HEENT assessment nursing: a systematic guide

HEENT assessment — head, eyes, ears, nose, and throat — is the most cranial-nerve-dense portion of the physical examination. Within a single systematic sweep, you are simultaneously testing CN II through CN XII while evaluating structures that signal some of the most time-sensitive conditions in medicine: increased intracranial pressure (papilledema on fundoscopy), tension pneumothorax (tracheal deviation), meningitis (neck stiffness), and Graves’ disease (thyroid bruit). For nursing students, HEENT is not just a sequence of inspection steps — it is a neurological stress test disguised as an anatomy tour.

This guide walks through each HEENT sub-system in assessment order, connects every structure to its cranial nerve, provides the Weber and Rinne interpretation logic that most resources omit, and closes with a red-flag table and NCLEX content covering the findings most likely to appear on boards.

For the full head-to-toe framework, see head-to-toe assessment. For cranial nerve mnemonics and a reference table, see cranial nerves mnemonic. For the neurological exam that follows HEENT in clinical practice, see neurological assessment nursing.

Equipment and patient preparation

Equipment needed:

• Penlight or ophthalmoscope with lens dial
• Snellen chart (or near-vision card for bedside)
• Otoscope with appropriate speculum (largest that fits comfortably)
• 512 Hz tuning fork (optimal for Weber and Rinne — high enough to detect pure-tone loss, low enough for bone conduction)
• Tongue blade
• Gloves
• Gauze (for tongue depressor)
• Nasal speculum (or otoscope with wide speculum)
• Stethoscope (bell for thyroid bruit and carotid auscultation)

Positioning: Seated upright at the examiner’s eye level. The patient’s head should be roughly at the examiner’s eye level — place a short patient on a raised exam table, or sit yourself down.

Lighting: Overhead room lighting for gross inspection; penlight for directed illumination of the oral cavity, nares, and pupil responses; otoscope for tympanic membrane; ophthalmoscope for fundus.

Sequence: Proceed anatomically head-to-toe and lateral-to-medial within each region: scalp → face → eyes → ears → nose → mouth/throat → neck. This prevents backtracking and ensures nothing is skipped.

Head: inspection and palpation

Scalp and skull

Inspect the scalp by parting the hair systematically, examining the entire surface. Look for:

• Lesions: Seborrheic keratoses (benign, waxy, “stuck-on” appearance), actinic keratoses (scaly, rough, premalignant), nevi, alopecia areata (well-demarcated patches of hair loss)
• Infestations: Pediculosis capitis (head lice) — nits appear as white oval specks cemented to hair shafts, unlike dandruff which brushes off freely
• Scaling: Psoriasis (silvery-white plaques with underlying erythema), seborrheic dermatitis (yellowish, greasy scales along the hairline)

Palpate the skull with the fingertips in a systematic pattern, noting any masses, depressions, or tenderness. A normal skull is smooth and symmetric. Crepitus over the calvaria raises concern for fracture and requires immediate escalation.

Palpate the temporal arteries bilaterally by pressing gently along the course of the artery just anterior to the tragus, running toward the temple. In giant cell arteritis (temporal arteritis), the artery becomes thickened, nodular, and exquisitely tender, often with overlying erythema. Any patient over 50 presenting with new temporal headache, jaw claudication, or sudden visual changes — with a tender, pulseless temporal artery — is a clinical emergency. Untreated, this condition causes irreversible blindness within days.

Face

Inspect the face for symmetry. Ask the patient to smile, raise their eyebrows, puff their cheeks, and show their teeth — these maneuvers activate CN VII (facial nerve). Asymmetry localizes:

• Upper and lower face affected equally: Peripheral CN VII lesion (Bell’s palsy, parotid tumor, Lyme disease neuroborreliosis)
• Lower face only (forehead spared): Central CN VII lesion (stroke, brain tumor) — the forehead is bilaterally represented at the cortex, so a central lesion spares forehead movement

Inspect for facial edema, malar rash (systemic lupus erythematosus), facial plethora (polycythemia vera, Cushing syndrome), or the coarsened features of acromegaly or hypothyroidism. Inspect for periorbital ecchymosis (“raccoon eyes”) — a sign of basilar skull fracture requiring immediate notification.

Eye assessment

Visual acuity — CN II (optic nerve)

Test visual acuity before any other eye examination. If your penlight is already shining at the patient, you risk accommodating the pupil and invalidating the acuity test.

Snellen chart: Position the patient 20 feet (6 meters) from the chart. Test each eye separately while the other is occluded. Record the smallest line read with fewer than two errors. Document as 20/X (the denominator is the distance at which a normal eye reads that line). Normal vision is 20/20.

Near-vision card: For bedside testing when a Snellen chart is unavailable, hold the near-vision card at 14 inches (35 cm). Normal near acuity is Jaeger 1 or Snellen equivalent 20/20 at near.

If the patient wears corrective lenses, test with lenses in place first (corrected acuity), then without (uncorrected). Document both. Corrected acuity is the clinically relevant baseline.

Confrontation visual fields: A quick bedside screen for gross visual field defects. Sit directly opposite the patient at arm’s length. Cover one eye of each (you cover your left, patient covers their right — you are now testing corresponding fields). Bring a target (wiggling finger, cotton ball) in from the periphery in each of the four quadrants. The patient reports when they first see the target. Compare to your own visual field as a reference.

Field defects suggest:

• Bitemporal hemianopia (loss of both outer fields): pituitary tumor compressing the optic chiasm
• Homonymous hemianopia (same side of field lost in both eyes): contralateral occipital lobe lesion (stroke)
• Monocular field loss: ipsilateral retinal or optic nerve pathology

Extraocular movements — CN III, IV, VI

Ask the patient to keep their head still and follow your finger with their eyes only. Trace an H-pattern in the air (two horizontal passes at top and bottom, joined by a vertical center line). This traces the six cardinal positions of gaze, each testing a specific muscle and its cranial nerve.

Nystagmus: A few beats of nystagmus at extreme lateral gaze is normal (end-gaze nystagmus). Sustained, large-amplitude, or vertical nystagmus is abnormal and suggests a posterior fossa lesion, vestibular disorder, or medication effect (phenytoin, benzodiazepines, ethanol).

Superior oblique (CN IV, trochlear): The superior oblique moves the eye down and in. CN IV palsy produces vertical diplopia worst when looking down and toward the nose — patients characteristically tilt their head away from the affected side to compensate. This is the most commonly missed extraocular palsy because it is subtle.

Pupil assessment — PERRLA

PERRLA stands for Pupils Equal, Round, Reactive to Light and Accommodation. Each element has a distinct clinical implication.

Direct and consensual light reflex (CN II in, CN III out):

1. Dim the room. Ask the patient to fix their gaze on a distant point (prevents accommodation-driven constriction).
2. Shine the penlight from the lateral side into one eye. Note constriction of that pupil (direct reflex) and simultaneous constriction of the contralateral pupil (consensual reflex).
3. Repeat on the other side.
4. Document pupil size in millimeters (normal 2–6 mm in a normally lit room), equality, and reactivity (brisk, sluggish, absent).

Swinging flashlight test (Marcus Gunn pupil): Rapidly alternate the penlight from eye to eye every 2 seconds. Normally both pupils remain equally constricted. If one pupil paradoxically dilates when the light swings to it (relative afferent pupillary defect, RAPD), this indicates an ipsilateral optic nerve or severe retinal lesion — the affected eye carries less light signal than the normal eye, so the reflex arc is weaker.

Accommodation reflex: Ask the patient to focus on a distant object, then rapidly on your finger held 6 inches away. Normal response: both pupils constrict as the eyes converge. Tests the same efferent limb as the light reflex (CN III), but through a different cortical pathway.

Clinical pupil patterns to recognize:

• Unequal pupils (anisocoria >1 mm): Up to 20% of the population has physiologic anisocoria (equal reactivity, no ptosis). Pathologic causes include CN III palsy (dilated, unreactive, ptosis, eye deviated down and out — a blown pupil is a surgical emergency until herniation is ruled out), Horner syndrome (miosis + ptosis + anhidrosis from disrupted cervical sympathetic chain), and traumatic iritis (irregular pupil, photophobia).
• Fixed, dilated pupils bilaterally: Brain herniation, atropine toxicity, or post-cardiac arrest anoxia.
• Pinpoint pupils bilaterally: Opioid toxicity, pontine hemorrhage, organophosphate poisoning.

External eye structures

Inspect with the penlight before touching:

• Eyelids: Ptosis (drooping — CN III palsy, Horner syndrome, myasthenia gravis), ectropion (lid margin turns outward), entropion (lid margin turns inward, lashes abrade cornea), stye (hordeolum — tender, red nodule at lid margin from infected lash follicle), chalazion (painless, firm nodule within the lid from blocked meibomian gland)
• Conjunctiva and sclera: Pull the lower lid down to expose the palpebral conjunctiva — normally pink and moist. Pallor of the palpebral conjunctiva suggests anemia. Injected conjunctiva (red, diffuse) with discharge suggests conjunctivitis; unilateral injection with ciliary flush (perilimbal redness) suggests iritis or acute angle-closure glaucoma. Scleral icterus (yellow sclera) appears when serum bilirubin exceeds 2–3 mg/dL and is earlier than skin jaundice.
• Cornea: Should be clear. Arcus senilis (gray-white arc at the corneal periphery) is normal in patients over 60; in younger adults it suggests hyperlipidemia.
• Iris: Note color and regularity. An irregular, “keyhole” iris suggests prior iridectomy (glaucoma treatment).

Fundoscopic examination (ophthalmoscope)

A brief summary of key findings for nursing students:

• Normal optic disc: Well-defined margins, creamy yellow-pink color, cup-to-disc ratio <0.5
• Papilledema: Blurred disc margins, disc elevation, venous engorgement, flame hemorrhages — indicates elevated intracranial pressure; a neurology emergency
• Arteriovenous (AV) nicking: Retinal arterioles crossing veins and compressing them — sign of long-standing hypertension
• Cotton-wool spots: Fluffy white patches — microinfarcts of the nerve fiber layer from hypertension, diabetes, HIV retinopathy
• Flame hemorrhages: Spread along nerve fiber layer in a superficial, flame-shaped pattern — hypertensive retinopathy
• Dot-blot hemorrhages: Small, round, deep retinal hemorrhages — diabetic retinopathy
• Copper-wire / silver-wire arterioles: Progressive arteriolar sclerosis in chronic hypertension

Ear assessment

External ear

Inspect the auricle (pinna) for:

• Shape and symmetry: Low-set ears (below the eye-ear reference line) suggest chromosomal abnormalities (Down syndrome, Turner syndrome)
• Lesions: Actinic keratoses and squamous cell carcinoma are common on the auricle due to sun exposure; the helix is the most frequent site
• Darwin’s tubercle: Small, benign cartilaginous nodule on the upper helix — a common normal variant
• Tophi: Chalky-white deposits within the antihelix or helix — urate crystal deposits in gout

Palpate for tenderness:

• Tragus tenderness: Palpate the tragus (the small cartilaginous flap anterior to the canal). Tenderness suggests otitis externa (swimmer’s ear — inflammation of the external canal), not otitis media.
• Mastoid tenderness: Palpate firmly over the mastoid process behind the ear. Mastoid tenderness with erythema and postauricular swelling suggests mastoiditis — a complication of untreated otitis media that requires urgent evaluation because intracranial extension (epidural abscess, meningitis) is possible.
• Auricle movement: Gently pull the auricle superiorly and posteriorly. Pain with this maneuver confirms otitis externa.

Otoscopic examination

Select the largest speculum that fits comfortably in the canal. For adults, pull the auricle up and back to straighten the S-shaped ear canal. For children under 3, pull down and back.

Advance the otoscope with your hand braced against the patient’s cheek — if the patient moves, your hand moves with them, protecting the canal from injury.

Normal tympanic membrane findings:

Inspect the canal for cerumen impaction, foreign bodies, polyps, or discharge. Bloody or clear discharge following head trauma suggests a basilar skull fracture — do not irrigate; notify the provider immediately.

Hearing assessment

Whisper test (gross screen): Stand 1–2 feet behind the patient to prevent lip reading. Occlude one ear by gently pressing the tragus. Exhale fully, then whisper three numbers or words. The patient repeats them. A passing score is repeating at least 2 of 3 correctly.

Weber test (512 Hz tuning fork): Strike the tuning fork and place its stem on the top of the skull at the midline. Ask the patient where they hear the sound — left, right, or equally in both ears.

Rinne test (512 Hz tuning fork): Strike the tuning fork and place it on the mastoid process (bone conduction, BC). When the patient reports it has faded, immediately move the vibrating tines to just outside the ear canal (air conduction, AC). Ask: “Where is it louder — now, or before?”

The Weber lateralization logic: In conductive loss, the affected ear has external or middle ear interference blocking ambient noise. When the tuning fork vibrates the skull, that bone-conducted signal reaches the cochlea of the affected ear free from “masking” by ambient sound — so the affected ear hears the vibration more strongly, pulling the Weber to that side. In sensorineural loss, the cochlea or nerve on the damaged side is less sensitive, so the healthy ear dominates.

Nose and sinus assessment

External inspection and nasal patency

Inspect the external nose for symmetry, deviation, lesions, or edema. The nose is composed of a bony upper third (nasal bones) and a cartilaginous lower two-thirds (lateral and alar cartilages). Trauma that affects the bony portion requires imaging to exclude fracture.

Nasal patency: Ask the patient to breathe through their nose while you occlude each nostril in turn with your finger. They should be able to breathe comfortably through each side alone. Complete unilateral obstruction warrants further evaluation.

Internal inspection (nasal speculum or otoscope)

Tilt the patient’s head slightly back. Insert the speculum gently — never advance it posteriorly against the nasal septum. Open the speculum vertically (top and bottom, not side to side) to widen the nasal passage.

Inspect:

• Septum: The nasal septum is deviated in up to 80% of adults to some degree. A deviated septum is only clinically significant when it obstructs airflow or contributes to recurrent sinusitis. Septal perforation (visible hole through the septum) causes a whistling sound on inspiration; causes include cocaine use, trauma, previous surgery, granulomatosis with polyangiitis, and sarcoidosis.
• Turbinates: The inferior and middle turbinates fill most of the visible nasal cavity. Normal turbinates are pink and moist, similar in color to the gingiva. Turbinate changes:
  • Boggy, pale, bluish: Allergic rhinitis — the most common cause of turbinate edema
  • Erythematous, edematous: Viral or bacterial rhinitis
  • Atrophic, crusted: Atrophic rhinitis, overuse of nasal decongestant sprays (rhinitis medicamentosa)
• Nasal mucosa: Should be pink, moist, without lesions or polyps
• Nasal polyps: Smooth, pale, glistening, grape-like masses arising from the middle meatus — associated with allergic rhinitis, chronic sinusitis, aspirin sensitivity (Samter’s triad: asthma + nasal polyps + aspirin sensitivity), and cystic fibrosis in children
• Discharge: Clear (allergic/viral), purulent yellow-green (bacterial sinusitis or rhinitis), unilateral blood-tinged (foreign body in a child, malignancy in an adult, trauma)

Sinus assessment

The accessible paranasal sinuses in bedside assessment are the frontal and maxillary sinuses.

Palpation and percussion:

• Frontal sinuses: Press firmly upward under the supraorbital ridge on each side (not over the bony bridge). Tenderness suggests frontal sinusitis.
• Maxillary sinuses: Press the thumbs firmly against the cheeks below the zygomatic arch, just lateral to the nasal bones. Tenderness suggests maxillary sinusitis.

Transillumination: Performed in a completely darkened room. Place a strong penlight firmly against the inner canthus of the eye to transilluminate the maxillary sinuses; normally a reddish glow is visible over each cheek. For frontal sinuses, place the light below the supraorbital ridge. Absent transillumination on one side suggests fluid or mucosal thickening in that sinus. This test has limited sensitivity and specificity, but provides useful supporting evidence when sinus tenderness is present.

Mouth and throat assessment

Lips

Inspect for color, moisture, symmetry, and lesions. Angular cheilitis (cracking at the corners of the mouth) suggests iron deficiency, vitamin B deficiency, or ill-fitting dentures. A single, painful vesicular lesion on the vermilion border indicates herpes simplex labialis (cold sore). Leukoplakia (white, non-scrapable plaques on the oral mucosa or lips) requires biopsy to exclude malignant transformation.

Teeth and gums

Note the number of teeth, evidence of decay (brown or black discoloration, visible cavities), and whether the patient has dentures. Ask the patient to remove dentures before inspecting — dentures can hide significant oral pathology.

Gingiva: Should be pink, firm, and tightly adherent to the teeth. Assess for:

• Gingivitis: erythema, swelling, bleeding on inspection
• Gingival hyperplasia: overgrowth associated with phenytoin use, cyclosporine, and calcium channel blockers (especially nifedipine)
• Buccal line: A bluish-black line at the gum–tooth junction (Burton’s line) is a classic finding in lead poisoning

Tongue and buccal mucosa

Ask the patient to open their mouth and extend their tongue toward you — this tests CN XII (hypoglossal nerve). The tongue should protrude in the midline. Deviation to one side indicates a CN XII lesion on that side (the paralyzed side allows the functional contralateral genioglossus to push the tongue toward the weak side).

Inspect the tongue surfaces:

• Dorsum: Normally covered with papillae. Geographic tongue (erythematous patches with serpiginous white borders, migrating over days) is benign. Hairy tongue (elongated filiform papillae, brown or black coloring) results from antibiotic use, smoking, or poor oral hygiene.
• Ventral surface: Lift the tongue. Inspect the ventral surface and the floor of the mouth — this is where the majority of oral squamous cell carcinomas arise. Any persistent white or red lesion on the floor of the mouth or lateral tongue in a tobacco or alcohol user requires urgent referral.
• Frenulum: Short lingual frenulum (ankyloglossia, “tongue-tie”) restricts tongue elevation and lateral movement.

Inspect the buccal mucosa (inner cheeks) and hard and soft palates. Normal mucosa is pink and moist. Koplik spots (small white spots with a red areola on the buccal mucosa opposite the lower molars) are pathognomonic for measles and precede the exanthem by 1–2 days.

Oropharynx and tonsils — CN IX, X

Use a tongue blade on the middle third of the tongue (not the tip, which triggers the gag reflex). Depress gently and ask the patient to say “Ahh.” Assess:

• Tonsillar size: Graded 1+ (visible), 2+ (halfway to uvula), 3+ (3/4 to the uvula), 4+ (touching midline, “kissing tonsils”). Exudate suggests strep pharyngitis or infectious mononucleosis. Unilateral tonsillar enlargement in an adult requires evaluation to exclude lymphoma.
• Uvula: Should rise symmetrically in the midline when the patient says “Ahh” — tests CN X (vagus). Deviation of the uvula toward one side indicates a CN X lesion on the contralateral side (the functioning side lifts normally; the paralyzed side droops, allowing the uvula to be pulled toward the intact side).
• Gag reflex: CN IX (sensory afferent) and CN X (motor efferent). Touch the posterior pharynx with a tongue blade. Absence of the gag reflex is significant when combined with dysphagia or dysphonia; an intact gag reflex does not guarantee a safe swallow — the swallow reflex is distinct.
• Posterior pharyngeal wall: Cobblestoning (irregular lymphoid follicle hypertrophy) suggests postnasal drip from allergic or chronic rhinosinusitis. Purulent exudate tracks down the posterior wall in strep pharyngitis.

Neck assessment

Range of motion

Ask the patient to:

1. Flex (chin to chest) — normal ~45°
2. Extend (chin toward ceiling) — normal ~55°
3. Lateral flexion (ear toward shoulder, no shrugging) — normal ~40° bilaterally
4. Rotation (turn head to each side) — normal ~70° bilaterally

Meningismus (meningeal irritation signs): Nuchal rigidity is the cardinal finding — resistance and pain on passive neck flexion with the patient supine. Assess in any febrile patient with headache, altered mental status, or photophobia. Do not apply force; resistance is the finding.

• Kernig’s sign: With the patient supine, flex the hip to 90° and attempt to extend the knee. Resistance and pain (positive) suggest meningeal irritation.
• Brudzinski’s sign: Passive flexion of the neck causes involuntary flexion of the hips and knees (positive) — meningeal irritation.

Lymph node palpation

Palpate lymph node chains systematically using the pads of the index and middle fingers in a gentle circular motion. Work in a consistent sequence to avoid missing nodes:

1. Preauricular — anterior to the tragus
2. Posterior auricular — over the mastoid process
3. Occipital — at the base of the skull posteriorly
4. Submental — under the chin in the midline
5. Submandibular — along the inner margin of the mandible
6. Anterior cervical chain — along the sternocleidomastoid (SCM) anteriorly
7. Posterior cervical chain — posterior to the SCM
8. Deep cervical chain — palpated by pressing beneath the SCM
9. Supraclavicular — in the hollow above the clavicle — this is the highest-yield lymph node region for malignancy (Virchow’s node on the left = abdominal/pelvic malignancy)
10. Infraclavicular — below the clavicle

For each palpable node, document: size (in cm), number, consistency (soft, rubbery, hard), mobility (mobile vs. fixed), tenderness, and overlying skin changes.

Clinical interpretation:

• Tender, mobile, soft nodes: Reactive lymphadenopathy from local infection or viral illness — the most common finding
• Rubbery, non-tender, mobile nodes: Lymphoma (Hodgkin disease classically causes rubbery cervical nodes)
• Hard, non-tender, fixed nodes: Metastatic carcinoma until proven otherwise
• Posterior cervical and occipital chains specifically: Enlarged in infectious mononucleosis (EBV), rubella, toxoplasmosis, and HIV primary infection

Thyroid palpation and auscultation

The thyroid gland lies in the anterior neck, with its isthmus crossing the trachea at the 2nd and 3rd tracheal rings (approximately 2–3 cm below the cricoid cartilage). The two lobes extend laterally to either side of the trachea.

Anterior approach (most commonly taught in US nursing programs): Stand in front of the patient. Place the index and middle fingers of both hands on either side of the trachea just below the cricoid cartilage, with fingertips touching each lobe. Ask the patient to swallow a sip of water — thyroid tissue rises with the trachea during swallowing, allowing you to feel the tissue pass under your fingers. This swallowing maneuver is what distinguishes thyroid tissue from other anterior neck masses.

Posterior approach (Bickley technique, preferred by many examiners): Stand behind the patient. Curl the fingers of both hands around the neck anteriorly, placing them on either side of the trachea. Use the same swallowing maneuver.

What to assess:

• Size: Document as normal, mildly enlarged (visible on neck extension), moderately enlarged (visible at rest), or grossly enlarged (goiter visible from across the room)
• Consistency: Soft and smooth (normal, hyperthyroid), firm and nodular (multinodular goiter, thyroid cancer), rock-hard (Riedel thyroiditis, anaplastic carcinoma)
• Nodules: Note size, consistency, mobility, and tenderness. A single, firm, non-tender, fixed nodule in an adult is carcinoma until proven otherwise.
• Tenderness: Thyroiditis (viral or autoimmune) produces a tender, firm gland

Thyroid auscultation: Using the bell of the stethoscope, listen over each thyroid lobe. A thyroid bruit (soft, continuous “whooshing” sound) reflects markedly increased blood flow through a hyperplastic, hypervascular gland. It is a classic finding in Graves’ disease (the most common cause of hyperthyroidism) and distinguishes true hyperthyroidism from states with high thyroid hormones but normal vascularity (e.g., thyroiditis or exogenous hormone ingestion).

Carotid auscultation

With the patient’s head turned slightly away from the side being examined and holding their breath (to eliminate tracheal sounds), place the bell of the stethoscope over the carotid triangle (angle of the jaw, midpoint of the SCM). A bruit (harsh, blowing systolic sound) suggests turbulent flow from carotid stenosis. Carotid bruits are more common with advancing age and hypertension, and their presence warrants further evaluation with carotid duplex ultrasound. Never palpate both carotids simultaneously — bilateral pressure can reduce cerebral perfusion.

Tracheal position

Stand in front of the patient and place the index finger in the sternal notch, pressing gently. Slide laterally to feel the tracheal position. The trachea should be in the midline. Deviation should be noted by the direction it is pulled or pushed:

• Pulled toward the affected side: Lung collapse (atelectasis), fibrosis, pneumonectomy — the affected side contracts and drags the trachea toward it
• Pushed away from the affected side: Tension pneumothorax, large pleural effusion, mediastinal mass — the affected side expands and displaces the trachea away

Tracheal deviation in the context of respiratory distress with hypotension and absent breath sounds on one side is a tension pneumothorax until proven otherwise — this is a clinical diagnosis requiring immediate needle decompression, not a chest X-ray.

HEENT red-flag findings

Documentation language

A concise HEENT documentation note in nursing practice:

Head: normocephalic, atraumatic. Temporal arteries non-tender, pulse 2+ bilaterally. Facial symmetry intact; CN VII testing normal. Eyes: visual acuity 20/20 OU with corrective lenses. PERRLA at 3 mm; direct and consensual light reflex brisk bilaterally. No RAPD. Extraocular movements intact through 6 cardinal positions. Conjunctivae pink and moist; sclerae white. Ears: bilateral auricles normal without tenderness. TMs pearly gray, light reflexes intact bilaterally, no perforation. Whisper test passed bilaterally. Weber midline; Rinne AC > BC bilaterally. Nose: septum midline, mucosa pink and moist, no polyps. Maxillary and frontal sinuses non-tender. Mouth: lips without lesions; 28 teeth present, dentition in good repair. Oral mucosa and tongue pink and moist; tongue protrudes midline. Oropharynx: uvula rises midline; tonsils 1+ bilaterally without exudate; posterior pharynx clear. Neck: supple; full ROM without rigidity. Trachea midline. Thyroid non-palpable. Lymph nodes: no cervical, submandibular, or supraclavicular lymphadenopathy. Carotid pulses 2+ bilaterally without bruits.

NCLEX tips: 15 testable facts

1. Weber lateralizes to the affected ear in conductive hearing loss (cerumen impaction, otitis media, ossicular damage). The bone-conducted sound bypasses the blocked canal and reaches the cochlea of the affected ear with less ambient masking.
2. Weber lateralizes to the unaffected ear in sensorineural hearing loss (presbycusis, noise-induced loss, acoustic neuroma, ototoxicity from aminoglycosides or loop diuretics). The intact cochlea picks up the vibration better.
3. Rinne: AC > BC = normal (Rinne positive). Air conduction should always be louder and longer than bone conduction in normal hearing. Rinne positive also appears in sensorineural loss — the ratio is preserved, but volume is diminished overall.
4. Rinne: BC ≥ AC = conductive hearing loss (Rinne negative). The bone conduction pathway bypasses the mechanical obstruction and reaches the cochlea directly.
5. Thyroid bruit = Graves’ disease. A bruit over the thyroid reflects hypervascular, hyperplastic thyroid tissue from TSH receptor stimulation. Absence of bruit does not exclude Graves’ disease.
6. Tracheal deviation away from the affected side = tension pneumothorax or large pleural effusion (the affected side pushes). Tracheal deviation toward the affected side = atelectasis or fibrosis (the affected side pulls).
7. CN III palsy: pupil is dilated, unreactive, with ptosis and the eye deviated down and out (the unopposed action of CN IV and CN VI). This is a surgical emergency until herniation or aneurysm is excluded.
8. Uvula deviates toward the healthy side in a unilateral CN X lesion (the functioning side lifts; the weak side droops, pulling the uvula toward the intact side). This is counterintuitive — the uvula moves away from the lesion.
9. Tongue deviates toward the affected side in a CN XII lesion (the functioning genioglossus on the healthy side pushes the tongue toward the weak side).
10. RAPD (Marcus Gunn pupil) = ipsilateral optic nerve lesion. The affected eye carries less light signal; when the light swings to that eye, both pupils paradoxically dilate because the weaker afferent signal produces a weaker pupilloconstrictor response.
11. Low-set ears (inferior to a line drawn from the outer canthus of the eye to the occiput) suggest chromosomal abnormalities and warrant a genetics referral.
12. Koplik spots are pathognomonic for measles and appear 1–2 days before the maculopapular exanthem. They are small, bluish-white spots on the buccal mucosa opposite the lower molars.
13. Tragus tenderness = otitis externa (swimmer’s ear); moving the auricle also reproduces the pain. Tenderness over the mastoid alone = mastoiditis.
14. Never irrigate an ear with a known or suspected tympanic membrane perforation. Irrigation can introduce water into the middle ear, leading to otitis media, vertigo, or worsening of the perforation.
15. Papilledema indicates elevated intracranial pressure. A lumbar puncture in the presence of papilledema can cause uncal herniation from the sudden pressure gradient — neuroimaging must precede lumbar puncture when papilledema is present.

NCLEX practice questions

Question 1

The nurse performs a Weber test by placing a vibrating 512 Hz tuning fork on the patient’s forehead. The patient states the sound is louder in the right ear. Which finding is most consistent with this result?

A) Normal bilateral hearing
B) Right sensorineural hearing loss
C) Right conductive hearing loss
D) Left sensorineural hearing loss

Correct answer: C — Right conductive hearing loss

Rationale: In the Weber test, sound lateralizes to the affected ear when the cause is conductive hearing loss. The external or middle ear obstruction (cerumen, effusion, ossicular disruption) blocks ambient sound from entering the affected ear, reducing the masking effect. The bone-conducted tuning fork signal then reaches the cochlea of the affected ear with less competition, making the vibration sound louder on that side. In sensorineural hearing loss, the affected cochlea is less sensitive, so the sound lateralizes to the unaffected (better-hearing) ear — the opposite pattern.

Question 2

During a HEENT assessment, the nurse observes that a patient’s uvula deviates to the left when the patient says “Ahh.” Which statement best explains this finding?

A) There is a left CN X (vagus) lesion causing uvular pull to the left
B) There is a right CN X (vagus) lesion causing the right side to droop
C) The finding is a normal variant and requires no follow-up
D) There is a CN IX (glossopharyngeal) lesion causing uvular deviation

Correct answer: B — There is a right CN X (vagus) lesion causing the right side to droop

Rationale: The uvula deviates away from the side of the CN X lesion. The functioning left CN X elevates the left side of the soft palate and uvula normally. The right CN X is paralyzed, so the right side of the palate droops. This allows the active left side to pull the uvula toward itself — leftward deviation indicates a right-sided lesion.

Question 3

A 68-year-old patient presents with a new frontal headache, jaw pain when chewing, and sudden blurring of vision in the right eye. During HEENT assessment, the nurse palpates the right temporal artery and finds it to be tender, thickened, and non-pulsatile. Which action should the nurse take first?

A) Document the finding in the medical record and alert the primary provider at the next scheduled rounding
B) Notify the provider immediately and anticipate orders for emergent laboratory work and corticosteroid therapy
C) Perform bilateral Rinne and Weber tests to evaluate for sensorineural hearing loss
D) Schedule the patient for an elective ophthalmology appointment within one week

Correct answer: B — Notify the provider immediately and anticipate orders for emergent laboratory work and corticosteroid therapy

Rationale: This presentation is classic for temporal arteritis (giant cell arteritis) — age over 50, new temporal headache, jaw claudication, and visual symptoms with a tender, non-pulsatile temporal artery. Left untreated, temporal arteritis can cause permanent blindness within 24–72 hours from ischemic optic neuropathy. High-dose corticosteroids (prednisone 1 mg/kg/day) should be started on clinical suspicion, before biopsy results are available, because the risk of vision loss outweighs the risk of a short course of steroids. This is a same-day emergency, not an elective referral.

Question 4

The nurse is assessing a patient in the emergency department following a motor vehicle collision. The patient is alert but confused. Which HEENT finding requires the most immediate nursing action?

A) Bilateral periorbital ecchymosis (“raccoon eyes”)
B) Tracheal deviation to the right with labored breathing, hypotension, and absent breath sounds on the left
C) Submandibular lymph nodes palpable and tender bilaterally
D) Right tympanic membrane with a visible perforation and dried blood in the canal

Correct answer: B — Tracheal deviation to the right with labored breathing, hypotension, and absent breath sounds on the left

Rationale: Tracheal deviation away from the affected side combined with respiratory distress, hypotension, and absent breath sounds on the contralateral side describes tension pneumothorax — a immediately life-threatening emergency requiring emergent needle decompression (14g angiocath, second intercostal space, midclavicular line). This cannot wait for a chest X-ray. Raccoon eyes (A) indicate basilar skull fracture and require notification but not immediate intervention to prevent imminent death. The tympanic membrane perforation (D) requires notification and no irrigation, but is not immediately life-threatening. Bilateral tender submandibular nodes (C) are consistent with reactive lymphadenopathy and do not represent an emergency.

Question 5

During otoscopic examination, the nurse notes that the right tympanic membrane appears amber-yellow with loss of the normal light reflex. The patient reports two weeks of muffled hearing but no ear pain. The Weber test lateralizes to the right ear. Which condition does this presentation most strongly suggest?

A) Acute bacterial otitis media
B) Otitis externa
C) Middle ear effusion (serous otitis media)
D) Sensorineural hearing loss from acoustic neuroma

Correct answer: C — Middle ear effusion (serous otitis media)

Rationale: The amber-yellow tympanic membrane with absent light reflex indicates fluid in the middle ear space. The lack of pain distinguishes this from acute bacterial otitis media, which is typically exquisitely painful. The absence of tragus or canal tenderness excludes otitis externa. Weber lateralization to the right — the affected ear — confirms conductive hearing loss (fluid blocks conduction through the ossicular chain, reducing ambient masking and allowing bone-conducted sound to be heard preferentially in that ear). Sensorineural hearing loss produces the opposite Weber pattern (lateralization to the unaffected ear) and would not produce the amber TM appearance.

Summary: HEENT assessment at a glance

HEENT assessment integrates the examination of six anatomical regions and the functional testing of ten cranial nerves within a single systematic sequence. The head introduces inspection and palpation technique, including the temporal artery — often the earliest physical sign of a sight-threatening vasculitis. The eye examination progresses from visual acuity to extraocular movements, pupil responses, and fundoscopy, each layer testing a different component of the visual and oculomotor pathways. The ear examination combines otoscopic structural assessment with functional hearing testing through the Weber and Rinne tests, whose interpretation requires understanding the mechanical difference between conductive and sensorineural loss. Nose and sinus assessment extends into the upper respiratory tract and can reveal allergic, infectious, or anatomical contributors to chronic respiratory symptoms. The oral and oropharyngeal examination covers CN IX, X, and XII and surfaces findings — uvular deviation, Koplik spots, floor-of-mouth lesions — that carry disproportionate clinical significance relative to the time taken to assess them. The neck closes the examination with lymph node palpation, thyroid assessment, carotid auscultation, and tracheal position — the last of which, when deviated in a deteriorating patient, demands immediate escalation.

For the full body examination that follows HEENT, see respiratory assessment nursing. For the cranial nerve examination performed in detail during neurological assessment, see neurological assessment nursing. For GCS and LOC context when evaluating pupils in acutely ill patients, see Glasgow Coma Scale.