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Nursing Skill: Head-to-Toe Assessment
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?✔✔ Wash hands and introduce themselves to the client
Why is it important to explain each step of the head-to-toe assessment to the client?✔✔ It promotes cooperation and reduces anxiety
What is the nurse assessing when checking the client’s orientation to person, place, and time?✔✔ Level of consciousness
How is pupil reactivity assessed during a head-to-toe assessment?✔✔ Shine a light in each eye and observe constriction
What is the nurse evaluating when they ask the client to smile, frown, and raise eyebrows?✔✔ Cranial nerve function
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What should the nurse listen for when auscultating lung sounds?✔✔ Clear breath sounds or presence of abnormal sounds like crackles or wheezes
What is the purpose of inspecting the oral cavity during the assessment?✔✔ To check for hydration, lesions, and oral hygiene
How should the nurse assess the carotid arteries?✔✔ One side at a time to prevent reduced cerebral blood flow
What does capillary refill time indicate?✔✔ Peripheral perfusion and circulation
How is skin turgor assessed?✔✔ By pinching the skin and observing how quickly it returns to place
What does a delay in skin turgor returning to normal indicate?✔✔ Possible dehydration
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Why is palpation of the abdomen performed after auscultation?✔✔ Because palpation can alter bowel sounds
What finding is expected during auscultation of normal bowel sounds?✔✔ Intermittent gurgling sounds every 5 to 15 seconds
What does the nurse assess by gently pressing on all four abdominal quadrants?✔✔ Tenderness, distension, or abnormal masses
What position should the client be in for accurate lung assessment?✔✔ Sitting upright if tolerated
What is the purpose of asking the client to squeeze the nurse’s fingers?✔✔ To assess upper extremity strength and motor function
What is the best way to assess for edema in the lower legs?✔✔ Press over the tibia and ankle to check for pitting
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