Head to Toe Assessment Questions

Question 1

Adduction

Answer 1

Movement toward the midline

Question 2

Abduction

Answer 2

Movement away from the body

Question 3

Supination

Answer 3

Palms upward

Question 4

Pronation

Answer 4

palms downward

Question 5

Flexion

Answer 5

Decreasing the angle of a joint

Question 6

Extension

Answer 6

increasing the angle of a joint

Question 7

Inversion

Answer 7

Feet turned inward

Question 8

Eversion

Answer 8

Feet turned outward

Question 9

Lordosis

Answer 9

“Swayback”: Increased lumbar curvature above buttocks most often found in young children. neuromuscular problem with hip or posture

Question 10

Scoliosis

Answer 10

Lateral curvature of the spine. Begin screening for this from 11-14 and treatment at 40 degree curvature.

Question 11

Kyphosis

Answer 11

Exaggeration of the posterior thoracic spine curvature which can be due to osteoporosis (hunched Back)

Question 12

Romberg Test

Answer 12

Has a patient stand still with eyes open, then with eyes closed. Tests their balance

Question 13

Wheeze

Answer 13

Continuous musical sounds

Caused by high velocity airflow through significantly narrowed airways

Question 14

Stridor

Answer 14

Harsh honking wheeze with severe bronchospasm

Air passing through a very constricted airway. Secondary to croup or a swallowed object caught in the airway

Question 15

Crackles

Answer 15

Fluid in the lungs. Bubbling sounds. Not cleared with coughing

Common in the lower lung lobes

Question 16

Rhonchi

Answer 16

Loud, Low pitched, Rumbling course sounds heard throughout lungs.

Typically secondary to mucus/fluid in larger airways. May be cleared with coughing

Question 17

Chest Excursion

Answer 17

Holding hands on the back while the person breathes and seeing what happens to your hands. They should expand equally

Question 18

Vocal Fremitus

Answer 18

External vibration while a pt talks. (the 99 test)

Lack of vibration may be due to: Accumulation of mucus, Lung Collapse, Lung lesion

Question 19

Cheyne-Stokes

Answer 19

Alternating periods of deep rapid breathing followed by periods of apnea.
Associated with end-of-life

Question 20

Biots Respirations

Answer 20

Irregular breathing pattern characterized by varying shallow respirations followed by periods of apnea
Associated with intracranial pressure and respiratory compromise.

Question 21

Kussmal Respirations

Answer 21

A type of hyperventilation marked by exaggerated deep, regular, rapid breathing.

Normal with exercise

May be present with: aspirin (asa) overdose, pain, fever, hysteria, cardiac and or respiratory disease, Diabetic Ketoacidosis

Question 22

ABCDE

Answer 22

Test for abnormal mole: Asymmetrical, Border, Color (black? dark brown? changing?), Diameter (no more than 6mm), Evolution

Question 23

Braden Scale Range

Answer 23

6-23. Lower=higher risk for pressure injury

Question 24

Braden Scale Purpose

Answer 24

Assigns a number for the likelihood of developing a pressure injury

Question 25

Cranial Nerve 1 (Name, Function, and Sensory or Motor)

Answer 25

Olfactory: Sensory: Sense of smell: test with a scent under the nose

Question 26

Cranial Nerve 2 (Name, Function, and Sensory or Motor)

Answer 26

Optic: sensory: visual acuity: test with the snellen chart

Question 27

Cranial Nerve 3 (Name, Function, and Sensory or Motor)

Answer 27

Oculomotor: Motor: Extra ocular movement: Pupil Dilation: test with PERRLA

Question 28

Cranial Nerve 4 (Name, Function, and Sensory or Motor)

Answer 28

Trochlear: Motor: Up/down eye movement: test with 6 fields gaze

Question 29

Cranial Nerve 5 (Name, Function, and Sensory or Motor)

Answer 29

Trigeminal: motor + sensory: jaw movement + feeling in face: test with a cottonball to the face and clenching jaw

Question 30

Cranial Nerve 6 (Name, Function, and Sensory or Motor)

Answer 30

Abducens: motor: lateral eye movement: test with 6 fields gaze test

Question 31

Cranial Nerve 7 (Name, Function, and Sensory or Motor)

Answer 31

Facial: sensory + motor: taste on front of tongue + facial expression: test by smiling and tasting

Question 32

Cranial Nerve 8 (Name, Function, and Sensory or Motor)

Answer 32

Auditory: Sensory: Hearing: Test with the whisper test

Question 33

Cranial Nerve 9 (Name, Function, and Sensory or Motor)

Answer 33

Glossopharyngeal: Sensory + Motor: Gag reflex and taste on the back of the tongue: test by tasting

Question 34

Cranial Nerve 10 (Name, Function, and Sensory or Motor)

Answer 34

Vagus: Sensory + Motor: swallowing/movement of vocal cords: test by swallowing

Question 35

Cranial Nerve 11 (Name, Function, and Sensory or Motor)

Answer 35

Spinal Accessory: Motor: movement of head and shoulders: test by having pt. move head and shoulders

Question 36

Cranial Nerve 12 (Name, Function, and Sensory or Motor)

Answer 36

Hypoglosseal: Motor: Positioning of the tongue: Test by moving the tongue

Question 37

Glasgow Coma Scale (ranges and tests)

Answer 37

Objective numerical scale measuring level of conscience Range: 3-15 Eye-Opening: 1-4 Verbal Response: 1-5 Motor Response: 1-6

Question 38

Enuresis

Answer 38

Bed wetting

Question 39

Hematuria

Answer 39

Blood in the urine

Question 40

polyuria

Answer 40

excessive urination (more than 2500-3000mL/24h)

Question 41

pyuria

Answer 41

pus in urine

Question 42

nocturia

Answer 42

Awakens at night to urinate a lot

Question 43

stress incontinence

Answer 43

Urination when the bladder receives stress (laughter, pressing on the bladder, shock)

Question 44

One organ in the RUQ

Answer 44

Liver & Gallbladder

Question 45

One organ in the LUQ

Answer 45

Stomach & Spleen

Question 46

One organ in the RLQ

Answer 46

Appendix

Question 47

One organ in the LLQ

Answer 47

Sigmoid Colon, left ovary, Left ureter

Question 48

Ptosis

Answer 48

Drooping of the eyelid

Question 49

Strabismus

Answer 49

Cross-eyed

Question 50

Exophthalmos

Answer 50

Bulging of the Eyes

Question 51

Myopia

Answer 51

Nearsightedness

Question 52

Hyperopia

Answer 52

Far sightedness

Question 53

Presbyopia

Answer 53

Age-related loss of near vision

Question 54

Allen's Test

Answer 54

The Allen’s test ensures that the ulnar pulse and radial pulses are both working properly

Question 55

Pulse Deficit

Answer 55

Palpate radial while listening to apical pulse. If there is a difference, then the pulse is not reaching the peripheral pulse

Question 56

Clubbing

Answer 56

Indicative of inadequate blood flow to the hands. No space between fingernails when they are pressed together.

Question 57

Four Heart Valves

Answer 57

Aortic, Pulmonic, Tricuspid, Mitral