Tina Jones is a pleasant, 28-year-old African American woman who to the
emergency department for evaluation of a right foot injury and is admitted
for IV antibiotics. She is now admitted to your unit for care.
Learning Objective
Develop strong physical assessment skills in relation to different body systems.
Develop strong communication skills, accurate and appropriate documentation
skills. Continue to develop strong communication skills.
Getting Ready
1. For an otoscopic examination of the external auditory canal of an adult,
the examiner should do which of the following?
a. Pull the auricle straight up
b. Pull the earlobe down
c. Pull the auricle up and back
d. Pull the auricle straight back
Correct answer: C. Pull auricle up and back
2. During shift change, it is noted that a new patient is severely hard of
hearing. What is the most important question for you to ask about this
patient initially?
a. What means of communication does the patient use?
b. Is the patient aware of the latest technology to assist them?
c. Has the patient ever been hospitalized before?
d. Can a family member stay with the patient to interpret?
Correct answer: What means of communication does the
patient use
3. List four (4)four signs of possible eye problems.
Redness, pain, discharge, dry eyes, trouble adjusting to dark rooms,
difficulty focusing on near or distant objects, change in color of the
iris, dark spots at the center of viewing
Assessment
In the evaluation phase of assessment, ensure the information collected is complete,
accurate and documented appropriately. The nurse must draw on critical thinking and
problem solving skills to make clinical decisions and plan care for the patient being
assessed. If any abnormal findings are identified, the nurse must ensure that appropriate
action is taken. This may include communicating the findings to the medical team
List five (5) specific items you would inspect in a focused HEENT assessment.
Why?
1.Eyes: for vision difficulty, swelling, redness, cloudiness, or infection
2.Ears: for hearing loss or infection
3.Throat: for infection or difficulty swallowing
5. Head: for trauma or abnormalities
5. Nose: for discharge, membrane condition, or sense of smell
List three (3) specific items you would palpate in a focused HEENT assessment.
Why?
1. Lymph nodes: to see if there is infection, tenderness, or swelling
2. Jaw: for symmetry or abnormality
3. Head: for trauma or tenderness
HEENT Prep-Answer Key