Health & Physical Assessment in Nursing, 4e (Fenske/Watkins/Saunders/D'Amico/Barbarito)

Chapter 28 Complete Health Assessments: Putting the Pieces Together

1. The nurse is preparing to perform a physical examination on a client. Which should the nurse begin the assessment with?

1. Measurements.

2. Appearance and mental status.

3. Vital signs.

4. Inspect the skin, hair, and nails.

Page Ref: 734-735

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment

Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 28.1: Apply knowledge and skills to conduct a general survey and physical assessment of patients in the community setting.

MNL Learning Outcome: 28.1: Perform a health history and general survey for a patient in the community setting.

1. Which clients will require a rapid assessment? Select all that apply.

1. The client had an open appendectomy 2 days ago and is preparing to be discharged today.

2. The client was admitted to the hospital yesterday and is being treated with intravenous antibiotics for pneumonia.

3. The client has just been received from the Post Anesthesia Care Unit.

4. The nurse is new to the unit and is planning care for the four clients that have been assigned to the nurse.

5. The client begins to complain of difficulty breathing. The client's oxygen saturation level has decreased from 93% on room air this morning to 87%.

Page Ref: 740

Cognitive Level: Applying

Client Need & Sub: Safe and Effective Care Environment; Establishing Priorities

Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 28.5: Identify special considerations that guide assessments in community and hospital settings.

MNL Learning Outcome: 28.4: Perform a physical assessment for a patient a patient in the hospital setting.

1. The educator has completed discussing the topic of rapid assessment with the new nursing staff. Which statement by a nurse indicates that further education is required?

1. "The rapid assessment should last approximately 10 minutes."

2. "I should perform a rapid assessment for all of my assigned clients at the beginning of the shift to help me prioritize care."

3. "The rapid assessment will help me establish baseline data about the client."

4. "After I perform the rapid assessments on the clients I've been assigned, I can go back and get more information during my routine assessments."

Page Ref: 740

Cognitive Level: Applying

Client Need & Sub: Safe and Effective Care Environment; Establishing Priorities

Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 28.3: Outline the data to collect in the rapid assessment.

MNL Learning Outcome: 28.4: Perform a physical assessment for a patient a patient in the hospital setting.

1. During the assessment of a client's head and neck, the nurse observes the client's facial expressions and the face for symmetry and movement. Which cranial nerves is the nurse assessing? Select all that apply.

1. IV.

2. V.

3. VI.

4. VII.

5. VIII.

Page Ref: 735

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 28.1: Apply knowledge and skills to conduct a general survey and physical assessment of patients in the community setting.

MNL Learning Outcome: 28.2: Perform a physical assessment for a patient in the community setting.

1. The nurse is preparing to test the client's peripheral fields of vision. Which cranial nerve is the nurse assessing?

1. I.

2. II.

3. III.

4. IV.

Page Ref: 736

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention

Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 28.4: Outline the data to collect in the routine assessment.

MNL Learning Outcome: 28.2: Perform a physical assessment for a patient in the community setting.

1. The nurse is preparing to inspect the posterior chest of a client. Which should the nurse anticipate assessing? Select all that apply.

1. Respiratory excursion.

2. Symmetry.

3. Thoracic configuration.

4. Musculoskeletal development.

5. Upper extremity range of motion and movement against resistance.

Page Ref: 736

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Health Screening

Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 28.4: Outline the data to collect in the routine assessment.

MNL Learning Outcome: 28.2: Perform a physical assessment for a patient in the community setting.

1. The nurse is performing a rapid assessment for assigned clients. Which clients require immediate medical assistance? Select all that apply.

1. The client is pale and is breathing in a shallow manner.

2. The client that is experiencing dyspnea.

3. The client is rating his pain at a 3 out of a 10 on a pain scale.

4. The client is unable to follow directions.

5. The nurse determines that the client's level of consciousness is decreasing.

Page Ref: 741

Cognitive Level: Analyzing

Client Need & Sub: Safe and Effective Care Environment; Establishing Priorities

Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 28.5: Identify special considerations that guide assessments in community and hospital settings.

MNL Learning Outcome: 28.4: Perform a physical assessment for a patient a patient in the hospital setting.

1. The nurse performing a routine assessment is evaluating the client's activity. Which should the nurse include in the assessment? Select all that apply.

1. Environmental hazards.

2. Level of consciousness.

3. Presence and use of assistive devices.

4. Location of the call light.

5. Body posture and position.

Page Ref: 743

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention

Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 28.2: Apply knowledge and skills to conduct a general survey and physical assessment of patients in the hospital setting.

MNL Learning Outcome: 28.3: Perform a health history and general survey for a patient in the hospital setting.

1. The nurse has several clients that need routine assessments as well as prescriptions that are due to be administered. A few of the clients do not speak English. Which action should the nurse take?

1. Administer the prescriptions.

2. Locate a hospital interpreter.

3. Use the family member to interpret the information.

4. Perform the assessment and administer the prescriptions.

Page Ref: 743

Cognitive Level: Applying

Client Need & Sub: Safe and Effective Care Environment; Management of Care

Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 28.5: Identify special considerations that guide assessments in community and hospital settings.

MNL Learning Outcome: 28.3: Perform a health history and general survey for a patient in the hospital setting.

1. The nurse is preparing to assess a client's skin. Which techniques should the nurse be prepared to perform? Select all that apply.

1. Inspection.

2. Percussion.

3. Measure.

4. Palpation.

5. Auscultation.

Page Ref: 735

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment

Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 28.4: Outline the data to collect in the routine assessment.

MNL Learning Outcome: 28.2: Perform a physical assessment for a patient in the community setting.

1. Which assessment should the nurse perform after assessing a client's appearance and mental status?

1. Assess vital signs.

2. Obtain a height and weight.

3. Instruct the client to change into a gown.

4. Explain the purpose of the health assessment.

Page Ref: 734

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Health Screening

Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 28.1: Apply knowledge and skills to conduct a general survey and physical assessment of patients in the community setting.

MNL Learning Outcome: 28.2: Perform a physical assessment for a patient in the community setting.

1. The nurse is preparing to assess the pain of a young child. Which initial assessment is most appropriate?

1. Ask the parent if the child has been experiencing pain.

2. Use a numerical pain rating scale.

3. Use a FACES pain rating scale.

4. Ask the child to point to any area that is hurting.

Page Ref: 735

Cognitive Level: Applying

Client Need & Sub: Psychosocial Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 28.2: Apply knowledge and skills to conduct a general survey and physical assessment of patients in the hospital setting.

MNL Learning Outcome: 28.3: Perform a health history and general survey for a patient in the hospital setting.

1. Which equipment should the nurse use to evaluate cranial nerve VIII?

1. Safety pin.

2. Pen light.

3. Tuning fork.

4. Wisp of cotton.

Page Ref: 736

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment

Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 28.1: Apply knowledge and skills to conduct a general survey and physical assessment of patients in the community setting.

MNL Learning Outcome: 28.2: Perform a physical assessment for a patient in the community setting.

1. The nurse is preparing to assess a client's mouth and throat. Which cranial nerves should the nurse anticipate testing? Select all that apply.

1. X.

2. IX.

3. XI.

4. VII.

5. XII.

Page Ref: 736

Cognitive Level: Analyzing

Client Need & Sub: Health Promotion and Maintenance; Health Screening

Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 28.4: Outline the data to collect in the routine assessment.

MNL Learning Outcome: 28.2: Perform a physical assessment for a patient in the community setting.

1. The nurse is preparing to assess the pulmonic area of a client's heart. Which anatomical location should the nurse place the bell of the stethoscope?

1. Fourth intercostal space left sternal edge.

2. Second intercostal space right sternal edge.

3. Second intercostal space left sternal edge.

4. Fifth intercostal space at the sternal border.

Page Ref: 737

Cognitive Level: Understanding

Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment

Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 28.4: Outline the data to collect in the routine assessment.

MNL Learning Outcome: 28.2: Perform a physical assessment for a patient in the community setting.

1. The nurse is preparing to document the findings of an assessment. Which concepts should the nurse's documentation reflect? Select all that apply.

1. Agency policy.

2. Standard precautions.

3. Patient safety.

4. Primary and secondary data.

5. Professional standards.

Page Ref: 738

Cognitive Level: Applying

Client Need & Sub: Safe and Effective Care Environment; Concepts of Management

Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 28.2: Apply knowledge and skills to conduct a general survey and physical assessment of patients in the hospital setting.

MNL Learning Outcome: 28.4: Perform a physical assessment for a patient a patient in the hospital setting.

1. The nurse is preparing to assess the cerebellar function of a client. Which testing should the nurse anticipate performing? Select all that apply.

1. Graphesthesia.

2. Finger to nose test.

3. Stereognosis.

4. Heel-shin test.

5. Bilateral tendon reflexes.

Page Ref: 738

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Health Screening

Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 28.4: Outline the data to collect in the routine assessment.

MNL Learning Outcome: 28.2: Perform a physical assessment for a patient in the community setting.

1. The nurse is preparing to palpate an apical pulse. For which findings should the nurse assess the pulse? Select all that apply.

1. Heaves.

2. Intensity.

3. Rate.

4. Quality.

5. Location.

Page Ref: 737

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Health Screening

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 28.4: Outline the data to collect in the routine assessment.

MNL Learning Outcome: 28.2: Perform a physical assessment for a patient in the community setting.

1. The nurse is preparing to perform a rapid assessment. Which should the nurse understand is the primary technique that will be used during the assessment?

1. Observation.

2. Inspection.

3. Auscultation.

4. Palpation.

Page Ref: 741

Cognitive Level: Analyzing

Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 28.3: Outline the data to collect in the rapid assessment.

MNL Learning Outcome: 28.4: Perform a physical assessment for a patient a patient in the hospital setting.

1. The educator is discussing prioritizing nursing actions with a nurse. Which statement made by the nurse indicates further teaching is needed?

1. "Nursing actions are prioritized after a rapid assessment."

2. "Nursing actions are prioritized after the data has been collected."

3. "Nursing actions are prioritized after a comprehensive assessment is obtained."

4. "Nursing actions are prioritized after obtaining report on the clients."

Page Ref: 740

Cognitive Level: Applying

Client Need & Sub: Safe and Effective Care Environment; Establishing Priorities

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 28.2: Apply knowledge and skills to conduct a general survey and physical assessment of patients in the hospital setting.

MNL Learning Outcome: 28.3: Perform a health history and general survey for a patient in the hospital setting.

1. The nurse is preparing to perform a rapid assessment. Which initial action should the nurse take?

1. Enter the room.

2. Perform hand hygiene

3. Note isolation precautions, latex allergies, or fall precautions.

4. Identify yourself and explain that you will be providing care for a given time period.

Page Ref: 740-741

Cognitive Level: Analyzing

Client Need & Sub: Safe and Effective Care Environment; Establishing Priorities

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 28.3: Outline the data to collect in the rapid assessment.

MNL Learning Outcome: 28.3: Perform a health history and general survey for a patient in the hospital setting.

1. A client tells the nurse they do want the alarms turned off on their infusion pump. Which response should the nurse provide?

1. "The alarms are on for your safety."

2. "Let me evaluate why your alarms are going off."

3. "I will turn down the sound so the alarms do not bother you."

4. "It is against the hospital policy to turn off the alarms."

Page Ref: 740

Cognitive Level: Applying

Client Need & Sub: Safety and Infection Control; Accident/Error/Injury Prevention

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 28.2: Apply knowledge and skills to conduct a general survey and physical assessment of patients in the hospital setting.

MNL Learning Outcome: 28.4: Perform a physical assessment for a patient a patient in the hospital setting.

1. The educator is preparing to review the hospital National Patient Safety Goals (NPSG) with a nurse. Which goals should the educator include when discussing the NPSG of using medicines safely? Select all that apply.

1. Review new medications.

2. Document reactions to medications.

3. Record and report medication information.

4. Provide written discharge instructions for each medication.

5. Confirm the client's mediation regimen with the healthcare provider.

Page Ref: 740

Cognitive Level: Applying

Client Need & Sub: Safety and Infection Control; Accident/Error/Injury Prevention

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 28.2: Apply knowledge and skills to conduct a general survey and physical assessment of patients in the hospital setting.

MNL Learning Outcome: 28.3: Perform a health history and general survey for a patient in the hospital setting.

1. The nurse notices that a client has difficulty moving their head. Which cranial nerve should the nurse assess?

1. X.

2. IX.

3. VI.

4. XI.

Page Ref: 736

Cognitive Level: Applying

Client Need & Sub: Physiological Integrity; Mobility/Immobility

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 28.1: Apply knowledge and skills to conduct a general survey and physical assessment of patients in the community setting.

MNL Learning Outcome: 28.1: Perform a health history and general survey for a patient in the community setting.

1. The nurse is preparing to perform a breast assessment for an adult female. Which techniques should the nurse anticipate using during the assessment? Select all that apply.

1. Instruct the client to flex their pectoral muscles.

2. Instruct the client to lean forward.

3. Instruct the client to press their hands on their hips.

4. Instruct the client to lift their arms over their head.

5. Instruct the client to push their upper extremities against resistance.

Page Ref: 736

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 28.1: Apply knowledge and skills to conduct a general survey and physical assessment of patients in the community setting.

MNL Learning Outcome: 28.2: Perform a physical assessment for a patient in the community setting.

1. The nurse is preparing to palpate the inguinal region of a client. For which should the nurse assess the area for? Select all that apply.

1. Bruits.

2. Pulses.

3. Aneurysms.

4. Hernias.

5. Lymph nodes.

Page Ref: 737

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 28.1: Apply knowledge and skills to conduct a general survey and physical assessment of patients in the community setting.

MNL Learning Outcome: 28.2: Perform a physical assessment for a patient in the community setting.

1. The nurse is planning to integrate the Romberg test in a client's assessment. During which system assessment should the nurse consider integrating the test?

1. Musculoskeletal.

2. Neurologic system.

3. Mental status.

4. Head, neck, and lymphatics.

Page Ref: 737

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 28.4: Outline the data to collect in the routine assessment.

MNL Learning Outcome: 28.2: Perform a physical assessment for a patient in the community setting.

1. The nurse is preparing to perform a rapid assessment. Which should the nurse plan on including in the assessment? Select all that apply.

1. Vital signs.

2. General appearance.

3. Client identification.

4. Facial expression.

5. Speech for clarity.

Page Ref: 741

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 28.3: Outline the data to collect in the rapid assessment.

MNL Learning Outcome: 28.2: Perform a physical assessment for a patient in the community setting.

1. Which is the primary purpose for the documentation of a rapid assessment? Select all that apply.

1. Create a care plan for the client.

2. Establish a baseline for ongoing care.

3. Prioritize nursing actions.

4. Communication tool for the client's condition.

5. Prioritize nursing interventions.

Page Ref: 740

Cognitive Level: Applying

Client Need & Sub: Safe and Effective Care Environment; Concepts of Management

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 28.3: Outline the data to collect in the rapid assessment.

MNL Learning Outcome: 28.4: Perform a physical assessment for a patient a patient in the hospital setting.

1. Which should the nurse include when performing a routine assessment of the abdomen? Select all that apply.

1. Skin temperature.

2. Urine output.

3. Last bowel movement.

4. Auscultation of vascular sounds.

5. Auscultation of bowel sounds.

Page Ref: 742

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment

Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 28.4: Outline the data to collect in the routine assessment.

MNL Learning Outcome: 28.2: Perform a physical assessment for a patient in the community setting.