Test 3 Flashcards
1
Q
What eye structure is defined as uniform color, muscle controls the size of the pupil?
A
Iris
2
Q
The distance between the upper and lower eyelids is called:
A
Palpebral fissure
3
Q
What color should the sclera be?
A
White
4
Q
What is the structure assessed by pulling down the lower eyelid as the patient looks up?
A
Conjunctiva
5
Q
What is a drooping eyelid called?
A
Ptosis
6
Q
The patient tells the nurse that the room is spinning around them. Dysfunction of which cranial nerve might cause this?
A
Acoustic
7
Q
What substance is found in the external ear canal and protects the ear from foreign bodies and irritants?
A
Cerumen
8
Q
Swollen tonsils that touch the uvula are graded ______.
A
4+
9
Q
The dorsal surface of the tongue should be symmetrical, midline, moist, pink and _______.
A
Rough with papillae
10
Q
The cranial nerve responsible for movement of the eyeballs are the oculomotor, trochlear, and _________.
A
Abducens
11
Q
What is another name for the acoustic nerve?
A
Vestibular cochlear
12
Q
What is orientation x2?
A
- Name
- Location
13
Q
What are the four assessing techniques when assessing head and neck?
A
- interview
- inspection
- palpation
- percussion/auscultation (very rare)
14
Q
What is the normal symmetry for a skull noted as?
A
Normocephalic
15
Q
What body part tells so much about the condition of a patient?
A
The face
16
Q
How should skin appear on a head and neck assessment?
A
- Smooth
- Dry
- In tact (Free of lesions)
- Color uniform
17
Q
How should the neck appear on a neck assessment?
A
Erect and straight
18
Q
What should be palpated in a head and neck assessment?
A
Lymph nodes
19
Q
How are carotid arteries graded?
A
With the same grading scale as any other pulse
20
Q
Where can the carotid artery be found?
A
Anterior to the sternocleidomastoid muscle
21
Q
What vertebrae is the large boney prominence at the base of the neck?
A
C7
22
Q
What is the normal finding for lymph nodes?
A
None found
23
Q
If a lymph node is palpable, what should its size be?
A
Less than 1 cm (soft and mobile)
24
Q
What does the enlargement of a lymph node indicate?
A
Infection or dysfunction (ie: cancer)
25
What is the name for enlarged lymph nodes?
Lymphadenopathy
26
What are considered peripheral nerves?
Cranial nerves
27
Why do we assess cranial nerves?
- possibility of stroke
- head injury
- encephalitis
- meningitis
28
What illnesses influence the cranial nerves and cause change?
- Parkinson’s disease
- Multiple sclerosis (causes nerve sheath)
- Diabetes with peripheral neuropathy
- Hypertension
29
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
Facial Nerve
30
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?
Trigeminal Nerve
31
What nerve is assessed by checking the patient’s vision?
Optic nerve
32
What tests are performed in order to check a patient’s vision?
- Snellen Chart (letters)
- Peripheral vision
- PERRLA (Pupils Equal Round Reactive to Light & Accommodates)
33
__________ is when light is shined from the side to identify the pupil reaction.
Direct reaction
34
___________ is when light is shined in 1 pupil and constriction happens in the eye, but the pupil in the other eye also constricts.
Consensual reaction
35
____________ means the pupils will change.
Accommodation
36
What nerve is assessed by performing the whisper test?
Acoustic (Vestibular Cochlear)
37
What 3 cranial nerves are assessed when checked for eyeball movement?
- Abducens
- Oculomotor
- Trochlear
38
What is the Six Cardinal Points of Gaze test?
Moving a light and having patient’s eyes follow for six different directions
39
What cranial nerve is assessed when having the patient stick out his/her tongue and moving it side to side?
Hypoglossal
40
What cranial nerve is assessed when having the patient stick out their tongue and say “ah”?
Glossopharyngeal
41
What nerve innervates the uvula?
Glossopharyngeal
42
What nerve is assessed by having the patient swallow?
Vagus
43
What nerve is assessed by having the patient shrug their shoulders?
Accessory
44
Which cranial nerve is assessed by having the patient smell something?
Olfactory
45
What is cranial nerve I?
Olfactory
46
What is cranial nerve II?
Optic nerve
47
What is cranial nerve III?
Oculomotor
48
What is cranial nerve IV?
Trochlear
49
What is cranial nerve V?
Trigeminal
50
What is cranial nerve VI?
Abducens
51
What is cranial nerve VII?
Facial nerve
52
What is cranial nerve VIII?
Vestibular cochlear (acoustic)
53
What is cranial nerve IX?
Glossopharyngeal
54
What is cranial nerve X?
Vagus
55
What is cranial nerve XI?
Accessory
56
What is cranial nerve XII?
Hypoglossal
57
Where are the frontal sinuses located?
Above the eyebrows
58
What are the maxillary sinuses located?
On either side of the nose
59
Why do we palpate sinuses?
To determine if there is infection?
60
What condition is characterized by: swollen puffy eyes, congestion, colorful drainage, pain or discomfort in the face, and headaches?
Sinus infection
61
What kind of headache is usually over the forehead, side of the head, or at the base of the skull?
Tension headache
62
What type of headache can come from clenching teeth together?
Tension headache
63
What type of headache comes from a viral infection or from allergies?
Sinus headache
64
What type of headache is usually accompanied by a respiratory infection and runny nose?
Sinus headache
65
What type of headache is localized?
Cluster headache
66
What type of headache is typically timetable? (Ex: Happens between 12-3 and then again 12 hours later)
Cluster headache
67
What are the two types of vascular headaches?
- Cluster
| - Migraine
68
What type of chronic headaches cause vascular constriction?
Migraines
69
What type of headache is accompanied by photophobia, nausea, and vomiting?
Migraine
70
What type of headache can present with an aura?
Migraine
71
What are the nursing diagnoses for headaches?
- Acute Pain
| - Impaired comfort
72
What are the nursing diagnoses for enlarged thyroid?
- Impaired swallowing (w/fear of choking)
| - Ineffective airway clearance
73
What is the distance between the upper and lower eyelid called?
Palpebral fissure
74
What the name for a drooping eyelid?
Ptosis
75
When assessing the cornea, what is the normal finding?
Clear
76
Which cranial nerve is responsible for moving the eye laterally?R
Abducens
77
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?
Torticollis
78
What muscles form the iris?
Ciliary
79
Damage to _________ can alter pupil size?
Ciliary muscles
80
What sinuses are not palpable?
Ethmoid and Sphenoid
81
What are the largest salivary glands?
Parotid glands
82
Where are the parotid glands located?
Superficial to and behind the mandible
83
Where are the submandibular salivary glands located?
Within the lower mandible
84
What regulates the pupil size and movement?
The iris
85
How should the sclera appear on an assessment?
White to pale yellow
86
What does blue sclera on an adult indicate?
Indicate intraocular pressure which damages the retina
87
What does blue sclera on a newborn indicate?
Normal finding (for awhile)
88
What is the normal finding of the conjuctiva?
Pink and no drainage
89
What is the abnormal finding of conjuctiva?
Bright pink, red, cyanosis, jaundice, shot with capillaries, drainage
90
What color will the sclera appear in conjuctival jaundice?
Yellow
91
What color does the conjuctiva turn in a patient suffering from cyanosis?
Lavender
92
Lack of color in the conjunctiva is called ___________.
Conjunctiva pallor
93
Patient’s ________ status can be assessed by checking the patient’s eyes.
Hydration
94
What are some of the subjective questions when assessing the nose?
- Any pain
- Any drainage
- Change of smell
- Breath out of both nostrils equally
95
The septum should be _________.
Midline
96
How can inflammation of the nasal passages be identified?
By red rim around nostrils
97
Why is a deviated septum significant to a nurse?
The larger nostril should be used when placing an NG tube
98
What are the subjective questions when performing an ear assessment?
- Pain
- Hearing Changes
- Drainage
99
What is the normal finding of the ear assessment?
- Top of ear is at same level as corners of eye
- No drainage
- Patent
100
What refers specifically to the feeling of spinning?
Vertigo
101
Umbrella term for a state of imbalance
Dizziness
102
How can vertigo or dizziness be assessed?
- Romberg test
| - Head tilt
103
How can hearing be assessed?
Whisper test
104
How can the symmetry of the nose be assessed?
By looking at the nasolabial fold
105
When looking at the ventral side of the tongue, what are we assessing?
- Veins
- Most and shiny
- Pools of spit (sublingual salivary glands)
106
What condition can be assessed by looking at the hard palate?
Jaundice
107
Where should the uvula appear when doing a throat assessment?
Midline
108
What grade would tonsils seen behind the anterior pillars receive?
1+
109
What grade would tonsils receive if they are touching the uvula?
4+
110
When assessing the thyroid and finding an enlargement, what is this called?
Goiter
111
An abnormally large head is called _______
Macrocephaly
112
What is the only moveable bone of the face?
The mandible
113
Edema of the lips
Angioedema
114
Inflammation at the corners of the mouth (crackers corners of the lips)
Angular chelitis
115
What is the normal size of the ear?
4-10 cm
116
What should the angle of attachment of the ear be?
Less than 10 degrees
117
What is macrotia?
Abnormally large ears (greater than 10 cm)
118
What are hard, whitish or cream-colored non tender deposits of uric acid crystals (indicative of gout) on the ear called?
Tophi
119
What is another name for middle ear hearing loss?
Conductive hearing loss
120
What is another name for inner ear hearing loss?
Sensorineural hearing loss
121
The Weber and Rinne test is used to assess which cranial nerve?
Cochlear (XIII)
122
What medical device is used to inspect the external auditory canal, middle ear and eardrum?
Otoscope
123
Inflammation of the outer ear causing redness, inflammation, discharge and pain; can be related to infection or swimmer’s ear
Ostitis externa
124
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
Otitis media
125
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.
Serous otitis media
126
Fungal infection of the external auditory canal
Otomycosis
127
A ruptured tympanic membrane; a dark oval hole will be present in the membrane
Perforated tympanic membrane
128
How many muscles attach to the sclera to control eye movement, secure the eyeball to the socket, and allow sight in different directions?
Six
129
A clouding of the lens that causes blurry, decreased, or loss of vision.
Cataract
130
What device is used to measure intraocular pressure?
Tonometry
131
The buildup of intraocular pressure that damages the eye’s optic nerve causing loss of peripheral vision.
Glaucoma
132
A deterioration of the central part of the retina causing loss of central vision.
Macular degeneration
133
What is farsightedness referred to as?
Hyperopia
134
What is nearsightedness referred to as?
Myopia
135
What test is utilized to assess central vision?
Amsler’s Grid
136
What is unequal size of pupils referred to as?
Anisocoria
137
What is the largest part of the brain?
Cerebrum (composes about 2/3 of brain mass)
138
How many lobes of the brain are there?
4 (Front, Temporal, Parietal, Occipital)
139
What are the two pathways of the CNS?
Sensory and Motor
140
How many cranial nerves are there?
12
141
What cranial nerves emerge from the cerebrum?
The first and second pairs
142
Where do the remaining 10 cranial nerve pairs emerge from?
The brain stem
143
How big is the spinal cord?
45 cm
144
How many pairs of spinal nerves do humans have?
31
| 8 cervical; 12 thoracic; 5 lumbar; 5 sacral; 1 coccygeal
145
What two tests can be performed to assess a patient’s level of consciousness/mental status?
Mini-Mental State Exam (MMSE) or Glasgow Coma Scale
146
Mnemonic for cranial nerves functions
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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)
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