Chapter 28: Pulling It All Together: Integrated Head-to-Toe Assessment

After inspecting the skin of the legs, feet, and toes, what should the nurse do?

palpate pulses

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

A student nurse asks the instructor why it is necessary to do a comprehensive health assessment on a new client. What would be the instructor's best response?

"The comprehensive health assessment integrates all body systems and helps give the nurse an overall impression of the client's condition."

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 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."

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?

"Your blood pressure is elevated, so we should talk more after I complete your assessment."

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.

Rashes Lesions Infestations

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 for the client's permission to perform the assessment

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.

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

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

Focused

A nurse has been assigned a group of clients. On which client should the nurse perform an integrated head-to-toe assessment first?

72-year-old client admitted with hypotension who has had 180 mL urine output in the past 8 hours

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

Abdominal reflex

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.

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 Explain that the client will need to change into a gown

During which part of a head-to-toe physical examination should the nurse palpate the epitrochlear lymph nodes?

Arm, hands, and fingers

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

Auscultation of a client's heart murmur.

What would be included in a shift assessment? Select all that apply.

Auscultation of lungs on a client with pneumonia Inspection of skin on a client that is not mobile Palpating pulses on a client with PVD

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

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

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

Complete blood count

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

Comprehensive

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

Fall

The head-to-toe assessment is a very important tool in providing the best possible care to a client. What is the reason for a comprehensive health assessment? Select all that apply.

Helps the nurse identify risk factors for potential health problems Integrates all body systems Gives the nurse an overall impression of the client's condition

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

Inspection

A nurse is performing a head-to-toe examination of a client. At which point should the nurse first put on gloves?

Just before the mouth and throat assessment

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

A nurse is preparing equipment for a head-to-toe examination of a client. Equipment for assessment of which of the following body regions is the nurse most likely to need for the typical client assessment?

Mouth and throat

The nurse is assessing a client who has a radial pulse of 138 beats per minute. What action should the nurse take?

Obtain the apical pulse for one full minute.

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.

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?

Opens up teaching/learning moments

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?

Perform a focused assessment on the 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 2-3+

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

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

Safety

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

Skin

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 ophthalmoscope

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?

Stand behind the client and palpate the sides of the trachea.

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

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?

Taking vital signs.

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

Tell about the client's concerns

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

VII

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

When should the nurse assess the costovertebral angle for tenderness?

after assessing the 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?

analysis of assessment findings

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 arrives to a healthcare facility for an initial appointment. Which type of assessment should the nurse expect to complete with this client?

complete

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

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

The nurse is conducting a cephalic to caudal assessment with a newly admitted client. Why should the nurse compare findings from side to side?

determine symmetry

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.

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

gait

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

height and weight

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

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

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

In order to assess a client's abdominal reflexes, what should the nurse include in the physical examination?

light stroking inward from all quadrants

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

The nurse is conducting a physical exam for a client. When conducting the physical examination on the posterior thorax, what equipment should the nurse have on hand? Select all that apply.

pen ruler stethoscope

A nurse in a clinic performs a head-to-toe assessment on a 62-year-old male client. The assessment reveals the following: alert and cooperative, lungs diminished in the bases, increased secretions in the larger airway, respirations 22 breaths/min, pulses 1+, capillary refill greater than 3 seconds, abdomen soft and nontender, skin warm and dry with cool lower extremities, and client moves all extremities well with full range of motion.

respiratory function cardiovascular system

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

skin

The nurse completes the assessment of a client's reflexes. Which position should the nurse place the client to assess the Romberg sign?

standing

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

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 auscultate the lungs

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

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 fever and increased white blood cells