When performing the nursing physical assessment, the nurse uses head-to-toe organization. When using this method, the nurse begins with a:

skin assessment

neurological assessment

respiratory assessment

circulatory assessment

Answer and Explanation

The Correct Answer is B

A. Skin assessment. – While skin assessment is important, it is not the first step in a head-to-toe physical examination.

B. Neurological assessment. – The neurological assessment is performed first because it establishes baseline cognitive function, level of consciousness, and cranial nerve responses, which are essential for assessing overall patient status.

C. Respiratory assessment. – The respiratory system is assessed after neurological status has been established.

D. Circulatory assessment. – While circulation is vital, it is typically evaluated after neurological and respiratory assessments.

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Correct Answer is A

Explanation

A. Jaundice – Jaundice results from elevated bilirubin levels, commonly due to liver disease, hemolysis, or bile duct obstruction. The yellow discoloration is most noticeable in the sclera.

B. Erythema – Erythema refers to redness of the skin, often due to inflammation or increased blood flow.

C. Ecchymosis – Ecchymosis refers to bruising caused by blood leakage under the skin.

D. Fetid – Fetid refers to a foul odor, not a discoloration of tissues.

A. nursing assessment B. nursing interview C. health history D. review of systems

Correct Answer is D

Explanation

A. Nursing assessment – A nursing assessment is the broader process of gathering patient information, including subjective and objective data, but does not specifically refer to a body system review.

B. Nursing interview – A nursing interview is a method used to gather subjective data from the patient, but it does not systematically review all body systems.

C. Health history – A health history includes past medical conditions, surgeries, and family history but does not systematically assess all body systems.

D. Review of systems – The review of systems (ROS) is a structured approach where the nurse systematically collects data about normal function and any changes in each body system.

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When performing the nursing physical assessment, the nurse uses head-to-toe organization. When using this method, the nurse begins with a:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When the color of the sclera is yellow due to bilirubin that infiltrates all tissues of the body it is called:

Correct Answer is A

Explanation

The nurse uses a systematic method for collecting data on all body systems including normal functioning and any noted changes. This system is:

Correct Answer is D

Explanation

The study of all factors involved in the development of the disease or the cause of the disease is termed:

Auscultation of the heart sounds will result in a lubb-dupp sound when using the bell and the diaphragm of the stethoscope. The lub part of the sound is caused by the:

Free flow or withdrawal of fluids from a wound or a cavity is termed:

The patient has been found to have edema of the lower extremities. The nurse is assessing whether or not it is pitting and to what degree. After pressing the skin against a bony prominence for 5 seconds, the nurse identifies 4+ pitting edema because the rebound time is:

The nurse is obtaining a history of the patient's present illness. The PQRST system is being used for the interview. In this system the R is:

Febrile is an abnormal elevation of:

When a disease results in a structural change in an organ that interferes with its functioning, this is a/an:

There are four categories of factors that increase the individual's vulnerability to developing a disease. These categories are genetic, physiological, age and lifestyle. These factors are called: