Head-to-Toe Physical Assessment Review

A set of question-and-answer flashcards covering the key physical-assessment techniques, normal findings, and documentation points discussed in the lecture transcript.

Which cranial nerve is tested by asking the patient to identify a familiar smell?

Cranial Nerve I – Olfactory

When you ask the patient to say “ah,” what normal finding should you observe in the uvula?

Uvula rises and remains midline, indicating intact CN IX (Glossopharyngeal) and CN X (Vagus)

Which two cranial nerves are primarily assessed when you test gag reflex and swallowing?

CN IX (Glossopharyngeal) and CN X (Vagus)

What tongue finding confirms an intact Hypoglossal nerve (CN XII)?

Tongue protrudes midline and moves easily side-to-side without deviation

How is the Trigeminal nerve (CN V) sensory branch tested during a head-to-toe exam?

Lightly touch the face with a cotton ball and ask the patient to report when it is felt

Which cranial nerve is checked when the patient smiles, frowns, or puffs out cheeks?

Cranial Nerve VII – Facial

What maneuver evaluates the spinal accessory nerve (CN XI)?

Shrug shoulders and turn head against resistance

A normal temporomandibular joint (TMJ) assessment should reveal what findings?

Full range of motion, no redness, swelling, crepitus, or pain

What three characteristics should oral mucosa exhibit in a healthy patient?

Pink, moist, and intact

Which finding indicates adequate dentition?

Teeth present, well aligned, without obvious decay

What does capillary refill of less than 2 seconds signify?

Normal peripheral perfusion

At what angle should normal nail beds lie?

Less than 160° (no clubbing)

How are radial and ulnar pulses documented when they are normal?

2+ bilaterally, equal and regular

What hand exercise is used to test bilateral grip strength?

Patient squeezes examiner’s two fingers and pulls toward self

Describe the normal anteroposterior (AP) to transverse chest ratio in an adult.

1 : 2 (elliptical and symmetrical)

How many total lung‐auscultation sites are performed in a complete adult assessment, according to the lecture?

26 sites (anterior, posterior, and lateral combined)

What patient instruction must accompany every placement of the stethoscope when listening to lungs?

“Take a deep breath in and let it out; tell me if you feel dizzy.”

Why must the examiner move female breast tissue aside during anterior lung auscultation?

Sound cannot be heard through dense breast tissue; need access to intercostal spaces

State the correct sequence for heart auscultation using the diaphragm.

Aortic → Pulmonic → Erb’s Point → Tricuspid → Mitral (APETM)

Where is the point of maximal impulse (PMI) normally located?

Left 5th intercostal space, mid-clavicular line

After locating the PMI, which two assessments are performed?

Palpate for thrills (should be none) and count apical pulse for a full minute

Which heart sound is normally louder at the base of the heart?

S2

Which heart sound is normally louder at the apex (mitral area)?

S1

What additional step is required after listening with the diaphragm at each cardiac landmark?

Auscultate the same spots with the bell to detect low-pitched sounds

How are normal heart sounds documented when no abnormalities are present?

S1 and S2 crisp, regular; no murmurs or extra heart sounds

Where do you begin auscultating bowel sounds, and why?

Right lower quadrant because that is where the ileocecal valve produces the loudest activity

How are normal bowel sounds described?

Active in all four quadrants

What technique assesses abdominal tenderness?

Light palpation in all four quadrants, observing for pain or guarding

What skin finding indicates good hydration during a turgor test?

Pinched skin quickly returns to baseline (elastic)

Explain how to check neck range of motion (ROM).

Ask patient to flex, extend, rotate, and laterally bend neck; should be full and pain-free

A trachea that is ‘midline’ signifies what?

No deviation; absence of masses, tension pneumothorax, or large effusion

What statement documents a normal carotid artery exam?

'Carotid pulses 2+ bilaterally; no bruits, pain, or tenderness'

During vital signs, why is radial pulse counted while respirations are silently observed?

Prevents the patient from altering breathing pattern

What margin of error is acceptable between student and instructor respiratory counts, per lecture?

Within ±4 breaths per minute

Why is it preferable to perform lower-extremity ROM with the patient standing?

Easier visualization of hip, knee, and ankle movement without bed interference

What does ‘crepitus noted in right shoulder’ mean in documentation?

Audible or palpable grating in the joint during movement, suggesting cartilage wear