Head to toe EAQ-final

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Which physical examination technique is the nurse performing when listening to heart sounds?

Auscultation (correct)

Which position is preferred for performing an examination of the female genitourinary tract?

Lithotomy (correct)

Which assessment is performed first while the nurse initiates the general survey?

Inspecting appearance and behavior. (correct)

Which physical assessment technique is the nurse using when tapping a patients skin with the fingertips to vibrate underlying tissues and organs

Percussion Signup and view all the answers

which area is the nurse preparing to assess when instructing a patient to assume the Lithotomy position?

Genitalia and Genital Tract Signup and view all the answers

Which action during palpation made by the new nurse would require correction by the charge nurse?

Palpates tender areas first. Signup and view all the answers

Which action would the nurse take when preparing to perform a physical examination on an adult patient?

Maintain the appropriate room temperature. Signup and view all the answers

Which position would the nurse ask the patient to assume to examine the rectum?

Knee-Chest Signup and view all the answers

Which position provides easy access to a patients pulse sites during a physical examination?

Supine Signup and view all the answers

Which scale is used to weight infants?

Platform Signup and view all the answers

Which action would the nurse take when preparing to assess a patients abdomen, genitalia, and rectum?

Allow the patient to use the restroom. Signup and view all the answers

Which statement made by the nurse indicates a correct understanding of physical examination positioning?

While assessing a patients heart, I'll ask the patient to assume the lateral recumbent position Signup and view all the answers

A nurse has to position a patient in the lithotomy position. Which statement about the lithotomy position is true? Select all that apply.

This position facilitates insertion of vaginal speculum. Signup and view all the answers

Which behavioral change would the nurse observe in an intimate partner violence (IPV) victim?

A sense of helplessness Signup and view all the answers

While assessing a victim of intimate partner violence, which common physical indicator would the nurse anticipate?

Human bite marks Signup and view all the answers

At what angle would the nurse elevate the head of the examination table so that the patient is comfortable during the physical assessment?

30 Signup and view all the answers

Which action would the nurse take during inspection to get the best results?

Make sure that adequate lighting is available Signup and view all the answers

Which position facilitates assessing the head and neck?

Sitting Signup and view all the answers

Which portion of the hand is used to assess the thickness of skin?

Palmar surface Signup and view all the answers

Which question would the nurse ask as part of the CAGE questionnaire?

"Have you ever felt bad or guilty about your drinking or drug use?" Signup and view all the answers

Which behavioral finding would alert the nurse to possible older-adult abuse?

Physical and/or cognitive impairment Signup and view all the answers

Which finding is common among victims of intimate partner violence (IPV)?

Change in voice Signup and view all the answers

Which parameter can be measured by lightly grasping the body part with the fingertips?

Turgor, elasticity Signup and view all the answers

Which technique indicates a nurse has a correct understanding of using palpation to examine different areas of the body?

Use the palmar surface of the hand to assess excursion of the thorax Signup and view all the answers

Which information would the nurse share with a young mother to help her quickly evaluate whether her child has a fever?

Place the back of the hand against the child's forehead Signup and view all the answers

Which finding would alert the nurse to possible intimate partner violence. SATA.

Trouble Swallowing Signup and view all the answers

Which question would the nurse ask a patient according the the CAGE questionnaire to assess alcohol abuse? SATA

"Do you feel guilty about drinking?" Signup and view all the answers

Which factor affects a patient's ability to assume various positions during a physical examination?

Mobility Signup and view all the answers

Which statement indicates a correct understanding of the difference between percussion and palpitation?

"Percussion is the use of only the fingers to vibrate the underlying tissues and organs, where as palpation involves the use of different parts of the hand to assess body parts." Signup and view all the answers

When caring for an adult who has a history of tremors and vomiting, which patient information would support a nurse's suspicion that the patient is potentially abusing alcohol?

Expresses both guilt and annoyance surrounding drinking. Signup and view all the answers

When the patient's urine smells of ammonia, which condition with the nurse assess for?

Renal failure Signup and view all the answers

Which position is usually recommended when the nurse is assessing a patient's heart and lungs?

Sitting Signup and view all the answers

Which factor causes body odor?

Poor hygiene Signup and view all the answers

Which area of the hand with the nurse use in palpating the liver?

Entire Palmar surface of the hand Signup and view all the answers

physical examination positioning

Heart = Lateral recumbent Genital tract = lithotomy Breast = spine Musculoskeletal system = prone Signup and view all the answers

To which physical technique is the nurse referring to when stating "you need to have good visual, hearing, and olfactory abilities to perform this technique"

Inspection Signup and view all the answers

Which action with the nurse take while examining a child?

Ask a child's parents open ended questions Signup and view all the answers

Which patient assessment finding would alert the nurse to substance abuse in an adult?

Reports sleep disturbance and insomnia Signup and view all the answers

Which parameter would the nurse assess during the general survey? Select all that apply. One, some, or all responses may be correct.

Age Signup and view all the answers

As a nurse prepares to provide morning care and treatments, it is important to question a patient about a latex allergy before which intervention? (Select all that apply.)

Applying adhesive tape to anchor a nasogastric tube Signup and view all the answers

Which finding would the nurse observe in an older adult who is a victim of abuse? SATA

Bedsores Signup and view all the answers

Arrange in the correct order the events that occur when a nurse measures the length of a infant.

Position the infant supine on a firm surface = 1 records the infants length to the nearest 0.5 cm = 4 use a tape measure to measure the length from the head to the bottom of the feet = 3 Hold the infants head while making the infants leg straight at the knees = 2 Signup and view all the answers

Which cancer screening is recommended for a 30 year old female patient? SATA

Uterine Signup and view all the answers

Which action made by the nurse during palpation will help promote relaxation in an anxious patient?

Ask the patient to take slow, deep breaths Signup and view all the answers

Which patient position promotes relaxation of abdominal muscles during a physical examination?

Dorsal recumbent Signup and view all the answers

Which action made by a nurse during psychological preparation of a patient before a physical examination can limit the patient's communication ability?

Exhibiting a quiet, formal behavior Signup and view all the answers

Which information would the nurse include in a teaching session to new orienting nurses about keeping a physical examination well organized?

Carry out painful procedures at the end of the examination Signup and view all the answers

Which behavioral finding in children indicates possible abuse?

Regressed behavior Signup and view all the answers

The nurse would further assess for which condition when a patient's breath has a sweet and fruity odor?

Diabetic acidosis Signup and view all the answers

Which scale would be used to weigh an obese patient who had extensive surgery and is non-weight bearing for 24 hours? SATA

bed Signup and view all the answers