NURS 198 Head to Toe Assessment
QUESTIONS WITH COMPLETE
CORRECT SOLUTIONS
The nurse is assessing an adult client with a family history of stroke. The nurse should contact
the healthcare provider immediately due to which assessment finding?
- Diminished carotid pulses
- Redness and swelling over the sinuses
- Immobile lymph nodes
- Conductive hearing loss - correct answer ✔✔ diminished carotid
The nurse is documenting normal findings after assessing the client's skin. Which of the
following are examples of normal findings?
- Skin is warm, dry, and intact
- Mucous membranes are pale and moist
- Skin color is within the client's normal parameters
- The skin of the sacrum and heels is reddened - correct answer ✔✔ Skin is warm, dry, and
intact
When integrating the total physical examination the nurse should:
- assess cranial nerve I (olfactory) with the other 11 cranial nerves at the same time.
- perform the Mental Status Exam after examining all other body systems.
- integrate the rectal examination with the abdominal examination.
- assess peripheral vascular status when examining the lower extremities. - correct answer ✔✔
, When performing a head-to-toe assessment, during which part would the nurse assess the
motor function of cranial nerve VII? - correct answer ✔✔ head and face
The nurse would palpate the axillae during examination of which area? - correct answer ✔✔
breasts
The nurse has just performed the head-to-toe assessment on a new client. At the end of the
assessment, what should the nurse do LAST? - correct answer ✔✔ wash hands before leaving
the room
When obtaining subjective data from a new client, you focus primarily on... - correct answer
✔✔ evaluating risk factors
During the Rinne test for checking the bone conduction of the sound, where should the nurse
place the stem of the vibrating tuning fork? - correct answer ✔✔ on the mastoid area
The best approach to use when performing a total physical examination on a client is... - correct
answer ✔✔ a head-to-toe integrated assessment of body systems.
The nurse has been asked to perform a stereognosis test on an adult client. Which instructions
should the nurse provide to the client before performing the test? - correct answer ✔✔ "With
your eyes closed, identify the object I place in your hand."
The nurse is conducting a cephalic to caudal assessment with a newly admitted client. Why
should the nurse compare findings from side to side? - correct answer ✔✔ determine symmetry
When preparing to do a comprehensive health assessment, the nurse obtains the client's
permission based on an understanding of which of the following?
- The client has the right to refuse.
- Permission maintains the client's confidentiality.
QUESTIONS WITH COMPLETE
CORRECT SOLUTIONS
The nurse is assessing an adult client with a family history of stroke. The nurse should contact
the healthcare provider immediately due to which assessment finding?
- Diminished carotid pulses
- Redness and swelling over the sinuses
- Immobile lymph nodes
- Conductive hearing loss - correct answer ✔✔ diminished carotid
The nurse is documenting normal findings after assessing the client's skin. Which of the
following are examples of normal findings?
- Skin is warm, dry, and intact
- Mucous membranes are pale and moist
- Skin color is within the client's normal parameters
- The skin of the sacrum and heels is reddened - correct answer ✔✔ Skin is warm, dry, and
intact
When integrating the total physical examination the nurse should:
- assess cranial nerve I (olfactory) with the other 11 cranial nerves at the same time.
- perform the Mental Status Exam after examining all other body systems.
- integrate the rectal examination with the abdominal examination.
- assess peripheral vascular status when examining the lower extremities. - correct answer ✔✔
, When performing a head-to-toe assessment, during which part would the nurse assess the
motor function of cranial nerve VII? - correct answer ✔✔ head and face
The nurse would palpate the axillae during examination of which area? - correct answer ✔✔
breasts
The nurse has just performed the head-to-toe assessment on a new client. At the end of the
assessment, what should the nurse do LAST? - correct answer ✔✔ wash hands before leaving
the room
When obtaining subjective data from a new client, you focus primarily on... - correct answer
✔✔ evaluating risk factors
During the Rinne test for checking the bone conduction of the sound, where should the nurse
place the stem of the vibrating tuning fork? - correct answer ✔✔ on the mastoid area
The best approach to use when performing a total physical examination on a client is... - correct
answer ✔✔ a head-to-toe integrated assessment of body systems.
The nurse has been asked to perform a stereognosis test on an adult client. Which instructions
should the nurse provide to the client before performing the test? - correct answer ✔✔ "With
your eyes closed, identify the object I place in your hand."
The nurse is conducting a cephalic to caudal assessment with a newly admitted client. Why
should the nurse compare findings from side to side? - correct answer ✔✔ determine symmetry
When preparing to do a comprehensive health assessment, the nurse obtains the client's
permission based on an understanding of which of the following?
- The client has the right to refuse.
- Permission maintains the client's confidentiality.
