Head-to-Toe Physical Assessment & Cranial Nerves Review

Flashcards testing clinical concepts, cranial nerve tests, anatomical landmarks, and normal assessment values from a complete head-to-toe nursing examination.

What four questions are asked to assess if a patient is alert and oriented $\times 4$?

1. What is your name?
2. Can you tell me where you are right now?
3. Do you know what time it is?
4. Can you tell me why you're here?

What are the normal findings for capillary refill and skin turgor in the physical assessment?

Skin turgor is brisk with no tenting. Capillary refill on fingernails and toenails is less than $3\,\text{seconds}$ bilaterally.

How is Cranial Nerve 1 (Olfactory) assessed, and what indicates an intact result?

The patient closes their eyes, occludes one nostril, and identifies a scent (such as an alcohol swab near the nose), repeated on the other side. Correctly identifying the smell confirms the nerve is intact.

Which cranial nerves are tested using the 6 cardinal fields of gaze, pupillary light reflex, and accommodation?

Cranial Nerve 3 (Oculomotor), Cranial Nerve 4 (Trochlear), and Cranial Nerve 6 (Abducens).

How is Cranial Nerve 5 (Trigeminal) assessed for motor and sensory function?

Sensory function is tested by touching the face, arms, and legs with hard or soft objects while the patient's eyes are closed. Motor function is tested by having the patient clench their jaw while the clinician palpates the temporomandibular joint.

What phrase is spoken by the patient to evaluate Cranial Nerves 9 (Glossopharyngeal), 10 (Vagus), and 12 (Hypoglossal)?

"RIGHT, TIGHT, DYNAMITE"

How is Cranial Nerve 11 (Spinal Accessory) evaluated during the examination?

By asking the patient to shrug their shoulders against resistance and turn their head against the clinician's hand to check for equal bilateral strength.

What position should the head of the bed (HOB) be in when checking for jugular venous distention (JVD)?

Elevated to $30\text{--}45^\circ$.

According to this diagram of head and neck lymph nodes, which anatomical region drains into the submental lymph nodes?

The lower lip, floor of the mouth, and apex of the tongue.

What anatomical locations correspond to the five key cardiac auscultation landmarks?

1. Aortic: 2nd right intercostal space
2. Pulmonic: 2nd left intercostal space
3. Erb's Point: 3rd left intercostal space
4. Tricuspid: 4th left intercostal space
5. Mitral (Apical): 5th left intercostal space, midclavicular line

What are the correct respiratory rate and normal breath sound findings recorded in the chest assessment?

Respiratory rate is $16\,\text{breaths per minute}$ with a regular, unlabored pattern. Vesicular breath sounds are heard throughout peripheral lung fields with no adventitious sounds.

What is the expected normal finding when testing for bronchophony while auscultating the posterior lung fields?

When the patient repeats "99", all spoken sounds are muffled and indistinct throughout all five levels.

What is the correct sequence of examination techniques for the abdominal (GI/GU) assessment?

1. Inspection (checking symmetry, contour, and presence of pulsations)
2. Auscultation (listening for active bowel sounds in all 4 quadrants)
3. Light palpation (using 3 fingers in a circular motion across 4 quadrants)

What standard numerical grade is assigned to normal peripheral pulses and deep tendon reflexes (DTRs)?

A grade of $2+$ bilaterally.

How is the Romberg test conducted and what constitutes a negative result?

The patient stands with feet together and arms at their side, then closes their eyes for $30\,\text{seconds}$. A negative test means the patient maintains balance and posture upright with minimal swaying.