Head-to-Toe Assessment

A nurse is assessing a patient’s neck with the patient seated. Which of the following is considered an unexpected finding?

• Jugular vein distention

• Midline Trachea

• Lack of bruits in carotid arteries

• Thyroid symmetry bilaterally

A nurse is inspecting the patient’s ears with an otoscope. Which of the following findings would be considered normal?

• A small plastic bead

• Brownish black tympanic membrane

• Perforation of the tympanic membrane

• Small amount of cerumen

In which arteries are bruits considered normal?

• Carotid arteries

• Temporal arteries

• Aortic artery

• None of the above

Neck rotation on each side should be:

• 120 degrees

• 70 degrees

• 10 degrees

• 45 degrees

Which of the following cranial nerves is assessed by observing the patient making specific facial movements?

• Cranial Nerve VII

• Cranial nerve XI

• Olfactory nerve

• Acoustic nerve

For which reflex is the normal response plantar flexion of the foot?

• Brachioradialis

• Patellar

• Triceps

• Achilles

What is the purpose of having the patient clench his teeth and smile?

• It tests two-point discrimination.

• It tests CN VII and lets you observe tooth occlusion.

• It tests the abdominal reflexes.

• It tests CN III, IV, and VI.

Which of the following is not included in a head-to-toe assessment?

• Near vision test

• Testing the spinal reflexes

• Exercise stress test

• Balance tests

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.

Which of the following is part of monitoring and care?

• Explain that no additional screening will ever be needed.

• Stay in the room while the patient is returning to street clothes.

• Keep the patient’s glasses until they are back in street clothes.

• Ask the patient if she/he has any questions or concerns about the exam.