Putting it All Together

The nurse prepares to complete a head-to-toe assessment on a client. For which assessments should the nurse wear gloves? Select all that apply. 1. Eyes 2. Breasts 3. Skin, hair, nails 4. Musculoskeletal 5. Thorax and lungs

1. Eyes 2. Breasts 3. Skin, hair, nails 5. Thorax and lungs

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? 1. Snellen chart 2. Stethoscope 3. Ophthalmoscope 4. Otoscope

1. Snellen chart

The client has been admitted with pneumonia. What should the nurse assess? 1. Sputum 2. Heart tones 3. Peripheral pulses 4. Swelling

1. Sputum

During the admission assessment of a new client, the nurse is now preparing to assess the client's thyroid gland. How should the nurse perform this assessment? 1. Stand behind the client and palpate the sides of the trachea. 2. Auscultate over the client's trachea while asking the client to hold his or her own breath. 3. Lightly percuss slightly off midline over the client's trachea. 4. Observe the midline of the client's neck while asking him or her to bear down.

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

How should a nurse assess graphesthesia as part of the physical assessment of arms, hands, and fingers? 1. Write a number in the palm of the client's hand 2. Place a quarter or key in the client's hand 3. Ask the client to touch finger to nose with eyes closed 4. Evaluate sensitivity of position of fingers

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

After auscultating bowel sounds the nurse lightly strokes each side of the client's abdomen. What is the purpose of this technique? 1. assess abdominal reflex 2. determine the liver border 3. find the lower pole of the left kidney 4. change the character of bowel sounds

1. assess abdominal reflex

When examining a client's musculoskeletal system, for which assessment should the client be in a seated position? 1. elbow flexion 2. hip abduction 3. hip adduction 4. knee extension

1. elbow flexion

How will the nurse, who is conducting the physical assessment, encourage the client to be honest and open in identifying the health problem? 1. By explaining how the assessment will be conducted. 2. By explaining that all information will be kept confidential. 3. By explaining the assessment technique before performing it. 4. By offering the client and opportunity to ask questions.

2. By explaining that all information will be kept confidential

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? 1. Center of the head. 2. On the mastoid area. 3. Behind the client's head. 4. Near the ear canal.

2. On the mastoid area.

Which of the following equipment will the nurse gather to conduct a physical examination of a client's eyes? (Select all that apply.) 1. Thermometer 2. Snellen chart 3. Rosenbaum card 4. Ophthalmoscope 5. Tuning fork

2. Snellen chart 4. Ophthalmoscope 5. Tuning fork

When should the nurse assess the costovertebral angle for tenderness? 1. during percussion of the abdomen 2. after assessing the posterior thorax 3. while assessing range of motion of the spine 4. before palpating the lower pole of the left kidney

2. after assessing the posterior thorax

The nurse notices that a client has a brilliant smile when asked about children. What should the nurse document about this finding? 1. the client is pleasant 2. cranial nerve VII intact 3. the client likes children 4. routine dental visits occur

2. cranial nerve VII intact

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? 1. to assess pedal pulses 2. to auscultate the lungs 3. to assess jugular venous pressure 4. to check the radial pulse

2. to auscultate the lungs

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? 1. Decreased activity level 2. Altered nutrition 3. Fatigue 4. Depression

3. Fatigue

To properly evaluate a male client's genitalia, the nurse should have the client do which of the following? 1. Assist client to supine position with head elevated 2. Lower the examination table with client in supine position 3. Have the client stand and face the nurse with gown raised 4. Ask the client to fold the gown to the waist and sit with the arms hanging freely

3. 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? 1. Grouping body systems together to limit position changes 2. Examining the right side of the body and then the left 3. Head-to-toe assessment 4. Major body systems first approach

3. 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? 1. validate findings 2. identify problems 3. determine symmetry 4. compare with the medical record

3. determine symmetry

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? 1. scalp 2. pulses 3. tongue 4. axillae

3. tongue

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? 1. "Tell me which number I am tracing on your back with my finger." 2. "Quickly flip your hands back and forth on your knees as I demonstrate." "3. Touch the tip of your nose, then the tip of my finger as I move my finger." 4. "With your eyes closed, identify the object I place in your hand."

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

The nurse is preparing to assess a client's reflexes. At which point during the assessment should this be completed? 1. after assessing the abdomen 2. after assessing cranial nerve function 3. after assessing the anterior and posterior thorax 4. after assessing the motor function of the lower extremities

4. after assessing the motor function of the lower extremities