Jensen Ch.30: Head-to-Toe Assessment of the Adult

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?"

When documenting a comprehensive assessment, which statement would the nurse record as the reason for seeking health care?

"I haven't had a checkup in over 5 years."

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."

A nurse knows that a normal capillary bed refills in how many seconds?

1 to 2

The nurse would test for stereognosis during which part of the comprehensive exam?

Arms, hands and fingers

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

Complete blood count

When conducting a complete head-to-toe assessment on an adult client, which of the following factors is most likely to require adaptations by the nurse?

Cultural considerations

When observing a client's behavior, which of the following would be most important for the nurse to compare the observations with?

Developmental stage

The 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

A nurse has completed a comprehensive nursing health history of the client and now is beginning the physical assessment. Which assessment should the nurse perform first?

General survey

When discussing health assessment, the nursing instructor would tell the students that potential or actual problems are identified in order to focus on areas requiring what?

Health teaching

A 27-year-old hospital client tells the nurse that she is being abused at home by her spouse. What is one action the nurse should take?

Make a referral to the social worker.

A nurse is preparing to complete a comprehensive assessment on a client. When collecting objective data, what would the nurse do first?

Observe the client's overall appearance.

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.

The nurse completes the assessment of a client's heart. What should be assessed next?

breasts

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

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

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

A 54-year-old man is found to be anemic. Which of the following nursing diagnoses is most likely to be recorded in his plan of care?

Fatigue

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

Femoral Dorsalis pedis Popliteal Posterior tibial

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

Femoral Dorsalis pedàs Popliteal Posterior tibial

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.

Health history Inspection Auscultation Percussion Palpation

An adult client states she has been drinking a very large amount of water since she has begun walking everyday. She has been transported to the emergency room due to acute confusion. Which electrolyte imbalance is most likely the cause of this client's symptoms?

Hyponatremia

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.

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

Inspection

While giving a client a bath, a student nurse observes the color of the client's skin as having a yellowish tinge. What term would be used to document this assessment?

Jaundice

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

Mouth and pharynx

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

Neck

An adult client is brought via ambulance to the emergency department. Vital signs are blood pressure 84/62, pulse 122 beats/min, respirations 36 breaths/min, temperature 37.4°C (99.3°F), and oxygen saturation 78% on nonrebreather mask at 10 L of oxygen. The client is anxious and sitting in the tripod position. Which problem does the nurse need to address immediately?

Oxygen saturation of 78%

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

Skin

A nurse is preparing to perform the nurse's first complete assessment of a client at a hospital. Which of the following should the nurse consult to find out what can legally be assessed and diagnosed?

State's nurse practice act

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).

A nurse is performing an assessment within the legal parameters of assessment and diagnosis. Where would the nurse find these legal guidelines?

The state's Nurse Practice Act

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?

Thought processes

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

True

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?

Tuning fork

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

VII

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

VII

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

Wears dentures; denies problems with eating, chewing, and swallowing.

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?

assess mental status

When integrating the total physical examination the nurse should

assess peripheral vascular status when examining the lower extremities.

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

standing

A nurse who is skilled in assessment is to obtain a comprehensive health assessment. The nurse would most likely be able to complete this assessment within which time frame?

½ hour

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

Peripheral vascular assessment

A nurse is examining a client with cirrhosis of the liver and notes the presence of edema. The nurse determines that the indentation remains for several seconds and the skin swelling is obvious on inspection. How should the nurse quantify the severity of the finding?

3+ pitting edema

When interviewing a client, the nurse inquires about the presence of pain. The client states that she is in a great deal of pain. Which of the following should the nurse do next?

Ask the client to rate the pain on a scale from 0 to 10

When you enter the room of a hospitalized client, the intravenous pump is alarming. The client is restless, moaning, crying, and exhibiting guarding behavior. An uneaten meal is sitting on the over-bed table; several family members are arguing loudly. What would be your priority?

Assessing for pain

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

Assessment of the genitalia and rectum

A nurse inspects a client's ears and notices that the auricles are lower than the corner of each eye. The nurse should assess this client for other findings of what type of disorder?

Chromosomal

The nurse is documenting findings of a comprehensive assessment. Which statement would be categorized as part of the general survey?

Client alert and cooperative; sitting comfortably on chair with hands in lap

A client is admitted to the health care facility for the onset of a stroke. To test the function of cranial nerve I, the nurse should ask the client to do which of the following?

Close eyes and assess for smell

A client has been assigned a nursing diagnosis of fatigue related to anemia as evidenced by pale skin, statements of tiredness, and low hematocrit and hemoglobin values. What would be an appropriate nursing intervention for this client?

Collaborate with the physician to treat anemia

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?

Drape

The nurse notes dull lung percussion along the lower right lobe of an adult client. Which intervention should the nurse initiate right away for this client?

Encourage turning, coughing, and deep breathing

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.

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

Head and face

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

Head and face assessment

The nurse is preparing to conduct a physical examination of an adolescent client as part of general physical assessment. Which examination approach would be the most appropriate this client?

Head-to-toe assessment

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

Observe the overall appearance

A female older adult client is being assessed by a male nurse on a medical unit in the hospital. During the physical examination, the client states, "It is against my religious customs to have physical contact with a male who is not my husband. May I carry on with a female nurse please?" What is the nurse's best response?

Offer to exchange client assignments with a female nurse.

It is important for the nurse to apprise the client of what the nurse is doing and what the nurse finds as it does what?

Opens up teaching/learning moments

A 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?

Otoscope

The nurse would auscultate for voice sounds during which part of the comprehensive examination?

Posterior chest

The nurse is documenting the description and amount of wound drainage present in a Stage III pressure ulcer. Which term should the nurse use to describe bloody drainage observed when the dressing was removed?

Sanguineous

The nurse is documenting normal findings after assessing the client's skin.Which of the following are examples of normal findings?

Skin is warm, dry, and intact

A nurse working in a clinic is planning to conduct vision screenings for a group of low-income women. What equipment would be needed to test vision?

Snellen chart

Which placement of the hands demonstrates proper technique by a nurse for palpating the thyroid gland?

Standing behind the client, place the fingers on either side of the trachea below the cricoid cartilage

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

Test the client's pupillary response to light.

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

The client has the right to refuse the assessment.

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

The client has the right to refuse.

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

The client's developmental stage

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

The client's health needs

The nurse is using a mnemonic device during the client's head-to-toe assessment. This tool will allow the nurse to address what component of assessment?

The client's present health concern

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 recognizes that the normal breath sounds that are auscultated over the peripheral lung fields are what type of sound?

Vesicular

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.)

Vision Spinal motion Balance

How should a nurse assess graphesthesia as a part of the physical assessment of arms, hands, and fingers?

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

How should a nurse assess graphesthesia as part of the physical assessment of arms, hands, and fingers?

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

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

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

Before beginning a physical assessment it is important for the nurse to

acquire your client's verbal permission to perform the physical examination.

The nurse is preparing to assess a client's reflexes. At which point during the assessment should this be completed?

after assessing the motor function of the lower extremities

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

assess abdominal reflex

A client is supine with the head of the examination table at a 30-degree angle. What should the nurse assess at this time?

carotid arteries

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

complete

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

cranial nerve VII intact

A client turns the head to the right after the nurse whispers the direction to do so in the client's left ear. What information should the nurse obtain from the client's response?

cranial nerve VIII is intact

When obtaining subjective data from a new client, you focus primarily on

evaluating risk factors

When supine, a client's knees do not touch the examination table. On what area should the nurse focus to learn more information about this finding?

flexion and extension

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

gait

Examination of the skin should be

integrated throughout the head-to-toe examination.

During a physical examination the nurse assesses a client's anterior neck, carotid arteries, heart and lung sounds, and breasts before assisting the client to a seated position to examine the back. What is the best explanation for using this approach?

it limits the number of times the client had to change position

A client with congestive heart failure presents to the emergency department with soreness from swelling of the ankles. When conducting the physical examination of this client, the nurse would require a stethoscope for which reason?

to auscultate the lungs

A client with congestive heart failure presents with edema of the ankles. When conducting a physical examination of this client, the nurse requires a stethoscope for which purpose?

to auscultate the lungs

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.

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

Breasts

When assessing the abdomen, which assessment technique is used last?

Palpation

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

Asymmetrical smile

A client has a nursing diagnosis of ineffective coping related to repeat episodes of diarrhea and financial stressors. Which of the following is an appropriate intervention for this nursing diagnosis?

Accurately assess stressors and effectiveness of coping methods

The nurse is assessing an elderly client. The client knows her name but does not know what day it is. The client is also unfamiliar with her situation. How would the nurse state these findings in the chart?

Alert and oriented times 1

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?

Anterior thorax

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

Arm, hands, and fingers

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

Arms

An adult female client is about to undergo a physical assessment conducted by a nurse practitioner at the gynecology clinic. The nurse is preparing the room for a complete head-to-toe examination, along with a genitalia and rectal assessment and screening through the Papanicolaou test. What should the nurse do next before proceeding?

Ask for the client's permission to perform the assessment

The nurse notes that a client suffers from chronic obstructive pulmonary disease (COPD). Which assessment finding is the nurse most likely to observe in this client?

Barrel chest

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

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

A 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?

Deficient Fluid Volume

What characteristics of the nasal mucosa should the nurse recognize as normal findings upon inspection?

Dark pink, moist, and free of exudate

Two body systems that may be logically integrated and assessed at the same time are the

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

While examining a client's head the nurse notes that several pieces of needed equipment are missing. Which item should be used to assess aspects of the ears and nose?

otoscope

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

palpation of the sinuses