Client Health Assessment Flashcards

A practical nurse is assessing a client's peripheral pulses. Which site is most appropriate for assessing circulation to the foot?

Answer: Dorsalis pedis artery

The dorsalis pedis artery on the dorsum of the foot is the primary site used to assess distal circulation to the foot.

When performing a mental status assessment, which component does the practical nurse evaluate by asking the client to subtract serial 7s from 100?

Answer: Concentration and calculation

Serial 7 subtraction tests concentration and calculation ability, which is a component of cognitive function in a mental status exam.

A practical nurse notes that a client's trachea is deviated to the left. Which condition should the nurse suspect?

Answer: Right-sided tension pneumothorax

A right-sided tension pneumothorax creates pressure that pushes the trachea away from the affected side, toward the left.

During abdominal assessment, the practical nurse should perform the techniques in which order?

Answer: Inspection, auscultation, percussion, palpation

Abdominal assessment follows the order of inspection, auscultation, percussion, and palpation to avoid altering bowel sounds before listening.

A practical nurse is assessing skin turgor in an elderly client. Which finding is expected due to normal aging?

Answer: Skin tents briefly and returns within 3 seconds

Decreased skin elasticity in older adults causes mild tenting with a slightly delayed return, which is a normal age-related change rather than a sign of dehydration.

Which assessment finding indicates early hypoxia in a client?

Answer: Restlessness and confusion

Restlessness and confusion are early signs of hypoxia as the brain is highly sensitive to decreased oxygen levels.

A practical nurse is assessing deep tendon reflexes and documents a '4+' response. What does this indicate?

Answer: Hyperreflexia with clonus

A 4+ reflex response indicates hyperreflexia with clonus, which may suggest an upper motor neuron disorder.