Prep-U Chapter 21 Putting It All Together

As part of the equipment, a nurse makes sure to have a speculum for an assessment to perform on a client. In which part of the assessment is the nurse most likely to use a speculum?

Female genitalia

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

To properly evaluate a male client's genitalia, the nurse should have the client do which of the following?

Have the client stand and face the nurse with gown raised

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

VII

When integrating the total physical examination the nurse should

assess peripheral vascular status when examining the lower extremities.

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

True

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

Breasts

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

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

Arms

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

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

Asymmetrical smile

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 the client's four abdominal quadrants

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

CVA tenderness

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

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

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 assessed

The nurse is preparing to enter the client's room. Before doing so, the nurse should assess her own:

Demeanor

The nurse prepares to conduct a history and complete physical examination. What should the nurse explain to the client as being the major purpose for this comprehensive evaluation?

Develop a plan of care

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 has a hand-held Snellen. When in the sequence of assessment should the nurse assess visual acuity?

Eye Assessment

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 Palpitation

A nurse is caring for a client who uses a hearing aid for amplifying sound. During the Rinne test for checking the bone conduction of the sound, where should the nurse place the stem of the vibrating tuning fork?

On the mastoid area

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

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

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

Popliteal Femoral Dorsalis Pedas Posterior tibial

The nurse is conducting a head-to-toe assessment on a client. Which observation(s) by the nurse would be cause for concern? Select all that apply.

Rashes Lesions Infestations

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-asses as needed

At the beginning of the exam the nurse performs a general survey. What would the nurse assess at this time?

Safety

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

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

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?

Taking vital signs

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 Test

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

The nurse is completing the general survey. In addition to observing the client's appearance, the nurse would assess which of the following?

Vital signs

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

Examination of the skin should be

integrated throughout the head-to-toe examination