Chapter 22: Conducting a Head-to-Toe Examination

Chapter 22: Conducting a Head-to-Toe Examination

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

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 patient’s 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