NR509 Head to Toe Assessment Questions and Answers Updated 2022

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NR509 Head to Toe Assessment Questions and Answers Updated 2022 Abdomen: Auscultation Correct Answer- *Bowel sounds* - present, normoative all 4 quadrants *Bruits* - with bell *Aortic* - right bel... ow xiphoid process, midline *L renal* - above & lateral to L of umbilicus *R renal* - above & right to umbilicus *Iliac* - L below umbilicus & R below umbilicus ---No bruits heard Abdomen: Inspection Correct Answer- Contours & symmetry No distortions Abdomen: Palpation Correct Answer- Palpate all 4 quadrants for *tenderness & masses* --No masses noted Palpate liver & spleen (verbalize) *Liver* - upper right quad, note if you feel edge of liver *Spleen* - upper left quad...come laterally - note if you feel edge of spleen Perform *Blumberg's sign* (verbalize) - hand vertically 90 deg - press down into abdomen...rebound tenderness = +blumberg - peritonitis Abdomen: Percussion Correct Answer- Percuss all 4 quadrants: TympanyDullness Flatness ---All areas normal & tympanic Ankle strength Correct Answer- Bilateral Dorsi/plantar flex against resistance - 5/5 strength Anterior chest: Inspection & Auscultation Correct Answer- Inspect for obvious deformities & symmetry Auscultate lungs in anterior lung fields --Intercostal spaces *6 spaces* CN 2 Correct Answer- *Optic nerve* *Central vision* *Snellen pocket eye chart 6 ft away, cover one eye...read lowest line possible...repeat other eye --- 20/20 left eye, right eye, both eyes *Peripheral vision* Stand up at eye level, look straight ahead, do not move head. --Hands forward from back --Hands down from above --Hands come from belowCheck *pupillary response to light* (PERRL) --Ophthalmoscope light --Stare at nose --Come from side....pupil constricts...check other eye ----Pupils 2-3mm, respond to light equally CN 5 Correct Answer- *Trigeminal nerve* Motor component - palpate over the master muscle as patient clenches jaw --No distortions, great strength Sensory component -- close eyes, let me know where you feel my touch -- forehead, cheeks, chin, nose CN 7 Correct Answer- *Facial nerve* [Show More]

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