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nsg106 > head to toe yoost > Flashcards

head to toe yoost Flashcards

1
Q

what determines ski color and hue

A

pigment

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2
Q

what causes white pinkish skin

A

low melanin

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3
Q

absence of pigment is called

A

albinism

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4
Q

what is cyanosis

A

blue discoloration of the skin nail beds or mucous

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5
Q

what causes cyanosis

A

casoconstriction or deoxygenated hemoglobin in blood vessels newar skin

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6
Q

what is erythema

A

redness of skin

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7
Q

syoptoms of erythema

A

congestion or dialation of superficial vessels in skin,

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8
Q

what causes erythema

A

skin injury
sunburn
infection
fever

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9
Q

purpura is

A

bleeding underneath the skin

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10
Q

what does purpura indicate

A

vascular coagulation, platelet disorder

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11
Q

jaundice

A

yellow hue to skin, mucous membrain, eyes

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12
Q

causes of jaundice

A

excess bilirubin, liver failure

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13
Q

best site to check for jaundice

A

sclera, the hard palate, darker skinned people

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14
Q

pallor is

A

pale or lighetened skin tone

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15
Q

pallor causes

A

illness, emotional shock, stress, decreased exposure to sunlight, anemia, may be genetic

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16
Q

where is pallor observed

A

face, oral mucosa, nail beds, palms of hands, conjuctiva of eye

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17
Q

vitiligo is

A

loss of skin pigment

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18
Q

vitiligo causes

A

result of autoimmune response

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19
Q

skin lesions causes

A

benign, age related skin, skin tags, cherry angiomas, keratosis, warts, freckles

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20
Q

what is petechiae

A

tiny dark red spots

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21
Q

what does petechiae idicate

A

hemorrhage (blood) under skin

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22
Q

skin malignancies

A

a type of canser

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23
Q

taninng before age 35 increase the risk for

A

melanoma (deadliest skin canser)

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24
Q

skin lesion types

A

macule/ patch
papule/plaque
nodule
tumor
vesicle/bulla
pustule
wheal
burrow
cyst

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25
Q

Macule/Patch is

A

flat
>1cm

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26
Q

papule/plaque looks

A

solid, raised
>0.5cm

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27
Q

nodule looks like

A

raised with defined borders
0.5-2 cm

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28
Q

tumor looks like

A

solid mass
undefined bordes
>1-2cm

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29
Q

vesicle/bulla looks like

A

circumscribed
raised
<0.5

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30
Q

pustule

A

similar to vesicle, acne

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31
Q

wheal look like

A

hives, insect bites

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32
Q

burrow looks like

A

linear or circular
scabies mites

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33
Q

cyst look like

A

encapsulated fluid/ solid mass
cyst

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34
Q

Turgor

A

skin elasticity or ability to resist deformity after being displaced

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35
Q

edema is

A

swelling

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36
Q

edema cause

A

buildup of fluid in underlying tissue
trauma to an area
impairment of venous return

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37
Q

if you find hair on ___ etc it not normal

A

lips, palms, soles of feet, niples, labia minora, penis

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38
Q

types of skin cancer

A

basal cell carcinoma
squamous cell carcinoma
melanoma

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39
Q

basal cell carcinoma causes

A

sun exposure
fair complexions
family history
weakened immune system
radiation therapy
age

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40
Q

what causes squamous cell carcinoma

A

chronic sun exposure
rest as same for basal cell carcinoma

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41
Q

causes of melanoma

A

sun exposure

fair complexions
freckling
light hair

multiple moles

male gender

history of cancer in family or person

immune suppression

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42
Q

ABCDE when looking for malenoma

A

a= asymmetry
b=border
c=color
d=diameter
e=evolving

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43
Q

assymmetry of melanoma

A

one half of leasion do not match other half

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44
Q

border of malenoma

A

irregular/ uneven

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45
Q

color of malenoma

A

tan, brown, black, white, red, blue

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46
Q

diamertar of malenoma

A

6+ cm

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47
Q

evolving in malenoma

A

changes in shape color size

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48
Q

Documentation of Pitting Edema size

A

slight pit 2mm

depper pit 4mm

deep pit 6mm

very deep pit 8mm

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49
Q

when hair grow on lip its called

A

hirsutism

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50
Q

permanent or temprorary hair loss is called

A

alopecia

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51
Q

pruritus means

A

itching

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52
Q

nails are supposed to be

A

hard

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53
Q

Nail Shape abnormalietes

A

splinter hemorrhage
paronychia
clubbing
beaus lines
koilonychia
muehrcke

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54
Q

what does splinter hemorrhage look like and causes

A

red or purple
brown streak on nail bed

Minor trauma, trichinosis, subacute bacterial endocarditis

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55
Q

Paronychia what does look like and why

A

Inflammation of the skin at the base of the nail

causes:

Local infection

Acute: Staphylococcus aureus, herpes simplex virus

Chronic: Candida albicans, Pseudomonas spp.

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56
Q

Clubbing what does look like and why

A

Enlargement of the fingertips, softening of the nail bed, and flattening of the nail; angle between the nail plate and the nail often greater than 180 degrees

Nail injury, systemic injury, eczema, psoriasis, paronychia

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57
Q

Koilonychia what does look like and why

A

Concave curves of the nail, with thinning of the nail plate; also called “spoon nail”

Iron deficiency anemia, repeated chemical trauma, syphilis

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58
Q

Beau’s lines what does look like and why

A

Transverse ridging in nails due to a temporary halt in nail growth

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59
Q

Muehrcke lines what does look like and why

A

Double band of white lines (leukonychia)

Renal disease

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60
Q

Obtaining a health history begins with

A

patient interview

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61
Q

Physical examination requires

A

privacy

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62
Q

Equipment Used for Physical Examination

A

Patient gown
* Scale
* Height assessment tool
* Sphygmomanometer with cuff
* Stethoscope with bell and diaphragm
* Thermometer
* Wristwatch
* Pulse oximeter
* Disposable pads and/or examination table paper
* Bath blanket or sheet
* Gloves
* Cotton applicators and/or cotton balls
* Eye chart
* Flashlight or penlight
* Otoscope and ophthalmoscope
* Tuning fork
* Tongue depressor
* Reflex hammer
* Tape measure or ruler
* Specimen containers, as needed

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63
Q

The following should be done with all specimen containers

A

Handle with gloves.
* Wipe clean of debris.
* Mark or label with the patient’s identification information.
* Bag after collection before sending the specimen to the laboratory.

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64
Q

Patient’s emotional and physical responses often depend on their level of

A

comfort or anxiety

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65
Q

positions required for physical assessment depends on the patient’s level of

A

mobility, physical strength, and comorbid conditions

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66
Q

comorbid conditions is

A

two or more medical conditions existing simultaneously

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67
Q

chief complaint

A

presenting problem

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68
Q

clinical manifestations

A

signs and symptoms

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69
Q

Physical Examination Positions

A

Supine
Dorsal recumbent position
fowler
lithotomy
prone
left lateral recumbent
knee chest

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70
Q

supine position is to examine

A

To examine the head and neck, anterior thorax and lungs, breasts, axillae, heart, abdomen, extremities, and pulses

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71
Q

Dorsal recumbent is to examine

A

To examine the head and neck, anterior thorax and lungs, breasts, axillae, heart, and abdomen

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72
Q

fowler is to examine

A

To examine the head and neck, anterior thorax and lungs, breasts, axillae, heart, abdomen, lower extremities, and pulses

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73
Q

Lithotomy is to examine

A

To examine the female genitalia

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74
Q

Prone is to examine

A

To examine the back, spine, posterior aspect of the head, neck, thorax, buttocks, and lower extremities

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75
Q

Left lateral recumbent is to examine

A

To examine the rectal and perineal areas

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76
Q

Knee-chest is to examine

A

rectal area

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77
Q

accumulation of cerebrospinal fluid in the ventricles of the brain is called

A

hydrocephalus

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78
Q

crossed eyes is called

A

Strabismus

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79
Q

causes of strabismus

A

due to muscle weakness or paralysis

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80
Q

seeing double is called

A

diplopia

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81
Q

The eyes are positioned on each side of the nasal bone, approximately

A

1 to 2 inches apart from one inner canthus to the other

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82
Q

When abnormal drooping of the eyelid occurs, the condition is known as

A

ptosis

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83
Q

The sclera is examined to check its

A

color and ensure that it is intact, without lesions

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84
Q

the cornea refracts light and accounts for approximately ______ of the eye’s total optical power

A

two-thirds

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85
Q

Documentation of a normal pupillary reflex examination is recorded as

A

PERRLA

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86
Q

PERRLA stands for

A

pupils equal, round, reactive to light and accommodation

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87
Q

Movement of the eyes in all directions is controlled by the combined function of three cranial nerves which are

A

III, oculomotor; IV, trochlear; and VI, abducens

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88
Q

rapid, shaking, involuntary movement of the eyes is called

A

nystagmus

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89
Q

cranial nerve II control

A

patency and central vision

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90
Q

if a patient cant see far what nerve Is likely the cause

A

cranial nerve 2

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91
Q

Cataracts are

A

Opacity or clouding of the eye lens

92
Q

cataracts causes

A

Increasing age, female gender
* Prolonged sun exposure
* Cigarette smoking, alcohol or steroid use
* Diet low in antioxidants

93
Q

Glaucoma is

A

Optic neuropathy, usually associated with increased intraocular pressure

94
Q

Glaucoma causes

A

Increased age, African or Hispanic ancestry
* Migraines, diabetes, low blood pressure
* Increased intraocular pressure
* Family history
* Eye injury

95
Q

Macular Degeneration

A
  • Deterioration of the macula, the area on the retina that is responsible for central vision, allowing for clear vision of fine details; Two types: dry and wet
96
Q

Macular Degeneration causes

A
  • Family history, white ancestry
  • Overactive immune system causing inflammation
  • Smoking, hypertension, hypercholesterolemia
97
Q

Myopia is

A

Nearsightedness

98
Q

myopia causes

A

Familial history

99
Q

Hyperopia is

A

Farsightedness

100
Q

Hyperopia causes

A

Familial history

101
Q

Presbyopia is

A

age-related loss of near vision

102
Q

Presbyopia causes

A

Age older than 40 years

103
Q

Ophthalmoscope is used for

A

Examination of the internal structures of the eye

104
Q

Physical examination of the ear begins with direct inspection and palpation of

A

outer ear

105
Q

Inspect the external ear canal for

A

discharge or drainage

106
Q

purulent means

A

containing pus

107
Q

purulent can indicate

A

indicate infection or foreign body penetration of the middle ear

108
Q

cerumen is

A

earwax

109
Q

cerumen color should be

A

yellow to dark brown

110
Q

Insert the speculum no more than 1 to

A

1.5 cm

111
Q

tinnitus is ______ _______ ______ in the ears

A

ringing, buzzing, or roaring in the ears

112
Q

tinntitus indicate

A

hearing loss, overuse of salicylates
symptomatic of diseases that cause vertigo

113
Q

whats vertigo

A

disequilibrium, spinning sensation

114
Q

vertigo causes

A

Ménière disease

115
Q

Hearing loss may result from

A

trauma, aging, heredity, disease, medication, and prolonged exposure to high-decibel sound

116
Q

three primary types of hearing loss are

A

sensorineural, conductive, and mixed

117
Q

Sensorineural hearing loss is due to

A

inner ear damage

118
Q

Conductive hearing loss occurs when

A

something interferes with the transmission of sound via vibration to the inner ear

119
Q

most common causes of vibration interruption

A

Fluid in the middle ear and cerumen accumulation

120
Q

Mixed hearing loss results from

A

middle-ear and nerve damage

121
Q

Weber Test is conducted when

A

patient complains of hearing loss in one ear

122
Q

what is weber test conducted with

A

tuning fork

123
Q

Rinne Test compares ______and _______ conduction

A

bone, air

124
Q

Air-conducted sound should be heard _______as long as bone-conducted sound

A

twice

125
Q

Patients with inner ear disorders often experience a loss of

A

equilibrium and vertigo.

126
Q

Romberg Test is conducted to assess the patient’s

A

equilibrium

127
Q

Inability to stay balanced with eyes closed during romberg test may indicate

A

vestibular disease

128
Q

The nose and sinuses are inspected and palpated with the patient

seated or standing?

A

seated

129
Q

The skin on and around the nose should be

A

smooth, even, and consistent with the color of facial skin tones

130
Q

excoriation means

A

abrasion due to rubbing or scratching

131
Q

Ask the patient to breathe through one nostril at a time, while the opposite nostril is pressed closed with a fingertip to check for

A

if air passes freely through nostrils

132
Q

epistaxis is

A

noesbleed

133
Q

epistaxis causes

A

high blood pressure or diabetes.

134
Q

Assessment of the mouth, throat, and neck provides the nurse with the opportunity to evaluate many aspects of the patient’s health status, including:

A
  • Oral hygiene
  • Condition of the teeth and gums
  • Hydration status
  • Airway patency
  • Ability to meet nutrition needs
  • Patency of cerebral blood flow
135
Q

Dry, cracked lips are called

A

cheilitis

136
Q

cheilitis causes

A

dehydration from limited oral intake or exposure to excessive heat (hyperthermia) or cold

137
Q

To test cranial nerve VII (facial nerve) function, ask the patient to demonstrate

A

clenching the teeth and then smiling if they can do it that good It indicates its working normally

138
Q

inspect the teeth for

A

color, irregular shape, cavities, and Loose or missing teeth

139
Q

Using a _____ _______ and ________, inspect the buccal mucosa, teeth, gums, tongue, uvula, tonsils, and palate for color, texture, lesions, ulcers, bleeding, and patency

A

tongue blade, penlight

140
Q

The superficial lymph nodes in the neck, are _______ ______ under normal circumstances

A

not palpable

141
Q

lymph nodes becomes enlarged when

A

it receives drainage from a specific area of infection or disease

142
Q

The jugular veins are observed for ________ and ________

A

distention, blood flow

143
Q

JVD stand for

A

jugular vein distention

144
Q

carotid arteries, which provide ______ supply to the _____, are assessed for _____of _____ _____

A

blood, head, patency, blood flow

145
Q

bruit is

A

abnormal “swooshing” sound

146
Q

Inspect the thyroid gland for ______and _______

A

position, enlargment

147
Q

The thyroid gland is the _______ endocrine gland in the body

A

largest

148
Q

Assessment of respiratory status begins with questioning the patient about

A

risks for pulmonary complications

149
Q

Questions
Respiratory System

A
  • How far can you walk on level ground?
  • How many stairs are you able to climb without becoming short of breath?
  • Do you have a cough? If so, when did it start?
  • Do you cough up mucus or blood? If so, describe the color and consistency.
  • Can you lie flat when sleeping?
  • Do you snore?
  • Do you use oxygen or breathing machines at home? If so, how often and at what setting?
  • Do you ever experience shortness of breath either at rest or with exercise?
  • Do you have any pain with breathing?
  • Is the pain associated with coughing, shortness of breath, trauma, nasal congestion, or sore throat?
  • Does chest pain cause splinting, shallow breathing, or uneven chest expansion, or does it radiate to the back, neck, or arms?
  • What relieves the chest pain associated with respiration?
  • Do you have any recent history of trauma or infection?
  • Do you have a history of chronic conditions that affect respiration, including allergies, emphysema, chronic obstructive pulmonary disease, tuberculosis, cystic fibrosis, or asthma?
  • Do you have a history of tumors or lung cancer?
  • Do you use tobacco or marijuana? If so, how many years and packs per day?
  • Have you been exposed to dust, fumes, or smoke in the environment at work or home?
  • Have you traveled out of the country recently?
150
Q

Inspection of the anterior and posterior thorax for symmetry and shape includes inspecting the following

A

chest hair for color, thickness, and even distribution

Nipples should be centered on either side of the sternum

Observe the spine (normally is midline and straight)

Ribs should slope downward

scapulae lie flat on either side of the spine

anteroposterior (AP) measurement of the chestnormal ratios of 1:2 to 5:7.

151
Q

Normal breathing patterns are _______, _______, and effortless

A

relaxed, automatic, effortless

152
Q

normal respiratory rate

A

12 and 20 bpm

153
Q

Chest pain, shortness of breath, coughing, or diaphoresis may occur when

A

pulmonary embolism (PE), deep vein thrombosis (DVT) is present

154
Q

the two types of venous thromboembolism (VTE)

A

pulmonary embolism (PE)
deep vein thrombosis (DVT)

155
Q

Tactile fremitus is decreased or absent in patients with conditions that obstruct lung tissue, such as

A

pneumothorax, tumors, pleural effusion, or COPD

156
Q

Tactile fremitus can increase with _____

A

pneumonia or consolidation close to the chest wall.

157
Q

atelectasis is

A

collapse of all or part of the lung

158
Q

breath sounds may be decreased or absent because of _______

A

atelectasis

159
Q

normal Breath Sound tracheal pitch quality amplitude and location

A

Pitch high
Quality harsh
Amplitude loud
Over the trachea

160
Q

normal Breath Sound Bronchial pitch quality amplitude and location

A

Pitch high
Quality hollow
Amplitude loud
Over the main bronchi

161
Q

normal Breath Sound Bronchovesicular pitch quality amplitude and location

A

Pitch medium
Quality mixed
Amplitude medium
Posterior between the scapulae; anterior around the upper sternum in the first two intercostal spaces

162
Q

normal Breath Sound pitch quality amplitude and location: vesicular

A

Pitch low
Quality blowing
Amplitude soft
Over most of the lung fields

163
Q

Assist the patient into a supine position or raise the head of the bed 45 degrees to inspect and palpate the ________

A

Cardiac function (heart)

164
Q

Adventitious Breath Sounds

A

Crackles
Rhonchi
Wheezing
Stridor
Pleural friction rub

165
Q

Crackles sounds like

A

Brief crackling, popping sounds

166
Q

Rhonchi sounds like

A

Low-pitched, snoring sounds

167
Q

Wheezing sounds like

A

High-pitched, whistling sound

168
Q

Stridor sounds like

A

Intense, high-pitched, and continuous monophonic wheeze or crowing sound

169
Q

Pleural friction rub sounds like

A

Low-pitched, grating, or creaking sound

170
Q

Health Assessment Questions
Cardiovascular System

A

Are you experiencing chest pain? If so, describe the pain. When was its onset or when did the pain begin? What is its duration or how long have you had this pain? What are the characteristics of the pain (sharp, stabbing, aching, burning, viselike)? Where is the pain? Does the pain radiate? What relieves the pain? Are there any other symptoms associated with the pain?
* Do you have any palpitations or extreme fatigue?
* Do you have any difficulty breathing or difficulty lying flat when sleeping?
* Do you have any past medical history of cardiac surgery or hospitalizations for cardiac events or disorders?
* Have you ever had acute rheumatic fever, swollen or painful joints, or inflammatory rheumatism?
* Do you have any chronic illnesses such as hypertension, hyperlipidemia, diabetes, coronary artery disease, congenital heart defects, or bleeding disorders?
* Do you have a family history of diabetes, heart disease, hypertension, hyperlipidemia, obesity, congenital or acquired heart defects, or sudden death at a young age? If so, include age at the time of diagnosis and death of first-degree relatives.
* Are you on an anticoagulant? Do you have a coagulation disorder?
* Does your employment include physical demands, emotional stress, or environmental hazards such as chemicals, heat, sunlight, or dust?
* Do you use tobacco? If so, at what age did you start? How many packs per day? Have you stopped using it?
* How often do you use alcohol or recreational drugs? If used, what type of alcohol or recreational drugs do you prefer?
* What is your nutritional status? Have you lost or gained weight recently?
* What do you do to relax?
* Do you exercise? How much and how often?
* Do you have aching, cramping, or pain in the legs while walking or exercising? If so, when did it start, how long have you had it, and what are its characteristics? Does anything relieve the pain?
* Have you ever had loss of consciousness or transient syncope? If so, was the episode associated with any other symptoms?
* Does shortness of breath interfere with your activities of daily living?
* Do you have any tingling, numbness, or coldness in your hands or feet?
* Do you have edema or swelling in your hands, feet, or ankles? If so, what makes it worse? What reduces the edema?
* Have you had any recent change in hair loss or growth on your hands, feet, or ankles?
* Has anything restricted blood flow to your extremities (cast, surgery, trauma, tight clothing)?

171
Q

two distinct ______ sounds, known as S1 (“lub”) and S2 (“dub”), are heard

A

heart

172
Q

An entire S1 plus S2 (“lub-dub”) cycle constitutes _______ heartbeat

A

one

173
Q

Failure of the heart to beat at regular successive intervals is called

A

dysrhythmia

174
Q

pulse deficit is when

A

patient’s radial pulse rate is slower than the apical pulse rate

175
Q

Cardiac murmurs are

A

blowing or swishing sounds heard in systole or diastole

176
Q

Cardiac murmurs cause

A

increased or abnormal blood flow through the valves of the heart

177
Q

a thrill is

A

an abnormal vibration felt on palpation

178
Q

a thrill is detected with a _____

A

murmur

179
Q

Murmurs are graded according to intensity
what are the 5 grades

A

Grade 1: Scarcely audible with a good stethoscope in a quiet room
Grade 2: Quiet but readily audible with a stethoscope
Grade 3: Easily heard with a stethoscope
Grade 4: A loud, obvious murmur with a palpable thrill
Grade 5: Very loud with a palpable thrill; heard over the pericardium and elsewhere in the body (radiates)
Grade 6: Heard with a stethoscope off the chest; thrill palpable and visible

180
Q

A Doppler ultrasound unit may be used to assess weak

A

peripheral pulses

181
Q

tortuosity meaning

A

bending and twisting

182
Q

While assessing the patient’s Peripheral pulse, the nurse notes its

A

intensity, rate, and rhythm, existence of blood vessel tenderness, tortuosity, nodularity

183
Q

Intensity or volume of peripheral pulses is graded on a scale of 0 to 3:

A

0 Absent pulse (unable to palpate)
1 Diminished (weaker than expected; difficult to palpate)
2 Normal (able to palpate with normal pressure)
3 Bounding (may be able to see pulsation; does not disappear with palpation)

184
Q

Femoral pulses are best assessed with the patient in the ______ or ____ ______ position.

A

supine, low Fowler

185
Q

Phlebitis is the

A

inflammation of a vein

186
Q

the five Ps of circulation

A

pain, pallor, pulselessness, paresthesia (numbness or tingling), and paralysis

187
Q

paresthesia is

A

numbness or tingling

188
Q

Lordosis is

A

a condition that causes an increased lumbar curvature just above the buttocks area

189
Q

Kyphosis is

A

an outward curvature of the thoracic spine

190
Q

Scoliosis is

A

a sideways or S-shaped curvature of the spine and is always abnormal

191
Q

Health Assessment Questions
Musculoskeletal System

A
  • Do you have any pain or stiffness in your joints, muscles, or back? If so, when did it begin? Where is the pain or stiffness? What is its quality? Is the pain burning, aching, shooting, constant, or intermittent? Does anything aggravate or relieve the pain?
  • Are you able to perform activities of daily living, such as dressing or preparing meals, without musculoskeletal discomfort?
  • Can you climb stairs and walk without limping?
  • Do you have numbness or tingling in your extremities?
  • Are you able to engage in strenuous activity or exercise?
  • Have you experienced any recent trauma to any of your bones, joints, soft tissue, or nerves?
  • Do you have any chronic illnesses that may affect the musculoskeletal system, including cancer, osteoporosis, arthritis, and renal or neurologic disorders?
  • Do you have any known skeletal deformities or a congenital history that may affect the musculoskeletal system?
  • Do you have any family history of arthritis (rheumatoid, osteoarthritis, ankylosing spondylitis), back problems (scoliosis, spina bifida), or genetic disorders (osteogenesis imperfecta, rickets, dwarfing syndrome)?
  • Does your diet include adequate calcium and vitamin D?
192
Q

hypertonicity is

A

increase in muscle tone

193
Q

hypotonicity is

A

decrease in muscle tone

194
Q

Clonus is a _____ ______ ______ of the muscle

A

repetitive vibratory contraction

195
Q

Clonus causes

A

muscle and tendon stretch

196
Q

Reflex responses to deep tendon and cutaneous reflexes are documented using a subjective scale as follows:

A

4+ Very brisk, hyperactive with clonus
3+ Brisker than average, slightly hyperactive
2+ Average, normal
1+ Sluggish or diminished
0 No response

197
Q

Reflex of muscle and normal response to Tendon Reflex Assessment: Biceps

A

Biceps contraction and flexion

198
Q

Reflex of muscle and normal response to Tendon Reflex Assessment:
triceps

A

Extension of the forearm

199
Q

Reflex of muscle and normal response to Tendon Reflex Assessment: Achilles ankle jerk

A

Plantar flexion of the foot

200
Q

Reflex of muscle and normal response to Tendon Reflex Assessment: Quadriceps or patellar knee jerk

A

Extension of the leg

201
Q

Reflex of muscle and normal response to Tendon Reflex Assessment: Plantar

A

Adults and children: Plantar flexion of the toes and forefoot

Infants: Dorsiflexion of the big toe and fanning out of the toes (positive Babinski sign)

202
Q

Cranial Nerve Function and Assessment:
Cranial Nerve I: Olfactory (Sensory)

A

Transmits the sense of smell

After assessing patency of both nares, have the patient close the eyes, obstruct one naris, and inhale to identify a common scent.

203
Q

Cranial Nerve Function and Assessment:

Cranial Nerve II: Optic (Sensory)

A

Transmits visual information to the brain; located in the optic canal

Check visual acuity (have the patient read newspaper print or use a Snellen chart), and test visual fields for each eye.

204
Q

Cranial Nerve Function and Assessment: Cranial Nerve III: Oculomotor (Motor)

A

Innervates four of the six muscles that collectively execute most eye movements; responsible for pupillary constriction and dilation

Assess pupil size and light reflex; note direction of gaze.

205
Q

Cranial Nerve Function and Assessment:
Cranial Nerve IV: Trochlear (Motor)

A

Innervates muscles responsible for downward and inward gaze of the eyes

Ask the patient to gaze downward, temporally, and nasally.

206
Q

Cranial Nerve Function and Assessment:
Cranial Nerve V: Trigeminal (Sensory and Motor)

A

responsible for the corneal reflex; receives sensation from the face and innervates the muscles of mastication

Motor: Palpate jaws and temples while patient clenches teeth.

Sensory: With the patient’s eyes closed, gently touch a cotton ball to all areas of the face.

207
Q

Cranial Nerve Function and Assessment:
Cranial Nerve VI: Abducens (Motor)

A

Innervates muscles responsible for outward gaze of the eyes

Assess directions of gaze.

208
Q

Cranial Nerve Function and Assessment:
Cranial Nerve VII: Facial (Sensory and Motor)

A

Provides motor innervation to the muscles of facial expression; receives the sense of taste from the anterior two-thirds of the tongue; provides innervation to the salivary glands (except parotid) and the lacrimal gland

Motor: Check symmetry of the face by having the patient frown, close eyes, lift eyebrows, and puff cheeks.

Sensory: Assess the patient’s ability to recognize taste (sugar, salt, lemon juice).

209
Q

Cranial Nerve Function and Assessment:
Cranial Nerve VIII: Vestibulocochlear or Auditory-Vestibular (Sensory)

A

Vestibular branch: Carries impulses for equilibrium

Cochlear branch: Carries impulses for hearing

Assess the patient’s ability to hear a spoken and whispered word.

210
Q

Cranial Nerve Function and Assessment:
Cranial Nerve IX: Glossopharyngeal (Sensory and Motor)

A

Receives taste from the posterior third of the tongue; provides innervation to the parotid gland; and provides motor innervation for swallowing

Sensory: Assess the patient’s ability to taste sour or sweet on last two-thirds of tongue.

Motor: Check for presence of the gag reflex by inserting a tongue blade two-thirds into the pharynx.

211
Q

Cranial Nerve Function and Assessment:
Cranial Nerve X: Vagus (Sensory and Motor)

A

Supplies innervation to the larynx and soft palate responsible for speech and swallowing; provides parasympathetic fibers to nearly all thoracic and abdominal smooth muscles

Depress the tongue with a tongue blade and have the patient say “ah” or yawn. The uvula and soft palate should rise and be symmetric. Assess speech for hoarseness.

212
Q

Cranial Nerve Function and Assessment:
Cranial Nerve XI: Spinal Accessory (Motor)

A

Cranial root: Works with vagus nerve to control the muscles of the soft palate, pharynx, and larynx

Spinal root: Innervates muscles of the neck and back

Have the patient rotate the head and shrug the shoulders against passive resistance.

213
Q

Cranial Nerve Function and Assessment:
Cranial Nerve XII: Hypoglossal (Motor)

A

Provides motor innervation to muscles of the tongue not innervated by the vagus nerve and to other glossal muscles; is important for swallowing and speech articulation

Assess tongue control (e.g., have the patient stick out the tongue and move it from side to side).

214
Q

Level of orientation and mental status are assessed by determining the patient’s ability to identify _____, _______,________,______

A

person, place, time, and situation

215
Q

Glasgow Coma Scale

A

Eye opening:
Spontaneous 4
To verbal command 3
To pain 2
None 1

Verbal:
Oriented 5
Confused but able to answer questions 4
Inappropriate responses 3
Incomprehensible speech 2
None 1

Motor:
Obeys commands 6
Purposeful movement to painful stimulus 5
Withdraws from pain 4
Abnormal (spastic) flexion, decorticate posture 3
Extensor (rigid) response, decerebrate posture 2
None 1

Possible total score range 3–15

216
Q

Health Assessment Questions
Abdomen (Gastrointestinal tract)

A
  • Do you have any pain or difficulty with swallowing?
  • Have you experienced difficulty eating, weight change, or lack of appetite?
  • Do you have nausea, vomiting, regurgitation of food, frequent burping, heartburn, indigestion, or bloating? If so, what do you do to relieve the symptoms?
  • Are you experiencing abdominal pain? If so, what are the characteristics of the pain? Are there any associated symptoms? Does anything relieve the pain?
  • What is your typical 24-hour food intake?
  • Have you experienced any changes in bowel habits: diarrhea, constipation, incontinence, or frequent passing of gas?
  • Have you noticed any blood in your stool?
  • Do you have problems with hemorrhoids?
  • Have you ever had abdominal surgery?
  • Do you or any family members have a history of abdominal illnesses such as gallbladder disease, cancer, or irritable bowel syndrome?
217
Q

Health Assessment Questions urinary tract

A
  • Are you experiencing any difficulty with urination: Frequency, urgency, or difficulty starting or stopping your stream of urine?
  • Do you have a history of urinary tract or kidney infections or kidney stones?
  • Is there pain or burning when you urinate?
  • Have you noticed a change in your frequency of urination: Less often or more often than previously?
  • Do you feel that you empty your bladder when you urinate?
  • Do you have to get up at night to urinate? If so, how many times?
218
Q

striae meaning

A

stretch marks resulting from pregnancy or from weight loss or gain

219
Q

The nurse visually inspects the skin over the abdomen, noting

A

color, tone, scars, bruises, lesions, venous patterns, striae, drains, tubes, and stomas

220
Q

peristalsis is

A

progressive wave action causing movement of contents through the gastrointestinal system

221
Q

borborygmi is heard as

A

loud grumbling

222
Q

stenosis means

A

narrowing

223
Q

Assessment of the Male Genitalia
include

A

size and shape of the penis and testes

distribution of pubic hair across the perineal area (Before puberty, in preadolescents, pubic hair is absent in the groin area)

enlargement and darkening of the testicles, appearance of pubic hair, and lengthening of the penis

pubic area should be free of rashes, lesions, masses, and obvious deformity

Observe for smegma

224
Q

smegma is

A

a whitish substance under the foreskin of penis

225
Q

prostate cancer screening is recomended to start at age

A

45

nsg106 (17 decks)

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