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 C
Explanation
Choice A rationale
The clavicle is a superficial bone forming part of the shoulder girdle and does not serve as a primary site for eliciting deep tendon reflexes. Deep tendon reflexes involve muscle stretch and nerve innervation.
Choice B rationale
The scapula is a large, triangular bone located on the posterior aspect of the rib cage and is not an anatomical landmark used for assessing deep tendon reflexes. Reflexes are elicited from tendons connected to muscles.
Choice C rationale
The patella, or kneecap, is the anatomical landmark where the patellar tendon connects to the quadriceps muscle. Tapping this tendon elicits the patellar reflex, a commonly assessed deep tendon reflex indicating spinal nerve integrity.
Choice D rationale
The sternum, or breastbone, is a flat bone located in the center of the chest and is not associated with the elicitation of deep tendon reflexes. Deep tendon reflexes are assessed at specific musculotendinous junctions.
Correct Answer is D
Explanation
Choice A rationale
Checking for a cream order is insufficient for anaphylactic-like symptoms. Wheezing, dizziness, and anxiety indicate a systemic hypersensitivity reaction, potentially compromising respiratory and cardiovascular systems. Topical treatments address localized dermatological issues, not acute, life-threatening systemic responses requiring immediate medical intervention.
Choice B rationale
Simply noting a possible drug allergy in the chart without immediate action is insufficient for these severe symptoms. Wheezing and dizziness suggest anaphylaxis, a life-threatening acute hypersensitivity reaction involving systemic histamine release, leading to bronchoconstriction and vasodilation. Prompt intervention, like epinephrine, is critical.
Choice C rationale
Encouraging fluid intake to flush the drug is ineffective and potentially harmful during an acute allergic reaction. The body's elimination processes are not significantly accelerated by increased fluid intake to counteract rapid systemic histamine release. This response delays critical medical intervention for potentially life-threatening symptoms.
Choice D rationale
Calling for help and contacting the physicianSTAT is the immediate and appropriate action. Wheezing, anxiety, dizziness, and blotches suggest an anaphylactic reaction, a severe, rapid-onset allergic response requiring urgent medical attention. Prompt communication facilitates rapid assessment, intervention (e.g., epinephrine), and management of potential airway compromise.
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