Head-to-Toe Sherpath

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

Social situation

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

Abdominal/Genital

Which priority action would the nurse take before beginning an examination of the breasts and genitals? Ensure proper positioning of the patient. Provide a quiet, calm environment. Ensure respect for the patient's privacy. Provide education regarding self-examinations.

Ensure respect for the patient's privacy

Which region would the nurse palpate to assess for aortic vibrations? Epigastric area Midaxillary area Midthoracic area Periumbilical area

Epigastric area

Which part of the eye would the nurse palpate gently to assess for nodules or pain? Lens Eyelid Cornea Orbital bone

Eyelid

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

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

Which physical assessment findings related to the musculoskeletal system would the nurse report to the health care provider? Select all that apply. Pain Lesions Absence of crepitus Abnormal posture or gait Presence of deep tendon reflexes

Pain Lesions Abnormal posture or gait

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

Palpation of popliteal pulse

Which component of the gastrointestinal assessment does the nurse evaluate using the diaphragm of the stethoscope? Wheezes Blood flow Bowel sounds Breath sounds

Bowel sounds

hich components are included in the neurologic system? Skull Brain Nerves Spinal cord Carotid artery

Brain Nerves Spinal cord

Which member of the health care team can perform internal vaginal and prostate examinations? Registered nurse Health care provider Patient care technician Certified nursing assistant

Health care provider

Which technique would the nurse use to palpate the breast tissue? Both hands Palm of one hand Two to three fingers Thumb and forefinger

Two to three fingers

The abdominal and gastrointestinal organs are assessed during the evaluation of which body systems? Select all that apply. Urinary Digestive Endocrine Circulatory Reproductive

Urinary Digestive

Which unexpected findings from the abdominal assessment would the nurse document in the electronic health record and report to the health care provider? Flat abdomen Visible protrusions Rebound tenderness Hyperactive bowel sounds Bowel sounds in all quadrants

Visible protrusions Rebound tenderness Hyperactive bowel sounds

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

Social assessment Physical examination Evaluation of activities of daily living Comprehensive history

Which question would the nurse ask to gather health history information about the patient's head and neck? Do you have a history of vertigo? Do you have a history of tonsillitis? Have you ever experienced dizziness? Have you experienced pain or discharge around your eyes?

Have you ever experienced dizziness? --------------------------------------- history of vertigo? --> info on the ears history of tonsilitis --> info on the mouth and throat pain or discharge around your eyes --> info on eyes

When collecting information about the patient's current health status related to the cardiovascular system, which questions would the nurse ask? Have you recently gained or lost weight? Are you experiencing chest pain? Do you have edema or swelling in your ankles? Have you ever had loss of consciousness or fainted? Have you been hospitalized for a cardiac event?

Have you recently gained or lost weight? Are you experiencing chest pain? Do you have edema or swelling in your ankles?

Which assessment techniques would the nurse use during examination of the respiratory system? Palpation Inspection Evaluation Percussion Auscultation

Palpation Inspection Auscultation

Which assessment techniques would the nurse use during the abdominal assessment? Select all that apply. Palpation Inspection Percussion Observation Auscultation

Palpation Inspection Auscultation

Which physical assessment techniques would the nurse use during examination of the cardiac and peripheral vascular systems? Palpation Inspection Interview Percussion Auscultation

Palpation Inspection Auscultation

Which techniques would the nurse use when assessing a patient's head, eyes, ears, nose, and throat? Select all that apply. Palpation Inspection Evaluation Percussion Auscultation

Palpation Inspection Auscultation

Why is palpation a apart of the musculoskeletal system assessment?

Palpation is a necessary component of the musculoskeletal assessment so that the nurse can detect - masses - crepitus - tenderness The nurse also must palpate muscles and bones

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

Palpation of apical pulse

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

Patient seated with back exposed

Which part of the nose would the nurse palpate to assess for swelling, drainage, and tenderness? Nostrils Mucosa Sinuses Septum

Sinuses

Which assessment technique would the nurse use during the neurologic assessment? Inspection Reflexology Percussion Auscultation

Inspection

Which assessment techniques would the nurse use when assessing the musculoskeletal system? Palpation Inspection Percussion Observation Auscultation

Inspection and Palpation

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

Inspection of facial symmetry

During the breast and genital examination, which findings would the nurse document and report to the health care provider? Select all that apply. Lesions on the genitalia Presence of hemorrhoids Unusual odor or discharge Excoriation of the breast tissue Symmetry of the breast tissue

Lesions on the genitalia Presence of hemorrhoids Unusual odor or discharge Excoriation of the breast tissue

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

Observe the patient walk heel to toe

In which areas would the nurse use a reflex hammer to assess for deep tendon reflexes? Patellae Biceps Triceps Phalanges Achilles tendon

Biceps, Triceps, Patella, and Achilles tendon

Which techniques would the nurse utilize when assessing the integumentary system? Palpation Inspection Percussion Auscultation Evaluation

Palpation Inspection

Babinski Reflex

Babinski Reflex --> stroking the sole of the foot to illicit plantarflexion (normal finding)

Which signs would the nurse associate with arterial insufficiency? Pallor Edema Paralysis Numbness Pulselessness

Arterial Insufficiency: Pallor, Paralysis, Numbness, and Pulselessness Edema --> venous insufficiency

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

Ask the patient to lean over the examination table Instruct the patient to relax the buttocks Inspect the perianal area Palpate rectal sphincter tone

Which actions would the nurse implement during auscultation of the cardiovascular system? Select all that apply. Listen at all three valves Evaluate for symmetry Assess rate and rhythm Feel for quality of pulses Use both sides of stethoscope

Assess rate and rhythm Use both sides of stethoscope

When the nurse identifies clubbing of a patient's nails, which type of medical condition would the nurse suspect as the cause? Cardiac Neurologic Gastrointestinal Musculoskeletal

Cardiac

The nurse associates abnormalities of the skin, hair, or nails with potential disorders of which systems? Cardiac Sensory Neurologic Respiratory Hematologic

Cardiac --> clubbing of the nails, pale skin Respiratory --> clubbing of the nails, decreased capillary refill Hematologic --> ecchymosis/bruising of the skin

Which anatomic structure would the nurse auscultate during the examination of the throat? Jugular veins Thyroid glands Carotid arteries Subclavian arteries

Carotid arteries

Which nerve does the nurse examine by evaluating eye movements and pupillary reflexes? Motor nerve Cranial nerve Sensory nerve Accessory nerve

Cranial nerve

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

Inspecting the spine

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

Deep palpation of all quadrants

Which characteristic is the nurse assessing when placing thumbs on either side of the spine during the respiratory system assessment? Lung capacity Lung shape Respiratory rate Depth of respirations

Depth of respirations

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

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

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

Inspect the skin and contour Auscultate all four quadrants Percuss all four quadrants for tone Lightly palpate all four quadrants Deeply palpate all four quadrants

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

Inspecting jugular venous distention and pulsation

Which techniques would the nurse utilize to auscultate the patient's chest during the respiratory assessment? Select all that apply. Listen for a full respiratory cycle. Use a systematic pattern. Assess at least two lobes. Feel for depth of breathing. Listen for unexpected sounds.

Listen for a full respiratory cycle. Use a systematic pattern. Listen for unexpected sounds.

In which position would the nurse place the female patient to examine the female genitalia? Sims Supine Fowler Lithotomy

Lithotomy

When examining the head and its associated structures, which unexpected findings would the nurse document? Select all that apply. Lumps Edema Lesions Symmetry Discoloration

Lumps Edema Lesions Discoloration

Which potential findings would the nurse assess during the palpation phase of the musculoskeletal examination? Select all that apply. Masses Crepitus Tenderness Deep tendon reflexes Postural abnormalities

Masses Crepitus Tenderness

Which aspects does the nurse assess while palpating the chest during the respiratory system assessment? Select all that apply. Respiratory rate Masses Skin moisture Front-to-back diameter Breathing effort

Masses Skin moisture

Which component of the focused neurologic examination addresses emotional state? Sensation Mental status Motor function Cranial nerves

Mental status

Which components does the nurse assess during the musculoskeletal examination? Mobility Bone disease Tendon injury Cartilage disorder Exercise level

Mobility Bone disease Tendon injury Exercise level

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

Neck

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

Neurologic

Which instrument would the nurse use to assess the pupillary reflexes? Penlight Otoscope Reflex hammer Tongue blade

Penlight

Which aspect of cardiovascular function does the nurse assess when inspecting the skin and lower extremities? Apical pulse Peripheral pulses Peripheral perfusion Heart rhythm

Peripheral perfusion

Which finding indicates a problem associated with bone loss, such as osteoporosis? Gross disfigurement Abnormal reflexes Postural abnormalities Decreased pulse strength

Postural abnormalities

Which findings would the nurse recognize as abnormal during assessment of the male genitalia? Select all that apply. Rashes Lesions Masses Dimpling Discharge

Rashes Lesions Masses Discharge

Match the skin assessment term to the appropriate description Redness Yellow Pallor Blue

Redness = Erythema Yellow = Jaundice Pallor = White, cardiac issue Blue = cyanosis, respiratory

Which additional body system would the nurse evaluate when assessing the cardiovascular and peripheral vascular systems? Respiratory Genitourinary Gastrointestinal Musculoskeletal

Respiratory

Which action allows the nurse to focus questions about the musculoskeletal system during the health history interview? Review of health records Organization of equipment Analysis of the review of systems Completion of the physical examination

Review of health records

Which nerve does the nurse assess when applying dull and sharp stimuli to different areas of the body? Motor nerve Cranial nerve Sensory nerve Accessory nerve

Sensory nerve

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

Signs of dementia

Which patient position enables the nurse to perform an examination of the gastrointestinal system? Sims Prone Supine Fowler

Supine

Which components would the nurse assess during palpation of the skin? Select all that apply. Clubbing Swelling Skin texture Discoloration Skin temperature

Swelling Skin texture Skin temperature

Which elements are included in the assessment of the hips of an adult patient? Testing range of motion Palpating popliteal pulse Auscultating systematically Percussing for finger bone dullness Palpating for stability of joint

Testing range of motion Palpating for stability of joint

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

Testing the gag reflex

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

The Romberg test