Head-to-toe assess

Nurse is performing an assessment of client's abdomen. Which of the following actions should nurse take?

Auscultate sounds prior to palpating.

Nurse is evaluating older adult client for alteration in orientation. Which of the following questions should nurse ask client?

Can you tell me what month it is?

Nurse is preparing to conduct head-to-toe assessment on client in outpatient setting. At which of the following times should the nurse plan to collect info about client's general appearance?

During an interview about client's health history. When introducing themselves to client. While collecting VS.

Nurse is assessing client's posterior and lateral chest. Which of the following actions should nurse take?

Observe for use of accessory muscles during inspiration.

Nurse is planning to complete a physical assessment on client. Which of the following actions should nurse plan to include?

Use quotation marks when documenting client statements.

Nurse is inspecting anterior chest of client. Which of the following findings should nurse report to provider?

Distended veins in one breast

Nurse is preparing to assess status of client's upper extremities. Which of the following actions should nurse take?

Inspect the condition of each fingernail. Compare the amplitude of the radial pulses bilaterally. Palpate shoulder, elbow, wrist and finger joints.

Nurse is performing assessment on client who reports ear pain. Which of the following actions should nurse take?

Palpate mastoid area for pain.

Nurse is preparing to perform a head-to-toe assessment on client. Which of the following tools should nurse plan to gather?

Penlight. Stethoscope. Sphygmomanometer.

Nurse is performing assessment of client's lower extremities. Which of the following actions should nurse include?

Inspect pattern of hair distribution.

Nurse is assessing client's neck. Which of the following should nurse ask client to perform during this assessent?

Instruct client to swallow. Apply downward pressure and ask client to shrug shoulders. Request client move their head forward and backward then side to side.

Nurse is preparing to care for group of clients in acute care setting. Which of the following assessments should nurse plan to perform on every client?

Lung sounds. Bowel sounds. Pedal pulses. Mental status.

Nurse in outpatient setting is performing a head-to-toe assessment on client. Which of the following should nurse inspect when performing a general survey of client?

Nutritional status. Hygiene. Posture.

Nurse is assessing client's radial pulse rate. Which of the following should nurse collect while performing this action?

Regularity of pulse. Strength of pulse.

Nurse is assessing a client's vital signs. While counting the number of respirations, which of the following info should nurse collect?

Characteristic of respirations