Why does the nurse utilize a head-to-toe approach when performing physical examinations of patients?
The head-to-toe format excludes unnecessary body systems.
It is a systematic way to include all body systems.
It requires that painful procedures be done first.
It reduces time by allowing examination of only one side.
The Correct Answer is B
Choice A rationale
The head-to-toe format does not exclude unnecessary body systems; rather, it aims to systematically include all major body systems to ensure a comprehensive assessment. Excluding systems could lead to missed findings and an incomplete understanding of the patient's health status. A thorough examination requires a complete survey, even if initial symptoms point to a specific area, to identify any related or unrelated issues.
Choice B rationale
A head-to-toe approach provides a structured and systematic method for examining all body systems. This ensures that no area is overlooked, promoting a comprehensive data collection process. It allows for a logical flow, minimizing omissions and facilitating the identification of interconnections between different bodily functions. This organization enhances efficiency and thoroughness in clinical assessment.
Choice C rationale
The head-to-toe approach does not mandate that painful procedures be done first. In fact, best practice dictates that painful or uncomfortable assessments should generally be deferred until the end of the examination to maintain patient cooperation and trust. Starting with non-painful assessments allows the patient to acclimate and reduces anxiety, improving the overall quality of the examination.
Choice D rationale
A head-to-toe assessment does not reduce time by examining only one side of the body. A comprehensive physical examination requires bilateral assessment of most structures and systems to identify asymmetries or unilateral abnormalities. Limiting the examination to one side would provide an incomplete and potentially misleading clinical picture. Full evaluation ensures all relevant data are collected.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Orientation to person, place, and time is a fundamental component of cognitive assessment, indicating intact neurological function. Knowing one's full name demonstrates personal orientation. Recognizing the hospital and its location signifies place orientation. Providing the correct month and year, even without the exact day, suggests a reasonable grasp of temporal orientation, reflecting adequate higher cortical processing.
Choice B rationale
The inability to state one's location and an incorrect year indicate significant deficits in both place and time orientation. This suggests impaired cognitive function, potentially due to delirium, dementia, or other neurological issues affecting memory and executive functions. Such a response would warrant further comprehensive cognitive evaluation.
Choice C rationale
While knowing one's name indicates personal orientation, confusion about the date points to a deficit in time orientation. This partial disorientation suggests some level of cognitive impairment, necessitating further assessment to determine the underlying cause and extent of the confusion.
Choice D rationale
Hesitation regarding location and complete inability to state the date demonstrate significant disorientation to both place and time. This pattern of response is indicative of impaired cognitive function and necessitates a thorough neurological and cognitive workup to identify potential etiologies.
Correct Answer is D
Explanation
Choice A rationale
Drug tolerance refers to a phenomenon where a patient's response to a specific drug decreases over time, requiring larger doses to achieve the same therapeutic effect. This often occurs due to physiological adaptations, such as altered receptor sensitivity or increased drug metabolism, and is distinct from simply taking multiple medications.
Choice B rationale
A pharmacogenetic reaction involves an individual's unique genetic makeup influencing their response to a drug, leading to altered drug metabolism, efficacy, or adverse effects. This is a specific type of drug response based on genetic variations and is not synonymous with the practice of taking numerous medications.
Choice C rationale
Drug toxicity refers to adverse effects that occur when the concentration of a drug in the body exceeds the therapeutic range, leading to harmful or undesirable physiological effects. While taking multiple drugs can increase the risk of toxicity, toxicity itself is a consequence, not the term for taking numerous drugs.
Choice D rationale
Polypharmacy is the medical term used to describe the practice of taking multiple medications concurrently, often more than is medically necessary or when the potential for adverse drug interactions and side effects outweighs the benefits. This is a common issue in older adults due to the presence of multiple chronic conditions requiring different pharmacological interventions.
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