Head to Toe assessment
ADPIEAnswer - Assessment
Diagnosis
Planning
Implementation
Evaluation
True/False: There is only one way to perform a head to toe examinationAnswer -
FALSE - there is NO "one way" to perform it
When performing an exam on an adult, which body region/area should be saved for
last? For neonates and infants?Answer - adults - examine genitalia last
neonates, infants - examine ears last
True/False: Head to Toe exams should be smooth and logical.Answer - TRUE
Hospitalized patients do not receive a complete head to toe exam every 24 hours; they
require _______ exam at least every 8 hours.Answer - specialized or focused exam
(**more often if in ICU**)
When are head to toe examinations performed?Answer - upon patient's first entry in an
outpatient setting and during annual check ups
A patient presents to the emergency department complaining of abdominal pain. Which
component of the health examination should the nurse consider
doing first?
A. The nurse should get a complete history on the patient prior to the abdominal
examination.
B. The nurse should get a detailed history of the pain and perform a focused
assessment.
C. The nurse should examine the abdomen first, then ask pertinent questions related to
the pain.
D. The nurse should document the chief complaint and perform a head‐to‐toe
examination.Answer - B. The nurse should get a detailed history of the pain and perform
a focused assessment.
To conserve the patient's energy, what should you do (or not do) when performing a
complete exam?Answer - Minimize the number of times the patient has to change
positions
Biographic dataAnswer - name
address
marital status
, source of info - patient, parent, other
Health HistoryAnswer - childhood and chronic illnesses
accidents
hospitalizations
OB hx
immunizations
last exam
allergies and current meds
When asking questions regarding family hx, what is the key information?Answer -
parents health
ROS: general or detailed?Answer - detailed
The nurse is completing a ROS during a health assessment. The nurse knows that
the ROS is considered:
A. factual information that incorporates objective information.
B. a systematic approach to obtaining objective information.
C. a systematic approach to obtaining subjective information.
D. an important component of the social history.Answer - C. a systematic approach to
obtaining subjective information.
Functional AssessmentAnswer - self-concept
activity and exercise
sleep and rest
nutrition
alcohol
interpersonal relationships
coping and stress management
Where should the patient be when the skin is being examined? What is assessed during
a basic check of the skin?Answer - sitting on the exam table -- examine both hands and
the nails...continue to examine the skin throughout the assessment
What cranial nerve can be assessed while observing the face and facial expressions?
Answer - cranial nerve 7
What cranial nerve can be assessed while performing the confrontation test to test
visual fields?Answer - cranial nerve 2
Which cranial nerve can be assessed while checking the 6 cardinal positions of gaze
and the corneal light reflex?Answer - cranial nerves 3, 4, 6
What is the cue to patients when performing the whisper test? Which cranial nerve is
this a test of?Answer - cue = "Repeat what I say."
ADPIEAnswer - Assessment
Diagnosis
Planning
Implementation
Evaluation
True/False: There is only one way to perform a head to toe examinationAnswer -
FALSE - there is NO "one way" to perform it
When performing an exam on an adult, which body region/area should be saved for
last? For neonates and infants?Answer - adults - examine genitalia last
neonates, infants - examine ears last
True/False: Head to Toe exams should be smooth and logical.Answer - TRUE
Hospitalized patients do not receive a complete head to toe exam every 24 hours; they
require _______ exam at least every 8 hours.Answer - specialized or focused exam
(**more often if in ICU**)
When are head to toe examinations performed?Answer - upon patient's first entry in an
outpatient setting and during annual check ups
A patient presents to the emergency department complaining of abdominal pain. Which
component of the health examination should the nurse consider
doing first?
A. The nurse should get a complete history on the patient prior to the abdominal
examination.
B. The nurse should get a detailed history of the pain and perform a focused
assessment.
C. The nurse should examine the abdomen first, then ask pertinent questions related to
the pain.
D. The nurse should document the chief complaint and perform a head‐to‐toe
examination.Answer - B. The nurse should get a detailed history of the pain and perform
a focused assessment.
To conserve the patient's energy, what should you do (or not do) when performing a
complete exam?Answer - Minimize the number of times the patient has to change
positions
Biographic dataAnswer - name
address
marital status
, source of info - patient, parent, other
Health HistoryAnswer - childhood and chronic illnesses
accidents
hospitalizations
OB hx
immunizations
last exam
allergies and current meds
When asking questions regarding family hx, what is the key information?Answer -
parents health
ROS: general or detailed?Answer - detailed
The nurse is completing a ROS during a health assessment. The nurse knows that
the ROS is considered:
A. factual information that incorporates objective information.
B. a systematic approach to obtaining objective information.
C. a systematic approach to obtaining subjective information.
D. an important component of the social history.Answer - C. a systematic approach to
obtaining subjective information.
Functional AssessmentAnswer - self-concept
activity and exercise
sleep and rest
nutrition
alcohol
interpersonal relationships
coping and stress management
Where should the patient be when the skin is being examined? What is assessed during
a basic check of the skin?Answer - sitting on the exam table -- examine both hands and
the nails...continue to examine the skin throughout the assessment
What cranial nerve can be assessed while observing the face and facial expressions?
Answer - cranial nerve 7
What cranial nerve can be assessed while performing the confrontation test to test
visual fields?Answer - cranial nerve 2
Which cranial nerve can be assessed while checking the 6 cardinal positions of gaze
and the corneal light reflex?Answer - cranial nerves 3, 4, 6
What is the cue to patients when performing the whisper test? Which cranial nerve is
this a test of?Answer - cue = "Repeat what I say."
