Nursing Head to Toe Assessment

These flashcards cover the key components of performing a nursing head to toe assessment.

The sequence of assessment for each body system is __________, palpate, percuss, and auscultate.

inspect

For the abdomen, the assessment sequence changes to inspect, __________, percuss, and palpate.

auscultate

Before starting the assessment, the nurse must perform __________ and provide privacy.

hand hygiene

To assess neurological status, the nurse should verify the patient's __________, date of birth, and current events.

name

A normal body mass index (BMI) greater than ________ indicates obesity.

30

During the head assessment, the nurse checks for any involuntary __________ of the face.

movements

Cranial nerve V is the __________ nerve, which is responsible for mastication.

trigeminal

While assessing the eyes, the acronym P-E-R-R-L-A stands for pupils __________, equal, round, reactive to light and accommodation.

responsive

An inspection of the tympanic membrane should show a __________ gray translucent color.

pearly

Cranial nerve VII is responsible for __________ expression assessments.

facial

When inspecting the abdomen, a scaphoid contour indicates that the abdomen is __________.

inward

To assess bowel sounds, the nurse should listen for __________ sounds in all four quadrants of the abdomen.

normal

A normal heart rate for an adult is between ________ beats per minute.

60 and 100

Muscle strength is tested by having the patient push against the nurse's __________.

hands

A positive Babinski reflex in adults indicates a __________ response instead of toes curling downward.

negative

Inspect the skin for __________ and any signs of breakdown, especially in immobile patients.

moles

During a head to toe assessment, the nurse should assess the patient's __________ as they respond to questions.

emotional status

To assess the patient's level of consciousness, one must evaluate if they're __________ and oriented to time, place, person, and situation.

alert

A clinical sign indicating respiratory distress could be the use of __________ muscles to breathe.

accessory

Normal capillary refill time should be less than ________ seconds.

2