A: To assess the back and listen to posterior lung sounds, the nurse should place the client in the high Fowler's position. In this position, the client is sitting up with the head of the bed at a 90-degree angle. The high Fowler's position is used for performing an assessment that would require the client to sit up, such as the face and head, chest, and back.

D: Abnormal lung sounds are usually associated with chronic bronchitis, and their absence is a negative finding. Chest pain is a positive finding, and radiation is not expected for all chest pain. Elevated BP in hypertension is a positive finding, and pupils that are equal and react to light and accommodation are normal findings.

C: Subjective data or symptoms are obtained by interview during history taking. These data can be described only by the patient or caregiver. Objective data or signs are data that are obtained on physical examination. Comprehensive data are obtained from a detailed health history and physical examination of 1 or more body systems.

C: When a patient describes a feeling, the nurse should ask about the factors surrounding the situation to clarify the aetiology of the problem. An incorrect nursing diagnosis may be made if the statement is taken literally and its meaning is not explored with the patient. A sense of “being tired and unable to function” does not necessarily indicate a need for rest or sleep, and there is no way to know that treatment will relieve the problem.

A: A comprehensive health history assessment collects data about the client's entire health history and any medications, surgical procedures, or family health issues that are present. It is most appropriate when the provider does not know the client, such as when a new client is seen at a health clinic, or when the client needs help with a general concern that could have many causes, such as fatigue. A focused assessment concentrates on the client's current issue, while a follow-up assessment is important after a client has been seen for the same issue.

C: There are two sides of the stethoscope that the nurse may use with auscultation: the bell and the diaphragm. The bell side is used to hear low-pitched sounds, while the diaphragm is used for high-pitched sounds. The bell is used to assess the S3 and S4 heart sound, as these are low-pitched sounds. S1, S2 sounds and high-frequency murmurs are best heard with the diaphragm of the stethoscope.

A: The Glasgow Coma Scale is a method of determining the neurological state of a client who has suffered an injury that could impact brain function. The lower the level determined with the GCS, the more likely the client has a significant brain injury and is most likely unconscious and not responding. A GCS score less than 9 indicates that the client is impaired enough that he may not be able to breathe on his own without assisted ventilation. When the score is less than 9, the nurse should prepare for intubation (which will be at the discretion of the provider)._x000D__x000D_A non-rebreather mask would not be enough to sustain ventilation in this client. Oxygen via nasal cannula is not enough to sustain ventilation in a client with a GCS score <9. A room air trial is inappropriate for a client with a GCS score <9. This client needs breathing support.

A: An infant’s ear canal is positioned lower than older children and adults.

B: The nurse will prioritize using the ABCs, or airway, breathing, then circulation. However, while obtaining vital signs, the nurse will also notify the provider to get an EKG (ECG). The EKG will happen right after vital signs are obtained._x000D__x000D_While dizziness can be caused by an arrhythmia of the heart, the nurse will be obtaining vital signs while initiating contact with the provider in order to get an EKG (ECG) ordered._x000D__x000D_A full neurological exam and drawing blood can be performed after vital signs and EKG checks are complete.

C: The watch is used to assess pulses, the stethoscope is used to hear pulses and heart sounds, and the BP cuff is used to assess BP. The percussion (reflex) hammer is used to assess reflexes.

A: The spleen is located in the left upper quadrant (LUQ). If it is enlarged or inflamed it will be extremely painful for the client. The physician must be careful because the spleen could rupture upon palpation. The appendix is located in the right lower quadrant (RLQ). The liver is located in the right upper quadrant (RUQ). The gallbladder is located in the right upper quadrant (RUQ).

B: A nurse should use the same efficient sequence in each examination to avoid forgetting a procedure, a step in the sequence, or a body part. However, a specific method is not required. Patient’s safety, comfort, and privacy are considerations but are not the priorities. The nursing history data should be collected in an interview to avoid prolonging the examination.

D: Data is required regarding the immediate problem, but gathering additional information can be delayed. The patient should not receive pain medication before pertinent information related to allergies or the nature of the problem is obtained. Questions that require brief answers do not elicit adequate information for a health profile.

D: The usual sequence of physical assessment techniques is inspection, palpation, percussion, and auscultation. However, because palpation and percussion can alter bowel sounds, in abdominal assessment the sequence should be inspection, auscultation, percussion, and palpation.

A: When assessing a client through palpation, the nurse may use different parts of the hand to find differing signs related to the client's condition. The pads of the fingers are best used for palpating pulsations such as with an abdominal aortic aneurysm, edema, and crepitus, as well as determining moisture content of the skin. The dorsal aspect of the hand is commonly used to assess skin temperature.