PrepU - Chapter 28: Putting It All Together (head-to-toe)

When assessing an IV site, what should be included? Select all that apply. - Location of site - Type and size of device - Type of fluid - Rate of infusion

- Location of site - Type and size of device - Type of fluid - Rate of infusion

Which of the following equipment will the nurse gather to conduct a physical examination of a client's eyes? (Select all that apply.) - Thermometer - Snellen chart - Rosenbaum card - Ophthalmoscope - Tuning fork

- Snellen chart - Rosenbaum card - Ophthalmoscope

Order the parts of the physical examination of the neck in the correct sequence from first to last. All options must be used.

1. Inspect the front of the neck for masses, enlarged nodes, or deviation. 2. Inspect the position of the trachea. 3. Inspect the thyroid gland. 4. Test the head and neck for range of motion. 5. Palpate the head, neck, and subclavicular lymph nodes. 6. Palpate the thyroid.

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? A. Collaborate with the physician to treat anemia B. Evaluate adequacy of exercise C. Evaluate urinary patterns D. Have the client explain an energy-conservation plan to offset the effects of fatigue

A. Collaborate with the physician to treat anemia

The client has decreased sensation in his legs. What additional assessment should the nurse include? A. Fall B. Surgical site C. Bloodstream infection D. Sepsis

A. Fall

What type of assessment would the nurse perform when assessing pain after medicating? A. Focused B. Urgent C. Comprehensive D. Shift

A. Focused

How should a nurse assess graphesthesia as part of the physical assessment of arms, hands, and fingers? A. Write a number in the palm of the client's hand B. Place a quarter or key in the client's hand C. Ask the client to touch finger to nose with eyes closed D. Evaluate sensitivity of position of fingers

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

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? A. it limits the number of times the client had to change position B. the nurse was following the front to back assessment approach C. the nurse did not want to miss collecting important information D. there was limited time available to complete the entire assessment

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

How will the nurse, who is conducting the physical assessment, encourage the client to be honest and open in identifying the health problem? A. By explaining how the assessment will be conducted. B. By explaining that all information will be kept confidential. C. By explaining the assessment technique before performing ti. D. By offering the client and opportunity to ask questions.

B. By explaining that all information will be kept confidential.

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? A. Center of the head. B. On the mastoid area. C. Behind the client's head. D. Near the ear canal.

B. On the mastoid area.

A client visits the health care facility with reports of mild hearing loss. The nurse prepares to perform which test to compare bone and air conduction? A. Weber's B. Rinne C. Whisper D. Audiometry

B. Rinne

The best approach to use when performing a total physical examination on a client is A. a toe-to-head integrated assessment of body systems. B. a head-to-toe integrated assessment of body systems. C. a total body system approach examining each body system individually. D. any approach that is convenient for you and the client.

B. a head-to-toe integrated assessment of body systems.

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? A. cranial nerve XI is intact B. cranial nerve VIII is intact C. the client understands directions D. the client knows the difference between left and right

B. cranial nerve VIII is intact

Two body systems that may be logically integrated and assessed at the same time are the A. eye and ear exams. B. eye exam and cranial nerves II, III, IV, and VI. C. ear exam and cranial nerves IV, VI, and VIII. D. ear and nose exams.

B. eye exam and cranial nerves II, III, IV, and VI.

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? A. to assess pedal pulses B. to auscultate the lungs C. to assess jugular venous pressure D. to check the radial pulse

B. to auscultate the lungs

A client with congestive heart failure presents with edema of the ankles. When conducting a physical examination of this client, the nurse requires a stethoscope for which purpose? A. to assess pedal pulses B. to auscultate the lungs C. to assess jugular venous pressure D. to check radial pulses

B. to auscultate the lungs

The nurse has entered a client's room to begin a head-to-toe assessment. The client appears anxious, is pale, and is struggling to breathe. What is the nurse's priority action? A. Assess blood pressure. B. Check for pupil reaction. C. Ensure a patent airway. D. Count respirations.

C. Ensure a patent airway.

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? A. Decreased activity level B. Altered nutrition C. Fatigue D. Depression

C. Fatigue

To properly evaluate a male client's genitalia, the nurse should have the client do which of the following? A. Assist client to supine position with head elevated B. Lower the examination table with client in supine position C. Have the client stand and face the nurse with gown raised D. Ask the client to fold the gown to the waist and sit with the arms hanging freely

C. Have the client stand and face the nurse with gown raised

The nurse is preparing to conduct a physical examination of an adolescent client as part of general physical assessment. Which examination approach would be the most appropriate this client? A. Grouping body systems together to limit position changes B. Examining the right side of the body and then the left C. Head-to-toe assessment D. Major body systems first approach

C. Head-to-toe assessment

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? A. Hypokalemia B. Hyperkalemia C. Hyponatremia D. Hypernatremia

C. Hyponatremia

It is important for the nurse to apprise the client of what the nurse is doing and what the nurse finds as it does what? A. Causes assessment findings to be more accurate B. Speeds up the pace of the assessment C. Opens up teaching/learning moments D. Instills a friendly feeling toward you in the patient

C. Opens up teaching/learning moments

The nurse is documenting the description and amount of wound drainage present in a Stage III pressure ulcer. Which term should the nurse use to describe bloody drainage observed when the dressing was removed? A. Fibrinous B. Serous C. Sanguineous D. Purulent

C. Sanguineous

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? A. Hospital policy B. Supervising physician C. State's nurse practice act D. Federal law

C. State's nurse practice act

Before beginning a physical assessment it is important for the nurse to A. explain to the client in detail how each body system will be assessed. B. explain to the client the purpose of every physical assessment technique you will be using. C. acquire your client's verbal permission to perform the physical examination. D. acquire your client's written permission to perform the physical examination.

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

When integrating the total physical examination the nurse should A. perform the Mental Status Exam after examining all other body systems. B. assess cranial nerve I (olfactory) with the other 11 cranial nerves at the same time. C. assess peripheral vascular status when examining the lower extremities. D. integrate the rectal examination with the abdominal examination.

C. assess peripheral vascular status when examining the lower extremities.

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

C. complete

The nurse is conducting a cephalic to caudal assessment with a newly admitted client. Why should the nurse compare findings from side to side? A. validate findings B. identify problems C. determine symmetry D. compare with the medical record

C. determine symmetry

When supine, a client's knees do not touch the examination table. On what area should the nurse focus to learn more information about this finding? A. gait B. limb length C. flexion and extension D. abduction and adduction

C. flexion and extension

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? A. "Tell me which number I am tracing on your back with my finger." B. "Quickly flip your hands back and forth on your knees as I demonstrate." C. "Touch the tip of your nose, then the tip of my finger as I move my finger." D. "With your eyes closed, identify the object I place in your hand."

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

When you enter the room of a hospitalized patient, the intravenous pump is alarming. The patient 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? A. Troubleshooting the infusion pump B. Talking with family members C. Assessing nutrition D. Assessing for pain

D. Assessing for pain

The nurse is assessing cranial nerves and should look for which sign of cranial nerve VII damage? A. Hearing loss B. Puffy "moon" face C. Tongue deviation D. Asymmetrical smile

D. Asymmetrical smile

The nurse is conducting an abdominal assessment with a client. What should the nurse do prior to documenting that a client's bowel sounds are absent? A. Measure oxygen saturation B. Complete the entire assessment C. Auscultate for heart and lung sounds D. Auscultate the abdomen for 5 minutes

D. Auscultate the abdomen for 5 minutes

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? A. Administer a nebulizer treatment B. Order a chest x-ray C. Begin antibiotic therapy through intravenous route D. Encourage turning, coughing, and deep breathing

D. Encourage turning, coughing, and deep breathing

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? A. Mood, feelings, and expression B. Thought processes and perception C. Level of consciousness D. Remote memory of the past

D. 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? A. Hearing acuity B. Pedal pulses C. Oxygen saturation D. Safety

D. Safety

A nurse is conducting a physical examination and is percussing the gastric area of a patient. What percussion tone is normally heard in this area? A. Flat B. Dull C. Resonant D. Tympany

D. Tympany

The nurse is preparing to assess a client's reflexes. At which point during the assessment should this be completed? A. after assessing the abdomen B. after assessing cranial nerve function C. after assessing the anterior and posterior thorax D. after assessing the motor function of the lower extremities

D. after assessing the motor function of the lower extremities

A client is supine with the head of the examination table at a 30-degree angle. What should the nurse assess at this time? A. hand grasps B. bowel sounds C. cranial nerves D. carotid arteries

D. carotid arteries

The nurse completes the assessment of a client's reflexes. Which position should the nurse place the client to assess the Romberg sign? A. prone B. supine C. sitting D. standing

D. standing