Head to Toe Assessment (Module 2) Flashcards
Place in order the steps to take an initial manual brachial artery blood pressure.
A. Cleanse Hands
B. Chose appropriate size blood pressure cuff
C. Cleanse equipment
D. Have patient sitting in a comfortable position with arm at heart level
E. Place stethoscope over brachial artery
F. Inflate the cuff 30mm HG above the patient usual BP reading
G. Open valve and allow air to escape slowly (2 to 3 mm Hg per second)
H. Assess BP in both arms
I. Document findings
When assessing pain in a 5 year old, which of the following standard pain scales is appropriate to use?
Wong Baker (FACES)
Place in order the techniques used by the RN when performing an abdominal assessment.
A. Inspect
B. Auscultate
C. Percuss
D. Palpate
What techniques are used by the RN to assess breath sounds?
A. Position the patient upright
B. Instruct the patient to take slow deep breaths
C. Listen sequentially side to side
What is the RN assessing in the picture below?
The strength of the lower extremities
What is the initial finding expected by the RN with a person with altered mental status?
Inability to identify time
Which circle indicates the best location for the RN to place the stethoscope when auscultating an apical pulse?
Apex (apical area), 5th intercostal space mid-clavicular line on the left side of the chest
When the RN performs a physical assessment on a 4 month old infant what is an unexpected finding?
Ribbon like stool (s/s of Hirschsprung disease (absence of nerve cell in the muscles of a section of the bowel)
What ongoing physical assessment by the RN are required for a patient with a fractured wrist that had a cast applied? Select all that apply
A. Sensation
B. Motion of fingers
C. Skin temperature
D. Distal Capillary refill
What are examples of the RN applying basic medical asepsis principles in the patient environment? Select all that apply
A. Have the patient ask all persons entering room “Are your hands clean?”
B. Clean the stethoscope with antiseptic wipe before and after use
C. Teach the patient cough etiquette
D. Maintain personal Hygiene
The RN notices paleness of the conjunctiva. Which laboratory finding would the Rn expect to be abnormal?
Hemoglobin (pallor decreased amount circulating blood)
What is an expected finding when the RN performs a physical assessment on a woman at 36 week of pregnancy? Select all that apply
A. Thin watery fluid leaking from the breast
B. Fundus height at xiphoid process
C. Dizzy when lying on her back
D. Fetal heart rate of 150 beats per minute
A patient arrives for a physical examination dressed with two (2) different shoes, wearing no socks, and a bathrobe over clothes. There is a 22 pound weight loss since last visit 6 months ago. When asked about attire, the patient does not respond. What mental health issue would the RN suspect this patient has?
Dementia (pt with cognitive impairment disorders have difficulty with self-care and inadequate nutrition)
What age specific accommodation is made by the RN when performing a physical assessment on a toddler?
Allow toddler to handle the stethoscope
Which technique is most appropriate for the RN to use when assessing skin turgor in an older adult?
Lightly pinch the skin over the sternum (or under the clavicle by lifting a fold of skin with the thumb and first finger)
Identify normal values for vital signs for:
A. Newborn (Temp. 36.8C (98.2F), Pulse 80 to 180, respiration’s 30 to 80, B/P 73/55)
B. 2 Year Old (Temp. 37.7C (99.9F), Pulse 80 to 140, respiration’s 20 to 40, B/P 90/55)
C. 7 Year Old (Temp. 37C (98.6F), Pulse 75 to 120, respiration’s 15 to 25, B/P 95/75)
D. Adult (Temp 37C (98.6F), Pulse 60 to 100, respiration’s 12 to 20, B/P 120/80)
According to the standards set by the national Heart, Lung, and Blood institute, identify the range a body mass index (BMI) value indicates an adult patient as:
A. Underweight (Less than 18.5)
B. Normal weight (18.6 to 24.9)
C. Overweight (25 to 29.9)
D. Obese (30 to 34.9)
- This question relates to analyzing the data from Mrs. Feinstein’s physical assessment. Base your answers on the physical assessment.
• What data from Mrs. Feinstein’s physical assessment indicates to the RN the presence of a current significant health problem?
A. Respiration’s at rest are 30 and shallow
B. Breath sounds diminished in bases
C. Reports pain when taking a deep breath
D. Oxygen Saturation level of 90% on 2L of O2 NC
- This question relates to analyzing the data from Mrs. Feinstein’s physical assessment. Base your answers on the physical assessment.
• Which physical findings from the skin assessment performed by the RN signify a significant health problem for Mrs. Feinstein?
Ecchymosis (hx of recent falls)
- This question relates to analyzing the data from Mrs. Feinstein’s physical assessment. Base your answers on the physical assessment.
• Which physical findings obtained by the RN indicates significant health issues for Mrs. Feinstein? Select all that apply
A. Heart rate of 100 beats per minute
B. B/P 80/56
C. Pain level of 6 on 10 scale with movement
- This question relates to analyzing the data from Mrs. Feinstein’s physical assessment. Base your answers on the physical assessment.
• Based on Mrs. Feinstein’s physical assessment, what body systems have current significant health problems? Select all that apply
A. Musculoskeletal
B. Cardiovascular
C. Respiratory
- This question relates to analyzing the data from Mrs. Feinstein’s physical assessment. Base your answers on the physical assessment.
• Mrs. Feinstein’s respirations are shallow and the rate is 30 breaths per minute. Based on this finding, which independent nursing intervention would be appropriate?
A. Keep in an upright position
Which action by the student nurse indicates to the RN that more teaching is needed about weighing an infant?
The infant is wearing a diaper
A patient with a two day history of vomiting comes to the Emergency Department and reports muscle weakness, leg cramps and fatigue. Which laboratory result does the RN anticipate to be abnormal?
Potassium
The RN anticipates an increase in which vital sign when a patient has an acute blood loss related to trauma?
Heart Rate
On physical exam the patient has bilateral pitting pedal edema. Which nursing assessment would be most accurate to help determine fluid volume excess?
Weigh the patient
Where should the RN place the stethoscope to best auscultate the middle lobe of the lung?
?
Place the components of the physical assessment for a child in correct order.
?
Which is the earliest clue observed by the RN that a patient has impaired mental status?
Unable to identify the season
A patient is admitted to the hospital with hypovolemia r/t severe diarrhea. What is a priority intervention to be initiated by the RN?
Place the patient on contact precautions
A patient with decreased hair on the lower legs, skin that is cool to touch, and thickened toenails indicates to the RN a chronic problem which chronic problem with which body system?
Cardiovascular
Which method should the RN use when measuring vital signs on a patient with an uncontrolled essential tremor?
?
A patient is admitted to the Emergency Department with altered mental status. Vital signs taken reveal: B/P 80/50, pulse 50 regular, and respiratory rate 6 breaths per minute. What additional information would be a priority for the RN to seek?
Opioid Use
Which assessments should the RN perform when evaluating a patient with peripheral artery insufficiency of the lower extremities? Select all that apply
?
Which clinical findings indicate to the RN that a child is experiencing an acute respiratory problem? Select all that apply
?
A patient’s systolic blood pressure is 30 mm Hg higher than the baseline. What could be the cause of a falsely elevated blood pressure reading?
Arm is unsupported during measurement
When performing an abdominal assessment on a patient who had an appendectomy 24 hours ago, which quadrant should the RN palpate last?
Lower right quadrant
What is the RN looking for when assessing the sclera of a dark skinned patient admitted with gall bladder disease?
Jaundice
How should the RN assess the hydration status of an acutely ill six month old infant with a 24 hour history of vomiting and water stools?
Anterior fontanel
What is best practice by the RN when obtaining a blood pressure and Korotkoff sounds are heard immediately after releasing the air in the cuff?
Release all the air and wait one minute before retaking
A patient with a history of frequent falls with fractures exhibits muscle weakness and bone pin. The RN suspects which nutritional deficiency?
Vitamin D
A woman who delivered baby 6 weeks ago is seeking care for extreme fatigue with frequent crying episodes. She appears tires, has slumped posture, and clothing appears unclean. What area requires a more detailed assessment by the RN?
Psychological
