Head-to-Toe Assessment Script Questions and Correct
Answers |Already Graded A+||Brand New Version!!!
Entire Assessment Needs To Be 10-12 Minutes
Infection Control/Hand Hygiene Both Need To Be Maintained
My name is Katherine and I'm a student nurse. I'm going to be conducting your head-to-toe
examination. Do you have any questions for me today? - CORRECT ANSWER -Okay, let's get
started then. Can you state your full name for me? And what is your data of birth? (Go wash
hands)
Gather equipment: Stethoscope, pen light, watch with second hand. - CORRECT ANSWER -
I'm 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 ________________
- CORRECT ANSWER -I'm going to be observing the patient's skin throughout the exam. May I
remove your glasses? Your facial features look symmetrical. (Put on gloves)The scalp does not
have any lesions or pest inhabitants. Remove gloves and gel hands.
HEAD - CORRECT ANSWER -
Assess Orientation: Person, Place, Time, Purpose - CORRECT ANSWER -
Assess Pain: OLDCART/ICE if Pain present - CORRECT ANSWER -
Assess Allergies - CORRECT ANSWER -What are they and what happens? Last time it
happened?
, Assess Psychosocial Status - CORRECT ANSWER -Appearance. Overall mood? Hows school?
Sleep? Family? Stress? How do you cope? Any SI, HI?
Skin inspection - CORRECT ANSWER -Olive skin, pink undertone. No cyanosis, pallor,
erythema, or jaundice.
-Dry, moist, wet
-No visible patches, broken skin, lesions, etc
-Smooth, firm, and even.
Inspect Scalp - CORRECT ANSWER --Lesions, scale, hair
-Hair color
-Texture: Think or fine; straight, wavy, or curly.
-Distribution: evenly, uneven.
Eyes: pupil size and light reaction. - CORRECT ANSWER --PERRLA
6 Cardinal Fields of Gaze - CORRECT ANSWER -Draw wagon wheel or "H" in front of them.
Observe for Nystagmus (uncontrolled eye twitching)
Inspect Ears - CORRECT ANSWER -I'm going to touch your ears now to feel for any lumps or
tenderness. Please let me know if you feel any discomfort. (Pinna, tragus) Good. I don't see
redness, drainage or swelling.
Inspect Mouth - CORRECT ANSWER -Let's take a look at your mouth and throat. (use tongue
blade and light) Your gums look 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.
Answers |Already Graded A+||Brand New Version!!!
Entire Assessment Needs To Be 10-12 Minutes
Infection Control/Hand Hygiene Both Need To Be Maintained
My name is Katherine and I'm a student nurse. I'm going to be conducting your head-to-toe
examination. Do you have any questions for me today? - CORRECT ANSWER -Okay, let's get
started then. Can you state your full name for me? And what is your data of birth? (Go wash
hands)
Gather equipment: Stethoscope, pen light, watch with second hand. - CORRECT ANSWER -
I'm 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 ________________
- CORRECT ANSWER -I'm going to be observing the patient's skin throughout the exam. May I
remove your glasses? Your facial features look symmetrical. (Put on gloves)The scalp does not
have any lesions or pest inhabitants. Remove gloves and gel hands.
HEAD - CORRECT ANSWER -
Assess Orientation: Person, Place, Time, Purpose - CORRECT ANSWER -
Assess Pain: OLDCART/ICE if Pain present - CORRECT ANSWER -
Assess Allergies - CORRECT ANSWER -What are they and what happens? Last time it
happened?
, Assess Psychosocial Status - CORRECT ANSWER -Appearance. Overall mood? Hows school?
Sleep? Family? Stress? How do you cope? Any SI, HI?
Skin inspection - CORRECT ANSWER -Olive skin, pink undertone. No cyanosis, pallor,
erythema, or jaundice.
-Dry, moist, wet
-No visible patches, broken skin, lesions, etc
-Smooth, firm, and even.
Inspect Scalp - CORRECT ANSWER --Lesions, scale, hair
-Hair color
-Texture: Think or fine; straight, wavy, or curly.
-Distribution: evenly, uneven.
Eyes: pupil size and light reaction. - CORRECT ANSWER --PERRLA
6 Cardinal Fields of Gaze - CORRECT ANSWER -Draw wagon wheel or "H" in front of them.
Observe for Nystagmus (uncontrolled eye twitching)
Inspect Ears - CORRECT ANSWER -I'm going to touch your ears now to feel for any lumps or
tenderness. Please let me know if you feel any discomfort. (Pinna, tragus) Good. I don't see
redness, drainage or swelling.
Inspect Mouth - CORRECT ANSWER -Let's take a look at your mouth and throat. (use tongue
blade and light) Your gums look 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.
