Which of the following is the first action during the physical assessment of the client quizlet?

Correct answer:

4, 2, 1, 5, & 3

Before initiating an abdominal assessment, the nurse should inquire if the client has a history of abdominal pain. The nurse should begin the assessment with an inspection of the client's abdomen, noting skin integrity, contour, and symmetry. Next, the nurse should auscultate for bowel sounds, vascular sounds, and peritoneal friction rubs. Auscultation precedes palpation and percussion because movement or stimulation of the bowel can increase bowel motility and create false results from heightened bowel sounds. After auscultation, the nurse should percuss the abdomen using a systematic pattern beginning in the lower right quadrant and proceeding to the upper right quadrant, the upper left quadrant, and then the lower left quadrant to determine the presence of tympany and dullness. The final step the nurse should take is to palpate the abdomen, beginning with light palpation, to detect any area of tenderness or muscle guarding.

Correct answer:

1, 3, & 4

-Education is correct. The educational background of the client is an interpersonal variable that affects the communication process. Other interpersonal variables are sociocultural background, health status, emotions, pain, and relationships.

-Feedback is incorrect. Feedback is the message that the sender returns in the communication process. It is not an interpersonal variable.

-Gender is correct. Gender is an interpersonal variable that affects the communication process. Other interpersonal variables are sociocultural background, health status, emotions, pain, and relationships.

-Perception is correct. Perception provides a uniquely personal view to a client's experience and is an interpersonal variable that affects communication. Other interpersonal variables are sociocultural background, health status, emotions, pain, and relationships.

-Time is incorrect. Time is a critical element of the communication process, but it is not an interpersonal variable.

Correct answer:

1, 2, 3, & 5

-More difficulty seeing due to a greater sensitivity to glare is correct. Older adults have an increased susceptibility to glare, greater difficulty in seeing at low levels of illumination, and alterations in color perception.

-Decreased cough reflex is correct. Older adults have a decreased cough reflex, increased airway resistance, fewer alveoli, and a greater risk for respiratory infections.

-Decreased bladder capacity is correct. Older adults have a decreased bladder capacity and a reduction in renal blood flow.

-Decreased systolic blood pressure is incorrect. Older adults have increased systolic blood pressure, thickening of blood-vessel walls, and decreased peripheral circulation.

-Dehydration of intervertebral discs is correct. Older adults have dehydration of intervertebral discs, decreased muscle strength and mass, and decalcification of bones.

A newly admitted patient is in acute pain, has not been sleeping well lately, and is having
difficulty breathing. How should the nurse prioritize these problems?
a. Breathing, pain, and sleep
b. Breathing, sleep, and pain
c. Sleep, breathing, and pain
d. Sleep, pain, and breathing

ANS: A, C, E, F
Chapter 1 - Evidence-Based Assessment 11
Physical Examination and Health Assessment 8th Edition 0323510809
Clustering related cues helps the nurse recognize relationships among the data. The cues r/t
the patient's respiratory status (e.g., wheezes, cough, report of dyspnea, respiration rate and
rhythm) are all related. Cues r/t bowels and peripheral edema are not r/t the respiratory cues.
Hypoactive bowel sounds and +2 edema of the left hand are separate cues that do not relate to
the other cues. The other cues (wheezes, cough, report of dyspnea, respiration rate and
rhythm) all relate to the patient's respiratory status. The cues of bowel sounds and peripheral
edema are not r/t the respiratory cues.
DIF: Cognitive Level: Analyzing (Analysis)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care

ANS: B
By saying "Oh, don't worry about labor so much. I have been through it, and although it is
painful, many good medications are available to decrease the pain" the nurse is providing
false assurance or reassurance. This may give the nurse a false sense of having provided
comfort. However, for the woman, providing false assurance or reassurance actually
trivializes her anxiety, and effectively denies any further talk of it, thus, closing off
communication. The nurse's statement, "Oh, don't worry about labor so much. I have been
through it, and although it is painful, many good medications are available to decrease the
pain" is not therapeutic because it trivializes the patient's anxiety about pain, and effectively
denies any further talk of it, thus, closing off communication.
DIF: Cognitive Level: Analyzing (Analysis)
MSC: Client Needs: Psychosocial Integrity

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