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NURS 190 Physical Assessment MIDTERM Exam, Kim Hein.(Latest UPDATE) | 100% CORRECT ANSWERS

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PA MIDTERM Kim Hein 1. The nurse is performing a comprehensive skin assessment. Which of the following pieces of equipment is appropriate to use during the skin assessment? (2 Points) doppler Wo... od's lamp Reflex hammer Goniometer 2. Which of the following is an expected finding in a healthy client on assessment of Stensen's ducts? (2 Points) red glow is present midline and symmetric saliva is present redness is present 3. Which of the following signs or symptoms does the nurse recognize in a client with hypothyroidism? (Select all that apply) (2 Points) Fatigue intolerance to cold increased cardiac output constipation 4. The client has a new diagnosis of right sided heart failure. The nurse understands a client with right sided heart failure may have edema and jugular vein distension. (2 Points) True False 5. The nurse performs the Romberg test to assess for: (2 Points) balance hearing vision loss cranial nerve 6 dysfunction 6. Which of the following techniques will the nurse perform to assess for signs of breast abnormalities? (2 Points) inspection, palpation, and auscultation inspection and palpation inspection, palpation, and percussion palpation and auscultation 7. The nurse is caring for a client with obesity. The nurse places the client in which of the following positions to best hear heart sounds? supine prone sitting upright lef t lateral 8. State at which location(s) the S1 sound (lub) is heard loudest on cardiac auscultation. State why the S1 is loudest at these locations. (Write 1-2 sentences). If you are you are at the proper location, you will hear the sound the loudest. (2 Points) 9. The nurse palpates an enlarged lymph node at the back of the ear, over the mastoid bone. The nurse documents this location as: (2 Points) posterior auricular submental posterior occular occipital 10. The older adult client is admitted with new onset pain and pressure to their eyes. On inspection, the sclera is red and the pupil is an irregular shape to the left eye. The nurse should further assess for: (2 Points) macular degeneration cataracts presbyopia Glaucoma BOOK REF. PG 253 11. The client is seen in the urgent care center with a suspected fungal infection to the fingernails. The nails are thick, yellow, and lifting off the nail bed. The nurse documents this finding as: (2 Points) clubbing Onycholysis BOOK REF PG. 203 beau's lines splinter hemmorage 12. The nurse assesses the client's radial pulses and documents these findings: 68 beats per minute, regular, 2+, symmetrical. The physician asks the nurse, "What was the client's pulse amplitude?" The best response of the nurse: (2 Points) "68 beats per minute" "regular" "2+" BOOK REF PG 404 "symmetrical" 13. The nurse is performing a cardiac auscultation and hears a harsh, blowing sound that is very loud at the 4th ICS, left sternal border. No thrill is present. The nurse understands this murmur is graded as: (2 Points) grade 4 grade 2 grade 3 grade 5 14. Which of the following clients is most at risk for developing a deep-vein thrombosis? (2 Points) A 30 year old client with is 1 week post delivery of a baby A 60 year old client who is on anticoagulant medications A 45 year old client on oral contraceptives and smokes A 40 year old female with underwent laser eye surgery 15. The nurse is performing an otoscope exam on a child in the outpatient clinic. Which of the following safety measures should the nurse observe when performing this exam? (2 Points) Position the dorsal surface of the hand on the child's head Look in the right eye with the nurse's right eye Pull the pinna up and back Look in the right ear while holding the scope in the left hand 16. Which of the following terms best describes a complete inspiratory phase and expiratory phase of breathing? (2 Points) Cardiac cycle Eupnea pneumothorax respiratory cycle 17. The client reports during the interview that they see a physician for medical care and say a nightly prayer to improve health. The nurse documents this data as which of the following? (2 Points) family history health beliefs health patterns medical history 18. The nurse is required to clean equipment, such as the stethoscope, before and after each use with a patient. (2 Points) True False 19. The nurse performing a skin assessment of a client notes the client has vascular skin lesions that are flat, bright red in color, with tiny vessels that radiate out from the center of the lesion. The nurse concludes the lesions are which of the following? (2 Points) petechiae venous stars spider angiomas port wine stain 20. The nurse notices the client has on torn clothing and is walking with a walker when entering the examination room. Which one of the following components should also be included in the general survey? (2 Points) biographical data health patterns mental status medical history 21. When assessing a client with peripheral arterial disease, the nurse assesses the client for which of the following signs and symptoms that would be consistent with arterial insufficiency? (2 Points) brownish discoloration to the skin on the ankles normal skin temperature peripheral edema leg pain while walking REF BOOK PG 398 & PG 413 22. Capillary refill is an indication of arterial status (2 Points) False True 23. The nurse assesses the posterior tibial pulse at this location: (2 Points) benind the knee directly above the antecubital area on top of the foot, between the great toe and first toe between the ankle and Achilles tendon 24. The client is seen by the nurse in the urgent care center with complaints of a headache in the frontal lobes. On collection of history, the nurse learns the client had a "bad cold" about two weeks ago. Which of the following should the nurse perform for a comprehensive sinus assessment? (2 Points) palpation, direct percussion, transillumination inspection, palpation, percussion, and auscultationte palpation, direct percussion, auscultation inspection and palpation 25. The nurse is caring for a client with end stage emphysema and plans to perform a respiratory auscultation. Which of the following is the best position for this client during the exam? (2 Points) supine prone sitting upright 26. The nurse is performing an assessment of the client's head and neck. Which of the following findings in the assessment warrants further follow up? (2 Points) midline trachea symmetric facial features non-palpable cervical lymph node crepitus on TMJ evaluation 27. The nurse is performing an ear assessment on a client. Findings: Redness, swelling, and drainage on inspection of the auricle and ear canal. Tympanic membrane is flat, grey, no white patches present. The nurse suspects: (2 Points) Otitis externa Scaring on the tympanic membrane Tophi Otitis media 28. The nurse is asking the client when the migraine headache started. The nurse is assessing in OLDCART: (2 Points) characteristics location relieving factors onset 29. This type of percussion produces a flat sound over bone such as the ribs: (2 Points) Blunt Direct Indirect Light 30. The nurse plans to complete an assessment of the head and neck lymph nodes. The nurse plans to: (2 Points) use strong pressure to the jaw and neck use a slow, gentle circular motion using fingerpads REF VIDEO palpate with the tips of the fingers to all locations auscultate with the bell of the stethoscope 31. The nurse is asking the client to describe how much and what type of exercise they participate in weekly. The nurse is assessing: (2 Points) biographical data social history health patterns general survey 32. The nurse performs palpation during a respiratory assessment of the client's thorax for: (select all that apply) (2 Points) masses vesicular sounds respiratory expansion crepitus tenderness 33. The nurse understands the importance of collecting subjective data first in a health assessment. Which of the following are included in subjective data collection? (Select all that apply) (2 Points) asking family history asking the client how much they weigh asking the client social history measuring a client's height 34. Type in your name and student ID number to confirm you are following all the WCU testing guidelines. 35. Which client with advanced breast cancer is asking the nurse to explain "peau d'orange." The nurse responds: (2 Points) This is a nipple discharge of serous fluid This is edema to the breast due to blocked lymph nodes This is an orange color that results from your medications Peau d'orange is eczema to the nipple 36. The nurse is planning on performing a cardiac assessment. The nurse assesses this area at the 2nd ICS, right sternal border: (2 Points) pulmonic aortic pulmonary mitral 37. The nurse is assessing the client's temporal artery. Which of the following findings is a concern? (2 Points) no bruits elasticity smooth tenderness 38. Which of the following are risk factors for development of cardiovascular disease? (Select all that apply) (2 Points) stress smoking family history of cardiovascular disease obesity 39. The nurse educator is working with a nursing student in the clinical setting. Which one of the following actions by the student needs additional instruction by the nurse educator in regard to assessment and documentation of capillary refill? (2 Points) the student checks the left hand nail bed and then afterwards the right hand nail bed the student documents cap refill of 2 seconds after assessing normal findings the student presses on the edge of the nail bed the student compresses the client's entire nail bed 40. The nurse is working in an eye clinic. Which patient is a priority for the nurse to assess first? (2 Points) 80 year old client awaiting cataract surgery 45 year old client reporting difficulty seeing close up over the last several months 65 year old client, African American, reporting new onset pain and pressure to the eyes 60 year old client with history of diabetes who reports trouble seeing traffic signs when driving after dark 41. The parent reports on a well visit to the pediatrician's office that their child's eyes wonder off in different directions at times. Which of the following tests is most appropriate for the nurse to perform to address this reported problem? (2 Points) cover/uncover Snellen confrontation PERRLA 42. The nurse hears soft, low pitched sounds on auscultation of the lung fields. The nurse documents these sounds as: (2 Points) tracheal bronchial bronchovesicular vesicular 43. The nurse assesses skin turgor to the client at this location: (2 Points) palmer surface hand above the clavicle on the clavicle under the clavicle 44. The client has lesions on their posterior thorax that appear as concentric circles of color. The nurse documents these lesions as: (2 Points) Grouped Confluent Discrete Target 45. The elementary school child is having difficulty reading textbook material that is close up. The nurse documents this eye condition as: (2 Points) myopia hyperopia presbyopia strabismus 46. The client enters the emergency room with shortness of breath and a high fever. The nurse counts 26 respirations over a minute period. The clients breathing is rapid and shallow. The nurse documents: (2 Points) bradypnea hyperventilation tachycardia tachypnea 47. The nurse suspects the client has dehydration. What would the nurse assess in the head to toe assessment to confirm the client has signs or symptoms of dehydration? State 2 items and the abnormal findings for each. (Write no more than 2 sentences) I would assess mucous membranes, an abnormal finding pale and I would assess skin turgor, an abnormal finding would be tenting. (2 Points) 48. The nurse documents 1+ edema to the left lower extremity. What technique did the nurse perform to document this finding? (2 Points) auscultation percussion palpation Inspection 49. The nurse plans to assess the carotid arteries for bruits. To assess for bruits, the nurse: (2 Points) palpates using very light pressure auscultates with the diaphragm of the stethoscope Ask the client to swallow water auscultates with the bell of the stethoscope 50. Prior to auscultating the carotid arteries, what instruction does the nurse give the client? (2 Points) hold your breath swallow take a deep breath report pain and I will stop the assessment 51. What type of activity is the nurse performing during health assessment? (2 Points) writes nursing diagnosis develops a plan of care collects data provides nursing education 52. Which of the following would not be appropriate to include in an interview for risk factors for glaucoma? (2 Points) Do you have hypertension? Do you have diabetes? Do you wear glasses to read? Do you have a history of trauma to your eyes? 53. Which of the following conditions will not impact breathing and lung expansion? (2 Points) pectus excavatum kyphosis pectus carinatum scoliosis 54. Which of the following clients is a priority for the nurse to perform an assessment for respiratory expansion? (2 Points) 70 year old client with a history of smoking and new diagnosis of COPD 16 year old client with a broken finger, with a history of asthma A client with a new diagnosis of bronchitis and reporting fatigue client in a motor vehicle accident with tracheal deviation 55. The 14 year old male client is going through puberty and reports an enlargement of breast tissue bilaterally. The best action of the nurse is: (2 Points) reassure the teen this is a normal finding due to hormonal changes refer the client to a physician for further evaluation of this disorder assess for further signs of breast cancer ask the client if his mother or sister has a history of breast cancer 56. The nurse auscultates the heart and palpates the carotid artery at the same time to assess for a: (2 Points) grade 4 murmur pulse deficit ventricular hypertrophy pulse pressure 57. The client with left sided heart failure is admitted with a new episode of shortness of breath. The nurse understand these lung sounds are frequently heard in left side sided heart failure: (2 Points) rhonchi crackles pleural rub stridor 58. The nurse is performing a comprehensive assessment of the breast system. Which of the following needs further evaluation by the nurse? (2 Points) smooth texture breasts of equal shape and size reports of nipple discharge similar venous patterns bilaterally 59. The nurse performs which technique to assess for tactile fremitus? (2 Points) percussion inspection auscultation palpation 60. The mother receives a letter from her son's school stating a child in the class has measles. The school recommends the mother examine the child for: (2 Points) enlarged lymph nodes to the neck white spots in the child's mouth one fluid filled lesion on the child's mouth fluid filled lesions that start on the child's thorax 61. The nurse is testing PERRLA in an adult client and the client asks the nurse to explain accommodation. Which of the following is the best response by the nurse? (2 Points) "Accommodation is when your pupil size adjusts from far to near" "Accommodation is when your pupils constrict when an object is moved farther away" "This means your pupils constrict when I shine the light in your eye." "This means your pupils dilate when I shine the light in your eye" The nurse is asking the client to describe how much caffeine they drink on a daily basis. The nurse is assessing: (2 Points) general survey health patterns social history biographical data 2. The nurse plans to assess the carotid arteries for bruits. To assess for bruits, the nurse: (2 Points) palpates using very light pressure Ask the client to swallow water auscultates with the bell of the stethoscope auscultates with the diaphragm of the stethoscope 3. The client with left sided heart failure is admitted with a new episode of shortness of breath. The nurse understand these lung sounds are frequently heard in left side sided heart failure: (2 Points) crackles rhonchi stridor pleural rub Reference Repeated Question 4. Type in your name and student ID number to confirm you are following all the WCU testing guidelines. 5. When assessing a client with peripheral arterial disease, the nurse assesses the client for which of the following signs and symptoms that would be consistent with arterial insufficiency? (2 Points) peripheral edema brownish discoloration to the skin on the ankles normal skin temperature leg pain while walking 6. Which of the following clients is a priority for the nurse to perform an assessment for respiratory expansion? (2 Points) A client with a new diagnosis of bronchitis and reporting fatigue 70 year old client with a history of smoking and new diagnosis of COPD client in a motor vehicle accident with tracheal deviation 16 year old client with a broken finger, with a history of asthma 7. Which of the following are signs or symptoms of hyperthyroidism? (select all that apply) (2 Points) intolerance to cold enlarged thyroid on palpation increased heart rate anxiety fatigue 8. The nurse gives these instructions to the client when assessing for tactile fremitus? (2 Points) please take a deep breath swallow say "99" hold your breath 9. The nurse is performing a cardiac auscultation and hears a harsh, blowing sound that is very loud at the 4th ICS, left sternal border. The nurse feels a soft vibration at the tricuspid area. The nurse understands this murmur is graded as: (2 Points) grade 3 grade 2 grade 4 grade 5 10. Which of the following conditions is associated with aging? (2 Points) pectus excavatum pectus carinatum scoliosis kyphosis 11. The nurse is educating a group of young adult females on modifying risk factors to decrease their risk of breast cancer. Which of the following are modifiable breast cancer risk factors? (select all that apply) (2 Points) alcohol intake physical activity obesity/weight control family history 12. The nurse is arriving to work on a medical surgical floor. Which client is a priority for the nurse to assess? (2 Points) 45 year old male complaining of chest pain 65 year old female with orange peel appearance to breast 25 year old client on an inhaler and oral medications for asthma 50 year old post surgical client asking to use the toilet 13. The nurse is performing an assessment of the client's head and neck. At which location does the nurse place the finger pads to assess the client's TMJ? (2 Points) in front of the tragus at the mastoid process crepitus underneath the jaw, near the tip of the mandible Reference picture : 14. The nurse is working in an eye clinic. Which patient is a priority for the nurse to assess first? (2 Points) 80 year old client awaiting cataract surgery 45 year old client reporting difficulty seeing close up over the last several months 65 year old client, African American, reporting new onset pain and pressure to the eyes 60 year old client with history of diabetes who reports trouble seeing traffic signs when driving after dark Reference: Repeated Question 15. The nurse assesses the brachial pulse at this location: (2 Points) on top of the foot, between the great toe and first toe directly above the antecubital area behind the knee between the ankle and Achilles tendon Reference The antecubital fossa is the shallow depression located in front of the median cubital vein of your arm. 16. The client has vitiligo and large, flat lesions on the skin. The lesions are non palpable and 2-3 cm each in measurement. The nurse documents these lesions as: (2 Points) wheals plaques macules Patches Reference Notes patches are flat nonpalpable change in skin color >1cm irregular border 17. The nurse plans to complete an assessment of the head and neck lymph nodes. The nurse plans to: (2 Points) use strong pressure to the jaw and neck auscultate with the bell of the stethoscope use a slow, gentle circular motion using fingerpads palpate with the tips of the fingers to all locations Reference notes, use finger pad in circular motion 18. The nurse is planning on performing a cardiac assessment. The nurse assesses the area at the 2nd ICS, left sternal border: (2 Points) pulmonary aortic pulmonic Mitral Reference notes 19. The nurse shines the light in the client's right eye and notices the left eye pupil constricts with a slower response. What action should the nurse take? (2 Points) ask another nurse to verify the finding document normal findings ask the client if they had recent surgery in the right eye contact the physician 20. The nurse receives report that the client has 4+ edema to the left lower extremity. The nurse expects to find: (2 Points) 2 mm of edema slight edema 4mm of edema a large amount of edema Reference notes +4 edema = 8mm 21. Which of the following would not be appropriate to include in an interview for risk factors for glaucoma? (2 Points) Do you have diabetes? Do you wear glasses to read? Do you have hypertension? Do you have a history of trauma to your eyes? Reference Repeated Question 22. Capillary refill is an indication of venous status. (2 Points) False True Reference it's arterial 23. The nurse performing a skin assessment of a client notes the client has vascular skin lesions that are flat, bright red in color, with tiny vessels that radiate out from the center of the lesion. The nurse concludes the lesions are which of the following? (2 Points) port wine stain petechiae venous stars spider angiomas Reference notes- flat, bright red 24. The nurse performs palpation during a respiratory assessment of the client's thorax for: (select all that apply) (2 Points) respiratory expansion crepitus tenderness fremitus Masses Reference Repeated Question 25. The nurse notices the client has on torn clothing and is walking with a walker when entering the examination room. Which one of the following components should also be included in the general survey? (2 Points) health patterns biographical data medical history behavior 26. The client enters the emergency room with shortness of breath and a high fever. The nurse counts 26 respirations over a minute period. The clients breathing is rapid and shallow. The nurse documents: (2 Points) hyperventilation tachycardia tachypnea bradypnea 27. The nurse is palpating the client's temporal artery. Which of the following is a normal, expected finding in a healthy adult client? (2 Points) no bruits elastic, non tender, smooth inflammation tenderness 28. State two (2) items the nurse would assess in a head to toe assessment on a client complaining of dizziness. State a normal or abnormal finding for each. (Write 1-2 sentences) (2 Points) 29. Which of the following clients is most at risk for developing a deep-vein thrombosis? (2 Points) A 30 year old client with is 1 week post delivery of a baby A 60 year old client who is on anticoagulant medications A 45 year old client on oral contraceptives and smokes A 40 year old female with underwent laser eye surgery 30. The nurse educator is working with a nursing student in the clinical setting. Which one of the following actions by the student needs additional instruction by the nurse educator in regard to assessment and documentation of capillary refill? (2 Points) the student compresses the client's entire nail bed the student presses on the edge of the nail bed the student documents cap refill of 2 seconds after assessing normal findings the student checks the left hand nail bed and then afterwards the right hand nail bed 31. Prior to auscultating the carotid arteries, what instruction does the nurse give the client? (2 Points) hold your breath take a deep breath report pain and I will stop the assessment swallow 32. Which part of the stethoscope does the nurse use to assess the mitral heart rate? (2 Points) diaphragm bell 33. The nurse hears soft, low pitched sounds on auscultation of the lung fields. The nurse documents these sounds as: (2 Points) bronchovesicular tracheal bronchial vesicular 34. The client reports during the interview that they see a physician for medical care and say a nightly prayer to improve health. The nurse documents this data as which of the following? (2 Points) health patterns medical history health beliefs family history 35. The nurse is taking an adult client's blood pressure. The first sound heard is at 128, the sounds get louder, more crisp, then more muffled. The last sound is heard at 68. No sound is heard at 66. The nurse documents the blood pressure as: (2 Points) 128 beats per minute 128/66 mmHg 128/68 mmHg 66/128 mmHg 36. The nurse assesses skin turgor to the client at this location: (2 Points) on the clavicle above the clavicle under the clavicle palmer surface hand 37. The nurse is performing an ear assessment on a client. Findings: no redness, swelling, or drainage on inspection of the auricle. Ear canal is pink with small amount cerumen present. Tympanic membrane is red, bulging, with no visible cone of light. The nurse suspects: (2 Points) Otitis media Scaring on the tympanic membrane Tophi Otitis externa 38. The client is wearing oxygen and has a long history of emphysema. What position is best to place this client when performing a physical assessment? (2 Points) supine prone left lateral sitting upright 39. The client is admitted with a suspected drug overdose and respiratory depression. Respirations are shallow and deep with periods of apnea in an irregular pattern. The nurse documents this condition as: (2 Points) Obstructive breathing Hyperventilation Cheyne-Stokes Biot's respirations 40. The client has lesions that are circular but united on their posterior and anterior thorax. The nurse documents these lesions as: (2 Points) discrete Target polycyclic confluent 41. The elementary school child is having difficulty reading material on the classroom white board that is about 20 feet away. The nurse suspects the client has: (2 Points) myopia strabismus presbyopia hyperopia 42. The nurse is performing an otoscope exam on a child's left ear in the outpatient clinic. The nurse should hold the otoscope in their hand. (2 Points) right left 43. The school nurse is assessing students for the annual health fair. Which of the following tests is most appropriate for the nurse to perform to assess distant visual acuity? (2 Points) cover/uncover Snellen PERRLA confrontation 44. This type of percussion produces a dull sound over organs such as the liver: (2 Points) Indirect Light Direct Blunt 45. Which client with advanced breast cancer is asking the nurse to explain "peau d'orange." The nurse responds: (2 Points) This is an orange color that results from your medications This is edema to the breast due to blocked lymph nodes Peau d'orange is eczema to the nipple This is a nipple discharge of serous fluid 46. Which of the following are signs of breast malignancy? (select all that apply) (2 Points) nipple discharge breast lump on palpation dimpling over a quadrant nipple retraction 47. The 14 year old male client is going through puberty and reports an enlargement of breast tissue bilaterally. The best action of the nurse is: (2 Points) reassure the teen this is a normal finding due to hormonal changes ask the client if his mother or sister has a history of breast cancer refer the client to a physician for further evaluation of this disorder assess for further signs of breast cancer 48. The client's fingernails have a 160 degree angle, have pink nail beds, and are clean with a hard nail plate. The nurse understands this finding is consistent with: (2 Points) normal findings beau's lines splinter hemmorage clubbing 49. The client has an enlarged lymph node to the right side of the neck. The node is soft, squishy, and movable. The nurse documents this location as: (2 Points) submaxillary retropharyngeal cervical chain Submandibular Ref- Cervical lymph nodes are simply lymph nodes located in the neck region 50. What action does the nurse perform during a health assessment? (2 Points) develops a nursing diagnosis provides nursing interventions collects data writes a care plan 51. The nurse assesses the client's radial pulses and documents these findings: 68 beats per minute, regular, 2+, symmetrical. The physician asks the nurse, "What was the client's pulse rhythm?" The best response of the nurse: (2 Points) "68 beats per minute" "regular" "2+" "Symmetrical" 52. The nurse hears the S1 loudest at the base of the heart on cardiac auscultation. (2 Points) True False 53. The nurse understands a client with left sided heart failure may report shortness of breath and present with crackles to the lung fields. (2 Points) True False Ref- both signs of left sided heart failure 54. The nurse is performing a comprehensive assessment of the breast system on a 40 year old female. Which of the following needs further evaluation by the nurse? (2 Points) change in size of one breast nipple same color as the areolae similar venous patterns bilaterally smooth texture 55. Which of the following are considered subjective data? (Select all that apply) (2 Points) Lungs with vesicular sounds to all fields client reports family history of high blood pressure Blood pressure 120/82mmHG client denies pain 56. The nurse is testing PERRLA in an adult client and the client asks the nurse to explain accommodation. Which of the following is the best response by the nurse? (2 Points) "This means your pupils dilate when I shine the light in your eye" "This means your pupils constrict when I shine the light in your eye." "Accommodation is when your pupils constrict when an object is moved farther away" "Accommodation is when your pupil size adjusts from far to near" 57. The BSN prepared nurse understands the unique changes that occur as client's age. State 2 changes you would consider normal in your physical assessment for the older adult client. (Write 1-2 sentences) Central vision loss due to macular degeneration and decrease in heart rate are two normal changes that would be considered normal for an older adult client during a physical assessment. Ref- notes (2 Points) 58. The older adult client is admitted with pain and pressure to the eyes. On inspection, the sclera is red and the pupil is an irregular shape to the left eye. The nurse should further assess for: (2 Points) macular degeneration cataracts presbyopia glaucoma 59. The nurse is asking the client with a migraine headache what they do to alleviate the pain. The nurse is assessing in OLDCART: (2 Points) onset characteristics location relieving factors 60. The client is in atrial fibrillation and the nurse plans to assess for a pulse deficit. To perform this assessment, the nurse palpates the carotid pulse while: (2 Points) auscultating the mitral area of the heart asking another nurse to palpate the opposite carotid artery comparing to the blood pressure reading palpating the radial pulse 61. The client is seen by the nurse in the urgent care center with complaints of a headache in the frontal lobes. On collection of history, the nurse learns the client had a "bad cold" about two weeks ago. Which of the following should the nurse perform for a comprehensive sinus assessment? (2 Points) inspection and palpation palpation, direct percussion, transillumination inspection, palpation, percussion, and auscultation palpation, direct percussion, auscultation [Show More]

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