Health Assessment3

Documentation: "A diamond-shaped opening is visible between the two fingernails, indicating a nail angle of at least ____ degrees."

160

Approximately ____ lymph nodes are in the head and neck region, serving as part of the immune system.

80

Which of the following teaching points would the nurse emphasize related to eye health? A.Always wear eye protection for occupational exposures. B.Eat a diet high in animal protein and dairy. C.Exercise five times a week for at least 20 minutes. D.Get at least 7 hours of sleep each night.

A.Always wear eye protection for occupational exposures.

Which of the following are appropriate interventions for the patient who is at risk for ear infection? Select all that apply. A.Be current on immunizations. B.Avoid secondhand smoke. C.Clean only external ear. D.Have audiogram yearly

A.Be current on immunizations. B.Avoid secondhand smoke. C.Clean only external ear.

The inner ear A.contains the malleus, incus, and stapes. B.conducts sound waves to the external ear. C.translates sound to the nerves and brainstem. D.provides the body with proprioception

A.contains the malleus, incus, and stapes.

_______ Inequality of pupil size Normal finding, or CNS disease

Anisocoria

_______ may be anular, arciform, iris, linear, polymorphous, punctuate, serpiginous, nummular/discoid, umbilicated, filiform, or verruciform

Configurations

A patient presents with a complaint of drooping of his eyes, cheeks, and mouth on one side. This finding is most likely associated with pathology of which cranial nerve?

Cranial nerve V

Hearing ________ are the measurement units of amplitude.

Decibels

_______ lesions arise from previously normal skin and include maculae, papules, nodules, tumors, polyps, wheals, blisters, cysts, pustules, vesicles, and abscesses.

Primary

The cardinal fields of gaze assessment allows you to detect _____ ____ that cause misalignment or uncoordinated eye movements.

muscle defects

Objective data What are you looking for when Inspect nasal cavity?

+Mucosa ---Dark pink & smooth without swelling +Septum ---Midline, straight and intact ---Suspect cocaine abuse for perforations +Turbinates ---Swollen & red = possible upper respiratory infection (URI) ---Pale & boggy = chronic allergies -------Nasal polyps are smooth, pale, benign growth found in many patients with chronic allergies

Intraocular structures What are the Three layers of tissue?

+Sclera and cornea +Uvea ---Iris, ciliary body and choroid +Retina ---Optic disc ---macula

What are Some issues that indicate an acute assessment?

+Severe epistaxis +Ludwig angina +Infection in floor of mouth; edema leads to obstruction +Abrupt loss of smell +May indicate brain tumor; MRI for evaluation +Hard, fixed nodes could indicate cancer +Aspiration of loose teeth or foreign body

When Documenting Abnormal Findings for nose throat and mouth?

+Use appropriate medical terminology +Address buccal mucosa and area under tongue +Mention posterior palate and tonsils +Address both inspection and palpation

What are some labs and diagnostic tests for nose, throat, and mouth?

+White blood count +Culture and sensitivity +Biopsy ---Fine needle ---Incisional +X-ray (nose, sinuses, teeth) +CT scan (nose, sinuses) ----CT scan is the gold standard for diagnosing sinus disease +Laryngoscopy +Sleep study

Lymphatics larger than ____ cm, fixed, irregular or hard or rubbery require emergency investigation!

1

What is the grading scale for enlarged tonsils?

1+ tonsil obstructs 0-25% to midline 2+ tonsil obstructs 25-50% to midline 3+ tonsil obstructs 50-75% to midline 4+ tonsil obstructs 7o5-100% to midline

What is the 3 basic test that assess the movement of the extraocular muscles?

1. The corneal light reflex (Hirschberg test) 2. The cover test 3. The cardinal fields of gaze test

NURSING DIAGNOSES Impaired skin integrity related to pressure sore on clients left heel NI: Turn or alternate client's position at least every ____ hrs.

2

Sunscreen must be applied every ___ hours for maximum benefit.

2

Which of the following scores for distance vision indicates the patient with the poorest vision? A.200/20 B.18/20 C.24/20 D.20/100

20/100

A fair-skinned, blonde, 18 year old woman is at the clinic for a skin examination. She reports that she always truns red within 10 minutes of going outside. She is planning a trip to Mexico and wants to avoid getting sunburned. Which of the following would be included in the teaching? A. Excessive exposure to UVA and UVB rays increases risk of sunburn and skin cancer B. Apply a sunscreen or sunblock at least 51 to 30 minutes before sun exposure C. Avoid sun exposure between 10 am and 4 pm to reduce UVA and UVB exposure D. A mild sunburn is acceptable in a fair-skinned blonde person.

A mild sunburn is acceptable in a fair-skinned blonde person.

Which of the following patients is most likely to have hearing loss? A.Caucasian man older than 70 years of age B.Hispanic woman older than 50 years of age C.Asian man younger than 30 years of age D.African American girl younger than 10 years of age

A.Caucasian man older than 70 years of age

Risk factors for hearing loss include which of the following? Choose all that are correct. A.Frequent ear infections B.Being current on immunizations C.Exposure to smoke D.Decreased age

A.Frequent ear infections C.Exposure to smoke

Cues of hearing loss include which of the following? Choose all that are correct. A.Using a loud or monotonous voice B.Asking to repeat questions C.Concentrating on lip movement D.Leaning forward to hear

A.Using a loud or monotonous voice B.Asking to repeat questions C.Concentrating on lip movement D.Leaning forward to hear

The function of the ear is for A.hearing and equilibrium. B.equilibrium and perforations. C.perforations and balance. D.balance and equilibrium

A.hearing and equilibrium.

The nurse recognizes that the 60-year-old patient may have difficulty reading fine print because of A.the loss of accommodation. B.anisocoria. C.amblyopia. D.asthenopia.

A.the loss of accommodation.

Documentation" Is this describing normal or abnormal skin turgor? "A persistent pinch, or tenting, indicates dehydration."

Abnormal

What assess is this Acute airway obstruction may limit the opportunity for data collection other than specifics related to current client status?

Acute Assessment

The thyroid cartilage is larger, shield shaped, and in the mid-neck; it is sometimes referred to as the _____ _____ in males.

Adam's apple

Lifespan Considerations: What is the abnormal/rationale findings to these questions: Do you have a history of diabetes, glaucoma, or high blood pressure?

Aging increases risks for visual complications related to other chronic diseases that affect blood vessels in the retina and fluid in the eye

Air and Bone Conduction ______, the most efficient method, is the normal pathway for sounds to travel to the inner ear.

Air Conduction

Hearing _______ is the change in atmospheric pressure against the TM and is directly related to the intensity of a sound.

Amplitude

Palpable, tender, and warm lymph nodes usually indicate an infection in the area from which the lymph vessels drain to that node ____ _____ nodes: pharyngitis

Anterior cervical

____ ______ _____-deep under the sternocleidomastoid muscle

Anterior cervical chain

What is the ABCDE'S ASSESSMENT OF MELANOMA?

Asymmetry Border irregularity Color Diameter of more than 6 mm Evolution of lesion over time

Diagnostic Testing, Hearing What is a simple screening device consists of headphones and a box that delivers tones to each ear at variable frequencies and volumes?

Audiometer

Which of the following patients would require immediate nursing care? A.An 8-year-old girl with pink conjunctivae and drainage B.A 20-year-old man with sudden visual loss after playing football C.A 52-year-old woman with clouding of vision D.A 77-year-old man with loss of vision in his peripheral fields

B.A 20-year-old man with sudden visual loss after playing football

The cranial nerves involved with eye movement include A.II, V, and VII. B.III, IV, and VI. C.IV, V, and VIII. D.V, VI, and VII.

B.III, IV, and VI.

The nurse assesses the response of the eye to light and documents normal findings as A.PEERLA. B.PERRLA. C.PERLLA. D.PERLAA.

B.PERRLA.

A public health nurse is performing annual vision screening for residents in senior housing. Which of the following charts would the nurse most likely be using? A.Allen chart B.Snellen chart C.Ishihara cards D.Confrontation cards

B.Snellen chart

A nursing diagnosis appropriate for a patient with ear problems is A.kinesthetic disturbed perception. B.disturbed sensory perception. C.sensory perception, gustatory. D.olfactory sensory perception

B.disturbed sensory perception.

Cultural and environmental considerations What is Minor cleft of posterior soft palate, found in 1/250 people?

Bifid uvula

_____ of skin tissue is indicated for those disorders that manifest changes in color, size, or shape.

Biopsy

The ABCDEs of melanoma identification include (select all that apply) A Asymmetry B. Birthmark C. Color D. Diameter

Birthmark

Air and Bone Conduction _______ uses a different pathway, bypassing the external ear and delivering sound waves/vibrations directly to the inner ear through the skull.

Bone Conduction

A score of 14 -18 on the ______ Scale or less than 14 on the Norton Scale indicates a high risk of pressure ulcer development.

Braden

______ are most often associated with a toxic goiter, hyperthyroidism, or thyrotoxicosis

Bruits

______ are classified based on depth of tissue destruction and percentage of total body surface area (TBSA) affected.

Burns

When working with an older adult, what would the nurse emphasize as increased risks for the patient? A.Myopia and strabismus B.Blepharitis and chalazion C.Glaucoma and cataracts D.Exophthalmos and presbyopia

C.Glaucoma and cataracts

Peripheral vision is evaluated by the nurse using the A.corneal light test. B.cover test. C.confrontation test. D.cardinal fields of gaze test.

C.confrontation test.

Tinnitus is described as A.inability to hear well. B.dizziness. C.ringing in the ear. D.ear pain

C.ringing in the ear.

Stand behind the patient to palpate the cervical spine and neck. ___ and ____ spinous processes should be prominent.

C7 T1

What cranial nerve controls the oculomotor?

CN III

What cranial nerve controls; Lateral (Toward Temple) Elevation, abduction

CN III

What cranial nerve controls; Medial (Toward Nose) Elevation, adduction Depression, abduction

CN III

What cranial nerve controls the trochlear?

CN IV

What cranial nerve controls; Lateral (Toward Temple) Depression, abduction

CN IV

What cranial nerve controls the abducens?

CN VI

What cranial nerve controls; Lateral (Toward Temple) Abduction

CN VI

Evaluation of headaches may include what 3 test?

CT MRI Lumbar puncture

The assessment of Cranial Nerves, what is check when Cranial Nerve IV, Trochlear is observed? and VI Abducens

Cardinal Fields of gaze

_______ formation continues over the lifespan, which may make ears seem more prominent in older adults.

Cartilage

What is an abnormal accumulation of squamous epithelium within the middle ear?

Cholesteatoma

The nurse is admitting a 75 year old man with a 50 year history of smoking one pack of cigarettes per day. Among the patient's concerns is his chronic shortness of breath. One nail finding that demonstrates chronic hypoxia is

Clubbing

______ is identified when the angle of the nail to the finger is more than 160 degrees. This indicates chronic hypoxia

Clubbing

Hearing Difficulties _______ hearing loss occurs when sound wave transmission through the external or middle ear is disrupted.

Conductive

_____-dried excretions

Crust

______ involves placement of a cup on the skin surface, and then applying heat to form a vacuum.

Cupping

Which of the following symptoms would the nurse expect the patient to report as translucent specks that drift across the visual field? A.Blind spot B.Ptosis C.Halo D.Floater

D.Floater

Which of the following differentiates the RN assessment from the APRN assessment? A.History and risk factors B.Symptom analysis C.Inspection and palpation D.Otoscopic assessment

D.Otoscopic assessment

Which of the following is an outcome appropriate for a patient with hearing impairment? A.Provide a communication board or picture to assist teaching. B.Minimize background noise and close door. C.Stand in front of patient and explain procedure. D.Patient explains plan to accommodate hearing impairment

D.Patient explains plan to accommodate hearing impairment

Infants and children Infants are nose-breathers Senses of smell and taste present at birth __________ teeth present by 2 ½ years of age Permanent teeth present by age 12-13 years

Deciduous

______ vascular supply is often initially found in the extremities, particularly the hands and feet.

Decreased

What is the diagnosis? "Wears eyeglasses, uses contacts, uses computer assistive devices"

Disturbed sensory perception

While examining the patient's neck, the nurse finds the trachea midline but has difficulty palpating the thyroid. What action would the nurse take next?

Document this finding as normal.

What are some abnormal findings for nose, throat and mouth?

Epistaxis Rhinitis Sinusitis Deviated Septum Nasal Polyps Perforated Septum Black Hairy Tongue Gingival Hyperplasia / Gingivitis Tonsillitis Smooth Tongue Carcinoma Leukoplakia Enlarged tonsils

________ can be assessed by using the Romberg test

Equilibrium

______-lesion resulting from scratching or excessive rubbing

Excoriation

INSPECTION ______ features +Symmetry and size +Nasolabial folds are symmetric

Facial

What are some Common mouth and upper respiratory symptoms?

Facial pressure, pain, headache Snoring and sleep apnea Obstructive breathing Nasal congestion Epistaxis Halitosis Anosmia Cough Pharyngitis Dysphagia Dental pain Voice changes Oral lesions

Physical examination of a patient reveals an enlarged tonsillar node. Acutely infected nodes would be

Firm but movable and tender

Hearing ________, the number of cycles per second the sound waves make, is measured in units of hertz (Hz)

Frequency

Objective Data WHen transilluminating the sinuses. ______ = There should be a red glow over the frontal sinus area _______ = There should be a red glow on the hard palate

Frontal Sinus Maxillary Sinus

What is clear rhinorrhea stimulated by smell and taste of food? (nasal drainage when they smell food)

Gustatory rhinitis

EXAMPLE NARRATIVE NOTE _______: Client hair is thick, silky, evenly distributed on head. Client does have variable amount of body hair. No signs of infection or infestation observed.

Hair

INSPECTION ______ +Distribution and quantity +Texture +Cleanliness

Hair

INSPECTION ______ +Centered +Proportional to body, erect, without tics, tremors, unusual movements

Head

_______ -excessive hairiness in women. Can develop on body and face-affecting persons self image.generalized hirsutism can result from certain drug therapies or from endocrine problems (ovarian dysfunction): Cushings syndrome and acromegaly.

Hirsutism

What are these symptoms for? Do you have any of these symptoms: fatigue; weight loss; anxiety; palpitations; rapid pulse; heat intolerance; fine, limp hair; diaphoresis; muscle weakness?

Hyperthyroidism

What are these symptoms for? Do you have any of these symptoms: fatigue; anorexia; cold intolerance; dry skin; brittle, coarse hair; menstrual irregularities; weight gain or difficulty losing weight; decreased libido?

Hypothyroidism

_____ _____: turns the eye upward and abducts and turns the eye laterally

Inferior oblique

_____ ______: rotates the eye downward and adducts and rotates the eye medially

Inferior rectus

______ each fingernail and toenail. Assess for color, thickness, and consistency.

Inspect

These are common ______ symptoms •Pruritus •Rash (multiple lesions) •Single lesion or wound

Integumentary

_______ structures Three chambers Anterior chamber Posterior chamber Vitreous chamber

Intraocular

Color vision is assessment using ______ cards.

Ishihara

Lifespan Considerations: What is the abnormal/rationale findings to these questions: Do you have any trouble managing your usual activities because of vision changes? Have you stopped doing any activities because of vision changes?

It is important to focus on any visual impairment and how the patient functions with it.

The _____ chart is used to assess near vision.

Jaeger

A 22 year old patient presents to the clinic with a large firm mass on her left earlobe. She had her ears pierced approximately 3 weeks ago. The mass began as a small bump and progressively enlarged to its current size of approximately 2.5 cm (1 in) in diameter. It is not tender, reddened, or seeping any drainage. What is the term used to describe this secondary skin lesion?

Keloid

(Static / Kinetic) Confrontation: Patient looks ahead. Ask the patient to say now when your fingers come into view of the quadrates. Do this in all 4 quadrants.

Kinetic

____ _____: moves the eye laterally (toward the temple)

Lateral rectus

______ from contact or allergic dermatitis are usually on the body part exposed to an irritant or allergen.

Lesions

________ from trauma may be petechiae, purpura, ecchymoses, hematomas, lacerations, abrasions, puncture wounds, or avulsions.

Lesions

_________ is condition of firmly attached, white patchy lesions with well-defined borders; from chronic irritation, smoking, excessive alcohol use.

Leukoplakia

If the lymph node is palpable, what question is this describing? "which lymphatic chain and where along that chain is the node"

Location

_____ ____ larger than 1 cm, fixed, irregular, hard, or rubbery require emergency investigation. Such signs raise the possibility of cancer.

Lymph nodes

Methicillin-resistant Staphylococcus aureus (____) is an organism that may be found in wounds.

MRSA

_______ lesions could be ecchymosis, pressure point, or tinea versicolor.

Macular

Objective Data What are some preparation for doing a assessments for nose, mouth, and throat?

Make client comfortable Wear gloves Have client remove dentures

______ _____: moves the eye medially

Medial rectus

______ < 2mm (fails to dilate in the dark) Morphine, drugs for glaucoma, stroke that affects brainstem

Miosis

All of the following skin lesions are papular except A. warts B. Ance C. Moles D. Herpes zoster

Moles

Objective Data When Inspecting & palpating the buccal mucosa, gums, & tongue, what are you looking for?

Mucosa & gums should be pink, moist, and smooth Tongue should be pink and moist with papillae on the dorsal surface

_______ >6mm (fails to constrict with light) Coma, brain trauma, atropine, fright (sympathetic nervous system)

Mydriasis

Documentation: "_____ are smooth, translucent, and consistent in color and thickness. Longitudinal ridging is common in aging patients. Longitudinal pigmentation in dark-skinned patients is a normal variant."

Nails

EXAMPLE NARRATIVE NOTE ______: Client has light brown nails with convex curve shape. Nails are smooth and intact with the epidermis. Capillary refill < 3 seconds.

Nails

C7 spinous process (vertebra prominens)

Name this structure

_____ pain associated with fever and headache may signify serious illness such as meningitis

Neck

_____ pain, a common symptom, is most often related to muscle tension or spasm.

Neck

Are these normal or abnormal findings? "Hair evenly distributed, clean, brown. Scalp with even coloration, skin intact. Cranium size proportional to body, symmetrical. Face with symmetrical movement of facial muscles. Skin smooth, consistent color, intact. Neck with full range of motion, symmetrical. Lymph nodes and salivary glands nonpalpable, nontender. Thyroid gland palpable midline, symmetrical, smooth, rubbery, and nontender. Thyroid isthmus midline. No bruit."

Normal

Is this normal or abnormal findings? "Patient alert and following conversation with no evidence of hearing loss. Denies hearing difficulty, vertigo, tinnitus, and otalgia."

Normal

Is this normal or abnormal findings? Denies pain, trauma, visual changes, blind spots, floaters, halos, and discharge. No changes in ability to perform ADLs.

Normal

Is this normal or abnormal findings? Eyebrows full and appropriate to age. Eyelashes evenly distributed. Blinking every 2-3 seconds. Eyes round, symmetrical, and in parallel alignment. Lacrimal apparatus not enlarged or tender. Conjunctiva with small vessels visible. Sclera clear and white. Lens is transparent. Iris is brown, smooth, and without vascularity. PERRLA.

Normal

Is this normal or abnormal findings? Inspection "The head is centered, proportional to the body (1/7), erect, and without tremors, tics, or unusual movements. The cranium is round without obvious deformities. The neck muscles are symmetrical."

Normal

Are these normal or abnormal findings? "Patient reports no unusual, severe, or frequent headaches. Denies loss of neck mobility or neck pain. Denies any lumps or masses in the neck. Reports no difficulties with fatigue, weight change, temperature discomfort, skin changes, sweating, or other unusual findings."

Normal findings

Not a question, just a picture of the outer ear.

Not a question, just a picture of the outer ear.

_______ assessment of the skin is performed in a head-to-toe format if the patient is seeking a complete skin assessment, usually in a dermatology clinic for cancer screening.

Objective

________-base of the skull

Occipital

______ adults Gustatory rhinitis Decrease in saliva production and number of taste buds Resorption of gums and mandible bone tissue Loss of teeth Malocclusion can exacerbate pain from Temporomandibular joint (TMJ) dysfunction

Older

Lifespan Considerations: What is the abnormal/rationale findings to these questions: When did you last have a test for glaucoma?

Older adults are at increased risk; glaucoma screening is not recommended by primary care providers for older adults without vision problems

Healthy People goals What goals are these? Decrease number of people with untreated dental caries Reduce incidence of periodontitis Increase early detection of oral/pharyngeal cancer Increase number of people who use preventive services in oral healthcare system annually Increase number of oral health services in local communities

Oral

__________ = lymphatic tissue hypertrophy may occur in tonsils and adenoids in response to chronic infections (sinusitis, otitis media), and might cause airway obstruction.

Oropharynx

______ results from the slow fusion of any combination of the ossicles in the middle ear

Otosclerosis

Objective Data What are some Equipment needed to assesses nose, mouth and throat?

Otoscope, Nasal speculum, Tongue blades, Cotton gauze, Gloves, Penlight, Scents to identify

_____ lesions for tenderness, mobility, and consistency. Apply gentle pressure and attempt to move the skin under your finger.

Palpate

_______ lesions may indicate acne, warts, nevi, insect bites, or early varicella.

Papular

A nurse observes a skin lesion with well-defined borders on the upper left thigh. It is 1.5 cm in diameter, flat. hypopigmented, and nonpalpable. WHat is the correct terminology for this lesion?

Patch

COMMON LABORATORY AND DIAGNOSTIC TESTING: +Scraping +Culture and sensitivity +_____ test +Biopsy

Patch

Documentation ______ denies pruritus, skin lesions, excessive dryness of skin. Denies changes to existing moles.

Patient

_______ include asymmetrical, confluent, diffuse, discrete, generalized, grouped, localized, satellite, symmetrical, or zosteriform

Patterns

_____ lesions are commonly psoriasis or lichen simplex.

Plaque

Which of the following best describes the instructions the nurse should give a patient when assessing the thyroid from the posterior approach?

Please tilt your head slightly down and to one side.

______ _____-behind the ear, superficial to the mastoid process; otitis media

Posterior auricular

Palpable, tender, and warm lymph nodes usually indicate an infection in the area from which the lymph vessels drain to that node ______ _____ nodes: mononucleosis

Posterior cervical

____ _____ ______-along the edge of the trapezius muscle

Posterior cervical chain

_______-in front of the ear

Preauricular

The lymph nodes that lie in front of the mastoid bone are the

Preauricular nodes

________, a common form of sensorineural loss, results from gradual degeneration of nerves and sensory hair cells of the organ of Corti.

Presbycusis

_______ lesions may be further described as nonelevated, elevated-solid, or fluid-filled.

Primary

_______ lesions include acne, furuncles, and carbuncles.

Pustular

A patient has several red, inflamed, superficial, palpable lesions containing a thickened yellowish substances. How would the nurse document this lesion? A. Papule B. Pustule C. Cyst D. Vesicle

Pustule

______ assessment of the eye involves assessing for foreign bodies, lacerations, or hyphema (blood in the anterior chamber of the eye); and testing extraocular movements.

Rapid

____ and fever in a patient should raise suspicion of an infectious process.

Rash

While assessing a patient, the nurse finds a palpable lymph node in the left supraclavicular region. Which of the following should be the next action?

Recognize that it is not common to palpate lymph nodes in this region and they must be carefully evaluated.

Risk Assessment and Health-Related Patient Teaching What are some Smoking is a major risk?

Respiratory inflammation Allergic rhinitis Chronic sinusitis Head and neck cancer

The ______ test examines the difference between BC and AC. 1. Place the base of the handle on the patient's mastoid process 2. Instruct the patient to tell you when he or she no longer hears the sound of the fork. Note the number of seconds. 3. move the tip of the tuning fork to the front of the external auditory 4. Instruct the patient to inform you when he or she no longer hears the sound.

Rinne

What is the diagnosis? "Near or far vision impaired, difficulty seeing in low lighting, difficulty seeing at night"

Risk for Injury

Inspection No visible Swelling, Pulsations, thyroid gland or lymph node Enlargement, Neck masses, venous Distention (______) This represents what?

SPEND

The ______ is defined as the amount of time a product protects the skin from reddening, as compared to the amount of time for unprotected skin to redden

SPF

What gland Begin digestion Xerostomia; decreased salivary flow Aging, damage to glands, emotions Blockage of the parotid duct Increases chance of periodontal disease due to pH imbalance and precipitation of calcium

Salivary Glands

A 24 year old patient reports an itchy red rash under her breasts. Examination reveals large, reddened, moist patches under both breasts in the skin folds. Several smaller, raised, red lesions surround the edges of the larger patch. What is the correct terminology for the distribution pattern of these smaller lesions?

Satellite

_____ lesions follow primary lesions (e.g., scar tissue, crusts from dried burns).

Secondary

What helps patients identify potentially problematic lesions through the detection of moles?

Self Skin-Examination (SSE)

_______ hearing loss results from a problem somewhere beyond the middle ear, from inner ear to auditory cortex. Sites of dysfunction include the cochlea, organ of Corti, auditory nerve, and auditory cortex.

Sensorineural

Documentation "_____ temperature is consistently warm or cool and appropriate, considering the environmental temperature."

Skin

EXAMPLE NARRATIVE NOTE ______: Client skin uniform in color, unblemished and no presence of foul odor. good skin turgor.

Skin

Urgent Assessment ____ findings indicating dehydration, cyanosis, or impaired skin integrity (acute lacerations) require prompt evaluation and intervention with fluids, oxygen administration, skin repair, or a combination.

Skin

Documentation: What is this describing? "The skin promptly recoils to its normal position."

Skin Turgor

Healthy People goals What goals are these? Further evolution of biomedical sleep research Quantification of health risks associated with SDB across lifespan Progress in U.S.-based phase III SDB treatment trials in children/adults

Sleep disordered breathing

Which of the following descriptions is most consistent with a patient who has hypothyroidism?

Slightly obese female with periorbital edema and a flat facial expression, who complains of constipation, deceased appetite, and fatigue

Risk Assessment and Health-Related Patient Teaching What are 3 health risk?

Smoking is a major risk Daily teeth brushing and flossing Dietary nutrition

The _____ E chart can be used for people who cannot read or speak English

Snellen

Air and Bone Conduction ______ is perceived in two ways: air conduction (AC) and bone conduction (BC)

Sound

______ of the head and neck is essential to avoid further neurological injury.

Stabilization

(Static / Kinetic) Confrontation: Close one eye, looking ahead and the nurse shows 1 to 4 fingers in all 4 quadrants.

Static

Person and Family history is (subject or objective) data.

Subjective

_______ data collection begins with the health history, continues with questions about specific eye conditions, and ends with detailed collection of information involving areas of concern.

Subjective

(Subject or object) data collect Assessment of risk factors +Family history +Personal history +Current health status +Medications and supplements +Dental health +Psychosocial history

Subjective Data Collection

_______-between the angle & tip of the mandible

Submandibular

_______-behind tip of mandible

Submental

_______ protection from clothing depends on how much skin is covered, fabric color, and fabric weave.

Sunburn

_______ absorb harmful UV rays; sunblocks deflect rays, preventing absorption.

Sunscreens

_____ ____: turns the eye downward and abducts (toward the temple) and rotates the eye laterally

Superior oblique

______ _____: elevates the eye upward and adducts (toward the nose) and rotates the eye medially (inward)

Superior rectus

What is the six extraocular muscles control eye movement and hold the eye in place in the socket?

Superior rectus Inferior rectus Lateral rectus Medial rectus Superior oblique Inferior oblique

Palpable, tender, and warm lymph nodes usually indicate an infection in the area from which the lymph vessels drain to that node ________ nodes: these must be carefully evaluated as a possible sign of metastatic cancer.

Supraclavicular

Palpable, warm lymph nodes=INFECTIONS ______ nodes: lung and abdominal cancers

Supraclavicular

________-just above and behind the clavicle, in the angle formed by the clavicle and sternocleidomastoid muscle

Supraclavicular

Objective Data WHat are you looking for when inspecting the nose?

Symmetry, shape, skin lesions, signs of infection

Lymph nodes

These is showing the location of what?

An 83 year old woman is undergoing a routine physical examination. Which of the following assessment findings would the nurse consider an expected age related variation? A. Thinning of the skin B. Increased skin turgor C. Hypopigmented flat macules and patches over sun exposed areas D. Multiple purplish bruised on the arms and legs

Thinning of the skin

Lifespan Considerations: What is the abnormal/rationale findings to these questions: Have you noticed any tunneling of your visual field?

This is a symptom of macular degeneration.

Lifespan Considerations: What is the abnormal/rationale findings to these questions: Have you ever had your eyes checked for glaucoma, cataracts, or other eye conditions?

This provides you with an opportunity to promote eye health.

Lifespan Considerations: What is the abnormal/rationale findings to these questions: Have you ever tripped or fallen because of changes in your vision?

This question assesses awareness and presence of visual impairments.

Palpation, Documentation ______ is smooth, rubbery, moveable, non-tender, symmetrical, and barely palpable beneath the sternocleidomastoid

Thyroid

_______ is a perception of buzzing or ringing in one or both ears that does not correspond with an external sound.

Tinnitus

Screening / RN Assessment: What is the purpose of this technique? Test cardinal fields of gaze.

To assess for movement of the eye in several planes of movement

Focused or Advanced Practice Examination What is the purpose of this technique? Test kinetic confrontation.

To assess the gross peripheral boundaries

Focused or Advanced Practice Examination What is the purpose of this technique? Perform cover test.

To assess the presence and amount of ocular deviation

Focused or Advanced Practice Examination What is the purpose of this technique? Assess color vision.

To evaluate ability to differentiate color Color Blindness

Screening / RN Assessment: What is the purpose of this technique? Test near vision.

To evaluate ability to read

Screening / RN Assessment: What is the purpose of this technique? Test distance vision.

To evaluate ability to see far, drive

Screening / RN Assessment: What is the purpose of this technique? Inspect external eyes

To evaluate for symmetry, redness, and obvious deformities

Screening / RN Assessment: What is the purpose of this technique? Inspect and palpate lacrimal apparatus and conjunctiva.

To evaluate swelling, tenderness

Screening / RN Assessment: What is the purpose of this technique? Test pupillary reflex.

To evaluate the pupil's response to direct and consensual light source

Focused or Advanced Practice Examination What is the purpose of this technique? Test static confrontation.

To screen for differences in the visual field from side-to-side and inferior and superior

Focused or Advanced Practice Examination What is the purpose of this technique? Test corneal light reflex.

To test for strabismus

Healthy People goals What goals are these? Implement policies to reduce tobacco use and initiation among youth/adults Increase access to smoking cessation treatment programs Establish policies to reduce exposure to second-hand smoke Increase cost of tobacco and advertising; restrict sale to minors

Tobacco use

________-at the angle of the mandible

Tonsillar

_______ of the sinuses is not a common assessment technique, when x-ray and CT scan are much more illustrative of problems.

Transillumination

______ is a measure of skin elasticity, decreases as a result of thinning of the dermis and reduced elastin production.

Turgor

______ waves are directly linked with skin cancers, especially basal cell and squamous cell cancers.

UVB

______-loss of skin surface, extending into dermis, subcutaneous, fascia, muscle, bone, or all

Ulcer

A patient presents to the clinic with erythematous vesicles on the face and chest. Some vesicles have broken open, revealing a moist, shallow, ulcerated surface; some have scabbed over. The nurse suspects which of the following infectious illnesses?

Varicella

______ lesions may be herpes simplex, varicella, or impetigo.

Vesicular

Intraocular structures _____ = Neural pathway

Vision

______ impairments can begin to affect the older adult's functional capacity, decreasing ability to drive and perform usual activities.

Visual

______ is characterized by areas of no pigmentation.

Vitiligo

The _______ test helps to differentiate the cause of unilateral hearing loss. After activating the fork, place its handle on the midline of the parietal bone in line with both ears

Weber

Objective Data When inspect the teeth, what are you looking for?

White with smooth edges & free of debris

The _____ light test may diagnose scalp infections caused by a particular group of spore-producing microorganisms.

Wood

_____ or incisions: describe wounds related to trauma; petechiae, purpura, ecchymoses, hematomas, lacerations, abrasions, puncture wounds, avulsions

Wounds

Usually NO lymph nodes are palpable in the ______

adult

Usually, no lymph nodes are palpable in the _____.

adult

Changes in the weather, seasons, and ozone layer _____ the intensity of UV rays

affect

Acute _______ intoxication can cause temporary blurred vision, pupil dilation, eye redness, double vision. Chronic alcohol abuse leads to permanently reduced vision because of a nutritional degeneration of the optic nerve.

alcohol

For the ______ approach, have the patient tilt the head slightly back. Locate the thyroid and cricoid cartilages.

anterior

Black hairy tongue may follow _______ therapy, or be from compromised immune system. Is a fungal infection.

antibiotic

The spores, located on hair strands, fluoresce _______ under the Wood light.

apple green

The most accurate way to evaluate hearing is by having an audiologist perform an _______ in a soundproof room.

audiogram

Hemotympanum, otorrhea, or tympanic membrane rupture may indicate _______ from pressure changes or a basilar skull fracture

barotrauma

AUSCULTATION +Use ____ of stethoscope to listen over carotid arteries. +Client holds breath +Listen for bruits +Might also auscultate thyroid area with bell +Check for bruit or soft rushing sound

bell

If the thyroid is enlarged, either unilaterally or bilaterally, auscultate over each lobe for a bruit using the _____ of the stethoscope

bell

Structures of the head and neck interact with multiple _______ systems—integumentary, neurological, musculoskeletal, respiratory, vascular, gastrointestinal, lymphatic, and endocrine.

body

Hearing The ________ detects origination of the sound and can distinguish from which ear the electrical impulses originated, even though there may be only a slight delay of sound from one ear to the other.

brainstem

The examiner should take care not to _______ in when inspecting infected throat.

breathe

Both natural and artificial forms of UV light are __________; exposure to UV light directly increases the risk of skin cancer

carcinogenic

Palpate the temporal artery in the space above the ______ near the scalp line.

cheekbone

Hearing The ______ interprets two components of sound: amplitude (volume) and frequency (pitch).

cochlea

A common practice among Southeast Asians is ______, in which they rub a coin or other object across the skin in a specific manner to treat various health concerns

coining

If the lymph node is palpable, what question is this describing? "how hard or soft is the node? It should be smooth and slightly soft."

consistency

The ______ test is for presence and amount of ocular deviation. The light level should be low, with no direct light sources shining in the patient's eyes. At rest, the extraocular muscles should have very little activity.

cover

As you proceed with inspection and palpation of the eye, assess for sensory and motor function of _____ ____ II, III, IV, and VI

cranial nerves

Intensity of UV waves is greatest during midday; exposure between 10 AM and 4 PM increases potentially ______ effects.

damaging

Delayed return of skin color to normal after direct pressure indicates ______ circulation. Altered circulation can result in pallor or rubor of an extremity.

decreased

UVA waves are longer and have _______ skin penetration than UVB waves

deeper

While assessing the skin of a 24-year-old patient, the nurse notes decreased skin turgor. The nurse should further assess for signs and symptoms of

dehydration

If the lymph node is palpable, what question is this describing? "There should not be any matting together of lymph nodes."

delimitation

Assess ______ visual acuity by having the patient read the Snellen or Allen chart

distance

Using the _____ surface of the hands, assess skin temperature.

dorsal

Reflection of UV waves off sand, concrete, snow, and water _______ UV exposure and its damaging effects.

doubles

The _____ is divided into three distinct portions: (1) the external ear, most of which is visualized easily without tools; (2) the middle ear, a small space behind the tympanic membrane (TM) extending to the pharyngotympanic (auditory) tube (formerly called the eustachian tube); and (3) the inner ear, the vestibular portion. All three portions contribute to the process of hearing.

ear

TERMINOLOGY +Lymph______-swelling +Lymph_______-inflammation +Lymph_____-disease or enlargement of lymph nodes

edema adenitis adenopathy

Adults older than 70 years of age face greater delays in the _______ responses in the brain; thus, it takes longer for the brain to interpret input.

electrical

The visual field refers to what in the ________ is visible when the eye fixates on a stationary object.

environment

Erosion-loss or ______ layer

epidermal

Hearing The ______ ear channels sound waves into the external auditory canal through the TM, to ossicles in the inner ear via the oval window, then to the cochlea.

external

These are ______ structures: +Support and protect +Eyelids +Palpebral fissure +Limbus +Conjunctiva +Lacrimal apparatus

extraocular

Nasolabial folds symmetric.  Client denies fatigue or sudden weight loss or gain.  No history of thyroid disease. Neck muscles equal in size.  Client showed coordinated, smooth head movement with no discomfort. All client lymph nodes are non palpable, non tender. Trachea palpates midline of the neck. Thyroid gland is not visible on inspectionGlands of the thyroid ascend during swallowing. Client head rounded; normocephalic and symmetrical. No nodules, masses or depressions upon palpation of the skull Neck erect without tenderness and flexes easily, no masses palpated

extraocularThis is the documentation, read it

As the nurse, you need to assess for risk factors related to ____ problems, including family history, trauma, illnesses, and occupational hazards.

eye

Lymph nodes +Using _____ ____ of 2nd, 3rd, 4th fingers, gently palpate with small circles, varying amount of pressure over each lymphatic region

finger pads

Preparing for hearing test: Begin the examination by ______ washing your hands in warm water.

first

You assess and describe wounds, lesions, rashes, and hematomas separately during the ______ assessment.

focused

For suspected _______ infections, a culture using a preparation of potassium hydroxide (KOH) may confirm diagnosis.

fungal

Acute _____ is caused by an acute blockage of the fluid at the base between the iris and cornea.

glaucoma

People with ______ loss are at increased risk for depression, dissatisfaction with life, reduced functional health, and withdrawal from social activities.

hearing

Pigmentation is consistent throughout the body. Patients with dark skin may have _______ skin on the palms and soles.

hypopigmented

While reviewing laboratory values for thyroid function on an adult patient, the nurse sees that the TSH is elevated, and the T3 and T4 are decreased. The nurse recognizes that these findings are indicative of

hypothyroidism

Racial groups that have higher rates of glaucoma have thicker _____.

irides

Just below the cricoid cartilage, the ______ of the thyroid should be palpable as a smooth, rubbery band that rises and falls with swallowing.

isthmus

Stand behind client, put your hands around their neck, place your fingers of both hands on lower trachea. Ask him to swallow, feel the thyroid ______ rise with swallowing

isthmus

Hair-formed from _______produced by matrix cells in the dermal layer of the skin. Each hair lies in a hair follicle

keratin

Formation of tears decreases as a result of loss of fatty tissue in the _____ _____.

lacrimal apparatus

Always examine the infected eye _____.

last

When evaluating a _________, you will need to classify it as a primary (new) or secondary (a change in primary lesion) then determine if its solid or fluid filled and describe its characteristics, pattern/distribution (configuration), location. Include a description of symmetry, borders, color, configuration, diameter, drainage (exudates-serous, serousanguineous, sanguineous, hemorrhaging, purulent

lesion

Fissure-______ break in skin surface

linear

Best place to check cyanosis - _____ and mouth

lips

The major chains of _____ ______ in the neck are the preauricular, posterior auricular, occipital, superficial cervical (extending from the tonsillar to supraclavicular nodes), deep cervical, posterior cervical, submental, and submandibular

lymph nodes

Hard, rubbery, irregular, fixed, and nontender lymph nodes are a possible sign of _______.

lymphoma

HEALTHY PEOPLE GOALS RELATED TO INTEGUMENTARY HEALTH +Reduce rate of ______ cancer deaths +Increase proportion of persons who use protective measures that may reduce the risk of skin cancer

melanoma

UVA waves are responsible for some _______ but are chiefly responsible for the effects of photoaging, specifically wrinkling and leathering of the skin.

melanomas

If the lymph node is palpable, what question is this describing? "It should be freely movable."

mobility

Palpable, warm lymph nodes=INFECTIONS Posterior cervical nodes: ________

mononucleosis

Patients may experience referred neck pain from ______ ______. If cardiac origin is suspected, focus assessments and interventions on the heart

myocardial infarction

This are example of ______ note +Skin mostly warm and dry +No skin lesions or breakdown +Skin pink cool and dry +No site swelling or redness +3 cm. bruise noted on right thigh +Sacral area reddened. Will speak to wound RN about frequent repositioning and use of protective skin barrier cream

narrative

Ask client to move _____ through entire ROM and shrug shoulders

neck

The major ______ muscles may be used as accessory muscles of respiration when the patient has difficulty breathing.

neck

IT is normal for the thyroid for being (palpable / nonpalpable)

nonpalpable

What is epistaxis?

nose bleed

A _____ diagnosis is a clinical judgment about responses to health problems or life processes.

nursing

Hearing The basal membrane in the cochlea vibrates the receptor hair cells of the _________, which transfer the signal into electrical impulses for the auditory nerve.

organ of Corti

Exposure to cigarette smoke, propping bottles for babies to feed, and bottle feeding in a supine position are all environmental factors that increase risk for ______ media.

otitis

Socioeconomic status and environmental exposure are indicators of risk for ______ media.

otitis

Palpable, warm lymph nodes=INFECTIONS Posterior auricular nodes: ____ _____

otitis media

If inspection of the outer ear canal reveals a foreign object, it is best to refer the patient to an _______ for removal of the object.

otolaryngologist

NURSING DIAGNOSES Pain related to tissue and injury treatments NI: Use _____ ____ to identify current pain intensity and effectiveness of pain medication

pain scale

Skin moisture and texture: _______ surface of fingers and hands

palmar

If ______ lymph node, describe: +Location: which lymphatic chain and where +Size: mm or cm +Consistency: hard, soft...it should be smooth, slightly soft, and non-tender +Mobility: freely moveable +Delimitation: no matting together of lymph nodes +Temperature: warmth +Tenderness +Edema +Erythema

palpable

Emphasize to _____ the importance of wearing helmets and the use of seatbelts and child safety restraints to protect the head and neck.

patients

Palpable, warm lymph nodes=INFECTIONS Anterior cervical nodes: _______

pharyngitis

When documenting the ______ assessment, the nurse must take care to describe the location of scalp or cranium findings according to the bones and sutures

physical

When assessing hydration, the nurse will

pinch a fold of skin just below the midpoint of one of the clavicles and allow the skin to recoil to normal

For the ________ approach, locate the thyroid and cricoid cartilages and the thyroid isthmus by palpation while standing behind the patient.

posterior

Palpation Compare nodes bilaterally in the following sequence:

preauricular posterior auricular occipital submental submandibular tonsillar deep anterior cervical chain posterior cervical supraclavicular

__________ women Rhinitis from increased vascularity and hormonal effects on mucosal lining Increased sinus infections, epistaxis Hyperemic gums bleed easily

pregnant

Recent ______ may indicate toxic exposure, insect bites, parasite infestations, or viral exanthems such as varicella.

pruritus

Inspection: Erythema is redness, but _____ is dependent redness.

rubor

Ultraviolet B (UVB) waves, which are ________ than ultraviolet A (UVA) waves, are more likely to cause sunburn.

shorter

If the lymph node is palpable, what question is this describing? "in millimeters or centimeters"

size

NURSING DIAGNOSES Impaired tissue integrity related to delayed wound healing NI: Determine ____ and depth of wound (stage)

size

General ______ assessment includes color, texture, moisture, turgor, and temperature.

skin

NURSING DIAGNOSES Risk for infection related to break in _____ NI: Practice frequent handwashing and universal precautions

skin

Changes in _____, ______, or _____ may be the first clue to other health problems.

skin hair nails

Do not remove immobilization devices until the ____ is cleared of injury

spine

The _________ muscle arises from the sternum and medial clavicle and extends to behind the ear.

sternocleidomastoid

The corneal light reflex tests for ______.

strabismus

The eyes sit deeper in the orbits from loss of ______ fat.

subcutaneous

A ______ scraping of disordered skin for microscopic examination may help to identify the type of lesion.

superficial

These are common head and neck _______. Headache •Neck pain •Limited neck movement •Facial pain •Lumps or masses •Hypothyroidism •Hyperthyroidism •Sleepiness

symptoms

Hearing The auditory nerve then delivers those impulses to the auditory cortex in the _______ lobe of the brain, which interprets them as sound and assigns meaning to them.

temporal

If the lymph node is palpable, what question is this describing? "with an acute infection or inflammation, a node may be tender. With malignancy, nodes are usually nontender."

tenderness

Palpation of the thyroid gland reveals important landmarks of the trachea. These are noted when assessing for tracheal deviation, which accompanies a potentially life-threatening condition called ______ _______.

tension pneumothorax

Atrophy/striae-_______ of skin from loss of skin structures

thinning

Palpate the _______, either from the anterior or posterior approach.

thyroid

The ________ muscle arises from the occipital bone and vertebra and fans out to the clavicle and scapula.

trapezius

Any history of ______ to the head, neck, or both warrants a careful assessment of these structures for bleeding, swelling, loss of mobility, or pain.

trauma

COMPREHENSIVE SKIN ASSESSMENTPALPATION Skin _______: tenting

turgor

The nurse can best evaluate the strength of the sternocleidomastoid muscle by having the patient

turn his or her head against resistance

Swelling or bulging of the ____ indicates acute otitis media

tympanic membrane

When using the otoscope, hold the patient's ear at the helix and lift up and back to align the canal for best visualization of the _______.

tympanic membrane

Assess for _____ by applying direct pressure to the skin surface with the pads of your fingers.

vascularity

The _______ test evaluates for loss of high-frequency sounds. Have the patient repeat what you have said. Repeat on the opposite side.

whisper

Classify the ______ as partial or full thickness

wound

Conjunctivae are thinner and may appear _____ from decreased perfusion.

yellowish

What are some components of Self Skin-Examination (SSE)?

•A solid tan, brown, black, or skin-toned color •Size smaller than 6 mm in diameter (approximately the size of a pencil eraser) •Well-defined edges •Usually round or oval shape with a flat or dome-like surface •Emergence before 30 years of age

Of Melanoma detection, what is ABCDEs

•Asymmetry •Border irregularity •Color •Diameter of more than 6 mm •Evolution of lesion over time

The assessment of Cranial Nerves, what is check when Cranial Nerve III, Oculomotor is observed?

•Cardinal fields of gaze •Eyelid inspection •Pupil reaction (direct/consensual/accommodation)

What are the steps in a Self Skin-Examination?

•Get fully undressed and stand in front of a full-length mirror •Carefully scan the entire body, using a handheld mirror to look at areas difficult to see (e.g., soles of feet). •When examining the scalp, use a comb or blow dryer to part the hair and examine the scalp section by section. •Report any suspicious lesion to the health care provider.

What is the nursing interventions for eye related problems?

•Identify name and purpose of visit when entering patient's personal space. •Keep furniture out of pathways and keep cords against walls. •Ensure access to eyeglasses or magnifiers as needed

What are some healthy goals for the ears?

•Reduce new cases of work-related noise-induced hearing loss. •Increase access by patients who have hearing impairments to hearing rehabilitation services and adaptive devices including hearing aids, cochlear implants, or tactile or other assistive or augmentative devices. •Increase the proportion of persons who have had a hearing examination on schedule.

What are the goals for Healthy People 2020 goals for integumentary health?

•Reduce the rate of melanoma cancer deaths. •Increase the proportion of persons who use at least one of the following protective measures that may reduce the risk of skin cancer: avoid the sun between 10 AM and 4 PM, wear sun-protective clothing when exposed to sunlight, use sunscreen with a sun protection factor (SPF) of 15 or higher, and avoid artificial sources of UV light.

The assessment of Cranial Nerves, what is check when Cranial Nerve II, Optic nerve is observed?

•Visual acuity •Visual fields •Funduscopic examination