HA- Putting it all toghter

When assessing the legs, feet, and toes, which pulses would the nurse expect to palpate? Select all that apply.

Femoral, Dorsalis pedís, Popliteal and Posterior tibia Explanation: When assessing the legs, feet, and toes, the nurse would palpate the femoral, popliteal, dorsalis pedis, and posterior tibial pulses. The brachial pulse is palpated when assessing the arms, hands, and fingers. The temporal pulse would be palpated when examining the head and face.

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

It is appropriate to tell a patient the findings of the physical examination.

True

A nurse is preparing a patient for a physical assessment. The patient appears anxious about the assessment. Which statement by the nurse would be most appropriate?

"Let me tell you what I will be doing. It should not be painful." Explan: The patient may be anxious for many reasons. Tell the patient that the assessments should not be painful. Explaining the assessment in general terms can help decrease the patient's embarrassment, fear of possible abnormal physical findings, or fear of "failing" a test.

The nurse is assessing a client's judgment during a comprehensive head-to-toe assessment. How can the nurse best appraise this aspect of cognitive function?

"What would you do if you found a stamped, addressed envelope on the ground?" Explan: Judgment is usually gauged by asking the client about his or her response to a hypothetical situation. None of the other listed questions requires the client to exercise judgment in a scenario.

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." Explan: 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.

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

Arm, hands, and fingers Explan: 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.

A nurse would expect to assess the epitrochlear lymph nodes when assessing which of the following?

Arms Explan: The epitrochlear lymph nodes would be palpated when the nurse assesses a client's arms.

The nurse will palpate a client's axillae during a head-to-toe assessment. The nurse should combine this with examination of which area?

Breasts Explan: During the breast examination, the nurse palpates the axillae. The axillae are anatomically closest to the breasts.

The nurse is planning the comprehensive head-to-toe assessment of a client. What assessment should the nurse usually conduct last?

Assessment of the genitalia and rectum Explan: In most cases, the nurse performs the assessment of the client's genitalia and rectum at the conclusion of the assessment. This minimizes the infection risk associated with these assessments, as well as limits the time that the client is exposed.

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

Asymmetrical smile Explan: 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.

During which of the following assessments should the nurse use the bell of the stethoscope during auscultation?

Ausculation of a patient's heart murmur. Explanation: The bell of the stethoscope is used to listen to low-pitched sounds, such as heart murmurs. The diaphragm of the stethoscope is used to listen to high-pitched sounds such as normal heart sounds, breath sounds, and bowel sounds.

When performing an assessment, the nurse will inspect which area from the back of the patient?

CVA tenderness

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 Explan: Bed should be at lowest, locked position before leaving the hospital room to prevent falls. All other safety checks are correct.

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

Complete blood count Explan: 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.

A nurse is preparing to complete a comprehensive health assessment on a female client. Prior to beginning the assessment, the client states, "I'm really having a good deal of pain in my hip now." What would be most appropriate for the nurse to do?

Delay the full exam until the client's pain has been addressed. Explan: The client's physical and mental statuses determine how much of the exam a nurse may perform at one time. If a client is experiencing significant pain, an extensive assessment should wait until the client is more comfortable. It would be inappropriate to begin the assessment or explain the reason for the assessment. Although education on pain control may be needed, the client is in pain now and comfort is the priority.

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 Explan: 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 Explan: 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.

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 Explan: 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.

When performing a head-to-toe assessment, during which part would the nurse assess the motor function of cranial nerve VII?

Head and face Explan: Cranial nerve VII is evaluated while examining the head and face by having the client smile, frown, show teeth, blow out cheeks, raise eyebrows, and tightly close eyes. No cranial nerves are tested during the mental status exam. When examining the ears, the nurse would evaluate cranial nerve VIII when assessing hearing. When examining the mouth and throat, the nurse would evaluate CN X, IX, and sensory function of CN VII.

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 Explan: 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.

A nurse is assessing a client's vital signs. Which of the following should be considered the fifth vital sign?

Pain Explan: Pain is considered the "5th vital sign" and is assessed following temperature, pulse, respirations, and blood pressure, which are the first four vital signs.

The nurse is palpating the client's tonsillar, submandibular, and submental lymph nodes. The nurse is most likely examining which area during a comprehensive assessment?

Neck Explan: During the neck assessment, the nurse would palpate the preauricular, postauricular, occipital, tonsillar, submandibular, and submental lymph nodes. These nodes are in the region of the neck, not the abdomen, face, or nose and sinuses.

A nurse is going to complete a comprehensive assessment on a client. When collecting objective data, which of the following would the nurse do first?

Observe the overall appearance Explan:When collecting objective data, the nurse would start with a general survey and observe the client's overall appearance first. Then the nurse would assess vital signs, take body measurements, and assess mental status.

The nurse is unable to palpate a pedal pulse in the right leg of an adult client. What the nurse's best action?

Obtain a Doppler to verify absent pulse. Explan: Diminished or absent pulses. If present, obtain Doppler for assessment. Bounding (4) pulses are also abnormal. The nurse should first confirm the absence of a pedal pulse, then notify the healthcare provider. Elevating the leg promotes venous return but does not promote arterial flow to aid in palpating a pulse. If the pulse is absent in the right leg, the cause could be a blood clot. Applying sequential devices could potentially mobilize a clot leading to pulmonary embolus.

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. Explanation: The nurse should place the stem of the vibrating tuning fork on the mastoid area behind the ear to test for bone conduction of sound waves in the tested ear. The stem is placed in the center of the head to determine equality or disparity of bone-conducted sound when conducting Weber's test. The tuning fork is not placed behind the client's head because it does not help in assessing the bone conduction of the sound. Placing the tuning fork near the ear canal facilitates the testing of air conduction of sound in the tested ear.

The nurse should ensure that a Doppler ultrasound is available when performing what assessment?

Peripheral vascular assessment Explanation: A Doppler ultrasound is often needed to identify some of the peripheral pulses during the peripheral vascular assessment. It is not normally required during the respiratory, abdominal, or musculoskeletal assessments.

When inspecting the face for facial symmetry, what would the nurse have the client do? (Select all that apply.)

Raise eyebrows, Frown, Smile and Close eye Explan: Face: inspect facial features for symmetry (cranial nerve VII, facial: symmetry of face— raise eyebrows, frown, close eyes, smile, puff out cheeks).

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 and Infestation Explan: 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. Explan: PERRLA stands for pupils equal, round, reactive to light, and accomodate. 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 opthamologist consult, Weber test (hearing), or Romberg test (balance) based on these results.

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

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 Explan: Wound drainage is classifi ed as serous (clear), sanguineous (bloody), serosanguineous (mixed), fi brinous (sticky yellow), or purulent (pus). Note any signs or symptoms of infection.

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

Skin Explan: 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.

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

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

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. Explan: 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 is completing an abbreviated head-to-toe assessment of a client. What would the nurse perform when assessing the client's eyes?

Test the client's pupillary response to light. Explan: During the abbreviated head-to-toe assessment, the nurse should test eye reaction to light and accommodation. Assessment of vision and the cover test are not normally included in a brief head-to-toe assessment.

When preparing to do a comprehensive health assessment, the nurse obtains the client's permission based on an understanding of which principle?

The client has the right to refuse the assessment. Explan: The nurse asks the client's permission to complete the assessment because the client has the right to refuse, and asking permission fosters the client's autonomy. In addition, some parts of the physical examination require touching or exposing the client, which also requires the client's permission. The primary rationale for permission is the client's legal and ethical right to refuse. This principle supersedes considerations such as rapport, disclosure, and client comfort, even though each is valid.

When analyzing data related to a client's behavior, the nurse should compare the observations with which of the following?

The client's developmental stage Explan: Comparing behavior with developmental stage would be most important because it will let the nurse know if this client is behaving appropriately for that level. For most clients, this comparison is more significant than correlating behavior with motivation, vital signs, or body mass index.

The nurse is preparing to gather equipment prior to a client's head-to-toe assessment. The nurse's selection of equipment should be based primarily on what variable?

The client's health needs Explan: Several variables influence the nurse's selection of equipment, including the nurse's expertise and the client's level of participation. However, the client's health status and health needs are paramount. The nurse's timeline must sometimes be accommodated, but this is not a primary considerations.

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

VII Explan: 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.

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 and Erythema Explan:Erythema and warmth are indications of an infection. Pallor is an indication of anemia. Jaundice indicates an issue with liver function. Increased tenting indicates low body fluid volume.

The nurse is performing a head-to-toe assessment of a client. What would be an example of information obtained during the review of the client's body systems?

Wears dentures; denies problems with eating, chewing, and swallowing. Explanation: The statement about dentures and no problem with eating, chewing, and swallowing reflects a review of the client's body system, specifically the mouth and throat. The statement about the father dying from a heart attack reflects family health history. Use of over-the-counter antacids would reflect lifestyle and health practices, specifically medication use. The statement about vaginal delivery reflects the client's past health history.

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 Explan: 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 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 Explan: 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.

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 Explan: Lightly stroking each side of the abdomen is done to determine the presence of the abdominal reflex. Percussion and palpation help determine the liver border. Deep palpation is used to find the lower pole of the left kidney. Stroking the abdomen is not done to change the character of the client's bowel sounds.

When integrating the total physical examination the nurse should

assess peripheral vascular status when examining the lower extremities. Explan: 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 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 EXplan: 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 prepares to conduct a history and complete physical examination. What should the nurse explain to the client as being the major purpose for this comprehensive evaluation?

develop a plan of care Explan: The integration of history taking and physical examination produces the health assessment. This combination of information for each body system provides the nurse with the knowledge of the individual to develop a plan of care. The nurse does not diagnose problems or determine the need for further testing. The nurse's history and complete physical examination is not done to validate the healthcare provider's findings.

The nurse completes the assessment of a client's reflexes. Which position should the nurse place the client to assess the Romberg sign?

standing Explan: The Romberg test is completed with the client in a standing position. This test is not completed in a prone, supine, or sitting position.

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. Explan: When using a head-to-toe approach, some body systems may be assessed in combination. When performing an eye assessment you will also be performing part of the neurologic exam for cranial nerves II, III, IV, and VI, which affect vision and eye movements.

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.

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 Explan: 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 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 Explan: 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.

A patient with cardiac issues has just had a cardiac examination in the supine position. The next step in the examination would be

performing the cardiac assessment in the left lateral position

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 Explan: 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.

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