LAB: Clinical Examination, Head-to-toe & Focused Assessment

Topics:
1. Complete physical and health assessment
2. Clinical head-to-toe
3. Focused assessments
Read:
1. Potter & Perry Chapter 32 : Health Assessment & Physical Examination
2. Pocket Companion for Physical Examination and Health Assessment,
Canadian ed (2nd) Jarvis: page 33-34
Videos to watch:
https://www.youtube.com/watch?v=9Fxb8icOTOA
To watch prior to coming to lab

Pre-lab assignments:
1. Complete glossary
Items to bring to lab:

1. Lab book
2. Jarvis Handbook
3. Stethoscope

1. Review material and check for knowledge gaps

2. Schedule an appointment to practice caregiving skills in practice lab

Study for quiz

CWA PROGRAM – Clinical Examination & Focused Assessment LAB (3h)

Objectives:
Complete health assessment:
 Identify the different components of a complete health assessment
 Practice and compare the difference in data collection between a general survey,
physical examination, nursing health history and focused assessment
 Define and describe key terms related to a complete health assessment

Physical Assessment
 Identify data to collect from the nursing history before a physical examination
 Discuss the purposes of physical assessment
 Describe basic physical examination techniques.

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  Describe the essential techniques used in the physical examination of body systems and
regions.
 Explain the specific characteristics to be assessed during the physical examination of
body systems and regions.
 Demonstrate the techniques used with each physical assessment skill.
 Explain the rationale for the techniques and procedures of physical examination
 Describe physical measurements and expected findings made in assessing each body
system of an adult.
 Discuss normal physical findings in a young, a middle-aged, and an older adult.
 Identify how nurses use physical assessment skills during routine nursing care
 Document physical examination findings using the standard format, appropriate
terminology, physical examination criteria, and principles of recording.

Focused Assessment
 Distinguish the difference between a complete physical examination (i.e. head-to-toe
assessment) and a focused assessment based on the client’s specific needs
 Discuss and identify different components of a detailed focused assessment
 Conduct a detailed nursing assessment of specific body system(s) related to presenting
problems/client’s specific needs
 Describe how to implement techniques and procedures of a physical examination into a
focused assessment
 Document focused assessment findings using standard format, appropriate terminology,
physical examination criteria, and principles of recording.
 Discuss and carry out a focused assessment based on abnormal findings, clinical data
and client’s specific needs

Glossary

Alopecia
Anterior
Auscultation
Bilateral
Body mass index
(BMI)
Capillary refill
Cerumen
Cochlea
Consolidation

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 Clubbing
Distal
Dorsal
Edema
Ecchymosis
Goiter
Health history
Inferior
Inspection
Lymphadenopathy
Objective data
Palpation
Percussion
Peristalsis
PERRLA
Point of maximum
impulse (PMI)
Posterior
Proximal
Rebound tenderness
Subjective data
Superior
Tenting
Turgor
Unilateral

Health Assessment:

A health assessment is a systematic method of collecting and analyzing data for the purpose of
planning patient-centered care. Nurses are often the first person who comes into the contact
with a patient. Therefore, it is extremely important for nurses to have strong assessment skills
to detect subtle changes in the patient’s condition, as well as, their overall wellbeing. The
nurse must use their critical thinking and ability to interpret data to determine the meaning of
client’s behaviour and physiological status. The nurse uses many types of assessment skills to
obtain their data such as: physical assessment, complete health assessment, nursing history,
general surveys, and interviews.

A complete health assessment consists of a comprehensive health history and a complete

physical assessment.

A health history is the gathering of data on a patient to help determine the patient’s concerns
and assist them to find a resolution for their concerns. The success of the health history is
dependent on a partnership between the nurse and the patient. It is very important for the

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nurse to use relational nursing practices, build therapeutic relationships and earn trust with
their patient.
Components of the health history consists the following information:

Biographical Data
 Name
 Address, phone number
 Birth date, birthplace
 Sex
 Marital status
 Race, ethnic origin
 Occupation
 Dependents
 Source of history

Current health status

 Record of the reason for seeking care
 Analysis of symptoms
 Records current medications patient is taking

Past health history

 Childhood illnesses
 Surgeries, hospitalizations
 Serious injuries
 Medical problems
 Medications
 Allergies
 Immunizations
 Recent travel or military service

Family history
 Includes the age and health of blood relatives (grandparents, parents, siblings)
 Age and cause of death of blood relatives
 Age and health of spouse and children
 Any family history of heart disease, hypertension, stroke diabetes, blood disorders,
cancer, arthritis, allergies, obesity, alcoholism, mental illness, kidney disease, TB

Review of the systems

 Asks specific questions for each body system and analyzes any positive symptoms

Psychosocial profile
 Health practices and beliefs
 Typical day
 Nutritional patterns

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  Activity/exercise patterns
 Pets/hobbies
 Sleep/rest patterns
 Socioeconomic status
 Roles/relationships
 Social supports, stress/coping patterns

Complete physical assessment:

A complete physical assessment is a review of each body system. The purpose of the
examination is to gather data in order to make clinical judgments and develop a nursing care
plan for the patient. Data from the assessment can be used to determine the patient’s
condition and prioritize the unmet needs for the patient. Nurses can improve the quality of
care provided to the patient by using continuity in care, as well as, making ongoing and
comprehensive assessments.
The quality of the head-to-toe examination will improve with a systematic approach. This
means that the nurse will complete their assessments for one system before moving onto the
next system. See below for a description of the data obtained within each system.
The general survey is the initial step in the head-to-toe sequence. The intent of the general
survey is to determine the reason for the patient’s visit. Initial data obtained is based on an
inspection and analysis of the patient’s appearance and behavior.

Head to Toe Sequence:

 General Survey
1. Observation of the client’s general appearance and behaviour
2. Measurement of height, weight and vital signs
3. Many components are assessed while taking the health history
4. Evaluate client’s clothing, hygiene, state of well-being, nutritional status,
emotional status, speech patterns, LOC, affect, posture, gait, coordination,
balance, gross deformities

 Vital signs
1. Perform vital signs (BP, HR, RR’ Temp, O2 Sat)

 Integument-Skin, Hair Nails

1. Assessment of the integument involves inspection and palpation and sometimes
olfactory sense
2. Inspect and palpate client’s visible skin for colour, lesions, texture and warmth
3. Continue observation of the skin when examining each body part
4. Note hair colour, texture and distribution over the body
5. Observe hands and nails for clubbing and other abnormalities (terms to describe
skin: Pallor, Cyanosis, Jaundice, Vitiligo, Albinism, Edema, Lesion)

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 Head and Face
1. Note head shape, size and position
2. note scalp tenderness, lesions or masses
3. observe for facial symmetry
4. test eyes for acuity
5. inspect general appearance of eyes and eyelids
6. inspect the pupils, sclera and conjunctiva
7. perform pupillary reaction to light and accommodation
8. Inspect external ear and canal for size, colour, symmetry, position, tenderness
9. Nose - test for patency of each nostril - test sense of smell
10. Mouth - inspect and palpate lips and oral mucosa, inspect teeth, gums and
palate, inspect tongue
o Terms associated with the eye: Cataracts, Glaucoma, mydriasis, miosis, aniscoria

 Neck
1. Inspect and palpate for masses, abnormal pulses or tracheal deviation
2. Palpate carotid pulses
3. Assess ROM of neck
4. Observe head movement
5. Palpate thyroid gland - more advanced

 Upper Extremities
1. Test ROM and strength
2. Test hand grips
3. Palpate pulses
4. Inspect nails and capillary refill

 Chest and back

1. Assess skin and begin with posterior thorax(back) first
2. Inspect shape and symmetry of thorax inspect spine
3. Check ROM of spine
4. Percuss and auscultate lung sounds posteriorly
5. Inspect , percuss and auscultate lungs anteriorly
6. Auscultate heart sounds

 Abdomen
1. Inspect skin
2. Inspect for shape, scars, movements, abnormalities
3. Auscultate for bowel sounds
4. Palpate lightly for tenderness
5. Palpate femoral arteries

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  Genitals, rectum and anus
1. Often not a nursing responsibility depending on clinical setting
2. Test stool for occult blood

 Lower extremities
1. Inspect for skin colour, hair distribution, temperature, edema, varicose veins,
muscle size
2. Test for ROM, muscle strength and sensation
3. Palpate pulses
4. Observe gait
Terms used in describing lower extremities: atrophy, hypertrophy, flaccidity, spasticity, tremor

Before beginning the physical assessment:

Preparing the client for the exam is an extremely important part of the process as many
patients experience anxiety. Throughout the examination, it is important to respond
appropriately to the verbal and nonverbal cues from the patient. If at any time, the patient
appears extremely uncomfortable, it is best to postpone the examination or address the cause
of the patient’s anxiety. There are many steps a nurse can take to reduce the client’s anxiety
and promote comfort throughout the examination.

Steps to reduce anxiety:

 Provide a thorough explanation of the purpose of the examination
 Provide a more detailed explanation as you work through each system
 Use simple words to explain the procedure and avoid medical jargon
 Allow a third person in the room (especially, if the client is the opposite gender)
 Provide a calm environment
 Prepare the client - explain, empty bladder, provide gown
 Prepare the environment - well-lit, equipment organized, provide privacy, warm room
 Positioning - patient’s condition, age and energy level should be taken into
consideration
 Draping- arranged to expose only areas being assessed

Helpful hints for head-to-toe examination:

 Wash your hands (make sure they are warm)
 Listen to the client
 Provide a warm environment
 Work from head to toe
 Compare side to side
 Use the time not only to assess but teach
 leave sensitive or painful areas to the end of exam

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Focused Assessments
A focused assessment, or problem-based assessment, is a detailed assessment of a specific
problem or complaint. A focused assessment is commonly used within an outpatient client,
emergency department, or within a clinical setting when there are abnormalities within the
clinical findings. It can also be used when a client’s condition or time prevents a comprehensive
assessment.

Examples: client complains of abdominal pain, client admitted with a head injury, client has a
cast applied to lower leg, nurse administers a cardiac medication to the patient

Documentation of a Head to Toe Assessment

Mr. T, aged 50, appears stated age, well-nourished. He is alert and oriented in no obvious
distress. Appearance, behaviour and speech are appropriate. T- 37 P- 76 R -16 BP 124/82 O2
Sat 98% RA. No reports of pain. Lung sounds clear bilaterally, no cough, no SOB. Peripheral
pulses present x4, cap refill less than 3 seconds, no cyanosis noted. Abdomen soft, not
distended, BS active x4 quadrants, no complaints of pain upon palpation. Pt states no difficulty
or burning with urination. Uses urinal prn. Pt states last BM yesterday AM, brown and soft.
Upon inspection coccyx appears red, Proshield applied, encouraged pt to turn on his sides
frequently. Pt has an NS lock on his right forearm that is CD&I, flushes easily, no complaints of
pain. Pt`s family at bedside. Signature:________________

 Documentation is charted by systems in the majority of clinical settings. The entry is put
it at the beginning of your shift and then any subsequent focused assessments are
written after the initial head to toe assessment.

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 Guide - Head to toe Assessment
General Appearance: p. 23-27 Measurements: Pain: p.33-34
Facial expression appropriate to situation, sad, flat, angry Temp: p.27 P:________________________
Body position relax, comfortable, tensed, holding body Pulse: p.28 Q: _______________________
part BP: p.29 R:________________________
Level of consciousness alert, oriented, drowsy, lethargic Resp: p.28-29 S: ________________________
Coloration colour tone even, pallor, cyanosis, jaundiced SpO2: T:________________________
Nutritional status weight within normal, emaciated, Weight: ______kg U:________________________
obesity Height: ______cm
Speech clear, understandable, slurred, garbled BMI:_____ Date:_________
Hearing intact, hearing aid, hard of hearing
Personal hygiene clean, groomed, unkempt hair, absent
or excessive makeup
Neurological system: p.210 Communication speech intact, aphasia, repetitive
Orientation oriented time/place/person. questions
Disoriented Ability to swallow intact, dysphagia,
Memory intact/ altered longterm/short term If applicable:
Facial droop facial asymmetry, bell’s palsy, ptosis  GCS : score= _____ /15
Sensation intact, decreased, absent,  Pupils: pupils round, equal and reactive to light
Cardiovascular system: p.137-143 RUE Pink, pale, warm, cold, sensation intact / decreased/
Pulse Apical-radial Tachycardia, regular/irregular, : absent, mobility intact/ decreased/ absent, no edema,
bounding, weak pitting edema, radial pulse strong/ weak, regular/
Capillary refill 2 sec, > 3sec irregular and symmetrical
Peripheral IV in place ____________________________ _______________________________________
CWSM (of all 4 extremities) LUE: ________________________________________
Peripheral circulation: Skin color, temp, sensation, ________________________________________
mobility, edema, and peripheral pulses(strength, rhythm, RLE: ________________________________________
symmetry) p.153-156 ________________________________________
LLE:
Respiratory System: p.120-126 Inspection: elliptic, symmetric, barrel chest,
FiO2 __________________________________________ Palpation: symmetric chest expansion, superficial, deep,,
Respiration labored, non labored, bradypnea, tachypnea asymmetrical chest expansion
Cough, mucus production _______________________ Auscultation lung sounds clear, crackles, ronchi, wheezes,
decreased breath sounds.
Abdomen: p.163-170 Inspection: coutour flat, rounded, protuberant, symmetrical,
Diet: ________________________________________ bulges, hernia, discoloration scars, redness
Nutritional intake/appetite (/4): ___________________ Auscultation : #/minute, hyperactive/ hypoactive
Last BM (quality/quantity): Palpation: soft, non tender, guarding, rigidity, masses
Bowel elimination pattern: Intake= /8hours
Genito-urinary: ch 17 or ch 18 Inspection: lesions, discharge
Urine clear yellow urine, cloudy, amber, presence Palpation: swelling, masses, tenderness
of blood, #ml, void x #, Continent, urinal, Urinary Output= /8hours
catheter
Skin , hair, nails and mucosas: p.38-43 Oral mucosa/tongue______________________________
Inspection: skin tone, pallor, pigmented lesions, Skin integrity: describe lesions, wound, drain, dressings
erythrema, cyanosis, bruising, clubbing of nails, ______________________________________________
distribution of hair ______________________________________________
Palpation: temperature, moisture, diaphoresis, Braden Scale score= _____
texture, thickness, turgor, coarse hair, fine hair.
Musculoskeletal and Mobility: p.176-185 Inspection: size and coutour of joints, swelling, deformity
Risk for Palpation: tenderness, heat, swelling, palpable fluid

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fall_____________________________________ ROM complete, limited (which joint??)
Level of assistance for mobility/walking Muscle strength atrophy, muscle spasm, paresis,
_____________ weakness
tolerance to movement
__________________________
ED winter 2013 Jarvis Pocket Companion 5th e

Head to Toe Worksheet

General Appearance: Pain: Interpretation

Neurological system:

Cardiovascular system:

Respiratory System:

Abdomen:

Genito-urinary:

Skin , hair, nails and mucosa:

Musculoskeletal and Mobility:

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 Labs

Station 1

Complete a head-to-toe exam on your partner. Use the head-to-

toe assessment sheet in the lab workbook to guide your
assessments.
The nurse should begin by assessing the head and neck structures, including the hair
and skin, and progressing methodically down the body to incorporate all the body
systems.

1. With your partner discuss what data is obtained during the examination of each different
system.

2. Provide feedback to your partner on their head-to-toe exam.

 Did their exam have a systematic approach?
 Did your partner assess each of the systems?
 Did they use appropriate techniques to complete their assessments?
 Did they create a safe and respectful environment?

3. Discuss why it is important to conduct an organized physical examination?

4. What is the purpose of the AINEES assessment? How can it help the nursing team guide
elderly client care?

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 Station 2

Complete an assessment of the skin, hair and nails.

The nurse should use the skills of inspection, palpation, and olfaction to assess the
integument’s function and integrity.
When examining the skin, the nurse should note color, moisture, temperature, texture,
turgor, vascularity, edema, and lesions.

1. Practice assessing the following components of an integumentary assessment:

Routine technique
Skin  Inspect for general color and localized variations in skin color
 Palpate the skin for texture, temperature, moisture, mobility, turgor
and thickness
Scalp and hair  Inspect and palpate for surface characteristics, hair distribution,
texture, quantity, and color
Facial and body hair  Inspect for distribution, color, quantity, and hygiene
Nails  Inspect for shape, color, contour, consistency, thickness and cleanliness
 Assess capillary refill (press on nail bed, color should return in 2
seconds or less)

2. Discuss normal finding for assessment of skin, hair and nails.

3. Discuss causes for abnormal findings of skin, hair and nails.

4. What nursing interventions can be implemented for the following:

 Alopecia

 Cellulitis

 Candidiasis

 Pressure injuries

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 Petechiae

 Striae

 Clubbing

 Poor skin turgor

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 Station 3

Complete an assessment of the cardiovascular system.

 Compare the assessment of heart function with findings of the vascular
assessment. Assess cardiac function through the anterior thorax.
 During inspection and palpation, look for visible pulsations and exaggerated lifts,
and palpate for the apical pulse.
 Auscultation of the heart detects normal heart sounds, extra heart sounds, and
murmurs.

1. With a partner, practice conducting an in-depth cardiovascular assessment.

 What objective data will need to obtain?
 What subjective data will you need to obtain?

2. With a partner, palpate the following pulses:

 Carotid
 Radial
 Brachial
 Ulnar
 Popliteal
 Posterior tibial
 Dorsal pedalis

3. On the mannequin provided, label the following sites:

 Apical pulse
 PMI
 S1
 S2
 S3
 S4

4. Discuss parts of the nursing history that apply to the heart.

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 Station 4

Complete an assessment of the respiratory system.

Assessment of the respiratory system includes subjective and objective data.

Objective data: chest symmetry, breath sounds, skin color, level of consciousness,
respiration rate, pulse oximetry, use of accessory muscles

Subjective data: cough, SOB, chest pain with breathing, past medical history, smoking,
environmental exposure, self-care behaviors

Assessment techniques: inspection, auscultation, palpation and percussion.

1. Complete a focused respiratory assessment and nursing health history for the
respiratory system on your partner.

Structure Assessments
Nursing health history Cough/sputum, fever, chills, smoking, chest pain while breathing,
past medical history, medications, dyspnea, etc
Inspection Symmetry, use of accessory muscles, respiration rate, skin color, O2
saturation, level of consciousness, anxiety, speech, body position, etc
Auscultation Adventitious lung sounds on anterior and posterior chest (crackles,
rhonchi, friction rub, wheezing, etc)

2. On the diagram below, identify the location for the placement of your stethoscope.
For each abnormal lung sounds, identify at least two (2) possible causes:

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Website reference: https://www.sciencedirect.com/topics/nursing-and-health-professions/auscultation

Station 5

Complete an assessment of the head and neck.

 Inspect the patient’s head, noting the position, size, shape, and contour.
 Examination of the eyes includes inspection of external and internal eyes
structures and extraocular movement and assessment of visual acuity and visual
fields.
 The ear assessment determines the integrity of the ear structures and hearing
acuity.
 Assess the integrity of the nose and sinuses by using inspection and palpation.
 Assess the mouth and pharynx to detect signs of overall health, determine oral
hygiene needs, and develop therapies for patients with dehydration, restricted
intake, oral trauma or oral airway obstruction.
 Assessment of the neck includes assessing the neck muscles, lymph nodes of the
head and neck, carotid arteries, jugular veins, thyroid glands, and trachea.

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 1. Practice the following assessments refer to the Jarvis pages for techniques:

Structure Assessments
Eyes  Snellen chart for visual acuity
(Jarvis, pg. 62)  Peripheral vision examination
 Inspection of the conjunctiva, sclera, lashes, use of glasses, vision
difficulty, pupils (size/shape/response to light/accommodation),
cornea (should not be cloudy)
Ears  Inspect for size/shape, skin integrity
(Jarvis, pg. 81)  Otoscope examination (see details listed on Jarvis, pg. 81)
 Whisper test (see details listed on Jarvis, pg. 81).
 Tuning fork test (see details listed on Jarvis, pg. 81).
Nose & mouth  Inspect nose for discharge, position, skin integrity, obstructions
(Jarvis, pg. 95).  Inspect lips for dryness, cracking, lesions, color
 Inspect the mucous membranes for color and moisture
 Inspect the tongue for color, signs of oral thrush, ulcerations,
lesions, nodules, etc
Throat  Inspect the tonsils, color, lesions
Head and Neck  Lymph nodes (Location, size, shape (regular vs irregular border),
(Jarvis, pg. 55). mobility (mobile vs fixed), tenderness (tender vs non-tender),
texture (soft vs firm)
 Thyroid gland (what laboratory test are used to assess the
functioning of the thyroid gland?, how will you palpate the thyroid
gland?, is the thyroid gland normally palpable?)
 Trachea (What is the normal position of the trachea?)

Station 6

Complete an assessment of the gastrointestinal system.

1. Do a focussed GI assessment on your partner.

2. Write 5 questions you will ask your partner to collect data on the gastrointestinal
system.

3. Create a list of objective and subjective data you will assess during an assessment of the
GI system.

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 Objective :

Subjective :

4. Identify findings that can be obtained during an exam of the gastrointestinal system
using the following assessment techniques:

Structure Assessments
Inspection

Auscultation

Palpation

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 Station 7

Mrs. Langely is an 82 year-old female admitted with acute kidney injury (AKI) related to
the use of an antibiotic to treat a urinary tract infection (UTI). In report, the night shift
nurse reports that Mrs. Langley is doing well but is febrile with a temperature of 38.1.
Her foley drained 200cc over night and was given sodium polystryene sulfonate
(Kayaxelate) for a potassium level of 6.1. You are doing your morning rounds to assess

your patients.

1. With your partner(s), define “focused assessment”.

2. What is the importance of focused assessments?

3. Using the data in the above case, identify focused assessments required to gather data?

4. What assessment techniques will you use to gather your data?

5. With a partner, perform a complete morning focused assessment based on the data
provided in the scenario. One student will be the nurse and the other student will be
Mrs. Langley.

6. Document your key findings of your morning assessment.

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 Station 8

Complete an assessment of the neurological system.

The nurse should gather appropriate subjective and objective data during a neurological
exam:

Objective data: mental health, cranial nerve function, motor system, sensory system,
reflexes

Subjective data: head ache, head injury, dizziness, vertigo, seizures, tremors, weakness,
numbness, tingling, difficulty swallowing, past medical history, use of
medications/substance abuse

1. Practice assessing the following components of a basic neurological assessment

on your partner:

Routine technique
Mental Status: Alertness, level of consciousness, emotions, general appearance, mood,
Appearance, cooperation. Assess the speech for clarity. Does the patient maintain eye
behaviour, speech contact?
Orientation Oriented to time, place and person
Sensory function Pain, light touch
Motor function Coordination, strength, balance, reflexes, pupil reaction to light

2. Provide a list of questions you will use to obtain objective and subjective data
when conducting a nursing history of the neurological system:

Objective data Subjective data

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LAB Quiz – to be posted on Moodle (students can answer questions on-line)
1. What is the purpose of assessment?
a. To make a diagnostic conclusion
b. To delegate nursing responsibility
c. To teach the client about his or her health
d. To establish a database concerning the client

2. During data clustering, the nurse performs which of the following?

a. Provides documentation of nursing care
b. Reviews data with other health care providers
c. Makes inferences about patterns of information
d. Organizes cues into patterns that lead to identification of nursing diagnoses

3. Which of the following is subjective information to be entered in the client’s medical

record?
a. Skin warm and dry.
b. Pain intensity 8 out of 10.
c. Breath sounds clear to auscultation.
d. Amber urine in sufficient quantities.

4. Which of the following is objective information to be recorded in the client’s medical

record?
a. Anxious over upcoming test
b. Increasing stress over past two months
c. Performs breast self-examination monthly
d. Voided 250 mL of clear yellow urine

5. The nurse asks the client whether the client has any allergies. This is an example of
which of the following?
a. Health history data
b. Biographical information
c. History of present illness
d. Environmental history data

6. In a review of systems, asking about the last time a client had a tuberculosis (TB) skin
test is a question that would fit under which of the following categories?
a. Laboratory data
b. Immunizations
c. Lower respiratory system
d. Upper respiratory system

7. A review of systems is based on information obtained from the client during the
interview. This information is an example of ______________ data.

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8. Besides high blood pressure (BP) values, what other signs and symptoms may the
nurse observe if hypertension is present?
a. Unexplained pain and hyperactivity
b. Headache, flushing of the face, and nosebleed
c. Dizziness, mental confusion, and mottled extremities
d. Restlessness and dusky or cyanotic skin that is cool to the touch

9. Which of the following values for vital signs would the nurse address first?
a. Pulse rate = 72 beats per minute
b. Respirations = 28 breaths per minute
c. BP = 160/86 mm Hg
d. Oxygen saturation by pulse oximetry = 87%
e. Temp = 37.2°C, tympanic

10. Using an oral electronic thermometer, the nurse checks the early morning
temperature of a patient. The patient’s temperature is 36.7°C. The patient’s
remaining vital signs are in the normally acceptable range. What should the nurse do
next?
a. Check the patient’s temperature history.
b. Document the results; the temperature is normal.
c. Recheck the temperature every 15 minutes until it is normal.
d. Check the temperature using another method.

11. The nurse finds that the systolic BP of an adult patient is 88 mm Hg. What are the
appropriate nursing interventions?
a. Check other vital signs.
b. Recheck the BP, and give the patient orange juice
c. Recheck the BP after ambulating the patient safely.
d. Recheck the BP, make sure the patient is safe, and report the findings.

12. Which of the following sets of vital signs are considered normal for an adult?
a) BP 122/82 mm Hg; Temp 37; Pulse rate 84 beats per minute; Respirations 18
breaths per minute
b) BP 108/78 mm Hg; Temp 36; Pulse rate 62 beats per minute; Respirations 22
breaths per minute
c) BP 164/84 mm Hg; Temp 35.8; Pulse rate 102 beats per minute; Respirations 20
breaths per minute
d) BP 120/80 mm Hg; Temp 37; Pulse rate 42 beats per minute; Respirations 10
breaths per minute

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 13. The nurse conducts a general survey of an adult patient, which includes which of the
following?
a. Checking appearance and behaviour
b. Measuring vital signs
c. Asking about a review of systems
d. Conducting a detailed health history

14. To correctly palpate the patient’s skin for temperature, which part of the hands does
the nurse use?
a. Base of the hands
b. Fingertips of the hands
c. Dorsal surface of the hands
d. Palmar surface of the hands

15. To auscultate the patient’s lung fields, the nurse uses a systematic pattern that
compares which of the following?
a. Side to side
b. Top to bottom
c. Anterior to posterior
d. Interspace to interspace

16. The patient is being assessed for range of joint movement. The nurse asks the
patient to move the arm toward the body so she can evaluate which of the
following?
a. Flexion
b. Extension
c. Abduction
d. Adduction

17. The techniques of physical assessment are inspection, palpation, percussion, and
auscultation. The order in which these techniques are used is slightly different
during abdominal examination than during examination of other body areas. The
nurse should perform which procedures first?
a. Palpation and inspection
b. Inspection and percussion
c. Palpation and auscultation
d. Inspection and auscultation

References:
Giddens, J.F. & Wilson, S. (2013). Health assessment for nursing practice, 5 th edition. Missouri:
Elsevier.

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