HEAD TO TOE ASSESSMENT SCRIPT QUESTIONS AND ANSWERS 2024/2025.

HEAD TO TOE
ASSESSMENT SCRIPT
QUESTIONS AND
ANSWERS 2024/2025.


My name is Stacey and I'm a student nurse. I'm going
to be conducting your head-to-toe examination. Do
you have any questions for me today? - answer-Okay,
let's get started then. Can you state your full name
for me? And what is your data of birth? (Go wash
hands)



I'm going to take your vital signs now. Let me first
estimate your blood pressure and we'll come back to
that. Your pulse is ______ and your respirations are
_______/minute. Your temperature is ___________. Now
I'm going to take blood pressure. Your blood

, pressure is ________________ - answer-I'm going to be
observing the patient's skin throughout the exam.
May I remove your glasses? Your facial features look
symmetrical. (Put on gloves)The scalp does not have
any lesions or pest inhabitants. Remove gloves and
gel hands.



I'm going to feeling for any lumps or tenderness in
your face. Does this hurt? Now I'm going to check
your sinuses. Does this hurt?(press up under
eyebrows) How about this (press up under
zygomatic). Let's check your to see that your jaw is
working smoothly (press at TMJ). Good, I don't feel
any clicking or crepitus and your jaw opens
smoothly. - answer-Now I'm going to test facial
sensation with this cotton ball. I'm going to have you
shut your eyes and tell me "now" when you feel the
cotton on your skin like this (brush cotton on pts
arm). Can you shut your eyes please? (brush cotton
on forehead, cheek and mandible). Good, you can
open your eyes now. (palpate temporalis) Can you
clench your jaw? Good. (palpate masseter) Clench
again. Good. Your facial sensations are intact and
your have good jaw strength so I know that your 5th
cranial nerve is intact.