Funds: Exam 1-5 for Final Questions With Complete
Solutions
Absent Pulse
Indicates occlusion; verify with Doppler.
Capillary Refill
Normal <2 seconds.
Cyanosis Types
Central (lips/tongue) vs. peripheral (fingers/toes).
Central Cyanosis
Low oxygenation; respiratory/cardiac cause.
Peripheral Cyanosis
Poor perfusion or vasoconstriction.
Skin Assessment Acronym CM LETT HAN
Check: Color, Moisture, Lesions, Edema, Temperature, Turgor,
Hair, Arterial Pulses, Nails.
Breast Nipple Assessment
Skin condition, symmetry, discharge evaluation.
Expected Nipple Findings
Round/oval, Montgomery glands visible, smooth.
Unexpected Nipple Findings
Dry scaling, discharge, inversion, direction change.
,Unexpected Skin Changes in Breast
Thick skin, dimpling, edema, unilateral rash, peau d'orange.
Unexpected Breast Shape Changes
Bulging, contour abnormalities, retraction.
Breast Self-Exam Timing
Monthly, 7-10 days after menstruation.
Breast Self-Exam Technique
Use pads of fingers, circular motion, inspect and palpate.
HEENT Assessment Formula
Skin, Shape, Size, Symmetry, Pain, Function.
Age-Related HEENT Changes
Presbyopia, cataracts, dry eyes, presbycusis, decreased
taste/smell.
Oral Assessment Expected Findings
Pink, moist mucosa with no lesions.
Unexpected Oral Findings
Candidiasis, petechiae.
Conjunctiva Assessment
Pink conjunctiva; sclera white; check with thumb pads.
PERRLA
Pupils equal, round, reactive to light and accommodation.
,Sinus Assessment
Palpate frontal and maxillary sinuses.
Expected Sinus Finding
Nontender, symmetrical.
Unexpected Sinus Finding
Tenderness → infection.
Neck Assessment
Inspect/palpate symmetry, trachea midline, thyroid normal.
Unexpected Neck Findings
Enlarged lymph nodes, JVD, limited ROM.
Causes of Unexpected HEENT Findings
Clubbing (hypoxia), jaundice (liver), cyanosis (hypoxemia),
pallor, dry mucosa.
Unequal Pupils
May indicate neurological injury.
Bell's Palsy
Temporary facial paralysis; inability to wrinkle forehead.
Tinnitus
Ringing/buzzing in ears.
Focused HEENT Health History
PQRST, chief complaint, PMH, meds, lifestyle.
, Head Assessment Expected Findings
Normocephalic, symmetrical features.
Unexpected Head Findings
Asymmetry, lumps, lesions, tenderness.
Unexpected Hair Findings
Alopecia and hirsutism.
Skin Tone Considerations
Dark skin: cyanosis gray; pallor ashen; jaundice sclera/palms.
Lymph Node Assessment
Palpate in sequence using circular motion.
Expected Lymph Node Findings
Soft, movable, nontender, not visible.
Unexpected Lymph Node Findings
Hard, fixed, tender nodes.
Skin Turgor Expected
Rises easily and returns quickly.
Skin Turgor Variations
Slower return in older adults due to elasticity decline.
Skin Turgor Unexpected
Tenting indicates dehydration or weight loss.
Tonsil Grading
Solutions
Absent Pulse
Indicates occlusion; verify with Doppler.
Capillary Refill
Normal <2 seconds.
Cyanosis Types
Central (lips/tongue) vs. peripheral (fingers/toes).
Central Cyanosis
Low oxygenation; respiratory/cardiac cause.
Peripheral Cyanosis
Poor perfusion or vasoconstriction.
Skin Assessment Acronym CM LETT HAN
Check: Color, Moisture, Lesions, Edema, Temperature, Turgor,
Hair, Arterial Pulses, Nails.
Breast Nipple Assessment
Skin condition, symmetry, discharge evaluation.
Expected Nipple Findings
Round/oval, Montgomery glands visible, smooth.
Unexpected Nipple Findings
Dry scaling, discharge, inversion, direction change.
,Unexpected Skin Changes in Breast
Thick skin, dimpling, edema, unilateral rash, peau d'orange.
Unexpected Breast Shape Changes
Bulging, contour abnormalities, retraction.
Breast Self-Exam Timing
Monthly, 7-10 days after menstruation.
Breast Self-Exam Technique
Use pads of fingers, circular motion, inspect and palpate.
HEENT Assessment Formula
Skin, Shape, Size, Symmetry, Pain, Function.
Age-Related HEENT Changes
Presbyopia, cataracts, dry eyes, presbycusis, decreased
taste/smell.
Oral Assessment Expected Findings
Pink, moist mucosa with no lesions.
Unexpected Oral Findings
Candidiasis, petechiae.
Conjunctiva Assessment
Pink conjunctiva; sclera white; check with thumb pads.
PERRLA
Pupils equal, round, reactive to light and accommodation.
,Sinus Assessment
Palpate frontal and maxillary sinuses.
Expected Sinus Finding
Nontender, symmetrical.
Unexpected Sinus Finding
Tenderness → infection.
Neck Assessment
Inspect/palpate symmetry, trachea midline, thyroid normal.
Unexpected Neck Findings
Enlarged lymph nodes, JVD, limited ROM.
Causes of Unexpected HEENT Findings
Clubbing (hypoxia), jaundice (liver), cyanosis (hypoxemia),
pallor, dry mucosa.
Unequal Pupils
May indicate neurological injury.
Bell's Palsy
Temporary facial paralysis; inability to wrinkle forehead.
Tinnitus
Ringing/buzzing in ears.
Focused HEENT Health History
PQRST, chief complaint, PMH, meds, lifestyle.
, Head Assessment Expected Findings
Normocephalic, symmetrical features.
Unexpected Head Findings
Asymmetry, lumps, lesions, tenderness.
Unexpected Hair Findings
Alopecia and hirsutism.
Skin Tone Considerations
Dark skin: cyanosis gray; pallor ashen; jaundice sclera/palms.
Lymph Node Assessment
Palpate in sequence using circular motion.
Expected Lymph Node Findings
Soft, movable, nontender, not visible.
Unexpected Lymph Node Findings
Hard, fixed, tender nodes.
Skin Turgor Expected
Rises easily and returns quickly.
Skin Turgor Variations
Slower return in older adults due to elasticity decline.
Skin Turgor Unexpected
Tenting indicates dehydration or weight loss.
Tonsil Grading
