KHEAD TO TOE ASSESSMENT
QUESTIONS AND ANSWERS GRADED
A+
The nurse is assessing skin turgor. Which technique will the nurse use?
Press lightly on the forearm.
Press lightly on the fingertips.
Grasp a fold of skin on the sternal area.
Grasp a fold of skin on the back of the hand. - Grasp a fold of skin on the sternal area.
A patient in the emergency department is reporting left lower abdominal pain. Which proper order will
the nurse follow to perform the comprehensive abdominal examination?
Percussion, palpation, auscultation
Percussion, auscultation, palpation
Inspection, palpation, auscultation
Inspection, auscultation, palpation - Inspection, auscultation, palpation
Having misplaced a stethoscope, a nurse borrows a colleague's stethoscope. The nurse next enters the
patient's room and identifies self, washes hands with soap, and states the purpose of the visit. The nurse
performs proper identification of the patient before auscultating the patient's lungs. Which critical
health assessment step should the nurse have performed?
Running warm water over stethoscope
Draping stethoscope around the neck
Rubbing stethoscope with betadine
Cleaning stethoscope with alcohol - Cleaning stethoscope with alcohol
During a genitourinary examination of a 30-year-old male patient, the nurse identifies a small amount of
a white, thick substance on the patient's uncircumcised glans penis. What is the nurse's next step?
Record this as a normal finding.
, Avoid embarrassing questions about sexual activity.
Notify the provider about a suspected sexually transmitted infection.
Tell the patient to avoid doing self-examinations until symptoms clear. - Record this as a normal finding.
A teen female patient reports intermittent abdominal pain for 12 hours. No dysuria is present. Which
action will the nurse take when performing an abdominal assessment?
Assess the area that is most tender first.
Ask the patient about the color of her stools.
Recommend that the patient take more laxatives.
Avoid sexual references such as possible pregnancy. - Ask the patient about the color of her stools.
The paramedics transport an adult involved in a motor vehicle accident to the emergency department.
On physical examination, the patient's level of consciousness is reported as opening eyes to pain and
responding with inappropriate words and flexion withdrawal to painful stimuli. Which value will the
nurse report for the patient's Glasgow Coma Scale score?
5
7
9
11 - 9
An older-adult patient is taking aminoglycoside for a severe infection. Which assessment is the priority?
Eyes
Ears
Skin
Reflexes - Ears
A nurse is assessing a patient's cranial nerve IX. Which items does the nurse gather before conducting
the assessment? (Select all that apply.)
Vial of sugar
Snellen chart
QUESTIONS AND ANSWERS GRADED
A+
The nurse is assessing skin turgor. Which technique will the nurse use?
Press lightly on the forearm.
Press lightly on the fingertips.
Grasp a fold of skin on the sternal area.
Grasp a fold of skin on the back of the hand. - Grasp a fold of skin on the sternal area.
A patient in the emergency department is reporting left lower abdominal pain. Which proper order will
the nurse follow to perform the comprehensive abdominal examination?
Percussion, palpation, auscultation
Percussion, auscultation, palpation
Inspection, palpation, auscultation
Inspection, auscultation, palpation - Inspection, auscultation, palpation
Having misplaced a stethoscope, a nurse borrows a colleague's stethoscope. The nurse next enters the
patient's room and identifies self, washes hands with soap, and states the purpose of the visit. The nurse
performs proper identification of the patient before auscultating the patient's lungs. Which critical
health assessment step should the nurse have performed?
Running warm water over stethoscope
Draping stethoscope around the neck
Rubbing stethoscope with betadine
Cleaning stethoscope with alcohol - Cleaning stethoscope with alcohol
During a genitourinary examination of a 30-year-old male patient, the nurse identifies a small amount of
a white, thick substance on the patient's uncircumcised glans penis. What is the nurse's next step?
Record this as a normal finding.
, Avoid embarrassing questions about sexual activity.
Notify the provider about a suspected sexually transmitted infection.
Tell the patient to avoid doing self-examinations until symptoms clear. - Record this as a normal finding.
A teen female patient reports intermittent abdominal pain for 12 hours. No dysuria is present. Which
action will the nurse take when performing an abdominal assessment?
Assess the area that is most tender first.
Ask the patient about the color of her stools.
Recommend that the patient take more laxatives.
Avoid sexual references such as possible pregnancy. - Ask the patient about the color of her stools.
The paramedics transport an adult involved in a motor vehicle accident to the emergency department.
On physical examination, the patient's level of consciousness is reported as opening eyes to pain and
responding with inappropriate words and flexion withdrawal to painful stimuli. Which value will the
nurse report for the patient's Glasgow Coma Scale score?
5
7
9
11 - 9
An older-adult patient is taking aminoglycoside for a severe infection. Which assessment is the priority?
Eyes
Ears
Skin
Reflexes - Ears
A nurse is assessing a patient's cranial nerve IX. Which items does the nurse gather before conducting
the assessment? (Select all that apply.)
Vial of sugar
Snellen chart
