Client Health Assessment Flashcards

During a focused respiratory assessment, the practical nurse auscultates high-pitched musical sounds on exhalation. How are these best described?

Answer: Wheezes

Wheezes are high-pitched musical sounds from narrowed airways, heard primarily on exhalation, associated with asthma and COPD.

A client opens eyes to voice, speaks confused words, and localizes pain. What is the Glasgow Coma Scale total?

Answer: 12

Eye opening to voice = 3, confused speech = 4, localizes pain = 5. Total GCS = 3+4+5 = 12.

When assessing a wound for infection, which finding is most concerning?

Answer: Increased warmth, redness, purulent drainage, and fever

Warmth, redness, purulent drainage, and fever are classic signs of wound infection requiring prompt reporting and treatment.

The apical pulse is 96 bpm but the radial pulse is 78 bpm. How should this be documented?

Answer: Pulse deficit of 18 beats per minute

A pulse deficit is the difference between apical and radial rates (96-78=18), indicating some contractions lack sufficient force to produce a peripheral pulse.

In what order should abdominal assessment techniques be performed?

Answer: Inspection, auscultation, percussion, palpation

Abdominal assessment sequence: inspection, auscultation, percussion, palpation. Auscultation precedes palpation to get unaltered bowel sounds.

A postoperative extremity is pale, cold, and the client reports numbness and tingling. What does this indicate?

Answer: Compromised arterial circulation requiring emergency assessment

Pallor, coolness, and paresthesias indicate compromised arterial circulation requiring emergency evaluation.