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Health Assessment > Test 3 > Flashcards

Test 3 Flashcards

1
Q

What eye structure is defined as uniform color, muscle controls the size of the pupil?

A

Iris

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2
Q

The distance between the upper and lower eyelids is called:

A

Palpebral fissure

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3
Q

What color should the sclera be?

A

White

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4
Q

What is the structure assessed by pulling down the lower eyelid as the patient looks up?

A

Conjunctiva

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5
Q

What is a drooping eyelid called?

A

Ptosis

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6
Q

The patient tells the nurse that the room is spinning around them. Dysfunction of which cranial nerve might cause this?

A

Acoustic

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7
Q

What substance is found in the external ear canal and protects the ear from foreign bodies and irritants?

A

Cerumen

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8
Q

Swollen tonsils that touch the uvula are graded ______.

A

4+

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9
Q

The dorsal surface of the tongue should be symmetrical, midline, moist, pink and _______.

A

Rough with papillae

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10
Q

The cranial nerve responsible for movement of the eyeballs are the oculomotor, trochlear, and _________.

A

Abducens

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11
Q

What is another name for the acoustic nerve?

A

Vestibular cochlear

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12
Q

What is orientation x2?

A
  • Name

- Location

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13
Q

What are the four assessing techniques when assessing head and neck?

A
  • interview
  • inspection
  • palpation
  • percussion/auscultation (very rare)
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14
Q

What is the normal symmetry for a skull noted as?

A

Normocephalic

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15
Q

What body part tells so much about the condition of a patient?

A

The face

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16
Q

How should skin appear on a head and neck assessment?

A
  • Smooth
  • Dry
  • In tact (Free of lesions)
  • Color uniform
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17
Q

How should the neck appear on a neck assessment?

A

Erect and straight

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18
Q

What should be palpated in a head and neck assessment?

A

Lymph nodes

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19
Q

How are carotid arteries graded?

A

With the same grading scale as any other pulse

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20
Q

Where can the carotid artery be found?

A

Anterior to the sternocleidomastoid muscle

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21
Q

What vertebrae is the large boney prominence at the base of the neck?

A

C7

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22
Q

What is the normal finding for lymph nodes?

A

None found

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23
Q

If a lymph node is palpable, what should its size be?

A

Less than 1 cm (soft and mobile)

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24
Q

What does the enlargement of a lymph node indicate?

A

Infection or dysfunction (ie: cancer)

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25
Q

What is the name for enlarged lymph nodes?

A

Lymphadenopathy

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26
Q

What are considered peripheral nerves?

A

Cranial nerves

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27
Q

Why do we assess cranial nerves?

A
  • possibility of stroke
  • head injury
  • encephalitis
  • meningitis
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28
Q

What illnesses influence the cranial nerves and cause change?

A
  • Parkinson’s disease
  • Multiple sclerosis (causes nerve sheath)
  • Diabetes with peripheral neuropathy
  • Hypertension
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29
Q

What nerve is being assessed when:

  • asking the patient to make faces
  • having the patient lift their eyebrows, smile and frown
  • close their eyelids tightly
  • puff out their cheeks
A

Facial Nerve

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30
Q

What cranial nerve innervates the muscles of the face and can be assessed by:
-having patient clench jaw while palpating masseter muscle and temporal muscles?

A

Trigeminal Nerve

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31
Q

What nerve is assessed by checking the patient’s vision?

A

Optic nerve

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32
Q

What tests are performed in order to check a patient’s vision?

A
  • Snellen Chart (letters)
  • Peripheral vision
  • PERRLA (Pupils Equal Round Reactive to Light & Accommodates)
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33
Q

__________ is when light is shined from the side to identify the pupil reaction.

A

Direct reaction

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34
Q

___________ is when light is shined in 1 pupil and constriction happens in the eye, but the pupil in the other eye also constricts.

A

Consensual reaction

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35
Q

____________ means the pupils will change.

A

Accommodation

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36
Q

What nerve is assessed by performing the whisper test?

A

Acoustic (Vestibular Cochlear)

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37
Q

What 3 cranial nerves are assessed when checked for eyeball movement?

A
  • Abducens
  • Oculomotor
  • Trochlear
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38
Q

What is the Six Cardinal Points of Gaze test?

A

Moving a light and having patient’s eyes follow for six different directions

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39
Q

What cranial nerve is assessed when having the patient stick out his/her tongue and moving it side to side?

A

Hypoglossal

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40
Q

What cranial nerve is assessed when having the patient stick out their tongue and say “ah”?

A

Glossopharyngeal

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41
Q

What nerve innervates the uvula?

A

Glossopharyngeal

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42
Q

What nerve is assessed by having the patient swallow?

A

Vagus

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43
Q

What nerve is assessed by having the patient shrug their shoulders?

A

Accessory

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44
Q

Which cranial nerve is assessed by having the patient smell something?

A

Olfactory

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45
Q

What is cranial nerve I?

A

Olfactory

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46
Q

What is cranial nerve II?

A

Optic nerve

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47
Q

What is cranial nerve III?

A

Oculomotor

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48
Q

What is cranial nerve IV?

A

Trochlear

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49
Q

What is cranial nerve V?

A

Trigeminal

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50
Q

What is cranial nerve VI?

A

Abducens

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51
Q

What is cranial nerve VII?

A

Facial nerve

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52
Q

What is cranial nerve VIII?

A

Vestibular cochlear (acoustic)

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53
Q

What is cranial nerve IX?

A

Glossopharyngeal

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54
Q

What is cranial nerve X?

A

Vagus

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55
Q

What is cranial nerve XI?

A

Accessory

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56
Q

What is cranial nerve XII?

A

Hypoglossal

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57
Q

Where are the frontal sinuses located?

A

Above the eyebrows

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58
Q

What are the maxillary sinuses located?

A

On either side of the nose

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59
Q

Why do we palpate sinuses?

A

To determine if there is infection?

60
Q

What condition is characterized by: swollen puffy eyes, congestion, colorful drainage, pain or discomfort in the face, and headaches?

A

Sinus infection

61
Q

What kind of headache is usually over the forehead, side of the head, or at the base of the skull?

A

Tension headache

62
Q

What type of headache can come from clenching teeth together?

A

Tension headache

63
Q

What type of headache comes from a viral infection or from allergies?

A

Sinus headache

64
Q

What type of headache is usually accompanied by a respiratory infection and runny nose?

A

Sinus headache

65
Q

What type of headache is localized?

A

Cluster headache

66
Q

What type of headache is typically timetable? (Ex: Happens between 12-3 and then again 12 hours later)

A

Cluster headache

67
Q

What are the two types of vascular headaches?

A
  • Cluster

- Migraine

68
Q

What type of chronic headaches cause vascular constriction?

A

Migraines

69
Q

What type of headache is accompanied by photophobia, nausea, and vomiting?

A

Migraine

70
Q

What type of headache can present with an aura?

A

Migraine

71
Q

What are the nursing diagnoses for headaches?

A
  • Acute Pain

- Impaired comfort

72
Q

What are the nursing diagnoses for enlarged thyroid?

A
  • Impaired swallowing (w/fear of choking)

- Ineffective airway clearance

73
Q

What is the distance between the upper and lower eyelid called?

A

Palpebral fissure

74
Q

What the name for a drooping eyelid?

A

Ptosis

75
Q

When assessing the cornea, what is the normal finding?

A

Clear

76
Q

Which cranial nerve is responsible for moving the eye laterally?R

A

Abducens

77
Q

What condition is a stif neck with muscle spasm of the sternocleidomastoid muscle on one side of the body causing a lateral flexion contracture of the cervical spine musculature?

A

Torticollis

78
Q

What muscles form the iris?

A

Ciliary

79
Q

Damage to _________ can alter pupil size?

A

Ciliary muscles

80
Q

What sinuses are not palpable?

A

Ethmoid and Sphenoid

81
Q

What are the largest salivary glands?

A

Parotid glands

82
Q

Where are the parotid glands located?

A

Superficial to and behind the mandible

83
Q

Where are the submandibular salivary glands located?

A

Within the lower mandible

84
Q

What regulates the pupil size and movement?

A

The iris

85
Q

How should the sclera appear on an assessment?

A

White to pale yellow

86
Q

What does blue sclera on an adult indicate?

A

Indicate intraocular pressure which damages the retina

87
Q

What does blue sclera on a newborn indicate?

A

Normal finding (for awhile)

88
Q

What is the normal finding of the conjuctiva?

A

Pink and no drainage

89
Q

What is the abnormal finding of conjuctiva?

A

Bright pink, red, cyanosis, jaundice, shot with capillaries, drainage

90
Q

What color will the sclera appear in conjuctival jaundice?

A

Yellow

91
Q

What color does the conjuctiva turn in a patient suffering from cyanosis?

A

Lavender

92
Q

Lack of color in the conjunctiva is called ___________.

A

Conjunctiva pallor

93
Q

Patient’s ________ status can be assessed by checking the patient’s eyes.

A

Hydration

94
Q

What are some of the subjective questions when assessing the nose?

A
  • Any pain
  • Any drainage
  • Change of smell
  • Breath out of both nostrils equally
95
Q

The septum should be _________.

A

Midline

96
Q

How can inflammation of the nasal passages be identified?

A

By red rim around nostrils

97
Q

Why is a deviated septum significant to a nurse?

A

The larger nostril should be used when placing an NG tube

98
Q

What are the subjective questions when performing an ear assessment?

A
  • Pain
  • Hearing Changes
  • Drainage
99
Q

What is the normal finding of the ear assessment?

A
  • Top of ear is at same level as corners of eye
  • No drainage
  • Patent
100
Q

What refers specifically to the feeling of spinning?

A

Vertigo

101
Q

Umbrella term for a state of imbalance

A

Dizziness

102
Q

How can vertigo or dizziness be assessed?

A
  • Romberg test

- Head tilt

103
Q

How can hearing be assessed?

A

Whisper test

104
Q

How can the symmetry of the nose be assessed?

A

By looking at the nasolabial fold

105
Q

When looking at the ventral side of the tongue, what are we assessing?

A
  • Veins
  • Most and shiny
  • Pools of spit (sublingual salivary glands)
106
Q

What condition can be assessed by looking at the hard palate?

A

Jaundice

107
Q

Where should the uvula appear when doing a throat assessment?

A

Midline

108
Q

What grade would tonsils seen behind the anterior pillars receive?

A

1+

109
Q

What grade would tonsils receive if they are touching the uvula?

A

4+

110
Q

When assessing the thyroid and finding an enlargement, what is this called?

A

Goiter

111
Q

An abnormally large head is called _______

A

Macrocephaly

112
Q

What is the only moveable bone of the face?

A

The mandible

113
Q

Edema of the lips

A

Angioedema

114
Q

Inflammation at the corners of the mouth (crackers corners of the lips)

A

Angular chelitis

115
Q

What is the normal size of the ear?

A

4-10 cm

116
Q

What should the angle of attachment of the ear be?

A

Less than 10 degrees

117
Q

What is macrotia?

A

Abnormally large ears (greater than 10 cm)

118
Q

What are hard, whitish or cream-colored non tender deposits of uric acid crystals (indicative of gout) on the ear called?

A

Tophi

119
Q

What is another name for middle ear hearing loss?

A

Conductive hearing loss

120
Q

What is another name for inner ear hearing loss?

A

Sensorineural hearing loss

121
Q

The Weber and Rinne test is used to assess which cranial nerve?

A

Cochlear (XIII)

122
Q

What medical device is used to inspect the external auditory canal, middle ear and eardrum?

A

Otoscope

123
Q

Inflammation of the outer ear causing redness, inflammation, discharge and pain; can be related to infection or swimmer’s ear

A

Ostitis externa

124
Q

Inflammation of the inner ear causing pain, inflammation, pressure, and a build-up of fluid; bright, bulging ear drum with diminished or no cone of visible light

A

Otitis media

125
Q

An accumulation of fluid in the middle ear caused by an obstruction of the Eustachian tube; tympanic membrane will appear to be a yellow color, with air bubbles and bulging.

A

Serous otitis media

126
Q

Fungal infection of the external auditory canal

A

Otomycosis

127
Q

A ruptured tympanic membrane; a dark oval hole will be present in the membrane

A

Perforated tympanic membrane

128
Q

How many muscles attach to the sclera to control eye movement, secure the eyeball to the socket, and allow sight in different directions?

A

Six

129
Q

A clouding of the lens that causes blurry, decreased, or loss of vision.

A

Cataract

130
Q

What device is used to measure intraocular pressure?

A

Tonometry

131
Q

The buildup of intraocular pressure that damages the eye’s optic nerve causing loss of peripheral vision.

A

Glaucoma

132
Q

A deterioration of the central part of the retina causing loss of central vision.

A

Macular degeneration

133
Q

What is farsightedness referred to as?

A

Hyperopia

134
Q

What is nearsightedness referred to as?

A

Myopia

135
Q

What test is utilized to assess central vision?

A

Amsler’s Grid

136
Q

What is unequal size of pupils referred to as?

A

Anisocoria

137
Q

What is the largest part of the brain?

A

Cerebrum (composes about 2/3 of brain mass)

138
Q

How many lobes of the brain are there?

A

4 (Front, Temporal, Parietal, Occipital)

139
Q

What are the two pathways of the CNS?

A

Sensory and Motor

140
Q

How many cranial nerves are there?

A

12

141
Q

What cranial nerves emerge from the cerebrum?

A

The first and second pairs

142
Q

Where do the remaining 10 cranial nerve pairs emerge from?

A

The brain stem

143
Q

How big is the spinal cord?

A

45 cm

144
Q

How many pairs of spinal nerves do humans have?

A

31

8 cervical; 12 thoracic; 5 lumbar; 5 sacral; 1 coccygeal

145
Q

What two tests can be performed to assess a patient’s level of consciousness/mental status?

A

Mini-Mental State Exam (MMSE) or Glasgow Coma Scale

146
Q

Mnemonic for cranial nerves functions

A 
I. Some  (sensory)
II. Say (sensory)
III. Marry for (motor)
IV. Money (motor)
V. But (both)
VI. My (motor)
VII. Big (both)
VIII. Brother (both)
IX. Says (sensory)
X. Brains (both)
XI. Matter (motor)
XII. More (motor)

Health Assessment (7 decks)

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