Chapter 28 - Pulling it All Together : Integrated Head-to-Toe Assessment

The nurse uses deep palpation of the abdomen to assess the client for presence of an abdominal mass. The client grimaces and grips the hand rails of the bed. Which response by the nurse is best?

"We can take a break anytime." Explanation: In order to ensure the client remains comfortable throughout the physical examination, the client's facial expressions and other cues about pain should be noted. The nurse should offer to take a break and continue on with the physical examination by assessing other areas in a less invasive way. The client should be made aware that he or she has the power to take a break from the examination for some relief if there is pain. Asking the client to deep breaths not helpful in this situation because it minimizes the client's comfort and does not address the underlying cause of the pain. Taking vital signs would probably show that the client's blood pressure is higher than normal because pain and anxiety can increase blood pressure, heart rate, and respiratory rate. Ana assessment of the vital signs should be complete prior to beginning the physical examination. Stopping the physical examination altogether is not correct because the assessment is largely incomplete and important clinical data that can negatively impact the client's health may be missed.

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." Explanation: Stereognosis is the ability to identify objects correctly by touch to test the sensory cortex. Graphesthesia is the ability to correctly identify a number traced on the skin. Coordination is tested with rapid alternating movements and the finger to nose tests.

A nurse should use light palpation of the abdomen to obtain objective data about which characteristic of the abdomen?

Abdominal reflex Explanation: The nurse uses light palpation for assessment of the abdominal reflex. Abnormalities of the aorta, enlargement of the liver, and irregularities of the abdominal organs are assessed through deep palpation.

During which part of a head-to-toe physical examination should the nurse palpate the epitrochlear lymph nodes?

Arm, hands, and fingers Explanation: The epitrochlear lymph nodes are found on the inside of the upper arm, just above the elbow. They are assessed during the arm, hands, and fingers assessment.

An adult female client is about to undergo a physical assessment conducted by a nurse practitioner at the gynecology clinic. The nurse is preparing the room for a complete head-to-toe examination, along with a genitalia and rectal assessment and screening through the Papanicolaou test. What should the nurse do next before proceeding?

Ask for the client's permission to perform the assessment Explanation: Following completion of the health history previously described, the nurse explains the process for the physical examination, from head to toe and including auscultation of the heart and lung sounds, auscultation and palpation of the abdomen, and screening for neuromuscular problems. Because some assessments may be uncomfortable (e.g., breast, gynecological), the nurse asks the client for permission to perform them. Once the nurse has the client's permission, the nurse would ask the client if the client prefers to have a third person in the room or, if appropriate, a same-gender nurse. The nurse would take care to preserve modesty; however, this would not be the immediate next step. Alterations to the order of the examination would be unlikely unless the client had an emergency concern.

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

Asymmetrical smile Explanation: Facial asymmetry may indicate damage to facial nerve (cranial nerve [CN] VII) or a serious condition such as a stroke. Enlarged bones or tissues are associated with acromegaly. A puffy "moon" face is associated with Cushing syndrome. The hypoglossal nerve is tested by looking for tongue deviation. Hearing is tested when cranial nerve VIII is assessed.

The hospitalized client is at risk for ineffective tissue perfusion. What should the nurse assess to identify ineffective tissue perfusion?

Capillary refill Explanation: Capillary refill is used to assess the client's tissue perfusion. Nutritional status, mobility and skin moisture are not indicators of perfusion.

A client is admitted to the health care facility for the onset of a stroke. To test the function of cranial nerve I, the nurse should ask the client to do which of the following?

Close eyes and assess for smell Explanation: To assess the function of cranial nerve I (olfactory), the nurse should ask the client to close the eyes and assess for smell. The nurse asks the client to say "aah" and observes the rise of the uvula as part of the assessment of the mouth and throat. Cranial nerve VII and IX are assessed by asking the client to identify taste with the eyes closed. When testing for cranial nerves IX and X, the nurse asks the client to press the tongue against the tongue blade to assess tongue strength.

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 Explanation: The most appropriate intervention would be to collaborate with the provider to treat anemia. Steps might include an evaluation of nutrition and sleep patterns.

An adult client complains of dark stools for the past 3 days. Which lab should the nurse review right away?

Complete blood count Explanation: Dark stool may indicate presence of blood. Therefore the hemoglobin and hematocrit should be assessed to check for blood loss. Loose stools would be a concern for potassium loss. While coagulation studies should be reviewed; the priority is to check for blood loss, then determine a possible cause such as low platelets or other coagulation disorder. A compromised liver can result in bleeding; however, the CBC should be assessed first to determine blood loss and need for immediate intervention such as transfusion.

What type of assessment would a nurse perform on a client being admitted to the hospital?

Comprehensive Explanation: The nurse in the hospital performs a comprehensive assessment of the client on admission. This assessment is more detailed and complete than screening and focused assessments that evaluate progress toward a goal later in the stay. "Acute" is not a term commonly used to describe a type of assessment.

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 Explanation: Dull lung percussion indicates increased consolidation as with pneumonia. Encouraging turning, coughing, and deep breathing is the only independent nursing intervention that can be begun right away. While nebulizer treatments, obtaining a chest x-ray, and starting antibiotics are usually warranted for pneumonia; the nurse must notify the healthcare provider first.

A nurse is conducting the general survey at the beginning of the head-to-toe assessment. Which of the following does the nurse need to address as part of the general survey?

Evaluate personal hygiene Explanation: The nurse would actually palpate the skin for moisture once he or she was at the portion of the assessment focusing specifically on the skin. The nurse would auscultate the lungs and check for peripheral pulses at the portion of the assessment focusing specifically on the respiratory and cardiac systems. Inspecting skin color, appearance, and hygiene is done as part of the general survey.

The nurse has a hand-held Snellen. When in the sequence of assessment should the nurse assess visual acuity?

Eye assessment Explanation: If a hand-held Snellen is available, then inserting visual acuity in the eye assessment is appropriate.

The client has decreased sensation in his legs. What additional assessment should the nurse include?

Fall Explanation: Because of decrease peripheral sensation in the legs, the client is at increased risk for falls. There is no data to support increased risk for sepsis, bloodstream or surgical site infections for this client.

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 Explanation: An appropriate nursing diagnosis would be fatigue related to anemia as evidenced by low hematocrit, hemoglobin; client pale, tired.

What type of assessment would the nurse perform when assessing pain after medicating?

Focused Explanation: The focused assessment concentrates on assessing for anticipated problems specific to the client's problems. A comprehensive assessment is more detailed and complete than shift and focused assessments, which evaluate progress toward a goal later in the stay. The shift assessment is performed at the beginning of the shift and includes an abbreviated exam.

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?

General survey Explanation: The nurse should begin the physical assessment with a general survey.

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 Explanation: To evaluate a male client's genitalia, the nurse should have the client stand and face the nurse with gown raised. The nurse should ask the client to fold the gown to the waist and sit with the arms hanging freely when assessing the anterior chest. The client should not be lying supine for this examination.

The head-to-toe assessment is a very important tool in providing the best possible care to a client. What is the reason for a comprehensive health assessment? Select all that apply.

Integrates all body systems Gives the nurse an overall impression of the client's condition Helps the nurse identify risk factors for potential health problems Explanation: The comprehensive health assessment integrates all body systems; findings help the nurse form an overall impression of the client and his or her condition. Complete subjective data collection includes data related to the client's history and risk factors.

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 Explanation: The nurse should first put on gloves just before the mouth and throat assessment, as this is typically the first contact the nurse will have with the client's mucous membranes or bodily fluids. The general survey and mental status examination come before the mouth and throat assessment and do not require gloves. The rectal assessment comes at the end of the examination and will require a new set of gloves.

To assess a client's abdominal reflexes, which assessment should be included in the physical examination?

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.

The nurse has completed examining the client's nose and sinuses. Which body area should the nurse examine next?

Mouth and pharynx Explanation: If following a head-to-toe examination approach, the nurse should examine the client's mouth and pharynx after examining the nose and sinuses. The neck is done after assessing the mouth and pharynx. The posterior thorax is examined after the neck. The anterior thorax is examined after the posterior thorax.

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?

Opens up teaching/learning moments Explanation: Letting the client know what you are doing and your findings, such as blood pressure results, opens up teaching/learning moments and develops a rapport with your client.

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

Palpation Explanation: The sequence of techniques used to assess the abdomen is inspection, auscultation, percussion, and palpation. Percussion and palpation stimulate bowel sounds and thus are done after auscultation of the abdomen.

When doing a shift assessment on a new client, the nurse notes that the popliteal pulses are within normal limits (WNL). How would the nurse chart this?

Popliteal pulses 2-3+ Explanation: Correct documentation would be, "Popliteal pulses 2-3+." Therefore, the remaining options are incorrect.

The nurse is conducting a head-to-toe assessment on a client. Which observation(s) by the nurse would be cause for concern? Select all that apply.

Rashes Lesions Infestations Explanation: The nurse inspects the skin with each corresponding body area for rashes, lesions, or infestations (such as fleas or lice). Freckles and goose bumps would not be noted as a concern.

The nurse has reviewed the previous physical assessment notes on a client and sees the following documentation: PERRLA, L 6-4, R 6-4. What is the nurse's best action for follow-up care on this client?

Re-assess as needed. Explanation: PERRLA stands for pupils equal, round, reactive to light, and accommodate. L 6-4, R 6-4 indicates the pupil sizes of both eyes changed from 6 mm to 4 mm when testing pupil reaction. These results are normal for an adult. There is no indication or need for an ophthalmologist consult, Weber test (hearing), or Romberg test (balance) based on these results.

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 Explanation: As a part of the Mini-Mental Status Exam, the nurse will assess remote memory of the past. Assessment of mood, feelings, and expression, thought processes and perception, and level of consciousness are part of general mental state assessment.

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?

Rinne Explanation: The nurse should perform Rinne test to compare between bone and air conduction in the client with mild hearing loss. Weber's test and audiometry are done to determine diminished hearing in one ear. The Whisper test is done to evaluate hearing.

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

Safety Explanation: General survey: wash hands; assess the environment for (a) noise, (b) safety, (c) privacy, and (d) lighting.

When performing a shift assessment, the nurse identifies the client has on a sequential compression device. What must the nurse then assess?

Skin Explanation: Sequential compression devices are placed on extremities. It is important that skin under these devices be at least every shift. These devices do not affect breath sounds, blood sugar or body temperature.

A nurse should perform an ongoing assessment of which system throughout the entire examination?

Skin Explanation: The nurse should assess the skin with each part of the head-to-toe assessment looking for color changes or any suspicious lesions. General survey and mental status are assessed early in the exam process. The heart is part of the cardiovascular exam.

A nurse working in a clinic is planning to conduct vision screenings for a group of low-income women. What equipment would be needed to test vision?

Snellen chart Explanation: A Snellen chart is used as a screening test for distant vision. It consists of characters in 11 lines of different-sized type, with the largest characters at the top of the chart and the line of smallest characters at the bottom. Vision is recorded as a score; for example, 20/20 is normal vision. A stethoscope is used to auscultate body sounds. An ophthalmoscope is used to assess the inner eye. An otoscope is used to inspect the nasal passages.

The client has been admitted with pneumonia. What should the nurse assess?

Sputum Explanation: Swelling, heart tones and peripheral pulses are related to circulatory system The sputum of a client with pneumonia should be assessed.

During the admission assessment of a new client, the nurse is now preparing to assess the client's thyroid gland. How should the nurse perform this assessment?

Stand behind the client and palpate the sides of the trachea. Explanation: Assessment of the thyroid gland is performed by palpating each side of the client's trachea. Percussion, auscultation, and inspection are not central to assessment of the thyroid gland.

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?

State's nurse practice act Explanation: Before performing a complete assessment, read your state's Nurse Practice Act to find out what you can legally assess and diagnose. Although it is also important to know hospital policy, it is the nurse practice act of the state in which you are practicing that determines what is legal for you to perform. The supervising physician does not determine what is legal for you to perform. Nursing practice is regulated primarily at the state, not federal, level.

A nurse is performing a general survey of a client admitted to the hospital. Which of the following actions is an element of this procedure?

Taking vital signs. Explanation: The general survey is the first component of the physical assessment. It includes observing the client's overall appearance and behavior, taking vital signs, and measuring height and weight. Information from the general survey provides clues to the client's overall health. Palpating the integument and assessing the head and neck are part of the physical assessment and identifying risk factors for altered health occurs in the health history.

When collecting subjective data, the nurse gives the client time and encouragement to do what?

Tell about the client's concerns Explanation: The nurse gives the client time and encouragement to tell their story and experience of health or illness. Doing so provides an opportunity for the client to express concerns; it often forms the foundation for a therapeutic relationship. Subjective data collection involves learning about the client's family history and health concerns, but the nurse would steer the conversation away from social discussions of the client's family or too many unrelated complaints. Common findings are part of objective data collection and are driven by the health provider, not the nurse.

The nurse has palpated a client's radial pulses bilaterally and has documented the results of this assessment as "radial pulses 1+ bilaterally." How should this assessment finding be interpreted?

The client's weak pulses may be indicative of cardiovascular disease. Explanation: A peripheral pulse that is documented as 1+ is considered weak, a finding that may be indicative of decreased cardiac output.

The nurse is assessing the head and neck areas of an adult client and discovers several abnormal findings. Which assessment finding requires priority nursing care?

Tracheal deviation. Explanation: Intervening with a tracheal deviation is priority to protect the airway. Reduces carotid pulses may indicated carotid stenosis which does directly affect airway. Distended jugular veins can indicate heart failure which does not directly affect airway. Immobile and tender lymph nodes are suspicious for malignancy but do not directly affect airway as immediately as a deviated trachea. The deviated trachea is also an indicator of tension pneumothorax which is life threatening if not correctly emergently.

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

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.

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 Explanation: Graphesthesia can be assessed by writing a number in the palm of the client's hand. Stereognosis is assessed by placing a quarter or key in the client's hand. Asking the client to touch the nose with a finger with eyes closed is used to assess the client's coordination. Sensation is evaluated by testing sensitivity of position of fingers.

The best approach to use when performing a total physical examination on a client is

a head-to-toe integrated assessment of body systems. Explanation: A head-to-toe approach is more convenient for performing a comprehensive assessment, which integrates the assessment of all body systems. This approach conserves time and energy for both the client and nurse.

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

acquire your client's verbal permission to perform the physical examination. Explanation: Get your client's permission to ask personal questions and to perform the various physical assessments.

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 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.

During the general survey a client comments about the extremely cold weather even though the client lives in a major northeastern United States city and the month is July. What action should the nurse take?

assess mental status Explanation: The client's statement is inconsistent with the current weather which could indicate an alteration in mental status. It would be appropriate for the nurse to assess this client's mental status at this time. Offering a blanket, measuring body temperature, and adjusting the temperature of the examination room assumes that the client currently feels cold. This is a misinterpretation of the client's statement.

When integrating the total physical examination the nurse should

assess peripheral vascular status when examining the lower extremities. Explanation: When you assess the legs you will be assessing the parts of the skin (color and condition of skin on legs), peripheral vascular system (pulses, color, edema, lesions of legs), musculoskeletal system (movement, strength, and tone of legs), and neurologic system (ankle and patellar reflexes, clonus).

A client is supine with the head of the examination table at a 30-degree angle. What should the nurse assess at this time?

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.

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 Explanation: Responding appropriately to the "whisper test" assesses cranial nerve VIII. Sternocleidomastoid and lower trapezius muscle strength determines if cranial nerve XI is intact. The nurse's direction was not to assess the client's understanding of directions or knowing the difference between left and right.

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 Explanation: A complete assessment is performed in a cephalic to caudal sequence comparing side to side for symmetry. This approach is not used to validate findings, identify problems, or to compare with the medical record.

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?

flexion and extension Explanation: Since the legs are not able to be completely extended, the nurse should focus on knee flexion and extension. Gait would not help determine if the client is experiencing an alteration in knee function. Limb length would not help explain the reason for the alteration in knee function. The knee is not assessed for abduction or adduction although movement of the knee occurs to assess for abduction and adduction of the hip.

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

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.

The nurse is beginning a complete assessment of a client. What should be included as part of the general survey?

height and weight Explanation: Height and weight are usually included with the general survey. Skin temperature would be assessed during the skin assessment. Facial expression would be noted when assessing the head. Ambulatory status would be determined when assessing the neurologic or musculoskeletal systems.

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 Explanation: Some systems overlap and can be interwoven during the examination. This limits the number of times clients need to change position from sitting to lying to standing, which can be difficult for clients who have pain, dyspnea, or limited range of motion. A front to back approach is not identified as a method to perform a physical examination. Grouping examination areas is not done to avoid missing important information or because of limited time to complete the entire assessment.

While conducting a physical examination with the client in the seated position, the nurse begins the cardiovascular assessment. In order to listen for aortic insufficiency, the nurse should ask the client to move into which position?

lean forward Explanation: Leaning forward brings the ventricular apex and left ventricular outflow closer to the chest wall, enhancing detection of the point of maximal impulse and aortic insufficiency. For much of the cardiovascular examination, the client should be in the supine position; however, it is difficult to assess aortic insufficiency in this way. The three positions required for the cardiovascular assessment are sitting, lying with the head of the bed increased to 30 degrees, and left lateral decubitus.

In order to assess a client's abdominal reflexes, what should the nurse include in the physical examination?

light stroking inward from all quadrants Explanation: The abdominal reflex is stimulated by stroking around the umbilicus. If reflexes are normal, the nurse should note contraction of the muscles. Auscultating for bowel sounds will not assist the nurse in assessing abdominal reflexes because this would assess the gastrointestinal system rather than the musculoskeletal system. Light palpation should be used to identify masses, tenderness, and the client's face for expressions in response to pain. Percussion of the abdomen helps to listen for sounds that provide information about the liver, kidney, and spleen.

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 Explanation: An otoscope can be used to assess both the ears and nose. The tip would need to be changed between the assessment of these areas. A pen light would not be sufficient to assess the ears and nose. A cotton swab should not be inserted into these body orifices. An ophthalmoscope would not be appropriate to assess the ears or nose.

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 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.

In order to conduct a physical examination of the eye muscles, the nurse should prepare to administer which tests?

six cardinal directions of gaze convergence near reaction cover-uncover test Explanation: Tests that can be used to examine the eye muscle strength include the six cardinal directions of gaze, convergence, near reaction, and the cover-uncover test. Confrontation is used to examine visual fields.

The nurse wants to assess a client's 5th cranial nerve. What approach should be used?

stroke each side of the cheek with a cotton wisp Explanation: Assessing for response to light sensation over the cheeks determines the status of cranial nerve V. Frowning and puffing out the cheeks assesses cranial nerve VII. Palpating the jaw for areas of pain or tenderness assesses motor function of the temporomandibular joint.

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?

to auscultate the lungs Explanation: The nurse requires a stethoscope to assess for the presence of fluid in the lungs, indicating the client also has pulmonary edema. Pedal and radial pulses can be assessed using the tips of the fingers directly over the sites where these pulses are 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. A penlight helps identify jugular filling.

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 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.

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 Explanation: A gauze pad is used when assessing the tongue. A gauze pad is not needed when assessing the scalp, pulses, or axillae.