Head-to-Toe Assessment Review

In which order should the abdomen be assessed?

• Inspect, palpate, percuss, auscultate

• Auscultate, palpate, percuss, inspect

• Palpate, inspect, auscultate, percuss

• Inspect, auscultate, percuss, palpate

What is the purpose of auscultating the abdomen before palpation and percussion?

• To get a baseline of bowel sounds

• To prevent alteration of bowel sounds

• To assess for any masses or lesions

• To check for tenderness or pain

What information can be collected by observing the patient during a head-to-toe assessment?

• Emotional status, skin color, hygiene

• Vital signs, pain rating, height and weight

• Cranial nerve function, respiratory rate, BMI

• Blood pressure, skin breakdown, posture

What should be assessed during the inspection of the head?

• Skin color, facial symmetry, abnormal movements

• Hair condition, beard abnormalities, skin breakdown

• Temporal artery pulsations, cranial nerve 7 function, facial expressions

• Hygiene, posture, abnormal smell

How should the temporal artery be assessed?

• Palpate bilaterally and check for tenderness

• Inspect for any masses or indentations

• Auscultate for abnormal sounds

• Test cranial nerve 5 function

What is the purpose of testing cranial nerve 3, 4, and 6?

• To assess eye movements and detect nystagmus

• To check for pupillary constriction and accommodation

• To evaluate olfactory function

• To assess hearing and balance

What is the normal size range for pupils?

• 1-3 millimeters

• 3-5 millimeters

• 5-7 millimeters

• 7-9 millimeters

How should the tympanic membrane be inspected?

• Pull the pinna down and back

• Pull the pinna up and forward

• Use an otoscope to visualize the membrane

• Palpate for any tenderness or masses

What cranial nerve is responsible for the sense of smell?

• Cranial nerve 1

• Cranial nerve 5

• Cranial nerve 8

• Cranial nerve 12

No adaptations are necessary when assessing patients of different age groups.

• true

• false