Exam (elaborations)
2024 NR509 HEAD TO TOE ASSESSMENT EXAM WITH CORRECT ANSWERS
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2024 NR509 HEAD TO TOE ASSESSMENT EXAM WITH CORRECT ANSWERS
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2024 NR509 HEAD TO TOEASSESSMENT EXAM WITH
CORRECT ANSWERS
Abdomen: Inspection - CORRECT-ANSWERSContours & symmetry
No distortions
Abdomen: Auscultation - CORRECT-ANSWERS*Bowel sounds* - present,
normoative all 4 quadrants
*Bruits* - with bell
*Aortic* - right below 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: Percussion - CORRECT-ANSWERSPercuss all 4 quadrants:
Tympany
Dullness
Flatness
---All areas normal & tympanic
Abdomen: Palpation - CORRECT-ANSWERSPalpate 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
Lower extremities: Inspection - CORRECT-ANSWERSInspect skin integrity of
lower extremities
--No lesions or edema
ROM of hips - CORRECT-ANSWERSPassive unilateral ROM of hips
, Flexion
Abduction
Adduction
Internal Rotation
External rotation
**hip extension not tested for this exam
ROM of knees - CORRECT-ANSWERSPassive unilateral ROM of the knees
Flexion
Extension
Knee strength - CORRECT-ANSWERSStrength at the knees (bilateral)
Flex/extend against resistance - 5/5 strength
ROM of ankles - CORRECT-ANSWERSPassive unilateral ROM of ankles
Dorsiflexion
Plantar flexion
Rotation
Ankle strength - CORRECT-ANSWERSBilateral
Dorsi/plantar flex against resistance - 5/5 strength
Pedal pulse - CORRECT-ANSWERSAssess dorsalis pedal pulse
--2+ & equal bilaterally
Spine: Inspection & Palpation - CORRECT-ANSWERSPatient standing
Inspect & palpate
Expected curvatures
Alignment
Tenderness
Spine: ROM - CORRECT-ANSWERSROM of spine
*Flexion* - bend over, touch toes
*Extension* - straighten up, extend backwards
*Lateral flexion* - one side, then other
*Rotation* - right & left
--good, active ROM
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