Virtual Challenge: Timothy Lee (head-to- toe) Questions and Answers | Latest Version | 2025/2026 | Correct & Verified

Virtual Challenge: Timothy Lee (head-to- toe) Questions and Answers | Latest Version | 2025/2026 | Correct & Verified What is the first action a nurse should take before beginning Timothy Lee’s head-to-toe assessment? Verify the patient's identity and explain the procedure. What is the best position for Timothy Lee to be in during abdominal inspection? Supine with arms at his sides and knees slightly bent. When assessing the pupillary response in Timothy Lee, what normal finding should the nurse expect? Pupils equal, round, reactive to light and accommodation. How should the nurse assess skin turgor on Timothy Lee? Pinch the skin under the clavicle and observe how quickly it returns. Which tool is used to assess Timothy Lee’s deep tendon reflexes? 2 Reflex hammer. What should the nurse listen for when auscultating Timothy Lee’s bowel sounds? Gurgling sounds occurring every 5 to 15 seconds. What does it indicate if Timothy Lee has cool, pale extremities and delayed capillary refill? Poor peripheral circulation. What is the correct method to check for pedal edema in Timothy Lee? Press gently over the shin and observe for indentation. Why is it important to assess Timothy Lee’s orientation to person, place, and time? To evaluate his level of consciousness and cognitive function. How should the nurse check for carotid pulse in Timothy Lee? Palpate one side at a time to avoid reducing blood flow to the brain. What is the purpose of inspecting Timothy Lee’s oral mucosa? 3 To assess hydration status and signs of infection. How can the nurse assess for scoliosis in Timothy Lee? Ask him to bend forward and observe the spine for asymmetry. What does a positive Babinski reflex in Timothy Lee, an adult, indicate? Neurological dysfunction. Why would the nurse ask Timothy Lee to shrug his shoulders against resistance? To assess cranial nerve XI (spinal accessory nerve). How does the nurse test for strength in Timothy Lee’s upper extremities? Ask him to squeeze the nurse’s hands. What should the nurse observe when inspecting Timothy Lee’s gait? Balance, symmetry, and coordination. What is the significance of inspecting Timothy Lee’s nails?