Chapter 30: Head-to-Toe Assessment of the Adult

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." "I had my appendix removed when I was 14 years old" "I have an aunt who had breast cancer." "I try not to let the pain affect my life."

"I haven't had a checkup in over 5 years." The statement about not having had a checkup in over 5 years reflects the reason for seeking health care. The statement about not letting the pain affect life reflects a history of the present health concern. The statement about appendix removal at age 14 reflects the client's past health history. The statement about an aunt with breast cancer reflects the client's family history.

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? "Touch the tip of your nose, then the tip of my finger as I move my finger." "Quickly flip your hands back and forth on your knees as I demonstrate." "Tell me which number I am tracing on your back with my finger." "With your eyes closed, identify the object I place in your hand."

"With your eyes closed, identify the object I place in your hand." 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 will get more proficient with experience." "Sometimes you have to cut corners." "You can't; it's impossible."

"You will get more proficient with experience." 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.

A nurse knows that a normal capillary bed refills in how many seconds? 3 to 4 1 to 2 Less than 1 5 to 6

1 to 2 Normal capillary refill is 1 to 2 seconds. Capillary refill exceeding 2 seconds may indicate vasoconstriction.

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 Gradually increase activity as tolerated Monitor intake and output Monitor effectiveness of medication used to treat diarrhea

Accurately assess stressors and effectiveness of coping methods This client's nursing diagnosis and related factors do not correspond with problems related to activity tolerance. The appropriate intervention is consistent with measures to reduce stress and coping, which are necessary to assist with the problem of ineffective coping.

At which time would a nurse observe and evaluate jugular venous pressure? Before examining the abdomen After assessing the heart After examining the breasts When moving from the posterior to the anterior chest

After examining the breasts The nurse would observe and evaluate jugular venous pressure after examining the breasts and before assessing the heart. This time would be appropriate because the client would move from a sitting position to a supine position.

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? Spinal motion Balance Posterior thorax Anterior thorax

Anterior thorax 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.

The nurse is performing an abbreviated head-to-toe assessment of a client. When the nurse asks the client about his pain, the client states, "My stomach's really killing me right now." How should the nurse first respond to this client's statement? Tell the client pain will be addressed after the assessment. Offer the client an oral analgesic medication . Ask the client to rate his pain on a 0-to-10 scale. Assess the client's level of consciousness.

Ask the client to rate his pain on a 0-to-10 scale. The nurse should follow up a complaint of pain by asking the client to rate it. This assessment must precede interventions such as administering analgesia. It would most often be inappropriate to delay addressing the client's pain in order to complete the full assessment. A complaint of pain does not necessarily indicate a need to assess LOC.

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

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

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? Cardiovascular Chromosomal Immune Endocrine

Chromosomal The auricle of the ear should align with the corner of each eye. Misaligned or low set ears may be seen with genitourinary or chromosomal disorders.

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? Evaluate urinary patterns Have the client explain an energy-conservation plan to offset the effects of fatigue Collaborate with the physician to treat anemia Evaluate adequacy of exercise

Collaborate with the physician to treat anemia 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? Liver function panel Complete blood count Electrolyte panel Coagulation studies

Complete blood count 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.

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? Decreased activity level Depression Altered nutrition Fatigue

Fatigue 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? Mental status examination General survey Eye assessment Skin assessment

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

To properly evaluate a male client's genitalia, the nurse should have the client do which of the following? Lower the examination table with client in supine position Have the client stand and face the nurse with gown raised Ask the client to fold the gown to the waist and sit with the arms hanging freely Assist client to supine position with head elevated

Have the client stand and face the nurse with gown raised 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.

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. 1Health history 2Inspection 3Percussion 4Auscultation 5Palpation

Health history Inspection Auscultation Percussion Palpation 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.

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? Hyperkalemia Hypokalemia Hypernatremia Hyponatremia

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.

During the assessment of a female client, which physical examination techniques should the nurse use to assess the vagina? Deep palpation Light palpation Transillumination Inspection

Inspection 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.

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

Opens up teaching/learning moments 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.

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? Contact the nurse who performed the admission assessment. Document findings. Perform a comprehensive assessment on the client. Perform a focused assessment on the client.

Perform a focused assessment on the client. 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.

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? Capillary refill in index finger less than 3 seconds Deep tendon reflexes 3+ bilaterally Aorta palpable, smooth Positive Babinski sign

Positive Babinski sign 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.

A nurse has finished examining a client's nose and sinuses and is about to examine the client's mouth and throat. What would be most important for the nurse to do? Warm the hands Obtain a tuning fork Collect a saliva specimen Put on gloves

Put on gloves Examination of the mouth requires the nurse to come in contact with the client's secretions and to touch the tongue. Therefore the nurse should put on gloves. Warming the hands would be appropriate anytime the nurse touches the skin. There is no need to get a tuning fork or collect a saliva specimen.

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? Refer for ophthalmologist consult. Perform the Weber test. Re-assess as needed. Conduct the Romberg test.

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.

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? Purulent Sanguineous Fibrinous Serous

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.

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

Snellen chart ophthalmoscope 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.

When preparing to do a comprehensive health assessment, the nurse obtains the client's permission based on an understanding of which of the following? It ensures that the client will answer personal questions. Permission maintains the client's confidentiality. The client has the right to refuse. The client's level of comfort will be increased

The client has the right to refuse. The nurse asks the client's permission to complete the assessment because the client has the right to refuse, and asking permission fosters the client's autonomy. In addition, some parts of the physical examination require touching or exposing the client, which requires the client's permission also. Permission does not maintain confidentiality, nor does it ensure that the client will answer personal questions. Thorough explanation, preparation, and respect will help to increase the client's level of comfort.

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 Standing in front of the client, hook the fingers into the clavicle and press firmly and deeply Standing behind the client, place fingers at the base of the ears and palpate along the sternomastoid muscle on either side Standing in front of the client, place the fingers just below and under the mandible

Standing behind the client, place the fingers on either side of the trachea below the cricoid cartilage To correctly palpate the thyroid gland, the nurse should use a posterior approach. Stand behind the client and place the thumbs on the nape of the neck and fingers on either side of the trachea below the cricoid cartilage. Displace the trachea to one side and feel deeply in front of the sternomastoid muscle. To palpate the submandibular nodes, the nurse should stand in front of the client and place the fingers just below and under the mandible. Hooking the fingers into the clavicle and pressing firmly and deeply is the correct technique for palpation of the supraclavicular nodes. Standing behind the client, placing fingers at the base of the ears and palpate along the sternomastoid muscle on either side is the correct technique for palpation of the superficial cervical nodes.

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 Federal law Supervising physician Hospital policy

State's nurse practice act 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.

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 nurse's level of expertise The client's health needs

The client's health needs 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 an assessment within the legal parameters of assessment and diagnosis. Where would the nurse find these legal guidelines? The state's Nurse Practice Act The client's informed consent documents The institution's policies and procedures guidelines The nurse's terms of license

The state's Nurse Practice Act The nurse should check the state's Nurse Practice Act to find out what the nurse can legally assess and diagnose. Informed consent documents do not specify these guidelines. The Nurse Practice Act supersedes a nurse's terms of license or an institution's policies.

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 Tongue depressor Tuning fork Ophthalmoscope

Tuning fork 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.

Before beginning a physical assessment it is important for the nurse to explain to the client in detail how each body system will be assessed. acquire your client's verbal permission to perform the physical examination. acquire your client's written permission to perform the physical examination. explain to the client the purpose of every physical assessment technique you will be using.

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 cranial nerve function after assessing the abdomen after assessing the motor function of the lower extremities after assessing the anterior and posterior thorax

after assessing the motor function of the lower extremities 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.

When integrating the total physical examination the nurse should assess cranial nerve I (olfactory) with the other 11 cranial nerves at the same time. 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 peripheral vascular status when examining the lower extremities 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 abdomen assessment of the posterior thorax assessment of the lower extremities assessment of the genitalia and rectum

assessment of the genitalia and rectum 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.

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 cranial nerves bowel sounds hand grasps

carotid arteries 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 urgent evaluative complete

complete 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.

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

elbow flexion 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 obtaining subjective data from a new client, you focus primarily on assessing the client's use of alcohol assessing the client's coping ability evaluating risk factors assessing family cohesion

evaluating risk factors Complete subjective data are usually collected once and include information related to the client's history and risk factors.

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

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

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? beginning with the musculoskeletal assessment of the extremities major body systems first approach head-to-toe assessment grouping body systems together to limit position changes

head-to-toe assessment 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.

A nurse is performing an abdominal assessment. The correct order of assessment techniques would be inspect, auscultate, deeply palpate, lightly palpate inspect, deeply palpate, lightly palpate, auscultate inspect, auscultate, lightly palpate, deeply palpate inspect, lightly palpate, auscultate, deeply palpate

inspect, auscultate, lightly palpate, deeply palpate

In order to assess a client's abdominal reflexes, what should the nurse include in the physical examination? light stroking inward from all quadrants auscultation of bowel sounds percussion for abdominal sounds light palpation of each quadrant

light stroking inward from all quadrants 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.

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

neck 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? otoscope ophthalmoscope pen light cotton swab

otoscope 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.

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. level of consciousness overall physical and sexual development concentration, ability to focus and follow directions overall skin coloring facial symmetry

overall physical and sexual development overall skin coloring 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.

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 to assess jugular venous pressure to check radial pulses to assess pedal pulses

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.

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

to auscultate the lungs 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 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 ¼ hour 2 hours 1 hour

½ hour To perform a complete interview and total physical examination may take up to 2 hours for the novice nurse and only 30 minutes for a skilled practitioner.

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." "Your blood pressure is elevated, so we should talk more after I complete your assessment." "How often do you have blurred vision and numbness and tingling?" "You are an older adult so it's normal to have high blood pressure."

"Your blood pressure is elevated, so we should talk more after I complete your assessment." 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 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? 2+ pitting edema 3+ pitting edema 1+ pitting edema 5+ pitting edema

3+ pitting edema The nurse should quantify the finding as 3+ pitting edema, since the indentation remains for several seconds and a skin swelling is obvious by general inspection. In case of 1+ pitting edema, there is a slight indentation (2 mm) with normal contours and the associated interstitial fluid volume is 30% above normal. 2+ pitting edema indicates that the indentation is deeper after pressing (4 mm) and lasts longer than a 1+, with fairly normal contours. In the case of 5+ brawny edema, there is no pitting; tissue palpates as firm or hard, and the skin surface appears shiny, warm, and moist.

A nurse has been assigned a group of clients. On which client should the nurse perform an integrated head-to-toe assessment first? 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 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 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).

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

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.

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

Arms 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 would test for stereognosis during which part of the comprehensive exam? Posterior and lateral chest Arms, hands and fingers Legs, feet, and toes Nose and sinuses

Arms, hands and fingers Stereognosis is assessed by placing a familiar object such as a key or quarter in the client's hand to determine if they can identify this. Although part of the neurologic exam, it would be done when examining the arms, hands, and fingers of the comprehensive exam.

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? Decide whether to alter the process of starting at the head and proceeding to the feet Ask for the client's permission to perform the assessment Uncover only the part being examined, covering everything else Ask if the client wants an observer for the assessment

Ask for the client's permission to perform the assessment 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 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? Talking with family members Assessing nutrition Troubleshooting the infusion pump Assessing for pain

Assessing for pain Guarding is an indication of pain. This is the priority problem for the nurse to address.

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

Asymmetrical smile 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.

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

Client alert and cooperative; sitting comfortably on chair with hands in lap 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? Document absent bowel sounds. Palpate and percuss the abdomen. Notify the health care provider of this abnormal finding. Continue to auscultate for a total of 5 minutes.

Continue to auscultate for a total of 5 minutes. 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 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? Presence of a family member Cultural considerations Psychosocial challenges Patient expectations

Cultural considerations Assess psychosocial, spiritual, and cultural history; language of choice; and need for interpreter. You may ask, "Do you have any special religious, spiritual, or cultural needs? Would you like an interpreter?"

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 Order a chest x-ray Begin antibiotic therapy through intravenous route Administer a nebulizer treatment

Encourage turning, coughing, and deep breathing 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? Allow the client a break between the two parts of the history/exam. Establish a routine for the assessment. Intersperse the physical exam with the history. Gather health history information first.

Establish a routine for the assessment. 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.

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? Interdisciplinary collaboration Health teaching Nutritional supplementation Psychological testing

Health teaching After collecting and analyzing all these data, you determine potential and actual risk factors for the client and use this information to plan specific screening, health promotion, and client teaching activities.

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 Assess the client's vital signs Take body measurements Assess mental status

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

Obtain the apical pulse for one full minute. 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.

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? Explain nurse-client boundaries to the client. Inform the client about privacy and confidentiality. Offer to exchange client assignments with a female nurse. Tell the client that these are not North American customs.

Offer to exchange client assignments with a female nurse. In accordance with the ETHNIC model for ethnographic geriatric education, collaboration plays a part in the assessment of the older adult with a cultural identity different from the health care provider. In an effort to be collaborative, culturally competent, and maintain the nurse-client relationship, the nurse should exchange client assignments with a female nurse. Although it is important to discuss privacy and confidentiality with the client, this is not the concern she wants to have addressed by making a request for a female nurse. The nurse-client boundary is a critical element of the therapeutic relationship. This can be explained to the client; however, it does not address the cultural factors impacting the assessment of this individual client. To tell the client that these are not North American customs communicates an ethnocentric view of health and does not promote culturally competent care.

A nurse who works on a day-surgery unit conducts a thorough, head to toe assessment of each client prior to the client's scheduled surgery. The nurse would document an unexpected finding if unable to palpate a client's: Thyroid gland Peripheral pulses Liver Lymph nodes

Peripheral pulses Nonpalpable peripheral pulses are an unexpected finding, which warrants further assessment and follow-up. The liver, lymph nodes, and thyroid are not normally palpable in healthy individuals.

A 43-year-old man comes to the ED with new onset of chest pain. Which of the following questions is a priority at the time of admission? On a scale of 1 to 10, how do you rate your pain? What did you do to cause your pain? Have you ever had this pain before? Have you eaten recently?

On a scale of 1 to 10, how do you rate your pain? The nurse assesses pain location, duration, intensity, quality, alleviating/aggravating factors, pain goal, and functional goal. Asking the client what was done to cause the pain is not a priority question. Asking the client if they have eaten recently or had this pain before could be important, but is not the most important question at the time of admission to the ED.

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

On the mastoid area. 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.

Once a client has been assessed, the nurse uses data to formulate a care plan that assists with achieving specific outcomes for the individual client. What must the nurse keep in mind when deciding on which outcomes are appropriate for each client? Select all that apply. Outcomes must be realistic to achieve Outcomes have no time frame for being met Outcomes must be specific to the client Outcomes must be measurable Outcomes must always be achieved

Outcomes must be specific to the client Outcomes must be realistic to achieve Outcomes must be measurable Outcomes are specific to the client, realistic to achieve, and measurable and have a time frame for completion.

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

Palpation 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.

During the physical assessment of a client, the nurse uses the head-to-toe approach. What are the advantages of this approach? Select all that apply. Makes the problem easily identifiable because the findings tend to be clustered. Reduces the number of position changes required of the client. Takes less time because the nurse doesn't have to constantly move around the client. Examines the same areas of the body several times before the assessment is complete.

Reduces the number of position changes required of the client. Takes less time because the nurse doesn't have to constantly move around the client. The head-to-toe approach helps to prevent overlooking some aspect of data collection, reduces the number of position changes required of the client, and takes less time because the nurse doesn't have to constantly move around the client. Findings tend to be clustered, making the problem more easily identifiable in the body systems approach. However, in using the body systems approach, the same areas of the body are examined several times before the assessment is completed.

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

VII 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 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? States her father died of a heart attack at age 70. Vaginal delivery of two children without complications. Wears dentures; denies problems with eating, chewing, and swallowing. Uses over-the-counter antacid for occasional heartburn.

Wears dentures; denies problems with eating, chewing, and swallowing The statement about dentures and no problem with eating, chewing, and swallowing reflects a review of the client's body system, specifically the mouth and throat. The statement about the father dying from a heart attack reflects family health history. Use of over-the-counter antacids would reflect lifestyle and health practices, specifically medication use. The statement about vaginal delivery reflects the client's past health history.

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 Place a quarter or key in the client's hand Evaluate sensitivity of position of fingers Ask the client to touch finger to nose with eyes closed

Write a number in the palm of the client's hand 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. Sensation is evaluated by testing sensitivity of position of fingers.

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 the client likes children routine dental visits occur the client is pleasant

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

cranial nerve VIII is intact 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 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 apparent age stated age

developmental stage 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.

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

palpate pulses 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.

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? 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 thyroid

palpation of the sinuses 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.

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

standing 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 ask the client to frown ask the client to puff out the cheeks palpate the jaw for areas of pain or tenderness

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 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 shortness of breath expiratory wheezing green, yellow sputum

swelling of lower extremities shortness of breath weight gain 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).