Head to Toe assessment

ADPIEAnswer - Assessment Diagnosis Planning Implementation Evaluation True/False: There is only one way to perform a head to toe examinationAnswer - FALSE - there is NO "one way" to perform it When performing an exam on an adult, which body region/area should be saved for last? For neonates and infants?Answer - adults - examine genitalia last neonates, infants - examine ears last True/False: Head to Toe exams should be smooth and logical.Answer - TRUE Hospitalized patients do not receive a complete head to toe exam every 24 hours; they require _______ exam at least every 8 hours.Answer - specialized or focused exam (**more often if in ICU**) When are head to toe examinations performed?Answer - upon patient's first entry in an outpatient setting and during annual check ups A patient presents to the emergency department complaining of abdominal pain. Which component of the health examination should the nurse consider doing first? A. The nurse should get a complete history on the patient prior to the abdominal examination. B. The nurse should get a detailed history of the pain and perform a focused assessment. C. The nurse should examine the abdomen first, then ask pertinent questions related to the pain. D. The nurse should document the chief complaint and perform a head‐to‐toe examination.Answer - B. The nurse should get a detailed history of the pain and perform a focused assessment. To conserve the patient's energy, what should you do (or not do) when performing a complete exam?Answer - Minimize the number of times the patient has to change positions Biographic dataAnswer - name address marital status source of info - patient, parent, other Health HistoryAnswer - childhood and chronic illnesses accidents hospitalizations OB hx immunizations last exam allergies and current meds When asking questions regarding family hx, what is the key information?Answer - parents health ROS: general or detailed?Answer - detailed The nurse is completing a ROS during a health assessment. The nurse knows that the ROS is considered: A. factual information that incorporates objective information. B. a systematic approach to obtaining objective information. C. a systematic approach to obtaining subjective information. D. an important component of the social history.Answer - C. a systematic approach to obtaining subjective information. Functional AssessmentAnswer - self-concept activity and exercise sleep and rest nutrition alcohol interpersonal relationships coping and stress management Where should the patient be when the skin is being examined? What is assessed during a basic check of the skin?Answer - sitting on the exam table -- examine both hands and the nails...continue to examine the skin throughout the assessment What cranial nerve can be assessed while observing the face and facial expressions?Answer - cranial nerve 7 What cranial nerve can be assessed while performing the confrontation test to test visual fields?Answer - cranial nerve 2 Which cranial nerve can be assessed while checking the 6 cardinal positions of gaze and the corneal light reflex?Answer - cranial nerves 3, 4, 6 What is the cue to patients when performing the whisper test? Which cranial nerve is this a test of?Answer - cue = "Repeat what I say." test of cranial nerve 8 When using a tongue blade and penlight to test their gag reflex, which cranial nerve is this also testing?Answer - cranial nerve 9 and 10 When cuing the patient to stick out their tongue, which cranial nerve is also assessed?Answer - cranial nerve 12 When assessing a patient's ROM & muscle strength against resistance, the nurse asks the patient to shrug his shoulders. Which cranial nerve is also being assessed with this test?Answer - cranial nerve 11 Is the thyroid palpated anteriorly or posteriorly?Answer - posteriorly What should the patient do to help assess for tactile fremitus?Answer - repeat "99" What are the posterior lung sounds?Answer - bronchovesicular and vesicular What are the anterior lung sounds?Answer - vesicular, bronchovesicular, bronchial When examining a female's breasts, in what position should she be in?Answer - supine (lying flat or 30 degrees) When examining a male's breasts, in what position should he be in?Answer - males can remain sitting up during the exam In what position is the patient to inspect neck vessels (i.e. Jugular vein)Answer - supine - at a 30 degree angle at least What side of the stethoscope is used to auscultate S1 and S2? Which side for S3 and S4 and murmurs?Answer - S1, S2 = diaphragm S3, S4, murmurs = bell Resonance is generally heard over which area? And tympany is heard over what?Answer - resonance = over lungs tympany = over air How does an examiner inspect for scoliosis?Answer - by standing behind the patient and ask the patient to bend over and touch their toes What position is a female in to inspect the cervix and vaginal walls and procure specimens?Answer - lithotomy At what age do children begin to have their BPs assessed using cuffs?Answer - age 3 or older True/False: When a baby is being fussy, it is best just to continue with trying to measure their head circumference.Answer - FALSE - if a baby is fussy, wait until the end of the exam to measure head circumference What is considered the "worst" part of an exam to a small child? When should it be assessed?Answer - ears -- assess last Ortolani signAnswer - assesses hip stability -- a click/clunk means the hip needs to be reduced Denver IIAnswer - monitors development - assesses gait, jumping, hopping, building a block tower, throwing a ball When assessing a child's abdomen, how should the child be positioned?Answer - sitting on exam table or on parent's lap True/False: When assessing the mouth and throat of a young child, the tongue blade should only be used as a last resort.Answer - TRUE What are some strategies to have a successful assessment of the ears if a young child is apprehensive?Answer - get parents to help assist use puppet allow patients to "play" with otoscope Head to Toe exams are generally the same -- however, be aware of _____ _____.Answer - developmental considerations SOAPAnswer - Subjective Objective Assessment Plan When completing a health assessment of an older adult with mobility problems, the sequence should: A) begin with the physical examination followed by the health history. B) be from head to toe to prevent missing any important assessments. C) be arranged to minimize the number of position changes for the patient and the examiner. D) start with the most invasive assessments.Answer - C) be arranged to minimize the number of position changes for the patient and the examiner. Which of the following assessments should be performed last on a 4‐week‐old infant? A) Auscultate breath sounds B) Otoscopic examination of the tympanic membrane C) Weight, length, and head circumference D) Palpate fontanels and suture linesAnswer - B) Otoscopic examination of the tympanic membrane Which of the following tests would be used to screen a young child for developmental delays? A) Denver II test B) Snellen test C) Cerebellar function test D) Ortolani testAnswer - A) Denver II test To gain the trust of a young child, the examiner should: A) sit down and hold the child during the examination. B) focus on the child by asking him or her questions. C) ask the parent to stay in the waiting area. D) first focus on the parent as the child plays with a toy.Answer - A) sit down and hold the child during the examination. Which approach to a complete physical assessment should be used for an adolescent? A) Head‐to‐toe approach B) Focused approach C) Systems approach divided into 2 or 3 visits D) Problem‐centered approachAnswer - A) Head‐to‐toe approach The examiner is assessing the extraocular muscles. Which of the following tests would be inappropriate? A) corneal light reflex B) six cardinal positions of gaze C) confrontation test D) cranial nerve III, IV, and VI testingAnswer - A) corneal light reflex During auscultation of breath sounds, the examiner should: A) compare sounds on the left and right side. B) listen with the bell of the stethoscope. C) instruct the patient to breathe in and out through the nose. D) only listen to the posterior chest for adventitious sounds.Answer - A) compare sounds on the left and right side. The examiner should auscultate for carotid bruits if the patient: A) is middle‐aged or older. B) is pregnant and has gestational diabetes. C) complains of abdominal pain. D) has enlarged, tender cervical lymph nodes.Answer - A) is middle‐aged or older. The patient sways and starts to fall when asked to stand with feet together and arms at sides with the eyes closed. This finding would be documented as a: A) positive Babinski sign. B) positive Ortolani sign. C) positive Romberg sign. D) positive modified Allen test.Answer - C) positive Romberg sign. The blood pressure readings for a 42‐year‐old male for the past two outpatient visits were 158/92 mm Hg and 146/94 mm Hg. The examiner would interpret the findings as: A) normal. B) prehypertension. C) stage 1 hypertension. D) stage 2 hypertension.Answer - C) stage 1 hypertension.