What is the very first thing a nurse should do at the beginning of a head to toe assessment?

Fundamentals of Nursing (NCLEX Exams)

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There are 35 questions to complete.

1.The very first thing a nurse will assess when doing a head to toe examination is what?

1. head
   
2. eyes
   
3. ears 
4. general appearance

2. When assessing a clients physical appearance a nurse will note which of the following? (select all that apply)

1. clients age
2. clients gender
3. clients speech
4. Palpate maxillary and facial sinuses

3. When it comes to assessing the clients physical appearance which of the following lists what a nurse would look for?

1. gender,age, ethnicity, dress, speech, level of conciousness
2. religion,age, ethnicity, dress, speech, level of conciousness
3. age, gender, ethnicity, dress, diet, speech, level of conciousness
4. gender,age, ethnicity, marital status, dress, speech, level of conciousness

4. Nurse Becky has her client come in and looks at the way he is dressed what is she looking for?

1. that her client has a good fashion sense
2. that her client feels comfortable with her
3. that her client’s dress is appropriate for his gender, age, and time of the year
4. that her client’s dress is appropriate for his gender, societal status, and marital status

5. What could the nurse assess based solely on the way the client walks into the room?

1. gender and age
2. dress and signs of illness
3. signs of illness, well nourished
4. gait and posture

6. Nurse Dave has his client come in and proceeds to ask him his name, his date of birth, if he knows where he is, and what day of the week it is. In doing this Dave is testing his clients what?

1. intelligence coeffient
2. level of conciousness
3. social and cognitive skills
4. physical and mental development

7. A nurse should assess a client’s level of conciousness to ensure they are oriented how? (select all that apply)

1. oriented to time
2. oriented to place
3. oriented to person
4. understands and responds to questions appropriately
5. all of the above

8. Which of the following would be considered normal observations regarding a client’s speech?

1. that it is rushed and garbbled
2. it is articulate and easy to understand
3. it is articulate but spoken in a language other than English
4. it is hapazard and sing-song like

9. Nurse George has just assessed his client’s articulation, language, and other aspects of his speech. In doing this which cranial nerves has he just assessed?

1. cranial nerves 4 and 5
2. cranial nerves 6 and 12
3. cranial nerves 9 and 12
4. cranial nerves 10 and 12

10. What is the very first thing a nurse should do at the begining of a head to toe assessment?

1. state the clients name and age
2. introduce yourself to the client
3. have the client walk in and take a seat
4. state the client’s gender and ethnicity

11. Which of the following would be considered normal nursing observations regarding general appearance?

1. client is well groomed
2. dress is appropriate for the season
3. no visible signs of illness noted
4. client appears well-nourished
5. all of the above

12. Which of the following would a nurse include in the general appearance portion of the assessment as normal observations regarding the client’s greeting?

1. client greets with a smile, not a frown
2. client furows brow and blinks erratically
3. client is making eye contact
4. client doesn’t appear to be in distress
5. facial expression cannot be identified

13. Which to things would a nurse state they are going to do at the end of the general appearance portion of the head to toe assessment?

1. record vitals and emotions
2. record vision and pain level
3. record vitals and pain level
4. record level of conciousness and general appearance

14. If a client reports they are in pain what would a nurse do first?

1. call the doctor immediately
2. document it immediately
3. assess client’s pain on scale 0 to 10
4. assess client’s pain on scale 0 to 20

15. A nurse conducting an assesment on a clients head would do what first?

1. inspect and palpate hair
2. inspect and palpate scalp
3. look at patient’s prior medical history
4. inspect and palpate sinuses to control spread of germs

16. Before a nurse palpates a person’s scalp what is the very first action they should take?

1. preform hand hygiene
2. ask the client how their hair feels
3. go ahead and inspect the client’s scalp
4. go right ahead and palpate client’s scalp with bare hands.

17. When it comes to hand hygiene and your client you should always do what?

1. inform client you’ve washed your hands
2. wear gloves so they don’t worry
3. wash hands in patient’s presence
4. wash hands outside patient’s room

18. Nurse Rain is assessing his client’s scalp after putting on clean gloves he begins to palpate the hair which of the following things would he be looking for? (select all that apply)

1. hair color
2. hair texture
3. hair distribution
4. Lice, alopecia
5. carcinomas of the skin

19. Which of the following would not be considered normal findings when assessing the scalp and hair of a middle aged man?

1. thinning hair
2. receding hair line
3. alopecia
4. Lice

20. When palpating the client’s temporal artery what should a nurse remember to do?

1. state the depth
2. state the location
3. state the temperature
4. state the force

21. Which would be a normal observation for a nurse stating the force of a temporal artery?

22. Nurse Joan asks her client Freedy to clench his jaw as she continues to palpate his head. When she asks him to do this what is Nurse Joan most likely trying to palpate?

1. Freedy’s temporal artery
2. Freedy’s temporomandibular joint
3. Freedy’s submandibular joint
4. Freedy’s submental joint

23. A nurse palpates a client’s temporomandibular joint, then asks him to clench his teeth. In doing this the nurse is assessing which cranial nerve?

1. cranial nerve 5
2. cranial nerve 7
3. cranial nerve 3
4. cranial nerve 4

24. A nurse doing her assessment proceeds to palpate a client’s frontal and maxillary sinuses. What should she make sure she checks for?

1. swelling
2. lesions
3. tenderness
4. tactile signs of carcinoma

25. Nurse Bill when doing his head to toe assessment on his client asks him to smile, frown, wrinkle forehead, puff cheeks, raise eyebrows, close eye lids In doing this the nurse is assessing which cranial nerve?

1. cranial nerve 5
2. cranial nerve 7
3. cranial nerve 3
4. cranial nerve 4

26. When doing an assessment on a client’s eyes the very first thing that a nurse should look at is?

1. eyes internal structures
2. color of the iris’s of the eye
3. the pupils reactivity to light
4. eyes external structures

27. The three things a nurse needs to check for when doing an examination on the eyes regarding the external structures is?

1. eyelash distribution, coloring, drainage
2. eyelash texture, shape of eyes, redness
3. Shape of eyes, pupils reactivity, iris’s color
4. drainage, possible tumors, irritation

28. Nurse Fred when examining his client’s eyes takes a light cotton ball and gently brushes it across his client’s eyes to elicit a blink this is known as what?

1. consensual light reflex test
2. corneal reflex test
3. red light reflex
4. PERRLA

29. When a nurse preforms a corneal reflex test which cranial nerve are they assessing?

1. cranial nerve 5
2. cranial nerve 7
3. cranial nerve 3
4. cranial nerve 4

30. When preforming an assesment on a patient’s eyes what might the nurse use the opthalamoscope for?

1. consensual light reflex test
2. corneal reflex test
3. red light reflex
4. PERRLA

31. Which of the following would be considered a normal observation regarding a client’s red light reflex?

1. red light reflex is displaced
2. red light reflex is intact
3. drainage is visible
4. red light reflex is abscent

32. A nurse would use either a Snelling chart or the finger wingle test to assess a client’s what?

1. hearing
2. consensual light reflex
3. vision
4. bone conduction

33. A nurse doing a head to toe assessment has his client stand 20 feet away from a chart and while blocking one eye asks him to read the smallest line he can then does the same thing in the other eye. The nurse is most likely assessing his client’s what?

1. hearing
2. consensual light reflex
3. vision
4. bone conduction

34. When a nurse does an assessment on a client’s vision using either the Snelling chart or newspaper finger-wiggle test which cranial nerve are they assessing?

1. cranial nerve 5
2. cranial nerve 7
3. cranial nerve 3
4. cranial nerve 2

35. A nurse would most likely have a client read a newspaper the wiggle their finger out to the side to test their client’s what?

1. spacial awareness
2. vision
3. peripheral vision
4. farsightedness

Answer

1. D. general appearance
2. A,B,C
3. A. gender,age, ethnicity, dress, speech, level of conciousness
4. C. that her client’s dress is appropriate for his gender, age, and time of the year
5. D. gait and posture
6. B. level of conciousness
7. E. all of the above
8. B,C
9. D. cranial nerves 10 and 12
10. C. have the client walk in and take a seat
11. E. all of the above
12. A,C.
13. C. record vitals and pain level
14. C. assess client’s pain on scale 0 to 10
15. B. inspect and palpate scalp
16. A. preform hand hygiene
17. C. wash hands in patient’s presence
18. A,B,C,D
19. C,D
20. D. state the force
21. D. +2
22. B. Freedy’s temporomandibular joint
23. A. cranial nerve 5
24. C. tenderness
25. B. cranial nerve 7
26. D.eyes external structures
27. A. eyelash distribution, coloring, drainage
28. B. corneal reflex test
29. A. cranial nerve 5
30. C. red light reflex
31. B. red light reflex is intact
32. C. vision
33. C. vision
34. D. cranial nerve 2
35. C. peripheral vision

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