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Health Assessment 1 Exam- Book Test Bank Study Guide
Head to Toe Exam
Begin the exam with the patient sitting
Enter room, close curtain, wash hands
Introduce yourself to the patient with pronouns, confirm patient’s name and DOB
Share your pronouns. Ask for patient’s preferred name and pronouns.
Ask about allergies
Medications, latex, food, environmental, seasonal
Explain to the patient that you will be doing a head-to-toe physical exam
Cranial Nerves
1. Use Snellen eye chart – have patient cover right eye and read the smallest
line they can. Next, have patient cover left eye and read the smallest line they
can. Lastly, have patient (with glasses on if they wear glasses) read the
smallest line they can with both eyes.
2. Confrontation- have the patient cover their right eye and tell them to look
at your nose. Then test each visual field and ask them what number of
fingers you are holding up. Do the same with the left eye.
3. Turn off lights and use ophthalmoscope (look for red-reflex)
4. Test for pupillary reaction (direct vs. consensual)
A light beam shining onto one retina causes pupillary constriction in that eye,
termed direct reaction to light, and in the contralateral eye, the consensual
reaction to light
5. EOM
Test the six extraocular movements (EOMs). Ask patient to follow your finger
(without moving their head) as you sweep through the six cardinal directions of
gaze. Make a wide “H” in the air, lead the patient’s gaze. CN III, CN IV, and CN
VI
Convergence
Convergence: Ask the patient to follow your finger or pencil as you move it in
toward the bridge of the nose.
6. Facial Movements (CN VII)
Instruct patient to close eyes and try to gently open their eyes while telling
them “don’t let me open your eyes”, raise eyebrows, smile, frown, puff out
cheeks (and don’t let me press the air out), show me your teeth
7. Trigeminal Sensory
Sharp/Dull with cotton ball. Have patient close their eyes and ask them to tell
you if it’s sharp/dull and where on the face (example: sharp, right chin)
8. Trigeminal Motor
Palpate temporal and masseter strength
(Use your index and middle finger to palpate, ask patient to open their mouth
and clench their teeth while touching the temporal muscle followed by the
masseter muscle. Ask the patient to move the jaw side to side)
This study source was downloaded by 100000854279382 from CourseHero.com on 05-30-2023 13:53:36 GMT -05:00
https://www.coursehero.com/file/157115704/Head-to-Toe-Examdocx/
, 9. Hearing (whisper test)
Have patient cover right ear, and go over to the left ear and whisper three
words
Do the same on the right side
10. Tongue movement/ say AHHHHH
move tongue to the right, left, up
stick tongue out and move it side to side
look at teeth
11. Shoulder Strength
Ask patient to shrug shoulders and “don’t let me push your shoulders down)
12. Sternocleidomastoid Strength
put hand on patient’s right cheek and ask them to move against your hand
do same for the left
Weber and Rinne Test
• Weber Test: Imagine a W on top of the head). Set the fork into light
vibration. Place the base of the fork firmly on top of the patient’s head or on
the midforehead. Ask where the patient hears the sound best: “On one side
or
both sides?” Normally, the vibration is heard in the midline or equally in both
ears.
• Rinne Test: Compares air conduction (AC) and bone conduction (BC). Place
the base of a lightly vibrating tuning fork on the mastoid bone, behind the ear
This study source was downloaded by 100000854279382 from CourseHero.com on 05-30-2023 13:53:36 GMT -05:00
https://www.coursehero.com/file/157115704/Head-to-Toe-Examdocx/
Health Assessment 1 Exam- Book Test Bank Study Guide
Head to Toe Exam
Begin the exam with the patient sitting
Enter room, close curtain, wash hands
Introduce yourself to the patient with pronouns, confirm patient’s name and DOB
Share your pronouns. Ask for patient’s preferred name and pronouns.
Ask about allergies
Medications, latex, food, environmental, seasonal
Explain to the patient that you will be doing a head-to-toe physical exam
Cranial Nerves
1. Use Snellen eye chart – have patient cover right eye and read the smallest
line they can. Next, have patient cover left eye and read the smallest line they
can. Lastly, have patient (with glasses on if they wear glasses) read the
smallest line they can with both eyes.
2. Confrontation- have the patient cover their right eye and tell them to look
at your nose. Then test each visual field and ask them what number of
fingers you are holding up. Do the same with the left eye.
3. Turn off lights and use ophthalmoscope (look for red-reflex)
4. Test for pupillary reaction (direct vs. consensual)
A light beam shining onto one retina causes pupillary constriction in that eye,
termed direct reaction to light, and in the contralateral eye, the consensual
reaction to light
5. EOM
Test the six extraocular movements (EOMs). Ask patient to follow your finger
(without moving their head) as you sweep through the six cardinal directions of
gaze. Make a wide “H” in the air, lead the patient’s gaze. CN III, CN IV, and CN
VI
Convergence
Convergence: Ask the patient to follow your finger or pencil as you move it in
toward the bridge of the nose.
6. Facial Movements (CN VII)
Instruct patient to close eyes and try to gently open their eyes while telling
them “don’t let me open your eyes”, raise eyebrows, smile, frown, puff out
cheeks (and don’t let me press the air out), show me your teeth
7. Trigeminal Sensory
Sharp/Dull with cotton ball. Have patient close their eyes and ask them to tell
you if it’s sharp/dull and where on the face (example: sharp, right chin)
8. Trigeminal Motor
Palpate temporal and masseter strength
(Use your index and middle finger to palpate, ask patient to open their mouth
and clench their teeth while touching the temporal muscle followed by the
masseter muscle. Ask the patient to move the jaw side to side)
This study source was downloaded by 100000854279382 from CourseHero.com on 05-30-2023 13:53:36 GMT -05:00
https://www.coursehero.com/file/157115704/Head-to-Toe-Examdocx/
, 9. Hearing (whisper test)
Have patient cover right ear, and go over to the left ear and whisper three
words
Do the same on the right side
10. Tongue movement/ say AHHHHH
move tongue to the right, left, up
stick tongue out and move it side to side
look at teeth
11. Shoulder Strength
Ask patient to shrug shoulders and “don’t let me push your shoulders down)
12. Sternocleidomastoid Strength
put hand on patient’s right cheek and ask them to move against your hand
do same for the left
Weber and Rinne Test
• Weber Test: Imagine a W on top of the head). Set the fork into light
vibration. Place the base of the fork firmly on top of the patient’s head or on
the midforehead. Ask where the patient hears the sound best: “On one side
or
both sides?” Normally, the vibration is heard in the midline or equally in both
ears.
• Rinne Test: Compares air conduction (AC) and bone conduction (BC). Place
the base of a lightly vibrating tuning fork on the mastoid bone, behind the ear
This study source was downloaded by 100000854279382 from CourseHero.com on 05-30-2023 13:53:36 GMT -05:00
https://www.coursehero.com/file/157115704/Head-to-Toe-Examdocx/
