Quiz #12: Head-to-toe Assessment

Question 1

A nurse who works on a day-surgery unit conducts a thorough, head-to-toe assessment of each client prior to the client’s scheduled surgery. The nurse would document an unexpected finding if unable to palpate a client’s:
a) Liver
b) Thyroid gland
c) Lymph nodes
d) Peripheral pulses

Answer 1

d) Peripheral pulses

Question 2

Upon assessment of an older adult, the nurse notes the client’s skin to have a yellow color. The nurse recognizes and documents this skin color as which of the following?
a) Jaundice
b) Pallor
c) Cyanosis
d) Ecchymosis

Answer 2

a) Jaundice

Question 3

If the patient’s skin color is cyanotic or pale, breathing is difficult, posture is strained, facial expression is anxious, or overall appearance indicates distress, the nurse focuses on the immediate problem.
a) True
b) False

Answer 3

a) True

Question 4

Nurses assess ability to perform self-care activities, or __________.

Answer 4

Activities of Daily Living

Question 5

When conducting a focused health assessment, the nurse asks questions specifically targeting the client’s:
a) Gender
b) Sexual orientation
c) Specific issues and symptoms
d) Culture

Answer 5

c) Specific issues and symptoms

Question 6

When inspecting the patient’s skin, the nurse should look for _____________, which may include scabies, lice, and fleas.

Answer 6

Infestations

Question 7

The physical exam begins with the head-to-toe assessment.
a) True
b) False

Answer 7

b) False

Question 8

The nurse usually performs a complete physical exam with elements in the following order:
a) Ears, back, lungs, arms
b) Head, abdomen, lungs, legs
c) Face, heart, legs, arms
d) Eyes, heart, abdomen, legs

Answer 8

d) Eyes, heart, abdomen, legs

Question 9

The nurse is conducting a head-to-toe assessment on a client. Which observation(s) by the nurse would be cause for concern? Select all that apply.
a) Freckles
b) Goose bumps
c) Infestations
d) Lesions
e) Rashes

Answer 9

c) Infestations
d) Lesions
e) Rashes

Question 10

A high school football player presents to the hospital with dizziness, headache, sleepiness, increased tenting of the skin, and decreased turgor following an intensive practice in the summer heat. Which of the following nursing diagnoses can the nurse formulate based on this info?
a) Acute confusion
b) Risk for imbalanced fluid volume
c) Deficient fluid volume
d) Activity intolerance

Answer 10

c) Deficient fluid volume