HENT Highlights
What should the nurse expect to find when assessing the oral mucosa of a healthy adult?
Pink, moist mucous membranes with no lesions
What are the normal heart sounds heard during auscultation?
S1 and S2
What are expected breath sounds over most lung fields?
Clear and equal bilaterally
What order should the nurse perform an abdominal assessment in?
Inspect → Auscultate → Palpate
What type of language should always be used when documenting findings?
Objective, factual language
The nurse notes asymmetry of the face and drooping on one side when the patient smiles. What might this indicate?
Possible cranial nerve VII deficit (Bell’s palsy or stroke)
Capillary refill greater than 3 seconds may indicate what?
Poor peripheral perfusion or dehydration
The nurse hears fine crackles at the bases. What could this indicate?
Fluid in alveoli (CHF, pneumonia)
Bowel sounds are heard every 5–15 seconds in all quadrants. Is this expected or unexpected?
Expected finding
Write a correct documentation example: “The patient looks tired.”
“Patient observed with drooping eyelids, slow responses, and states, ‘I feel tired.’”
The patient’s tonsils are red, swollen, and have white exudate. Is this expected or unexpected?
Unexpected — may indicate tonsillitis
The nurse hears a swishing or blowing sound between heartbeats. What is this called?
A murmur (unexpected)
The patient’s respiratory rate is 8 breaths per minute. What is this called and why is it concerning?
Bradypnea — may indicate respiratory depression
The nurse notes rigidity and rebound tenderness in the abdomen. What could this indicate?
Peritonitis or acute inflammation
What should be documented if no abnormal findings are noted in a system?
“Within defined limits (WDL)” or “No abnormal findings noted”
When assessing the eyes, pupils are unequal and one is sluggish to react to light. What does this suggest?
Possible neurological impairment or increased ICP
The patient has +2 pitting edema in both ankles. What condition could this represent?
Heart failure or fluid overload
The nurse observes the patient using accessory muscles to breathe. What does this suggest?
Increased work of breathing or respiratory distress
The patient’s abdomen is distended and firm with no bowel sounds. What could this suggest?
Bowel obstruction or ileus
The nurse hears wheezes in the upper lobes. What’s the correct way to document?
“Expiratory wheezes auscultated bilaterally in upper lobes.”
A patient reports ringing in the ears and dizziness. What two systems might you consider related?
HENT and neurological systems (possible vertigo, Meniere’s disease)
The patient’s apical pulse is irregular. What should the nurse do next?
Reassess, obtain full minute count, and notify provider—possible arrhythmia
Breath sounds are absent in the right lower lobe. What condition might cause this?
Atelectasis, pleural effusion, or pneumothorax
The patient reports nausea and pain in the right upper quadrant. What organ might be affected?
Gallbladder (possible cholecystitis)
Why is it incorrect to document “Patient appears anxious”?
“Appears” is subjective — document observable behaviors instead (e.g., pacing, fidgeting, rapid speech).