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Head to Toe Assessment Practice Exam (PM)*
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Question 1
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
Question 2
A nurse palpates a client’s temporomandibular joint, then asks him to clench his teeth. In doing this the nurse is assessing which cranial nerve?
A
cranial nerve 5
B
cranial nerve 7
C
cranial nerve 3
D
cranial nerve 4
Question 3
When a nurse does an assessment on a client’s vision using either the Snelling chart or newspaper finger-wiggle test which cranial nerve are they assessing?
A
cranial nerve 5
B
cranial nerve 7
C
cranial nerve 3
D
cranial nerve 2
Question 4
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
Question 5
When it comes to hand hygiene and your client you should always do what?
A
inform client you’ve washed your hands
B
wear gloves so they don’t worry
C
wash hands in patient’s presence
D
wash hands outside patient’s room
Question 6
Which of the following would be considered normal observations regarding a client’s speech? (select all that apply)
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
Question 7
When preforming an assesment on a patient’s eyes what might the nurse use the opthalamoscope for?
A
consensual light reflex test
B
corneal reflex test
C
red light reflex
D
PERRLA
Question 8
Which of the following would be considered a normal observation regarding a client’s red light reflex?
A
red light reflex is displaced
B
red light reflex is intact
C
drainage is visible
D
red light reflex is abscent
Question 9
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
Question 10
When palpating the client’s temporal artery what should a nurse remember to do?
A
state the depth
B
state the location
C
state the temperature
D
state the force
Question 11
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
Question 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
Question 13
A nurse conducting an assesment on a clients head would do what first?
A
inspect and palpate hair
B
inspect and palpate scalp
C
look at patient’s prior medical history
D
inspect and palpate sinuses to control spread of germs
Question 14
If a client reports they are in pain what would a nurse do first?
A
call the doctor immediately
B
document it immediately
C
assess client’s pain on scale 0 to 10
D
assess client’s pain on scale 0 to 20
Question 15
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
Question 16
Nurse Fred when examining his client’s eyes takes a light cotton ball and gently brushes it across his client’s eyes to elicit a blink this is known as what?
A
consensual light reflex test
B
corneal reflex test
C
red light reflex
D
PERRLA
Question 17
A nurse would use either a Snelling chart or the finger wingle test to assess a client’s what?
A
hearing
B
consensual light reflex
C
vision
D
bone conduction
Question 18
What could the nurse assess based solely 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
Question 19
When a nurse preforms a corneal reflex test which cranial nerve are they assessing?
A
cranial nerve 5
B
cranial nerve 7
C
cranial nerve 3
D
cranial nerve 4
Question 20
When doing an assessment on a client’s eyes the very first thing that a nurse should look at is?
A
eyes internal structures
B
color of the iris’s of the eye
C
the pupils reactivity to light
D
eyes external structures
Question 21
Which of the following would not be considered normal findings when assessing the scalp and hair of a middle aged man? (select all that apply)
A
thinning hair
B
receding hair line
C
alopecia
D
Lice
Question 22
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
Question 23
A nurse doing her assessment proceeds to palpate a client’s frontal and maxillary sinuses. What should she make sure she checks for?
A
swelling
B
lesions
C
tenderness
D
tactile signs of carcinoma
Question 24
The three things a nurse needs to check for when doing an examination on the eyes regarding the external structures is?
A
eyelash distribution, coloring, drainage
B
eyelash texture, shape of eyes, redness
C
Shape of eyes, pupils reactivity, iris’s color
D
drainage, possible tumors, irritation
Question 25
Before a nurse palpates a person’s scalp what is the very first action they should take?
A
preform hand hygiene
B
ask the client how their hair feels
C
go ahead and inspect the client’s scalp
D
go right ahead and palpate client’s scalp with bare hands.
Question 26
Nurse Joan asks her client Freedy to clench his jaw as she continues to palpate his head. When she asks him to do this what is Nurse Joan most likely trying to palpate?
A
Freedy’s temporal artery
B
Freedy’s temporomandibular joint
C
Freedy’s submandibular joint
D
Freedy’s submental joint
Question 27
Nurse Bill when doing his head to toe assessment on his client asks him to smile, frown, wrinkle forehead, puff cheeks, raise eyebrows, close eye lids In doing this the nurse is assessing which cranial nerve?
A
cranial nerve 5
B
cranial nerve 7
C
cranial nerve 3
D
cranial nerve 4
Question 28
Which would be a normal observation for a nurse stating the force of a temporal artery?
A
+1
B
+3
C
+4
D
+2
Question 29
A nurse would most likely have a client read a newspaper the wiggle their finger out to the side to test their client’s what?
A
spacial awareness
B
vision
C
peripheral vision
D
farsightedness
Question 30
Which of the following would a nurse include in the general appearance portion of the assessment as normal observations regarding the client’s greeting? (select all that apply)
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
Question 31
Nurse Rain is assessing his client’s scalp after putting on clean gloves he begins to palpate the hair which of the following things would he be looking for? (select all that apply)
A
hair color
B
hair texture
C
hair distribution
D
Lice, alopecia
E
carcinomas of the skin
Question 32
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
Question 33
A nurse doing a head to toe assessment has his client stand 20 feet away from a chart and while blocking one eye asks him to read the smallest line he can then does the same thing in the other eye. The nurse is most likely assessing his client’s what?
A
hearing
B
consensual light reflex
C
vision
D
bone conduction
Question 34
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
Question 35
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
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Exam Mode – Questions and choices are randomly arranged, time limit of 1min per question, answers and grade will be revealed after finishing the exam.
Head to Toe Assessment Practice Exam (EM)*
Choose the letter of the correct answer. You have 35 mins to finish this exam. Good luck!
Start
Congratulations - you have completed Head to Toe Assessment Practice Exam (EM)*.
You scored %%SCORE%% out of %%TOTAL%%.
Your performance has been rated as %%RATING%%
Your answers are highlighted below.
Question 1
Nurse Joan asks her client Freedy to clench his jaw as she continues to palpate his head. When she asks him to do this what is Nurse Joan most likely trying to palpate?
A
Freedy’s temporal artery
B
Freedy’s temporomandibular joint
C
Freedy’s submandibular joint
D
Freedy’s submental joint
Question 2
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
Question 3
Which of the following would not be considered normal findings when assessing the scalp and hair of a middle aged man? (select all that apply)
A
thinning hair
B
receding hair line
C
alopecia
D
Lice
Question 4
When doing an assessment on a client’s eyes the very first thing that a nurse should look at is?
A
eyes internal structures
B
color of the iris’s of the eye
C
the pupils reactivity to light
D
eyes external structures
Question 5
A nurse palpates a client’s temporomandibular joint, then asks him to clench his teeth. In doing this the nurse is assessing which cranial nerve?
A
cranial nerve 5
B
cranial nerve 7
C
cranial nerve 3
D
cranial nerve 4
Question 6
If a client reports they are in pain what would a nurse do first?
A
call the doctor immediately
B
document it immediately
C
assess client’s pain on scale 0 to 10
D
assess client’s pain on scale 0 to 20
Question 7
A nurse would use either a Snelling chart or the finger wingle test to assess a client’s what?
A
hearing
B
consensual light reflex
C
vision
D
bone conduction
Question 8
Nurse Fred when examining his client’s eyes takes a light cotton ball and gently brushes it across his client’s eyes to elicit a blink this is known as what?
A
consensual light reflex test
B
corneal reflex test
C
red light reflex
D
PERRLA
Question 9
A nurse would most likely have a client read a newspaper the wiggle their finger out to the side to test their client’s what?
A
spacial awareness
B
vision
C
peripheral vision
D
farsightedness
Question 10
When a nurse does an assessment on a client’s vision using either the Snelling chart or newspaper finger-wiggle test which cranial nerve are they assessing?
A
cranial nerve 5
B
cranial nerve 7
C
cranial nerve 3
D
cranial nerve 2
Question 11
Which of the following would a nurse include in the general appearance portion of the assessment as normal observations regarding the client’s greeting? (select all that apply)
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
Question 12
When it comes to hand hygiene and your client you should always do what?
A
inform client you’ve washed your hands
B
wear gloves so they don’t worry
C
wash hands in patient’s presence
D
wash hands outside patient’s room
Question 13
A nurse doing a head to toe assessment has his client stand 20 feet away from a chart and while blocking one eye asks him to read the smallest line he can then does the same thing in the other eye. The nurse is most likely assessing his client’s what?
A
hearing
B
consensual light reflex
C
vision
D
bone conduction
Question 14
When palpating the client’s temporal artery what should a nurse remember to do?
A
state the depth
B
state the location
C
state the temperature
D
state the force
Question 15
Which of the following would be considered normal observations regarding a client’s speech? (select all that apply)
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
Question 16
What could the nurse assess based solely 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
Question 17
Nurse Rain is assessing his client’s scalp after putting on clean gloves he begins to palpate the hair which of the following things would he be looking for? (select all that apply)
A
hair color
B
hair texture
C
hair distribution
D
Lice, alopecia
E
carcinomas of the skin
Question 18
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
Question 19
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
Question 20
A nurse doing her assessment proceeds to palpate a client’s frontal and maxillary sinuses. What should she make sure she checks for?
A
swelling
B
lesions
C
tenderness
D
tactile signs of carcinoma
Question 21
Which would be a normal observation for a nurse stating the force of a temporal artery?
A
+1
B
+3
C
+4
D
+2
Question 22
When a nurse preforms a corneal reflex test which cranial nerve are they assessing?
A
cranial nerve 5
B
cranial nerve 7
C
cranial nerve 3
D
cranial nerve 4
Question 23
The three things a nurse needs to check for when doing an examination on the eyes regarding the external structures is?
A
eyelash distribution, coloring, drainage
B
eyelash texture, shape of eyes, redness
C
Shape of eyes, pupils reactivity, iris’s color
D
drainage, possible tumors, irritation
Question 24
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
Question 25
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
Question 26
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
Question 27
A nurse conducting an assesment on a clients head would do what first?
A
inspect and palpate hair
B
inspect and palpate scalp
C
look at patient’s prior medical history
D
inspect and palpate sinuses to control spread of germs
Question 28
Before a nurse palpates a person’s scalp what is the very first action they should take?
A
preform hand hygiene
B
ask the client how their hair feels
C
go ahead and inspect the client’s scalp
D
go right ahead and palpate client’s scalp with bare hands.
Question 29
Nurse Bill when doing his head to toe assessment on his client asks him to smile, frown, wrinkle forehead, puff cheeks, raise eyebrows, close eye lids In doing this the nurse is assessing which cranial nerve?
A
cranial nerve 5
B
cranial nerve 7
C
cranial nerve 3
D
cranial nerve 4
Question 30
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
Question 31
When preforming an assesment on a patient’s eyes what might the nurse use the opthalamoscope for?
A
consensual light reflex test
B
corneal reflex test
C
red light reflex
D
PERRLA
Question 32
Which of the following would be considered a normal observation regarding a client’s red light reflex?
A
red light reflex is displaced
B
red light reflex is intact
C
drainage is visible
D
red light reflex is abscent
Question 33
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
Question 34
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
Question 35
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
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Text Mode
1.The very first thing a nurse will assess when doing a head to toe examination is what?
head
eyes
ears
general appearance
2. When assessing a clients physical appearance a nurse will note which of the following? (select all that apply)
clients age
clients gender
clients speech
Palpate maxillary and facial sinuses
3. When it comes to assessing the clients physical appearance which of the following lists what a nurse would look for?
gender,age, ethnicity, dress, speech, level of conciousness
religion,age, ethnicity, dress, speech, level of conciousness
age, gender, ethnicity, dress, diet, speech, level of conciousness
gender,age, ethnicity, marital status, dress, speech, level of conciousness
4. Nurse Becky has her client come in and looks at the way he is dressed what is she looking for?
that her client has a good fashion sense
that her client feels comfortable with her
that her client’s dress is appropriate for his gender, age, and time of the year
that her client’s dress is appropriate for his gender, societal status, and marital status
5. What could the nurse assess based solely on the way the client walks into the room?
gender and age
dress and signs of illness
signs of illness, well nourished
gait and posture
6. 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?
intelligence coeffient
level of conciousness
social and cognitive skills
physical and mental development
7. A nurse should assess a client’s level of conciousness to ensure they are oriented how? (select all that apply)
oriented to time
oriented to place
oriented to person
understands and responds to questions appropriately
all of the above
8. Which of the following would be considered normal observations regarding a client’s speech?
that it is rushed and garbbled
it is articulate and easy to understand
it is articulate but spoken in a language other than English
it is hapazard and sing-song like
9. 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?
cranial nerves 4 and 5
cranial nerves 6 and 12
cranial nerves 9 and 12
cranial nerves 10 and 12
10. What is the very first thing a nurse should do at the begining of a head to toe assessment?
state the clients name and age
introduce yourself to the client
have the client walk in and take a seat
state the client’s gender and ethnicity
11. Which of the following would be considered normal nursing observations regarding general appearance?
client is well groomed
dress is appropriate for the season
no visible signs of illness noted
client appears well-nourished
all of the above
12. Which of the following would a nurse include in the general appearance portion of the assessment as normal observations regarding the client’s greeting?
client greets with a smile, not a frown
client furows brow and blinks erratically
client is making eye contact
client doesn’t appear to be in distress
facial expression cannot be identified
13. 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?
record vitals and emotions
record vision and pain level
record vitals and pain level
record level of conciousness and general appearance
14. If a client reports they are in pain what would a nurse do first?
call the doctor immediately
document it immediately
assess client’s pain on scale 0 to 10
assess client’s pain on scale 0 to 20
15. A nurse conducting an assesment on a clients head would do what first?
inspect and palpate hair
inspect and palpate scalp
look at patient’s prior medical history
inspect and palpate sinuses to control spread of germs
16. Before a nurse palpates a person’s scalp what is the very first action they should take?
preform hand hygiene
ask the client how their hair feels
go ahead and inspect the client’s scalp
go right ahead and palpate client’s scalp with bare hands.
17. When it comes to hand hygiene and your client you should always do what?
inform client you’ve washed your hands
wear gloves so they don’t worry
wash hands in patient’s presence
wash hands outside patient’s room
18. Nurse Rain is assessing his client’s scalp after putting on clean gloves he begins to palpate the hair which of the following things would he be looking for? (select all that apply)
hair color
hair texture
hair distribution
Lice, alopecia
carcinomas of the skin
19. Which of the following would not be considered normal findings when assessing the scalp and hair of a middle aged man?
thinning hair
receding hair line
alopecia
Lice
20. When palpating the client’s temporal artery what should a nurse remember to do?
state the depth
state the location
state the temperature
state the force
21. Which would be a normal observation for a nurse stating the force of a temporal artery?
+1
+3
+4
+2
22. Nurse Joan asks her client Freedy to clench his jaw as she continues to palpate his head. When she asks him to do this what is Nurse Joan most likely trying to palpate?
Freedy’s temporal artery
Freedy’s temporomandibular joint
Freedy’s submandibular joint
Freedy’s submental joint
23. A nurse palpates a client’s temporomandibular joint, then asks him to clench his teeth. In doing this the nurse is assessing which cranial nerve?
cranial nerve 5
cranial nerve 7
cranial nerve 3
cranial nerve 4
24. A nurse doing her assessment proceeds to palpate a client’s frontal and maxillary sinuses. What should she make sure she checks for?
swelling
lesions
tenderness
tactile signs of carcinoma
25. Nurse Bill when doing his head to toe assessment on his client asks him to smile, frown, wrinkle forehead, puff cheeks, raise eyebrows, close eye lids In doing this the nurse is assessing which cranial nerve?
cranial nerve 5
cranial nerve 7
cranial nerve 3
cranial nerve 4
26. When doing an assessment on a client’s eyes the very first thing that a nurse should look at is?
eyes internal structures
color of the iris’s of the eye
the pupils reactivity to light
eyes external structures
27. The three things a nurse needs to check for when doing an examination on the eyes regarding the external structures is?
eyelash distribution, coloring, drainage
eyelash texture, shape of eyes, redness
Shape of eyes, pupils reactivity, iris’s color
drainage, possible tumors, irritation
28. Nurse Fred when examining his client’s eyes takes a light cotton ball and gently brushes it across his client’s eyes to elicit a blink this is known as what?
consensual light reflex test
corneal reflex test
red light reflex
PERRLA
29. When a nurse preforms a corneal reflex test which cranial nerve are they assessing?
cranial nerve 5
cranial nerve 7
cranial nerve 3
cranial nerve 4
30. When preforming an assesment on a patient’s eyes what might the nurse use the opthalamoscope for?
consensual light reflex test
corneal reflex test
red light reflex
PERRLA
31. Which of the following would be considered a normal observation regarding a client’s red light reflex?
red light reflex is displaced
red light reflex is intact
drainage is visible
red light reflex is abscent
32. A nurse would use either a Snelling chart or the finger wingle test to assess a client’s what?
hearing
consensual light reflex
vision
bone conduction
33. A nurse doing a head to toe assessment has his client stand 20 feet away from a chart and while blocking one eye asks him to read the smallest line he can then does the same thing in the other eye. The nurse is most likely assessing his client’s what?
hearing
consensual light reflex
vision
bone conduction
34. When a nurse does an assessment on a client’s vision using either the Snelling chart or newspaper finger-wiggle test which cranial nerve are they assessing?
cranial nerve 5
cranial nerve 7
cranial nerve 3
cranial nerve 2
35. A nurse would most likely have a client read a newspaper the wiggle their finger out to the side to test their client’s what?
spacial awareness
vision
peripheral vision
farsightedness
Answer
D. general appearance
A,B,C
A. gender,age, ethnicity, dress, speech, level of conciousness
C. that her client’s dress is appropriate for his gender, age, and time of the year