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NUR-216 Exam QUESTIONS AND VERIFIED ANSWERS EXAM 5 Modules 10-12
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NUR-216 Exam QUESTIONS AND VERIFIED ANSWERS EXAM 5 Modules 10-12
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lOMoAR cPSD| 22896205NUR-216 Exam 5 Modules 10-12 1
NUR-216 Exam QUESTIONS AND VERIFIED
ANSWERS 2024-2025 EXAM 5 Modules 10-12
Module 10:
HEAD TO TOE
★ Prepare for a head-to-toe assessment
○ Recognize the techniques and tools used to perform a head-to-toe assessment. (stethoscope (high
pitched sounds= Diaphragm, low pitched sounds= bell side), cotton balls, otoscope, tongue
blade)
○ Identify the organizational strategies in which to perform the steps of a systematic head-to-toe
assessment.
★ Assess general appearance
○ Demonstrate the knowledge for the order and skill involved in inspecting the client’s general
appearance. (odor, posture, weight, height, hair distribution, level of comfort, grooming, assisted
devices, overall appearance)
★ Assess vital signs and baseline measurements
○ Demonstrate the knowledge of skills involved in assessing vital signs and baseline
measurements to include (height/weight, capillary refill, pulse oximetry, temp, BP, ♥R, RR,
orientation status, Pain PQRST)
★ Assess head and face
○ Demonstrate the knowledge of skills and order of the steps involved in inspecting the head,
facial expressions, eyes, ears, nose, mouth, throat, and neck as part of a head-to-toe assessment
(cranial nerves assess, ROM, appearance)
★ Assess anterior, posterior, and lateral chest
○ Demonstrate the knowledge involved in inspecting the anterior chest, posterior chest, and lateral
chest. (observe RR, rhythm, o2 percentage, regular, irregular, resonate, SOB, distress, accessory
muscle use?, chest symmetry, expansion, “butterfly”, masses or nodules, adventitious sounds,
symmetrical movement, inspiration, expiration)
○ Determine the order to perform the steps for auscultating the anterior chest, posterior chest, and
lateral chest.
★ Assess upper extremities and lower extremities
○ Determine the order in which to perform the steps to assess upper and lower extremities.
○ Demonstrate the knowledge of skills involved in assessing upper and lower extremities by
inspecting and palpating pulses, temperature, color, lesions, sensation, push/pull strength, strong
firm, regular and manifestations of tenderness.
★ Assess abdomen
○ Determine the order in which to perform the steps to assess the abdomen. (inspect skin, contour,
umbilicus, pulsations, hair distribution, auscultate for bruits, percuss abdomen for kidney
infection, palpate for rigidity, masses, tumors, tenderness, hernias, light, deep, rebound
tenderness- Blumberg signs, CVA tenderness)** auscultate before palpating!!!
○ Demonstrate the knowledge of skills involved in inspecting, auscultating, and palpating the
abdomen.
★ Assess gait
○ Ambulate (Dizziness, assisted devices, romberg test last) ○ Complete remaining documentation
Head to Cranial Nerves Order
Cranial Nerve (I) Olfactory: Scent test, assess the nose for skin breakdown, drainage, bleeding, excessive dryness,
symmetry
Cranial Nerve (II) Optic: Snellen Chart!!
Cranial Nerve (III, IV, VI) Oculomotor, Trochlear, Abducens: PERRLA, pupil size, sclera appearance,
conjunctiva, inflammation, drainage, EOMS, 6 cardinal gaze
pg. 1
, lOMoAR cPSD| 22896205
NUR-216 Exam 5 Modules 10-12 2
Cranial Nerve (V) Trigeminal: clench jaw, release, cotton ball sensation of forehead, cheek, chin
Cranial Nerve (VII) Facial: smile, frown,puff up cheeks, raise eyebrows, close eyes tightly
Cranial Nerve (VIII) Vestibular aka Acoustic: Whisper test!
Cranial Nerve (IX, X, XII) Glossopharyngeal, Vagus, Hypoglossal: gag reflex, check uvula, swallow test, “light,
tight, dynamite”, assess mouth, lips, oral mucosa, gums, teeth, stick out tongue
Cranial Nerve (XI) Spinal Accessory: turn head laterally, shrug shoulder with resistance, strength 1-5 +?
Q: What Pt would require a focused assessment: arm
asymmetrical from the other, garbled speech, tripod position
Q: Findings that indicate a possible neurological condition in an adult?
- Unequal pupil size
- Uneven wrinkling of the forehead
- Unilateral absence of the nasolabial fold
Q: After assessing the neck, what do you assess next?
- UPPER extremities
Q: Correct order for auscultating ♥ sounds?
- Aortic, Pulmonary, Tricuspid, Mitral
Q: What should you report to the provider when inspecting the anterior chest of the Pt?
- Scaly rash on the nipple
- Firm, palpable lump in the midaxillary line
- Inaudible breath sounds in the right middle lobe
Q: Signs of respiratory distress:
- Stridor
- Retractions
Q: NOT a sign of respiratory distress?
- Barrel chest
Q: You observe the presence of a vascular ulcer on the pts left calf- what additional data should you gather?
- Assess the diameter of the wound w/ tape measure0
- Measure the circumference of the calves bilaterally
- Palpate all lower extremity pulses bilaterally
Q: Techniques you should implement when assessing the amplitude of a client’s carotid pulse?
- Palpate one artery at a time
Q: What should you report to the provider during abdominal assessment findings?
- Shiny, taut skin
Q: 1st thing a nurse will assess when doing a Head-to-toe examination is what?
- General appearance
Q: When assessing a client's physical appearance, what would you look for?
- Gender, age, ethnicity, dress, speech, LOC
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