Nursing Fundamentals Head to Toe Assessment Questions

Nursing Fundamentals Head to Toe Assessment Questions The very first thing a nurse will assess when doing a head to toe examination is what? A. head B. eyes C. ears D. general appearance - answer When assessing a clients physical appearance a nurse will note which of the following? (select all that apply) A. clients age B. clients gender C. clients speech D.Palpate maxillary and facial sinuses - answer When it comes to assessing the clients physical appearance which of the following lists what a nurse would look for? A. gender,age, ethnicity, dress, speech, level of conciousness B.religion,age, ethnicity, dress, speech, level of conciousness C. age, gender, ethnicity, dress, diet, speech, level of conciousness D.gender,age, ethnicity, marital status, dress, speech, level of conciousness - answer Nurse Becky has her client come in and looks at the way he is dressed what is she looking for? A. that her client has a good fashion sense B. that her client feels comfortable with her C. that her client's dress is appropriate for his gender, age, and time of the year D. that her client's dress is appropriate for his gender, societal status, and marital status What could the nurse assess based soley on the way the client walks into the room? A. gender and age B. dress and signs of illness C. signs of illness, well nourished D. gait and posture - Nurse Dave has his client come in and proceeds to ask him his name, his date of birth, if he knows where he is, and what day of the week it is. In doing this Dave is testing his clients what? A. intelligence coeffient B. level of conciousness C. social and cognitive skills D. physical and mental development - A nurse should assess a client's level of conciousness to ensure they are oriented how? (select all that apply) A. oriented to time B. oriented to place C. oriented to person D. understands and responds to questions appropriately E. all of the above - Which of the following would be considered normal observations regarding a client's speech? A. that it is rushed and garbbled B. it is articulate and easy to understand C. it is articulate but spoken in a language other than English D. it is hapazard and sing-song like - Nurse George has just assessed his client's articulation, language, and other aspects of his speech. In doing this which cranial nerves has he just assessed? A. cranial nerves 4 and 5 B. cranial nerves 6 and 12 C. cranial nerves 9 and 12 D. cranial nerves 10 and 12 - What is the very first thing a nurse should do at the begining of a head to toe assessment? A. state the clients name and age B. introduce yourself to the client C. have the client walk in and take a seat D. state the client's gender and ethnicity - Which of the following would be considered normal nursing observations regarding general appearance? A. client is well groomed B. dress is appropriate for the season C. no visible signs of illness noted D. client appears well-nourished E. all of the above - Which of the following would a nurse include in the general appearance portion of the assessment as normal observations regarding the client's greeting? A. client greets with a smile, not a frown B. client furows brow and blinks erratically C. client is making eye contact D. client doesn't appear to be in distress E. facial expression cannot be identified - Which to things would a nurse state they are going to do at the end of the general appearance portion of the head to toe assessment? A. record vitals and emotions B. record vision and pain level C. record vitals and pain level D. record level of conciousness and general appearance ................................................continued......................................................................