Chapter 28 Head-to-Toe Assessment

For which assessment could the neurologic and musculoskeletal systems be combined? gait abdomen respiratory peripheral vascular

gait

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

Asymmetrical smile

During which of the following assessments should the nurse use the bell of the stethoscope during auscultation? Ausculation of a patient's heart murmur. Ausculation of a patient's apical heart rate. Auscultation of a patient's breath sounds. Auscultation of a patient's bowel sounds.

Ausculation of a patient's heart murmur.

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? Decide whether to alter the process of starting at the head and proceeding to the feet Uncover only the part being examined, covering everything else Ask for the client's permission to perform the assessment Ask if the client wants an observer for the assessment

Ask for the client's permission to perform the assessment (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 (eg, 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.)

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 how the assessment will be conducted. By explaining that all information will be kept confidential. By explaining the assessment technique before performing ti. By offering the client and opportunity to ask questions.

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.) Correct tubes and drains intact Call bell within reach Correct intravenous lines and fluids Bed at mid-level, locked position Wearing client identification bracelet

Call bell within reach Correct intravenous lines and fluids Correct tubes and drains intact Wearing client identification bracelet Bed should be at lowest, locked position before leaving the hospital room to prevent falls. All other safety checks are correct.

The hospitalized client is at risk for ineffective tissue perfusion. What should the nurse assess to identify ineffective tissue perfusion? Capillary refill Skin moisture Mobility status Nutritional status

Capillary refill

A nurse is preparing a client for a head-to-toe examination. Which of the following should the nurse do at this time? Select all that apply. Discuss the purpose and importance of the health history with the client Acquire the client's permission to ask personal questions Validate and document assessment findings Explain your respect for the client's privacy and for confidentiality Formulate nursing diagnoses Explain that the client will need to change into a gown

Discuss the purpose and importance of the health history with the client Acquire the client's permission to ask personal questions Explain your respect for the client's privacy and for confidentiality Explain that the client will need to change into a gown

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

Encourage turning, coughing, and deep breathing

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? Grouping body systems together to limit position changes Examining the right side of the body and then the left Head-to-toe assessment Major body systems first approach

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? Hypokalemia Hyperkalemia Hyponatremia Hypernatremia

Hyponatremia If the sodium in your blood is too low, you have a condition called hyponatremia. It can happen because of certain medical conditions, some medicines you might be taking, or if you drink too much water.

During the assessment of a female client, which physical examination techniques should the nurse use to assess the vagina? Light palpation Deep palpation Transillumination Inspection

Inspection

Which situation would require the nurse to perform an urgent assessment? Select all that apply. Respiratory rate 24 Heart rate 64 Pulseless leg Temperature 102.5 °F (39.2 °C) Oxygen saturation 87%

Pulseless leg Temperature 102.5 °F (39.2 °C) Oxygen saturation 87%

At the beginning of the exam the nurse performs a general survey. What would the nurse assess at this time? Hearing acuity Pedal pulses Oxygen saturation Safety

Safety

When performing a shift assessment, the nurse identifies the client has on a sequential compression device. What must the nurse then assess? Skin Breath sounds Temperature Blood sugar

Skin

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

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? Hospital policy State's nurse practice act Federal law Supervising physician

State's nurse practice act

During a shift assessment, the nurse finds the client unable to speak and her face is asymmetrical. What does the nurse suspect? Bell's palsy Myocardial infarction Sepsis Stroke

Stroke Explanation: This client has neurological deficits as she cannot speak and her face is asymmetrical. Bell's palsy involves facial drooping but speech is intact. Sepsis is due to infection and a myocardial infarction is related to the heart. (less)

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. Palpating the integument. Identifying risk factors for altered health. Assessing the head and neck.

Taking vital signs. (The general survey is the first component of the physical assessment. It includes observing the patient's overall appearance and behavior, taking vital signs, and measuring height and weight. Information from the general survey provides clues to the patient'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.)

The nurse has palpated a patient'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 patient's weak pulses may be indicative of cardiovascular disease. The patient has normal peripheral pulses. The patient has increased radial pulses that may result from hypertension. The patient shows no signs of a circulatory health problem.

The patient's weak pulses may be indicative of cardiovascular disease.

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? Flat Dull Tympany Resonant

Tympany

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

VII

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 Place a quarter or key in the client's hand Ask the client to touch finger to nose with eyes closed Evaluate sensitivity of position of fingers

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

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

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

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

after assessing the motor function of the lower extremities

When should the nurse assess the costovertebral angle for tenderness? during percussion of the abdomen after assessing the posterior thorax while assessing range of motion of the spine before palpating the lower pole of the left kidney

after assessing the posterior thorax

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

assess peripheral vascular status when examining the lower extremities.

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 XI is intact cranial nerve VIII is intact the client understands directions the client knows the difference between left and right

cranial nerve VIII is intact

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

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

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 assess pedal pulses to auscultate the lungs to assess jugular venous pressure to check radial pulses

to auscultate the lungs