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. Prevent distortion of bowel sounds. – Palpation can stimulate peristalsis and alter bowel sounds, leading to inaccurate assessment findings.

B. Prevent distortion of vascular sounds. – While palpation might affect vascular sounds slightly, this is not the primary concern when assessing the abdomen.

C. Determine any areas of tenderness or pain. – While assessing for tenderness is important, auscultation precedes palpation primarily to avoid altering bowel sounds.

D. Allow the patient to relax and be comfortable. – While relaxation is beneficial, the sequence of assessment is based on maintaining accuracy in findings rather than patient comfort.

A. bruit B. crackle C. thrill D. Wheeze

Correct Answer is A

Explanation

A. Bruit – A bruit is an abnormal swishing sound heard over an artery due to turbulent blood flow, often caused by atherosclerosis or narrowing of the vessel.

B. Crackle – Crackles are abnormal lung sounds caused by fluid in the alveoli, not vascular turbulence.

C. Thrill – A thrill is a palpable vibration over a blood vessel or heart valve, indicating turbulent blood flow but is felt rather than heard.

D. Wheeze – A wheeze is a high-pitched respiratory sound caused by narrowed airways, not vascular abnormalities.

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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:

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Naxlex Comprehensive Predictor Exams

The main reason that auscultation precedes palpation of the abdomen is to:

Correct Answer is A

Explanation

As the assessment continues the nurse notes an abnormal swishing sound with auscultation of the carotid artery. The term for this sound is:

Correct Answer is A

Explanation

You answer Ms. B's call light just after lunch. She complains of severe abdominal pain. What type of assessment should you perform?

Fluid, cells or other substances that have been slowly discharged from body cells or blood vessels, through small pores or breaks in the cell membrane are called:

The protective response of body tissues to irritation, injury or pathogens is:

The most frequently used skill in the physical nursing assessment is:

The nurse has been assigned to care for a 62 year-old man. After introducing herself to the patient and explaining that she will be performing a nursing assessment, what is the first area to be assessed after taking vital signs?

The patient was admitted with a complaint of abdominal pain. Later the nurse observed the patient demonstrating dyspnea. This change in condition required an assessment called:

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:

Redness or inflammation of the skin or mucous membranes resulting from dilation and congestion of superficial capillaries is termed: