Head & Face
Expected skin finding?
Uniform color & smooth
Normal pupil size & characteristics?
3–5mm, round, equal
Normal TM appearance?
Pearly gray with cone of light
CN I tests what?
Smell
How to assess thyroid?
Swallow while palpating
Expected skull finding?
Round, symmetrical
PERRLA stands for?
Pupils equal, round, reactive to light & accommodation
Expected finding external ear?
Same coloration, no lesions
Expected nasal mucosa?
Pink, moist
Trachea should be?
Midline
Unexpected scalp finding: lice term?
Pediculus capitis
6 cardinal positions test what?
Extraocular movements
Rinne: normal = ?
AC > BC
Expected mouth finding?
Moist pink mucosa
CN XI checks what movement?
Shoulder shrug / head turn
Unexpected facial swelling under eyes.
Periorbital edema
What color should the sclera be in a normal assessment?
What variations are acceptable?
White/glossy (or clear)
A yellow tint in the eyes of clients with dark skin can be caused by a benign condition where the conjunctiva (the clear membrane over the eye's white part) yellows with age or sun exposure, which is common in people with more melanin.
Weber test assesses?
Lateralization
The nurse documents bloody drainage from the nares. What term describes this?
Epistaxis (unexpected finding)
Which cranial nerve is assessed by asking the patient to shrug shoulders and turn head against resistance?
CN XI (spinal accessory)
What do we assess on lymph nodes?
Size, tenderness, shape, mobility, warmth, consistency
The nurse notes that the eyelid droops over the pupil. What is this called?
Ptosis (unexpected finding)
Abnormal drainage from ear indicates?
Infection or trauma
During a HEENT exam, why does the nurse occlude one nare at a time?
To assess patency and airflow symmetry
The nurse feels a visible enlargement on the anterior neck when the patient swallows. What structure may be enlarged?
Thyroid gland