremities. Which of the following would be appropriate for the nurse to say to this client? "You really did a job on yourself while shaving!" "Are you in an abusive situation at home?" "Can you tell me what caused all of these scabs on your legs?" "Those scabs look painful. What happened to you?" "Can you tell me what caused all of these scabs on your legs?" The nurse is identifying a physical cue that is present during the physical examination. The nurse is attempting to validate the finding, without assuming the cause of the cue. In this case, the nurse is gathering more information about the cause of the scabs. The other options represent assumptions on the nurse's part as far as the cause of the lesions. Nursing Process: Evaluation Cognitive Level: Application Category: Physiological Integrity The nurse is preparing to conduct a physical assessment on a 20-year-old male client with a gaping wound on his right forearm. Which of the following should the nurse do before beginning this examination? Wash hands Put on goggles Put on a sterile gown Put on a face mask Wash Hands The nurse notices that a client walks with a limp and has long legs. Which of the following aspects of the general survey is this nurse assessing? Physical appearance Mental status Mobility Behavior Mobility The nurse observes the client's gait, posture, and range of motion when assessing mobility in the general survey. Physical appearance, mental status, and behavior are the other components of the general survey. Difficulty with gait and posture, such as limping, calls for further evaluation. During an admission assessment on a 79-year-old client, the nurse learns the client has been taking four different medications, all for the same health condition. What should the nurse do with this information? Document it in the medical record. Contact the primary care physician. Send an order for the medications to the pharmacy. Nothing. This is typical for clients in this age range. Older adults often consume several prescription medications. Overmedication may occur because older adults seek care from multiple health care providers without collaboration regarding treatment. Multiple medications for the same condition may combine to produce dangerous side effects. The nurse would document the medications in the medical record; however, the priority intervention is to call the physician and verify that they are aware of the situation. Sending an order to the pharmacy and doing nothing are not appropriate. The nurse needs more information about the prescribed medications. Prior to measuring a client's height and weight, the client states, "I am 5 feet 10 inches tall and weigh 160 pounds." Upon assessment, the nurse finds the client is shorter and weighs 15 pounds more. What can the nurse surmise from this finding? The client might have a self-image disturbance. The client is lying. The client is embarrassed about his/her weight. The client hasn't been weighed or measured in a long time. The client might have a self-image disturbance. Discrepancies between the stated height and weight and the actual measurements may provide clues to the client's self-image. Not enough information is provided to determine if the client is lying, is embarrassed about their height and weight, or has not had a height and weight assessment recently. Discrepancies in weight may also indicate the client's lack of awareness of sudden weight change that may be due to illness. A client tells the nurse, "It's okay that I'm 20 pounds overweight. Everyone in my family is much fatter." Which of the following would be the best response for the nurse to make at this time? "Being overweight contributes to the development of diabetes." "Do your family members have health problems related to being overweight?" "Being the lightest in your family must make you feel good." "How do you feel about being 20 pounds overweight?" "How do you feel about being 20 pounds overweight?" The client is overweight and is attempting to rationalize it by comparing herself with other family members. The fact is, the client is overweight, and the nurse needs more information on the client's feelings about this fact before educating the client on the risks of being overweight and obtaining family history. A client is brought into the emergency department after being rescued from a major motor vehicle accident. The nurse notes that the client's body temperature is 99.6°F. The nurse realizes that this finding might suggest: The temperature elevation is due to a diurnal variation. The client is ovulating. The client is stressed. The client has an underlying illness not yet diagnosed. The client is stressed. The most reasonable cause for the temperature elevation is stress. The temperature of a highly stressed client may be elevated as a result of increased production of epinephrine and norepinephrine, which increase metabolic activity and heat production. Core body temperature that is highest in the late evening and lowest in the early morning is an example of diurnal temperature variations. Ovulation can raise body temperature by as much as 0.5°F. This question doesn't identify the gender of the client. There is nothing to suggest that this client had an underlying infection or illness prior to the injury. The nurse is preparing to measure the temperature of a client with an endotracheal tube. Which method of temperature measurement should the nurse use for this client? Tympanic Rectal Axillary Oral Tympanic The tympanic temperature measures a client's core body temperature quickly and accurately. This method is the most comfortable and least invasive for the client. Rectal temperatures are used in clients who are comatose, confused, or unable to close their mouth. However, in these situations a tympanic temperature could be used and is less invasive. An oral temperature should not be used on this client because of the endotracheal tube and the inability to close the mouth. The axillary temperature is the least accurate of the temperature methods and isn't indicated since a tympanic device is available. A client has just walked the length of the hallway as part of her prescribed physical therapy program. When the nurse immediately assesses this client's apical pulse, the finding will most likely be: A reduced heart rate An elevated heart rate A heart rate that is the same as her resting heart rate An irregular heart rate An elevated heart rate The pulse rate will normally increase with exercise. This client just walked down the hall as part of the prescribed physical therapy program. A reduced heart rate might be assessed if the client was at rest. The heart rate should be higher than the resting heart rate due to exercise. Exercise should not produce irregularities in the rhythm of the pulse. The nurse is assessing the respiratory rate of a 35-year-old male client. Which of the following would indicate a normal finding for this client? Respiratory rate of 30 to 80 per minute Respiratory rate of 20 to 40 per minute Respiratory rate of 15 to 20 per minute Respiratory rate of 8 to 10 per minute Respiratory rate of 15 to 20 per minute The normal respiratory rate of adults is between 15 and 20 per minute. Respiratory rates of 30-80 per minute are the normal range for newborns. Respiratory rates of 20-40 per minute are considered normal for ages up to 1 year. A respiratory rate of 8-10 per minute is abnormally slow respirations for any age group. The nurse finds the blood pressure reading for a 75-year-old female to be 88/60. Which of the following should the nurse do first after measuring this blood pressure? Ensure that the correct cuff size was used to measure this blood pressure. Place the client in a standing position. Call the physician. Nothing. Extremely low blood pressures are normal in the elderly Ensure that the correct cuff size was used to measure this blood pressure. The bladder of the blood pressure cuff must fit the length and width of the client's limb. A cuff that is too narrow will produce a false high reading. Conversely, if the cuff is too wide, the reading will be falsely low. If the blood pressure is low, lowering the head of the bed, or placing the client in a supine position is recommended. Standing may further lower the blood pressure. The nurse needs to verify that this blood pressure measurement was correct and gather more assessment data before calling the physician. Low blood pressures are not normal in the elderly. With age, blood pressure tends to rise. The nurse is measuring an adult client's blood pressure and hears Korotkoff sounds. Which sound should the nurse recognize as being the diastolic measurement for this client? Phase 1 Phase 3 Phase 4 Phase 5 Phase 5 In adults, the diastolic pressure (Phase 5) is the point at which the sounds become inaudible. Phase 1 sounds are the first sounds heard and signify systolic blood pressure. Phase 3 is the period in which the sounds are louder. Phase 2 is the period during which the sounds are softer and longer. Phase 4 is the period during which the sounds become muffled. During a health interview of a client with residual radiculopathic pain after spinal surgery, the nurse learns that the client holds a full-time job, is married, and does at least half of the routine household activities. From this information, the nurse can accurately document: The client takes pain medication routinely. The pain doesn't interfere with normal activities of daily living. The client uses work to cope with the pain. The client is stoic. The pain doesn't interfere with normal activities of daily living. Assessment of the impact of pain on ADLs enables the nurse to understand the severity of the pain and the impact of the pain on the client's quality of life. There is not enough information to determine whether the client takes pain medication on a "routine" basis. Based on what the client has described as routine ADLs, the nurse can accurately document that the pain doesn't interfere with this client's normal activities. There is no information that implies that the client uses work to cope with the pain or is stoic. An elderly client comes into the pain clinic for follow-up care. The nurse notices that the client grimaces with position changes and continues to have difficulty walking. From this observation, which of the following w