head to toe assessment Flashcards

What's on the cards

1. How many patient identifiers should be confirmed before a nurse starts an assessment or takes vital signs?
2. A nurse charts "The patient appears anxious." Is that subjective or objective data?
3. What makes a piece of assessment data objective rather than subjective?
4. On a general survey, what gait is the expected finding?
5. Which general survey findings suggest the patient is dehydrated?
6. On a general survey, which findings count as critical conditions?
7. Which mnemonic gives a nurse an organized set of questions about pain and other symptoms?
8. What is the normal resting heart rate for an adult?
9. A patient's radial pulse is irregular. How long should the nurse count it?
10. Which pulse is the most accurate and is the one to take before giving cardiac medications?
11. Where on the chest is the apical pulse auscultated, and for how long?
12. Why is a tympanic temperature considered an accurate reading?
13. When should a nurse avoid the tympanic route for temperature?
14. A patient just finished a cup of hot coffee. How long should the nurse wait before an oral temperature?
15. What can make a fingertip pulse oximeter reading less accurate?
16. What is the normal range for blood oxygen saturation (SpO2)?
17. How long should a patient rest before a blood pressure is taken?
18. A patient smoked 15 minutes before a blood pressure check. What should the nurse do?
19. Which arm conditions rule out putting a blood pressure cuff on that arm?
20. Under what age is blood pressure not routinely measured unless there are cardiac concerns?
21. As the cuff deflates, what does the first Korotkoff sound mark?
22. How fast should a blood pressure cuff be deflated during a manual reading?
23. How wide should a blood pressure cuff be compared with the patient's arm?
24. What blood pressure drop on standing defines orthostatic hypotension?
25. When should an automatic blood pressure monitor not be used?
26. In what order does a routine neurological exam usually go?
27. Does a registered nurse normally use the stethoscope during a routine neurological assessment?
28. What does the charting abbreviation PERRLA mean?
29. When a patient shifts focus from a far object to a near one, what should the pupils do?
30. What result counts as a positive Romberg test?
31. How does a nurse test stereognosis?
32. What does testing for pronator drift help the nurse find?
33. On the 0 to 4+ deep tendon reflex scale, which grade is normal?
34. What does a reflex graded 4+ mean?
35. Which standardized tool is used to objectively assess and keep monitoring a patient's level of consciousness?
36. Which neurological assessment findings are classed as critical?
37. Where should the trachea sit when the nurse inspects the neck?
38. What should the uvula do when the patient says "Ah"?
39. A patient wears dentures. What should happen before the nurse inspects the mouth?
40. A patient had a recent stroke. What must happen before they get food, fluids or oral medication?
41. What color should the sclera and the conjunctiva be on eye inspection?
42. How far from a Snellen chart does the patient stand for a far-vision test?
43. What does the whispered voice test screen for?
44. Where is the aortic auscultation area?
45. Where is the pulmonic auscultation area?
46. Where is Erb's point?
47. A nurse hears a murmur that is not in any earlier note. What should they do?
48. What does an S3 heart sound suggest?
49. How are S3 and S4 heart sounds best heard?
50. What causes jugular vein distension, and on which side of the neck is it easiest to see?
51. A patient's lips and nail beds look bluish. What is the finding called, and what does it indicate?
52. Where should a nurse look for pallor in a patient with a darker skin tone?
53. How does a nurse tell pitting edema from nonpitting edema?
54. What does 4+ pitting edema look like?
55. Which lower-leg findings point to a possible deep vein thrombosis?
56. Where is the posterior tibial pulse felt?
57. A patient sits leaning forward with elbows on a bedside table, working to breathe. What is this position called?
58. Name signs of respiratory difficulty a nurse can see on inspection.
59. What is finger clubbing, and what causes it?
60. A chest whose front-to-back depth equals its width (a 1:1 ratio) is described how?
61. Which adventitious lung sound is a popping or crackling on inspiration when fluid builds up in the alveolar and interstitial spaces?
62. Which lung sound is a whistling noise, mostly on expiration, from airways narrowed by bronchoconstriction?
63. Near a chest tube site, the skin pops and crackles under the fingers. What is the finding, and what does it mean?
64. Why does palpation come after auscultation in an abdominal assessment?
65. In which quadrant does a nurse start listening for bowel sounds?
66. What can cause hypoactive bowel sounds?
67. What can hyperactive bowel sounds indicate?
68. While listening to the abdomen, a nurse hears a vascular sound. What should they do?
69. A patient reports pain in one area of the abdomen. When should that area be palpated?
70. Guarding or rigidity: which one is an involuntary sign of peritoneal inflammation?
71. What elimination question should a hospitalized patient be asked every day?
72. Can muscle atrophy from disuse be reversed?
73. Which type of muscle atrophy is the most severe?
74. What are the five key areas in a focused skin assessment?
75. Why is skin turgor a poor test for dehydration in older adults?
76. Which body areas need extra checks for pressure injury?
77. A patient has a red rash. What quick bedside check tells whether it blanches?
78. Jaundice turns which parts of the body yellow?
79. What are large petechiae called?

Answers are on the backs of the cards — or open the full head to toe assessment answer key to read them all at once.