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

Auscultate bowel sounds prior to palpating.

A nurse is assessing a client's neck. Which of the following should the nurse ask the client to perform during this assessment?

Instruct the client to swallow, apply downward pressure and ask the client to shrug their shoulders, and request the client move their head forward and backward and then side to side.

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

Regularity of the pulse and strength of the pulse.

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 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?

Nutritional status, hygiene, and posture.

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?

Penlight, stethoscope, and sphygmomanometer.

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 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 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?

During an interview about the client's health history, when introducing themselves to the client, and 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?

Inspect the condition of each fingernail, compare the amplitude of the radial pulses bilaterally, and 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 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?

Lung sounds, bowel sounds, pedal pulses, and mental status

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