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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? "Keep taking deep breaths; you will be okay." "Let's stop; I have all of the information we need." "Let's stop and take your vital signs." "We can take a break anytime."

"We can take a break anytime." In order to ensure the client remains comfortable throughout the physical examination, the client's facial expressions and other cues about pain should be noted. The nurse should offer to take a break and continue on with the physical examination by assessing other areas in a less invasive way. The client should be made aware that he or she has the power to take a break from the examination for some relief if there is pain. Asking the client to deep breaths not helpful in this situation because it minimizes the client's comfort and does not address the underlying cause of the pain. Taking vital signs would probably show that the client's blood pressure is higher than normal because pain and anxiety can increase blood pressure, heart rate, and respiratory rate. Ana assessment of the vital signs should be complete prior to beginning the physical examination. Stopping the physical examination altogether is not correct because the assessment is largely incomplete and important clinical data that can negatively impact the client's health may be missed.

The nurse has been asked to perform a stereognosis test on an adult client. Which instructions should the nurse provide to the client before performing the test? "Quickly flip your hands back and forth on your knees as I demonstrate." "With your eyes closed, identify the object I place in your hand." "Touch the tip of your nose, then the tip of my finger as I move my finger." "Tell me which number I am tracing on your back with my finger."

"With your eyes closed, identify the object I place in your hand." Stereognosis is the ability to identify objects correctly by touch to test the sensory cortex. Graphesthesia is the ability to correctly identify a number traced on the skin. Coordination is tested with rapid alternating movements and the finger to nose tests.

A new nurse asks the precepting nurse, "How can I possibly complete assessments on all my clients during my shift?" What is the best response by the nurse preceptor? "You will get more proficient with experience." "You can't; it's impossible." "Nursing is a fast-paced job. Once you know how to manage your time you will be able to do it." "Sometimes you have to cut corners."

"You will get more proficient with experience." Performing an integrated head-to-toe assessment takes time and practice; new practitioners will improve with practice. It would be unprofessional for the preceptor to tell the new nurse that "it is impossible" or that "you have to cut corners." Nursing is a fast-paced job, but even with good time management skills, the new nurse will need more experience to become proficient.

The nurse is caring for an older adult client with a blood pressure of 186/98 mm Hg. The client asks, "What is happening to me?" Which of the following is the best response by the nurse? "You are an older adult so it's normal to have high blood pressure." "You need to eliminate salt from your diet right away." "How often do you have blurred vision and numbness and tingling?" "Your blood pressure is elevated, so we should talk more after I complete your assessment."

"Your blood pressure is elevated, so we should talk more after I complete your assessment." It's important to be honest when data are abnormal, and this is best represented by the statement, "Your blood pressure is elevated, so we should talk more after I complete your assessment." The nurse should avoid false reassurances such as, "You are an older adult so it's normal to have high blood pressure." The nurse should provide objective data and avoid making statements like, "You need to eliminate salt from your diet" without all of the data being collected first. Although blood pressure may increase with age, the blood pressure described in the question is alarmingly high and will need to be addressed without upsetting the client. The client may become upset if the nurse continues to ask questions without responding to the client's concern first.

A nurse has been assigned a group of clients. On which client should the nurse perform an integrated head-to-toe assessment first? 45-year-old client admitted with a fever and coarse lung sounds, 02 saturations 94% on 2L NC, respirations 18 unlabored 82-year-old client who uses a walker and has decreased visual acuity 54-year-old client upper extremity motor strength 5/5 right arm, 4/5 left arm 72-year-old client admitted with hypotension who has had 180 mL urine output in the past 8 hours

72-year-old client admitted with hypotension who has had 180 mL urine output in the past 8 hours The nurse would perform an integrated head-to-toe assessment on the client with hypotension and decreased urine output first. This client's blood pressure is not sufficient enough to perfuse their kidneys, thus the decreased urine output (urine output should be at least 30 mL/hr). If the nurse does not see this client first, the client may suffer acute renal dysfunction due to decreased perfusion. The 82-year-old client is presenting with normal, age-related changes, for example, unsteady gait and decreased visual acuity. The client with the fever and coarse lung sounds demonstrates a stable condition with oxygen saturation of 94% on 2L NC and respirations of 18 that are unlabored. The 54-year-old client with 5/5 right arm motor strength versus 4/5 left arm motor strength is probably right-handed (the dominant arm will be stronger).

An adult client complains of dark stools for the past 3 days. Which lab should the nurse review right away? Liver function panel Coagulation studies Electrolyte panel Complete blood count

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 client being admitted to the hospital? Acute Focused Screening Comprehensive

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 not a term commonly used to describe a type of assessment.

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? Tests air conduction of sound in the tested ear. Compares air versus bone conduction sound. Measures hearing acuity at various sound frequencies. Determines the equality or disparity of bone-conducted sound.

Determines the equality or disparity of bone-conducted sound. Weber's test helps to determine the equality or disparity of bone-conducted sound. The Rinne test compares the air versus bone conduction of sound and tests air conduction of sound in the tested ear. Audiometry measures hearing acuity at different sound frequencies.

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

Explain your respect for the client's privacy and for confidentiality Acquire the client's permission to ask personal questions Discuss the purpose and importance of the health history with the client Explain that the client will need to change into a gown When preparing the client for a full-body examination, you should do the following: discuss the purpose and importance of the health history and physical assessment with your client; acquire your client's permission to ask personal questions and to perform the various physical assessments (i.e., breast, thorax, genitourinary exam); explain your respect for the client's privacy and for confidentiality; respect your client's right to refuse any part of the assessment; and explain that the client will need to change into a gown for the examination. Validating and documenting assessment findings and formulating nursing diagnoses are steps that should occur following the assessment.

To properly evaluate a male client's genitalia, the nurse should have the client do which of the following? Ask the client to fold the gown to the waist and sit with the arms hanging freely Have the client stand and face the nurse with gown raised Lower the examination table with client in supine position Assist client to supine position with head elevated

Have the client stand and face the nurse with gown raised To evaluate a male client's genitalia, the nurse should have the client stand and face the nurse with gown raised. The nurse should ask the client to fold the gown to the waist and sit with the arms hanging freely when assessing the anterior chest. The client should not be lying supine for this examination.

The nurse is assessing a client who has a radial pulse of 138 beats per minute. What action should the nurse take? Document bradycardia. Obtain the apical pulse for one full minute. Notify the health care provider. Assess the pedal pulses bilaterally.

Obtain the apical pulse for one full minute. When obtaining vital signs, if the pulse is irregular the apical pulse should be taken for one full minute before notifying the physician. The pulse would be described as tachycardia, not bradycardia. Assessing the pedal pulses bilaterally is important but is not the priority.

A nurse is caring for a client who uses a hearing aid for amplifying sound. During the Rinne test for checking the bone conduction of the sound, where should the nurse place the stem of the vibrating tuning fork? On the mastoid area. Behind the client's head. Near the ear canal. Center of the head.

On the mastoid area. The nurse should place the stem of the vibrating tuning fork on the mastoid area behind the ear to test for bone conduction of sound waves in the tested ear. The stem is placed in the center of the head to determine equality or disparity of bone-conducted sound when conducting Weber's test. The tuning fork is not placed behind the client's head because it does not help in assessing the bone conduction of the sound. Placing the tuning fork near the ear canal facilitates the testing of air conduction of sound in the tested ear.

When assessing the abdomen, which assessment technique is used last? Palpation Percussion Auscultation Inspection

Palpation The sequence of techniques used to assess the abdomen is inspection, auscultation, percussion, and palpation. Percussion and palpation stimulate bowel sounds and thus are done after auscultation of the abdomen.

While performing a head-to-toe assessment on a client admitted 2 days ago, the nurse observes that the pupils are unequal. The nurse reviews the client's chart and notes that pupils are documented as equal, round, and reactive on the comprehensive admission assessment. What is the first action of the nurse? Contact the nurse who performed the admission assessment. Perform a focused assessment on the client. Perform a comprehensive assessment on the client. Document findings.

Perform a focused assessment on the client. If there is a change in client assessment findings, the nurse should perform a focused assessment, not a comprehensive assessment, to determine if there are other deficits. In this case, the nurse should test cranial nerves and muscle strength of all limbs. Although the nurse would document findings, that step would come later. The admitting nurse will be questioned about the admission assessment (the nurse may have charted on the wrong client), but that is not the action the nurse should take first.

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? Conduct the Romberg test. Re-assess as needed. Perform the Weber test. Refer for ophthalmologist consult.

Re-assess as needed. PERRLA stands for pupils equal, round, reactive to light, and accommodate. 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 ophthalmologist consult, Weber test (hearing), or Romberg test (balance) based on these results.

Students are learning about subjective data collection. What data are collected subjectively? (Mark all that apply.) Risk factors Auscultated sounds Visualized signs Common symptoms Family history

Risk factors Common symptoms Family history Subjective data collection includes health promotion, risk factors, history of present problem, past medical and family histories, personal and social histories, and common symptoms. Auscultated sounds and visualized signs are part of objective data collection.

At the beginning of the exam the nurse performs a general survey. What would the nurse assess at this time? Pedal pulses Hearing acuity Safety Oxygen saturation

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

A nurse should perform an ongoing assessment of which system throughout the entire examination? Skin Mental status General survey Heart

Skin The nurse should assess the skin with each part of the head-to-toe assessment looking for color changes or any suspicious lesions. General survey and mental status are assessed early in the exam process. The heart is part of the cardiovascular exam.

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? Otoscope Snellen chart Stethoscope Ophthalmoscope

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 ophthalmoscope is used to assess the inner eye. An otoscope is used to inspect the nasal passages.

The client has been admitted with pneumonia. What should the nurse assess? Peripheral pulses Heart tones Sputum Swelling

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 client, the nurse is now preparing to assess the client's thyroid gland. How should the nurse perform this assessment? Observe the midline of the client's neck while asking him or her to bear down. Lightly percuss slightly off midline over the client's trachea. Stand behind the client and palpate the sides of the trachea. Auscultate over the client's trachea while asking the client to hold his or her own breath.

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

A nurse is performing a general survey of a client admitted to the hospital. Which of the following actions is an element of this procedure? Palpating the integument. Identifying risk factors for altered health. Assessing the head and neck. Taking vital signs.

Taking vital signs. The general survey is the first component of the physical assessment. It includes observing the client's overall appearance and behavior, taking vital signs, and measuring height and weight. Information from the general survey provides clues to the client'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? Express complaints Tell stories about his or her family List common findings Tell about the client's concerns

Tell about the client's concerns The nurse gives the client time and encouragement to tell their story and experience of health or illness. Doing so provides an opportunity for the client to express concerns; it often forms the foundation for a therapeutic relationship. Subjective data collection involves learning about the client's family history and health concerns, but the nurse would steer the conversation away from social discussions of the client's family or too many unrelated complaints. Common findings are part of objective data collection and are driven by the health provider, not the nurse.

How should a nurse assess graphesthesia as part of the physical assessment of arms, hands, and fingers? Place a quarter or key in the client's hand Ask the client to touch finger to nose with eyes closed Write a number in the palm of the client's hand Evaluate sensitivity of position of fingers

Write a number in the palm of the client's hand Graphesthesia can be assessed by writing a number in the palm of the client's hand. Stereognosis is assessed by placing a quarter or key in the client's hand. Asking the client to touch the nose with a finger with eyes closed is used to assess the client's coordination. Sensation is evaluated by testing sensitivity of position of fingers.

The nurse is preparing to assess a client's reflexes. At which point during the assessment should this be completed? after assessing the anterior and posterior thorax after assessing cranial nerve function after assessing the abdomen after assessing the motor function of the lower extremities

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.

After performing a comprehensive head-to-toe assessment on a client, the nurse notes the following: ● The client reports pain in bilateral lower extremities when walking short distances, which is relieved with rest. ● Pulses are weak, barely palpable in bilateral lower extremities. ● Bilateral feet are cool to touch. ● Total cholesterol > 200. ● The client smokes two packs of cigarettes daily for past 20 years. Which step of the nursing process is the nurse performing? development of a problem-based plan implementation of interventions documentation of subjective assessment findings analysis of assessment findings

analysis of assessment findings The nurse is clustering the cues collected during assessment to determine if a client concern (nursing problem) exists; this is analysis of assessment findings. The notes contain both subjective and objective information related to peripheral arterial disease. Next, the nurse would develop a problem-based plan based on the cues of "altered tissue perfusion" and lastly would develop and implement interventions to improve the client's circulation.

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? measure body temperature offer a blanket adjust examination room temperature assess mental status

assess mental status The client's statement is inconsistent with the current weather which could indicate an alteration in mental status. It would be appropriate for the nurse to assess this client's mental status at this time. Offering a blanket, measuring body temperature, and adjusting the temperature of the examination room assumes that the client currently feels cold. This is a misinterpretation of the client's statement.

When integrating the total physical examination the nurse should perform the Mental Status Exam after examining all other body systems. integrate the rectal examination with the abdominal examination. assess cranial nerve I (olfactory) with the other 11 cranial nerves at the same time. assess peripheral vascular status when examining the lower extremities.

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).

Two body systems that may be logically integrated and assessed at the same time are the ear exam and cranial nerves IV, VI, and VIII. eye and ear exams. eye exam and cranial nerves II, III, IV, and VI. ear and nose exams.

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? respiratory gait peripheral vascular abdomen

gait Observing the gait assesses both the musculoskeletal and neurologic systems. The abdominal, respiratory, and peripheral vascular assessments do not combine the neurologic and musculoskeletal systems.

The nurse is beginning a complete assessment of a client. What should be included as part of the general survey? height and weight skin temperature facial expression ambulatory status

height and weight Height and weight are usually included with the general survey. Skin temperature would be assessed during the skin assessment. Facial expression would be noted when assessing the head. Ambulatory status would be determined when assessing the neurologic or musculoskeletal systems.

A nurse performs a head-to-toe assessment on a newly admitted client. Data analysis reveals temperature 100.94°F (38.3°C), blood pressure 82/58 mm Hg, 02 saturation 95% on room air, productive cough, lethargy, diaphoresis, WBC 15,000 mm3, hemoglobin 9 g/dl, and hematocrit 29%. Based on the analysis of the data, which of the following client concerns is a priority? hypotension hypoxia pneumonia anemia

hypotension The nursing problem-based care plan focuses on the client's response to a condition or disease process, while a medical diagnosis focuses on the etiology of the condition or disease process. This client has become hypotensive in response to the respiratory infection, which appears to be pneumonia (fever causes vasodilation throughout the body, lowering blood pressure, increasing heart rate and consuming more oxygen, thereby lowering oxygen saturation levels). Pneumonia and anemia are medical conditions, and nursing problems are signs and symptoms caused by a medical condition; therefore, they are incorrect options. There are no signs or symptoms of hypoxia; the client's oxygen saturation is within normal limits. In nursing, the problem-based care plan would be impaired tissue perfusion as evidenced by low blood pressure. The nurse would develop a problem-based plan to correct the client's hypotension. A blood pressure of 82/58 mm Hg is a priority because it impairs perfusion to vital organs such as the brain (placing the client at risk for falls) and the kidneys (placing the client at risk for acute renal failure). Blood pressure should be addressed promptly to restore perfusion.

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? supine lean forward standing prone

lean forward Leaning forward brings the ventricular apex and left ventricular outflow closer to the chest wall, enhancing detection of the point of maximal impulse and aortic insufficiency. For much of the cardiovascular examination, the client should be in the supine position; however, it is difficult to assess aortic insufficiency in this way. The three positions required for the cardiovascular assessment are sitting, lying with the head of the bed increased to 30 degrees, and left lateral decubitus.

In order to assess a client's abdominal reflexes, what should the nurse include in the physical examination? auscultation of bowel sounds light stroking inward from all quadrants light palpation of each quadrant percussion for abdominal sounds

light stroking inward from all quadrants The abdominal reflex is stimulated by stroking around the umbilicus. If reflexes are normal, the nurse should note contraction of the muscles. Auscultating for bowel sounds will not assist the nurse in assessing abdominal reflexes because this would assess the gastrointestinal system rather than the musculoskeletal system. Light palpation should be used to identify masses, tenderness, and the client's face for expressions in response to pain. Percussion of the abdomen helps to listen for sounds that provide information about the liver, kidney, and spleen.

Which of the following equipment will the nurse gather to conduct a physical examination of a client's eyes? Select all that apply. thermometer otoscope ophthalmoscope tuning fork Snellen chart

ophthalmoscope Snellen chart The nurse will need a Snellen chart and ophthalmoscope to examine a client's eyes. The Snellen chart provides information about visual acuity. The ophthalmoscope is used to visualize the interior structure of the eye. An otoscope is used to inspect the ear canal. A thermometer is used for vital signs assessment. A tuning fork is used for the examination of the ears.

The nurse wants to assess a client's 5th cranial nerve. What approach should be used? stroke each side of the cheek with a cotton wisp ask the client to frown palpate the jaw for areas of pain or tenderness ask the client to puff out the cheeks

stroke each side of the cheek with a cotton wisp Assessing for response to light sensation over the cheeks determines the status of cranial nerve V. Frowning and puffing out the cheeks assesses cranial nerve VII. Palpating the jaw for areas of pain or tenderness assesses motor function of the temporomandibular joint.

As part of a head-to-toe assessment, a nurse reviews vital signs taken by an unlicensed assistive personnel (UAP). Which client should the nurse see first? temperature: 99.8°F (37.67°C), BP 92/52 mm Hg, pulse 60 regular, respirations 20, Sp02 95% 4L NC (nasal cannula) temperature: 101.66°F (38.7°C), BP 88/56 mm Hg, pulse 110 irregular, respirations 22, Sp02 93% 6L NC (nasal cannula) temperature: 96.8°F (36°C), BP 88/50 mm Hg, pulse 105 regular, respirations 18, Sp02 94% room air temperature: 98.06°F (36.7°C), BP 90/60 mm Hg, pulse 98 regular, respirations 24, Sp02 93% 2L nasal cannula

temperature: 101.66°F (38.7°C), BP 88/56 mm Hg, pulse 110 irregular, respirations 22, Sp02 93% 6L NC (nasal cannula) The client with temperature of 101.66°F (38.7°C), BP 88/56 mm Hg, pulse 110 irregular, respirations 22, Sp02 93% 6L NC is exhibiting an irregular pulse and is hypotensive, tachycardic, tachypneic, febrile, and slightly hypoxemic with 93% oxygen saturations while receiving 6 Liters of oxygen. This client should be seen first because all of the vital signs are abnormal. The client with temperature 98.06°F (36.7°C), BP 90/60 mm Hg, pulse 98 regular, respirations 24, Sp02 93% 2L NC is not a priority because only the respirations are slightly elevated. The client with temperature 96.8°F (36°C), BP 88/50 mm Hg, pulse 105 regular, respirations 18, Sp02 94% room air is not a priority because the client only has a slight decrease in blood pressure and a compensatory heart rate of 105 and regular respirations. The client with temperature 99.8°F (37.67°C), BP 92/52 mm Hg, pulse 60 regular, respirations 20, Sp02 95% 4L NC is not a priority because all of the vital signs are within normal limits.

A client with congestive heart failure presents to the emergency department with soreness from swelling of the ankles. When conducting the physical examination of this client, the nurse would require a stethoscope for which reason? to assess jugular venous pressure to auscultate the lungs to assess pedal pulses to check the radial pulse

to auscultate the lungs The stethoscope is required to assess for the presence of fluid in the lungs, indicating that the client also has pulmonary edema, a condition that can occur in clients with congestive heart failure. Pedal and radial pulses can be assessed using the tips of the fingers directly over the sites where these pulses can be 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 nurse should use light palpation of the abdomen to obtain objective data about which characteristic of the abdomen? Irregularities of the spleen Abdominal reflex Enlargement of the liver Abnormalities of the aorta

Abdominal reflex The nurse uses light palpation for assessment of the abdominal reflex. Abnormalities of the aorta, enlargement of the liver, and irregularities of the abdominal organs are assessed through deep palpation.

During which part of a head-to-toe physical examination should the nurse palpate the epitrochlear lymph nodes? Neck Anterior chest Arm, hands, and fingers Head and face

Arm, hands, and fingers The epitrochlear lymph nodes are found on the inside of the upper arm, just above the elbow. They are assessed during the arm, hands, and fingers assessment.

An adult female client is about to undergo a physical assessment conducted by a nurse practitioner at the gynecology clinic. The nurse is preparing the room for a complete head-to-toe examination, along with a genitalia and rectal assessment and screening through the Papanicolaou test. What should the nurse do next before proceeding? Ask if the client wants an observer for the assessment Decide whether to alter the process of starting at the head and proceeding to the feet Ask for the client's permission to perform the assessment Uncover only the part being examined, covering everything else

Ask for the client's permission to perform the assessment Following completion of the health history previously described, the nurse explains the process for the physical examination, from head to toe and including auscultation of the heart and lung sounds, auscultation and palpation of the abdomen, and screening for neuromuscular problems. Because some assessments may be uncomfortable (e.g., breast, gynecological), the nurse asks the client for permission to perform them. Once the nurse has the client's permission, the nurse would ask the client if the client prefers to have a third person in the room or, if appropriate, a same-gender nurse. The nurse would take care to preserve modesty; however, this would not be the immediate next step. Alterations to the order of the examination would be unlikely unless the client had an emergency concern.

The nurse is assessing cranial nerves and should look for which sign of cranial nerve VII damage? Asymmetrical smile Hearing loss Puffy "moon" face Tongue deviation

Asymmetrical smile Facial asymmetry may indicate damage to facial nerve (cranial nerve [CN] VII) or a serious condition such as a stroke. Enlarged bones or tissues are associated with acromegaly. A puffy "moon" face is associated with Cushing syndrome. The hypoglossal nerve is tested by looking for tongue deviation. Hearing is tested when cranial nerve VIII is assessed.

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? Evaluate urinary patterns Evaluate adequacy of exercise Collaborate with the physician to treat anemia Have the client explain an energy-conservation plan to offset the effects of fatigue

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.

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. In place greater than 2 days Color Odor Temperature Pain

Color Odor Temperature Pain The nurse assesses the client for signs and symptoms of a catheter associated urinary tract infection which include temperature, pain/tenderness, odor and color. A catheter associated urinary tract infection can occur at anytime.

While performing an integrated head-to-toe assessment on a client, the nurse does not hear bowel sounds after listening for 1 minute. What is the next best action of the nurse? Document absent bowel sounds. Notify the health care provider of this abnormal finding. Palpate and percuss the abdomen. Continue to auscultate for a total of 5 minutes.

Continue to auscultate for a total of 5 minutes. If bowel sounds are not heard, the nurse should listen for a total of 5 minutes (normal bowel sounds occur 5 to 35/min). The nurse would not notify the health care provider until the abdominal assessment was complete, including listening for bowel sounds for a total of 5 minutes. The nurse would not palpate or percuss the abdomen until auscultation has been completed. The nurse would not document absent bowel sounds until the abdomen was auscultated for 5 minutes.

The client has decreased sensation in his legs. What additional assessment should the nurse include? Fall Sepsis Surgical site Bloodstream infection

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? Depression Fatigue Altered nutrition Decreased activity level

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

What type of assessment would the nurse perform when assessing pain after medicating? Urgent Shift Comprehensive Focused

Focused The focused assessment concentrates on assessing for anticipated problems specific to the client'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.

The nurse is conducting a head-to-toe assessment on a client. Which observation(s) by the nurse would be cause for concern? Select all that apply. Infestations Lesions Freckles Rashes Goose bumps

Infestations Lesions Rashes The nurse inspects the skin with each corresponding body area for rashes, lesions, or infestations (such as fleas or lice). Freckles and goose bumps would not be noted as a concern.

During the assessment of a female client, which physical examination techniques should the nurse use to assess the vagina? Transillumination Inspection Deep palpation Light palpation

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.

A nurse is performing a head-to-toe examination of a client. At which point should the nurse first put on gloves? Just after the general survey Just before the rectal assessment Just before the mouth and throat assessment Just after the mental status examination

Just before the mouth and throat assessment The nurse should first put on gloves just before the mouth and throat assessment, as this is typically the first contact the nurse will have with the client's mucous membranes or bodily fluids. The general survey and mental status examination come before the mouth and throat assessment and do not require gloves. The rectal assessment comes at the end of the examination and will require a new set of gloves.

A nurse has introduced herself to a new client and asked the client to accompany her to an appropriate location for assessment. During this initial interaction with the client, the nurse is able to ascertain the client's: Level of consciousness Coping skills Judgement and insight Health maintenance

Level of consciousness The client's response to the nurse's introduction and direction gives useful information about his or her level of consciousness. During this brief interaction, the nurse would be less able to determine the client's judgment, insight, health maintenance or copings skills, though some elements of these may be evident.

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. Respiratory Neurologic Musculoskeletal Renal and genitalia Cardiovascular

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.

It is important for the nurse to apprise the client of what the nurse is doing and what the nurse finds as it does what? Causes assessment findings to be more accurate Opens up teaching/learning moments Speeds up the pace of the assessment Instills a friendly feeling toward you in the client

Opens up teaching/learning moments Letting the client know what you are doing and your findings, such as blood pressure results, opens up teaching/learning moments and develops a rapport with your client.

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 1-2+ Popliteal pulses 3-4+ Popliteal pulses 4+ Popliteal pulses 2-3+

Popliteal pulses 2-3+

After performing a physical assessment, the nurse recognizes that which of the following findings should be shared with the health care provider as soon as possible? Positive Babinski sign Deep tendon reflexes 3+ bilaterally Aorta palpable, smooth Capillary refill in index finger less than 3 seconds

Positive Babinski sign A positive Babinski sign is indicative of a possible poor neurological outcome and the health care provider should be notified immediately. The other findings are within defined limits and are expected findings.

A nurse performs the Mini-Mental Status Exam to assess cognitive abilities of a client. What will the nurse assess as a part of the Mini-Mental Status Exam? Remote memory of the past Mood, feelings, and expression Thought processes and perception Level of consciousness

Remote memory of the past As a part of the Mini-Mental Status Exam, the nurse will assess remote memory of the past. Assessment of mood, feelings, and expression, thought processes and perception, and level of consciousness are part of general mental state assessment.

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 Whisper Weber's Audiometry

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.

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? Hospital policy Federal law State's nurse practice act Supervising physician

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 part of a physical assessment for a client using palpation. What is the purpose of using this technique? A assess the sounds from the heart, lungs, and abdomen. To check the skin temperature and moisture. To observe specific parts for normal or abnormal characteristics. To determine the density of underlying structures.

To check the skin temperature and moisture. The nurse uses the palpation technique to obtain information about the skin temperature and moisture. The percussion technique is used to determine the location, size, and density of the underlying structure as per the quality of sound produced by the tapping. The auscultation technique is used to listen to the sound of the heart, lungs, and abdomen. The inspection technique is used to observe specific parts for normal or abnormal characteristics.

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

VII The nurse checks the function of cranial nerve VII when assessing the corneal reflexes during an eye assessment. Cranial nerves IX and X are assessed during the mouth and throat assessment. Cranial nerve XI is assessed during the assessment of the arms, hands, and fingers.

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. Jaundice Warmth Increased tenting Pallor Erythema

Warmth Erythema Erythema and warmth are indications of an infection. Pallor is an indication of anemia. Jaundice indicates an issue with liver function. Increased tenting indicates low body fluid volume.

Before beginning a physical assessment it is important for the nurse to acquire your client's written permission to perform the physical examination. explain to the client the purpose of every physical assessment technique you will be using. explain to the client in detail how each body system will be assessed. acquire your client's verbal permission to perform the physical examination.

acquire your client's verbal permission to perform the physical examination. Get your client's permission to ask personal questions and to perform the various physical assessments.

When should the nurse assess the costovertebral angle for tenderness? while assessing range of motion of the spine after assessing the posterior thorax before palpating the lower pole of the left kidney during percussion of the abdomen

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.

The nurse completes the assessment of a client's heart. What should be assessed next? back breasts lower extremities abdomen

breasts After assessing the heart, the nurse should proceed to examine the breasts. The back would have been assessed when completing the assessment of the neck and thyroid gland. The abdomen will be assessed after the breasts. The lower extremities will be assessed after the abdominal assessment.

A client is supine with the head of the examination table at a 30-degree angle. What should the nurse assess at this time? hand grasps cranial nerves carotid arteries bowel sounds

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.

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 XI is intact cranial nerve VIII is intact the client knows the difference between left and right the client understands directions

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.

When should the nurse assess a client's lymph nodes? during the assessment of the associated body area after assessing the abdomen while assessing the head and neck during the assessment of the anterior chest

during the assessment of the associated body area Since the lymph nodes are scattered throughout the body, the best approach is to assess this system while completing the assessment of the associated body area. The femoral nodes can be assessed after the abdomen however the neck and axilla region would not be included. The head and neck would be assessed during the head and neck assessment. The axillae would be assessed during the examination of the anterior chest but the other node locations would not be included at this time.

The nurse is conducting a cephalic to caudal assessment with a newly admitted client. Why should the nurse compare findings from side to side? identify problems determine symmetry compare with the medical record validate findings

determine symmetry A complete assessment is performed in a cephalic to caudal sequence comparing side to side for symmetry. This approach is not used to validate findings, identify problems, or to compare with the medical record.

When examining a client's musculoskeletal system, for which assessment should the client be in a seated position? hip adduction hip abduction knee extension elbow flexion

elbow flexion Elbow flexion should be assessed with the client in a seated position. Hip abduction, hip adduction, and knee extension should be assessed with the client in the supine or standing position.

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 the nurse was following the front to back assessment approach the nurse did not want to miss collecting important information there was limited time available to complete the entire assessment

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 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 cotton swab pen light ophthalmoscope

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.

The nurse is conducting a physical examination of a client. The general survey can provide the nurse with which information? Select all that apply. safety and privacy of the environment lighting and its impact on sight apical heart rate noise and its impact on hearing presence of fluid in the lungs

safety and privacy of the environment lighting and its impact on sight noise and its impact on hearing When the nurse conducts the general survey as part of the physical examination, the nurse obtains information related to the safety and privacy of the environment, noise and its impact on hearing, and lighting and its impact on sight. The apical heart rate and assessing for fluid in the lungs are not part of the general survey.

The nurse collects equipment prior to conducting a physical examination for a new client. For which body area should the nurse use a gauze pad during the assessment? axillae tongue scalp pulses

tongue A gauze pad is used when assessing the tongue. A gauze pad is not needed when assessing the scalp, pulses, or axillae.

While performing a head-to-toe assessment, the client reports leg pain. The nurse suspects a lower extremity infection. What sign(s) and symptom(s) would indicate an infection? Select all that apply. weeping drainage red and swollen absent pulses intermittent claudication fever and increased white blood cells

weeping drainage red and swollen fever and increased white blood cells An integrated assessment (inspection and palpation of the skin, assessment of vital signs, and lab values) of a client with a wound infection would reveal red (erythema), warm, swollen tissues with weeping drainage; fever; and increased white blood cells. Absent pulses would indicate arterial insufficiency or occlusion. Intermittent claudication is seen in clients with peripheral arterial disease.