Chapter 30: Head-to-Toe Assessment of the Adult
A nurse is performing an assessment within the legal parameters of assessment and diagnosis. Where would the nurse find these legal guidelines? The state's Nurse Practice Act The client's informed consent documents The nurse's terms of license The institution's policies and procedures guidelines
The state's Nurse Practice Act Explanation: The nurse should check the state's Nurse Practice Act to find out what the nurse can legally assess and diagnose. Informed consent documents do not specify these guidelines. The Nurse Practice Act supersedes a nurse's terms of license or an institution's policies. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 30: Head-to-Toe Assessment of the Adult.
A nurse is preparing a client for a physical assessment. The client appears anxious about the assessment. Which statement by the nurse would be most appropriate? "This is nothing to worry about. I won't hurt you." "Some of the examination may be painful, but I will be gentle." "Let me tell you what I will be doing. It should not be painful." "I have to do this, so just relax and it won't last long."
"Let me tell you what I will be doing. It should not be painful." Explanation: The client may be anxious for many reasons. Tell the client that the assessments should not be painful. Explaining the assessment in general terms can help decrease the client's embarrassment, fear of possible abnormal physical findings, or fear of "failing" a test. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 30: Head-to-Toe Assessment of the Adult, p. 893. Chapter 30: Head-to-Toe Assessment of the Adult - Page 893
aura
(n.) that which surrounds (as an atmosphere); a distinctive air or personal quality
At which time would a nurse observe and evaluate jugular venous pressure? After examining the breasts When moving from the posterior to the anterior chest After assessing the heart Before examining the abdomen
After examining the breasts Explanation: The nurse would observe and evaluate jugular venous pressure after examining the breasts and before assessing the heart. This time would be appropriate because the client would move from a sitting position to a supine position. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 30: Head-to-Toe Assessment of the Adult, p. 903. Chapter 30: Head-to-Toe Assessment of the Adult - Page 903
The nurse is examining a client who has an exacerbation of hip pain when in a sitting position. Which body system can the nurse examine with the client lying down? Posterior thorax Balance Spinal motion Anterior thorax TAKE ANOTHER QUIZ
Anterior thorax Explanation: The anterior thorax can be examined with the client lying down. The posterior thorax is best examined in the seated position. Balance and spinal motion are examined with the client standing. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 30: Head-to-Toe Assessment of the Adult, p. 905. Chapter 30: Head-to-Toe Assessment of the Adult - Page 905
The nurse should include which important safety checks before leaving a hospitalized client's room? (Select all that apply.) Call bell within reach Bed at mid-level, locked position Correct intravenous lines and fluids Wearing client identification bracelet Correct tubes and drains intact
Call bell within reach Correct intravenous lines and fluids Wearing client identification bracelet Correct tubes and drains intact Explanation: Bed should be at lowest, locked position before leaving the hospital room to prevent falls. All other safety checks are correct. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 30: Head-to-Toe Assessment of the Adult, p. 901. Chapter 30: Head-to-Toe Assessment of the Adult - Page 901
What characteristics of the nasal mucosa should the nurse recognize as normal findings upon inspection? Dark pink, moist, and free of exudate Pale, dry, with small amount of mucous Red, moist, and slightly swollen Pale pink, dry, and free of exudate
Dark pink, moist, and free of exudate Explanation: Normal nasal mucosa is dark pink, moist, and free of exudate. Nasal mucosa that is swollen and pale pink is seen in clients with allergies. Nasal mucosa that is red and swollen is seen in an upper respiratory infection. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 30: Head-to-Toe Assessment of the Adult, p. 903. Chapter 30: Head-to-Toe Assessment of the Adult - Page 903
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? Begin the comprehensive assessment and aim to complete it efficiently. Explain the reason for the client's assessment. Delay the full exam until the client's pain has been addressed. Provide education on pain control.
Delay the full exam until the client's pain has been addressed. Explanation: The client's physical and mental statuses determine how much of the exam a nurse may perform at one time. If a client is experiencing significant pain, an extensive assessment should wait until the client is more comfortable. It would be inappropriate to begin the assessment or explain the reason for the assessment. Although education on pain control may be needed, the client is in pain now and comfort is the priority. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 30: Head-to-Toe Assessment of the Adult, p. 904. Chapter 30: Head-to-Toe Assessment of the Adult - Page 904
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? Gather health history information first. Intersperse the physical exam with the history. Establish a routine for the assessment. Allow the client a break between the two parts of the history/exam.
Establish a routine for the assessment. Explanation: There is no one right way to integrate the entire health history and physical examination. However, it is important to stick to a routine to avoid omitting an important step that may delete significant data from the assessment. Short rest periods to help break up the assessment would be appropriate but not the most important. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 30: Head-to-Toe Assessment of the Adult, pp. 893-894. Chapter 30: Head-to-Toe Assessment of the Adult - Page 893-894
A nurse has completed a comprehensive nursing health history of the client and now is beginning the physical assessment. Which assessment should the nurse perform first? Mental status examination Skin assessment General survey Eye assessment
General survey Explanation: The nurse should begin the physical assessment with a general survey. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 30: Head-to-Toe Assessment of the Adult, p. 900. Chapter 30: Head-to-Toe Assessment of the Adult - Page 900
An adult client states she has been drinking a very large amount of water since she has begun walking everyday. She has been transported to the emergency room due to acute confusion. Which electrolyte imbalance is most likely the cause of this client's symptoms? Hypokalemia Hyperkalemia Hyponatremia Hypernatremia
Hyponatremia Explanation: Any unexpectedly high or low serum sodium level can be a reflection of sodium intake but is more likely a reflection of having too much or too little water, therefore diluting or concentrating the sodium. This client has been drinking a lot of water and likely has diluted sodium levels resulting in hyponatremia. Potassium imbalances affect neural and cardiac cell conduction, leading to arrythmias and possible cardiac arrest. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 30: Head-to-Toe Assessment of the Adult, p. 910. Chapter 30: Head-to-Toe Assessment of the Adult - Page 910
To assess a client's abdominal reflexes, which assessment should be included in the physical examination? Auscultate the bowel sounds. Lightly stroke inward from all quadrants. Lightly palpate each quadrant. Use percussion to listen for abdominal sounds.
Lightly stroke inward from all quadrants. Explanation: Abdominal reflexes are stimulated by stroking around the umbilicus. If reflexes are normal, the nurse should observe contraction of the abdominal muscles. Auscultating for bowel sounds is not the most effective way to assess abdominal reflexes. Light palpation should be used to assess for masses, tenderness, and the client's facial expression in response to the pressure. Percussion of the abdomen assists in hearing sounds that provide information about the liver, kidneys, and spleen. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 30: Head-to-Toe Assessment of the Adult, p. 906. Chapter 30: Head-to-Toe Assessment of the Adult - Page 906
A nurse is preparing to complete a comprehensive assessment on a client. When collecting objective data, what would the nurse do first? Assess the client's vital signs. Take the client's body measurements. Assess the client's mental status. Observe the client's overall appearance.
Observe the client's overall appearance. Explanation: When collecting objective data, the nurse would start with a general survey and observe the client's overall appearance first. Then the nurse would assess vital signs, take body measurements, and assess mental status. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 30: Head-to-Toe Assessment of the Adult, pp. 893-894. Chapter 30: Head-to-Toe Assessment of the Adult - Page 893-894
When analyzing data related to a client's behavior, the nurse should compare the observations with which of the following? The client's developmental stage The client's motivation for change The client's body mass index The client's vital signs
The client's developmental stage Explanation: Comparing behavior with developmental stage would be most important because it will let the nurse know if this client is behaving appropriately for that level. For most clients, this comparison is more significant than correlating behavior with motivation, vital signs, or body mass index. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 30: Head-to-Toe Assessment of the Adult.
During the eye assessment, a nurse performs part of the neurological examination for which cranial nerve? VII IX X XI
VII Explanation: The nurse checks the function of cranial nerve VII when assessing the corneal reflexes during an eye assessment. Cranial nerves IX and X are assessed during the mouth and throat assessment. Cranial nerve XI is assessed during the assessment of the arms, hands, and fingers. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 30: Head-to-Toe Assessment of the Adult, p. 901. Chapter 30: Head-to-Toe Assessment of the Adult - Page 901
The nurse is preparing to assess a client's reflexes. At which point during the assessment should this be completed? after assessing the abdomen after assessing cranial nerve function after assessing the anterior and posterior thorax after assessing the motor function of the lower extremities
after assessing the motor function of the lower extremities Explanation: Although many parts of the assessment can be completed at any time, assessment of the reflexes usually is completed after assessing the lower extremities and serves as a starting point for assessing neurologic functioning. Assessment of the reflexes would not occur after assessing the abdomen, cranial nerve function, or after assessing the anterior and posterior thorax. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 30: Head-to-Toe Assessment of the Adult, pp. 904-907. Chapter 30: Head-to-Toe Assessment of the Adult - Page 904-907
A client is supine with the head of the examination table at a 30-degree angle. What should the nurse assess at this time? hand grasps bowel sounds cranial nerves carotid arteries
carotid arteries Explanation: The head of the table or bed should be placed in a 30-degree angle when assessing the carotid arteries. Hand grasps can be assessed in the seated or standing position. The client should be supine when assessing bowel sounds. Cranial nerves can be assessed in the standing or seated position. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 30: Head-to-Toe Assessment of the Adult, p. 903. Chapter 30: Head-to-Toe Assessment of the Adult - Page 903
For which assessment could the neurologic and musculoskeletal systems be combined? gait abdomen respiratory peripheral vascular
gait Explanation: Observing the gait assesses both the musculoskeletal and neurologic systems. The abdominal, respiratory, and peripheral vascular assessments do not combine the neurologic and musculoskeletal systems. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 30: Head-to-Toe Assessment of the Adult, p. 908. Chapter 30: Head-to-Toe Assessment of the Adult - Page 908
Prior to conducting a mental status exam with a client who has a diagnosis of depression, the nurse can obtain which information by observing the client? grooming affect posture perceptions orientation
grooming affect posture Explanation: By simply observing the client, the nurse can conduct various parts of the mental status exam. These include grooming, which tells the nurse about the client's ability to carry out activities of daily living. Affect, an objective assessment of the client's mood, can be observed by watching the client's facial expression and level of animation. Posture can also be observed and is an important part of the mental status exam because it is a nonverbal communication of the client's mood. Recording these findings can help the nurse better understand the extent to which the client may be experiencing depression. In order to determine whether the client is experiencing perceptions (the client's way of interpreting the world around him or her) and orientation (whether the client is aware of the place, time, and date), the nurse would need to go beyond observation and ask specific questions. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 30: Head-to-Toe Assessment of the Adult, p. 912. Chapter 30: Head-to-Toe Assessment of the Adult - Page 912
Examination of the skin should be integrated throughout the head-to-toe examination. completed at the beginning of the physical assessment before proceeding to other parts of the exam. performed at the very end of the physical assessment. integrated and completed only with the musculoskeletal examination.
integrated throughout the head-to-toe examination. Explanation: As you perform each part of the head-to-toe assessment, assess skin for color variations, texture, temperature, turgor, edema, and lesions. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 30: Head-to-Toe Assessment of the Adult, pp. 900-901. Chapter 30: Head-to-Toe Assessment of the Adult - Page 900-901
In order to conduct an examination of the eye muscles, the nurse should prepare to administer which tests? Select all that apply. six cardinal directions of gaze convergence near reaction cover-uncover test confrontation
six cardinal directions of gaze convergence near reaction cover-uncover test Explanation: Tests that can be used to determine eye muscle strength include the six cardinal directions gaze, convergence, near reaction, and the cover-uncover test. Convergence is used to examine visual fields. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 30: Head-to-Toe Assessment of the Adult, p. 902. Chapter 30: Head-to-Toe Assessment of the Adult - Page 902
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 assess pedal pulses to auscultate the lungs to assess jugular venous pressure to check the radial pulse
to auscultate the lungs Explanation: The stethoscope is required to assess for the presence of fluid in the lungs, indicating that the client also has pulmonary edema, a condition that can occur in clients with congestive heart failure. Pedal and radial pulses can be assessed using the tips of the fingers directly over the sites where these pulses can be located. Jugular venous pressure is measured by palpating the carotid pulse and measuring the vertical distance between the sternal angle and the top of the jugular vein. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 30: Head-to-Toe Assessment of the Adult, pp. 905-906. Chapter 30: Head-to-Toe Assessment of the Adult - Page 905-906
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? 2 hours 1 hour ½ hour ¼ hour
½ hour Explanation: To perform a complete interview and total physical examination may take up to 2 hours for the novice nurse and only 30 minutes for a skilled practitioner. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 30: Head-to-Toe Assessment of the Adult, p. 893. Chapter 30: Head-to-Toe Assessment of the Adult - Page 893