Health Assessment 3204 exam 2

1. List the 4-point grading scale for the size of tonsils.

+1 = VISIBLE +2= tonsils are between the tonsillar pillars and the uvula +3= Tonsils are touching the uvula +4= Tonsils are touching eachother

______________________________________is the change in size to adjust for seeing objects at various distances.

Accommodation

What is the term for difference in pupil size

Anisocoria

The nurse is inspecting the cornea and lens of an elderly client and notices a white arc around the limbus of the client's eye. The nurse recognizes this condition, common in older adults, as which of the following?

Arcus senilis

_____________________ are densities in the lens

Cataracts

what is the word for double vision?

Diplopia

What is the term for bleeding from the nose

Epistaxis

Retinal structures in the myopic eye look smaller than normal? T OR F

False

When a person shifts from a far object to a near one, the pupils dilate T OR F

False

A nurse assesses the parallel alignment of a client's eyes by testing the corneal light reflex. Where should the nurse shine the penlight to obtain an accurate result?

Focused on the bridge of the nose

________ is when the patient is unable to see in half of the visual field and is generally in one side.

Hemianopsia

How do you inspect pupils?

In dim light, inspect the size, shape, and symmetry of each pupil. Measure the pupils with a guide such as a card or a flashlight with black circles of various sizes to facilitate measurement. Document the pupil size and note if the pupil is large (>5 mm), small (<3 mm), or unequal.

What is the term for drainage from the ear

Otorrhea

What is the common cause of conductive hearing loss in young adults?

Otosclerosis

Pain in eyes when patient is in the sun

Photophobia

____________________ or light sensitivity is usually from excess light entering the eye, which may overexcite the photoreceptors in the retina.

Photophobia

Define macular degeneration

Progressive, usually age-related, deterioration of the central part of the retina (macula), leading to loss of central vision which is most common cause of blindness. Most patients keep peripheral.

What is the term for a runny nose

Rhinorrhea

What are the names of visual acuity tests?

Snellen and Rosenbaum eye charts Near Vision Test Peripheral Vision test

What notation demonstrates the nurses understanding of effective documentation when the assessment findings identify thick, purulent drainage in both eyes of a client?

Thick, purulent drainage is noted at inner corner of both eyes.

What is perceived sound that has no external stimulus and commonly heard as musical ringing or roaring noise (EAR)?

Tinnitus

A few beats of nystagmus on extreme lateral gaze are normal. T/F

True

A yellow sclera indicates jaundice T or F

True

macular degeneration is a common cause of poor central vision in the elderly

True

What is the perception that a patient or environment is spinning or rotating?

Vertigo

What is the term for lazy eye

amblyopia

Word for farsightedness

hyperopia

The nurse is using the ophthalmoscope to examine the client's eyes. The nurse holds the scope

in the right hand for the right eye and in the left hand for the left eye

An adult client visits the clinic and tells the nurse that he has had excessive tearing in his left eye. The nurse should assess the client's eye for

lacrimal obstruction.

Describe Cataracts?

lens becomes opaque / cloudy resulting from a clumping of proteins in the lens

What is the term for constriction of pupils

miosis

What is the term for dilation of the pupils

mydriasis

Word for nearsightedness

myopia

What is the most common form of glaucoma

open angle glaucoma

Papilledema refers to swelling of the ______ ____ and anterior bulging of the physiologic cup.

optic disc

What would flashing lights mean

possible detachment if vitreous from retina

Word for aging vision

presbyopia

Describe Glaucoma

this is when there is increased intraocular pressure Patient is affected by: Loss of peripheral vision

If sudden visual loss is unilateral and painless consider the following:

vitreous hemorrhage from diabetes or trauma, macular degeneration, retinal detachment, retinal vein occlusion or central retinal artery occlusion