Client Health Assessment Flashcards

A practical nurse is assessing a 72-year-old client who presents with a sudden change in behaviour, inattention, and disorganized thinking that fluctuates throughout the day. The client's daughter reports he was perfectly lucid yesterday. Which assessment finding would most help differentiate delirium from dementia in this client?

Answer: The acute onset and fluctuating course of cognitive changes

The hallmark distinguishing feature of delirium versus dementia is its acute onset (hours to days) and characteristically fluctuating course — the client can appear lucid at one moment and confused the next. Dementia is gradual and progressive without such moment-to-moment fluctuation. Memory impairment, MMSE scores, and disorientation to date can occur in both conditions and are therefore not differentiating features.

During a cardiovascular assessment, a practical nurse auscultates an S3 heart sound in a 58-year-old client with a history of hypertension. Which interpretation of this finding is most clinically accurate?

Answer: It indicates ventricular gallop and may suggest heart failure or volume overload

An S3 heart sound (ventricular gallop) occurs early in diastole during rapid ventricular filling and suggests the ventricle has poor compliance or is volume overloaded, as seen in heart failure or cardiomyopathy. In a 58-year-old with hypertension, this is a pathological finding requiring follow-up. An S4 (not S3) reflects atrial contraction against a stiffened ventricle and is more common in hypertensive clients. S3 can be normal in children and young adults but is abnormal in adults over 40.

A practical nurse is performing a respiratory assessment on a client with a suspected right-sided pleural effusion. Which combination of assessment findings is most consistent with this condition?

Answer: Decreased tactile fremitus, dullness on percussion, and diminished breath sounds over the right base

Pleural effusion (fluid in the pleural space) produces a classic triad: decreased tactile fremitus (fluid dampens vibration transmission), dullness to percussion (fluid is dense), and diminished or absent breath sounds over the affected area. Increased fremitus with bronchial sounds suggests consolidation (pneumonia). Hyperresonance suggests pneumothorax, not effusion. Crackles suggest fluid within alveoli (pulmonary edema), not pleural fluid.

A practical nurse is assessing a client who reports intermittent leg pain that occurs with walking and resolves with rest. The nurse notes pallor of the affected limb on elevation and dependent rubor when the limb is lowered. Which additional finding would most strongly support a diagnosis of peripheral arterial disease rather than venous insufficiency?

Answer: An ankle-brachial index (ABI) of 0.6 in the affected limb

An ABI (ankle-brachial index) of 0.6 indicates significant arterial insufficiency (normal is 0.9–1.3; values below 0.9 suggest PAD, below 0.7 is moderate, below 0.5 is severe). The symptoms described — claudication, elevation pallor, and dependent rubor — are classic PAD findings. Pitting edema, varicosities, and hemosiderin staining around the medial malleolus are hallmarks of chronic venous insufficiency, not arterial disease.

While performing a neurological assessment, a practical nurse tests a client's cranial nerve function by asking the client to clench their teeth, palpating the masseter muscles bilaterally, and testing facial sensation with a wisp of cotton. Which cranial nerve is being primarily assessed with this sequence?

Answer: Cranial nerve V (Trigeminal)

Cranial nerve V (Trigeminal) has both motor and sensory components. Its motor branch innervates the muscles of mastication, including the masseter and temporalis (assessed by clenching the jaw). Its sensory branch carries sensation from the face, including touch (tested with cotton), pain, and temperature. CN VII (Facial) controls facial expression muscles and taste on the anterior tongue but does not innervate masticatory muscles. CN IX involves posterior tongue taste and pharyngeal sensation. CN XI controls the trapezius and sternocleidomastoid.

A practical nurse is assessing a client who is 36 hours post-operative following abdominal surgery. The client has no bowel sounds in all four quadrants after one full minute of auscultation per quadrant, a distended abdomen, and has not passed flatus. The client reports nausea but denies sharp or colicky pain. Which assessment action takes priority at this time?

Answer: Assess for additional signs of bowel obstruction, including abdominal girth measurement and pain character changes, and notify the physician

While some degree of post-operative ileus is expected after abdominal surgery, complete absence of bowel sounds across all quadrants at 36 hours with progressive distension and nausea warrants thorough assessment and physician notification. The practical nurse should measure abdominal girth (to track progression), monitor for pain character changes that might suggest obstruction versus ileus, and report findings — not independently insert an NGT, which requires a physician order. Option B is unsafe as it normalizes a potentially serious finding without escalation. Option A alone is insufficient given the complete absence of bowel sounds.