Health Assessment Chapter 30: Head to Toe

The nurse would test for stereognosis during which part of the comprehensive exam? A) Posterior and lateral chest B) Nose and sinuses C) Arms, hands and fingers D) Legs, feet, and toes

C) Arms, hands and fingers Explanation: Stereognosis is assessed by placing a familiar object such as a key or quarter in the client's hand to determine if they can identify this. Although part of the neurologic exam, it would be done when examining the arms, hands, and fingers of the comprehensive exam.

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? A) scalp B) pulses C) tongue D)axillae

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

The nurse is assessing a client's judgment during a comprehensive head-to-toe assessment. How can the nurse best appraise this aspect of cognitive function? A) "What would you do if you found a stamped, addressed envelope on the ground?" B) "What kinds of daily activities do you do to improve your health?" C) "Tell me who is the most important person in your life, and why you selected this person?" D) "Can you describe for me what your idea of the ideal vacation looks like?"

A) "What would you do if you found a stamped, addressed envelope on the ground?" Explanation: Judgment is usually gauged by asking the client about his or her response to a hypothetical situation. None of the other listed questions requires the client to exercise judgment in a scenario.

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

A) 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? A) Ask for the client's permission to perform the assessment B) Decide whether to alter the process of starting at the head and proceeding to the feet C) Uncover only the part being examined, covering everything else D) Ask if the client wants an observer for the assessment

A) Ask for the client's permission to perform the assessment Explanation: 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 should include which important safety checks before leaving a hospitalized client's room? (Select all that apply.) A) Call bell within reach B) Bed at mid-level, locked position C) Correct intravenous lines and fluids D) Wearing client identification bracelet E) Correct tubes and drains intact

A) Call bell within reach C) Correct intravenous lines and fluids D) Wearing client identification bracelet E) Correct tubes and drains intact Explanation: Bed should be at lowest, locked position before leaving the hospital room to prevent falls. All other safety checks are correct.

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

A) Complete blood count Explanation: 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 characteristics of the nasal mucosa should the nurse recognize as normal findings upon inspection? A) Dark pink, moist, and free of exudate B) Pale, dry, with small amount of mucous C) Red, moist, and slightly swollen D) Pale pink, dry, and free of exudate

A) Dark pink, moist, and free of exudate Explanation: Normal nasal mucosa is dark pink, moist, and free of exudate. Nasal mucosa that is swollen and pale pink is seen in clients with allergies. Nasal mucosa that is red and swollen is seen in an upper respiratory infection.

When observing a client's behavior, which of the following would be most important for the nurse to compare the observations with? A) Developmental stage B) Stated age C) Overall physical development D) Vital signs

A) Developmental stage Explanation: Comparing behavior with developmental stage would be most important because it will let the nurse know if this client is behaving appropriately for that level.

When assessing the client's legs, feet, and toes, which pulses would the nurse expect to palpate? Select all that apply. A) Femoral B) Brachial C) Temporal D) Dorsalis pedis E) Popliteal F) Posterior tibial

A) Femoral D) Dorsalis pedis E) Popliteal F) Posterior tibial Explanation: When assessing the legs, feet, and toes, the nurse would palpate the femoral, popliteal, dorsalis pedis, and posterior tibial pulses. The brachial pulse is palpated when assessing the arms, hands, and fingers. The temporal pulse would be palpated when examining the head and face. Reference:

An adult client is brought via ambulance to the emergency department. Vital signs are blood pressure 84/62, pulse 122 beats/min, respirations 36 breaths/min, temperature 37.4°C (99.3°F), and oxygen saturation 78% on nonrebreather mask at 10 L of oxygen. The client is anxious and sitting in the tripod position. Which problem does the nurse need to address immediately? A) Oxygen saturation of 78% B) Pulse of 122 C) Respirations of 36 D) BP of 84/62

A) Oxygen saturation of 78% Explanation: If skin color is cyanotic or pale, breathing is difficult, posture is strained, facial expression is anxious, and overall appearance indicates distress, the nurse focuses on the immediate problem. Other cues that indicate an unstable condition in a client are difficulty managing the airway; high or low respirations, pulse, or blood pressure; acute change in mental status; seizure; new onset of chest pain; or any other concerns by the nurse.

The nurse would auscultate for voice sounds during which part of the comprehensive examination? A) Posterior chest B) Abdomen C) Head and face D) Neck

A) Posterior chest Explanation: When examining the posterior chest, the nurse would auscultate for voice sounds such as bronchophony, egophony, and whispered pectoriloquy.

When preparing to do a comprehensive health assessment, the nurse obtains the client's permission based on an understanding of which of the following? A) The client has the right to refuse. B) Permission maintains the client's confidentiality. C) It ensures that the client will answer personal questions. D) The client's level of comfort will be increased

A) The client has the right to refuse. Explanation: The nurse asks the client's permission to complete the assessment because the client has the right to refuse, and asking permission fosters the client's autonomy. In addition, some parts of the physical examination require touching or exposing the client, which requires the client's permission also. Permission does not maintain confidentiality, nor does it ensure that the client will answer personal questions. Thorough explanation, preparation, and respect will help to increase the client's level of comfort.

A nurse is performing an assessment within the legal parameters of assessment and diagnosis. Where would the nurse find these legal guidelines? A) The state's Nurse Practice Act B) The client's informed consent documents C) The nurse's terms of license D) The institution's policies and procedures guidelines

A) The state's Nurse Practice Act Explanation: The nurse should check the state's Nurse Practice Act to find out what the nurse can legally assess and diagnose. Informed consent documents do not specify these guidelines. The Nurse Practice Act supersedes a nurse's terms of license or an institution's policies.

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

A) VII Explanation: 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 is performing a head-to-toe assessment of a client. What would be an example of information obtained during the review of the client's body systems? A) Wears dentures; denies problems with eating, chewing, and swallowing. B) States her father died of a heart attack at age 70. C) Uses over-the-counter antacid for occasional heartburn. D) Vaginal delivery of two children without complications.

A) Wears dentures; denies problems with eating, chewing, and swallowing. Explanation: The statement about dentures and no problem with eating, chewing, and swallowing reflects a review of the client's body system, specifically the mouth and throat. The statement about the father dying from a heart attack reflects family health history. Use of over-the-counter antacids would reflect lifestyle and health practices, specifically medication use. The statement about vaginal delivery reflects the client's past health history.

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

A) Write a number in the palm of the client's hand Explanation: 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.

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

A) Write a number in the palm of the client's hand Explanation: 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. Sensation is evaluated by testing sensitivity of position of fingers.

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? A) it limits the number of times the client had to change position B) the nurse was following the front to back assessment approach C) the nurse did not want to miss collecting important information D) there was limited time available to complete the entire assessment

A) it limits the number of times the client had to change position Explanation: 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.

Once a client has been assessed, the nurse uses data to formulate a care plan that assists with achieving specific outcomes for the individual client. What must the nurse keep in mind when deciding on which outcomes are appropriate for each client? Select all that apply. A)Outcomes must be specific to the client B) Outcomes must be realistic to achieve C) Outcomes must be measurable D) Outcomes have no time frame for being met E) Outcomes must always be achieved

A)Outcomes must be specific to the client B) Outcomes must be realistic to achieve C) Outcomes must be measurable Explanation: Outcomes are specific to the client, realistic to achieve, and measurable and have a time frame for completion.

When documenting a comprehensive assessment, which statement would the nurse record as the reason for seeking health care? A) "I try not to let the pain affect my life." B) "I haven't had a checkup in over 5 years." C) "I had my appendix removed when I was 14 years old" D) "I have an aunt who had breast cancer."

B) "I haven't had a checkup in over 5 years." Explanation: The statement about not having had a checkup in over 5 years reflects the reason for seeking health care. The statement about not letting the pain affect life reflects a history of the present health concern. The statement about appendix removal at age 14 reflects the client's past health history. The statement about an aunt with breast cancer reflects the client's family history.

A nurse knows that a normal capillary bed refills in how many seconds? A) Less than 1 B) 1 to 2 C) 3 to 4 D) 5 to 6

B) 1 to 2 Explanation: Normal capillary refill is 1 to 2 seconds. Capillary refill exceeding 2 seconds may indicate vasoconstriction.

A client has a nursing diagnosis of ineffective coping related to repeat episodes of diarrhea and financial stressors. Which of the following is an appropriate intervention for this nursing diagnosis? A) Gradually increase activity as tolerated B) Accurately assess stressors and effectiveness of coping methods C) Monitor effectiveness of medication used to treat diarrhea D) Monitor intake and output

B) Accurately assess stressors and effectiveness of coping methods Explanation: This client's nursing diagnosis and related factors do not correspond with problems related to activity tolerance. The appropriate intervention is consistent with measures to reduce stress and coping, which are necessary to assist with the problem of ineffective coping.

A client has been recovering from surgery in the hospital, and the nurse is beginning a shift by conducting an abbreviated head-to-toe assessment. How should the nurse assess the client's bowel sounds? A) Auscultate for 2 to 3 minutes in the client's right upper abdominal quadrant. B) Auscultate for bowel sounds in each of the client's four abdominal quadrants. C) Auscultate for 5 minutes to confirm the presence of consistent bowel sounds. D) Auscultate to determine which quadrant contains the most active bowel sounds.

B) Auscultate for bowel sounds in each of the client's four abdominal quadrants. Explanation: The nurse should listen to all four quadrants of the abdomen to assess bowel sounds, even in an abbreviated assessment. However, it is unnecessary to listen for several minutes, except when differentiating between hypoactive and absent bowel sounds.

The nurse is unable to palpate a pedal pulse in the right leg of an adult client. What the nurse's best action? A) Notify the healthcare provider. B) Obtain a Doppler to verify absent pulse. C) Elevate the client's right leg. D) Apply sequential compression devices.

B) Obtain a Doppler to verify absent pulse. Explanation: Diminished or absent pulses. If present, obtain Doppler for assessment. Bounding (4) pulses are also abnormal. The nurse should first confirm the absence of a pedal pulse, then notify the healthcare provider. Elevating the leg promotes venous return but does not promote arterial flow to aid in palpating a pulse. If the pulse is absent in the right leg, the cause could be a blood clot. Applying sequential devices could potentially mobilize a clot leading to pulmonary embolus.

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? A) Weber's B) Rinne C) Whisper D) Audiometry

B) 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.

Which placement of the hands demonstrates proper technique by a nurse for palpating the thyroid gland? A) Standing in front of the client, place the fingers just below and under the mandible B) Standing behind the client, place the fingers on either side of the trachea below the cricoid cartilage C) Standing in front of the client, hook the fingers into the clavicle and press firmly and deeply D) Standing behind the client, place fingers at the base of the ears and palpate along the sternomastoid muscle on either side

B) Standing behind the client, place the fingers on either side of the trachea below the cricoid cartilage Explanation: To correctly palpate the thyroid gland, the nurse should use a posterior approach. Stand behind the client and place the thumbs on the nape of the neck and fingers on either side of the trachea below the cricoid cartilage. Displace the trachea to one side and feel deeply in front of the sternomastoid muscle. To palpate the submandibular nodes, the nurse should stand in front of the client and place the fingers just below and under the mandible. Hooking the fingers into the clavicle and pressing firmly and deeply is the correct technique for palpation of the supraclavicular nodes. Standing behind the client, placing fingers at the base of the ears and palpate along the sternomastoid muscle on either side is the correct technique for palpation of the superficial cervical nodes.

When conducting a physical assessment, what should the nurse assess and document about size and shape of body parts? A) Actual measurements in centimeters. B) Symmetry (comparison of bilateral body parts). C) Indications of general health status. D) Vital signs of all extremities (arms and legs).

B) Symmetry (comparison of bilateral body parts). Explanation: When conducting a physical assessment, the nurse assesses and compares all bilateral body parts. The symmetry of parts of the body (such as the skull) and the extremities (arms and legs) is an important assessment to assess and document.

A nurse recognizes that the normal breath sounds that are auscultated over the peripheral lung fields are what type of sound? A) Bronchial B) Vesicular C) Tracheal D) Bronchovesicular

B) Vesicular Explanation: The normal breath sounds auscultated over the peripheral lung fields is vesicular. These are low pitched, soft amplitude, and long in inspiration and short in expiration. Bronchial sounds are auscultated over the trachea and thorax. These sounds are high pitched, loud in amplitude, and short during inspiration and long in expiration. Bronchovesicular sounds are auscultated over the major bronchi. These sounds are low pitched, moderate in amplitude, and same during inspiration and expiration.

The best approach to use when performing a total physical examination on a client is A) a toe-to-head integrated assessment of body systems. B) a head-to-toe integrated assessment of body systems. C) a total body system approach examining each body system individually. D) any approach that is convenient for you and the client.

B) 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.

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? A) offer a blanket B) assess mental status C) measure body temperature D) adjust examination room temperature

B) assess mental status Explanation: 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.

The nurse notices that a client has a brilliant smile when asked about children. What should the nurse document about this finding? A) the client is pleasant B) cranial nerve VII intact C) the client likes children D) routine dental visits occur

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

A client turns the head to the right after the nurse whispers the direction to do so in the client's left ear. What information should the nurse obtain from the client's response? A) cranial nerve XI is intact B) cranial nerve VIII is intact C) the client understands directions D) the client knows the difference between left and right

B) cranial nerve VIII is intact Explanation: 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

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? A) to assess pedal pulses B) to auscultate the lungs C) to assess jugular venous pressure D) to check the radial pulse

B) 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.

A nurse who is skilled in assessment is to obtain a comprehensive health assessment. The nurse would most likely be able to complete this assessment within which time frame? A) 2 hours B) 1 hour C) ½ hour D) ¼ hour

C) ½ hour Explanation: To perform a complete interview and total physical examination may take up to 2 hours for the novice nurse and only 30 minutes for a skilled practitioner.

A high school football player presents to the hospital with dizziness, headache, sleepiness, increased tenting of the skin, and decreased turgor following an intensive practice in the summer heat. Which of the following nursing diagnoses can the nurse formulate based on this information? A) Risk for Imbalanced Fluid Volume B) Activity Intolerance C) Deficient Fluid Volume D) Acute Confusion

C) Deficient Fluid Volume Explanation: Based on the symptoms listed, the nurse can formulate the diagnosis Deficient Fluid Volume as manifested by increased tenting of the skin and decreased turgor related to inadequate fluid intake during exercise in the heat. A diagnosis of Risk for Imbalanced Fluid Volume would not be appropriate, as the client is already demonstrating symptoms of dehydration. There is no indication of activity intolerance or acute confusion.

A nurse is preparing to complete a comprehensive health assessment on a female client. Prior to beginning the assessment, the client states, "I'm really having a good deal of pain in my hip now." What would be most appropriate for the nurse to do? A) Begin the comprehensive assessment and aim to complete it efficiently. B) Explain the reason for the client's assessment. C) Delay the full exam until the client's pain has been addressed. D) Provide education on pain control.

C) Delay the full exam until the client's pain has been addressed. Explanation: The client's physical and mental statuses determine how much of the exam a nurse may perform at one time. If a client is experiencing significant pain, an extensive assessment should wait until the client is more comfortable. It would be inappropriate to begin the assessment or explain the reason for the assessment. Although education on pain control may be needed, the client is in pain now and comfort is the priority.

A novice nurse is practicing how to complete a comprehensive assessment to gain confidence and skill. What would be most important for the nurse to remember? A) Gather health history information first. B) Intersperse the physical exam with the history. C) Establish a routine for the assessment. D) Allow the client a break between the two parts of the history/exam.

C) Establish a routine for the assessment. Explanation: There is no one right way to integrate the entire health history and physical examination. However, it is important to stick to a routine to avoid omitting an important step that may delete significant data from the assessment. Short rest periods to help break up the assessment would be appropriate but not the most important.

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? A) Decreased activity level B) Altered nutrition C) Fatigue D) Depression

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

As part of the equipment, a nurse makes sure to have a speculum for an assessment to perform on a client. In which part of the assessment is the nurse most likely to use a speculum? A) Musculoskeletal B) Male genitalia C) Female genitalia D) Mouth and throat

C) Female genitalia Explanation: A vaginal speculum would be used to assess a client's vagina as part of the female genitalia assessment.

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? A) Mental status examination B) Skin assessment C) General survey D) Eye assessment

C) General survey Explanation: The nurse should begin the physical assessment with a general survey.

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

C) Have the client stand and face the nurse with gown raised Explanation: 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 has completed examining the client's nose and sinuses. Which body area should the nurse examine next? A) Neck B) Posterior thorax C) Mouth and pharynx D) Anterior thorax

C) Mouth and pharynx Explanation: If following a head-to-toe examination approach, the nurse should examine the client'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.

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? A) Causes assessment findings to be more accurate B) Speeds up the pace of the assessment C) Opens up teaching/learning moments D) Instills a friendly feeling toward you in the client

C) Opens up teaching/learning moments Explanation: 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.

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? A) Refer for ophthalmologist consult. B) Perform the Weber test. C) Re-assess as needed. D) Conduct the Romberg test.

C) Re-assess as needed. Explanation: 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.

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? A) Fibrinous B) Serous C) Sanguineous D) Purulent

C) Sanguineous Explanation: Wound drainage is classified as serous (clear), sanguineous (bloody), serosanguineous (mixed), fibrinous (sticky yellow), or purulent (pus). Note any signs or symptoms of infection.

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? A) Hospital policy B) Supervising physician C) State's nurse practice act D) Federal law

C) 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.

The nurse is preparing to gather equipment prior to a client's head-to-toe assessment. The nurse's selection of equipment should be based primarily on what variable? A) The nurse's time allowance B) The nurse's level of expertise C) The client's health needs D) The client's level of participation

C) The client's health needs Explanation: Several variables influence the nurse's selection of equipment, including the nurse's expertise and the client's level of participation. However, the client's health status and health needs are paramount. The nurse's timeline must sometimes be accommodated, but this is not a primary considerations.

A nurse is preparing to assess a client's mental status using the Mini-Mental State Examination. The nurse would need to complete additional assessment of which of the following? A) Orientation B) Memory C) Thought processes D) Speech

C) Thought processes Explanation: The Mini-Mental State Examination tests level of orientation, memory, speech, and cognitive functions but does not evaluate mood, feelings, expressions, thought processes, or perceptions. Therefore additional assessment of these later areas would be necessary.

A nurse has explained the purpose and procedure for a comprehensive assessment and has directed the client to an appropriate position on the bed. The nurse has also provided a drape with which to cover the client. What is the primary purpose of providing a drape during the assessment process? A) To keep the client warm while body parts are exposed. B) To provide a barrier during palpation and percussion to ensure objective interpretation of findings. C) To provide the client with modesty during the assessment. D) To keep the client's skin dry during the assessment.

C) To provide the client with modesty during the assessment.

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

C) 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.

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

C) assess peripheral vascular status when examining the lower extremities. Explanation: 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).

A client arrives to a healthcare facility for an initial appointment. Which type of assessment should the nurse expect to complete with this client? A) urgent B) focused C) complete D) evaluative

C) complete Explanation: A complete assessment is performed on new clients or new admissions to a health care agency. A focused assessment targets specific body systems. An urgent assessment collects data on a particular health issue prior to implementing emergency interventions. Evaluative is not a type of assessment.

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

C) determine symmetry Explanation: 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 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? A) gait B) limb length C) flexion and extension D) abduction and adduction

C) 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.

The nurse is examining a client who has an exacerbation of hip pain when in a sitting position. Which body system can the nurse examine with the client lying down? A) Posterior thorax B) Balance C) Spinal motion D) Anterior thorax

D) Anterior thorax Explanation: The anterior thorax can be examined with the client lying down. The posterior thorax is best examined in the seated position. Balance and spinal motion are examined with the client standing.

When you enter the room of a hospitalized client, the intravenous pump is alarming. The client 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? A) Troubleshooting the infusion pump B) Talking with family members C) Assessing nutrition D) Assessing for pain

D) 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? A) Hearing loss B) Puffy "moon" face C) Tongue deviation D) Asymmetrical smile

D) 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.

The nurse will palpate a client's axillae during a head-to-toe assessment. The nurse should combine this with examination of which area? A) Neck B) Anterior chest C) Heart D) Breasts

D) Breasts Explanation: During the breast examination, the nurse palpates the axillae. The axillae are anatomically closest to the breasts.

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? A) Administer a nebulizer treatment B) Order a chest x-ray C) Begin antibiotic therapy through intravenous route D) Encourage turning, coughing, and deep breathing

D) 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.

When discussing health assessment, the nursing instructor would tell the students that potential or actual problems are identified in order to focus on areas requiring what? A) Psychological testing B) Interdisciplinary collaboration C) Nutritional supplementation D) Health teaching

D) Health teaching Explanation: After collecting and analyzing all these data, you determine potential and actual risk factors for the client and use this information to plan specific screening, health promotion, and client teaching activities.

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

D) 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.

The nurse is preparing to perform a comprehensive assessment of a client who has a diagnosis of Alzheimer's disease. How should the nurse accommodate the client's cognitive deficit when obtaining the client's health history? A) Get the client's history from the electronic health record, then do the physical assessment. B) Focus the assessment on aspects of the client's history that he is able to accurately describe. C) Perform the assessment as quickly as possible in order to minimize the client's stress. D) Supplement the client's statements with data from the client's friends and family.

D) Supplement the client's statements with data from the client's friends and family. Explanation: If the client is unable to provide all necessary data, it is appropriate to gather data from friends and family. The client's stress should be minimized, but assessing quickly is not necessarily the best way to achieve this. It would be inappropriate to limit the assessment to aspects that the client can describe or to completely forego the interview and rely solely on the health record. Reference:

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

D) after assessing the motor function of the lower extremities Explanation: 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.

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

D) carotid arteries Explanation: 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.