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 C

Explanation

A. Bruits – Bruits are abnormal vascular sounds heard over arteries, often due to turbulence from a narrowed vessel.

B. Tympany – Tympany is a drum-like sound produced during percussion over areas filled with air, such as the stomach.

C. Crackles – Crackles (rales) are discontinuous, bubbling breath sounds often heard on inspiration. They are associated with conditions like pneumonia, heart failure, and pulmonary fibrosis.

D. Thrill – A thrill is a palpable vibration over an artery or heart valve, indicating turbulent blood flow.

A. opening of the AV valves B. closing of the semilunar valves C. closing of the AV valves D. opening of the semilunar valves

Correct Answer is C

Explanation

A. Opening of the AV valves – The AV (atrioventricular) valves open silently during diastole; they do not create the "lub" sound.

B. Closing of the semilunar valves – The closing of the semilunar valves (aortic and pulmonary) produces the "dupp" sound, not the "lub."

C. Closing of the AV valves – The first heart sound (S1), or "lub," occurs when the mitral and tricuspid (AV) valves close at the beginning of systole.

D. Opening of the semilunar valves – The semilunar valves open silently during ventricular contraction; they do not produce the "lub" sound.

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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

Short, discrete, interrupted crackling or bubbling adventitious breath sounds heard most commonly on inspiration is termed:

Correct Answer is C

Explanation

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:

Correct Answer is C

Explanation

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:

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