NURS 101L - Head to Toe Assessment: Questions With
Solutions
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Sherpath Chapter 29- Chest and Abdominal Tr... HESI 366 STUDY GUIDE
348 terms 130 terms
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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
Solutions
Save
Students also studied
Sherpath Chapter 29- Chest and Abdominal Tr... HESI 366 STUDY GUIDE
348 terms 130 terms
Preview anaphylacticshock Preview FutureRN0911 Preview
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
