Podcast
Questions and Answers
Where does the nurse begin a head-to-toe assessment?
Where does the nurse begin a head-to-toe assessment?
- Neurologic assessment (correct)
- Respiratory assessment
- Circulatory assessment
- Skin assessment
What indicates decreased skin turgor in an older adult patient?
What indicates decreased skin turgor in an older adult patient?
- Swelling in the skin
- Rapid return of skin after being grasped
- Coloration changes in skin
- Slow return of skin after being grasped (correct)
When are crackles most often heard during a physical assessment?
When are crackles most often heard during a physical assessment?
- Following expiration
- Following inspiration
- During inspiration (correct)
- During expiration
What physiological change causes the 'lub' sound during heart auscultation?
What physiological change causes the 'lub' sound during heart auscultation?
What condition is primarily responsible for decreased skin turgor?
What condition is primarily responsible for decreased skin turgor?
During a physical assessment, adventitious lung sounds are checked. What are crackles classified by?
During a physical assessment, adventitious lung sounds are checked. What are crackles classified by?
What type of assessment method involves examining the body systematically from head to toe?
What type of assessment method involves examining the body systematically from head to toe?
In which phase of respiration are crackles generally heard?
In which phase of respiration are crackles generally heard?
Which heart valves closing primarily contributes to the 'dup' sound on auscultation?
Which heart valves closing primarily contributes to the 'dup' sound on auscultation?
What is the heart condition characterized by a heart rate of less than 60 contractions per minute called?
What is the heart condition characterized by a heart rate of less than 60 contractions per minute called?
What condition is indicated by a bluish discoloration of the skin and mucous membranes?
What condition is indicated by a bluish discoloration of the skin and mucous membranes?
Which term describes discoloration due to the extravasation of blood into subcutaneous tissues?
Which term describes discoloration due to the extravasation of blood into subcutaneous tissues?
What do you call the redness or inflammation that results from the congestion of superficial capillaries?
What do you call the redness or inflammation that results from the congestion of superficial capillaries?
Which of the following conditions is characterized by increased fragility of blood vessel walls?
Which of the following conditions is characterized by increased fragility of blood vessel walls?
What cardiovascular condition is primarily assessed by monitoring heart rate?
What cardiovascular condition is primarily assessed by monitoring heart rate?
What does the 'R' stand for in the PQRST system used for patient history intake?
What does the 'R' stand for in the PQRST system used for patient history intake?
Which method is particularly useful for detecting tenderness or masses during a physical examination?
Which method is particularly useful for detecting tenderness or masses during a physical examination?
When auscultating breath sounds, which sound is low-pitched, coarse, and has a gurgling quality?
When auscultating breath sounds, which sound is low-pitched, coarse, and has a gurgling quality?
What does the density of underlying tissue indicate during a physical assessment?
What does the density of underlying tissue indicate during a physical assessment?
Which of the following methods of examination is least likely to be used to assess tenderness in the abdomen?
Which of the following methods of examination is least likely to be used to assess tenderness in the abdomen?
Which technique would be the most appropriate for examining a patient with known respiratory issues?
Which technique would be the most appropriate for examining a patient with known respiratory issues?
What is typically the first step in a systematic approach to auscultating the thorax?
What is typically the first step in a systematic approach to auscultating the thorax?
Which of the following is NOT characteristic of sonorous wheezes?
Which of the following is NOT characteristic of sonorous wheezes?
In performing physical assessments, which finding would lead a nurse to suspect mucus presence in a patient's airways?
In performing physical assessments, which finding would lead a nurse to suspect mucus presence in a patient's airways?
Which of the following actions would be least effective when assessing a patient's abdomen for tenderness?
Which of the following actions would be least effective when assessing a patient's abdomen for tenderness?
What is indicated by a unilateral, dilated, and nonreactive pupil during a neurologic assessment?
What is indicated by a unilateral, dilated, and nonreactive pupil during a neurologic assessment?
Which position is optimal for inserting a vaginal speculum during an examination?
Which position is optimal for inserting a vaginal speculum during an examination?
In which position should the nurse place the patient to assess extension of the hip joint?
In which position should the nurse place the patient to assess extension of the hip joint?
What is the recommended position for assessing a patient for a heart murmur?
What is the recommended position for assessing a patient for a heart murmur?
What is the appropriate documentation when a nurse observes a patient experiencing a sudden audible expulsion of air from the lungs?
What is the appropriate documentation when a nurse observes a patient experiencing a sudden audible expulsion of air from the lungs?
What should the nurse document if a patient has profuse secretions of sweat?
What should the nurse document if a patient has profuse secretions of sweat?
What is the primary function of cranial nerve III?
What is the primary function of cranial nerve III?
During a physical assessment, frequent loose liquid stools indicate that a patient is experiencing what condition?
During a physical assessment, frequent loose liquid stools indicate that a patient is experiencing what condition?
Which of the following nerves is affected by increased intracranial pressure resulting in a nonreactive pupil?
Which of the following nerves is affected by increased intracranial pressure resulting in a nonreactive pupil?
What finding during a neurologic assessment suggests possible involvement of the oculomotor nerve?
What finding during a neurologic assessment suggests possible involvement of the oculomotor nerve?
Which term describes the protective response that clears the lungs of irritants?
Which term describes the protective response that clears the lungs of irritants?
What condition might be indicated by dark black, tarry stools in a patient?
What condition might be indicated by dark black, tarry stools in a patient?
Which position maximally exposes the genitalia for a vaginal examination?
Which position maximally exposes the genitalia for a vaginal examination?
Which of the following is NOT an objective finding that a nurse might document during an assessment?
Which of the following is NOT an objective finding that a nurse might document during an assessment?
What is the priority nursing action when a patient has a nonreactive pupil?
What is the priority nursing action when a patient has a nonreactive pupil?
What is the most appropriate action if a patient becomes unresponsive with fixed dilated pupils?
What is the most appropriate action if a patient becomes unresponsive with fixed dilated pupils?
A patient exhibits symptoms of excessive sweating during an assessment. What should be the nurse's documentation?
A patient exhibits symptoms of excessive sweating during an assessment. What should be the nurse's documentation?
Which of the following terms relates to the clinical assessment of a patient's respiratory distress?
Which of the following terms relates to the clinical assessment of a patient's respiratory distress?
What should a nurse assess if a patient presents with symptoms of mental or emotional stress and sweating?
What should a nurse assess if a patient presents with symptoms of mental or emotional stress and sweating?
Frequent loose liquid stools can result from which of the following?
Frequent loose liquid stools can result from which of the following?
Study Notes
Head-to-toe Assessment
- When performing a head-to-toe assessment, the nurse begins with a neurologic assessment
- Nursing Assessment is a crucial step within the nursing process
Skin Assessment
- Dehydration results in decreased skin turgor, which is assessed when the skin is grasped and raised, then observed for its return to the previous position.
Lung Sounds
- Crackles, which are classified as fine, medium, or coarse, are usually heard during inspiration.
Heart Sounds
- Auscultating the heart sounds with a stethoscope should result in a "lub-dup" sound.
- The "lub" sound is caused by the closing of the AV valves.
PQRST
- The PQRST system is used for the interview assessment
- The R in the PQRST system stands for "region"
Abdominal Examination
- Deep palpation is used to detect tenderness or masses in the abdomen
Breath Sounds
- Sonorous wheezes have a low-pitched, coarse, gurgling, snoring quality and usually indicate the presence of mucus in the trachea and large airways.
Neurologic Assessment
- A unilateral, dilated, and nonreactive pupil is a sign of pressure on the oculomotor nerve (cranial nerve III)
Patient Positioning
- The lithotomy position facilitates the insertion of a vaginal speculum
- The prone position is used to assess extension of a patient’s hip joint.
Physical Assessment Terminology
- A sudden audible expulsion of air from the lungs is classified as coughing
- Profuse secretions of sweat are referred to as diaphoresis
- Frequent passage of loose liquid stools are classified as diarrhea
- Bradycardia is a heart rate of less than 60 beats per minute
- Cyanosis is a bluish discoloration of the skin and mucous membranes caused by an increase of deoxygenated hemoglobin in the blood
- Ecchymosis is discoloration of the skin or mucous membrane caused by blood leaking into the subcutaneous tissues
- Erythema is redness or inflammation of the skin or mucous membranes caused by dilated and congested superficial capillaries
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Description
This quiz covers essential techniques for head-to-toe assessments in nursing, including skin evaluation, lung and heart sound auscultation, and abdominal examination methods. It also highlights critical assessment systems used in nursing practice. Test your knowledge on these fundamental clinical skills.
