Client Health Assessment Flashcards

A practical nurse is assessing a 74-year-old client with heart failure. During auscultation, an S3 gallop is heard at the apex. Which pathophysiological mechanism best explains this finding?

Answer: Rapid ventricular filling against a non-compliant, volume-overloaded ventricle in early diastole

An S3 gallop (ventricular gallop) occurs in early diastole (after S2) when blood rushes into a distended, poorly compliant ventricle. In heart failure, the ventricle is volume-overloaded and stiff, causing vibrations during rapid filling — the hallmark of an S3. An S4 (not S3) is associated with atrial contraction against a stiff ventricle. Mitral stenosis produces a different auscultatory profile (opening snap + diastolic rumble), and pulmonic valve changes affect the splitting of S2.

While performing a neurological assessment, the practical nurse applies a sternal rub to an unresponsive client. The client's upper extremities internally rotate, wrists flex, and fingers curl. The lower extremities extend and feet plantar flex. Which response is being documented?

Answer: Decerebrate (abnormal extension) posturing

The described pattern — internal rotation of arms, wrist flexion, finger curling WITH lower extremity extension and plantar flexion — is decerebrate posturing. This indicates a lesion at or below the midbrain/upper pons, which disconnects higher cortical control. Decorticate posturing involves arm FLEXION toward the core (elbows bent inward) with lower extremity extension, indicating a lesion above the midbrain (cortex/internal capsule). Opisthotonus is a generalized hyperextension of the back/neck (seen in meningitis or tetanus), not limb posturing.

A practical nurse assesses a client with chronic liver disease and notes asterixis. Which assessment technique is used to elicit this sign, and what does it indicate?

Answer: Asking the client to extend the arms and wrists with fingers spread and observing for a flapping tremor; indicates hepatic encephalopathy

Asterixis ("liver flap") is elicited by asking the client to hold arms outstretched with wrists dorsiflexed. A flapping, non-rhythmic tremor results from the inability to maintain sustained postures due to metabolic disturbances — most notably the accumulation of ammonia in hepatic encephalopathy. It can also occur in renal failure (uremic encephalopathy) and CO2 narcosis, but in the context of liver disease it strongly suggests hepatic encephalopathy requiring urgent intervention.

The practical nurse is assessing a client who reports difficulty swallowing and occasional choking on liquids but not solids. Which cranial nerve dysfunction is MOST likely responsible for this specific pattern?

Answer: Cranial Nerve IX (Glossopharyngeal) and X (Vagus) — impaired pharyngeal peristalsis and laryngeal protection

Dysphagia to liquids more than solids (thin liquids are harder to control than thick/solid boluses) specifically implicates the pharyngeal and laryngeal phase of swallowing. CN IX and X control the pharyngeal constrictor muscles, soft palate elevation, and vocal cord adduction for airway protection. Failure here allows thin liquids to spill into an unprotected airway before the swallow reflex triggers. CN XII weakness impairs tongue propulsion (affecting both consistencies equally in the oral phase), and CN VII affects lip seal and oral containment rather than pharyngeal/laryngeal protection.

During an abdominal assessment, the practical nurse notes a friction rub over the right upper quadrant. Which organ and associated condition does this finding MOST suggest?

Answer: Liver, indicating hepatic inflammation or tumour with peritoneal involvement

Abdominal friction rubs — a grating sound heard with the stethragm during breathing — indicate peritoneal inflammation of an underlying organ. A friction rub in the right upper quadrant overlies the liver and suggests hepatic pathology such as hepatocellular carcinoma, liver abscess, or hepatitis with capsular/peritoneal inflammation. Splenic friction rubs occur in the left upper quadrant. The gallbladder, though in the RUQ, does not typically produce auscultable friction rubs; acute cholecystitis presents with Murphy's sign instead. Renal pathology is posterolateral, not anterior.

A practical nurse is assessing a client's peripheral vascular status. The dorsalis pedis pulse is absent bilaterally, but the client reports calf pain only when walking that is relieved by rest. The skin is cool, shiny, and hairless below the knees. The ankle-brachial index (ABI) would be expected to fall in which range, and what does it indicate?

Answer: ABI 0.5–0.8, indicating moderate peripheral arterial disease consistent with intermittent claudication

The classic triad of intermittent claudication (exertional pain relieved by rest), absent distal pulses, and trophic skin changes (cool, hairless, shiny skin) is consistent with moderate peripheral arterial disease (PAD). An ABI of 0.5–0.8 corresponds to moderate PAD and correlates with claudication symptoms. An ABI 1.3 suggests non-compressible calcified vessels (common in diabetics/renal failure), and a normal ABI (0.9–1.2) would contradict the clinical presentation.