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Health Assessment for Nursing Practice 6th Edition Wilson Test Bank

Chapter 22: Conducting a Head-to-Toe Examination Wilson: Health Assessment for Nursing Practice, 6th Edition MULTIPLE CHOICE 1. When does the health assessment begin? a. 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

When the nurse and patient first meet, the nurse begins collecting data about the patient. Before options B to D, the nurse began collecting data about the patient, such as gait, posture, and hygiene. DIF: Cognitive Level: Understand REF: p. 475 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. 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

Palpation of upper extremities is performed in a routine head-to-toe examination. Lymph nodes are not palpated unless indicated. The data in options C and D are not routinely assessed unless indicated. DIF: Cognitive Level: Understand REF: p. 478 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. b. Muscle strength c. Heart sounds d. e. f. Position of the trachea ANS: A, D, E

Health Assessment for Nursing Practice 6th Edition Wilson Test Bank The data in options A, D, and E are observed during the general survey as the patient enters the examination area and greets the nurse. 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: p. 475 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems 2. Which techniques does a nurse use routinely to collect data when assessing a patient’s

posterior thorax? (Select all that apply.) a. b. Percussion of the costovertebral angle bilaterally c. d. Percussion of the posterior and lateral thorax for resonance e. f. I ANS: A, C, E, F

Options A, C, E, and F are performed in a routine head-to-toe assessment of the posterior thorax. Percussion of the costovertebral angle bilaterally is not performed unless indicated. For example, when the patient has a kidney disorder, percussion of the posterior and lateral thorax for resonance is not performed unless indicated. DIF: Cognitive Level: Apply REF: p. 478 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Aging Process 3. 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. c. d. e. Palpation of the anterior chest wall for thoracic expansion f. ANS: B, C, D, F

Options B, C, D, and F are performed in a routine head-to-toe assessment of the anterior thorax. Palpation of the thorax for fremitus and palpation of the anterior chest wall for thoracic expansion are not performed unless indicated. DIF: Cognitive Level: Apply REF: p. 478 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Aging Process 4. Which techniques does a nurse use routinely to collect data when assessing the abdomen of a

patient? (Select all that apply.)

Health Assessment for Nursing Practice 6th Edition Wilson Test Bank a. Testing for presence of abdominal reflexes b. c. Percussing in all quadrants for tone d. f.

Deeply palpating for tenderness, guarding, and masses

ANS: B, D, E

Options B, D, and E are performed in a routine head-to-toe assessment of the abdomen. Testing for abdominal reflexes for presence, percussing in all quadrants for tone, and deeply palpating for tenderness, guarding, and masses are not performed unless indicated. DIF: Cognitive Level: Apply REF: p. 479 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: Potential for Alteration in Body Systems 5. 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 ANS: A, C

Options A and C are performed in a routine head-to-toe assessment of the lower extremities. Assessing for knee stability with the drawer test, McMurray test, or Apley test is not performed unless indicated by knee instability. Assessing for nerve root compression with straight leg raises is not performed unless indicated. Palpating hips for stability and tenderness is not performed unless the patient has unstable hips. Testing for patellar and Achilles deep tendon reflexes bilaterally is not performed unless indicated. DIF: Cognitive Level: Apply

REF: p. 479...