Head-to-Toe Assessment Script Questions and Answers | Latest Version | 2025/2026 | Correct & Verified

Head-to-Toe Assessment Script Questions and Answers | Latest Version | 2025/2026 | Correct & Verified Why is it important to provide privacy during a head-to-toe assessment? To maintain client dignity and promote comfort What is the purpose of washing hands before and after an assessment? To prevent the spread of infection What is the correct order of physical assessment techniques (except for the abdomen)? Inspect, palpate, percuss, auscultate What is the correct order of assessment for the abdomen? Inspect, auscultate, percuss, palpate Why should the nurse assess the client's level of consciousness at the start of the assessment? To evaluate orientation and neurological status 2 What is the best way to assess orientation in a client? Ask about person, place, time, and situation What should the nurse observe when inspecting the head and face? Facial symmetry, skin condition, and head shape What is the normal finding when assessing pupils with a penlight? Pupils are equal, round, and react to light and accommodation (PERRLA) What is the best way to assess the client's visual acuity? Ask the client to read a near or distant object What should the nurse note when inspecting the ears? Shape, alignment, drainage, and presence of lesions How can the nurse assess hearing during a head-to-toe assessment? Speak softly or perform the whisper test 3 What is a normal finding when inspecting the nasal passages? Nasal mucosa pink, moist, and without drainage How should the nurse inspect the mouth and oral cavity? Use a penlight and tongue blade to check for moisture, lesions, and dentition What does the nurse assess when inspecting the neck? Symmetry, range of motion, and presence of lymph nodes or masses What is the expected finding when palpating the carotid arteries one at a time? A strong, equal pulse without bruit Why should the nurse listen for a bruit over the carotid artery? It may indicate turbulent blood flow from narrowing or blockage What should the nurse observe during chest inspection? Shape, symmetry, and respiratory effort 4 What is the best position for auscultating anterior lung sounds? Sitting upright with shoulders relaxed What are expected normal lung sounds over the vesicular areas? Soft, low-pitched breath sounds heard over peripheral lung fields What should the nurse do if crackles are heard during lung auscultation? Reassess after coughing and document the findings What is a normal heart rate range for an adult during auscultation? 60 to 100 beats per minute Where is the apical pulse located for auscultation? Left 5th intercostal space at the midclavicular line What should the nurse note when assessing