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

A student nurse asks the instructor why it is necessary to do a comprehensive health assessment on a new client. What would be the instructor's best response?

"The comprehensive health assessment integrates all body systems and helps give the nurse an overall impression of the client's condition."

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

Arm, hands, and fingers

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

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?

Assessing for pain

How will the nurse, who is conducting the physical assessment, encourage the client to be honest and open in identifying the health problem?

By explaining that all information will be kept confidential.

The nurse should include which important safety checks before leaving a hospitalized client's room? (Select all that apply.)

Call bell within reach Correct intravenous lines and fluids Wearing client identification bracelet Correct tubes and drains intact

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

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

Complete blood count

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

The nurse prepares to complete a head-to-toe assessment on a client. For which assessments should the nurse wear gloves? Select all that apply.

Eyes Breasts Skin, hair, nails Thorax and lungs

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

Fall

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

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

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

Focused

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

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

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?

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?

Hyponatremia

During the assessment of a female client, which physical examination techniques should the nurse use to assess the vagina?

Inspection

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

A nurse has introduced herself to a new client and asked the client to accompany her to an appropriate location for assessment. During this initial interaction with the client, the nurse is able to ascertain the client's:

Level of consciousness

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

Lightly stroke inward from all quadrants.

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

Mouth and pharynx

A nurse is preparing equipment for a head-to-toe examination of a client. Equipment for assessment of which of the following body regions is the nurse most likely to need for the typical client assessment?

Mouth and throat

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.

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

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

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

Safety

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?

Sanguineous

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

Skin

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

Which of the following equipment will the nurse gather to conduct a physical examination of a client's eyes? (Select all that apply.)

Snellen chart Rosenbaum card Ophthalmoscope

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

Sputum

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

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

Taking vital signs.

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

Tell about the client's concerns

What symptom(s) found during assessment would cause the nurse to suspect the client may be experiencing sepsis? Select all that apply.

Temperature greater than 102 °F (38.9 °C) Respiratory rate 36 breaths per minute Altered mental state Documented or suspected infection

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?

Tympany

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

VII

The nurse suspects that a client has an infection of the lower leg. What skin assessment finding caused the nurse to make this clinical determination? Select all that apply.

Warmth Erythema

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

a head-to-toe integrated assessment of body systems

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

After auscultating bowel sounds the nurse lightly strokes each side of the client's abdomen. What is the purpose of this technique?

assess abdominal reflex

When integrating the total physical examination the nurse should

assess peripheral vascular status when examining 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?

carotid arteries

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

The nurse notices that a client has a brilliant smile when asked about children. What should the nurse document about this finding?

cranial nerve VII intact

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 examining a client's musculoskeletal system, for which assessment should the client be in a seated position?

elbow flexion

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.

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

gait

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

height and weight

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

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

The nurse is seeing a client with a recent history of exposure to a family member who has influenza. The client reports a throbbing toothache when bending forward. Which assessment should the nurse be sure to include in the physical examination?

palpation of the sinuses

The nurse is preparing to assess a client's anterior thorax. In which position should the client be placed to assess the heart?

sitting

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

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

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