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 B
Explanation
Choice A rationale
Partially withdrawing and redirecting the needle after aspirating blood significantly increases the risk of tissue trauma, pain, and the formation of a hematoma at the injection site. Furthermore, there is a risk of inadvertently injecting medication into a blood vessel or the interstitial tissue, which could lead to complications such as nerve damage or localized irritation.
Choice B rationale
Aspirating blood indicates the needle tip has entered a blood vessel. Administering medication intravenously when an intramuscular injection is intended can have serious systemic consequences, including rapid absorption and potential adverse drug reactions or toxicity. Therefore, the safest action is to withdraw the needle, discard the contaminated medication, and prepare a new dose to ensure proper drug delivery.
Choice C rationale
Administering the drug despite aspirating blood significantly increases the risk of injecting the medication directly into a blood vessel (intravascular injection) rather than the muscle. This can lead to rapid systemic absorption, potentially causing adverse effects or toxicity, and may also result in a larger, more painful hematoma and delayed drug action.
Choice D rationale
Continuing to administer the drug after aspirating blood, regardless of the injection speed, is dangerous because it confirms the needle's placement within a blood vessel. Intravascular administration of an IM medication can lead to immediate systemic effects, allergic reactions, or drug overdose, bypassing the intended slower absorption rate of muscle tissue, and increasing risk of complications.
Correct Answer is A
Explanation
Choice A rationale
The vastus lateralis muscle is the preferred intramuscular injection site for infants and children due to its large muscle mass and lack of major nerves or blood vessels, minimizing the risk of injury. This site is easily accessible and provides a safe area for medication absorption in developing musculature.
Choice B rationale
The ventrogluteal site is generally considered safe and effective for intramuscular injections, but it requires precise anatomical landmark identification, which can be challenging in infants and young children, increasing the risk of sciatic nerve injury if landmarks are not accurately identified.
Choice C rationale
The dorsogluteal site is contraindicated for intramuscular injections in infants and children due to the risk of sciatic nerve damage. The sciatic nerve runs through this area, and the muscle mass is not fully developed in younger patients, making it a hazardous site.
Choice D rationale
The deltoid muscle is too small and underdeveloped in infants and young children to safely accommodate intramuscular injections. Its limited muscle mass increases the risk of injury to underlying nerves and blood vessels, and absorption capacity is reduced.
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