Head-to-Toe Assessment Checklist and Quiz
Head-to-toe assessment for independent study: walk through 79 original questions in head-to-toe order, from patient identifiers and the general survey to the skin, each answered from and quoted from the Open RN Nursing Skills textbook (2nd edition) on the National Library of Medicine's NCBI Bookshelf.
Head-to-toe nursing assessment quiz with answers: general survey, vital signs, blood pressure technique, neurological, head and neck, eye and ear, cardiovascular, respiratory, abdominal, musculoskeletal and skin findings, expected versus unexpected. Every answer is cited to the open Nursing Skills textbook hosted on the NIH National Library of Medicine Bookshelf.
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01How many patient identifiers should be confirmed before a nurse starts an assessment or takes vital signs?
At least two.
VERIFIED AGAINST THE SOURCE
“Use at least two patient identifiers before performing assessments, obtaining vital signs or providing care.”
— Open RN Nursing Skills, 2nd ed. (NIH NLM Bookshelf) ↗02A nurse charts "The patient appears anxious." Is that subjective or objective data?
Subjective. It is the nurse's inference, and inferences count as subjective data.
VERIFIED AGAINST THE SOURCE
“For example, documenting an inference, such as “The patient appears anxious,” is subjective data.”
— Open RN Nursing Skills, 2nd ed. (NIH NLM Bookshelf) ↗03What makes a piece of assessment data objective rather than subjective?
It is reproducible: another person can easily obtain the same data.
VERIFIED AGAINST THE SOURCE
“Objective data is reproducible, meaning another person can easily obtain the same data.”
— Open RN Nursing Skills, 2nd ed. (NIH NLM Bookshelf) ↗04On a general survey, what gait is the expected finding?
Smooth and even, with balance kept without help.
VERIFIED AGAINST THE SOURCE
“Gait is smooth and even and can maintain balance without assistance.”
— Open RN Nursing Skills, 2nd ed. (NIH NLM Bookshelf) ↗05Which general survey findings suggest the patient is dehydrated?
Dry skin and dry mucous membranes, sunken eyes in adults, and a sunken fontanel in infants.
VERIFIED AGAINST THE SOURCE
“Dry skin and dry mucous membranes; sunken eyes in adults; sunken fontanel in infants”
— Open RN Nursing Skills, 2nd ed. (NIH NLM Bookshelf) ↗06On a general survey, which findings count as critical conditions?
New unresponsiveness or altered mental status, trouble breathing, vital signs out of range, or cool, clammy or cyanotic skin.
VERIFIED AGAINST THE SOURCE
“Newly unresponsive or altered mental status; difficulty breathing; vital signs out of range; skin is cool, clammy, or cyanotic”
— Open RN Nursing Skills, 2nd ed. (NIH NLM Bookshelf) ↗07Which mnemonic gives a nurse an organized set of questions about pain and other symptoms?
PQRSTU.
VERIFIED AGAINST THE SOURCE
“The PQRSTU mnemonic is often used to assess pain, but it can also be used to assess many other symptoms.”
— Open RN Nursing Skills, 2nd ed. (NIH NLM Bookshelf) ↗08What is the normal resting heart rate for an adult?
60 to 100 beats per minute.
VERIFIED AGAINST THE SOURCE
“The normal adult pulse rate (heart rate) at rest is 60–100 beats per minute”
— Open RN Nursing Skills, 2nd ed. (NIH NLM Bookshelf) ↗09A patient's radial pulse is irregular. How long should the nurse count it?
A full 60 seconds.
VERIFIED AGAINST THE SOURCE
“It is considered best practice to assess a patient’s pulse for a full 60 seconds, especially if there is an irregularity to the rhythm.”
— Open RN Nursing Skills, 2nd ed. (NIH NLM Bookshelf) ↗10Which pulse is the most accurate and is the one to take before giving cardiac medications?
The apical pulse.
VERIFIED AGAINST THE SOURCE
“The apical pulse rate is considered the most accurate pulse and is indicated when obtaining assessments prior to administering cardiac medications.”
— Open RN Nursing Skills, 2nd ed. (NIH NLM Bookshelf) ↗11Where on the chest is the apical pulse auscultated, and for how long?
At the fifth intercostal space, midclavicular line, for one minute.
VERIFIED AGAINST THE SOURCE
“Auscultate the apical pulse at the fifth intercostal space, midclavicular line for one minute.”
— Open RN Nursing Skills, 2nd ed. (NIH NLM Bookshelf) ↗12Why is a tympanic temperature considered an accurate reading?
The tympanic membrane shares the same artery that supplies the hypothalamus.
VERIFIED AGAINST THE SOURCE
“It is an accurate measurement because the tympanic membrane shares the same vascular artery that perfuses the hypothalamus”
— Open RN Nursing Skills, 2nd ed. (NIH NLM Bookshelf) ↗13When should a nurse avoid the tympanic route for temperature?
When the patient may have an ear infection.
VERIFIED AGAINST THE SOURCE
“The tympanic method should not be used if the patient has a suspected ear infection.”
— Open RN Nursing Skills, 2nd ed. (NIH NLM Bookshelf) ↗14A patient just finished a cup of hot coffee. How long should the nurse wait before an oral temperature?
15 to 25 minutes.
VERIFIED AGAINST THE SOURCE
“Oral temperature should be taken 15 to 25 minutes following consumption of a hot or cold beverage or food”
— Open RN Nursing Skills, 2nd ed. (NIH NLM Bookshelf) ↗15What can make a fingertip pulse oximeter reading less accurate?
Nail polish or artificial nails.
VERIFIED AGAINST THE SOURCE
“Nail polish or artificial nails can affect the absorption of light waves from the pulse oximeter and decrease the accuracy of the SpO2 measurement”
— Open RN Nursing Skills, 2nd ed. (NIH NLM Bookshelf) ↗16What is the normal range for blood oxygen saturation (SpO2)?
95 to 100%.
VERIFIED AGAINST THE SOURCE
“the normal range for oxygen saturation of the blood is 95–100% (SpO2)”
— Open RN Nursing Skills, 2nd ed. (NIH NLM Bookshelf) ↗17How long should a patient rest before a blood pressure is taken?
At least five minutes.
VERIFIED AGAINST THE SOURCE
“Blood pressure assessment should be completed after the patient has rested for a minimum of five minutes.”
— Open RN Nursing Skills, 2nd ed. (NIH NLM Bookshelf) ↗18A patient smoked 15 minutes before a blood pressure check. What should the nurse do?
Note the nicotine use with the reading. Caffeine or nicotine within 30 minutes is documented.
VERIFIED AGAINST THE SOURCE
“If the patient has ingested caffeine or nicotine within 30 minutes before measuring blood pressure, this should be documented with the reading.”
— Open RN Nursing Skills, 2nd ed. (NIH NLM Bookshelf) ↗19Which arm conditions rule out putting a blood pressure cuff on that arm?
Current clots or a history of clots, lymphedema, wounds, a fistula, or IV access lines.
VERIFIED AGAINST THE SOURCE
“such as a history of clots or presence of current clots, lymphedema, wounds, a fistula, or current IV access lines”
— Open RN Nursing Skills, 2nd ed. (NIH NLM Bookshelf) ↗20Under what age is blood pressure not routinely measured unless there are cardiac concerns?
Under age 3.
VERIFIED AGAINST THE SOURCE
“Blood pressure measurement is not routinely performed on children under the age of 3 unless there are cardiac concerns.”
— Open RN Nursing Skills, 2nd ed. (NIH NLM Bookshelf) ↗21As the cuff deflates, what does the first Korotkoff sound mark?
The systolic blood pressure.
VERIFIED AGAINST THE SOURCE
“The first appearance of sounds, called Korotkoff sounds, are noted as the systolic blood pressure reading.”
— Open RN Nursing Skills, 2nd ed. (NIH NLM Bookshelf) ↗22How fast should a blood pressure cuff be deflated during a manual reading?
Slowly, no more than 2 to 3 mmHg per second.
VERIFIED AGAINST THE SOURCE
“It is important to deflate the cuff slowly at no more than 2-3 mmHg per second”
— Open RN Nursing Skills, 2nd ed. (NIH NLM Bookshelf) ↗23How wide should a blood pressure cuff be compared with the patient's arm?
About 40% of the arm's circumference.
VERIFIED AGAINST THE SOURCE
“The width of the cuff should be 40% of the person’s arm circumference”
— Open RN Nursing Skills, 2nd ed. (NIH NLM Bookshelf) ↗24What blood pressure drop on standing defines orthostatic hypotension?
A fall of at least 20 mmHg systolic or 10 mmHg diastolic within three minutes of standing.
VERIFIED AGAINST THE SOURCE
“orthostatic hypotension is defined as a decrease in blood pressure by at least 20 mmHg systolic or 10 mmHg diastolic within three minutes of standing”
— Open RN Nursing Skills, 2nd ed. (NIH NLM Bookshelf) ↗25When should an automatic blood pressure monitor not be used?
When the patient has a rapid or irregular rhythm, such as atrial fibrillation, or has tremors.
VERIFIED AGAINST THE SOURCE
“automatic blood pressure monitors should not be used if the patient has a rapid or irregular heart rhythm, such as atrial fibrillation, or has tremors”
— Open RN Nursing Skills, 2nd ed. (NIH NLM Bookshelf) ↗26In what order does a routine neurological exam usually go?
Mental status first, then sensory function, then motor function.
VERIFIED AGAINST THE SOURCE
“A routine neurological exam usually starts by assessing the patient’s mental status followed by evaluation of sensory function and motor function.”
— Open RN Nursing Skills, 2nd ed. (NIH NLM Bookshelf) ↗27Does a registered nurse normally use the stethoscope during a routine neurological assessment?
No. Auscultation is not typically part of the routine neuro check.
VERIFIED AGAINST THE SOURCE
“Auscultation is not typically performed by registered nurses during a routine neurological assessment.”
— Open RN Nursing Skills, 2nd ed. (NIH NLM Bookshelf) ↗28What does the charting abbreviation PERRLA mean?
Pupils equal, round, and reactive to light and accommodation.
VERIFIED AGAINST THE SOURCE
“PERRLA (Pupils are equal, round, and reactive to light and accommodation)”
— Open RN Nursing Skills, 2nd ed. (NIH NLM Bookshelf) ↗29When a patient shifts focus from a far object to a near one, what should the pupils do?
Constrict. Pupils constrict for near vision and dilate for far vision.
VERIFIED AGAINST THE SOURCE
“accommodation refers to the ability of the eye to adjust from near to far vision, with pupils constricting for near vision and dilating for far vision”
— Open RN Nursing Skills, 2nd ed. (NIH NLM Bookshelf) ↗30What result counts as a positive Romberg test?
The patient sways or cannot keep their balance.
VERIFIED AGAINST THE SOURCE
“A positive Romberg test occurs if the patient sways or is unable to maintain balance.”
— Open RN Nursing Skills, 2nd ed. (NIH NLM Bookshelf) ↗31How does a nurse test stereognosis?
With the patient's eyes closed, place a familiar object in their hand and ask them to name it.
VERIFIED AGAINST THE SOURCE
“To perform the stereognosis test, ask the patient to close their eyes; then place a familiar object in their hand and ask them to name it.”
— Open RN Nursing Skills, 2nd ed. (NIH NLM Bookshelf) ↗32What does testing for pronator drift help the nurse find?
Mild weakness of an upper limb.
VERIFIED AGAINST THE SOURCE
“Assessing for pronator drift helps to detect mild upper limb weakness.”
— Open RN Nursing Skills, 2nd ed. (NIH NLM Bookshelf) ↗33On the 0 to 4+ deep tendon reflex scale, which grade is normal?
2+.
VERIFIED AGAINST THE SOURCE
“Reflexes are graded from 0 to 4+, with “2+” considered normal”
— Open RN Nursing Skills, 2nd ed. (NIH NLM Bookshelf) ↗34What does a reflex graded 4+ mean?
Hyperactive with clonus (involuntary muscle contractions).
VERIFIED AGAINST THE SOURCE
“4+: Hyperactive with clonus (involuntary muscle contraction)”
— Open RN Nursing Skills, 2nd ed. (NIH NLM Bookshelf) ↗35Which standardized tool is used to objectively assess and keep monitoring a patient's level of consciousness?
The Glasgow Coma Scale (GCS).
VERIFIED AGAINST THE SOURCE
“The Glasgow Coma Scale (GCS) is a standardized tool used to objectively assess and continually monitor a patient’s level of consciousness”
— Open RN Nursing Skills, 2nd ed. (NIH NLM Bookshelf) ↗36Which neurological assessment findings are classed as critical?
Change in mental status or pupil response, facial drooping, slurred or absent speech, or sudden one-sided loss of strength.
VERIFIED AGAINST THE SOURCE
“Change in mental status, pupil responsiveness, facial drooping, slurred words or inability to speak, or sudden unilateral loss of motor strength”
— Open RN Nursing Skills, 2nd ed. (NIH NLM Bookshelf) ↗37Where should the trachea sit when the nurse inspects the neck?
Midline, with no visible enlargement of the lymph nodes or thyroid.
VERIFIED AGAINST THE SOURCE
“The trachea should be midline, and there should not be any noticeable enlargement of lymph nodes or the thyroid gland.”
— Open RN Nursing Skills, 2nd ed. (NIH NLM Bookshelf) ↗38What should the uvula do when the patient says "Ah"?
Stay midline and rise symmetrically.
VERIFIED AGAINST THE SOURCE
“Assess the uvula. It should be midline and should rise symmetrically when the patient says”
— Open RN Nursing Skills, 2nd ed. (NIH NLM Bookshelf) ↗39A patient wears dentures. What should happen before the nurse inspects the mouth?
Take the dentures out so the mucosa underneath can be assessed.
VERIFIED AGAINST THE SOURCE
“If the patient wears dentures, remove them so you can assess the underlying mucosa.”
— Open RN Nursing Skills, 2nd ed. (NIH NLM Bookshelf) ↗40A patient had a recent stroke. What must happen before they get food, fluids or oral medication?
A brief bedside swallow screen, done according to agency policy.
VERIFIED AGAINST THE SOURCE
“If the patient has had a recent stroke or you have any concerns about their ability to swallow, perform a brief bedside swallow study according to agency policy before administering any food, fluids, or medication by mouth.”
— Open RN Nursing Skills, 2nd ed. (NIH NLM Bookshelf) ↗41What color should the sclera and the conjunctiva be on eye inspection?
White sclera and pink conjunctiva.
VERIFIED AGAINST THE SOURCE
“The sclera should be white and the conjunctiva should be pink.”
— Open RN Nursing Skills, 2nd ed. (NIH NLM Bookshelf) ↗42How far from a Snellen chart does the patient stand for a far-vision test?
20 feet.
VERIFIED AGAINST THE SOURCE
“Test far vision by asking the patient to stand 20 feet away from a Snellen chart.”
— Open RN Nursing Skills, 2nd ed. (NIH NLM Bookshelf) ↗43What does the whispered voice test screen for?
Hearing impairment.
VERIFIED AGAINST THE SOURCE
“The whispered voice test is a simple test for detecting hearing impairment if done accurately.”
— Open RN Nursing Skills, 2nd ed. (NIH NLM Bookshelf) ↗44Where is the aortic auscultation area?
Second intercostal space, right of the sternum.
VERIFIED AGAINST THE SOURCE
“The aortic area is the second intercostal space to the right of the sternum.”
— Open RN Nursing Skills, 2nd ed. (NIH NLM Bookshelf) ↗45Where is the pulmonic auscultation area?
Second intercostal space, left of the sternum.
VERIFIED AGAINST THE SOURCE
“The pulmonic area is the second intercostal space to the left of the sternum.”
— Open RN Nursing Skills, 2nd ed. (NIH NLM Bookshelf) ↗46Where is Erb's point?
Third intercostal space, left of the sternum, just below the pulmonic area.
VERIFIED AGAINST THE SOURCE
“Erb’s point is directly below the pulmonic area and located at the third intercostal space to the left of the sternum.”
— Open RN Nursing Skills, 2nd ed. (NIH NLM Bookshelf) ↗47A nurse hears a murmur that is not in any earlier note. What should they do?
Report it to the health care provider right away.
VERIFIED AGAINST THE SOURCE
“New murmurs not previously recorded should be immediately communicated to the health care provider.”
— Open RN Nursing Skills, 2nd ed. (NIH NLM Bookshelf) ↗48What does an S3 heart sound suggest?
Fluid overload or heart failure. It is also called a ventricular gallop.
VERIFIED AGAINST THE SOURCE
“An S3 sound, also called a ventricular gallop, occurs with fluid overload or heart failure when the ventricles are filling.”
— Open RN Nursing Skills, 2nd ed. (NIH NLM Bookshelf) ↗49How are S3 and S4 heart sounds best heard?
Patient on their left side, with the stethoscope bell over the apex.
VERIFIED AGAINST THE SOURCE
“S3 and S4 sounds, if present, are often heard best by asking the patient to lie on their left side and listening over the apex with the bell of the stethoscope.”
— Open RN Nursing Skills, 2nd ed. (NIH NLM Bookshelf) ↗50What causes jugular vein distension, and on which side of the neck is it easiest to see?
Raised pressure in the superior vena cava makes the jugular vein bulge. It is easiest to see on the right.
VERIFIED AGAINST THE SOURCE
“Inspect the neck for JVD that occurs when the increased pressure of the superior vena cava causes the jugular vein to bulge, making it most visible on the right side of a person’s neck.”
— Open RN Nursing Skills, 2nd ed. (NIH NLM Bookshelf) ↗51A patient's lips and nail beds look bluish. What is the finding called, and what does it indicate?
Cyanosis. It indicates decreased perfusion and oxygenation.
VERIFIED AGAINST THE SOURCE
“Cyanosis is a bluish discoloration of the skin, lips, and nail beds and indicates decreased perfusion and oxygenation.”
— Open RN Nursing Skills, 2nd ed. (NIH NLM Bookshelf) ↗52Where should a nurse look for pallor in a patient with a darker skin tone?
The palms, the conjunctiva, or the inner lower lip.
VERIFIED AGAINST THE SOURCE
“For those with darker skin tones, assess for pallor on the palms, conjunctiva, or inner aspect of the lower lip.”
— Open RN Nursing Skills, 2nd ed. (NIH NLM Bookshelf) ↗53How does a nurse tell pitting edema from nonpitting edema?
Press on the swollen area. If it leaves an indentation, the edema is pitting. If not, it is nonpitting.
VERIFIED AGAINST THE SOURCE
“If no indentation occurs, it is referred to as nonpitting edema. If indentation occurs, it is referred to as pitting edema.”
— Open RN Nursing Skills, 2nd ed. (NIH NLM Bookshelf) ↗54What does 4+ pitting edema look like?
A deep indentation that takes more than 20 seconds to rebound.
VERIFIED AGAINST THE SOURCE
“4+ indicates a deep depression with a time lapse of over 20 seconds required to rebound”
— Open RN Nursing Skills, 2nd ed. (NIH NLM Bookshelf) ↗55Which lower-leg findings point to a possible deep vein thrombosis?
Redness, warmth and edema in one leg only.
VERIFIED AGAINST THE SOURCE
“Unilateral redness, warmth, and edema, indicating a possible deep vein thrombosis (DVT)”
— Open RN Nursing Skills, 2nd ed. (NIH NLM Bookshelf) ↗56Where is the posterior tibial pulse felt?
Just behind the medial malleolus (inner ankle bone).
VERIFIED AGAINST THE SOURCE
“The posterior tibial artery is located just behind the medial malleolus.”
— Open RN Nursing Skills, 2nd ed. (NIH NLM Bookshelf) ↗57A patient sits leaning forward with elbows on a bedside table, working to breathe. What is this position called?
The tripod position, a sign of respiratory distress.
VERIFIED AGAINST THE SOURCE
“People experiencing respiratory distress also often move into a tripod position, meaning they are leaning forward and placing their arms or elbows on their knees or on a bedside table.”
— Open RN Nursing Skills, 2nd ed. (NIH NLM Bookshelf) ↗58Name signs of respiratory difficulty a nurse can see on inspection.
Pursed-lip breathing, nasal flaring, audible breathing, intercostal retractions, anxiety and accessory muscle use.
VERIFIED AGAINST THE SOURCE
“Pursed-lip breathing, nasal flaring, audible breathing, intercostal retractions, anxiety, and use of accessory muscles are signs of respiratory difficulty.”
— Open RN Nursing Skills, 2nd ed. (NIH NLM Bookshelf) ↗59What is finger clubbing, and what causes it?
A bulbous enlargement of the fingertips, caused by chronic hypoxia.
VERIFIED AGAINST THE SOURCE
“Clubbing is a bulbous enlargement of the tips of the fingers due to chronic hypoxia.”
— Open RN Nursing Skills, 2nd ed. (NIH NLM Bookshelf) ↗60A chest whose front-to-back depth equals its width (a 1:1 ratio) is described how?
Barrel-chested.
VERIFIED AGAINST THE SOURCE
“A patient with a 1:1 ratio is described as barrel-chested.”
— Open RN Nursing Skills, 2nd ed. (NIH NLM Bookshelf) ↗61Which adventitious lung sound is a popping or crackling on inspiration when fluid builds up in the alveolar and interstitial spaces?
Fine crackles, also called rales.
VERIFIED AGAINST THE SOURCE
“Fine crackles, also called rales, are popping or crackling sounds heard on inspiration that occur in association with conditions that cause fluid to accumulate within the alveolar and interstitial spaces”
— Open RN Nursing Skills, 2nd ed. (NIH NLM Bookshelf) ↗62Which lung sound is a whistling noise, mostly on expiration, from airways narrowed by bronchoconstriction?
Wheezes.
VERIFIED AGAINST THE SOURCE
“Wheezes are whistling-type noises produced during expiration (and sometimes inspiration) when air is forced through airways narrowed by bronchoconstriction”
— Open RN Nursing Skills, 2nd ed. (NIH NLM Bookshelf) ↗63Near a chest tube site, the skin pops and crackles under the fingers. What is the finding, and what does it mean?
Crepitus, meaning air is trapped under the subcutaneous tissue.
VERIFIED AGAINST THE SOURCE
“Crepitus feels like a popping or crackling sensation when the skin is palpated and is a sign of air trapped under the subcutaneous tissues.”
— Open RN Nursing Skills, 2nd ed. (NIH NLM Bookshelf) ↗64Why does palpation come after auscultation in an abdominal assessment?
So the bowel sounds are heard accurately before touching disturbs them.
VERIFIED AGAINST THE SOURCE
“Palpation should occur after the auscultation of bowel sounds so that accurate, undisturbed bowel sounds can be assessed.”
— Open RN Nursing Skills, 2nd ed. (NIH NLM Bookshelf) ↗65In which quadrant does a nurse start listening for bowel sounds?
The right lower quadrant (RLQ), where bowel sounds are consistently heard.
VERIFIED AGAINST THE SOURCE
“Begin your assessment by gently placing the diaphragm of your stethoscope on the skin in the right lower quadrant (RLQ), as bowel sounds are consistently heard in that area.”
— Open RN Nursing Skills, 2nd ed. (NIH NLM Bookshelf) ↗66What can cause hypoactive bowel sounds?
Constipation, recent abdominal surgery, peritonitis or paralytic ileus.
VERIFIED AGAINST THE SOURCE
“Hypoactive bowel sounds may be present with constipation, after abdominal surgery, peritonitis, or paralytic ileus.”
— Open RN Nursing Skills, 2nd ed. (NIH NLM Bookshelf) ↗67What can hyperactive bowel sounds indicate?
Bowel obstruction or gastroenteritis.
VERIFIED AGAINST THE SOURCE
“Hyperactive bowel sounds may indicate bowel obstruction or gastroenteritis.”
— Open RN Nursing Skills, 2nd ed. (NIH NLM Bookshelf) ↗68While listening to the abdomen, a nurse hears a vascular sound. What should they do?
Report it to the provider. Vascular sounds should not be heard over the abdomen.
VERIFIED AGAINST THE SOURCE
“As you auscultate the abdomen, you should not hear vascular sounds. If heard, this finding should be reported to the health care provider.”
— Open RN Nursing Skills, 2nd ed. (NIH NLM Bookshelf) ↗69A patient reports pain in one area of the abdomen. When should that area be palpated?
Last.
VERIFIED AGAINST THE SOURCE
“When palpating the abdomen of a patient reporting abdominal pain, the nurse should palpate that area last.”
— Open RN Nursing Skills, 2nd ed. (NIH NLM Bookshelf) ↗70Guarding or rigidity: which one is an involuntary sign of peritoneal inflammation?
Rigidity. It is an involuntary reflex the patient cannot control, while guarding is a voluntary contraction.
VERIFIED AGAINST THE SOURCE
“Guarding refers to voluntary contraction of the abdominal wall musculature, usually the result of fear, anxiety, or the touch of cold hands. Rigidity refers to involuntary contraction of the abdominal musculature in response to peritoneal inflammation, a reflex the patient cannot control.”
— Open RN Nursing Skills, 2nd ed. (NIH NLM Bookshelf) ↗71What elimination question should a hospitalized patient be asked every day?
The date of their last bowel movement and flatus.
VERIFIED AGAINST THE SOURCE
“It is important to ask a hospitalized patient daily about the date of their last bowel movement and flatus”
— Open RN Nursing Skills, 2nd ed. (NIH NLM Bookshelf) ↗72Can muscle atrophy from disuse be reversed?
Often, yes, with exercise and improved nutrition.
VERIFIED AGAINST THE SOURCE
“Physiologic atrophy is caused by not using the muscles and can often be reversed with exercise and improved nutrition.”
— Open RN Nursing Skills, 2nd ed. (NIH NLM Bookshelf) ↗73Which type of muscle atrophy is the most severe?
Neurogenic atrophy, from an injured or diseased nerve.
VERIFIED AGAINST THE SOURCE
“Neurogenic atrophy is the most severe type of muscle atrophy. It can be from an injured or diseased nerve that connects to the muscle.”
— Open RN Nursing Skills, 2nd ed. (NIH NLM Bookshelf) ↗74What are the five key areas in a focused skin assessment?
Color, temperature, moisture, turgor, and lesions or skin breakdown.
VERIFIED AGAINST THE SOURCE
“There are five key areas to note during a focused integumentary assessment: color, skin temperature, moisture level, skin turgor, and any lesions or skin breakdown.”
— Open RN Nursing Skills, 2nd ed. (NIH NLM Bookshelf) ↗75Why is skin turgor a poor test for dehydration in older adults?
Their skin is already less elastic.
VERIFIED AGAINST THE SOURCE
“Skin turgor is not a reliable method to assess for dehydration in older adults because they have decreased skin elasticity”
— Open RN Nursing Skills, 2nd ed. (NIH NLM Bookshelf) ↗76Which body areas need extra checks for pressure injury?
Bony prominences, skin folds, the perineum, between fingers and toes, and under removable medical devices.
VERIFIED AGAINST THE SOURCE
“more prone to pressure injuries, such as bony prominences, skin folds, perineum, between digits of the hands and feet, and under any medical device that can be removed during routine daily care”
— Open RN Nursing Skills, 2nd ed. (NIH NLM Bookshelf) ↗77A patient has a red rash. What quick bedside check tells whether it blanches?
Press on it with a gloved finger and watch for whitening.
VERIFIED AGAINST THE SOURCE
“If erythema or rashes are present, it is helpful to apply pressure with a gloved finger to further assess for blanching (whitening with pressure).”
— Open RN Nursing Skills, 2nd ed. (NIH NLM Bookshelf) ↗78Jaundice turns which parts of the body yellow?
The skin and the sclera (whites of the eyes).
VERIFIED AGAINST THE SOURCE
“Jaundice causes skin and sclera (whites of the eyes) to turn yellow.”
— Open RN Nursing Skills, 2nd ed. (NIH NLM Bookshelf) ↗79What are large petechiae called?
Purpura.
VERIFIED AGAINST THE SOURCE
“Petechiae are tiny red dots caused by bleeding under the skin that may appear like a rash. Large petechiae are called purpura.”
— Open RN Nursing Skills, 2nd ed. (NIH NLM Bookshelf) ↗Know questions we're missing?
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