Ch. 28- Health Assessment

Wears dentures; denies problems with eating, chewing, and swallowing.

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?

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

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?

"Can you tell me the current month and year?"

The nurse is performing an abbreviated head-to-toe assessment of a hospitalized client. What question should the nurse ask when assessing the client's level of consciousness?

pulses color edema lesions

The nurse is performing an assessment of a client's legs. Which finding(s) should the nurse document as part of the peripheral vascular assessment? Select all that apply.

color size lesions exudates

The nurse is performing an assessment of the mouth and throat for a client. When inspecting the tonsils, which assessment findings should the nurse collect? Select all that apply.

assessment of the genitalia and rectum

The nurse is planning the comprehensive head-to-toe assessment of a client. What assessment should the nurse usually conduct last?

The client's health needs

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?

Supplement the client's statements with data from the client's friends and family.

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?

The client's present health concern

The nurse is using a mnemonic device during the client's head-to-toe assessment. This tool will allow the nurse to address what component of assessment?

Peripheral vascular assessment

The nurse should ensure that a Doppler ultrasound is available when performing what assessment?

breasts

The nurse will palpate a client's axillae during a head-to-toe assessment. The nurse should combine this with examination of which area?

Posterior chest

The nurse would auscultate for voice sounds during which part of the comprehensive examination?

Breasts

The nurse would palpate the axillae during examination of which area?

Arms, hands and fingers

The nurse would test for stereognosis during which part of the comprehensive exam?

Auscultate for bowel sounds in each of the client's four abdominal quadrants.

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?

Establish a routine for the assessment.

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?

Put on gloves

A nurse has finished examining a client's nose and sinuses and is about to examine the client's mouth and throat. What would be most important for the nurse to do?

Tuning fork

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?

The state's Nurse Practice Act

A nurse is performing an assessment within the legal parameters of assessment and diagnosis. Where would the nurse find these legal guidelines?

Saint Louis University Mental Status (SLUMS) Assessment

A nurse is preparing to assess a client's cognitive abilities. Which assessment tool should the nurse use?

Observe the client's overall appearance.

A nurse is preparing to complete a comprehensive assessment on a client. When collecting objective data, what would the nurse do first?

Delay the full exam until the client's pain has been addressed.

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?

Arms

A nurse plans to assess the client's epitrochlear lymph nodes. The nurse should combine this with examination of which area?

½ hour

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?

Abdomen

During which part of the comprehensive assessment would the nurse auscultate after inspecting but before percussing?

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

The nurse is assessing a client's judgment during a comprehensive head-totoe assessment. How can the nurse best appraise this aspect of cognitive function?

Test the client's pupillary response to light.

The nurse is completing an abbreviated head-to-toe assessment of a client. What would the nurse perform when assessing the client's eyes?

vital signs

The nurse is completing the general survey. In addition to observing the client's appearance, the nurse would assess which of the following?

neck

The nurse is palpating the tonsillar, submandibular, and submental lymph nodes. The nurse is most likely examining which area during a comprehensive assessment?

Remote memory Abstract reasoning Judgment

When assessing a client's cognitive capabilities, which of the following would the nurse assess? Select all that apply.

developmental stage

The nurse is performing a general survey as part of a comprehensive health assessment. When observing a client's behavior, which of the following would be most important for the nurse to compare the observations with?

skin color and condition peripheral vascular system neurologic system musculoskeletal system

A nursing instructor is describing the use of a head-to-toe approach for a comprehensive health assessment and how body systems may be combined, using the legs as an example. Which of the following would the instructor describe as being included in this assessment? Select all that apply.

Thought processes

After teaching a group of students about areas to include when examining a client's mental status, the instructor determines that the teaching was successful when the students identify which of the following as important?

Check the state's Nurse Practice Act.

Before performing a complete assessment, which of the following would be most important for the nurse to do?

Femoral Dorsalis pedis Popliteal Posterior tibial

When assessing the legs, feet, and toes, which pulses would the nurse expect to palpate? Select all that apply.

"I haven't had a checkup in over 5 years."

When documenting a comprehensive assessment, which statement would the nurse record as the reason for seeking health care?

Head and face

When performing a head-to-toe assessment, during which part would the nurse assess the motor function of cranial nerve VII?

The client has the right to refuse the assessment.

When preparing to do a comprehensive health assessment, the nurse obtains the client's permission based on an understanding of which principle?

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

Which statement about assessment findings obtained from a comprehensive assessment would be identified as part of the general survey?

overall physical and sexual development overall skin coloring

While performing a comprehensive assessment on a client, the nurse proceeds with the general survey. What data should the nurse collect during this portion of the assessment? Select all that apply.