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WorksheetsHead to Toe Assessments Review
Total questions: 40
Worksheet time: 20mins
Why is it important to have equipment and supplies organized before the exam?
It makes you look smarter to the patient.
It avoids interruptions and delays.
In case you are out of a supply, you can skip that part of the exam.
It lets you focus on the testing instead of the patient’s response.
Data such as headache, nasal stuffiness, and sore throat are example of what type of data?
Subjective Data
Objective Data
Secondary Data
Signs
The signs experienced by the patient are a type of what data?
Objective Data
Subjective Data
Secondary Data
Diagnostic Data
Patient's pain is 5/10
Objective
Subjective
The patient is warm to touch
Objective
Subjective
Which is not included in the Physical Examination Techniques in Health Assessment
Inspection
Palpation
Percussion
Auscultation
Extraction
Used to test pupillary constriction.
Ophthalmoscope
Penlight
Cover card
Snellen chart
Equipment used to measure the diastolic and systolic blood pressure
Sphygmomanometer
Thermometer (oral, rectal, tympanic)
Watch with second hand
Stethoscope
Where is the apical impulse located?
In the second left intercostal space at the midclavicular line
In the fifth left intercostal space at the midclavicular line
In the ninth left intercostal space at the midclavicular line
In the third left intercostal space at the midclavicular line
Auscultatory sites of the heart include
Aortic, buccal, tricuspid, and mitral areas
Pulmonic, buccal, tricuspid, and mitral areas
Aortic, pulmonic, tricuspid, and mitral areas
Plantar, buccal, tricuspid, and mitral areas
Which of the following findings during a cardiac assessment of an adult patient are considered normal?
S1 and S2 sounds
S1 and S3 sounds
S3 and S4 sound
S1 and S4 sounds
identify the sign given in image
Jugular vein distension
Subclavian vein distension
Carotid artery thrombosis
Pulmonary artery hypertension
What does the ‘C’ indicates in the picture shown in image?
Aortic valve
Pulmonic valve
Erb’s point
Tricuspid valve
Which pulse is palpated at the “A” point shown in the picture:
Carotid pulse
Bracheal pulse
Dosalis pedis pulse
Popliteal pulse
Identify the image
Halo sign
Battle sign
Raccoon sign
Cullen’s sign
Identify the test and which cranial nerve is assessed by using this test:
Gag reflex, cranial nerve IX
Platal reflex, cranial nerve X
Cough reflex, cranial nerve IX
Yawn reflex, cranial nerve XI
Identify the following test
Corneal reflex.
Pupil response to light.
Six cardinal fields of gaze.
Pupil response to light and accommodation
Identify the image in which nurse place left hand finger in the ICS and right hand finger taps the left hand finger with movement from the right wrist?
Inspection
Percussion
Palpation
Auscultation
Name this instrument which is used for physical assessment
sphygmomanometer
thermometer
blood glucose meter
stethoscope
Which one is a normal blood pressure?
120/80 mm
80/120 mmHg
120/80 mmHg
180/90 beats per min
Which are vital signs? (more than one answer)
pulse rate
body height
blood pressure
body temperature
Which measure oxygen level (pulse oximetry) ?
6. PERRLA is a medical abbreviation that means:
Pupil Equal Round Reactive to light
Pupil Equal Round Reactive to Light and Accomodation
Pupil Equally Red and Reactive to Light and Accomodation
Pupil Equally Red and Non Reactive to Light and Accomodation
8. To view the ear canal and tympanic membrane
Otoscope
Opthalmoscope
Otoscopic
Otic
What is a normal respiratory rate?
10-20 breaths /minute
12-20 breaths /minute
12-22 breaths /minute
10-22 breaths /minute
When auscultating over the lung fields the nurse hears a high-pitched, musical sound like a "squeak" on expiration. What is the proper documentation of this sound?
crackles
a squeak
rhonchi
wheezes
When assessing a patient for posterior thoracic expansion, the nurse
moves hands up and down patients lower back
observes the patient breathing from behind them
places hands on back with thumbs close together
places hands over thoracic region and instructs patient to talk
What is the appropriate way to auscultate lung sounds?
move up the right side of the chest and then down the left side
move side to side working down the chest, then move to sides
listen to the top of lungs front, back and sides, then bottom
listen to front and back of right lung then move to left lung fields
The nurse auscultating the lung fields of a child hears wheezing. The nurse associates this with what pathophysiology?
narrowing of the broncioles
fluid in the lungs
inflammation of the lung surface
normal finding
Which of the following can cause the nurse to hear falsely abnormal breath sounds?
placing the stethoscope directly on the chest
instructing the patient to take a deep breath
having the patient in the supine position
holding the diaphragm lightly against chest hair
The nurse recognizes which of the following as a sign of respiratory distress? Select all that apply.
nasal flaring
tachypnea
vesicular breath sounds
intercostal retractions
restlessness
Which artery do we palpate anterior to the ear?
tympanic
nasal
temporal
carotid
Before inserting an otoscope into the ear of an infant the nurse should
pull the pinna up and away
pull the pinna down and toward the nose
pull the pinna straight up
pull the pinna straight down
When palpating the abdomen the nurse uses which of the following techniques?
palpate lightly first in each quadrant, then deeply in each quadrant.
Palpate areas of pain first, and then palpate areas of non-pain.
Palpate light and then deep in one quadrant and then move to next quadrant.
Palpate deep first, if pain with deep palpation move to light palpation.
Assessment is performed in a head-to-toe sequence, beginning with the head and neck, progressing to the chest and abdomen, and then to the four extremities.
true
false
Instrument for visual examination of the ear
laryngoscope
spirometer
otoscope
stethoscope
What is the term that means pupils of unequal size?
Mydriasis
Anisocoria
Miosis
Papilledema
What is the functional reflex allowing the eyes to focus on near objects?
Corneal Light Reflex
Near Visual Acuity
Cover Test
Accommodation
What is a?
Right Upper Quadrant
Left Upper Quadrant
Right Lower Quadrant
Left Lower Quadrant
What is b?
Right Upper Quadrant
Left Upper Quadrant
Right Lower Quadrant
Left Lower Quadrant
