Ch.30 Head-to-Toe Assessment of the Adult

To properly evaluate a male client's genitalia, the nurse should have the client do which of the following?

Have the client stand and face the nurse with gown raised

A nurse is performing a part of a physical assessment for a client using palpation. What is the purpose of using this technique?

To check the skin temperature and moisture.

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

Peripheral vascular assessment

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?

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

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

- Femoral - Dorsalis pedàs - Popliteal - Posterior tibial

A nurse knows that a normal capillary bed refills in how many seconds?

1 to 2

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?

Assessing for pain

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

Assessment of the genitalia and rectum

Assessment of a client's bowel sounds is best obtained by performing which assessment technique?

Auscultation

A nurse inspects a client's ears and notices that the auricles are lower than the corner of each eye. The nurse should assess this client for other findings of what type of disorder?

Chromosomal

A client has been assigned a nursing diagnosis of fatigue related to anemia as evidenced by pale skin, statements of tiredness, and low hematocrit and hemoglobin values. What would be an appropriate nursing intervention for this client?

Collaborate with the physician to treat anemia

When conducting a complete head-to-toe assessment on an adult client, which of the following factors is most likely to require adaptations by the nurse?

Cultural considerations

When observing a client's behavior, which of the following would be most important for the nurse to compare the observations with?

Developmental stage

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?

Establish a routine for the assessment.

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?

Fatigue

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

Head and face assessment

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?

On the mastoid area.

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

Posterior chest

Which placement of the hands demonstrates proper technique by a nurse for palpating the thyroid gland?

Standing behind the client, place the fingers on either side of the trachea below the cricoid cartilage

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

The client has the right to refuse the assessment.

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?

The client's health needs

(T/F) It is appropriate to tell a client the findings of the physical examination.

True

A nurse recognizes that the normal breath sounds that are auscultated over the peripheral lung fields are what type of sound?

Vesicular

How should a nurse assess graphesthesia as part of the physical assessment of arms, hands, and fingers?

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

Before beginning a physical assessment it is important for the nurse to

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

The nurse is preparing to assess a client's reflexes. At which point during the assessment should this be completed?

after assessing the motor function of the lower extremities

The nurse completes the assessment of a client's heart. What should be assessed next?

breasts

A client arrives to a healthcare facility for an initial appointment. Which type of assessment should the nurse expect to complete with this client?

complete

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?

cranial nerve VIII is intact

When obtaining subjective data from a new client, you focus primarily on

evaluating risk factors

For which assessment could the neurologic and musculoskeletal systems be combined?

gait

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?

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

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?

tongue

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?

½ hour

The nurse is planning to assess a client's abdomen. Place the components of this assessment in the correct order in which the nurse should conduct them.

- Health history - Inspection - Auscultation - Percussion - Palpation

A nurse is reviewing findings from a client's health history to provide health-promotion education. The client is an adult with a diagnosis of morbid obesity. Which areas are most important for teaching opportunities for this client? Select all that apply.

- Nutrition - Physical activity - Weight reduction - Avoiding smoking and alcohol - Prevention of complications related to diagnosis

The nurse is conducting a physical examination of a client who has congestive heart failure. The general survey can provide the nurse with which information?

- edema of the face and limbs - presence of cyanosis - respiratory rate

The nurse is assessing cranial nerves and should look for which sign of cranial nerve VII damage?

Asymmetrical smile

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?

Accurately assess stressors and effectiveness of coping methods

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

Arms

What characteristics of the nasal mucosa should the nurse recognize as normal findings upon inspection?

Dark pink, moist, and free of exudate

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?

Deficient Fluid Volume

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?

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

A nurse is performing a head-to-toe examination of a client. At which point should the nurse first put on gloves?

Just before the mouth and throat assessment

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

Neck

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?

Oxygen saturation of 78%

When assessing the abdomen, which assessment technique is used last?

Palpation

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?

To provide the client with modesty during the assessment.

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?

Tuning fork

During the eye assessment, a nurse performs part of the neurological examination for which cranial nerve?

VII

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.