NUR 306 Ch. 22 PrepU : Putting it all Together

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

Gait

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

Peripheral Vascular Assessment

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

Breasts

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

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?

Breasts

As part of the equipment, a nurse makes sure to have a speculum for an assessment to perform on a client. In which part of the assessment is the nurse most likely to use a speculum?

Female Genitalia

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.

The nurse is conducting a cephalic to caudal assessment with a newly admitted client. Why should the nurse compare findings from side to side?

Determine symmetry

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

Dorsalis Pedis Popliteal Femoral Posterior Tibial

The nurse notes dull lung percussion along the lower right lobe of an adult client. Which intervention should the nurse initiate right away for this client?

Encourage turning, coughing, and deep breathing

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

Head and Face

The nurse is unable to palpate a pedal pulse in the right leg of an adult client. What the nurse's best action?

Obtain a Doppler to verify absent pulse

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 nurse performs the Mini-Mental Status Exam to assess cognitive abilities of a client. What will the nurse assess as a part of the Mini-Mental Status Exam?

Remote memory of the past

At the beginning of the exam the nurse performs a general survey. What would the nurse assess at this time?

Safety

A nurse is preparing to perform the nurse's first complete assessment of a client at a hospital. Which of the following should the nurse consult to find out what can legally be assessed and diagnosed?

States nursing practice act

When analyzing data related to a client's behavior, the nurse should compare the observations with which of the following?

Th clients developmental age

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 clients health needs

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?

Wears dentures

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

During a physical examination the nurse assesses a client's anterior neck, carotid arteries, heart and lung sounds, and breasts before assisting the client to a seated position to examine the back. What is the best explanation for using this approach?

it limits the number of times the client had to change position

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 a right to refuse the assessment