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. Edema. – Edema refers to fluid buildup in the interstitial spaces, leading to swelling in tissues. It can be caused by conditions such as heart failure, kidney disease, or inflammation.

B. Ecchymosis. – Ecchymosis refers to bruising caused by blood leakage into subcutaneous tissue, not fluid accumulation.

C. Pallor. – Pallor describes an abnormal pale appearance of the skin, often due to anemia or shock, rather than fluid accumulation.

D. Erythematosis. – Erythematosis is associated with redness and inflammation, not fluid retention.

A. Bradycardia B. Bounding radial pulse C. Urine output of 20mL/hr D. Cool skin

Correct Answer is D

Explanation

A. Percussion – Percussion involves tapping the body to assess underlying structures, not feeling for texture or consistency.

B. Auscultation – Auscultation is listening to body sounds (e.g., heart, lungs, and bowels) using a stethoscope, not feeling structures.

C. Inspection – Inspection is visual observation, not a tactile assessment.

D. Palpation – Palpation involves using the hands to assess the texture, size, consistency, and location of body structures, such as organs or lymph nodes.

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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

An abnormal accumulation of fluid in the interstitial spaces is described as:

Correct Answer is A

Explanation

A nurse is collecting data from a patient who has dehydration. Which findings should the nurse expect?

Correct Answer is D

Explanation

Listening for bowel sounds is done over all four quadrants of the abdomen using the diaphragm of the stethoscope. The normal rate of bowel sounds per minute is:

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The technique used in physical examination where the examiner feels the texture, size, consistency and location of certain parts of the body with the hands s

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