Head-to-Toe Assessment Practice Questions

1. Question 1
   • Pupil response, bowel sounds, and reflexes
   • Appearance, behavior, mobility, and vital signs
   • Family history, immunizations, and surgical history
   • Medication schedule, laboratory results, and allergies
2. Question 2
   • The patient walks with a steady, coordinated gait.
   • The patient is dressed appropriately for the weather.
   • The patient's skin appears evenly colored.
   • The patient answers questions using complete sentences.
3. Question 3
   • The patient sits upright and maintains eye contact.
   • The patient is clean and dressed appropriately.
   • The patient appears pale, diaphoretic, and markedly fatigued.
   • The patient moves independently from the chair to the bed.
4. Question 4
   • True
   • False
5. Question 5
   • Tell me what brought you in today.
   • You do not seem concerned about your symptoms.
   • I already know why you are here, so we can begin.
   • I will ask only questions that require yes or no answers.
6. Question 6
   • Vital signs provide baseline objective data about the patient's current status and help identify findings that may require further assessment.
7. Question 7
   • Patient seems like a poor historian.
   • Patient seated upright, clothing clean and appropriate, speech clear.
   • Patient appears anxious and difficult.
   • Patient looks unhealthy.
8. Question 8
   • measurements
9. Question 9
   • Recognize the change as unexpected and promptly communicate the finding according to clinical policy.
   • Wait until the end of the assessment to mention the finding.
   • Continue collecting demographic information without interruption.
   • Document the behavior as expected because the patient is resting.
10. Question 10
11. Question 11
    • The patient responds appropriately to questions.
    • The patient is disoriented to place and unable to follow simple directions.
    • The patient maintains a calm facial expression.
    • The patient speaks at a normal rate and volume.
12. Question 12
    • True
    • False
13. Question 13
    • Explain the assessment and invite the patient to ask questions.
    • Begin examining the patient before introducing yourself.
    • Use medical terminology without checking the patient's understanding.
    • Direct all questions to the family member even when the patient can respond.
14. Question 14
    • Patient has visibly increased work of breathing and cannot speak comfortably.
    • Patient reports a usual sleep routine.
    • Patient requests a different pillow.
    • Patient is quiet but responds appropriately.
15. Question 15
    • The patient's reason for seeking care
    • The patient's reported family history
    • The patient's preferred meal schedule
    • The patient's ability to move from sitting to standing
16. Question 16
    • They demonstrate that the patient has impaired cognition
    • They confirm that the patient is uncooperative
    • They indicate that the patient does not understand the assessment
    • They are objective behavioral findings that warrant further exploration
17. Question 17
    • Family history, diet, and sleep
    • Inspection, palpation, and percussion
    • Appearance, behavior, and mobility
    • Pain history, allergies, and medications
18. Question 18
    • Arrival is the only time vital signs can be collected
    • The patient's walking pattern establishes the medical diagnosis
    • Observing arrival replaces the need for a health history
    • Movement during arrival provides information about functional mobility
19. Question 19
    • To determine the patient's family risk
    • To establish the patient's preferred communication style
    • To identify change from the patient's baseline
    • To replace observation of behavior
20. Question 20
    • The patient appears poorly groomed
    • The patient walks with a widened base
    • The patient answers questions reluctantly
    • The patient repeatedly taps one foot
21. Question 21
    • Document only findings that confirm the patient's stated concern
    • Use diagnostic labels instead of describing what is seen
    • Record broad observations before allowing assumptions to guide the description
    • Delay all observations until the physical examination is complete
22. Question 22
    • Mobility should be considered only after family history is obtained
    • Vital signs should be separated from all other assessment data
    • Observable data should be separated from inferences about their cause
    • Behavior should be omitted because it is subjective
23. Question 23
    • The patient's chief reason for seeking care
    • The patient's ability to bathe independently
    • The patient's review of respiratory symptoms
    • The patient's name, age, and identifying information
24. Question 24
    • To determine the nurse's final diagnosis
    • To determine which family member should provide consent
    • To identify the patient's stated concern and priorities
    • To replace the physical assessment
25. Question 25
    • True
    • False
26. Question 26
    • Have any close relatives had a serious illness?
    • How do you manage bathing, dressing, eating, and toileting at home?
    • What medications were prescribed during your last admission?
    • Who is your primary health-care provider?
27. Question 27
    • The patient's current walking pattern
    • Previous illnesses, hospitalizations, surgeries, and allergies
    • A patient's current description of pain
    • The patient's current respiratory rate
28. Question 28
    • Subjective data are symptoms or information reported by the patient, whereas objective data are findings observed or measured by the nurse.
29. Question 29
    • What did you eat for breakfast today?
    • When did your current symptom begin?
    • What health conditions have affected your parents or siblings?
    • Can you lift both arms above your head?
30. Question 30
    • subjective

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