1
Head to Toe Assessment (In Order) Questions and Answers | Latest Version | 2025/2026 | Correct & Verified
What is the first action the nurse should take before beginning a head-to-toe assessment?✔✔ Perform hand hygiene and introduce self to the client
What is the first step of a physical assessment once you enter the room?✔✔ Assess the client's level of consciousness and general appearance
What is the first system assessed during a head-to-toe assessment?✔✔ Neurological system
After assessing level of consciousness, what should the nurse evaluate next?✔✔ Orientation to person, place, and time
What is included in the general survey portion of the assessment?✔✔ Appearance, posture, hygiene, mood, and speech
- / 2
2
After the neurological check, what part of the head-to-toe assessment comes next?✔✔ Head and face inspection
What is assessed when checking the pupils during the head-to-toe exam?✔✔ Pupil size, equality, and reaction to light
What should the nurse do to assess cranial nerves II and III?✔✔ Shine a light in the eyes and observe pupil constriction
How is the mouth assessed during a head-to-toe exam?✔✔ Inspect lips, mucosa, gums, teeth, and tongue for moisture and integrity
After inspecting the mouth, what area comes next in order?✔✔ Neck and lymph nodes
What should be assessed when examining the neck?✔✔ Trachea position, jugular veins, and lymph node tenderness or swelling
- / 2