Head to Toe Assessment (In Order) Questions and Answers | Latest Version | 2025/2026 | Correct & Verified

Head to Toe Assessment (In Order) Questions and Answers | Latest Version | 2025/2026 | Correct & Verified What is the first action the nurse should take before beginning a head-to-toe assessment? Perform hand hygiene and introduce self to the client What is the first step of a physical assessment once you enter the room? Assess the client's level of consciousness and general appearance What is the first system assessed during a head-to-toe assessment? Neurological system After assessing level of consciousness, what should the nurse evaluate next? Orientation to person, place, and time What is included in the general survey portion of the assessment? Appearance, posture, hygiene, mood, and speech 2 After the neurological check, what part of the head-to-toe assessment comes next? Head and face inspection What is assessed when checking the pupils during the head-to-toe exam? Pupil size, equality, and reaction to light What should the nurse do to assess cranial nerves II and III? Shine a light in the eyes and observe pupil constriction How is the mouth assessed during a head-to-toe exam? Inspect lips, mucosa, gums, teeth, and tongue for moisture and integrity After inspecting the mouth, what area comes next in order? Neck and lymph nodes What should be assessed when examining the neck? Trachea position, jugular veins, and lymph node tenderness or swelling 3 How is the respiratory system assessed during a head-to-toe exam? Inspect chest movement and auscultate lung sounds bilaterally What is the correct way to auscultate lung sounds? Use the diaphragm of the stethoscope, listening to full inspiration and expiration After lung auscultation, what system should the nurse assess next? Cardiovascular system Where is the apical pulse located for auscultation? Left 5th intercostal space, midclavicular line What is the nurse checking when palpating peripheral pulses? Strength, symmetry, and regularity of pulses What follows the cardiovascular assessment in a head-to-toe sequence? Abdomen assessment