1.The very first thing a nurse will assess when doing a 9.
9. Nurse George has just assessed his client’s
head to toe examination is what?
A. head
B. eyes
C. ears  10. What is the very first thing a nurse should do at the
D. general appearance
2. When assessing a clients physical appearance a nurse
will note which of the following? (select all that apply)
A. clients age
B. clients gender
C. clients speech
D. Palpate maxillary and facial sinuses
3. When it comes to assessing the clients physical
appearance which of the following lists what a nurse
would look for?
A. gender,age, ethnicity, dress, speech, level of
conciousness
B. religion,age, ethnicity, dress, speech, level of
conciousness
C. age, gender, ethnicity, dress, diet, speech, level
of conciousness
D. gender,age, ethnicity, marital status, dress,
speech, level of conciousness
4. Nurse Becky has her client come in and looks at the
way he is dressed what is she looking for?
A. that her client has a good fashion sense
B. that her client feels comfortable with her
C. that her client’s dress is appropriate for his
gender, age, and time of the year
D. that her client’s dress is appropriate for his
gender, societal status, and marital status
5. What could the nurse assess based solely on the way
the client walks into the room?
A. gender and age
B. dress and signs of illness
C. signs of illness, well nourished
D. gait and posture
6. Nurse Dave has his client come in and proceeds to ask
him his name, his date of birth, if he knows where he is,
and what day of the week it is. In doing this Dave is
testing his clients what?
A. intelligence coeffient
B. level of conciousness
C. social and cognitive skills
D. physical and mental development
7. A nurse should assess a client’s level of conciousness
to ensure they are oriented how? (select all that apply)
A. oriented to time
B. oriented to place
C. oriented to person
D. understands and responds to questions
appropriately
E. all of the above
8. Which of the following would be considered normal
observations regarding a client’s speech?
A. that it is rushed and garbbled
B. it is articulate and easy to understand
C. it is articulate but spoken in a language other
than English
D. it is hapazard and sing-song like
articulation, language, and other aspects of his speech. In
doing this which cranial nerves has he just assessed?
A. cranial nerves 4 and 5
B. cranial nerves 6 and 12
C. cranial nerves 9 and 12
D. cranial nerves 10 and 12
begining of a head to toe assessment?
A. state the clients name and age
B. introduce yourself to the client
C. have the client walk in and take a seat
D. state the client’s gender and ethnicity
11. Which of the following would be considered normal
nursing observations regarding general appearance?
A. client is well groomed
B. dress is appropriate for the season
C. no visible signs of illness noted
D. client appears well-nourished
E. all of the above
12. Which of the following would a nurse include in the
general appearance portion of the assessment as normal
observations regarding the client’s greeting?
A. client greets with a smile, not a frown
B. client furows brow and blinks erratically
C. client is making eye contact
D. client doesn’t appear to be in distress
E. facial expression cannot be identified
13. Which to things would a nurse state they are going to
do at the end of the general appearance portion of the
head to toe assessment?
A. record vitals and emotions
B. record vision and pain level
C. record vitals and pain level
D. record level of conciousness and general
appearance
14. If a client reports they are in pain what would a nurse
do first?
A. call the doctor immediately
B. document it immediately
C. assess client’s pain on scale 0 to 10
D. assess client’s pain on scale 0 to 20
15. A nurse conducting an assesment on a clients head
would do what first?
A. inspect and palpate hair
B. inspect and palpate scalp
C. look at patient’s prior medical history
D. inspect and palpate sinuses to control spread of
germs
16. Before a nurse palpates a person’s scalp what is the
very first action they should take?
A. preform hand hygiene
B. ask the client how their hair feels
C. go ahead and inspect the client’s scalp
D. go right ahead and palpate client’s scalp with
bare hands.
17. When it comes to hand hygiene and your client you
should always do what?
A. inform client you’ve washed your hands
B. wear gloves so they don’t worry
C. wash hands in patient’s presence
D. wash hands outside patient’s room
18. Nurse Rain is assessing his client’s scalp after D. eyes external structures
putting on clean gloves he begins to palpate the hair 27. The three things a nurse needs to check for when
which of the following things would he be looking for? doing an examination on the eyes regarding the external
(select all that apply) structures is?
A. hair color A. eyelash distribution, coloring, drainage
B. hair texture B. eyelash texture, shape of eyes, redness
C. hair distribution C. Shape of eyes, pupils reactivity, iris’s color
D. Lice, alopecia D. drainage, possible tumors, irritation
E. carcinomas of the skin 28. Nurse Fred when examining his client’s eyes takes a
19. Which of the following would not be considered light cotton ball and gently brushes it across his client’s
normal findings when assessing the scalp and hair of a eyes to elicit a blink this is known as what?
middle aged man? A. consensual light reflex test
A. thinning hair B. corneal reflex test
B. receding hair line C. red light reflex
C. alopecia D. PERRLA
D. Lice 29. When a nurse preforms a corneal reflex test which
20. When palpating the client’s temporal artery what cranial nerve are they assessing?
should a nurse remember to do? A. cranial nerve 5
A. state the depth B. cranial nerve 7
B. state the location C. cranial nerve 3
C. state the temperature D. cranial nerve 4
D. state the force 30. When preforming an assesment on a patient’s eyes
21. Which would be a normal observation for a nurse what might the nurse use the opthalamoscope for?
stating the force of a temporal artery? A. consensual light reflex test
A. +1 B. corneal reflex test
B. +3 C. red light reflex
C. +4 D. PERRLA
D. +2 31. Which of the following would be considered a
22. Nurse Joan asks her client Freedy to clench his jaw normal observation regarding a client’s red light reflex?
as she continues to palpate his head. When she asks him A. red light reflex is displaced
to do this what is Nurse Joan most likely trying to B. red light reflex is intact
palpate? C. drainage is visible
A. Freedy’s temporal artery D. red light reflex is abscent
B. Freedy’s temporomandibular joint 32. A nurse would use either a Snelling chart or the
C. Freedy’s submandibular joint finger wingle test to assess a client’s what?
D. Freedy’s submental joint A. hearing
23. A nurse palpates a client’s temporomandibular joint, B. consensual light reflex
then asks him to clench his teeth. In doing this the nurse C. vision
is assessing which cranial nerve? D. bone conduction
A. cranial nerve 5 33. A nurse doing a head to toe assessment has his client
B. cranial nerve 7 stand 20 feet away from a chart and while blocking one
C. cranial nerve 3 eye asks him to read the smallest line he can then does
D. cranial nerve 4 the same thing in the other eye. The nurse is most likely
24. A nurse doing her assessment proceeds to palpate a assessing his client’s what?
client’s frontal and maxillary sinuses. What should she A. hearing
make sure she checks for? B. consensual light reflex
A. swelling C. vision
B. lesions D. bone conduction
C. tenderness 34. When a nurse does an assessment on a client’s vision
D. tactile signs of carcinoma using either the Snelling chart or newspaper finger-
25. Nurse Bill when doing his head to toe assessment on wiggle test which cranial nerve are they assessing?
his client asks him to smile, frown, wrinkle forehead, A. cranial nerve 5
puff cheeks, raise eyebrows, close eye lids In doing this B. cranial nerve 7
the nurse is assessing which cranial nerve? C. cranial nerve 3
A. cranial nerve 5 D. cranial nerve 2
B. cranial nerve 7 35. A nurse would most likely have a client read a
C. cranial nerve 3 newspaper the wiggle their finger out to the side to test
D. cranial nerve 4 their client’s what?
26. When doing an assessment on a client’s eyes the A. spacial awareness
very first thing that a nurse should look at is? B. vision
A. eyes internal structures C. peripheral vision
B. color of the iris’s of the eye D. farsightedness
C. the pupils reactivity to light
Answer
1. D. general appearance
2. A,B,C
3. A. gender,age, ethnicity, dress, speech, level of
conciousness
4. C. that her client’s dress is appropriate for his
gender, age, and time of the year
5. D. gait and posture
6. B. level of conciousness
7. E. all of the above
8. B,C
9. D. cranial nerves 10 and 12
10. C. have the client walk in and take a seat
11. E. all of the above
12. A,C.
13. C. record vitals and pain level
14. C. assess client’s pain on scale 0 to 10
15. B. inspect and palpate scalp
16. A. preform hand hygiene
17. C. wash hands in patient’s presence
18. A,B,C,D
19. C,D
20. D. state the force
21. D. +2
22. B. Freedy’s temporomandibular joint
23. A. cranial nerve 5
24. C. tenderness
25. B. cranial nerve 7
26. D.eyes external structures
27. A. eyelash distribution, coloring, drainage
28. B. corneal reflex test
29. A. cranial nerve 5
30. C. red light reflex
31. B. red light reflex is intact
32. C. vision
33. C. vision
34. D. cranial nerve 2
35. C. peripheral vision