CH: 28 Head to Toe Assessment

The nurse uses deep palpation of the abdomen to assess the client for presence of an abdominal mass. The client grimaces and grips the hand rails of the bed. Which response by the nurse is best?

"We can take a break anytime."

A nurse should use light palpation of the abdomen to obtain objective data about which characteristic of the abdomen?

Abdominal reflex

When interviewing a client, the nurse inquires about the presence of pain. The client states that she is in a great deal of pain. Which of the following should the nurse do next?

Ask the client to rate the pain on a scale from 0 to 10

When you enter the room of a hospitalized patient, the intravenous pump is alarming. The patient is restless, moaning, crying, and exhibiting guarding behavior. An uneaten meal is sitting on the over-bed table; several family members are arguing loudly. What would be your priority?

Assessing for pain Guarding is an indication of pain. This is the priority problem for the nurse to address.

During which of the following assessments should the nurse use the bell of the stethoscope during auscultation?

Ausculation of a patient's heart murmur. The bell of the stethoscope is used to listen to low-pitched sounds, such as heart murmurs. The diaphragm of the stethoscope is used to listen to high-pitched sounds such as normal heart sounds, breath sounds, and bowel sounds.

A client has been assigned a nursing diagnosis of fatigue related to anemia as evidenced by pale skin, statements of tiredness, and low hematocrit and hemoglobin values. What would be an appropriate nursing intervention for this client?

Collaborate with the physician to treat anemia The most appropriate intervention would be to collaborate with the provider to treat anemia. Steps might include an evaluation of nutrition and sleep patterns.

An adult client complains of dark stools for the past 3 days. Which lab should the nurse review right away?

Complete blood count

An adult client complains of dark stools for the past 3 days. Which lab should the nurse review right away?

Complete blood count Dark stool may indicate presence of blood. Therefore the hemoglobin and hematocrit should be assessed to check for blood loss. Loose stools would be a concern for potassium loss. While coagulation studies should be reviewed; the priority is to check for blood loss, then determine a possible cause such as low platelets or other coagulation disorder. A compromised liver can result in bleeding; however, the CBC should be assessed first to determine blood loss and need for immediate intervention such as transfusion.

What type of assessment would a nurse perform on a patient being admitted to the hospital?

Comprehensive The nurse in the hospital performs a comprehensive assessment of the client on admission. This assessment is more detailed and complete than screening and focused assessments that evaluate progress toward a goal later in the stay. "Acute" is a simple distractor for this question.

A nurse is assessing a client who seems to have developed a hearing impairment after working at a construction site for a few months. The nurse is using the Weber test to assess the client's hearing acuity. Weber's test does which of the following?

Determines the equality or disparity of bone-conducted sound.

The nurse is assessing an adult client with a family history of stroke. The nurse should contact the healthcare provider immediately due to which assessment finding?

Diminished carotid pulses Carotid pulses may be reduced as a result of carotid stenosis which results in decreased blood flow to the brain. This decreased blood flow can lead to a stroke. Red and swollen sinuses, immobile lymph nodes, and conductive hearing loss are all abnormal findings but are not directly a concern for stroke as carotid stenosis.

The nurse notes dull lung percussion along the lower right lobe of an adult client. Which intervention should the nurse initiate right away for this client?

Encourage turning, coughing, and deep breathing

The nurse notes dull lung percussion along the lower right lobe of an adult client. Which intervention should the nurse initiate right away for this client?

Encourage turning, coughing, and deep breathing Dull lung percussion indicates increased consolidation as with pneumonia. Encouraging turning, coughing, and deep breathing is the only independent nursing intervention that can be begun right away. While nebulizer treatments, obtaining a chest x-ray, and starting antibiotics are usually warranted for pneumonia; the nurse must notify the healthcare provider first.

A nurse is preparing a client for a head-to-toe examination. Which of the following should the nurse do at this time? Select all that apply.

Explain that the client will need to change into a gown Acquire the client's permission to ask personal questions Explain your respect for the client's privacy and for confidentiality Discuss the purpose and importance of the health history with the client

The nurse has a hand-held Snellen. When in the sequence of assessment should the nurse assess visual acuity?

Eye assessment If a hand-held Snellen is available, then inserting visual acuity in the eye assessment is appropriate.

The client has decreased sensation in his legs. What additional assessment should the nurse include?

Fall Because of decrease peripheral sensation in the legs, the client is at increased risk for falls. There is no data to support increased risk for sepsis, bloodstream or surgical site infections for this client.

A 54-year-old man is found to be anemic. Which of the following nursing diagnoses is most likely to be recorded in his plan of care?

Fatigue An appropriate nursing diagnosis would be fatigue related to anemia as evidenced by low hematocrit, hemoglobin; patient pale, tired.

What type of assessment would the nurse perform when assessing pain after medicating?

Focused The focused assessment concentrates on assessing for anticipated problems specific to the patient's problems. A comprehensive assessment is more detailed and complete than shift and focused assessments, which evaluate progress toward a goal later in the stay. The shift assessment is performed at the beginning of the shift and includes an abbreviated exam.

A nurse has completed a comprehensive nursing health history of the client and now is beginning the physical assessment. Which assessment should the nurse perform first?

General survey

An adult client states she has been drinking a very large amount of water since she has begun walking everyday. She has been transported to the emergency room due to acute confusion. Which electrolyte imbalance is most likely the cause of this client's symptoms?

Hyponatremia Any unexpectedly high or low serum sodium level can be a reflection of sodium intake but is more likely a reflection of having too much or too little water, therefore diluting or concentrating the sodium. This client has been drinking a lot of water and likely has diluted sodium levels resulting in hyponatremia. Potassium imbalances affect neural and cardiac cell conduction, leading to arrythmias and possible cardiac arrest.

During the assessment of a female client, which physical examination techniques should the nurse use to assess the vagina?

Inspection The nurse should use the technique of inspection for assessment of the vagina. The nurse should insert the speculum and inspect the vagina for color, consistency, and discharge. Palpation is used for assessment of Bartholin's glands, the urethra, and Skene's glands. The transillumination technique is used to assess scrotal sac and the sinuses.

In which order should a nurse examine the abdomen of a client during the physical assessment?

Inspection, auscultation, percussion, palpation

To assess a client's abdominal reflexes, which assessment should be included in the physical examination?

Lightly stroke inward from all quadrants.

When assessing an IV site, what should be included? Select all that apply.

Location of site Type and size of device Type of fluid Rate of infusion

The nurse identifies during assessment that the client is at risk for the development of pressure ulcers. What findings did the nurse identify? Select all that apply.

Moisture Poor nutrition Altered sensory perception

The nurse is conducting a head-to-toe assessment on a client. Which body systems are typically integrated throughout the entire assessment? Select all that apply.

Neurologic Musculoskeletal Most areas of the musculoskeletal and neurologic systems are integrated and assessed throughout the examination. Certain areas of these two major body systems are completed separately and include spinal structure and gait. The respiratory, cardiovascular, and renal and genitalia are not integrated and assessed throughout the examination.

A nurse has been ordered to include an ear assessment as part of a head-to-toe examination of a client. Which of the following pieces of equipment will the nurse need for this assessment?

Otoscope An otoscope would be needed to assess the ears. An ophthalmoscope and a Snellen chart are used to assess the eyes. A stethoscope is needed for various assessments requiring auscultation but would not be needed to assess the ears.

When doing a shift assessment on a new client, the nurse notes that the popliteal pulses are within normal limits (WNL). How would the nurse chart this?

Popliteal pulses 2-3+

When inspecting the face for facial symmetry, what would the nurse have the client do? (Select all that apply.)

Raise eyebrows Frown Smile Close eyes

The nurse has reviewed the previous physical assessment notes on a client and sees the following documentation: PERRLA, L 6-4, R 6-4. What is the nurse's best action for follow-up care on this client?

Re-assess as needed. PERRLA stands for pupils equal, round, reactive to light, and accomodate. L 6-4, R 6-4 indicates the pupil sizes of both eyes changed from 6 mm to 4 mm when testing pupil reaction. These results are normal for an adult. There is no indication or need for an opthamologist consult, Weber test (hearing), or Romberg test (balance) based on these results.

A client visits the health care facility with reports of mild hearing loss. The nurse prepares to perform which test to compare bone and air conduction?

Rinne The nurse should perform Rinne test to compare between bone and air conduction in the client with mild hearing loss. Weber's test and audiometry are done to determine diminished hearing in one ear. The Whisper test is done to evaluate hearing.

Students are learning about subjective data collection. What data are collected subjectively? (Mark all that apply.)

Risk factors Common symptoms Family history

At the beginning of the exam the nurse performs a general survey. What would the nurse assess at this time?

Safety

At the beginning of the exam the nurse performs a general survey. What would the nurse assess at this time?

Safety General survey: wash hands; assess the environment for (a) noise, (b) safety, (c) privacy, and (d) lighting.

The nurse is documenting the description and amount of wound drainage present in a Stage III pressure ulcer. Which term should the nurse use to describe bloody drainage observed when the dressing was removed?

Sanguineous Wound drainage is classifi ed as serous (clear), sanguineous (bloody), serosanguineous (mixed), fi brinous (sticky yellow), or purulent (pus). Note any signs or symptoms of infection.

A nurse should perform an ongoing assessment of which system throughout the entire examination?

Skin

When performing a shift assessment, the nurse identifies the client has on a sequential compression device. What must the nurse then assess?

Skin Sequential compression devices are placed on extremities. It is important that skin under these devices be at least every shift. These devices do not affect breath sounds, blood sugar or body temperature.

A nurse working in a clinic is planning to conduct vision screenings for a group of low-income women. What equipment would be needed to test vision?

Snellen chart A Snellen chart is used as a screening test for distant vision. It consists of characters in 11 lines of different-sized type, with the largest characters at the top of the chart and the line of smallest characters at the bottom. Vision is recorded as a score; for example, 20/20 is normal vision. A stethoscope is used to auscultate body sounds. An ophthmalmoscope is used to assess the inner eye. An otoscope is used to inspect the nasal passages.

Which of the following equipment will the nurse gather to conduct a physical examination of a client's eyes? (Select all that apply.)

Snellen chart Rosenbaum card Ophthalmoscope The nurse will need a Snellen chart, Rosenbaum card, and ophthalmoscope to examine a client's eyes. The Snellen chart provides information about visual acuity. The Rosenbaum card provides information about near vision. The ophthalmoscope is used to visualize the interior structure of the eye. A thermometer is used for vital signs assessment. A tuning fork is used for the examination of the ears.

The client has been admitted with pneumonia. What should the nurse assess?

Sputum Swelling, heart tones and peripheral pulses are related to circulatory system The sputum of a client with pneumonia should be assessed.

During the admission assessment of a new patient, the nurse is now preparing to assess the patient's thyroid gland. How should the nurse perform this assessment?

Stand behind the patient and palpate the sides of the trachea. Assessment of the thyroid gland is performed by palpating each side of the patient's trachea. Percussion, auscultation, and inspection are not central to assessment of the thyroid gland.

A nurse is preparing to perform the nurse's first complete assessment of a client at a hospital. Which of the following should the nurse consult to find out what can legally be assessed and diagnosed?

State's nurse practice act Before performing a complete assessment, read your state's Nurse Practice Act to find out what you can legally assess and diagnose. Although it is also important to know hospital policy, it is the nurse practice act of the state in which you are practicing that determines what is legal for you to perform. The supervising physician does not determine what is legal for you to perform. Nursing practice is regulated primarily at the state, not federal, level.

A nurse is performing a general survey of a patient admitted to the hospital. Which of the following actions is an element of this procedure?

Taking vital signs. The general survey is the first component of the physical assessment. It includes observing the patient's overall appearance and behavior, taking vital signs, and measuring height and weight. Information from the general survey provides clues to the patient's overall health. Palpating the integument and assessing the head and neck are part of the physical assessment and identifying risk factors for altered health occurs in the health history.

When collecting subjective data, the nurse gives the client time and encouragement to do what?

Tell about the client's concerns

The client has a Foley catheter. What should be assessed related to catheter that may alert the nurse to an infection? Select all that apply.

Temperature Odor Color Pain

The nurse has palpated a patient's radial pulses bilaterally and has documented the results of this assessment as "radial pulses 1+ bilaterally." How should this assessment finding be interpreted?

The patient's weak pulses may be indicative of cardiovascular disease. A peripheral pulse that is documented as 1+ is considered weak, a finding that may be indicative of decreased cardiac output.

A nurse is performing a part of a physical assessment for a client using palpation. What is the purpose of using this technique?

To check the skin temperature and moisture.

The nurse is assessing the head and neck areas of an adult client and discovers several abnormal findings. Which assessment finding requires priority nursing care?

Tracheal deviation.

During the eye assessment, a nurse performs part of the neurologic examination for which cranial nerve?

VII

The nurse suspects that a client has an infection of the lower leg. What skin assessment finding caused the nurse to make this clinical determination? Select all that apply.

Warmth Erythema

Before beginning a physical assessment it is important for the nurse to

acquire your client's verbal permission to perform the physical examination.

The nurse is preparing to assess a client's reflexes. At which point during the assessment should this be completed?

after assessing the motor function of the lower extremities Although many parts of the assessment can be completed at any time, assessment of the reflexes usually is completed after assessing the lower extremities and serves as a starting point for assessing neurologic functioning. Assessment of the reflexes would not occur after assessing the abdomen, cranial nerve function, or after assessing the anterior and posterior thorax.

When should the nurse assess the costovertebral angle for tenderness?

after assessing the posterior thorax Since the costovertebral angle is located beneath the lower rib, it would be appropriate to assess this area for tenderness after assessing the posterior thorax. The client would have to change position if this area were assessed during percussion of the abdomen or before palpating the lower pole of the left kidney. Although the costovertebral angle can be assessed with the client standing, it might be best to assess this area while examining the posterior thorax and not wait until the spine is assessed for range of motion.

During the general survey a client comments about the extremely cold weather even though the client lives in a major northeastern United States city and the month is July. What action should the nurse take?

assess mental status

When integrating the total physical examination the nurse should

assess peripheral vascular status when examining the lower extremities. When you assess the legs you will be assessing the parts of the skin (color and condition of skin on legs), peripheral vascular system (pulses, color, edema, lesions of legs), musculoskeletal system (movement, strength, and tone of legs), and neurologic system (ankle and patellar reflexes, clonus).

The nurse completes the assessment of a client's heart. What should be assessed next?

breasts

A client is supine with the head of the examination table at a 30-degree angle. What should the nurse assess at this time?

carotid arteries

A client is supine with the head of the examination table at a 30-degree angle. What should the nurse assess at this time?

carotid arteries The head of the table or bed should be placed in a 30-degree angle when assessing the carotid arteries. Hand grasps can be assessed in the seated or standing position. The client should be supine when assessing bowel sounds. Cranial nerves can be assessed in the standing or seated position.

The nurse notices that a client has a brilliant smile when asked about children. What should the nurse document about this finding?

cranial nerve VII intact Assessment of cranial nerve VII is conducted by asking the client to smile. Since the client smiled (for a different reason) the nurse can document that this nerve function is intact. Stating that a client is pleasant is an opinion. The client may like children however that information is not a part of the complete assessment. Having a "brilliant" smile may or may not mean that the client has routine dental visits.

A client turns the head to the right after the nurse whispers the direction to do so in the client's left ear. What information should the nurse obtain from the client's response?

cranial nerve VIII is intact Responding appropriately to the "whisper test" assesses cranial nerve VIII. Sternocleidomastoid and lower trapezius muscle strength determines if cranial nerve XI is intact. The nurse's direction was not to assess the client's understanding of directions or knowing the difference between left and right.

The nurse is conducting a physical examination of a client who has congestive heart failure. The general survey can provide the nurse with which information?

edema of the face and limbs presence of cyanosis respiratory rate

The nurse is conducting a physical examination of a client who has congestive heart failure. The general survey can provide the nurse with which information?

edema of the face and limbs presence of cyanosis respiratory rate By just observing the client, the nurse can assess for swelling in the face and limbs typically known as edema. In clients with congestive heart failure, edema can result from the expansion of extracellular fluid. Body areas commonly affected by this type of swelling are the eyes, hands, and lower legs. Cyanosis, a bluish discolouration of lips and skin due to decreased oxygenation of the blood, can be observed by the nurse during the general survey. The respiratory rate can be observed by watching the rise and fall of the client's chest over one minute. If the client has noisy breathing, this makes assessment of the respiratory rate even less difficult for the nurse to do as part of the general survey. Both apical heart rate and assessment for fluid in the lungs must be done using a stethoscope over the client's chest for auscultation.

When examining a client's musculoskeletal system, for which assessment should the client be in a seated position

elbow flexion

Two body systems that may be logically integrated and assessed at the same time are the

eye exam and cranial nerves II, III, IV, and VI. When using a head-to-toe approach, some body systems may be assessed in combination. When performing an eye assessment you will also be performing part of the neurologic exam for cranial nerves II, III, IV, and VI, which affect vision and eye movements.

For which assessment could the neurologic and musculoskeletal systems be combined?

gait

Prior to conducting a mental status exam with a client who has a diagnosis of depression, the nurse can obtain which information by observing the client?

grooming affect posture

The nurse is beginning a complete assessment of a client. What should be included as part of the general survey?

height and weight

During a physical examination the nurse assesses a client's anterior neck, carotid arteries, heart and lung sounds, and breasts before assisting the client to a seated position to examine the back. What is the best explanation for using this approach?

it limits the number of times the client had to change position Some systems overlap and can be interwoven during the examination. This limits the number of times clients need to change position from sitting to lying to standing, which can be difficult for clients who have pain, dyspnea, or limited range of motion. A front to back approach is not identified as a method to perform a physical examination. Grouping examination areas is not done to avoid missing important information or because of limited time to complete the entire assessment.

While conducting a physical examination with the client in the seated position, the nurse begins the cardiovascular assessment. In order to listen for aortic insufficiency, the nurse should ask the client to move into which position?

lean forward

While examining a client's head the nurse notes that several pieces of needed equipment are missing. Which item should be used to assess aspects of the ears and nose?

otoscope An otoscope can be used to assess both the ears and nose. The tip would need to be changed between the assessment of these areas. A pen light would not be sufficient to assess the ears and nose. A cotton swab should not be inserted into these body orifices. An ophthalmoscope would not be appropriate to assess the ears or nose.

In order to conduct an examination of the eye muscles, the nurse should prepare to administer which tests? Select all that apply.

six cardinal directions of gaze convergence near reaction cover-uncover test Tests that can be used to determine eye muscle strength include the six cardinal directions gaze, convergence, near reaction, and the cover-uncover test. Convergence is used to examine visual fields.

A client with congestive heart failure presents with edema of the ankles. When conducting a physical examination of this client, the nurse requires a stethoscope for which purpose?

to auscultate the lungs The nurse requires a stethoscope to assess for the presence of fluid in the lungs, indicating the client also has pulmonary edema. Pedal and radial pulses can be assessed using the tips of the fingers directly over the sites where these pulses are located. Jugular venous pressure is measured by palpating the carotid pulse and measuring the vertical distance between the sternal angle and the top of the jugular vein. A penlight helps identify jugular filling.