Head to Toe Assessment
1. An 85-year-old man has come in for a physical examination, and the nurse notices that he uses a
cane. When documenting general appearance, the nurse should document this information under the section
that covers:
A) posture.
B) mobility.
C) mood and affect.
D) physical deformity.
ANS: B
Use of assistive devices would be documented under the mobility section. The other responses are all other
categories of the general appearance section of the health history.
2. The nurse is performing a vision examination. Which of these charts is most widely used for
vision examinations?
A) Snellen
B) Shetllen
C) Smoollen
D) Schwellon
ANS: A
The Snellen eye chart is most widely used for vision examinations. The other options are not tests for vision
examinations.
3. After the health history has been obtained, and before beginning the physical examination, the
nurse should ask the patient to first:
A) empty the bladder.
B) completely disrobe.
C) lie on the examination table.
D) walk around the room.
ANS: A
Before beginning the examination, the nurse should ask the person to empty the bladder (save the specimen if
needed), disrobe except for underpants, put on a gown, and sit with legs dangling off side of the bed or table.
This study source was downloaded by 100000869267694 from CourseHero.com on 07-31-2023 04:45:18 GMT -05:00
https://www.coursehero.com/file/96693292/Head-to-Toe-Assessmentdocx/
, 4. During a complete health assessment, how would the nurse test the patient’s hearing?
A) By observing how the patient participates in normal conversation
B) Using the whispered voice test
C) Using the Weber and Rinne tests
D) Testing with an audiometer
ANS: B
During the complete health assessment, the nurse should test hearing with the whispered voice test. The other
options are not correct.
5. The nurse has just completed an examination of a patient’s extraocular muscles. When
documenting the findings, the nurse should document the assessment of which cranial nerves?
A) II, III, VI
B) II, IV, V
C) III, IV, V
D) III, IV, VI
ANS: D
Extraocular muscles are innervated by cranial nerves III, IV, and VI.
6. A patient’s uvula rises midline when she says “ahh” and she has a positive gag reflex. The nurse
has just tested which cranial nerves?
A) IX, X
B) IX, XII
C) X, XII
D) XI, XII
ANS: A
Cranial nerves IX and X are being tested by having the patient say “ahh,” noting the mobility of the uvula, and
when assessing the patient’s gag reflex.
This study source was downloaded by 100000869267694 from CourseHero.com on 07-31-2023 04:45:18 GMT -05:00
https://www.coursehero.com/file/96693292/Head-to-Toe-Assessmentdocx/
1. An 85-year-old man has come in for a physical examination, and the nurse notices that he uses a
cane. When documenting general appearance, the nurse should document this information under the section
that covers:
A) posture.
B) mobility.
C) mood and affect.
D) physical deformity.
ANS: B
Use of assistive devices would be documented under the mobility section. The other responses are all other
categories of the general appearance section of the health history.
2. The nurse is performing a vision examination. Which of these charts is most widely used for
vision examinations?
A) Snellen
B) Shetllen
C) Smoollen
D) Schwellon
ANS: A
The Snellen eye chart is most widely used for vision examinations. The other options are not tests for vision
examinations.
3. After the health history has been obtained, and before beginning the physical examination, the
nurse should ask the patient to first:
A) empty the bladder.
B) completely disrobe.
C) lie on the examination table.
D) walk around the room.
ANS: A
Before beginning the examination, the nurse should ask the person to empty the bladder (save the specimen if
needed), disrobe except for underpants, put on a gown, and sit with legs dangling off side of the bed or table.
This study source was downloaded by 100000869267694 from CourseHero.com on 07-31-2023 04:45:18 GMT -05:00
https://www.coursehero.com/file/96693292/Head-to-Toe-Assessmentdocx/
, 4. During a complete health assessment, how would the nurse test the patient’s hearing?
A) By observing how the patient participates in normal conversation
B) Using the whispered voice test
C) Using the Weber and Rinne tests
D) Testing with an audiometer
ANS: B
During the complete health assessment, the nurse should test hearing with the whispered voice test. The other
options are not correct.
5. The nurse has just completed an examination of a patient’s extraocular muscles. When
documenting the findings, the nurse should document the assessment of which cranial nerves?
A) II, III, VI
B) II, IV, V
C) III, IV, V
D) III, IV, VI
ANS: D
Extraocular muscles are innervated by cranial nerves III, IV, and VI.
6. A patient’s uvula rises midline when she says “ahh” and she has a positive gag reflex. The nurse
has just tested which cranial nerves?
A) IX, X
B) IX, XII
C) X, XII
D) XI, XII
ANS: A
Cranial nerves IX and X are being tested by having the patient say “ahh,” noting the mobility of the uvula, and
when assessing the patient’s gag reflex.
This study source was downloaded by 100000869267694 from CourseHero.com on 07-31-2023 04:45:18 GMT -05:00
https://www.coursehero.com/file/96693292/Head-to-Toe-Assessmentdocx/
