Head to Toe Assessment (Module 2)

Question 1

Place in order the steps to take an initial manual brachial artery blood pressure.

Answer 1

A. Cleanse Hands
B. Chose appropriate size blood pressure cuff
C. Cleanse equipment
D. Have patient sitting in a comfortable position with arm at heart level
E. Place stethoscope over brachial artery
F. Inflate the cuff 30mm HG above the patient usual BP reading
G. Open valve and allow air to escape slowly (2 to 3 mm Hg per second)
H. Assess BP in both arms
I. Document findings

Question 2

When assessing pain in a 5 year old, which of the following standard pain scales is appropriate to use?

Answer 2

Wong Baker (FACES)

Question 3

Place in order the techniques used by the RN when performing an abdominal assessment.

Answer 3

A. Inspect
B. Auscultate
C. Percuss
D. Palpate

Question 4

What techniques are used by the RN to assess breath sounds?

Answer 4

A. Position the patient upright
B. Instruct the patient to take slow deep breaths
C. Listen sequentially side to side

Question 5

What is the RN assessing in the picture below?

Answer 5

The strength of the lower extremities

Question 6

What is the initial finding expected by the RN with a person with altered mental status?

Answer 6

Inability to identify time

Question 7

Which circle indicates the best location for the RN to place the stethoscope when auscultating an apical pulse?

Answer 7

Apex (apical area), 5th intercostal space mid-clavicular line on the left side of the chest

Question 8

When the RN performs a physical assessment on a 4 month old infant what is an unexpected finding?

Answer 8

Ribbon like stool (s/s of Hirschsprung disease (absence of nerve cell in the muscles of a section of the bowel)

Question 9

What ongoing physical assessment by the RN are required for a patient with a fractured wrist that had a cast applied? Select all that apply

Answer 9

A. Sensation
B. Motion of fingers
C. Skin temperature
D. Distal Capillary refill

Question 10

What are examples of the RN applying basic medical asepsis principles in the patient environment? Select all that apply

Answer 10

A. Have the patient ask all persons entering room “Are your hands clean?”
B. Clean the stethoscope with antiseptic wipe before and after use
C. Teach the patient cough etiquette
D. Maintain personal Hygiene

Question 11

The RN notices paleness of the conjunctiva. Which laboratory finding would the Rn expect to be abnormal?

Answer 11

Hemoglobin (pallor decreased amount circulating blood)

Question 12

What is an expected finding when the RN performs a physical assessment on a woman at 36 week of pregnancy? Select all that apply

Answer 12

A. Thin watery fluid leaking from the breast
B. Fundus height at xiphoid process
C. Dizzy when lying on her back
D. Fetal heart rate of 150 beats per minute

Question 13

A patient arrives for a physical examination dressed with two (2) different shoes, wearing no socks, and a bathrobe over clothes. There is a 22 pound weight loss since last visit 6 months ago. When asked about attire, the patient does not respond. What mental health issue would the RN suspect this patient has?

Answer 13

Dementia (pt with cognitive impairment disorders have difficulty with self-care and inadequate nutrition)

Question 14

What age specific accommodation is made by the RN when performing a physical assessment on a toddler?

Answer 14

Allow toddler to handle the stethoscope

Question 15

Which technique is most appropriate for the RN to use when assessing skin turgor in an older adult?

Answer 15

Lightly pinch the skin over the sternum (or under the clavicle by lifting a fold of skin with the thumb and first finger)

Question 16

Identify normal values for vital signs for:

Answer 16

A. Newborn (Temp. 36.8C (98.2F), Pulse 80 to 180, respiration’s 30 to 80, B/P 73/55)
B. 2 Year Old (Temp. 37.7C (99.9F), Pulse 80 to 140, respiration’s 20 to 40, B/P 90/55)
C. 7 Year Old (Temp. 37C (98.6F), Pulse 75 to 120, respiration’s 15 to 25, B/P 95/75)
D. Adult (Temp 37C (98.6F), Pulse 60 to 100, respiration’s 12 to 20, B/P 120/80)

Question 17

According to the standards set by the national Heart, Lung, and Blood institute, identify the range a body mass index (BMI) value indicates an adult patient as:

Answer 17

A. Underweight (Less than 18.5)
B. Normal weight (18.6 to 24.9)
C. Overweight (25 to 29.9)
D. Obese (30 to 34.9)

Question 18

1. This question relates to analyzing the data from Mrs. Feinstein’s physical assessment. Base your answers on the physical assessment.
   • What data from Mrs. Feinstein’s physical assessment indicates to the RN the presence of a current significant health problem?

Answer 18

A. Respiration’s at rest are 30 and shallow
B. Breath sounds diminished in bases
C. Reports pain when taking a deep breath
D. Oxygen Saturation level of 90% on 2L of O2 NC

Question 19

2. This question relates to analyzing the data from Mrs. Feinstein’s physical assessment. Base your answers on the physical assessment.
   • Which physical findings from the skin assessment performed by the RN signify a significant health problem for Mrs. Feinstein?

Answer 19

Ecchymosis (hx of recent falls)

Question 20

3. This question relates to analyzing the data from Mrs. Feinstein’s physical assessment. Base your answers on the physical assessment.
   • Which physical findings obtained by the RN indicates significant health issues for Mrs. Feinstein? Select all that apply

Answer 20

A. Heart rate of 100 beats per minute
B. B/P 80/56
C. Pain level of 6 on 10 scale with movement

Question 21

4. This question relates to analyzing the data from Mrs. Feinstein’s physical assessment. Base your answers on the physical assessment.
   • Based on Mrs. Feinstein’s physical assessment, what body systems have current significant health problems? Select all that apply

Answer 21

A. Musculoskeletal
B. Cardiovascular
C. Respiratory

Question 22

5. This question relates to analyzing the data from Mrs. Feinstein’s physical assessment. Base your answers on the physical assessment.
   • Mrs. Feinstein’s respirations are shallow and the rate is 30 breaths per minute. Based on this finding, which independent nursing intervention would be appropriate?

Answer 22

A. Keep in an upright position

Question 23

Which action by the student nurse indicates to the RN that more teaching is needed about weighing an infant?

Answer 23

The infant is wearing a diaper

Question 24

A patient with a two day history of vomiting comes to the Emergency Department and reports muscle weakness, leg cramps and fatigue. Which laboratory result does the RN anticipate to be abnormal?

Answer 24

Potassium

Question 25

The RN anticipates an increase in which vital sign when a patient has an acute blood loss related to trauma?

Answer 25

Heart Rate

Question 26

On physical exam the patient has bilateral pitting pedal edema. Which nursing assessment would be most accurate to help determine fluid volume excess?

Answer 26

Weigh the patient

Question 27

Where should the RN place the stethoscope to best auscultate the middle lobe of the lung?

Answer 27

?

Question 28

Place the components of the physical assessment for a child in correct order.

Answer 28

?

Question 29

Which is the earliest clue observed by the RN that a patient has impaired mental status?

Answer 29

Unable to identify the season

Question 30

A patient is admitted to the hospital with hypovolemia r/t severe diarrhea. What is a priority intervention to be initiated by the RN?

Answer 30

Place the patient on contact precautions

Question 31

A patient with decreased hair on the lower legs, skin that is cool to touch, and thickened toenails indicates to the RN a chronic problem which chronic problem with which body system?

Answer 31

Cardiovascular

Question 32

Which method should the RN use when measuring vital signs on a patient with an uncontrolled essential tremor?

Answer 32

?

Question 33

A patient is admitted to the Emergency Department with altered mental status. Vital signs taken reveal: B/P 80/50, pulse 50 regular, and respiratory rate 6 breaths per minute. What additional information would be a priority for the RN to seek?

Answer 33

Opioid Use

Question 34

Which assessments should the RN perform when evaluating a patient with peripheral artery insufficiency of the lower extremities? Select all that apply

Answer 34

?

Question 35

Which clinical findings indicate to the RN that a child is experiencing an acute respiratory problem? Select all that apply

Answer 35

?

Question 36

A patient’s systolic blood pressure is 30 mm Hg higher than the baseline. What could be the cause of a falsely elevated blood pressure reading?

Answer 36

Arm is unsupported during measurement

Question 37

When performing an abdominal assessment on a patient who had an appendectomy 24 hours ago, which quadrant should the RN palpate last?

Answer 37

Lower right quadrant

Question 38

What is the RN looking for when assessing the sclera of a dark skinned patient admitted with gall bladder disease?

Answer 38

Jaundice

Question 39

How should the RN assess the hydration status of an acutely ill six month old infant with a 24 hour history of vomiting and water stools?

Answer 39

Anterior fontanel

Question 40

What is best practice by the RN when obtaining a blood pressure and Korotkoff sounds are heard immediately after releasing the air in the cuff?

Answer 40

Release all the air and wait one minute before retaking

Question 41

A patient with a history of frequent falls with fractures exhibits muscle weakness and bone pin. The RN suspects which nutritional deficiency?

Answer 41

Vitamin D

Question 42

A woman who delivered baby 6 weeks ago is seeking care for extreme fatigue with frequent crying episodes. She appears tires, has slumped posture, and clothing appears unclean. What area requires a more detailed assessment by the RN?

Answer 42

Psychological