NR 302: Health
Assessment I: HEAD
TO CHEST RETURN
DEMONSTRATION
COMPLETE REVIEW
RATED A+
,
,The nurse is admitting a client with an infected left ear cyst. As part
of the admission, a head-to-chest assessment is indicated. Before
examining the client, it is important the nurse completes which
nursing actions? Select all that apply.
Sanitize the stethoscope endpiece with an alcohol swab
Observe the client's face and body language for signs of pain or
distress
Ask the client to empty their bladder
Organize supplies to avoid interruptions
Perform hand hygiene
A client-centered health assessment yields both subjective and
objective data. The nurse would ask questions to elicit _______ data
and would auscultate heart sounds to elicit ______ data.
Subjective
Objective
The nurse is inspecting the client's neck. Which three (3) health
assessment inspection steps will the nurse take during the neck
examination?
Observe for symmetry and midline alignment of the trachea
Observe for masses on the neck
Observe for full range of motion of the neck
Based on the notes and orders received, the nurse prepares to
complete a cardiovascular exam on the client. Which of these
components should be included in the examination? Select all that
apply.
Palpate pulses
Auscultate carotid arteries
In the table below, choose which supplies are indicated or not
indicated for the preparation for or performance of a head-to-chest
assessment.
Indicated: Clean gloves
Tongue blades
Soap or alcohol-based hand rub
, Stethoscope
Not Indicated: Sterile drape
Nurse is auscultating heart sounds and client increases television
volume to the max
Nurse asks client to lower television volume
Client breath sounds need to be auscultated and the client is in a
supine position
Client needs to be sitting upright to assess thorax and lungs
Nurse is assessing the skin and finds a mole of irregular shape that
client states bleeds periodically
Nurse uses ABCDEF mnemonic to assess and refers client to
healthcare provider for follow-up
Nurse asks client to take a deep breath and client grimaces in pain
Nurse conducts a focused pain assessment
The nurse in the skill video documented the following after
conducting an assessment on the client. Highlight the incorrect
information they documented.
Assessment: Vital Signs: Temp 100.8°F (38.2°C) PO, HR 78, RR 16,
SpO2 96% RA, 5'6" 185 lbs. Pain is 3/10 described as a tight
pain/leg cramp when resting, increases to 9/10 when moving. Does
spread and travel, but it is not constant. Client is calm and appears
relaxed. Speech is clear. AxO x4, PERRLA 2 mm. Face symmetrical
and appropriate for conversation. Head small and asymmetrical,
hair full/thick, skull intact. Trachea is not midline, no masses felt.
Lungs clear to auscultation throughout. No use of accessory muscles
noted, breathing effortless. No carotid bruit noted. Cardiac sounds
s1 s2 WNL.
Does spread and travel, but it is not constant
Head small and asymmetrical, hair full/thick, skull intact
Trachea is not midline
What information should be recorded in the Cardiovascular portion
of the I-SBAR Assessment section? Select all that apply.
Assessment I: HEAD
TO CHEST RETURN
DEMONSTRATION
COMPLETE REVIEW
RATED A+
,
,The nurse is admitting a client with an infected left ear cyst. As part
of the admission, a head-to-chest assessment is indicated. Before
examining the client, it is important the nurse completes which
nursing actions? Select all that apply.
Sanitize the stethoscope endpiece with an alcohol swab
Observe the client's face and body language for signs of pain or
distress
Ask the client to empty their bladder
Organize supplies to avoid interruptions
Perform hand hygiene
A client-centered health assessment yields both subjective and
objective data. The nurse would ask questions to elicit _______ data
and would auscultate heart sounds to elicit ______ data.
Subjective
Objective
The nurse is inspecting the client's neck. Which three (3) health
assessment inspection steps will the nurse take during the neck
examination?
Observe for symmetry and midline alignment of the trachea
Observe for masses on the neck
Observe for full range of motion of the neck
Based on the notes and orders received, the nurse prepares to
complete a cardiovascular exam on the client. Which of these
components should be included in the examination? Select all that
apply.
Palpate pulses
Auscultate carotid arteries
In the table below, choose which supplies are indicated or not
indicated for the preparation for or performance of a head-to-chest
assessment.
Indicated: Clean gloves
Tongue blades
Soap or alcohol-based hand rub
, Stethoscope
Not Indicated: Sterile drape
Nurse is auscultating heart sounds and client increases television
volume to the max
Nurse asks client to lower television volume
Client breath sounds need to be auscultated and the client is in a
supine position
Client needs to be sitting upright to assess thorax and lungs
Nurse is assessing the skin and finds a mole of irregular shape that
client states bleeds periodically
Nurse uses ABCDEF mnemonic to assess and refers client to
healthcare provider for follow-up
Nurse asks client to take a deep breath and client grimaces in pain
Nurse conducts a focused pain assessment
The nurse in the skill video documented the following after
conducting an assessment on the client. Highlight the incorrect
information they documented.
Assessment: Vital Signs: Temp 100.8°F (38.2°C) PO, HR 78, RR 16,
SpO2 96% RA, 5'6" 185 lbs. Pain is 3/10 described as a tight
pain/leg cramp when resting, increases to 9/10 when moving. Does
spread and travel, but it is not constant. Client is calm and appears
relaxed. Speech is clear. AxO x4, PERRLA 2 mm. Face symmetrical
and appropriate for conversation. Head small and asymmetrical,
hair full/thick, skull intact. Trachea is not midline, no masses felt.
Lungs clear to auscultation throughout. No use of accessory muscles
noted, breathing effortless. No carotid bruit noted. Cardiac sounds
s1 s2 WNL.
Does spread and travel, but it is not constant
Head small and asymmetrical, hair full/thick, skull intact
Trachea is not midline
What information should be recorded in the Cardiovascular portion
of the I-SBAR Assessment section? Select all that apply.
