Chapter 28 - Pulling it All Together : Integrated Head-to-Toe Assessment (Final)

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." 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.

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

Correct response: Eye assessment Explanation: If a hand-held Snellen is available, then inserting visual acuity in the eye assessment is appropriate

When assessing an IV site, what should be included? Select all that apply.

Explanation: Intravenous site assessment should include location, appearance, type and size of device, type of intravenous fluids and rate of infusion, and if the infusion is on a device.

Students are learning about subjective data collection. What data are collected subjectively? (Mark all that apply.)

Explanation: Subjective data collection includes health promotion, risk factors, history of present problem, past medical and family histories, personal and social histories, and common symptoms. Auscultated sounds and visualized signs are part of objective data collection.

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.

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.

The client has decreased sensation in his legs. What additional assessment should the nurse include?

Fall Explanation: Because of decrease peripheral sensation in the legs, the client is at increased risk for falls. There is no data to support increased risk for sepsis, bloodstream or surgical site infections for this client.

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 Explanation: An appropriate nursing diagnosis would be fatigue related to anemia as evidenced by low hematocrit, hemoglobin; client pale, tired.

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 Explanation: The nurse should begin the physical assessment with a general survey.

To assess a client's abdominal reflexes, which assessment should be included in the physical examination?

Lightly stroke inward from all quadrants. Explanation: Abdominal reflexes are stimulated by stroking around the umbilicus. If reflexes are normal, the nurse should observe contraction of the abdominal muscles. Auscultating for bowel sounds is not the most effective way to assess abdominal reflexes. Light palpation should be used to assess for masses, tenderness, and the client's facial expression in response to the pressure. Percussion of the abdomen assists in hearing sounds that provide information about the liver, kidneys, and spleen.

When doing a shift assessment on a new client, the nurse notes that the popliteal pulses are within normal limits (WNL). How would the nurse chart this?

Popliteal pulses 2-3+ Explanation: Correct documentation would be, "Popliteal pulses 2-3+." Therefore, the remaining options are incorrect.

The nurse is assessing the upper extremities of the client. What pulses should be assessed? Select all that apply.

Radial Brachial Explanation: The radial and brachial pulses can be assessed on the upper extremities. Pedal, popliteal and femoral are on the lower extremities.

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. 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

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

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

The nurse is beginning a complete assessment of a client. What should be included as part of the general survey?

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.

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?

"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 should use light palpation of the abdomen to obtain objective data about which characteristic of the abdomen?

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.

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

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.

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 Explanation: Following completion of the health history previously described, the nurse explains the process for the physical examination, from head to toe and including auscultation of the heart and lung sounds, auscultation and palpation of the abdomen, and screening for neuromuscular problems. Because some assessments may be uncomfortable (e.g., breast, gynecological), the nurse asks the client for permission to perform them. Once the nurse has the client's permission, the nurse would ask the client if the client prefers to have a third person in the room or, if appropriate, a same-gender nurse. The nurse would take care to preserve modesty; however, this would not be the immediate next step. Alterations to the order of the examination would be unlikely unless the client had an emergency concern.

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 Explanation: If the client reports or complains of pain, rate the pain using the 0-10 pain scale; then intervene to provide comfort measures and evaluate the effectiveness of such interventions. Offering the client some aspirin may or may not be an appropriate action later, but at the moment the nurse needs to further establish the severity and cause of the pain. The nurse should record the comment as a subjective finding after assessing for the severity of the pain. The Glasgow Coma Scale is used to assess level of consciousness.

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

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 preparing to examine a client's posterior thorax. Which of the following should be included in this examination?

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.

What would be included in a shift assessment? Select all that apply.

Auscultation of lungs on a client with pneumonia Inspection of skin on a client that is not mobile Palpating pulses on a client with PVD Explanation: Shift assessment is performed at the beginning of the shift and includes an abbreviated exam, with emphasis on risk areas, such as auscultation of lungs and abdomen, and assessment of circulation and level of consciousness. Asking health history would part of a comprehensive assessment. Follow up after medicating for pain is a focused assessment.

The hospitalized client is at risk for ineffective tissue perfusion. What should the nurse assess to identify ineffective tissue perfusion?

Capillary refill Explanation: Capillary refill is used to assess the client's tissue perfusion. Nutritional status, mobility and skin moisture are not indicators of perfusion.

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 Explanation: To assess the function of cranial nerve I (olfactory), the nurse should ask the client to close the eyes and assess for smell. The nurse asks the client to say "aah" and observes the rise of the uvula as part of the assessment of the mouth and throat. Cranial nerve VII and IX are assessed by asking the client to identify taste with the eyes closed. When testing for cranial nerves IX and X, the nurse asks the client to press the tongue against the tongue blade to assess tongue strength.

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 Explanation: The most appropriate intervention would be to collaborate with the provider to treat anemia. Steps might include an evaluation of nutrition and sleep patterns.

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

Complete blood count Explanation: Dark stool may indicate presence of blood. Therefore the hemoglobin and hematocrit should be assessed to check for blood loss. Loose stools would be a concern for potassium loss. While coagulation studies should be reviewed; the priority is to check for blood loss, then determine a possible cause such as low platelets or other coagulation disorder. A compromised liver can result in bleeding; however, the CBC should be assessed first to determine blood loss and need for immediate intervention such as transfusion.

The nurse is to perform an assessment on a newly admitted client. Which assessment would be most appropriate?

Comprehensive Explanation: A comprehensive assessment of a newly admitted client. This assessment is more detailed and complete than shift and focused assessments, which evaluate progress toward a goal later in the stay. A system assessment focuses on a body system.

What type of assessment would a nurse perform on a client being admitted to the hospital?

Comprehensive Explanation: The nurse in the hospital performs a comprehensive assessment of the client on admission. This assessment is more detailed and complete than screening and focused assessments that evaluate progress toward a goal later in the stay. "Acute" is not a term commonly used to describe a type of assessment.

A nurse is assessing a client who seems to have developed a hearing impairment after working at a construction site for a few months. The nurse is using the Weber test to assess the client's hearing acuity. Weber's test does which of the following?

Correct response: Determines the equality or disparity of bone-conducted sound. Explanation: Weber's test helps to determine the equality or disparity of bone-conducted sound. The Rinne test compares the air versus bone conduction of sound and tests air conduction of sound in the tested ear. Audiometry measures hearing acuity at different sound frequencies. Reference:

The nurse is assessing a client's skin. Which additional action should the nurse take while performing this assessment?

Correct response: 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. Reference:

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?

Correct response: 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.

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 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 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 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.

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.

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.

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 Explanation: To evaluate a male client's genitalia, the nurse should have the client stand and face the nurse with gown raised. The nurse should ask the client to fold the gown to the waist and sit with the arms hanging freely when assessing the anterior chest. The client should not be lying supine for this examination.

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

Inspection Explanation: The nurse should use the technique of inspection for assessment of the vagina. The nurse should insert the speculum and inspect the vagina for color, consistency, and discharge. Palpation is used for assessment of Bartholin's glands, the urethra, and Skene's glands. The transillumination technique is used to assess scrotal sac and the sinuses.

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

Inspection, auscultation, percussion, palpation Explanation: With physical examination of the abdomen, the nurse should auscultate before percussion or palpation to avoid alteration of the bowel sounds.

The head-to-toe assessment is a very important tool in providing the best possible care to a client. What is the reason for a comprehensive health assessment? Select all that apply.

Integrates all body systems Gives the nurse an overall impression of the client's condition Helps the nurse identify risk factors for potential health problems Explanation: The comprehensive health assessment integrates all body systems; findings help the nurse form an overall impression of the client and his or her condition. Complete subjective data collection includes data related to the client's history and risk factors.

A nurse is performing a head-to-toe examination of a client. At which point should the nurse first put on gloves?

Just before the mouth and throat assessment 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.

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:

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?

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.

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

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

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 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.

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

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 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?

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.

A client visits the health care facility with reports of mild hearing loss. The nurse prepares to perform which test to compare bone and air conduction?

Rinne 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.

When performing a shift assessment, the nurse identifies the client has on a sequential compression device. What must the nurse then assess?

Skin Explanation: Sequential compression devices are placed on extremities. It is important that skin under these devices be at least every shift. These devices do not affect breath sounds, blood sugar or body temperature.

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

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 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 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.

The client has been admitted with pneumonia. What should the nurse assess?

Sputum Explanation: Swelling, heart tones and peripheral pulses are related to circulatory system The sputum of a client with pneumonia should be assessed.

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?

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 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 Explanation: Before performing a complete assessment, read your state's Nurse Practice Act to find out what you can legally assess and diagnose. Although it is also important to know hospital policy, it is the nurse practice act of the state in which you are practicing that determines what is legal for you to perform. The supervising physician does not determine what is legal for you to perform. Nursing practice is regulated primarily at the state, not federal, level.

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. 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.

When collecting subjective data, the nurse gives the client time and encouragement to do what?

Tell about the client's concerns Explanation: The nurse gives the client time and encouragement to tell their story and experience of health or illness. Doing so provides an opportunity for the client to express concerns; it often forms the foundation for a therapeutic relationship. Subjective data collection involves learning about the client's family history and health concerns, but the nurse would steer the conversation away from social discussions of the client's family or too many unrelated complaints. Common findings are part of objective data collection and are driven by the health provider, not the nurse.

The nurse has palpated a client's radial pulses bilaterally and has documented the results of this assessment as "radial pulses 1+ bilaterally." How should this assessment finding be interpreted?

The client's weak pulses may be indicative of cardiovascular disease. Explanation: A peripheral pulse that is documented as 1+ is considered weak, a finding that may be indicative of decreased cardiac output.

A nurse is performing a part of a physical assessment for a client using palpation. What is the purpose of using this technique?

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?

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.

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

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.

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 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

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.

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

acquire your client's verbal permission to perform the physical examination. Explanation: Get your client's permission to ask personal questions and to perform the various physical assessments.

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 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 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.

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 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.

When integrating the total physical examination the nurse should

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).

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 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.

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 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.

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 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 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.

When examining a client's musculoskeletal system, for which assessment should the client be in a seated position?

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.

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

flexion and extension Explanation: Since the legs are not able to be completely extended, the nurse should focus on knee flexion and extension. Gait would not help determine if the client is experiencing an alteration in knee function. Limb length would not help explain the reason for the alteration in knee function. The knee is not assessed for abduction or adduction although movement of the knee occurs to assess for abduction and adduction of the hip.

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

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.

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 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 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.

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 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.

In order to conduct an examination of the eye muscles, the nurse should prepare to administer which tests? Select all that apply.

six cardinal directions of gaze convergence near reaction cover-uncover test Explanation: Tests that can be used to determine eye muscle strength include the six cardinal directions gaze, convergence, near reaction, and the cover-uncover test. Convergence is used to examine visual fields.

In order to conduct a physical examination of the eye muscles, the nurse should prepare to administer which tests?

six cardinal directions of gaze convergence near reaction cover-uncover test Explanation: Tests that can be used to examine the eye muscle strength include the six cardinal directions of gaze, convergence, near reaction, and the cover-uncover test. Confrontation is used to examine visual fields.

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

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.

The nurse wants to assess a client's 5th cranial nerve. What approach should be used?

stroke each side of the cheek with a cotton wisp Explanation: Assessing for response to light sensation over the cheeks determines the status of cranial nerve V. Frowning and puffing out the cheeks assesses cranial nerve VII. Palpating the jaw for areas of pain or tenderness assesses motor function of the temporomandibular joint.

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 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 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

The nurse collects equipment prior to conducting a physical examination for a new client. For which body area should the nurse use a gauze pad during the assessment?

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