Head
What are some common health assessment questions you might ask when examining the head and neck?
-History of headaches/family history of migraine headaches?
-Have you ever had a head injury? Loss of consciousness?
-Any lumps/ or swelling in the neck area?
-Any neck pain or problems with neck motion?
What does the acronym PERRLA stand for?
Pupils are equal, round, reactive to light, and accommodating.
What are some common health assessment questions you might ask when examining the ears?
Do you have problems hearing?
Do you experience ringing in either ear?
Have you ever experienced drainage when having pain?
Do you wear hearing aids?
Have you ever had a hearing exam?
What do you look for when checking the size and shape of the external nose?
You look for whether the nose is symmetrical, proportional to the face, and if the shape is normal without deformities or swelling.
What does it usually mean if the front of the neck is swollen?
It may be a sign of a thyroid problem.
Which cranial nerve is tested by asking a client to clench their teeth while the nurse palpates the masseter and temporalis muscles?
Cranial Nerve V: Trigeminal
Which cranial nerve is primarily responsible for visual acuity assessed by the Snellen chart?
Cranial Nerve II: Optic
When performing the whisper test, what is the nurse assessing?
Cranial Nerve VII- Vestibulocochlear
How do you describe the color and condition of the skin on the nose?
You describe the skin color (normally consistent with the person’s overall skin tone), checking for redness, bruising, dryness, or lesions.
What should healthy lips look like during an oral assessment?
They should be moist, symmetrical, and smooth, ranging in color from pink to plum like color
During head assessment, the nurse asks the client to identify light touch on both cheeks. This is evaluating which function of the trigeminal nerve?
Sensory
This condition is indicated by the yellowing of the sclera, liver dysfunction, and elevated bilirubin levels
Jaundice
Redness, edema, and purulent drainage from the ear canal can indicate this condition
Ear infection
What signs of inflammation or damage should you notice in the nose or nasal mucosa?
Signs to notice include redness, swelling, sores, bleeding, crusting, or any skin or mucosa integrity breaks.
What does it mean if the trachea is not in the middle of the neck?
It could be a sign of a mass in the neck or chest problem
The nurse observes facial asymmetry and weakness on one side when the patient smiles and puffs their cheeks. Which cranial nerve is likely impaired?
A nurse asks a patient to follow a penlight through the six cardinal fields of gaze. This action is assessing which cranial nerves?
Cranial Nerve III, IV, and VI: Oculomotor, Trochlear, Abducens
Which finding requires immediate follow-up?
A. The tympanic membrane is pearly gray and intact
B. Slight cerumen noted in the ear canal
C. Sudden onset of vertigo with nausea
D. The ear canal is pink with no lesion
C. Sudden onset of vertigo with nausea
Why is it important to check the color of the nasal mucosa?
It’s essential to check the color of the nasal mucosa because healthy mucosa is usually pink and moist; changes like redness, pallor, or swelling may indicate infection or inflammation.
During an oral exam, what might it mean if the mucosa is moist but has darker pigment areas?
This is a normal finding in clients with darker skin tones and is not considered abnormal.
A patient presents with the sudden onset of jaw pain, scalp tenderness, and visual changes. The nurse suspects temporal arteritis. Which complication is most urgent to assess?
A. Mandibular dislocation
B. Hemiparesis
C. Acute glaucoma
D. Vision loss due to optic nerve ischemia
D. Vision loss due to optic nerve ischemia
A patient reports double vision and has difficulty with downward gaze, especially when walking downstairs. The nurse suspects dysfunction in which cranial nerve?
A. CN VI- Abducens
B. CN II- Optic
C. CN IV - Trochlear
D. CN V- Trigeminal
C. Cranial Nerve IV: Trochlear
A nurse is assessing a patient with tinnitus and reports recent ototoxic medication use. Which assessment is the highest priority?
A. Cranial nerve IX for gag reflex
B. Pupillary response to light
C. Weber and Rinne tests
D. Balance and Romberg test (CN VIII function)
D. Balance and Romberg test (CN VIII function)
A client presents with a swollen, erythematous nasal mucosa and complains of facial pressure and nasal congestion. Which nursing action is the priority?
A. Recommend an over-the-counter decongestant
B. Assess for fever and purulent drainage
C. Instruct the client to use a warm compress
D. Educate the client about allergen avoidance
B. Assess for fever and purulent drainage
A nurse is performing an oral assessment on a client and observes that the mucosa is moist with patchy areas of dark pigmentation. Which actions should the nurse take?
A. Document the findings as a normal variation
B. Notify the provider of suspected cyanosis
C. Ask the client about tobacco use history
D. Prepare the client for an oral biopsy
A. Document the findings as a normal variation