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Head-to-Toe Assessment Script Exam Questions And Correct Answers
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Head-to-Toe Assessment Script Exam Questions AndCorrect Answers
Hi, my name is Stacey and I am a student nurse. Today I will be completing your
head-to-toe exam. Do you have any questions for me today? - RESPONSE Okay, well
then let's get started. Can you state your full name for me? And what is your date of
birth? (Go wash hands)
I am going to take your vital signs now. Let me first estimate your blood pressure and
we'll come back to that. Your pulse is ______ and your respirations are _______/minute.
Your temperature is ___________. Now I'm going to take blood pressure. Your blood
pressure is ________________ - ANSWER I'm going to be observing the patient's skin
throughout the exam. May I remove your glasses? Your facial features look symmetrical.
(Don gloves)The scalp is without lesions and uninhabited. Off gloves and gel hands.
I am going to palpate your face for lumpiness or tenderness. This hurt? Now I am going
to percuss your sinuses. This hurt? (press up under eyebrows) How about this (press up
under zygomatic). Let's check your to make sure that your jaw is working smoothly
(press at TMJ). Excellent, I don't feel any clicking or crepitus and your jaw opens
smoothly. - ANSWER Now I'm going to test facial sensation with this cotton ball. I'm
going to have you shut your eyes and tell me "now" when you feel the cotton on your
skin like this (brush cotton on pts arm). Can you shut your eyes please? (brush cotton on
forehead, cheek and mandible). Good, you can open your eyes now. (palpate
temporalis) Can you clench your jaw? Good. palpate masseter Clench again. Good.
Your facial sensations are intact and your have good jaw strength so I know that your
5th cranial nerve is intact.
Now we will examine your facial nerve. Can you frown? smile? show your teeth? now
puff out the cheeks. Great. The nerve is intact-ANSWER I'm going to check your eyes
now. (look for any redness or assymetry in eyes). Can you close your eyes for a second.
Great, the eyes, lids and lashes are all normal. Now, I'm going to check your eye
muscles. Can you follow my finger as I go through the six positions? Hold at extreme left
and right. Ok, and now just look at a point behind my head as I shine this light. Good,
your eye muscles are healthy, and I did not see any sign of lazy eye. The cranial nerves
, 3, 4 and 6 controlling eye moments are all intact. - ANSWER Let's take a look at the
cornea(light side to front). Good. Looks smooth and round with no scratches. Pull down
bottom lid the lining of the eyelid is pink and healthy.
Iris and pupil are round and symmetrical. I'm going to check your pupil reaction now.
Can I have you hold your hand up like this? Good: The pupillary responses are intact.
Now let me have you focus your gaze on a point on the wall behind me. Now look at my
finger. Good. Now look at my finger. Good, the pupils constricted and converged, which
is normal. Your optic and occulomotor nerves are intact. - ANSWER Now we're going to
check your hearing. What I'm going to do is whisper several words behind you. Please
repeat the words you hear. Can I have you block your right ear like this, (demonstrate)
and move the finger around slightly so it makes noise? Good. (Busstop, football,
raindrop) Now switch ears.
( keyboard, makeup, notebook. ) Good, your auditory nerve is intact. I am going to
palpate your ears now for any lumps or tenderness, so I am going to touch them. Let me
know if you have discomfort. You might feel a little discomfort. Pinna, tragus, that's ok. I
don't see any redness, drainage or swelling. - ANSWER I am going to look in at your
nasal cavity now. Put on gloves. Can you tip your head back for me? (elevate tip of nose,
shine light in each nare) I do notice that your septum is deviated but I don't see any
swelling. Your nasal passages appear healthy.
(off gloves and gel hands) Let's take a look at your mouth and throat. (use tongue blade
and light) Your gums appear pink and healthy, teeth are all present ,inside of the mouth
(buccal mucosa) is pink and smooth. I don't see any lesions on top of tongue, soft and
hard palates, tonsils or pharnyx. The mouth looks very healthy. - ANSWER Can I have
you stick out your tongue? The tongue is centered and you are able to stick it out. That
means your hypoglossal nerve is intact. Can you stick it out again and say "AH"?
Good, the soft palate and uvula elevate with that action, which informs me your 9th and
10th cranial nerves are intact. Now I am going to examine your neck. Let me know if you
have any tenderness where I touch. The trachea is @ midline and mobile @ the
suprasternal notch. I do not see or feel any masses/ swelling. - ANSWER Next I am going
to palpate your lymph nodes. Any pain or tenderness as I do this? Can I have you tilt
your head to the right, now the left. now shrug your shoulders. Good.
I did not feel any of your lymph nodes and they are not tender which means they are not
swollen, which would be a sign of infection. Can I have you shrug your shoulders against
my hand? Now, turn your head against my hand, the other side. Good, your shoulder and
neck muscles are strong and your spinal accessory nerve is intact. ANSWER Yes, can
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