Head to toe

Question 1

General Survey

Answer 1

• Assess:
  o Overall appearance
  o Hygiene & grooming
  o Nutritional status
  o Posture
  o Mobility
  o Mood and affect
  o Body language

Question 2

Observe ability to

Answer 2

o Speak
o Hear
o Follow directions

Question 3

Head & Face
Inspect:

Answer 3

• Skull size and shape
• Hair distribution
• Lesions
• Facial symmetry
• Facial expression

Question 4

Eyes
Inspect:

Answer 4

• Eyelids
• Sclera
• Conjunctiva
• Iris
• Pupils
• Eye movement

Question 5

Nose
Inspect:

Answer 5

• External appearance
• Nasal mucosa
• Drainage
• Nares patency

Question 6

Mouth & Throat
Inspect:

Answer 6

• Lips
• Oral mucosa
• Tongue
• Tonsils
• Pharynx
• Teeth

Question 7

Ears
Inspect:

Answer 7

• Color
• Condition
• Drainage

Question 8

Neck
Inspect:

Answer 8

• Trachea midline
• Lumps or lesions
• Ability to swallow
• Neck ROM

Question 9

Palpate

Answer 9

• Carotid pulse one at a time
  Assess:
• Shoulder strength against resistance

Question 10

Upper Extremities
Inspect:

Answer 10

• Skin color
• Lesions
• Symmetry
• Edema
• Nail condition

Question 11

Upper Extremities palpate

Answer 11

• Skin temperature
• Moisture
• Texture

Question 12

Upper Extremities Pulses

Answer 12

• Brachial
• Radial

Question 13

Lower Extremities
Inspect:

Answer 13

• Skin color
• Hair distribution
• Venous distention
• Symmetry of legs and feet
• Toenail condition

Question 14

Palpate Lower Extremities

Answer 14

• Temperature
• Moisture
• Tenderness

Question 15

Pulses Lower Extremities

Answer 15

• Posterior tibial
• Dorsalis pedis

Question 16

Anterior Chest Assessment
Back:
Inspect:

Answer 16

• Chest shape
• Breathing pattern
• Chest expansion symmetry
• Skin color
• Lesions or scars

Question 17

PMI location:

Answer 17

• 5th intercostal space
• Left midclavicular line

Question 18

Heart Auscultation:

Answer 18

• Aortic
• Pulmonic
• Tricuspid
• Mitral

Question 19

Listen for:

Answer 19

• S1
• S2
• Murmurs

Question 20

Lung Auscultation:

Answer 20

• Ladder pattern
• Compare bilaterally
• Listen during inspiration & expiration

Question 21

Posterior & Lateral Chest Inspect

Answer 21

• Chest shape
• Spine alignment
• Scapula symmetry
• Respiratory pattern
• Accessory muscle use
• Skin condition

Question 22

Posterior & Lateral Chest Auscultate

Answer 22

• Start near C7
• Move downward in ladder pattern
• Compare bilaterally

Question 23

Safety & Prioritization

Answer 23

• Address life-threatening findings first

Question 24

Examples requiring immediate action:

Answer 24

• Visible bleeding
• Severe pain
• Respiratory distress
• Altered mental status