CHAPTER 22: CONDUCTING A HEAD-TO-TOE EXAMINATION 2022

When does the health assessment begin? a. When the nurse first meets the patient b. When the patient tells the nurse his name and age c. When the nurse asks the patient the first health-related question d. When the patient consents to have a health assessment performed - Correct Answer-A When the nurse and patient first meet, the nurse begins collecting data about the patient. Which assessments are routine examination techniques of the upper extremities? a. Palpating the epitrochlear lymph nodes for size and tenderness b. Palpating the arms for skin characteristics, symmetry, tenderness, and deformities c. Testing the range of motion and muscle strength comparing one arm with the other d. Testing triceps, biceps, and brachioradialis deep tendon reflexes bilaterally - Correct Answer-B Palpation of upper extremities is performed in a routine head-totoe examination. 1. Which data does a nurse collect during the general survey when meeting a patient for the first time? Select all that apply. a. Gait b. Muscle strength c. Heart sounds d. Hearing and speech abilities e. Mood or affect f. Position of the trachea - Correct Answer-ANS: A, D, E Correct: These data are observed during the general survey as the patient enters the examination area and greets the nurse. Which techniques does a nurse use routinely to collect data when assessing a patient's posterior thorax? Select all that apply. a. Inspection of the thorax for symmetry of shoulders b. Percussion the costovertebral angle bilaterally c. Inspection of respiratory movement for symmetry, depth, and rhythm of respiration d. Percussion of the posterior and lateral thorax for resonance e. Palpation of vertebrae for alignment and tenderness f. Inspection of thorax for muscular development and scapular alignment - Correct Answer-ANS: A, C, E, F Correct: These techniques are performed in a routine head-to-toe assessment of the posterior thorax. Which techniques does a nurse use routinely to collect data when assessing a patient's anterior thorax? Select all that apply. a. Palpation of the thorax for fremitus b. Inspection of the skin for color, intactness, lesions, and scars c. Auscultation of breath sounds bilaterally d. Auscultation of heart sounds for rate, rhythm, frequency, and S1 and S2 e. Palpation the anterior chest wall for thoracic expansion f. Inspection of respiratory movement for symmetry and ease of respiration - Correct Answer-ANS: B, C, D, F Correct: These techniques are performed in a routine head-to-toe assessment of the anterior thorax. Which techniques does a nurse use routinely to collect data when assessing the abdomen of a patient? Select all that apply. a. Testing for presence of abdominal reflexes b. Inspecting skin for contour, scars, lesions, vascularity, and bulges c. Percussing in all quadrants for tone d. Lightly palpating for tenderness, guarding, and masses e. Auscultating for bowel sounds, bruits, and venous hums f. Deeply palpating for tenderness, guarding, and masses - Correct Answer-ANS: B, D, E Correct: These techniques are performed in a routine head-to-toe assessment of the abdomen. Which techniques does a nurse routinely use to collect data when assessing the lower extremities of a patient? Select all that apply. a. Inspecting of legs, ankles, and feet for skin characteristics and hair distribution b. Assessing for knee stability with the drawer test, McMurray test, or Apley test c. Palpating lower legs and feet for temperature, pulses, and tenderness d. Assessing for nerve root compression with straight leg raises e. Palpating hips for stability and tenderness f. Testing for patellar and Achilles deep tendon reflexes bilaterally - Correct AnswerANS: A, C Correct: These techniques are performed in a routine head-to-toe assessment of the lower extremities