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. edema B. exudate C. purulent D. Drainage

Correct Answer is D

Explanation

A. Edema – Edema is the accumulation of fluid in tissues, not the flow or withdrawal of fluids.

B. Exudate –Exudate is a fluid that escapes from blood vessels due to inflammation or injury, but it does not specifically refer to the free flow of fluid.

C. Purulent – Purulent refers to thick, pus-containing fluid, which indicates infection but does not describe fluid drainage in general.

D. Drainage – Drainage refers to the free flow or withdrawal of fluids from a wound, cavity, or tube, including blood, pus, or serous fluid.

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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

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

Correct Answer is A

Explanation

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

Correct Answer is D

Explanation

The elderly patient is being assessed for skin turgor. Which of the following actions should the nurse take?

Which would be included in an assessment of the peripheral vascular system? (select all that apply)

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

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

The nurse is collecting data during an initial assessment. The patient tells the nurse, "i have a tremendous headache and my stomach is upset." These findings are called:

When performing a physical examination of the patient, the nurse uses a technique that is particularly useful in identifying areas of tenderness. This technique is: