MARYVILLE NURS 612 EXAM 2 CORE HEAD-TO-
TOE ASSESSMENT AND CLINICAL FINDINGS
REVIEW 2026
◉ biot respirations.
Answer: irregular breathing that varies in depth and is interrupted
irregularly by intervals of apnea; associated with severe and
persistent increased intracranial pressure, resp compromise from
drug poisoning, or brain damage at the medulla and generally equals
poor prognosis
◉ peripheral areas related to respiratory assessment.
Answer: observe the lips and nails for cyanosis or pallor; lips for
pursing; fingers for clubbing; and alae nasi for flaring
◉ pleural friction rub.
Answer: dry, rubbing, or grating sound; palpable, coarse, grating
vibration; usually on inspiration; caused by inflammation of the
pleural surfaces; think feel of leather rubbing on leather
◉ thoracic expansion.
Answer: stand behind patient and place thumbs along spinal process
at level of 10th rib, with palms lightly in contact with the
,posterolateral surfaces; watch the thumbs during quiet and deep
breathing; loss of symmetry = problem on either 1 or both sides.
◉ crepitus.
Answer: crackly/crinkly sensation that can be palpated and heard, a
gentle bubbly feeling; indicates air in the subcutaneous tissue from a
rupture somewhere in the resp system, or infection with gas
producing organism
◉ palpating the chest and trachea.
Answer: palpate the throracic muscles and skeleton; feeling for
pulsations, areas of tenderness, bulges, depressions, masses, and
unusual movement
◉ tactile fremitus.
Answer: palpable vibration of the chest wall that results from speech
or other verbalizations. best felt posteriorly and laterally at the level
of the bifurcation of the bronchi; have patient say "99" while you
palpate with palmer surface of fingers or ulner aspect of the hand;
use firm, light touch
◉ abnormal tactile fremitus.
Answer: decreased of absent fremitus may be caused by excess air in
lungs or may indicate emphysema, pleural thickening, or effusion,
massive pulm edema, or bronchial obstruction. Increased fremitus
, often coarser or rougher in feel, caused by presence of fluids or solid
mass within the lungs.
◉ 7 characteristics of enlarged lymph nodes.
Answer: location, size and shape, consistency, mobility, discreteness,
tenderness, and warmth
◉ occipital lymph nodes.
Answer: lymph nodes at the base of the skull
◉ postauricular lymph nodes.
Answer: lymph nodes over the mastoid process, behind the ear
◉ preauricular lymph nodes.
Answer: lymph nodes in front of the ear
◉ parotid and retropharyngeal lymph nodes.
Answer: lymph nodes at the angle of the mandible (tonsillar)
◉ submandibular lymph nodes.
Answer: lymph nodes halfway between the angle and tip of the
mandible
TOE ASSESSMENT AND CLINICAL FINDINGS
REVIEW 2026
◉ biot respirations.
Answer: irregular breathing that varies in depth and is interrupted
irregularly by intervals of apnea; associated with severe and
persistent increased intracranial pressure, resp compromise from
drug poisoning, or brain damage at the medulla and generally equals
poor prognosis
◉ peripheral areas related to respiratory assessment.
Answer: observe the lips and nails for cyanosis or pallor; lips for
pursing; fingers for clubbing; and alae nasi for flaring
◉ pleural friction rub.
Answer: dry, rubbing, or grating sound; palpable, coarse, grating
vibration; usually on inspiration; caused by inflammation of the
pleural surfaces; think feel of leather rubbing on leather
◉ thoracic expansion.
Answer: stand behind patient and place thumbs along spinal process
at level of 10th rib, with palms lightly in contact with the
,posterolateral surfaces; watch the thumbs during quiet and deep
breathing; loss of symmetry = problem on either 1 or both sides.
◉ crepitus.
Answer: crackly/crinkly sensation that can be palpated and heard, a
gentle bubbly feeling; indicates air in the subcutaneous tissue from a
rupture somewhere in the resp system, or infection with gas
producing organism
◉ palpating the chest and trachea.
Answer: palpate the throracic muscles and skeleton; feeling for
pulsations, areas of tenderness, bulges, depressions, masses, and
unusual movement
◉ tactile fremitus.
Answer: palpable vibration of the chest wall that results from speech
or other verbalizations. best felt posteriorly and laterally at the level
of the bifurcation of the bronchi; have patient say "99" while you
palpate with palmer surface of fingers or ulner aspect of the hand;
use firm, light touch
◉ abnormal tactile fremitus.
Answer: decreased of absent fremitus may be caused by excess air in
lungs or may indicate emphysema, pleural thickening, or effusion,
massive pulm edema, or bronchial obstruction. Increased fremitus
, often coarser or rougher in feel, caused by presence of fluids or solid
mass within the lungs.
◉ 7 characteristics of enlarged lymph nodes.
Answer: location, size and shape, consistency, mobility, discreteness,
tenderness, and warmth
◉ occipital lymph nodes.
Answer: lymph nodes at the base of the skull
◉ postauricular lymph nodes.
Answer: lymph nodes over the mastoid process, behind the ear
◉ preauricular lymph nodes.
Answer: lymph nodes in front of the ear
◉ parotid and retropharyngeal lymph nodes.
Answer: lymph nodes at the angle of the mandible (tonsillar)
◉ submandibular lymph nodes.
Answer: lymph nodes halfway between the angle and tip of the
mandible
