Ch 28 Head-to-Toe

10. When assessing a client's mental status, which of the following would the nurse assess? Select all that apply. A) Remote memory B) Coping skills C) Speech D) Abstract reasoning E) Judgment

A) Remote memory C) Speech D) Abstract reasoning E) Judgment

17. During which part of the comprehensive assessment would the nurse auscultate after inspecting but before percussing? A) Abdomen B) Anterior chest C) Neck D) Heart

A) Abdomen

25. The nurse is completing an abbreviated head-to-toe assessment of a client. Which of the following should the nurse perform when assessing the client's eyes? A) Test the client's pupillary response to light. B) Test the client's visual fields. C) Perform the cover test. D) Test the client's vision.

A) Test the client's pupillary response to light.

8. 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

23. The nurse is performing an abbreviated head-to-toe assessment of a hospital client. What question should the nurse ask when assessing the client's level of consciousness? A) If there were a fire in your house, what would you do? B) How would you describe your overall level of stress? C) Can you tell me the current month and year? D) Can you tell me what you ate for breakfast this morning?

C) Can you tell me the current month and year?

16. The nurse is palpating the client's tonsillar, submandibular, and submental lymph nodes. The nurse is most likely examining which area during a comprehensive assessment? A) Nose and sinuses B) Abdomen C) Neck D) Face

C) Neck

2. When preparing to do a comprehensive health assessment, the nurse obtains the client's permission based on an understanding of which of the following principles? A) The client has the right to refuse the assessment. B) Obtaining permission enhances therapeutic rapport. C) The client will be more willing to disclose after giving permission. D) The client's level of comfort will be increased by granting explicit consent.

A) The client has the right to refuse the assessment.

18. 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

5. When analyzing data related to a client's behavior, the nurse should compare the observations with which of the following? A) The client's developmental stage B) The client's motivation for change C) The client's body mass index D) The client's vital signs

A) The client's developmental stage

28. The nurse is using the COLDSPA mnemonic during the client's head-to-toe assessment. This tool will allow the nurse to address what component of assessment? A) The client's present health concern B) The review of the client's body systems C) The client's personal health history D) The client's health practices profile

A) The client's present health concern

1. A nurse is performing an assessment within the legal parameters of assessment and diagnosis. These legal guidelines would be specified in which of the following? 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

11. The nurse is performing a head-to-toe assessment of a client. Which of the following 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.

29. 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 activities do you do to improve your health? C) Who is the most important person in your life, and why? D) What is your idea of the ideal vacation?

A) What would you do if you found a stamped, addressed envelope on the ground?

14. A nurse should assess the client's epitrochlear lymph nodes when assessing which of the following? A) Neck B) Arms C) Posterior chest D) Sinuses

B) Arms

24. The nurse is performing an abbreviated head-to-toe assessment of a client. When the nurse asks the client about his pain, the client states, My stomach's really killing me right now. How should the nurse first respond to this client's statement? A) Offer analgesia to the client B) Ask the client to rate his pain on a 0-to-10 scale C) Assess the client's level of consciousness D) Assure the client that his pain will be addressed immediately following the assessment

B) Ask the client to rate his pain on a 0-to-10 scale

27. The nurse is planning the comprehensive head-to-toe assessment of a client. What assessment should the nurse usually conduct last? A) Assessment of the abdomen B) Assessment of the genitalia and rectum C) Assessment of the lower extremities D) Assessment of the posterior thorax

B) Assessment of the genitalia and rectum

26. 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.

6. When performing a client's head-to-toe assessment, during which part would the nurse assess the motor function of cranial nerve VII? A) Mental status examination B) Head and face assessment C) Ears assessment D) Examination of mouth and throat

B) Head and face assessment

7. 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.

30. The nurse should ensure that a Doppler ultrasound is available when performing which of the following assessments? A) Respiratory assessment B) Peripheral vascular assessment C) Abdominal assessment D) Musculoskeletal assessment

B) Peripheral vascular assessment

9. A nurse has finished examining a client's nose and sinuses and is about to examine the client's mouth and throat. Which of the following would be most important for the nurse to do? A) Warm the hands B) Put on gloves C) Obtain a tuning fork D) Collect a saliva specimen

B) Put on gloves

13. A nurse is performing a head-to-toe assessment and is preparing to examine the client's ears. Which equipment would the nurse need to have readily available? A) Ophthalmoscope B) Tuning fork C) Facial tissues D) Stethoscope

B) Tuning fork

19. The nurse is documenting findings of a comprehensive assessment. Which statement would be categorized as part of the general survey? A) Hair neat and clean with white and gray streaks; no scalp lesions noted B) Sclera white; conjunctiva slightly reddened without lesions C) Client alert and cooperative; sitting comfortably on chair with hands in lap D) Head symmetrically round; neck nontender with full range of motion

C) Client alert and cooperative; sitting comfortably on chair with hands in lap

12. 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. Which of the following 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.

4. A novice nurse is practicing how to complete a comprehensive assessment to gain confidence and skill. Which of the following would be most important for the nurse to remember? A) Always gather objective data before subjective data. 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.

22. 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

3. The nurse is completing the general survey. In addition to observing the client's appearance, the nurse would assess which of the following? A) Mental status B) Cognitive abilities C) Vital signs D) Thought processes

C) Vital signs

15. 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

20. A nurse is preparing to complete a comprehensive assessment on a client. When collecting objective data, which of the following should the nurse do first? A) Assess the client's vital signs. B) Take the client's body measurements. C) Assess the client's mental status. D) Observe the client's overall appearance.

D) Observe the client's overall appearance.

21. 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) Obtain the client's history from the electronic health record and proceed with 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.