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
