NR206 Pulling It All Together: Integrated Heat-to-Toe Assessment

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? abduction and adduction flexion and extension gait limb length

flexion and extension

The nurse is preparing to conduct a physical examination of an adolescent client as part of a general physical assessment. Which examination approach would be the most appropriate for this client? beginning with the musculoskeletal assessment of the extremities major body systems first approach head-to-toe assessment grouping body systems together to limit position changes

head-to-toe 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? determine symmetry validate findings identify problems compare with the medical record

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. ear and nose exams. eye and ear exams. ear exam and cranial nerves IV, VI, and VIII.

eye exam and cranial nerves II, III, IV, and VI.

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

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

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

Comprehensive

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

Fall

A 54-year-old man is found to be anemic. Which of the following nursing diagnoses is most likely to be recorded in his plan of care? Depression Fatigue Decreased activity level Altered nutrition

Fatigue

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

Have the client stand and face the nurse with gown raised

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. Freckles Goose bumps Lesions Rashes Infestations

Lesions Rashes Infestations

The nurse will obtain the greatest amount of information about the thyroid gland by using which technique of assessment? Auscultation Percussion Palpation Inspection

Palpation

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? Capillary refill in index finger less than 3 seconds Deep tendon reflexes 3+ bilaterally Aorta palpable, smooth Positive Babinski sign

Positive Babinski sign

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

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

The hospitalized client is at risk for ineffective tissue perfusion. What should the nurse assess to identify ineffective tissue perfusion? Capillary refill Nutritional status Skin moisture Mobility status

Capillary refill

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

Complete blood count

When performing a shift assessment, the nurse identifies the client has on a sequential compression device. What must the nurse then assess? Breath sounds Temperature Blood sugar Skin

Skin

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

Sputum

When collecting subjective data, the nurse gives the client time and encouragement to do what? Tell stories about his or her family Express complaints Tell about the client's concerns List common findings

Tell about the client's concerns

After auscultating bowel sounds the nurse lightly strokes each side of the client's abdomen. What is the purpose of this technique? change the character of bowel sounds find the lower pole of the left kidney determine the liver border assess abdominal reflex

assess abdominal reflex

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

Write a number in the palm of the client's hand

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

a head-to-toe integrated assessment of body systems.

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

acquire your client's verbal permission to perform the physical examination.

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

assess peripheral vascular status when examining the lower extremities.

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? ophthalmoscope otoscope pen light cotton swab

otoscope

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 to assess jugular venous pressure to assess pedal pulses to check the radial pulse

to auscultate the lungs