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VN103 Head-to-Toe Assessment Questions and Answers | Latest Version | 2025/2026 | Correct & Verified
What is the first step before beginning a head-to-toe assessment?✔✔ Perform hand hygiene and introduce yourself to the patient
What is the purpose of conducting a head-to-toe assessment?✔✔ To collect comprehensive data about the patient’s physical condition
Why is it important to assess the patient's level of consciousness early in the assessment?✔✔ It helps determine the patient’s neurological status and ability to respond
What is the best way to assess orientation during a head-to-toe assessment?✔✔ Ask the patient their name, the date, location, and situation
What is the nurse assessing when checking pupil size and reaction?✔✔ Cranial nerve function and neurological response
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What does PERRLA stand for in an eye assessment?✔✔ Pupils Equal, Round, Reactive to Light and Accommodation
What is the best way to assess for symmetry of facial movements?✔✔ Ask the patient to smile, frown, and raise their eyebrows
What is the nurse listening for when auscultating lung sounds?✔✔ The presence and quality of breath sounds in all lobes
Why should the nurse compare breath sounds on both sides of the chest?✔✔ To identify differences that may indicate lung or airway issues
What is indicated by crackles heard during lung auscultation?✔✔ Fluid in the alveoli, possibly from pneumonia or heart failure
What does a normal heart sound include during auscultation?✔✔ Clear S1 and S2 sounds without extra beats, murmurs, or rubs
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