NURS 101L - Head to Toe Assessment: Questions With Solutions

NURS 101L - Head to Toe Assessment: Questions With
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Terms in this set (50)



1st NPSG Privacy, Wash Hands, Introduction, ID patient and wristband,
any known allergies


General Survey (4) Alert and Oriented x 4 (Person, Place, Time, Situation)
(1) Assess Level of Consciousness


General Survey (4) Mood/Affect, personal hygiene
(2) Assess overall demeanor of patient


General Survey (4) Speech (slurred), able to articulate, hearing (aids or HOH),
(3) Assess communication vision (difficulty seeing, blurred vision, double vision)


General Survey (4) Perform pain assessment - PQRST
(4) Assess Pain


Head and Neck (9) for bumps, if needed - check hair distribution, infestations, and
(1) Inspect: Head skin integrity


Head and Neck (9) for drainage, placement, tenderness and any abnormalities
(2) Inspect: Ears


Head and Neck (9) check for symmetry - facial droop, color (pale, flushed,
(3) Inspect: Face jaundice)


Head and Neck (9) redness, discharge - contacts, glasses, sclera, extra ocular
(4) Inspect: Eyes movements, pupil size, PERRLA (Pupils Equal Round Reactive
to Light Accommodation)


Head and Neck (9) overall condition, any drainage, patency (if applicable)
(5) Inspect: Nose


Head and Neck (9) for moisture, cracked lips, bleeding gums, tongue (swollen),
(6) Inspect: Mouth and gums can patient swallow, do they wear dentures, does the tongue
move appropriately, breath odor


Head and Neck (9) swollen lymph nodes - note size and location if present, JVD
(7) Inspect: Neck (at a 45 degree angle), goiter, deviated trachea