Deck 22: Conducting a Head-to-Toe Examination

Question 1

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

Answer 1

Inspecting of legs, ankles, and feet for skin characteristics and hair distribution
Palpating lower legs and feet for temperature, pulses, and tenderness

Question 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

Answer 2

Palpating the arms for skin characteristics, symmetry, tenderness, and deformities

Question 3

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 of 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

Answer 3

Inspection of the thorax for symmetry of shoulders
Inspection of respiratory movement for symmetry, depth, and rhythm of respiration
Palpation of vertebrae for alignment and tenderness
Inspection of thorax for muscular development and scapular alignment

Question 4

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

Question 5

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 of the anterior chest wall for thoracic expansion
F) Inspection of respiratory movement for symmetry and ease of respiration

Question 6

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

Question 7

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