ch. 28 head to toe

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

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

The nurse has entered a client's room to begin a head-to-toe assessment. The client appears anxious, is pale, and is struggling to breathe. What is the nurse's priority action?

ensure a patent airway

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.

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 Any unexpectedly high or low serum sodium level can be a reflection of sodium intake but is more likely a reflection of having too much or too little water, therefore diluting or concentrating the sodium. This client has been drinking a lot of water and likely has diluted sodium levels resulting in hyponatremia. Potassium imbalances affect neural and cardiac cell conduction, leading to arrythmias and possible cardiac arrest.

What symptom(s) found during assessment would cause the nurse to suspect the client may be experiencing sepsis? Select all that apply.

Temperature greater than 102 °F (38.9 °C) Respiratory rate 36 breaths per minute Altered mental state Documented or suspected infection

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

VII (facial) The nurse checks the function of cranial nerve VII when assessing the corneal reflexes during an eye assessment. Cranial nerves IX (glossopharyngeal) and X (vagus) are assessed during the mouth and throat assessment. Cranial nerve XI (accessory) is assessed during the assessment of the arms, hands, and fingers.

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 permission

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

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

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 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.

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 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.

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 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.

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 Wound drainage is classified as serous (clear), sanguineous (bloody), serosanguineous (mixed), fibrinous (sticky yellow), or purulent (pus). Note any signs or symptoms of infection.

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

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

skin

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."

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

Arm, hands, and fingers 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.

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

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

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

CBC 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 should recognize that which acute change in heart rate requires urgent attention and intervention in an adult hospitalized client?

Decrease to 44 beats/minute Acute and urgent situations such as the following warrant immediate attention and interventions: Acute change in heart rate to fewer than 50 or greater than 120 beats per minute.

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 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

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

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

Raise eyebrows Frown Smile Close eyes

Which of the following equipment will the nurse gather to conduct a physical examination of a client's eyes? (Select all that apply.)

Snellen chart Rosenbaum card Ophthalmoscope

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

Tell about the client's concerns

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

abdominal reflex 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.

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

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

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

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

stroke each side of the cheek with a cotton wisp 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 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 vitals

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 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.