Exam 1 Study Guide — Module 2: Vital Signs, Skin, Head & Neck, Senses, Breast-Part B

Which techniques are used for the head and neck exam?

• INSPECTION and PALPATION

- Exception: AUSCULTATE over the trachea if a neck lump is present (listen for stridor)

- No percussion;

How do you set up the client for a head and neck exam?

• Client SITTING, head at YOUR EYE LEVEL

- REMOVE glasses, hearing aids, and dentures

- Wear GLOVES for the eyes and mouth

- Penlight for direct lighting;

What is the head and neck exam SEQUENCE?

SKULL → FACE → EYES → EARS → NOSE/SINUSES → MOUTH/THROAT → NECK

(Top to bottom);

What questions belong in a focused head and neck history?

• Headaches — new pattern?

- Head injury — any LOSS OF CONSCIOUSNESS?

- Neck lumps or swelling

- Vision or hearing changes

- Ear drainage or pain

- Sinus pain, nasal drainage, allergies

- Trouble swallowing

- Dental care and mouth sores;

What are EXPECTED vs. UNEXPECTED head and face findings?

EXPECTED

- Round skull, no lumps

- Symmetric face (SLIGHT asymmetry is normal)

- Relaxed expression

UNEXPECTED

- MARKED facial asymmetry → STROKE or Bell's palsy

- Lumps or bruising → trauma

- Facial swelling → trauma, infection, heart or kidney problems;

How do you assess orientation?

Ask about 3 domains:

- PERSON — "What is your name?"

- PLACE — "Where are you right now?"

- TIME — "What year is it?"

Document each domain specifically, e.g., "Oriented to person and place, disoriented to time (states year is 2019).";

What does NEW disorientation mean, and what do you do?

• NEW disorientation = ACUTE change → NOTIFY immediately

- Possible causes: infection, low oxygen, medications, stroke

- NEVER blame it on age (CO2)

- First confirm the BASELINE (chart, family): is this new or long-standing?;

How do you check for a facial droop?

1. SMILE — look for a flattened nasolabial fold on one side

2. PUFF the cheeks

3. CLOSE the eyes tightly

4. RAISE the eyebrows

Then: check speech, grip strength in both hands, hold both arms up for 10 sec (drift).;

What is the nasolabial fold?

The crease running from the side of the nose to the corner of the mouth. A FLATTENED fold on one side when smiling suggests facial weakness (possible stroke).;

What does BE-FAST stand for?

• B — BALANCE loss (sudden)

- E — EYES: sudden vision change (double vision, vision loss)

- F — FACE droop

- A — ARM weakness or drift

- S — SPEECH slurred or word-finding trouble

- T — TIME to call for help

(American Stroke Association) Balance and Eyes catch strokes that spare the face, arm, and speech.;

What are the nursing actions for a SUSPECTED STROKE?

1. Take VITAL SIGNS

2. NOTIFY the provider IMMEDIATELY

3. Keep NPO (NOTHING by mouth — no water, ice chips, or thickened liquids) until a SWALLOW SCREEN is done

4. FALL PRECAUTIONS — bed low, call light in reach, bed alarm

5. Reorient the client

6. Document

Comfort for thirst: mouth care.;

Why does a client with a head injury on a blood thinner need close monitoring?

Blood thinners raise the risk of bleeding inside the skull, even if the client looks fine at first. Report the fall and monitor LEVEL OF CONSCIOUSNESS and PUPILS closely.;

What are EXPECTED vs. UNEXPECTED neck findings?

EXPECTED

- Trachea MIDLINE

- No lumps

- Full, painless range of motion

- Swallows without choking

UNEXPECTED

- Trachea SHIFTED → mass or chest problem

- Swelling at the FRONT of the neck → THYROID enlargement

- Visible lymph nodes → infection or cancer

- Trouble swallowing → inflammation or neurologic problem;

What is a NECK EMERGENCY, and what do you do?

SIGNS: neck lump + STRIDOR + can't finish sentences + accessory muscle use

MEANING: the airway is being blocked (ABCs)

ACTION: NOTIFY the provider IMMEDIATELY, keep the client NPO;

What is stridor?

A high-pitched noise during breathing in, caused by a narrowed or blocked upper airway. An EMERGENCY sign.;

How do you palpate lymph nodes, and in what order?

TECHNIQUE: finger PADS, gentle CIRCULAR motion, BOTH SIDES at the same time, head tilted slightly forward

ORDER:

1. Preauricular (front of ear)

2. Posterior auricular (behind ear)

3. Occipital (base of skull)

4. Submental (under chin)

5. Submandibular (under jaw)

6. Tonsillar (angle of jaw)

7. Anterior cervical

8. Posterior cervical

9. Supraclavicular (above collarbone) — LAST

(ATI: RN inspects, palpation is mainly the advanced provider's role.);

What are NORMAL vs. INFECTION vs. CANCER lymph node findings?

NORMAL

- Not felt, or SMALL (under 1 cm), SOFT, MOVABLE, NONTENDER

INFECTION (often)

- ENLARGED, TENDER, WARM, MOVABLE

CANCER (concern)

- ENLARGED, HARD, FIXED (doesn't move), NONTENDER, MATTED together

KEY: painless does NOT mean harmless. Small size doesn't rule out cancer if hard and fixed.;

Why is a painless, hard, fixed node more worrying than a painful one?

• Infection inflames nodes → TENDER and MOVABLE

- Cancer often grows PAINLESSLY and invades nearby tissue → FIXED in place;

Why is an enlarged supraclavicular node a red flag?

An enlarged SUPRACLAVICULAR node, especially on the LEFT, can signal cancer spreading from the CHEST or ABDOMEN. Report it.;

What does the NORMAL spine look like?

SIDE VIEW: a gentle S-shape

- Neck (cervical) curves IN

- Upper back (thoracic) curves OUT

- Lower back (lumbar) curves IN

BACK VIEW: straight, shoulders and hips level;

What are the 3 abnormal spinal curvatures?

• KYPHOSIS — exaggerated UPPER back rounding ("hunchback") → OLDER ADULTS, OSTEOPOROSIS. Seen from the SIDE.

- LORDOSIS — exaggerated LOWER back inward curve ("swayback") → PREGNANCY, OBESITY. Seen from the SIDE.

- SCOLIOSIS — SIDEWAYS S-curve → uneven shoulders/hips, RIB HUMP. Seen from the BACK. Screen ADOLESCENTS with the forward-bend test.;

What is kyphosis?

Exaggerated rounding of the upper (thoracic) back, the "hunchback." Common in older adults with osteoporosis, because weakened vertebrae compress.;