Head-to-Toe Quiz: Can You Assess Every System?

1. During neurological assessment, the nurse tests cranial nerve II. What function is being evaluated?

Vision

Eye movement

Facial sensation

Tongue movement

2. A nurse assesses the posterior thorax by palpating for tactile fremitus. Which finding suggests possible pneumonia?

Decreased fremitus

Increased fremitus

Absent fremitus

Bilateral equal fremitus

3. During capillary refill assessment, the nurse compresses the client's fingernail and releases it. Normal refill time is____seconds.

Less than 2

2–3

3–4

More than 5

4. A nurse notes a difference of 10 mmHg in blood pressure between the two arms. What is the most appropriate action?

Recheck the blood pressure immediately

Document as normal variation

Notify the provider if difference exceeds 20 mmHg

Repeat assessment on the lower reading arm

5. When assessing the extremities, the nurse checks for edema by pressing the skin for 5 seconds. Pitting edema that returns to baseline in 2 seconds is graded as____.

1+

2+

3+

4+

6. During throat examination, the nurse uses a tongue depressor and light to visualize the pharynx. Which finding is normal?

Bright red, swollen tonsils with exudate

Pink tonsils without exudate

White patches covering the palate

Pale mucosa with petechiae

7. A nurse is assessing the ears and performs Weber and Rinne tests. These tests evaluate which cranial nerve?

Cranial nerve V

Cranial nerve VII

Cranial nerve VIII

Cranial nerve IX

8. During eye examination, the nurse tests accommodation. Which action should the client perform?

Follow finger movement in all directions

Focus on distant object, then near object

Identify colors on a chart

Read letters at decreasing sizes

9. When assessing reflexes, a nurse documents a brisk reflex as 3+. What is the normal reflex grade?

1+

2+

3+

4+

10. A nurse assesses muscle strength and documents 4/5. What does this grade indicate?

Full strength against gravity and resistance

Weak strength against gravity and minimal resistance

No visible muscle contraction

Movement possible only with gravity eliminated

11. When performing a head-to-toe assessment, which vital sign should be assessed first?

Blood pressure

Temperature

Respiratory rate

Heart rate

12. When performing a skin assessment, which finding requires immediate intervention?

Scattered freckles on arms

Pale, cool, clammy skin with poor turgor

Tan skin with uniform pigmentation

Warm, pink skin with good capillary refill

13. A nurse is assessing the abdomen and hears high-pitched, tinkling bowel sounds. This finding is most consistent with which condition?

Normal peristalsis

Early bowel obstruction

Paralytic ileus

Severe gastroenteritis

14. During abdominal assessment, in which order should the nurse perform inspection, auscultation, percussion, and palpation?

Inspection, palpation, percussion, auscultation

Inspection, auscultation, percussion, palpation

Auscultation, inspection, palpation, percussion

Palpation, inspection, auscultation, percussion

15. A nurse notes JVD (jugular venous distention) at 4 cm above the sternal angle. This finding suggests which condition?

Normal venous pressure

Elevated venous pressure

Severe dehydration

Low hemoglobin

16. When assessing pupil response, what does PERRL stand for?

Pupils equal, round, reactive to light

Pupils enlarged, reactive, round, light-sensitive

Pupils equal, regular, responsive, luminous

Pupils examined, round, reactive, light-tested

17. During lung auscultation, which breath sound is heard over the trachea?

Vesicular

Bronchovesicular

Bronchial

Crackles

18. What is the normal respiratory rate range for a healthy adult at rest?

8–12 breaths per minute

12–20 breaths per minute

20–30 breaths per minute

30–40 breaths per minute

19. During cardiovascular assessment, a nurse palpates the apical pulse. At which anatomical location is this pulse found?

Fifth intercostal space at midclavicular line

Second intercostal space at right sternal border

Groin area along femoral artery

Inner wrist at radial artery