The nurse is preparing to examine several clients in the clinic ...

[ssal]

The nurse is preparing to examine several clients in the clinic setting. Which client would need the greatest degree of special consideration during a physical examination?
 
  1. An adult client with flu symptoms.
  2. A preschool-age client in for a well check-up.
  3. An adolescent client who complains of fatigue.
  4. An older adult client with chronic lung disease.

Question 2

While performing a physical assessment on an adult client, the nurse identifies an unfamiliar heart sound. The nurse suspects that this is a murmur. Which nursing action is most appropriate?
 
  1. Informing the client of the abnormality.
  2. Stopping the assessment and referring the client to the healthcare provider immediately.
  3. Bring in another examiner to assess the finding.
  4. Documenting the finding and reassessing at the client's next visit.

[reversalruiz]

Answer to Question 1

Correct Answer: 4
Clients who are frail, weak, debilitated, or suffering from a chronic illness may become extremely fatigued during the physical examination due to frequent position changes. The nurse should make every effort to minimize the number of position changes for the client and should complete the exam in a timely fashion. A client ill with an acute condition such as a flu-like illness is not the same risk category as the older client with a chronic disease. Assessment approaches and techniques may vary for children, but a 3-year-old is not considered at the same risk potential as a client with a chronic respiratory illness. Fatigue in a teenager may indicate anemia or it may be caused by lack of sleep, but in general the position changes required during the complete health assessment should not be taxing on a teen.

Answer to Question 2

Correct Answer: 3

The nurse needs to complete the assessment before deciding on the urgency of referral to the healthcare provider, and this includes having a colleague assess the nurse's unfamiliar finding. The finding should be investigated at this visit, first by asking another examiner to assess the concern. When the nurse identifies an unfamiliar finding, it is appropriate to consult with a colleague to assess the finding. Informing the client of the abnormality may cause the client undue anxiety, as the finding may be a normal variant.

[ssal]

Excellent

[AngeliqueG]

TYSM