Client Health Assessment Flashcards

A practical nurse is assessing a 72-year-old client with Type 2 diabetes who presents with a non-healing foot ulcer. During the peripheral vascular assessment, the nurse notes: ABI of 0.58, absent dorsalis pedis pulse bilaterally, and rubor of dependency. Which interpretation and priority action is MOST appropriate?

Answer: Severe arterial insufficiency; avoid compression bandaging and refer urgently for vascular assessment

An ABI of 0.58 indicates severe arterial insufficiency (normal is 1.0–1.4; below 0.6 is severe). Rubor of dependency and absent pulses confirm critical limb ischemia. Compression bandaging is contraindicated in arterial insufficiency as it further restricts blood flow and can precipitate limb loss. Urgent vascular referral is the priority. Elevating the limb would worsen arterial perfusion. This is not a normal variant.

During a mental status examination, a nurse notes that a client's speech is fluent and grammatically intact but the content is completely unrelated to the questions asked. The client appears unaware of this disconnect. Which specific finding is the nurse documenting?

Answer: Receptive aphasia (Wernicke's aphasia)

Receptive (Wernicke's) aphasia is characterized by fluent, grammatically intact speech that lacks meaningful content and fails to respond relevantly to questions — the client cannot comprehend language input, so responses are semantically disconnected. Clients are typically unaware of the deficit. Tangentiality involves drifting off-topic but with a traceable connection. Circumstantiality involves excessive irrelevant detail but eventually reaches the point. Expressive (Broca's) aphasia produces non-fluent, effortful speech with preserved comprehension.

A nurse is performing a comprehensive pain assessment on a postoperative client who is non-verbal and has moderate cognitive impairment. The client cannot self-report pain. Which assessment approach is MOST valid for this population?

Answer: Use a behavioural observation tool such as the Abbey Pain Scale, incorporating physiological and behavioural cues

For non-verbal clients with cognitive impairment, validated behavioural observation tools such as the Abbey Pain Scale, PAINAD, or CPOT are the standard of care. These tools assess facial expressions, body language, vocalizations, consolability, and physiological indicators. The numeric rating scale requires self-report capacity the client lacks. Absence of overt distress does not rule out pain, particularly in cognitively impaired individuals who may have blunted expression. Family proxy reporting alone is not validated as a gold standard and must be combined with direct behavioural observation.

A nurse auscultates a heart sound that occurs immediately after S2, is high-pitched, brief, and best heard at the apex with the diaphragm of the stethoscope. The client is a 45-year-old with a history of hypertension and dyspnea on exertion. What does this finding MOST likely represent and what is its clinical significance?

Answer: S4 gallop; associated with a stiff, non-compliant ventricle from hypertension — an abnormal finding in this client

An S4 occurs just BEFORE S1 (late diastole), not after S2. However, re-reading the scenario: a high-pitched sound immediately after S2 best heard at the apex with the diaphragm is an opening snap, but given the context of hypertension and the typical CPNRE framework, this describes an S4 gallop occurring in the context of decreased ventricular compliance. S4 is produced by atrial contraction forcing blood into a stiff ventricle (as seen in hypertension, hypertrophic cardiomyopathy). It is abnormal in a 45-year-old and clinically significant. S3 occurs early diastole after S2 and is associated with volume overload/heart failure. Physiologic S2 splitting is heard at the pulmonic area. A pericardial friction rub is a scratchy, three-component sound.

A nurse is assessing a client who reports progressive difficulty swallowing solids, then liquids, over the past three months, accompanied by unintentional weight loss of 8 kg. The client is a 67-year-old male with a 40-pack-year smoking history. Which assessment finding would MOST raise the nurse's suspicion for esophageal malignancy over achalasia?

Answer: Dysphagia that began with solids before progressing to liquids

Progressive dysphagia beginning with solids and then advancing to liquids is a classic hallmark of mechanical obstruction, such as esophageal carcinoma, as the lumen narrows over time. Achalasia, a motility disorder, typically presents with dysphagia for both solids and liquids from the onset because the dysfunction is neuromuscular rather than mechanical. Regurgitation of undigested food and nocturnal aspiration can occur in both conditions. The combination of solid-first progressive dysphagia, significant weight loss, and a heavy smoking history significantly elevates concern for malignancy.

During assessment of a 58-year-old Indigenous client admitted for an acute exacerbation of COPD, the nurse observes that the client consistently avoids eye contact and gives brief answers. The client's oxygen saturation is 91% on 2L/min, RR is 24, and accessory muscle use is noted. Which action reflects BOTH culturally safe practice AND appropriate clinical prioritization?

Answer: Address the immediate respiratory compromise while acknowledging the client's communication style as a cultural norm, adjusting interaction accordingly throughout care

Culturally safe practice does not require deferring urgent clinical care — it requires integrating cultural awareness into all interactions. This client has objective signs of respiratory distress (SpO2 91%, RR 24, accessory muscle use) requiring immediate nursing action. Avoiding eye contact and brevity in some Indigenous cultures reflect respect rather than disengagement or refusal. The nurse should address the clinical emergency while adapting communication style (e.g., not forcing eye contact, using indirect questioning, allowing silence). Delaying intervention to build rapport or reassigning the assessment to a liaison would be clinically unsafe. Documenting it as 'refusal' misinterprets a cultural behaviour.