A nurse is performing an assessment within the legal parameters of assessment and diagnosis. These legal guidelines would be specified in which of the following?
A) The state's Nurse Practice Act
When preparing to do a comprehensive health assessment, the nurse obtains the client's
permission based on an understanding of which of the following principles?
D) The client has the right to refuse the assessment.
The nurse is completing the general survey. In addition to observing the client's
appearance, the nurse would assess which of the following?
C) Vital signs
A novice nurse is practicing how to complete a comprehensive assessment to gain
confidence and skill. Which of the following would be most important for the nurse to
remember?
B) Establish a routine for the assessment.
When analyzing data related to a client's behavior, the nurse should compare the
observations with which of the following?
C) The client's developmental stage
When performing a client's head-to-toe assessment, during which part would the nurse assess the motor function of cranial nerve VII?
D) Head and face assessment
When documenting a comprehensive assessment, which statement would the nurse
record as the reason for seeking health care?
D) ìI haven't had a checkup in over 5 years.î
The nurse would test for stereognosis during which part of the comprehensive exam?
A) Arms, hands, and fingers
A nurse has finished examining a client's nose and sinuses and is about to examine the
client's mouth and throat. Which of the following would be most important for the nurse
to do?
D) Put on gloves
When assessing a client's mental status, which of the following would the nurse assess?
Select all that apply.
B) Remote memory
C) Speech
D) Abstract reasoning
E) Judgment
The nurse is performing a head-to-toe assessment of a client. Which of the following
would be an example of information obtained during the review of the client's body
systems?
A) Wears dentures; denies problems with eating, chewing, and swallowing.
A nurse is preparing to complete a comprehensive health assessment on a female client.
Prior to beginning the assessment, the client states, ìI'm really having a good deal of
pain in my hip now.î Which of the following would be most appropriate for the nurse to
do?
D) Delay the full exam until the client's pain has been addressed.
A nurse is performing a head-to-toe assessment and is preparing to examine the client's
ears. Which equipment would the nurse need to have readily available?
B) Tuning fork
A nurse should assess the client's epitrochlear lymph nodes when assessing which of the
following?
D) Arms
The nurse will palpate a client's axillae during a head-to-toe assessment. The nurse
should combine this with examination of which area?
B) Breasts
The nurse is palpating the client's tonsillar, submandibular, and submental lymph nodes.
The nurse is most likely examining which area during a comprehensive assessment?
C) Neck
During which part of the comprehensive assessment would the nurse auscultate after inspecting but before percussing?
D) Abdomen
When assessing the client's legs, feet, and toes, which pulses would the nurse expect to
palpate? Select all that apply.
C) Femoral
D) Dorsalis pedis
E) Popliteal
F) Posterior tibial
The nurse is documenting findings of a comprehensive assessment. Which statement would be categorized as part of the general survey?
A) Hair neat and clean with white and gray streaks; no scalp lesions noted
B) Sclera white; conjunctiva slightly reddened without lesions
C) Client alert and cooperative; sitting comfortably on chair with hands in lap
D) Head symmetrically round; neck nontender with full range of motion
C) Client alert and cooperative; sitting comfortably on chair with hands in lap
A nurse is preparing to complete a comprehensive assessment on a client. When
collecting objective data, which of the following should the nurse do first?
A) Observe the client's overall appearance.
The nurse is preparing to perform a comprehensive assessment of a client who has a diagnosis of Alzheimer's disease. How should the nurse accommodate the client's cognitive deficit when obtaining the client's health history?
A) Obtain the client's history from the electronic health record and proceed with physical assessment.
B) Focus the assessment on aspects of the client's history that he is able to accurately describe.
C) Perform the assessment as quickly as possible in order to minimize the client's stress.
D) Supplement the client's statements with data from the client's friends and family.
D) Supplement the client's statements with data from the client's friends and family.
The nurse is preparing to gather equipment prior to a client's head-to-toe assessment.
The nurse's selection of equipment should be based primarily on what variable?
C) The client's health needs
The nurse is performing an abbreviated head-to-toe assessment of a hospital client.
What question should the nurse ask when assessing the client's level of consciousness?
A) ìCan you tell me the current month and year?î
The nurse is performing an abbreviated head-to-toe assessment of a client. When the
nurse asks the client about his pain, the client states, ìMy stomach's really killing me
right now.î How should the nurse first respond to this client's statement?
assessment
A) Ask the client to rate his pain on a 0-to-10 scale
The nurse is completing an abbreviated head-to-toe assessment of a client. Which of the
following should the nurse perform when assessing the client's eyes?
D) Test the client's pupillary response to light.
A client has been recovering from surgery in the hospital, and the nurse is beginning a
shift by conducting an abbreviated head-to-toe assessment. How should the nurse assess
the client's bowel sounds?
A) Auscultate for bowel sounds in each of the client's four abdominal quadrants.
The nurse is planning the comprehensive head-to-toe assessment of a client. What
assessment should the nurse usually conduct last?
B) Assessment of the genitalia and rectum
The nurse is using the COLDSPA mnemonic during the client's head-to-toe assessment.
This tool will allow the nurse to address what component of assessment?
A) The client's present health concern
The nurse is assessing a client's judgment during a comprehensive head-to-toe
assessment. How can the nurse best appraise this aspect of cognitive function?
C) ìWhat would you do if you found a stamped, addressed envelope on the ground?î
The nurse should ensure that a Doppler ultrasound is available when performing which of the following assessments?
