Head-to-Toe Test

A nurse is evaluating an older adult client for an alteration in orientation. Which of the following questions should the nurse ask the client?

"Can you tell me what month it is?"

A nurse is assessing a client's vital signs. While counting the number of respirations, which of the following information should the nurse collect?

Characteristics of the respirations.

A nurse is inspecting the anterior chest of a client. Which of the following findings should the nurse report to the provider?

Distended veins in one breast.

A nurse is preparing to conduct a head-to-toe assessment on a client in an outpatient setting. At which of the following times should the nurse plan to collect information about the client's general appearance? (Select all that apply.)

During an interview about the client's health history. When introducing themselves to the client. While collecting the client's vital signs.

A nurse is preparing to assess the status of a client's upper extremities. Which of the following actions should the nurse take? (Select all that apply.)

Inspect the condition of each fingernail. Compare the amplitude of the radial pulses bilaterally. Palpate the shoulder, elbow, wrist, and finger joints.

A nurse is performing an assessment of a client's lower extremities. Which of the following actions should the nurse include in this assessment?

Inspect the pattern of hair distribution.

A nurse is assessing a client's neck. Which of the following should the nurse ask the client to perform during this assessment? (Select all that apply.)

Instruct the client to swallow. Apply downward pressure and ask the client to shrug their shoulders. Request the client move their head forward and backward and then side to side.

A nurse is preparing to care for a group of clients in an acute care setting. Which of the following assessments should the nurse plan to perform on every client? (Select all that apply.)

Lung sounds Bowel sounds Pedal pulses Mental status

A nurse in an outpatient setting is performing a head-to-toe assessment on a client. Which of the following should be nurse inspect when performing a general survey of the client? (Select all that apply.)

Nutritional Status. Hygiene. Posture.

A nurse is assessing a client's posterior and lateral chest. Which of the following actions should the nurse take?

Observe for the use of accessory muscles during inspiration.

A nurse is performing an assessment on a client who reports ear pain. Which of the following actions should the nurse take?

Palpate the mastoid area for pain.

A nurse is preparing to perform a head-to-toe assessment on a client. Which of the following tools should the nurse plan to gather? (Select all that apply.)

Penlight Stethoscope Sphygmomanometer

A nurse is assessing a client's radial pulse rate. Which of the following information should the nurse collect while performing this action? (Select all that apply.)

Regularity of the pulse. Strength of the pulse.

A nurse is planning to complete a physical assessment on a client. Which of the following actions should the nurse plan to include?

Use quotation marks when documenting client statements.

A nurse is performing an assessment of a client's abdomen. Which of the following actions should the nurse take?

Auscultate bowel sounds prior to palpating.