Health Assessment Extra Practice

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? "Let's stop; I have all of the information we need." "We can take a break anytime." "Let's stop and take your vital signs." "Keep taking deep breaths; you will be okay."

"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.

A nurse has been assigned a group of clients. On which client should the nurse perform an integrated head-to-toe assessment first? 45-year-old client admitted with a fever and coarse lung sounds, 02 saturations 94% on 2L NC, respirations 18 unlabored 82-year-old client who uses a walker and has decreased visual acuity 72-year-old client admitted with hypotension who has had 180 mL urine output in the past 8 hours 54-year-old client upper extremity motor strength 5/5 right arm, 4/5 left arm

72-year-old client admitted with hypotension who has had 180 mL urine output in the past 8 hours explanation- The nurse would perform an integrated head-to-toe assessment on the client with hypotension and decreased urine output first. This client's blood pressure is not sufficient enough to perfuse their kidneys, thus the decreased urine output (urine output should be at least 30 mL/hr). If the nurse does not see this client first, the client may suffer acute renal dysfunction due to decreased perfusion. The 82-year-old client is presenting with normal, age-related changes, for example, unsteady gait and decreased visual acuity. The client with the fever and coarse lung sounds demonstrates a stable condition with oxygen saturation of 94% on 2L NC and respirations of 18 that are unlabored. The 54-year-old client with 5/5 right arm motor strength versus 4/5 left arm motor strength is probably right-handed (the dominant arm will be stronger).

At which of the following points in the physical examination should the nurse assess a client's vital signs? After the respiratory system examination After the cardiovascular system examination After the mental status examination After the integumentary status examination

After the mental status examination explanation- The correct option is after the mental status examination. The client will likely be in a seated position at this point with the arm and anterior thorax available for the needed assessments associated with vital signs. The vital signs assessment is ideally completed prior to beginning any major body system examination because they can provide information to direct the focus to a major body system. This should be done before the integumentary, cardiovascular, and respiratory system examinations.

A nurse is performing a head-to-toe assessment on a new client. What should the nurse include in an integrated musculoskeletal and neurologic system assessment? Select all that apply. Have the client perform a tandem walk. Ask the client to rapidly touch their nose with their finger. Ask the client to hop on one leg. Observe the client's normal gait. Have the client stand with their feet wide apart and close the eyes for 5 minutes.

Ask the client to hop on one leg. Have the client perform a tandem walk. Ask the client to rapidly touch their nose with their finger. Observe the client's normal gait. explanation- Assessing the large body systems of musculoskeletal and neurological systems includes balance, gait, coordination such as hopping on one leg, observing normal gait, walking in tandem (heel-to-toe), rapidly touching finger to nose, and performing the Romberg test. The Romberg test is done with the client standing, feet together (not apart), having the client's eyes open initially, and then asking the client to close them, with the nurse watching for the length of time the client is able to maintain balance.

A nurse performs a general survey on a client at their annual check-up. The following information is obtained: ● Past medical history: hypertension, gastroesophageal reflux disease, diabetes ● Vital signs: temperature: 96.9°F (36.05°C); BP 138/80; heart rate 101 irregular; oxygen saturation (02 Sat) 94% on room air What is the next best action of the nurse? Document findings. Auscultate for a pulse rate deficit. Perform an emergent assessment. Notify the health care provider.

Auscultate for a pulse rate deficit. explanation- Because there is no history of an irregular heart rhythm, the nurse should auscultate for a pulse rate deficit and perform a focused assessment. Because there is no mention of congestive heart failure, the nurse would document findings, but this is not the best option. The nurse would complete the focused assessment (ask the client more questions about cardiac disease, family history, symptoms they might have been experiencing such as palpitations, shortness of breath, dizziness). There is no need to contact the health care provider or perform an emergent assessment because the client is stable.

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. Breasts Thorax and lungs Skin, hair, nails Eyes Musculoskeletal

Breasts Thorax and lungs Skin, hair, nails Eyes explanations- It is recommended that the nurse have gloves to apply when examining the client's eyes, breasts, skin, hair, and nails, and thorax and lungs. Gloves are not recommended when examining a client's musculoskeletal system.

A high school football player presents to the hospital with dizziness, headache, sleepiness, increased tenting of the skin, and decreased turgor following an intensive practice in the summer heat. Which of the following nursing diagnoses can the nurse formulate based on this information? Acute Confusion Deficient Fluid Volume Activity Intolerance Risk for Imbalanced Fluid Volume

Deficient Fluid Volume explanation- Based on the symptoms listed, the nurse can formulate the diagnosis Deficient Fluid Volume as manifested by increased tenting of the skin and decreased turgor related to inadequate fluid intake during exercise in the heat. A diagnosis of Risk for Imbalanced Fluid Volume would not be appropriate, as the client is already demonstrating symptoms of dehydration. There is no indication of activity intolerance or acute confusion.

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 Validate and document assessment findings Formulate nursing diagnoses Explain that the client will need to change into a gown Acquire the client's permission to ask personal questions Explain your respect for the client's privacy and for confidentiality

Discuss the purpose and importance of the health history with the client Explain that the client will need to change into a gown Acquire the client's permission to ask personal questions Explain your respect for the client's privacy and for confidentiality explanation- When preparing the client for a full-body examination, you should do the following: discuss the purpose and importance of the health history and physical assessment with your client; acquire your client's permission to ask personal questions and to perform the various physical assessments (i.e., breast, thorax, genitourinary exam); explain your respect for the client's privacy and for confidentiality; respect your client's right to refuse any part of the assessment; and explain that the client will need to change into a gown for the examination. Validating and documenting assessment findings and formulating nursing diagnoses are steps that should occur following the assessment.

After assisting a client to a lying position for the cardiovascular examination, what should the nurse do next? Wash hands. Auscultate the apical pulse. Elevate the head of the bed to a 30-degree angle. Inspect the precordium.

Elevate the head of the bed to a 30-degree angle. explanation- To thoroughly examine a client's cardiovascular system with the client in the lying position, the head of the bed should be elevated at a 30-degree angle because this position eases the nurse's ability to inspect and palpate cardiovascular structures by bring them closer to the chest wall and neck. The nurse can wash the hands several times throughout the examination but does not need to be done specifically before beginning the cardiovascular examination. The apical pulse is auscultated last. The precordium is inspected after the carotid arteries and jugular veins are examined.

When organizing the complete examination, the nurse understands that the following assessments should be performed with the client seated. Select all that apply. cardiovascular mental status abdomen integument musculoskeletal upper body

mental status integument musculoskeletal upper body

Order the parts of the physical examination of the neck in the correct sequence from first to last. All options must be used.

Inspect the front of the neck for masses, enlarged nodes, or deviation. Inspect the position of the trachea. Inspect the thyroid gland. Test the head and neck for range of motion. Palpate the head, neck, and subclavicular lymph nodes. Palpate the thyroid. explanation- During the physical examination of the neck, begin with the assessments that will cause the least amount of discomfort to the most. Inspecting is noninvasive and should be done first. Inspecting first provides cues as to where to focus the assessment. Testing range of motion requires the client to move and may cause some discomfort depending on the nature of the chief report. This should be completed before the nurse begins to palpate. Palpation tends to cause the greatest discomfort during the physical examination. This should be left to the end of the assessment of each body area. The last part of this sequence should be to palpate the thyroid last because the nurse should move behind the client in order to effectively assess this area of the neck.

A nurse should test a range of motion for a client's knees by asking the client to perform which movements? Select all that apply. Adduction Extension Flexion Rotation Hyperextension Abduction

Extension Flexion hyperextension explanation- The normal range of motion for the knee is flexion, extension, and hyperextension.

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

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

The nurse is performing an assessment of a client's nose and sinuses. What should the nurse include in the assessment? Select all that apply. Inspect the mucous membrane, septum, and turbinates. Have the client identify one familiar scent. Palpate the frontal and maxillary sinuses. Palpate for tenderness and patency. Inspect for symmetry, alignment, and deformity.

Inspect the mucous membrane, septum, and turbinates. Palpate the frontal and maxillary sinuses. Palpate for tenderness and patency. Inspect for symmetry, alignment, and deformity. explanation- The nurse should proceed with the assessment of the client's nose and sinuses by palpating for tenderness and patency; palpating the frontal and maxillary sinuses; inspecting the mucous membrane, septum, and turbinates; and inspecting for symmetry, alignment, and deformity. The nurse should have the client identify two different scents with the eyes closed.

The nurse is assessing a client's skin. Which additional action should the nurse take while performing this assessment? Assess pulses Instruct on preventive measure Identify skeletal abnormalities Analyze cardiovascular status

Instruct on preventive measure explanation- As the skin is being assessed, the nurse should instruct the client on how to examine the skin and to note any warning signs of cancer. The assessment is a good time to teach preventative measures. This is not the time to assess the pulses. Identify skeletal abnormalities, or to analyze the client's cardiovascular status.

A nurse is performing a head-to-toe examination of a client. At which point should the nurse first put on gloves? Just after the mental status examination Just before the mouth and throat assessment Just after the general survey Just before the rectal assessment

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.

The nurse is performing an abdominal assessment on a client. How should the nurse elicit the client's abdominal reflex? Lightly stroke inward in all quadrants. Deeply palpate all four quadrants. Palpate for the liver, kidneys, and spleen. Lightly palpate all four quadrants.

Lightly stroke inward in all quadrants. explanation- The nurse should elicit the abdominal reflex by lightly stroking inward in all quadrants. Lightly palpating all four quadrants, deeply palpating all four quadrants, and palpating for the liver, kidneys, and spleen should all be included in the abdominal assessment, but these actions do not elicit the abdominal reflex.

A nurse is preparing to complete a comprehensive assessment on a client. When collecting objective data, what would the nurse do first? Assess the client's mental status. Observe the client's overall appearance. Assess the client's vital signs. Take the client's body measurements.

Observe the client's overall appearance. explanation- 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. Elevate the client's right leg. Notify the healthcare provider. Apply sequential compression devices.

Obtain a Doppler to verify absent pulse. explanation- 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.

The nurse is assessing a client who has a radial pulse of 138 beats per minute. What action should the nurse take? Notify the health care provider. Document bradycardia. Obtain the apical pulse for one full minute. Assess the pedal pulses bilaterally.

Obtain the apical pulse for one full minute. explanation- When obtaining vital signs, if the pulse is irregular the apical pulse should be taken for one full minute before notifying the physician. The pulse would be described as tachycardia, not bradycardia. Assessing the pedal pulses bilaterally is important but is not the priority.

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? Causes assessment findings to be more accurate Instills a friendly feeling toward you in the client Speeds up the pace of the assessment Opens up teaching/learning moments

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.

As part of a head-to-toe assessment, a nurse obtains vital signs on a client admitted with pneumonia: temperature 101.12°F (38.4°C), heart rate 101 bpm, BP 90/56 mm Hg, O2 saturation 95% on room air. The nurse administers an antipyretic. What is the next best action of the nurse? Notify the health care provider. Perform a comprehensive assessment. Perform a head-to-toe integrated assessment. Apply oxygen.

Perform a head-to-toe integrated assessment. explanation- After each intervention (e.g., administering an antipyretic), the nurse will reassess the client for effectiveness of the intervention by performing an integrated head-to-toe assessment, for example, rechecking the client's temperature, heart rate, and blood pressure; assessing the temperature and moisture of the skin; and reevaluating lab values. A comprehensive assessment was completed at admission and is not warranted at this time. Because fever is expected with pneumonia and the nurse has an order for an antipyretic, the nurse does not need to contact the health care provider at this time. The client's oxygenation level is adequate (95% on room air).

The nurse should ensure that a Doppler ultrasound is available when performing what assessment? Musculoskeletal assessment Respiratory assessment Abdominal assessment Peripheral vascular assessment

Peripheral vascular assessment explanation- 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.

After performing a physical assessment, the nurse recognizes that which of the following findings should be shared with the health care provider as soon as possible? Positive Babinski sign Deep tendon reflexes 3+ bilaterally Capillary refill in index finger less than 3 seconds Aorta palpable, smooth

Positive Babinski sign explanation- A positive Babinski sign is indicative of a possible poor neurological outcome and the health care provider should be notified immediately. The other findings are within defined limits and are expected findings.

When inspecting the face for facial symmetry, what would the nurse have the client do? (Select all that apply.) Raise eyebrows Close eyes Frown Smile Stick out tongue

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

While assessing a client's musculoskeletal status, the nurse asks the client to perform lateral bends. Which of the following will this movement provide information about? Spinous processes Range of motion Spinal deformities Diaphragmatic excursion

Range of motion explanation- The assessment of range of motion is done with the client flexing, extending, laterally bending, and rotating the spine. Spinal deformities can be assessed using inspection alone. The spinous processes are assessed using inspection and palpation. In order to examine the diaphragmatic excursion, the nurse will need to percuss lung sounds.

A nurse is preparing to assess a client's cognitive abilities. Which assessment tool should the nurse use? Self-report Depression Questionnaire Saint Louis University Mental Status (SLUMS) Assessment Columbia Suicide Severity Rating Scale (CSSRS) Glasgow Coma Scale

Saint Louis University Mental Status (SLUMS) explanation- The nurse should use the Saint Louis University Mental Status (SLUMS) Assessment to assess a client's cognitive abilities. The Self-report Depression Questionnaire is used to assess the client for depression. The Glasgow Coma Scale is used to assess level of consciousness. The Columbia Suicide Severity Rating Scale (CSSRS) is used to assess for suicide risk.

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 nurse's time allowance The client's level of participation The client's health needs The nurse's level of expertise

The client's health needs explanation- 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.

A nurse is performing a part of a physical assessment for a client using palpation. What is the purpose of using this technique? To determine the density of underlying structures. A assess the sounds from the heart, lungs, and abdomen. To observe specific parts for normal or abnormal characteristics. To check the skin temperature and moisture.

To check the skin temperature and moisture. explanation- The nurse uses the palpation technique to obtain information about the skin temperature and moisture. The percussion technique is used to determine the location, size, and density of the underlying structure as per the quality of sound produced by the tapping. The auscultation technique is used to listen to the sound of the heart, lungs, and abdomen. The inspection technique is used to observe specific parts for normal or abnormal characteristics.

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? Reduced carotid pulses. Tracheal deviation. Distended jugular veins. Immobile, tender lymph nodes.

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.

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. Increased tenting Warmth Erythema Pallor Jaundice

Warmth Erythema explanation- 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.

During which part of the comprehensive assessment would the nurse auscultate after inspecting but before percussing?

abdomen explanation- The nurse inspects, and then auscultates, the abdomen. This is followed by percussion and then palpation.

A nurse should use light palpation of the abdomen to obtain objective data about which characteristic of the abdomen? Abnormalities of the aorta Enlargement of the liver Abdominal reflex Irregularities of the spleen

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.

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

after assessing the posterior thorax explanation-Since the costovertebral angle is located beneath the lower rib, it would be appropriate to assess this area for tenderness after assessing the posterior thorax. The client would have to change position if this area were assessed during percussion of the abdomen or before palpating the lower pole of the left kidney. Although the costovertebral angle can be assessed with the client standing, it might be best to assess this area while examining the posterior thorax and not wait until the spine is assessed for range of motion.

After performing a comprehensive head-to-toe assessment on a client, the nurse notes the following: ● The client reports pain in bilateral lower extremities when walking short distances, which is relieved with rest. ● Pulses are weak, barely palpable in bilateral lower extremities. ● Bilateral feet are cool to touch. ● Total cholesterol > 200. ● The client smokes two packs of cigarettes daily for past 20 years. Which step of the nursing process is the nurse performing? documentation of subjective assessment findings development of a problem-based plan analysis of assessment findings implementation of interventions

analysis of assessment findings explanation- The nurse is clustering the cues collected during assessment to determine if a client concern (nursing problem) exists; this is analysis of assessment findings. The notes contain both subjective and objective information related to peripheral arterial disease. Next, the nurse would develop a problem-based plan based on the cues of "altered tissue perfusion" and lastly would develop and implement interventions to improve the client's circulation.

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? adjust examination room temperature assess mental status offer a blanket measure body temperature

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.

The nurse is preparing to auscultate a client's heart sounds during the client's physical assessment. How should the nurse auscultate for the presence of a mitral murmur? at the right sternal border at the second intercostal space with the bell of the stethoscope at the midclavicular line at the fifth intercostal space with the diaphragm of the stethoscope at the apical impulse with the client in the left lateral decubitus position with the bell of the stethoscope at the left sternal border at the second intercostal space with the diaphragm of the stethoscope

at the apical impulse with the client in the left lateral decubitus position with the bell of the stethoscope explanation- The nurse should auscultate for the presence of a mitral murmur by having the client lay in the decubitus position and using the bell of the stethoscope. Auscultating the client's heart sounds at the right sternal border at the second intercostal space with the bell of the stethoscope, at the left sternal border at the second intercostal space with the diaphragm of the stethoscope, and at the midclavicular line at the fifth intercostal space with the diaphragm of the stethoscope are part of auscultating the client's heart sounds during the physical assessment, but these actions do not describe the appropriate way to auscultate for the presence of a mitral murmur.

The nurse completes the assessment of a client's heart. What should be assessed next? lower extremities breasts abdomen back

breasts explanation- After assessing the heart, the nurse should proceed to examine the breasts. The back would have been assessed when completing the assessment of the neck and thyroid gland. The abdomen will be assessed after the breasts. The lower extremities will be assessed after the abdominal assessment.

The nurse is preparing to enter the client's room. Before doing so, the nurse should assess her own: Breathing Personal history Skill set Demeanor

demeanor explanation- The nurse should assess her demeanor, and take a breath before entering the room.

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? validate the healthcare provider's findings develop a plan of care determine the need for further testing identify undiagnosed problems

develop a plan of care explanation- 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.

When should the nurse assess a client's lymph nodes? during the assessment of the anterior chest while assessing the head and neck after assessing the abdomen during the assessment of the associated body area

during the assessment of the associated body area explanation- Since the lymph nodes are scattered throughout the body, the best approach is to assess this system while completing the assessment of the associated body area. The femoral nodes can be assessed after the abdomen however the neck and axilla region would not be included. The head and neck would be assessed during the head and neck assessment. The axillae would be assessed during the examination of the anterior chest but the other node locations would not be included at this time.

When examining a client's musculoskeletal system, for which assessment should the client be in a seated position? hip adduction elbow flexion knee extension hip abduction

elbow flexion explanation- Elbow flexion should be assessed with the client in a seated position. Hip abduction, hip adduction, and knee extension should be assessed with the client in the supine or standing position.

The nurse is performing an assessment of the mouth and throat for a client. When inspecting the tonsils, which assessment findings should the nurse collect? Select all that apply. exudates color Wharton ducts size lesions

exudates color size lesions explanation- The nurse should inspect the tonsils for color, size, lesions, and exudates. Inspection of the Wharton ducts is performed when assessing the tongue.

The nurse is beginning a complete assessment of a client. What should be included as part of the general survey? skin temperature ambulatory status facial expression height and weight

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.

A nurse performs a head-to-toe assessment on a newly admitted client. Data analysis reveals temperature 100.94°F (38.3°C), blood pressure 82/58 mm Hg, 02 saturation 95% on room air, productive cough, lethargy, diaphoresis, WBC 15,000 mm3, hemoglobin 9 g/dl, and hematocrit 29%. Based on the analysis of the data, which of the following client concerns is a priority? pneumonia hypoxia anemia hypotension

hypotension explanation- The nursing problem-based care plan focuses on the client's response to a condition or disease process, while a medical diagnosis focuses on the etiology of the condition or disease process. This client has become hypotensive in response to the respiratory infection, which appears to be pneumonia (fever causes vasodilation throughout the body, lowering blood pressure, increasing heart rate and consuming more oxygen, thereby lowering oxygen saturation levels). Pneumonia and anemia are medical conditions, and nursing problems are signs and symptoms caused by a medical condition; therefore, they are incorrect options. There are no signs or symptoms of hypoxia; the client's oxygen saturation is within normal limits. In nursing, the problem-based care plan would be impaired tissue perfusion as evidenced by low blood pressure. The nurse would develop a problem-based plan to correct the client's hypotension. A blood pressure of 82/58 mm Hg is a priority because it impairs perfusion to vital organs such as the brain (placing the client at risk for falls) and the kidneys (placing the client at risk for acute renal failure). Blood pressure should be addressed promptly to restore perfusion.

A client is admitted with signs of liver dysfunction. As part of the head-to-toe assessment, the nurse would like to determine the size of the liver. Which assessment technique(s) will the nurse use to determine liver size? Select all that apply. inspection of the abdomen percussion deep palpation vibratory percussion moderate palpation

inspection of the abdomen percussion deep palpation explanation- The nurse would use deep palpation to determine enlargement of the liver, spleen, and kidneys. Percussion can also be used to determine liver location, size, and span but not irregularities such as masses. Light palpation, not moderate palpation, would be used to assess abdominal reflex and to identify tenderness and muscular resistance. Vibratory percussion does not exist. Inspecting the abdomen may provide some information about the liver if ascites is present.

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 prone supine standing

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 percussion for abdominal sounds light palpation of each quadrant auscultation of bowel sounds

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.

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? Genitalia Mouth and throat Eye and ear Rectum

mouth and throat explanation- The nurse rarely performs a total eye and ear examination and normally does not perform a genitalia and rectal examination. The client often sees specialists for these routine examinations. The mouth and throat, however, are commonly assessed by the nurse.

The nurse is conducting a head-to-toe assessment on a client. Which body systems are typically integrated throughout the entire assessment? Select all that apply. Neurologic Musculoskeletal Respiratory Renal and genitalia Cardiovascular

neurologic musculoskeletal explanation- Most areas of the musculoskeletal and neurologic systems are integrated and assessed throughout the examination. Certain areas of these two major body systems are completed separately and include spinal structure and gait. The respiratory, cardiovascular, and renal and genitalia are not integrated and assessed throughout the examination.

The nurse is conducting a physical examination of a client. The general survey can provide the nurse with which information? Select all that apply. noise and its impact on hearing presence of fluid in the lungs apical heart rate safety and privacy of the environment lighting and its impact on sight

noise and its impact on hearing safety and privacy of the environment lighting and its impact on sight explanation- When the nurse conducts the general survey as part of the physical examination, the nurse obtains information related to the safety and privacy of the environment, noise and its impact on hearing, and lighting and its impact on sight. The apical heart rate and assessing for fluid in the lungs are not part of the general survey.

While performing a comprehensive assessment on a client, the nurse proceeds with the general survey. What data should the nurse collect during this portion of the assessment? Select all that apply. overall physical and sexual development concentration, ability to focus and follow directions level of consciousness overall skin coloring facial symmetry

overal physical and sexual development overall skin coloring explanation- The client's overall physical and sexual development and overall skin coloring are both part of the general survey. Concentration and the ability to focus and follow directions, as well as level of consciousness, are part of the mental status examination. Facial symmetry is part of the examination of the head and face.

The nurse is planning to examine a client's thyroid. What additional body area can be assessed at this time? esophagus axillae posterior thorax shoulder strength

posterior thorax explanation- To examine the thyroid gland, move behind the sitting client, palpate the gland, and examine the back, posterior thorax, and lungs. The axillae would be assessed when examining the breasts or arms. The esophagus is not specifically assessed. Shoulder strength could be included with the cranial nerve or extremity assessment.

The nurse is beginning a mental status exam for a client who has a diagnosis of depression. What information can the nurse collect by observing the appearance of the client? Select all that apply. articulation of words cognition posture grooming affect

posture grooming explanation- The nurse can observe the appearance of the client, which includes grooming and posture. Articulation of words, affect, and cognition cannot be assessed by observation alone and will require the use of other assessment techniques by the nurse.

The nurse is performing an assessment of a client's legs. Which finding(s) should the nurse document as part of the peripheral vascular assessment? Select all that apply. lesions pulses strength edema movement color

pulses edema color lesions explanation- Pulses, color, edema, and lesions of the legs pertain to the peripheral vascular system and should be documented accordingly. Movement and strength are findings pertaining to the musculoskeletal system.

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? Mood, feelings, and expression Level of consciousness Remote memory of the past Thought processes and perception

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.

The nurse is preparing to conduct a physical examination of a client who experiences pain when moving positions. Which of the following can the nurse examine while the client is still standing? Select all that apply. Spinal motion Balance Lower extremities Vision Anterior thorax

vision spinal motion balance explanation- In the standing position, the nurse can examine a client's vision, spinal motion, and balance. The anterior thorax is examined in the seated or lying position. The lower extremities are examined in the lying position.

A nurse should perform an ongoing assessment of which system throughout the entire examination? Skin General survey Heart Mental status

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 nursing instructor is describing the use of a head-to-toe approach for a comprehensive health assessment and how body systems may be combined, using the legs as an example. Which of the following would the instructor describe as being included in this assessment? Select all that apply. musculoskeletal system gastrointestinal system neurologic system skin color and condition peripheral vascular system

skin color and condition peripheral vascular neurologic system explanation- Assessment of the legs would include 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). The gastrointestinal system is not a body system that is combined with assessment of the legs.

The nurse is conducting a physical exam for a client. When conducting the physical examination on the posterior thorax, what equipment should the nurse have on hand? Select all that apply. ruler sphygmomanometer stethoscope otoscope pen

stethoscope ruler pen explanation- The nurse should have a stethoscope, ruler, and pen on hand when conducting the physical exam on the posterior thorax to limit trips around the client. Assessments performed with an otoscope and sphygmomanometer are performed while conducting the physical examination on the anterior side of the client.

A nurse performs an integrated head-to-toe assessment on a client who is admitted with exacerbation of heart failure. What signs and symptoms would the nurse expect? Select all that apply. swelling of lower extremities weight gain green, yellow sputum expiratory wheezing shortness of breath

swelling of lower extremities shortness of breath weight gain explanation- When performing an integrated head-to-toe assessment on a client admitted with exacerbation of congestive heart failure, the nurse would expect the following signs and symptoms: edema (of lower extremities, abdomen), shortness of breath (due to congestion in the lungs—failure of the left ventricle to pump blood forward), weight gain, and pink frothy sputum (not green or yellow, which is seen in infectious states such as pneumonia or acute or chronic bronchitis). Crackles would be heard in the lungs, not wheezes (wheezing is caused by constriction of the bronchioles such as what occurs in asthmatic clients, not fluid in the lungs).

the nurse is completing the general survey. In addition to observing the client's appearance, the nurse would assess which of the following? cognitive abilities thought processes mental status vital signs

vital signs explanation- In addition to observing a client's appearance, the nurse would assess vital signs and take body measurements. The mental status examination, including cognitive abilities, mental status, and thought processes, would then be done.

After teaching a group of students about areas to include when examining a client's mental status, the instructor determines that the teaching was successful when the students identify which of the following as important? Level of orientation Recall ability Thought processes Ability to concentrate

thought process explanation- Components of a mental status examination include level of consciousness, posture and body movements, facial expressions, speech, mood/feelings/expressions, and thought processes and perceptions. Ability to concentrate, level of orientation, and recall ability are components related to a client's cognitive abilities.

While performing a head-to-toe assessment, the client reports leg pain. The nurse suspects a lower extremity infection. What sign(s) and symptom(s) would indicate an infection? Select all that apply. absent pulses weeping drainage red and swollen intermittent claudication fever and increased white blood cells

weeping drainage red and swollen fever and increased white blood cells explanation- An integrated assessment (inspection and palpation of the skin, assessment of vital signs, and lab values) of a client with a wound infection would reveal red (erythema), warm, swollen tissues with weeping drainage; fever; and increased white blood cells. Absent pulses would indicate arterial insufficiency or occlusion. Intermittent claudication is seen in clients with peripheral arterial disease.

A client is admitted with a diagnosis of dehydration. The nurse performs an integrated head-to-toe assessment. What sign(s) and symptom(s) would the nurse expect with a client who is dehydrated? Select all that apply. weight loss increased urine output increased tenting of the skin erythema pallor

weight loss increased tenting of the skin explanation- Signs and symptoms of dehydration include increased tenting of the skin, decreased urine output (not increased), and weight loss. Pallor is seen in anemia. Erythema is seen with infection.

The nurse is performing an abbreviated head-to-toe assessment of a hospitalized client. What question should the nurse ask when assessing the client's level of consciousness? "Can you tell me the current month and year?" "How would you describe your overall level of stress?" "If there were a fire in your house, what would you do?" "Can you tell me what you ate for breakfast this morning?"

"Can you tell me the current month and year?" explanation- Orientation to person, place, and time are among the essential components of LOC. Judgment, coping, and memory recall are not typically assessed in the abbreviated head-to-toe assessment.

The nurse is caring for an older adult client with a blood pressure of 186/98 mm Hg. The client asks, "What is happening to me?" Which of the following is the best response by the nurse? "You need to eliminate salt from your diet right away." "You are an older adult so it's normal to have high blood pressure." "How often do you have blurred vision and numbness and tingling?" "Your blood pressure is elevated, so we should talk more after I complete your assessment."

"Your blood pressure is elevated, so we should talk more after I complete your assessment." explanation- It's important to be honest when data are abnormal, and this is best represented by the statement, "Your blood pressure is elevated, so we should talk more after I complete your assessment." The nurse should avoid false reassurances such as, "You are an older adult so it's normal to have high blood pressure." The nurse should provide objective data and avoid making statements like, "You need to eliminate salt from your diet" without all of the data being collected first. Although blood pressure may increase with age, the blood pressure described in the question is alarmingly high and will need to be addressed without upsetting the client. The client may become upset if the nurse continues to ask questions without responding to the client's concern first.

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? Mental status examination Eye assessment Skin assessment General survey

General Survey explanation- The nurse should begin the physical assessment with a general survey.

The nurse is examining a client who has an exacerbation of hip pain when in a sitting position. Which body system can the nurse examine with the client lying down? Posterior thorax Anterior thorax Balance Spinal motion

Anterior thorax explanation- The anterior thorax can be examined with the client lying down. The posterior thorax is best examined in the seated position. Balance and spinal motion are examined with the client standing.

During which part of a head-to-toe physical examination should the nurse palpate the epitrochlear lymph nodes? Neck Head and face Arm, hands, and fingers Anterior chest

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.

When performing an assessment, the nurse will inspect which area from the back of the client? muscle strength neck CVA tenderness body measurements

CVA tenderness

The nurse is palpating the abdomen of a client newly admitted to the unit. What would be an abnormal finding? Nontender areas Nonpalpable organs Guarding Softness

Guarding explanation- Abnormal findings on abdominal palpation are large masses, hardness, tenderness with guarding or rigidity, and rebound tenderness. The nurse would expect the abdomen to be soft and nontender, with generally nonpalpable organs.

The nurse will obtain the greatest amount of information about the thyroid gland by using which technique of assessment? Auscultation Percussion Inspection Palpation

Palpation explanation- the thyroid gland is assessed by palpation, although it is not palpable in some clients.

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. Refer for ophthalmologist consult. Perform the Weber test. Conduct the Romberg test.

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.

How should a nurse assess graphesthesia as part of the physical assessment of arms, hands, and fingers? Place a quarter or key in the client's hand Write a number in the palm of 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 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 any approach that is convenient for you and the client. 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.

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.

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

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 compare with the medical record identify problems validate findings

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.

A nurse is performing an abdominal assessment. The correct order of assessment techniques would be

inspect, auscultate, lightly palpate, deeply palpate

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? scalp pulses tongue axillae

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

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?" "What kinds of daily activities do you do to improve your health?" "Tell me who is the most important person in your life, and why you selected this person?" "Can you describe for me what your idea of the ideal vacation looks like?"

"What would you do if you found a stamped, addressed envelope on the ground?" explanation- 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." "Touch the tip of your nose, then the tip of my finger as I move my finger." "Tell me which number I am tracing on your back with my finger." "Quickly flip your hands back and forth on your knees as I demonstrate."

"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 new nurse asks the precepting nurse, "How can I possibly complete assessments on all my clients during my shift?" What is the best response by the nurse preceptor? "Nursing is a fast-paced job. Once you know how to manage your time you will be able to do it." "You can't; it's impossible." "Sometimes you have to cut corners." "You will get more proficient with experience."

"You will get more proficient with experience." explanation- Performing an integrated head-to-toe assessment takes time and practice; new practitioners will improve with practice. It would be unprofessional for the preceptor to tell the new nurse that "it is impossible" or that "you have to cut corners." Nursing is a fast-paced job, but even with good time management skills, the new nurse will need more experience to become proficient.

The nurse is preparing to examine a client's posterior thorax. Which of the following should be included in this examination? Auscultation of the apical impulse Auscultation of lung sounds Subclavicular lymph nodes Romberg test

Auscultation of lung sounds explanation- The examination of a client's posterior thorax includes auscultation of lung sounds. Auscultation of the apical impulse is conducted during examination of the anterior thorax. Subclavicular lymph nodes are assessed during the examination of the neck. The Romberg test is performed during the neurological examination.

A nurse would expect to assess the epitrochlear lymph nodes when assessing which of the following? Arms Sinuses Neck Posterior chest

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

A nurse plans to assess the client's epitrochlear lymph nodes. The nurse should combine this with examination of which area? Neck Posterior chest Arms Sinuses

Arms explanation- The epitrochlear lymph nodes would be palpated when the nurse assesses a client's arms. The epitrochlear nodes are not located in the neck, chest, or sinuses.

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

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 nurse is conducting an abdominal assessment with a client. What should the nurse do prior to documenting that a client's bowel sounds are absent?

Ausculate the abdomen for 5 minutes explanation- One must listen for 5 minutes before determining that a client's bowel sounds are absent. There is no need to measure oxygen saturation, complete the entire assessment, or auscultate heart and lung sounds before determining that a client's bowel sounds are absent.

A client has been recovering from surgery in the hospital, and the nurse is beginning a shift by conducting an abbreviated head-to-toe assessment. How should the nurse assess the client's bowel sounds?

Auscultate for bowel sounds in each of the client's four abdominal quadrants. explanation- The nurse should listen to all four quadrants of the abdomen to assess bowel sounds, even in an abbreviated assessment. One must listen for 5 minutes to document absent bowel sounds. However, it is unnecessary to listen for several minutes, or for which quadrant contains the most active bowel sounds, except when differentiating between hypoactive and absent bowel sounds.

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

Auscultation of a client'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.

the nurse should include which important safety checks before leaving a hospitalized client's room? (Select all that apply.) Bed at mid-level, locked position Call bell within reach Correct intravenous lines and fluids Correct tubes and drains intact Wearing client identification bracelet

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

Which statement about assessment findings obtained from a comprehensive assessment would be identified as part of the general survey? Hair neat clean with white and gray streaks; no scalp lesions noted Client alert and cooperative; sitting comfortably on chair with hands in lap Sclera white; conjunctiva slightly reddened without lesions Head symmetrically round; neck nontender with full range of motion

Client alert and cooperative; sitting comfortably on chair with hands in lap explanation- The statement about the client alert and cooperative and sitting comfortably reflects information typically gathered during the general survey. The statement about the hair reflects examination of the skin and hair. The statement about the sclera and conjunctiva reflect data related to the eyes. The statement about the head and neck reflect data related to those areas.

While performing an integrated head-to-toe assessment on a client, the nurse does not hear bowel sounds after listening for 1 minute. What is the next best action of the nurse? Continue to auscultate for a total of 5 minutes. Notify the health care provider of this abnormal finding. Palpate and percuss the abdomen. Document absent bowel sounds.

Continue to auscultate for a total of 5 minutes. explanation- If bowel sounds are not heard, the nurse should listen for a total of 5 minutes (normal bowel sounds occur 5 to 35/min). The nurse would not notify the health care provider until the abdominal assessment was complete, including listening for bowel sounds for a total of 5 minutes. The nurse would not palpate or percuss the abdomen until auscultation has been completed. The nurse would not document absent bowel sounds until the abdomen was auscultated for 5 minutes.

When assessing the abdomen, which assessment technique is used last? Percussion Inspection Palpation Auscultation

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.

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? Provide education on pain control. Delay the full exam until the client's pain has been addressed. Explain the reason for the client's assessment. Begin the comprehensive assessment and aim to complete it efficiently.

Delay the full exam until the client's pain has been addressed. explanation- 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.

he nurse is assessing an adult client with a family history of stroke. The nurse should contact the healthcare provider immediately due to which assessment finding? Diminished carotid pulses Redness and swelling over the sinuses Conductive hearing loss Immobile lymph nodes

Diminished carotid pulses explanation- Carotid pulses may be reduced as a result of carotid stenosis which results in decreased blood flow to the brain. This decreased blood flow can lead to a stroke. Red and swollen sinuses, immobile lymph nodes, and conductive hearing loss are all abnormal findings but are not directly a concern for stroke as carotid stenosis.

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

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 novice nurse is practicing how to complete a comprehensive assessment to gain confidence and skill. What would be most important for the nurse to remember? Establish a routine for the assessment. Allow the client a break between the two parts of the history/exam. Intersperse the physical exam with the history. Gather health history information first.

Establish a routine for the assessment. explanation- There is no one right way to integrate the entire health history and physical examination. However, it is important to stick to a routine to avoid omitting an important step that may delete significant data from the assessment. Short rest periods to help break up the assessment would be appropriate but not the most important.

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 Check for peripheral pulses Auscultate the lungs Palpate the skin for moisture

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.

When performing a head-to-toe assessment, during which part would the nurse assess the motor function of cranial nerve VII? Head and face Ears Mouth and throat Mental status examination

Head and face explanation- 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.

The nurse is planning to assess a client's abdomen. Place the components of this assessment in the correct order in which the nurse should conduct them.

Heath history inspection ausculation percussion palpation explanation- As with all systems assessments, a health history is taken prior to physical assessment. In an abdominal assessment, auscultation precedes percussion and palpation because these assessments stimulate bowel sounds.

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? Center of the head. On the mastoid area. Behind the client's head. Near the ear canal.

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.

A nurse has been ordered to include an ear assessment as part of a head-to-toe examination of a client. Which of the following pieces of equipment will the nurse need for this assessment? Ophthalmoscope Stethoscope Snellen chart Otoscope

Otoscope explanation- An otoscope would be needed to assess the ears. An ophthalmoscope and a Snellen chart are used to assess the eyes. A stethoscope is needed for various assessments requiring auscultation but would not be needed to assess the ears.

While performing a head-to-toe assessment on a client admitted 2 days ago, the nurse observes that the pupils are unequal. The nurse reviews the client's chart and notes that pupils are documented as equal, round, and reactive on the comprehensive admission assessment. What is the first action of the nurse?

Perform a focused assessment on the client. explanation- If there is a change in client assessment findings, the nurse should perform a focused assessment, not a comprehensive assessment, to determine if there are other deficits. In this case, the nurse should test cranial nerves and muscle strength of all limbs. Although the nurse would document findings, that step would come later. The admitting nurse will be questioned about the admission assessment (the nurse may have charted on the wrong client), but that is not the action the nurse should take first.

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? Weber's Whisper Audiometry Rinne

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 Hearing acuity Pedal pulses Oxygen saturation

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

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 Stethoscope Otoscope Ophthalmoscope

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.

Which of the following can a nurse assess by palpation? Vision, hearing, cranial nerves Tissue density, gait, reflexes Heart sounds, lung sounds, blood pressure Temperature, turgor, moisture

Temperature, turgor, moisture explanation- Palpation is an assessment technique that uses the sense of touch. The hands and fingers can assess temperature, turgor, texture, moisture, vibrations, and shape.

Which of the following equipment will the nurse gather to conduct a physical examination of a client's eyes? Select all that apply. ophthalmoscope Snellen chart otoscope thermometer tuning fork

Snellen chart ophthalmoscope explanation- The nurse will need a Snellen chart and ophthalmoscope to examine a client's eyes. The Snellen chart provides information about visual acuity. The ophthalmoscope is used to visualize the interior structure of the eye. An otoscope is used to inspect the ear canal. A thermometer is used for vital signs assessment. A tuning fork is used for the examination of the ears.

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? Auscultate over the client's trachea while asking the client to hold his or her own breath. Observe the midline of the client's neck while asking him or her to bear down. Stand behind the client and palpate the sides of the trachea. Lightly percuss slightly off midline over the client's trachea.

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 performing a general survey of a client admitted to the hospital. Which of the following actions is an element of this procedure? Assessing the head and neck. Palpating the integument. Taking vital signs. Identifying risk factors for altered health.

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.

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 vision. Perform the cover test. Test the client's pupillary response to light. Test the client's visual fields.

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

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

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.

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

breasts explanation- During the breast examination, the nurse palpates the axillae. The axillae are anatomically closest to the breasts. The neck, perineum, and heart do not share anatomical proximity; therefore, the assessment of these areas would not be combined with palpation of the client's axillae.

The nurse would palpate the axillae during examination of which area?

breasts explanation- During the breast examination, the nurse would palpate the axillae.

When conducting a physical assessment, what should the nurse assess and document about size and shape of body parts?

symmetry (comparison of bilateral body parts) explanation- When conducting a physical assessment, the nurse assesses and compares all bilateral body parts. The symmetry of parts of the body (such as the skull) and the extremities (arms and legs) is an important assessment to assess and document.

After inspecting the skin of the legs, feet, and toes, what should the nurse do? percuss muscle tone measure thigh circumference auscultate for femoral bruit palpate pulses

palpate pulses explanation- After inspecting the skin the nurse should palpate the client's pulses. Percussion is not used to assess muscle tone. The femoral artery is not auscultated for bruits. Thigh circumference would be measured if there was a noticeable difference in size.

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

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.

A nurse has explained the purpose and procedure for a comprehensive assessment and has directed the client to an appropriate position on the bed. The nurse has also provided a drape with which to cover the client. What is the primary purpose of providing a drape during the assessment process?

To provide the client with modesty during the assessment.

A nurse is performing a head-to-toe assessment and is preparing to examine the client's ears. Which equipment would the nurse need to have readily available? Stethoscope Tuning fork Tongue depressor Ophthalmoscope

Tuning fork explanation- When examining a client's ears with a head-to-toe examination, the nurse would need to have an otoscope, to examine the tympanic membrane, and a tuning fork, to test hearing, readily available. An ophthalmoscope is needed to examine the internal eye structures. A tongue depressor would be used to assess the mouth. A stethoscope would be used in a variety of assessments, such as the chest, heart, neck for thyroid and carotid bruits, and the abdomen for bowel sounds and bruits of the major arteries.

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

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.

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 find the lower pole of the left kidney change the character of bowel sounds determine the liver border

assess abdominal reflex explanation- 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 perform the Mental Status Exam after examining all other body systems. assess peripheral vascular status when examining the lower extremities. integrate the rectal examination with the abdominal examination. assess cranial nerve I (olfactory) with the other 11 cranial nerves at the same time.

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).

The nurse is planning the comprehensive head-to-toe assessment of a client. What assessment should the nurse usually conduct last? assessment of the lower extremities assessment of the genitalia and rectum assessment of the posterior thorax assessment of the abdomen

assessment of the genitalia and rectum explanation- Examination of the male and female genitalia should be performed last, moving from the less-private to more-private examination for client comfort. Therefore, the assessment of the abdomen, lower extremities, and posterior thorax should be performed earlier in the assessment.

Assessment of a client's bowel sounds is best obtained by performing which assessment technique?

auscultation explanation- auscultation is the act of listening with a stethoscope to sounds produced within the body and will provide the nurse with assessment data related to bowel sounds. Inspection is the process of performing deliberate, purposeful observations in a systematic manner using visual, auditory, and olfactory senses in the process. Palpation is an assessment technique that uses the sense of touch. Percussion is the act of striking one object against another to produce a sound.

A client is supine with the head of the examination table at a 30-degree angle. What should the nurse assess at this time? cranial nerves bowel sounds hand grasps carotid arteries

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 arrives to a healthcare facility for an initial appointment. Which type of assessment should the nurse expect to complete with this client? focused complete evaluative urgent

complete explanation- A complete assessment is performed on new clients or new admissions to a health care agency. A focused assessment targets specific body systems. An urgent assessment collects data on a particular health issue prior to implementing emergency interventions. Evaluative is not a type of assessment.

Examination of the skin should be completed at the beginning of the physical assessment before proceeding to other parts of the exam. integrated and completed only with the musculoskeletal examination. integrated throughout the head-to-toe examination. performed at the very end of the physical assessment.

completed at the beginning of the physical assessment before proceeding to other parts of the exam. explanation- As you perform each part of the head-to-toe assessment, assess skin for color variations, texture, temperature, turgor, edema, and lesions.

The nurse notices that a client has a brilliant smile when asked about children. What should the nurse document about this finding? routine dental visits occur cranial nerve VII intact the client likes children the client is pleasant

cranial nerve VII intact explanation- Assessment of cranial nerve VII is conducted by asking the client to smile. Since the client smiled (for a different reason) the nurse can document that this nerve function is intact. Stating that a client is pleasant is an opinion. The client may like children however that information is not a part of the complete assessment. Having a "brilliant" smile may or may not mean that the client has routine dental visits.

The nurse is performing a general survey as part of a comprehensive health assessment. When observing a client's behavior, which of the following would be most important for the nurse to compare the observations with? vital signs developmental stage stated age apparent age

developmental stage explanation- 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. The client's stated age should be compared with the client's apparent age. Overall physical development and vital signs are not compared with the client's behavior. The nurse should differentiate between normal and abnormal findings identified throughout the exam, such as is done with vital signs.

The nurse is preparing to conduct an examination of a client's breasts and axilla. Which of the following equipment will the nurse need for this examination? 2 X 2 gauze Stethoscope Drape Penlight

drape explanation- The nurse will need a drape to ensure for the client's privacy during the examination of the breasts and axilla. A stethoscope would be required for auscultation which is not required during a breast and axilla examination. A penlight is generally used to assess eyes and mouth and would not be needed during a breast and axilla examination. A breast and axilla examination is non-invasive, therefore, 2 X 2 gauze will not be needed.

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

eye exam and cranial nerves II, III, IV, and VI. explanation- 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? abduction and adduction flexion and extension gait limb length

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? peripheral vascular abdomen respiratory gait

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 preparing to conduct a physical examination of an adolescent client as part of a general physical assessment. Which examination approach would be the most appropriate for this client? head-to-toe assessment grouping body systems together to limit position changes major body systems first approach beginning with the musculoskeletal assessment of the extremities

head-to-toe assessment explanation- Generally, a complete assessment is performed in a head-to-toe sequence, comparing side to side for symmetry. For a healthy adolescent client, this would be the most appropriate examination. Grouping body systems together to limit position changes would be appropriate for the client with pain, shortness of breath, or limited range of motion. Although some nurses may begin with a musculoskeletal assessment depending on the client's individual needs, it is best to proceed in a systematic head-to-toe fashion in general. A major body systems first approach is appropriate for the client with identified health problems that affect one or more major body systems.

In which order should a nurse examine the abdomen of a client during the physical assessment?

inspection, ausculation, percussion, palpation explanation- With physical examination of the abdomen, the nurse should auscultate before percussion or palpation to avoid alteration of the bowel sounds.

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? there was limited time available to complete the entire assessment the nurse was following the front to back assessment approach it limits the number of times the client had to change position the nurse did not want to miss collecting important information

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.

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: Judgement and insight Coping skills Health maintenance Level of consciousness

level of consciousness explanation- the client's response to the nurse's introduction and direction gives useful information about his or her level of consciousness. During this brief interaction, the nurse would be less able to determine the client's judgment, insight, health maintenance or copings skills, though some elements of these may be evident.

The nurse has completed examining the client's nose and sinuses. Which body area should the nurse examine next? Posterior thorax Mouth and pharynx Anterior thorax Neck

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.

the nurse is palpating the tonsillar, submandibular, and submental lymph nodes. The nurse is most likely examining which area during a comprehensive assessment? face neck nose and sinuses abdomen

neck explanation- During the neck assessment, the nurse would palpate the preauricular, postauricular, occipital, tonsillar, submandibular, and submental lymph nodes. The tonsillar, submandibular, and submental lymph nodes are not located in the nose and sinuses, abdomen, or face.

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? cotton swab otoscope ophthalmoscope pen light

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.

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

pain explanation- pain is considered the "5th vital sign" and is assessed following temperature, pulse, respirations, and blood pressure, which are the first four vital signs.

a new nurse is performing a head-to-toe assessment on a newly admitted client. The charge nurse intervenes when which of the following is observed? listens to the client lung sounds with the diaphragm of the stethoscope listens to the client's bowel sounds in each quadrant palpates bilateral carotid arteries when bruit is present asks the client their name, if they know where they are, and who is the president

palpates bilateral carotid arteries when bruit is present explanation- The charge nurse should intervene when they see the new nurse palpating bilateral carotid arteries when bruit is present. It is important to not palpate (compress the artery) when the blood flow may already be compromised. The nurse should listen to the bowel for a total of 5 minutes if none are heard in the first few minutes. Usually 5 to 35 sounds are heard in a minute. To assess neurological status the nurse should ask the client their name, where they are, and who is the president of the United States. The diaphragm of the stethoscope should be used to listen to high-pitched sounds such as lung sounds.

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 thyroid assessing the heart sounds with the client in a lateral position palpation of the sinuses asking the client to smell coffee beans

palpation of the sinuses explanation- A recent exposure to a family member with influenza along with the complaint of a throbbing toothache when the client bends forward should cue the nurse to assess for acute sinusitis. The assessment should include palpation of the sinuses. To determine if there is a loss or change to the sense of smell, the nurse would ask the client to smell something with a strong aroma, like coffee beans. The nurse should palpate the thyroid if the reported symptoms are consistent with a disorder of the thyroid gland such as hoarseness, enlarged thyroid, fatigue, and weight changes. If the client has a history of cardiac issues known to the nurse, assessment of the heart sounds is appropriate. In this case, however, the focus of the assessment should be the sinuses.

A client with cardiac issues has just had a cardiac examination in the supine position. The next step in the examination would be inspecting the carotid arteries for pulsations inspecting the precordium performing the cardiac assessment in the left lateral position auscultating the carotid arteries with the bell with the client holding his breath

performing the cardiac assessment in the left lateral position

The nurse would auscultate for voice sounds during which part of the comprehensive examination? Neck Posterior chest Abdomen Head and face

posterior Chest explanation- When examining the posterior chest, the nurse would auscultate for voice sounds such as bronchophony, egophony, and whispered pectoriloquy.

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 Freckles Lesions Infestations Goose bumps

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.

A nurse in a clinic performs a head-to-toe assessment on a 62-year-old male client. The assessment reveals the following: alert and cooperative, lungs diminished in the bases, increased secretions in the larger airway, respirations 22 breaths/min, pulses 1+, capillary refill greater than 3 seconds, abdomen soft and nontender, skin warm and dry with cool lower extremities, and client moves all extremities well with full range of motion. Complete the following sentence by choosing from the lists of options. The nurse should first address the client's ________________ followed by the client's ________________

respiratory function cardiovascular system explanation- The nurse should address airway and breathing first. The client is exhibiting signs of respiratory problems such as diminished lung sounds in the bases, increased secretions in the lung fields, and increased respiratory rate (22 breaths/min). After assessing the client's respiratory function, the nurse should address the client's circulation status. The client is exhibiting signs of impaired circulation; capillary refill time greater than 3 seconds, weak pulses (1+ bilaterally), and cool extremities. Assessment findings for gastrointestinal function, the neurological system, the musculoskeletal system, and the integumentary system are all normal.

When conducting a focused health assessment, the nurse asks questions specifically targeting the client's: culture. gender. sexual orientation. specific issues and symptoms.

specific issues and symptoms. explanation- The nurse focuses questions on issues and symptoms specific to the client. In this way, the client is viewed as a person who has multiple things that are affected by the health status. These questions are related to the client's primary problems and concerns. A focused assessment does not ask questions specifically about culture, gender, or sexual orientation.

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

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

As part of a head-to-toe assessment, a nurse reviews vital signs taken by an unlicensed assistive personnel (UAP). Which client should the nurse see first? temperature: 101.66°F (38.7°C), BP 88/56 mm Hg, pulse 110 irregular, respirations 22, Sp02 93% 6L NC (nasal cannula) temperature: 99.8°F (37.67°C), BP 92/52 mm Hg, pulse 60 regular, respirations 20, Sp02 95% 4L NC (nasal cannula) temperature: 98.06°F (36.7°C), BP 90/60 mm Hg, pulse 98 regular, respirations 24, Sp02 93% 2L nasal cannula temperature: 96.8°F (36°C), BP 88/50 mm Hg, pulse 105 regular, respirations 18, Sp02 94% room air

temperature: 101.66°F (38.7°C), BP 88/56 mm Hg, pulse 110 irregular, respirations 22, Sp02 93% 6L NC (nasal cannula) explanation- The client with temperature of 101.66°F (38.7°C), BP 88/56 mm Hg, pulse 110 irregular, respirations 22, Sp02 93% 6L NC is exhibiting an irregular pulse and is hypotensive, tachycardic, tachypneic, febrile, and slightly hypoxemic with 93% oxygen saturations while receiving 6 Liters of oxygen. This client should be seen first because all of the vital signs are abnormal. The client with temperature 98.06°F (36.7°C), BP 90/60 mm Hg, pulse 98 regular, respirations 24, Sp0293% 2L NC is not a priority because only the respirations are slightly elevated. The client with temperature 96.8°F (36°C), BP 88/50 mm Hg, pulse 105 regular, respirations 18, Sp02 94% room air is not a priority because the client only has a slight decrease in blood pressure and a compensatory heart rate of 105 and regular respirations. The client with temperature 99.8°F (37.67°C), BP 92/52 mm Hg, pulse 60 regular, respirations 20, Sp02 95% 4L NC is not a priority because all of the vital signs are within normal limits.

When conducting an eye muscle examination, the nurse will test the six cardinal directions of gaze assess pupil consensual light reaction assess the retina for color test confrontation

test the six cardinal directions of gaze

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

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

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.

A nurse has explained her intention to conduct Weber's test and Rinne's test. Which of the following pieces of equipment will the nurse require?

tuning fork explanation- Weber's test and Rinne's test are performed in order to assess sound conduction; both require a tuning fork.