Comprehensive

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

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

During a shift assessment, the nurse finds the client unable to speak and her face is asymmetrical. What does the nurse suspect?

Stroke This client has neurological deficits as she cannot speak and her face is asymmetrical. Bell's palsy involves facial drooping but speech is intact. Sepsis is due to infection and a myocardial infarction is related to the heart.

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

The nurse should include which important safety checks before leaving a hospitalized client's room? (Select all that apply.)

-Call bell within reach -Correct intravenous lines and fluids -Wearing client identification bracelet -Correct tubes and drains intact

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?

"With your eyes closed, identify the object I place in your hand." Explanation: 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.

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

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

Arm, hands, and fingers Explanation: 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 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 (eg, 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.)

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

The nurse is assessing cranial nerves and should look for which sign of cranial nerve VII damage?

Asymmetrical smile Explanation: 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.

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

Auscultation of a patient's heart murmur Explanation: 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.

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

The nurse notes that a client suffers from chronic obstructive pulmonary disease (COPD). Which assessment finding is the nurse most likely to observe in this client?

Barrel chest

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

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.

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 patient being admitted to the hospital?

Comprehensive Explanation: 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.

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 Explanation: 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.

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.

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

A nurse is conducting the general survey at the beginning of the head-to-toe assessment. Which of the following does the nurse need to address as part of the general survey?

Evaluate personal hygiene

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 Explanation: 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.

The nurse has entered a client's room to begin a head-to-toe assessment. The client appears anxious, is pale, and is struggling to breathe. What is the nurse's priority action?

Ensure a patent airway.

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

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

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

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

Frown Close eyes Raise eyebrows Smile

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?

Gneral survey

To properly evaluate a male client's genitalia, the nurse should have the client do which of the following?

Have the client stand and face the nurse with gown raised

The nurse is preparing to conduct a physical examination of an adolescent client as part of general physical assessment. Which examination approach would be the most appropriate this client?

Head-to-toe assessment Explanation: Generally a complete assessment is performed in a head-to-toe sequence, comparing side to side for symmetry. For a healthy adolescent client, this would be the most appropriate examination. Grouping body systems together to limit position changes would be appropriate for the client with pain, shortness of breath; or limited range of motion. The examination should be conducted comparing side to side in order to assess symmetry. A major body systems first approach is appropriate for the client with identified health problems that impact one or more major body systems.

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 Explanation: Any unexpectedly high or low serum sodium level can be a reflection of sodium intake but is more likely a refl ection 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.

Which situation would require the nurse to perform an urgent assessment? Select all that apply.

Pulseless leg Temperature 102.5 °F (39.2 °C) Oxygen saturation 87%

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

Inspection Explanation: 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 Explanation: With physical examination of the abdomen, the nurse should auscultate before percussion or palpation to avoid alteration of the bowel sounds.

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.

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

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

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

Risk factors Common symptoms Family history

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 has completed examining the client's nose and sinuses. Which body area should the nurse examine next?

Mouth and pharynx Explanation: If following a head-to-toe examination approach, the nurse should examine the patient's mouth and pharynx after examining the nose and sinuses. The neck is done after assessing the mouth and pharynx. The posterior thorax is examined after the neck. The anterior thorax is examined after the posterior thorax.

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

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 Explanation: 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.

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

When assessing the abdomen, which assessment technique is used last?

Palpation Explanation: 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.

A nurse is preparing to conduct a basic physical assessment of a client who has just been admitted to the unit. What equipment will the nurse require in order to perform this assessment?

Pen light or flashlight

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+

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 Explanation: 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 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

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 Explanation: 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.

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

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

Skin. The nurse should assess the skin with each part of the head-to-toe assessment looking for color changes or any suspicious lesion

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

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 Opthalmoscope Rosenbaum card Explanation: 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

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 Explanation: 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 Explanation: 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

What symptom(s) found during assessment would cause the nurse to suspect the client may be experiencing sepsis? Select all that apply.

Temperature greater than 102 °F (38.9 °C) Respiratory rate 36 breaths per minute Altered mental state Documented or suspected infection

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. Explanation: 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.

A nurse is conducting a physical examination and is percussing the gastric area of a patient. What percussion tone is normally heard in this area?

Tympany

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

VII

The nurse is preparing to conduct a physical examination of a client who experiences pain when moving positions. Which of the following can the nurse examine while the client is still standing? (Select all that apply.)

Vision Balance Spinal motion

The best approach to use when performing a total physical examination on a client is

a head-to-toe integrated assessment of body systems. Explanation: A head-to-toe approach is more convenient for performing a comprehensive assessment, which integrates the assessment of all body systems. This approach conserves time and energy for both the client and nurse.

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

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

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 auscultating bowel sounds the nurse lightly strokes each side of the client's abdomen. What is the purpose of this technique?

assess abdominal reflex Explanation: Lightly stroking each side of the abdomen is done to determine the presence of the abdominal reflex. Percussion and palpation help determine the liver border. Deep palpation is used to find the lower pole of the left kidney. Stroking the abdomen is not done to change the character of the client's bowel sounds.

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 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

When should the nurse assess a client's lymph nodes?

during the assessment of the associated body area

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

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.

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

fall

When supine, a client's knees do not touch the examination table. On what area should the nurse focus to learn more information about this finding?

flexion and extension Explanation: Since the legs are not able to be completely extended, the nurse should focus on knee flexion and extension. Gait would not help determine if the client is experiencing an alteration in knee function. Limb length would not help explain the reason for the alteration in knee function. The knee is not assessed for abduction or adduction although movement of the knee occurs to assess for abduction and adduction of the hip.

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

focused

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

gait Explanation: 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.

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

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 (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?

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

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

palpate pulses

The nurse is planning to examine a client's thyroid. What additional body area can be assessed at this time?

posterior thorax

The nurse is preparing to assess a client's anterior thorax. In which position should the client be placed to assess the heart?

sitting

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

skin

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 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 Explanation: 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.

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 Explanation: 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.