Chapter 22: Conducting a Head-to-Toe Examination Nursing School Test Banks

Chapter 22: Conducting a Head-to-Toe Examination
Test Bank

MULTIPLE CHOICE

1. 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
ANS: A

Feedback
A When the nurse and patient first meet, the nurse begins collecting data about the patient.
B Before this, the nurse began collecting data about the patient, such as gait, posture, and hygiene.
C Before this, the nurse began collecting data about the patient, such as gait, posture, and hygiene.
D Before this, the nurse began collecting data about the patient such as gait, posture, and hygiene.
DIF: Cognitive Level: Understand REF: 531
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment

2. 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
ANS: B

Feedback
A Lymph nodes are not palpated unless indicated.
B Palpation of upper extremities is performed in a routine head-to-toe examination.
C These data are not routinely assessed unless indicated.
D These data are not routinely assessed unless indicated.
DIF: Cognitive Level: Understand REF: 533
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment

MULTIPLE RESPONSE

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
ANS: A, D, E
Correct: These data are observed during the general survey as the patient enters the examination area and greets the nurse.
Incorrect: Although the nurse could detect firmness in a patients handshake, muscle strength testing is performed during the examination if indicated, not during the general survey. Data about heart sounds are collected during auscultation of the chest. Position of the trachea is determined by palpating the trachea during the examination.

DIF: Cognitive Level: Apply REF: 532
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment

2. Which techniques does a nurse use routinely to collect data when assessing a patients 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
ANS: A, C, E, F
Correct: These techniques are performed in a routine head-to-toe assessment of the posterior thorax.
Incorrect: Percussion of the costovertebral angle bilaterally is not performed unless indicated. For example, when the patient has a kidney disorder. Percussion of the posterior and lateral thorax for resonance is not performed unless indicated.

DIF: Cognitive Level: Apply REF: 534
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment

3. Which techniques does a nurse use routinely to collect data when assessing a patients 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
ANS: B, C, D, F
Correct: These techniques are performed in a routine head-to-toe assessment of the anterior thorax.
Incorrect: Palpation of the thorax for fremitus and palpation of the anterior chest wall for thoracic expansion are not performed unless indicated.

DIF: Cognitive Level: Apply REF: 534
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment

4. 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
ANS: B, D, E
Correct: These techniques are performed in a routine head-to-toe assessment of the abdomen.
Incorrect: Testing for abdominal reflexes for presence, percussing in all quadrants for tone, and deeply palpating for tenderness, guarding, and masses are not performed unless indicated.

DIF: Cognitive Level: Apply REF: 535
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment

5. 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
ANS: A, C
Correct: These techniques are performed in a routine head-to-toe assessment of the lower extremities.
Incorrect: Assessing for knee stability with the drawer test, McMurray test, or Apley test is not performed unless indicated by knee instability. Assessing for nerve root compression with straight leg raises is not performed unless indicated. Palpating hips for stability and tenderness is not performed unless the patient has unstable hips. Testing for patellar and Achilles deep tendon reflexes bilaterally is not performed unless indicated.

DIF: Cognitive Level: Apply REF: 535-536
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment

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