Head To Toe Ax

Question 1

What is the purpose of a head-to-toe assessment?

Answer 1

To systematically assess the patients physical status, tailored to their specific needs

Question 2

What are the standard 4 techniques used in physical assessments?

Answer 2

1. Inspect
2. Palpate
3. Percuss
4. Auscultate

Question 3

Why is the order of the physical assessment techniques different for the abdomen?

Answer 3

Palpation & percussion can alter bowel sounds; therefore, auscultation is done before them

Question 4

What is the correct order of assessment for the abdomen?

Answer 4

1. Inspect
2. Auscultate
3. Percuss
4. Palpate

Question 5

What are the first actions before starting a physical assessment?

Answer 5

Perform hand hygiene and ensure privacy.

Question 6

What should you do after hygiene and privacy?

Answer 6

Introduce yourself, explain the procedure, and check the patient’s armband.

Question 7

Why is checking the patient’s armband important?

Answer 7

To verify patient identity for safety and legal reasons.

Question 8

What questions do you ask to confirm patient identity and orientation?

Answer 8

Ask for name and DOB, then:
• “Can you tell me where we are right now?”
• “What year is it?”

Question 9

What does asking about location and time help confirm?

Answer 9

That the patient is alert and oriented (A&O).

Question 10

What vital information should be collected before the physical exam?

Answer 10

Vital signs including temperature, heart rate, respiratory rate, blood pressure, oxygen saturation, and pain level (0–10 scale).

Question 11

What physical measurements should be obtained pre-assessment?

Answer 11

Height and weight.

Question 12

What should you observe when assessing emotional status?

Answer 12

Response to you—are they:
• Calm?
• Agitated?
• Drowsy?
• Positive/negative emotional state?

Question 13

What other signs should be noted in mental/emotional status?

Answer 13

• Abnormal limb movement
• Delay in response
• Understanding of questions
• Abnormal facial expressions

Question 14

What aspects are evaluated in the head portion of the assessment?

Answer 14

• Skin colour
• Abnormal facial twitches
• Drooping or facial asymmetry
• Facial expressions

Question 15

Which cranial nerve is assessed by observing facial expressions?

Answer 15

Cranial Nerve VII (Facial Nerve)

Question 16

How do you test Cranial Nerve VII during a physical exam?

Answer 16

Ask the patient to:
• Close eyes tightly
• Smile
• Frown
• Puff out cheeks

Question 17

Why might orientation questions be especially important for certain patients?

Answer 17

They are especially needed for neuro assessments to check cognition and awareness.