HEENT pt 2 (study alongside notes)

When inspecting the external ear, observe ____________, ____________, ____________, and ____________; also look for lesions or visible drainage.

Position/placement, shape, size, symmetry

When palpating the external ear structures, check for any ____________.

Tenderness

An otoscope exam is considered an ____________ ____________ procedure.

Advanced practice

The Whisper Test assesses cranial nerve ___, the ____________ nerve.

VIII; vestibulocochlear

During the Whisper Test, the nurse stands ___ feet behind the client and whispers words while the client covers one ear.

1-2

In the Weber Test, a vibrating tuning fork is placed on top of the client’s ____________, and the client is asked if the sound is the same in both ears or louder in one.

Head

The ____________ test is performed if the Weber test is positive.

Rinne

During the Rinne Test, the tuning fork is first placed on the client’s ____________ ____________ to test bone conduction.

Mastoid process

After bone conduction is measured, the tuning fork is moved about ___ inch in front of the ear to test air conduction.

1

Normally, sound transmission through ____________ is about twice as long as transmission through ____________.

Air; bone

The ____________ Test (CN ___) evaluates balance.

Romberg; VIII

During the Romberg Test, the client stands with feet ____________, hands at ____________, and eyes open, then eyes closed.

Together; sides

A normal Romberg finding is that the patient maintains balance with ____________ swaying.

Minimal

A positive Romberg (swaying) indicates a ____________ or ____________ disorder.

Vestibular; cerebellar

When inspecting the external nose, note its ____________, ____________, and ____________, and observe for discharge or flaring.

Position; shape; size

To check nasal patency, have the client close their ____________, hold one ____________ closed, and breathe through the other.

Mouth; naris

Inspect the internal nose by having the client tilt their head back; the septum should be ____________ and ____________.

Intact; midline

A ____________ ____________ or ____________ may be used to inspect internal nasal structures if indicated.

Nasal speculum; otoscope

The sense of smell is tested by assessing cranial nerve ___, the ____________ nerve.

I; olfactory

Common scents used to test CN I include ____________ or ____________.

Lemon; vanilla

If indicated, inspect and palpate the ____________ and ____________ sinuses.

Frontal; maxillary

When inspecting the mouth externally, assess the placement of the ____________, their ____________, and overall ____________.

Lips; color; condition

Have the client purse their lips to better observe the ____________ of the mouth.

Movement

An equal smile indicates normal function of cranial nerve ___, the ____________ nerve.

VII; facial

The oral mucosa and gums should normally appear ____________, ____________, and ____________.

Pink; moist; intact

When inspecting and palpating the lower lip, note any ____________ or ____________.

Lesions; tenderness

To inspect the buccal mucosa, use a ____________ ____________ to retract the cheek and shine a ____________ onto the mucosa.

Tongue depressor; penlight

When examining gums, note their ____________ and check for any ____________, ____________, or ____________.

Color; bleeding; edema; lesions

When inspecting the teeth, assess their ____________, ____________, and ____________.

Number; color; condition

When assessing occlusion, observe the client’s ____________ and note any ____________ or ____________ teeth. Also assess the client’s ability to ____________ and ____________.

Bite; loose; missing; chew; swallow

To test cranial nerve ___, have the client stick out their tongue. The tongue should appear ____________ and remain ____________.

XII; symmetrical; midline

When examining the upper surface of the tongue, note its ____________, ____________, and ____________.

Texture; position; mobility

Palpate the tongue only if ____________.

Indicated

A dry and furry tongue may indicate ____________.

dehydration

A black, “hairy” tongue is a sign of a ____________ ____________.

fungal infection

When inspecting the tonsils and uvula, have the client tilt their head ____________ and open their mouth ____________.

Back; widely

Use a ____________ ____________ to depress the tongue and a ____________ to illuminate the area.

Tongue blade; penlight

When inspecting tonsils, note their ____________ and ____________, as well as any ____________, ____________, ____________, or ____________.

Size; color; discharge; redness; swelling; lesions

Normal tonsils should be ____________, ____________, ____________, and without ____________.

Small; pink; symmetrical; lesions

Have the client say “AH” to observe the uvula. It should rise ____________, which assesses cranial nerves ___ and ___.

Symmetrically; IX; X

When the client swallows, the ____________ and ____________ should rise, testing cranial nerves ___ and ___.

Larynx; trachea; IX; X

To test the gag reflex, touch the back of the ____________ ____________ with a tongue blade. This assesses cranial nerve ___.

Soft palate; X

A taste test, if indicated, assesses cranial nerve ___.

VII

When inspecting the neck, note the ____________, ____________ ____________, and any ____________.

Musculature; skin color; lesions

The neck should be ____________, ____________, and ____________ with full range of motion.

Erect; midline; symmetrical

To assess neck strength, have the client turn their head against your hand. This tests cranial nerve ___, the ____________ nerve.

XI; spinal accessory

A shoulder shrug also tests cranial nerve ___.

XI

The thyroid gland should normally not be ____________.

Visible

When inspecting the neck, also check for distention of the ____________ ____________.

Jugular veins

When palpating, assess the neck’s ____________ ____________, ____________, and for any ____________.

Skin temperature; texture; edema

Palpate the ____________ ____________ ____________ using light circular motions with 2–3 finger pads.

Cervical lymph nodes

Normally, lymph nodes are ____________ ____________.

Not palpable

____________ refers to enlarged lymph nodes that are palpable at ___ cm or greater.

Lymphadenopathy; 1

When palpating the thyroid (if indicated), it should feel ____________, ____________, and ____________.

Smooth; firm; non-tender

If the thyroid is enlarged, auscultate for ____________ using the ____________ of the stethoscope.

Bruits; bell

When palpating the carotid arteries, palpate ____________ ____________ at a time.

One side