Health Assessment

Question 1

anosmia

Answer 1

lack of sense of smell as a result of CN-I dysfunction

Question 2

clonus

Answer 2

hyperactive reflex indicating upper motor neuron disease

when present, there will be alternating flexion and extension

Question 3

diplopia

Answer 3

double vision

Question 4

hypalgesia

Answer 4

decreased pain sensation

Question 5

hyperesthesia

Answer 5

increased sensation to touch

Question 6

nystagmus

Answer 6

involuntary oscillations of the eye

Question 7

papillaedema

Answer 7

edema of the optic nerve as it enters the retina

Question 8

Oculomotor CN III

Trochlear CN IV

Abducens CN VI

Answer 8

occulomotor=Assess by having client move eyes through cardinal fields of gaze by following finger without moving head

evaluate client’s pupillary reaction to light and accomodation

pupils should be assessed for size regularity and equality

Question 9

Trigeminal Nerve (CN V)

Answer 9

close eyes, state when face is touched with cotton

eval corneal reflex by touching client’s eye with cotton

assess motor function by having client clench teeth

Question 10

Facial Nerve (CN VII)

Answer 10

Have client smile, frown, show teeth, close eyes, puff cheeks and raise eybrows

Assess muscle strength-have client puff cheek and attempt to push air through lips with pressure to cheek

Test anterior aspect of tongue for taste

Question 11

Acoustic Nerve (CN VIII)

Answer 11

determine adequate hearing and balance

Weber test-tuning fork on top of head-compares equality of hearing in both ears

Rinne test-tuning fork-bone conduction/air conduction

Romberg test-eyes closed, feet together-balance

Question 12

Glossopharyngeal (CN IX)

Vagus (CN X)

Answer 12

have client say “ah” and test gag reflex

observe client swallow

evaluate clients voice

Question 13

Spinal Accessory (CN XI)

Answer 13

shrug shoulders, look for symmetry

turn head to right and left

Question 14

Hypoglossal (XII)

Answer 14

stick out tongue

move laterally

push against cheek

Question 15

Stereognosis

Answer 15

have client id object placed in hand with eyes closed

Question 16

Topognosis

Answer 16

Client closes eyes, identify part of body touched

Question 17

Nystagmus

Answer 17

involuntary oscillation of the eyeball due to muscle weakness, disoriention, a neurological disorder, or action of some medications

Question 18

presbyopia

Answer 18

loss of elasticity of crystalline lens, possibly caused by loss of power of ciliary muscles and resulting in inability to focus on near objects

(age 40)

Question 19

ptosis

Answer 19

condition whereby eyelid droops because levator muscle too weak

Question 20

strabismus

Answer 20

eyes cannot be focused on same object-weakened eye muscles produce convergence of the eye toward the nose

Question 21

myopia

Answer 21

nearsightedness

unable to see objects in the distance

(opposite is hyperopia–unable to see near objects)

Question 22

papilledema

Answer 22

edema of optic nerve as it enters the retina

consistent with increased intracranial pressure

=Head injury!!!

Question 23

Otosclerosis

Answer 23

Abnormal growth of bone of the middle ear that prevents structures within the ear from working properly–conductive hearing loss that results in the pt needing increased volume to hear.

Question 24

Presbycusis

Answer 24

Hearing loss associated with age.

Question 25

Labyrinthitis

Answer 25

inflammation or infection of the labyrinth causing the sensation of spinning,but not hearing loss.