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NR509 Head to Toe Assessment Exam/47 Questions and Answers 2024
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NR509 Head to Toe Assessment Exam/47 Questions and Answers 2024
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NR509 Head to Toe Assessment Exam/47Questions and Answers 2024
Introduce yourself & patient - -Hi, my name is ________ and I will be
performing a physical examination for NR509 Advanced Physical Assessment
at Chamberlain University
My name is _____ and I give permission for this video assessment to be
uploaded to Chamberlain college of nursing
-Facial skin - -No discoloration or lesions
-Head - -Midline, symmetrical, normal in size
-Lymph node palpation (9 locations) - -*Preauricular* - in front of ear
*Post auricular* - behind ear
*Occipital* - back of head
Move forward - *tonsillar*
Under jawline - *submandibular*,
*Submental*
*Anterior cervical*
*Posterior cervical*
*Supraclavicular* - above clavicles
---Do not feel any enlargement, equal bilaterally
-CN 5 - -*Trigeminal nerve*
Motor component - palpate over the master muscle as patient clenches jaw
--No distortions, great strength
Sensory component -- close eyes, let me know where you feel my touch --
forehead, cheeks, chin, nose
-CN 7 - -*Facial nerve*
Inspect for facial symmetry with...
-Smile
-Frown
-Raise eyebrows
-Puff cheeks
-Pucker lips
----symmetrical bilaterally
, -Outer Ear: Inspection - -Inspect outer ear for nodules, skin lesions &
symmetry
-Ear: Inspection (Otoscope) - -Pull ear up & back
*Auditory canal* -- clear, no redness, swelling, drainage, or cerumen
*Tympanic membrane* -- pearly gray, no effusion in middle ear
Do same for other ear -- no redness, swelling, drainage, or cerumen,
tympanic membrane is pearly gray, no fluid in external auditory canal
-Ear: Palpation - -Palpate pinnae and tragus for nodules & tenderness
-CN 8 - -*Acoustic nerve* (hearing)
Whisper test - whisper words out of patient's sight & patient repeats words
back.
Test one ear at a time.
"one, two, three" and "four, five, six"
--Hearing intact bilaterally
-Eyes: Inspection - -*Conjunctiva* -- pink, clear, no drainage or lesions
*Sclera* - white & clear
-CN 2 - -*Optic nerve*
*Central vision*
*Snellen pocket eye chart
6 ft away, cover one eye...read lowest line possible...repeat other eye ---
20/20 left eye, right eye, both eyes
*Peripheral vision*
Stand up at eye level, look straight ahead, do not move head.
--Hands forward from back
--Hands down from above
--Hands come from below
Check *pupillary response to light* (PERRL)
--Ophthalmoscope light
--Stare at nose
--Come from side....pupil constricts...check other eye
----Pupils 2-3mm, respond to light equally
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