Ch. 28 Complete Health Assessment: Adult Head-to-Toe Examination (Evolve)

Which elements should be performed after light palpation of all quadrants of the abdomen in the adult patient? A. Percussion of all quadrants B. Auscultation for bowel sounds C. Deep palpation of all quadrants D. Inspection of abdominal contour

C. Deep palpation of all quadrants

Observing the patient's gait and testing balance are included in which element of the adult head-to-toe examination with patient standing? A. Spinal B. Abdominal C. Neurologic D. Musculoskeletal

C. Neurologic

Order the elements of the abdominal/genital assessment that should be performed while the male patient is standing. 1. Ask the patient to lean over examination table 2. Inspect the perianal area 3. Palpate rectal sphincter tone 4. Instruct the patient to relax the buttocks

1. Ask the patient to lean over examination table 4. Instruct the patient to relax the buttocks 2. Inspect the perianal area 3. Palpate rectal sphincter tone

Place the examination components in order for the adult patient who is supine. 1. Inspect abdomen 2. Percuss liver border 3. Palpate for pedal edema 4. Auscultate heart

1. Inspect abdomen 3. Palpate for pedal edema 2. Percuss liver border

Order the elements of an abdominal examination of an adult who is supine. 1. Deeply palpate all four quadrants 2. Inspect the skin and contour 3. Lightly palpate all four quadrants 4. Percuss all four quadrants for tone 5. Auscultate all four quadrants

2. Inspect the skin and contour 5. Auscultate all four quadrants 4. Percuss all four quadrants for tone 3. Lightly palpate all four quadrants 1. Deeply palpate all four quadrants

Place the elements of a seated examination in the correct order. 1. Inspect back and percuss posterior chest 2. Auscultate anterior chest and palpate breasts 3. Gather supplies and greet the patient 4. Assess head, ears, eyes, nose, and throat

3. Gather supplies and greet the patient 4. Assess head, ears, eyes, nose, and throat 1. Inspect back and percuss posterior chest 2. Auscultate anterior chest and palpate breasts

The healthcare provider palpates the prostate gland and seminal vesicles with the patient standing as part of which element of the examination? A. Spinal B. Rectal C. Neurologic D. Abdominal/Genital

D. Abdominal/Genital

Which elements are included in the review of systems for the functional assessment? Select all apply. A. Nutritional status B. Memory changes C. Urinary incontinence D. Prior falls or fear of falling E. Identification of caregivers

A. Nutritional status B. Memory changes C. Urinary incontinence D. Prior falls or fear of falling

Which components are included in the functional assessment? Select all apply. A. Social assessment B. Injury assessment C. Physical examination D. Evaluation of activities of daily living E. Comprehensive history

A. Social assessment C. Physical examination D. Evaluation of activities of daily living E. Comprehensive history

The assessment of financial resources and health insurance is included in which element of the functional examination? A. Social situation B. Review of systems C. Physical examination D. Activities of daily living

A. Social situation

Which elements are included in the assessment of the hips of an adult patient? Select all apply. A. Testing range of motion B. Palpating popliteal pulse C. Auscultating systematically D. Percussing for finger bone dullness E. Palpating for stability of joint

A. Testing range of motion E. Palpating for stability of joint

On which elements should the nurse focus when performing the physical examination component of the functional assessment? Select all apply. A. Determining caregiver's abilities B. Evaluating coordination and gait C. Assessing for dyspnea with exertion D. Asking about use of a cane or walker E. Measuring blood pressure while the patient is seated and standing

B. Evaluating coordination and gait C. Assessing for dyspnea with exertion E. Measuring blood pressure while the patient is seated and standing

Which element of the examination is best performed while the adult patient is reclining at 45 degrees? A. Testing range of motion of feet, ankles, and knees B. Inspecting jugular venous distention and pulsation C. Performing bimanual palpation of uterus and cervix D. Observing the patient move from lying down to a seated position

B. Inspecting jugular venous distention and pulsation Testing range of motion of feet, ankles, and knees is best performed while the patient is in the supine position with the legs exposed, not reclining at 45 degrees. Performing bimanual palpation of the uterus and cervix is best performed while the patient is in the lithotomy position, not reclining at 45 degrees. Observing how the patient moves from lying down to a seated position is best performed when the patient is in the supine position, not reclining at 45 degrees.

Which element of the examination would the nurse perform while the adult patient is in a standing position? A. Auscultating lungs B. Inspecting the spine C. Testing stereognosis D. Palpating the carotid pulse

B. Inspecting the spine

Which element of the assessment should be performed with the patient seated and wearing a gown? A. Percussion of the posterior chest B. Inspection of facial symmetry C. Auscultation of heart and lungs D. Palpation of axillary lymph nodes

B. Inspection of facial symmetry

Palpation of the thyroid and cervical lymph nodes is included in examination of which part of the body? A. Eyes B. Neck C. Mouth D. Pharynx

B. Neck

Which element of the assessment should be performed after assessment of the patient's back, posterior chest, and lungs? A. Weber test B. Palpation of apical pulse C. Palpation of posterior chest D. Inspection of spine and scapula

B. Palpation of apical pulse

Which examination component should be performed while the adult patient is supine with the legs exposed? A. Palpation of breast tissue B. Palpation of popliteal pulse C. Palpation for inguinal hernia D. Palpation for aortic pulsation

B. Palpation of popliteal pulse

Which elements are included in the assessment of the mouth and pharynx? A. Palpating the thyroid B. Testing the gag reflex C. Inspecting the septum D. Assessing the carotid pulse

B. Testing the gag reflex

Which element is included in the physical examination component of the functional assessment? A. Reviewing health insurance coverage B. Determining existence of advance directives C. Assessing the skin for signs of decubitus ulcers D. Asking the patient about activities of daily living

C. Assessing the skin for signs of decubitus ulcers

Which position should be used to inspect the back and auscultate the posterior lungs? A. Patient reclining at 45 degrees B. Patient supine with chest exposed C. Patient seated with back exposed D. Patient seated with chest exposed

C. Patient seated with back exposed

Which element is performed after inspection and palpation of the patient's spine while the patient is standing? A. Test abdominal reflexes B. Palpate axillary lymph nodes C. Assess radial and brachial pulses D. Observe the patient walk heel to toe

D. Observe the patient walk heel to toe

Which element of the functional assessment should be included during the review of systems? A. Blood pressure B. Ability to bathe C. Neurologic function D. Signs of dementia

D. Signs of dementia

Which assessment element of the adult head-to-toe examination is best performed with the patient standing? A. Palpating the abdomen B. Testing plantar reflexes C. Assessing jugular pulsation D. The Romberg test

D. The Romberg test