Health Assessments: Cranial Nerves + Review Questions
What are some abnormal findings associated with cranial nerve 7 (facial nerve)?
1) Bells' palsy which causes unilateral, central, and peripheral facial drooping 2) Lack of symmetry could be due to deficit following brain damage (such as from stroke, brain tumor, surgery, etc) 3) Result of complication related to sinus surgery, neurosurgery, etc
What are the functions of cholesterol?
1) Component of bile salts to aid in digestion 2) Protects cellular membrane integrity 3) Production of estrogen, testosterone, and cortisol
How much of the diet should be made of protein?
10%
What is considered a normal BMI?
18.5-24.8
What is considered an overweight BMI?
24.9-29.9
Which measurement is the best indicator of obesity?
BMI
If you were to jump rope, what movement is that?
Circumduction
What is the name for cranial nerve 9?
Glossopharyngeal
What does the verbal descriptive scale assess?
How the patient's pain feels to them
If you are performing a testicular exam, what are you palpating for?
Lumps, nodules, or masses
What factors are used to determine the amount of daily recommended vitamins?
Majority of vitamins come from food sources as long as food is not overcooked. Both vitamins and minerals are based on recommended daily allowance (RDA) according to age, lifestyle, and health of the client. RDA is based on a middle-aged adult with a 2,000 calorie a day diet
What is a supernumery nipple?
Milk lines that are present during gestation fail to disappear which causes a supernumerary nipple to remain. Is normal for females to have milk come out of this supernumery nipple when a woman is lactating
How often should men be doing testicular self exams?
Monthly
What is the name for Cranial Nerve 1?
Olfactory
What is an another word for an ear infection?
Otitis media
What instrument is used to look inside the ear?
Otoscope
What are normal findings of the scrotal tissue
Smooth, consistent and uniform
What is an expected finding related to the cilia of the ear in older adults?
Stiffening of cilia in the ears
What chart is used for assessment of visual acuity?
The Snellen Chart
How should the nurse assess gait and balance?
The nurse assesses gait by asking patient to move 4-5 steps forward (heel-to-toe) and then walk back to nurse
What are some abnormal findings of cranial nerve 3 (oculomotor), 4 (trochlear), and 6 (abducens)?
1) Disconjugate gaze: eyes do not turn together in the same direction 2) Opthalmolegia: paralysis/weakness of eye muscles 3) Nystagmus: Uncontrolled eye movements
What is the name of cranial nerve 6?
Abducens nerve
What could asymmetry and facial drooping of the face indicate?
Asymmetry and facial drooping of the face could indicate stroke or Bell palsy (a neurologic condition).
If you are suspecting an adult patient has dehydration, what might you ask about?
Caffeine intake as caffeine is dehydrating due to being a diuretic
What type of findings in the breast can indicate malignancy?
Dimpling or retraction of the breast
What is the name for cranial nerve 7?
Facial nerve
True or False: It is abnormal for a testis to be larger than the other
False. It is normal for one testicle to be larger than the other
What is the first thing you assess in a musculoskeletal assessment, as the patient walks into the room?
Gait
What is someone with a normal body type defined as?
Mesomorph
What is the name for cranial nerve 2?
Optic nerve
What is considered an obese BMI?
Over 30
Where should you palpate the axillary lymph nodes?
Palpated in upper outer breast tissue and tail of spence. Should support client's elbow and use three fingerpads of your other hand to palpate firmly the axillary nodes. Palpate high into the axillae and move downward against the ribs to feel the central nodes. Continue to move down the posterior axillae to feel for the posterior nodes. Use bimanual palpation to feel for the anterior axillary and finally palpate down the inner aspect of the upper arm
What is the function of cranial nerve 12?
Performs a MOTOR function by controlling tongue movement
How does epididymitis appear?
Scrotum appears enlarged, reddened. Caused by infection
Which measurement is the best indicator of adipose tissue?
Waist circumference
What would an assessment question be that determines whether an older patient is experiencing presbycusis?
"Do you have any difficulties hearing high-pitched sounds?"
Give examples of some questions you could ask regarding the male reproductive system in order to collect subjective data
1) Do you have any difficulties urinating? 2) Do you have difficulty maintaining an erection? 3) Do you feel any heaviness or dragging in your scrotum?
What are some abnormal findings with cranial nerve 10 (vagus)?
1) Dysphonia: impairment of voice box 2) Dysarthria: impairment of speech muscles (such as after stroke) 3) Pain 4) Organ dysfunction 5) Fainting (vasovagal-sudden drop in blood pressure and heart rate)
When using the FLACC scale for a 2 year old child, what aspects should you look at to assess for pain?
1) Face: Look for frown, clenched jaw or quivering chin 2) Legs: Look for kicking or legs drawn up 3) Activity: Are they shifting, squiring, arched, rigid or jerking 4) Cry: Are they crying steadily, whimpering, or not crying at all 5) Consolability: Are they difficult to comfort or can they be reassured
What type of subjective data should you collect when doing a female reproductive assessment?
1) History of present health concern using coldspa 2) Past health history ("Have you given birth to any children?" Have you had any prior breast disease or surgery on the breasts?") 3) Family history: "Do you have any family members who had breast cancer prior to menopause?" 4) Lifestyle and health practices: "Do you take contraceptives?" How much alcohol do you consume? 5) Estrogen exposures 6) Lumps, nipple discharge, or discomfort 7) Do they do self breast exams or do they know how? 8) When was your last mammogram/pap smear?
How might you assess hydration?
1) Intake and outtake 2) Weight changes 3) Blood pressure changes (orthostatic blood pressure) along with pulse rate 4) Dehydration will see low blood pressure when going from sitting to standing, while overhydration will see high blood pressure when going from sitting to standing
What are four functions of protein?
1) Makes hormones like insulin 2) Growth, repair, and maintenance of our body structure and tissue health 3) Makes enzymes for normal digestion 4) Maintains fluid and electrolyte balance
What are some tips for data collection during a pain assessment?
1) Observe body language and gestures throughout the interview 2) Ask questions in an open-ended format 3) Maintain client's privacy and ensure confidentiality 4) Review past and family histories in terms of pain ("What surgeries or other medical procedures have you had?", "What medical conditions do you have?") 5) Review lifestyle and health habits to determine how pain interferes with the client's life ("How does the pain affect your overall mood?" "Daily life and activities?") 6) Make sure to maintain a quiet and comfortable environment for the client that is being interviewed
What are the seven dimensions of pain?
1) Physical: Is the body's reaction to pain. Effect of anatomic structure and physiologic functioning on the experience of pain 2) Sensory: How the patient describes their pain such as where it is located, what it feels like, when it began 3) Behavioral: Verbal and nonverbal behaviors associated with pain (grimacing, guarding, forgetfulness, confusion, anxiety, depression) 4) Sociocultural: Effect of social and cultural background on the experience of pain (cultural influences on pain) 5) Cognitive: Thoughts, beliefs, attitudes, intentions, and motivations related to the experience of pain (impairments to cognition, rationale behind desired treatment) 6) Affective : Feelings and emotions which result from pain (depression, anger, frustration) 7) Spiritual: Meaning and purpose attributed to pain
What should you note when doing a breast inspection?
1) Size and shape of the breasts 2) Color and texture 3) Superficial venous pattern (prominent venous pattern may occur as a result of increased circulation due to a malignancy) 4) Note any retraction or dimpling as these are abnormal findings 5) Bilaterally note color, shape, size, and texture of areolas 6) Bilaterally note size and directions of the nipples
What are ways to physically assess for dehydration?
1) Skin turgor: is there skin tenting 2) Pitting edema 3) Dry tongue 4) Observing for skin moisture 5) Assess venous filling (assess when feet or arms are in dependent position, are veins in arm pronounced) 6) Pronounced neck veins indicates overhydration 7) Lung sounds (may hear rales in lower lobes of lungs if there is fluid volume overload)
Describe how to perform a self-testicular exam
1) Stand in front of a mirror and check for scrotal swelling 2) Use both hands to palpate the testicles it should be smooth and uniform 3) Use index and middle fingers under the testis and thumb on top, roll gently in a horizontal plane between thumb and fingers (make backward S on underside of testicle) 4) Feel for any evidence of a small lump or abnormality 5) Follow the same procedure and palpate upward along the testes 6) Locate the epididymus (cord like structure on top and back of testicle which stores sperm) 7) Repeat for other testicle 8) If you find any evidence of a small, pea like lump call physician!
How do you test the function of cranial nerve 7 (facial nerve)?
1) To test motor function ask client to smile, frown, wrinkle forehead, show teeth, raise eyebrows, or puff out cheeks. Should be assessing for symmetry 2) To test sensory function touch the anterior two thirds of the tongue with a moistened applicator dipped in an identifiable taste and have patient try to identify substance
What are some signs of fluid volume overload?
1) Weight gain of 6 to 10 lbs in a week 2) Pitting edema 3) Visible neck veins 4) Cracking lung sounds 5) Elevated pulse rate and blood pressure
What are some signs of dehydration?
1) Weight losses of 6 to 10 lbs in 1 week 2) Skin tenting 3) Thready pulse (+1 pulse) 4) Filling or emptying of venous filling more than 6 to 10 seconds 5) Flat veins in supine client 6) Dry tongue 7) Sunken eyes 8) Blood pressure decreased with elevated pulse rate
How much of the diet should be made up of saturated and unsaturated fats?
10% of calories should come from saturated fat while 20% should come from unsaturated fat
What is considered pre-albumin?
15-30 mg/dL. Only indicates protein stores in the last 5 days. Is helpful in understanding acute protein stores. Is severely depleted when under 5
What is the daily intake of water recommended?
2 L for males, 4 L for females
What amount of fiber should be included in the diet?
25 grams per day for females, 38 grams per day for males
Discuss what a normal pupillary response should be when assessing pupils using a penlight.
A normal pupillary response should be that the pupils should constrict when light is shined obliquely into the eye and the response should also be consensual and be seen in the other eye.
A nurse at a clinic is collecting data about pain from a client who reports severe abdominal pain. The nurse asks the client if there has been any accompanying nausea and vomiting. Which of the following pain characteristics is the nurse attempting to determine? A) Presence of associated manifestations B) Location of the pain C) Pain quality D) Aggravating and relieving factors
A) Presence of associated manifestations
A nurse is performing a neurologic examination for a client. Which of the following assessments should the nurse perform to test the client's balance? (Select all that apply) A) Romberg test B) Heel-to-toe walk C) Snellen test D) Spinal accessory function E) Rosenbaum test
A) Romberg test, B) Heel-to-toe walk
What is peau d'orange?
Abnormal breast finding which results from edema and is associated with cancer. Causes an orange peel appearance of the breast
What is accommodation? How is this assessed and what is an expected finding when performing this exam?
Accommodation is the converging and constriction of the pupils as an object moves closer to the eyes. It is assessed through having the patient focus on an object (such as your penlight) and slowly moving the tip in towards the nose. A normal finding is to see convergence and constriction of the pupils as the object moves in closer.
If we were to bring our arm into the center of the body, what movement is that?
Adduction
If you are performing any testicular/breast physical assessments, what is important to avoid possible litigation down the road?
Always have a chaperone or witness in the room
Name an example of nociceptive pain
An acute injury such as a broken arm or touching a hot stove top
What is an abnormal finding of Cranial Nerve 1 (Olfactory)?
Anosmia (inability to smell) could be due to olfactory tract lesion, congenital, or as a result of nasal or sinus problems
What is a scrotal hernia and how does it feel on palpation?
Appears as swelling in the scrotum and produces pain. Is a result of a loop of bowel protruding into the scrotum and will be felt as a soft mass and fingers cannot get above the mass
What is mastitits?
Area of the woman's breast becomes red, hot, and swollen. Believe that bacteria in the mouth causes bacteria to build up in the duct of the breast-antibiotics may be given
What is neuropathic pain?
Arises from abnormal or damaged pain nerves. Includes phantom limb pain and diabetic neuropathy. Is described as intense, shooting, burning, or pins and needles
What is nociceptive pain?
Arises from damage to or inflammation of tissue which is a noxious stimulus that triggers pain receptors called nocicepors and causes pain. It typically responds to opioid and non-opioid medication.
If there is a lump in the breast how can you better determine the difference between a cyst or a malignant tumor?
Ask if there is tenderness or pain while palpating, malignancies are usually not painful or tender
Discuss the steps necessary for palpating the thyroid using a posterior approach.
Ask patient to sit in a comfortable position and have patient look at the ceiling and place index fingers below cricoid cartilage and have client take a drink of water. Don't press too hard as it will not be felt. Displace using left hand and right hand to palpate and then do the opposite on the other side. Note size, shape and consistency of gland and identify any nodules or tenderness
How do you assess for skin turgor on an infant?
Assess for skin tenting using the back of the hand or belly
What are some abnormal findings associated with cranial nerve 11 (spinal accessory nerve)?
Asymmetry of muscle movements in shoulders
What are some abnormal findings associated with cranial nerve 12?
Atrophy of the tongue or involuntary muscle twitch or deviation to the affected side of the tongue (seen with a unilateral lesion)
What would the tympanic membrane look like in an inner ear infection (otitis media)?
Bright red, swollen with possible effusion that may appear yellow
If someone had neuropathic pain, what descriptors might they use to describe their pain?
Burning, tingling
At what age can we begin using the numerical scale?
By age 8 and should only be used for cognitively intact children and adults. Only evaluates one aspect of pain but is valuable for rating pain intensity
A nurse is caring for a client who reports pain with internal rotation of the right shoulder. This discomfort can affect the client's ability to perform which of the following activities? A) Exercising the deltoid muscles when using hand weights B) Brushing the hair on the back of the head C) Fastening or zipping closures on the back while dressing D) Reaching into a cabinet above the sink
C) Fastening or zipping closures on the back while dressing
A nurse is collecting data from a client who is reporting pain despite taking analgesia. Which of the following actions should the nurse take to determine the intensity of the client's pain? A) Ask the client what precipitates the pain B) Question the client about the location of the pain C) Offer the client a pain scale to measure their pain D) Use open-ended questions to identify the client's pain sensations
C) Offer the client a pain scale to measure their pain
What technique should you use to assess pain?
COLDSPA: Character of pain ("stabbing, shooting, cramping..") Onset of pain ("How long have you been feeling pain?") Location of pain ("Where do you feel the pain?" "Does the pain radiate to other areas of the body?") Duration of pain ("How does the pain last?" "When do you typically feel the pain?") Severity of pain (usually on a scale of 1 to 10) Patterns of pain Associating factors
What does it mean if a hernia is reducable?
Can be pushed or flattened out when you push against it gently (is the case with some inguinal and scrotal hernias)
What audience is the Wong-Baker FACES pain rating scale aimed at?
Children above the age of 3
What are some subjective statements that the client may report to the nurse that could indicate hypothyroidism?
Client could report feeling fatigue or tired all the time, irregularities in menstrual cycle, cold intolerance, trouble losing weight, muscle aches or myalgia, or having constipation
What are some subjective statements that the client may report to the nurse that could indicate hyperthyroidism?
Client could report heat intolerance, menstrual irregularities, heart palpitations, excessive sweating, anxiety, trouble sleeping, or trouble focusing or concentrating
Which cranial nerve is associated with prebuscysis?
Cranial nerve 8 (vestibulooculear/acoustic)
What testicular abnormality puts someone more at risk for testicular cancer?
Crytochoridism (undescended testes)
A nurse is discussing the care of a group of clients with a newly licensed nurse. Which of the following clients should the newly licensed nurse identify as experiencing chronic pain? A) A client who has a broken femur and reports hip pain B) A client who has incisional pain 72 hours following pacemaker insertion C) A client who has food poisoning and reports abdominal cramping D) A client who has episodic back pain following a fall 2 years ago
D) A client who has episodic back pain following a fall 2 years ago
Why are young children more susceptible to ear infections?
Due to the Eustachian tube being more horizontal and being harder to drain which results in more infections. The horizontal structure also allows for easier access of pathogens to the inner ear
What are some abnormal findings associated with cranial nerve 9 (glossopharyngeal nerve)?
Dysphagia which can lead to aspiration pneumonia
What is a person with a tall and slim body type defined as?
Ectomorph (does not gain weight easily)
If you had an individual who was overweight, what suggestions would you give them?
Encourage a healthy diet and lifestyle. Be cautious of fad diet and food restriction, reduce simple carbohydrates and highly processed food, higher intake of fruits, vegetables, and fish. 60 minutes of aerobic exercise, 4 times a week
What does waist circumference measure?
Extent of abdominal visceral fat in relation to body fat
What is the function of cranial nerve 3 (Oculomotor), cranial nerve 4 (trochlear), and cranial nerve 6 (Abducens)?
Eye movement and pupillary constriction. Is a MOTOR function nerve
What does FLACC stand for and how does it work?
Face, Legs, Activity, Cry, Consolability and is scored 0-10. Is for pediatric and non-verbal children (aged 2 months to 7 years). Observe body for 1-2 minutes and observe for tenderness and tone. If patient is asleep observe legs for more than 2 minutes. Each category is scored 0 to 2, ranging from a score of 0 to 10 (being the most pain, 0 being the least)
What is the physiological response to pain?
Fight or flight response (activation of sympathetic nervous system). Involves tachycardia, hypertension, anxiety, diaphoresis, muscle tension, increased blood glucose (release of cortiocosteroids and insulin), pupil dilation, pale, diaphoretic skin, increased respirations or hyperventilation
What is the function of the cranial nerve 10 (vagus nerve)?
Has sensory, motor, and autonomic functions (primarily parasympathetic) effects on viscera (glands, digestion, heart rate, cough reflex). Controls the motor functions of some mouth and speech functions.
How do you test the function of cranial nerve 5 (trigeminal nerve)?
Have patient open and close mouth while palpating jaw and masseter muscle to assess motor function. To assess sensory function use sharp and dull object (such as paper clip) and vary the sharp and dull stimulus in three areas (forehead, cheek, and chin) and compare sides
How do you assesses the functioning of cranial nerve 9 (glossopharyngeal nerve)?
Have patient open mouth and say "ah" and make sure uvula is rising and midline. Want to also assess ability to swallow by giving patient a drink of water.
How do you assess the functioning of cranial nerve 11 (spinal accessory nerve)?
Have patient shrug shoulders and perform head and neck movements side to side
How do you assess the functioning of cranial nerve 12?
Have patient stick tongue out and move it to each side against the resistance of a tongue depressor ("Stick out your tongue you're all done").
How do you assess the functioning of cranial nerve 10?
Have patient turn head and cough and assess speech
How do you test Cranial Nerve 1 (Olfactory)?
Have the client verbally identify an easily identifiable smell
What is the Bulge test?
Helps to detect small amounts of fluid in the knee. Have client be in supine position and use ball of hand to stroke the medial aspect of the knee 3-4 times and then press on the lateral side. If a bulge appears it is a positive sign for fluid in the knee.
If a male has trouble urinating, what is the first thing you are going to think of?
Hypertrophy/enlargement of the prostate
What is the name of cranial nerve 12?
Hypoglossal nerve
How do you tell if a patient has an external ear infection (otitis externa)?
If they have pain when you rub on the tragus that is evidence of an outer ear infection
Why is a small cup of water needed when palpating the thyroid?
In order to feel the thyroid gland moving up and down when palpating
What does a bluish/red tympanic membrane indicate?
Indicates blood behind the ear drum as a result of trauma
How is the breast area divided?
Into upper inner, upper outer, lower inner, and lower outer
What is a 24-hour food recall?
Involves a client listing all types and quantities of foods and beverages ingested in 24 hours. Is an efficient and easy method of identifying a client's intake. Allows you to assess patient's knowledge deficit and gain an understanding of their diet
Performing a self-breast exam is an important measure and while some lumps may be normal, not all lumps are. If you are examining a patient and note a lump in the breast, or you note a difference in their breast size, what is an appropriate follow-up question to ask?
Is this new or have you noticed it before?
What is hypospadias?
Is when the urethral meatus (urethral opening) is located underneath the glans on the ventral side. Is a result of a congenital defect in men. These men usually cannot be circumsized
What position should a woman be in when conducting a pelvic exam?
Lithotomy position
What are the three bones of the middle ear?
Malleus, incus, and stapes
What is the name for cranial nerve 3?
Oculomotor
What is a good pneumonic to remember the cranial nerves?
Oh, Oh, Oh, To Touch and Feel Very Genuine Virgins At Home
What is the instrument used for assessing the internal structures of the eye?
Ophthalmoscope
What is another word for an outer ear infection?
Otitis externa (swimmer's ear)
What scale would you use to assess pain in someone with dementia?
PAINAD (Pain assessment in advanced dementia). Used at admission, assessment every 8 hours, and when there is any change in status. Involves observing the adult adult for 3-5 minutes while they are performing some activity (such as bathing or moving). Assess for breathing, negative vocalization such as moaning, facial expression, body language, and consolability and grade on scale of 0 to 2 for each category. Scores range from 0 to 10, with 10 indicating the greatest pain
What is chronic/persistent pain?
Pain that lasts beyond the course of injury disease (often 6 months or more). Is characterized by periods of exacerbations and remission
What is acute/transient pain?
Pain which is usually caused by an injury or disease and subsides when the injury or disease is healed. Has a rapid onset which varies in intensity and duration. Acute pain has the potential to become chronic and there are practices which should be utilized to prevent this
How do you assess for a hernia?
Palpate inguineal lymph nodes (noting size, consistency and tenderness) while also having patient turn head and cough to feel for any bulges or masses that may appear
What are some abnormal findings of cranial nerve 2 (optic)?
Papilledema (swelling of the optic nerve), anopsia (loss of visual fields), presbyopia (sees better farther away or closer up, normal sign of aging)
How does the Wong-Baker FACES pain rating scale work?
Patient must be able to understand the scale and should not be used by a 3rd party. Should explain to the patient that each face is for a person who feels happy because they have no pain or sad because they have some pain: Face 0: Very happy because they have no pain Face 1: Hurts a little bit Face 2: Hurts a little more Face 3: Hurts even more Face 4: Hurts a lot Face 5: Hurts the worst Should point to each face using the words to describe the pain intensity and have the child choose the face which best describes their own pain and record the appropriate number.
Discuss some physical findings noted upon inspection that could indicate hypothyroidism.
Physical findings could be edema (especially periorbitally), higher diastolic blood pressure, thin brittle hair or brittle nails, bradycardia, pale and dry skin
What is the difference between a pre-albumin or albumin level?
Pre-albumin level is an indicator of protein stores within the last 5 days while albumin levels provide more of a long-term understanding of someone's protein intake
What is presbycusis? Who is most at risk for this? What type of sounds are most impaired if a patient has presbycusis?
Presbycusis is a loss of hearing beginning with loss of high frequency sounds. Older adult patients are most at risk for this type of hearing loss.
What does PERRLA mean?
Pupils equal, round, reactive to light and accomodation
What is the function of vitamins?
Release energy from protein, fat and carbohydrate to form hormones, red blood cells, genetic materials, and for proper functioning of the nervous system
What is the function of cranial nerve 8?
Responsible for hearing. Is a SENSORY function nerve. "Outer border of ear when traced makes a figure 8"
What does rhinorrhea mean? What are some reasons for rhinorrhea?
Rhinorrhea means runny nose of a thin, watery, clear nasal drainage. This can indicate a chronic allergy or in a client with a past head injury a cerebrospinal fluid leak.
What are some abnormal findings of cranial nerve 8 (vestibulocochlear/acoustic)?
Sensorineural hearing loss (hearing loss in the inner ear), conductive hearing loss (hearing loss in the middle ear), or vertigo (perception of motion such as spinning)
What is the function of cranial nerve 7 (facial nerve)?
Sensory component is the taste of anterior 2/3 of the tongue. Motor component is facial symmetry. Has BOTH sensory and motor functions
How should a normal, healthy tympanic membrane look upon exam?
Should appear pearly gray and shiny and translucent with a cone-shaped reflection at the 5'o clock mark in the right ear and 7 o'clock mark in the left ear.
What type of carbohydrates can raise blood sugar quickly?
Simple carbohydrates
What is the difference between simple and complex carbohydrates?
Simple carbs convert quickly to energy and raise blood sugar more quickly. They are not stored. Complex carbs convert more slowly to energy and do not cause rapid increases in blood pressure. They also spare protein from being used as an energy source and help protect our gut and bowel integrity.
Water is one of the most important nutrients. What objective assessment is used in relation to fluid intake and dehydration?
Skin turgor
How does a testicular tumor feel upon palpation?
Small, firm, nontender nodule on the testis. As the tumor grows, the client may report a feeling of heaviness. Will not transilluminate
What is the name of cranial nerve 11?
Spinal accessory nerve
What is pain?
Subjective experience and is whatever the person says it is. Defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage
What is the function of cranial nerve 5 (trigeminal nerve)?
Tactile sensation for face/anterior scalp and is also the muscles of mastication for chewing ("eat dinner at 5pm"). Is BOTH a motor and sensory nerve function
How do you test the function of cranial nerve 3 (oculomotor), 4 (trochlear), and 6 (abducens)?
Test by assessing 6 cardinal fields of vision, extraocular movements, and pupillary response to light (indirect and direct) and accommodation in both eyes. "3,4,6 make your eyes do tricks"
Describe the Weber and test. Specifically, what is lateralization and is this a normal or abnormal finding?
The Weber test is performed by striking a tuning fork with the back of your hand and placing it on top of the patient's head and ask them to say where they feel the vibrations best. If a patient hears it in their normal ear this indicates sensorineural hearing loss and if they hear it in the abnormal ear it indicates conductive hearing loss. Lateralization means they hear the sound in one ear, this is an abnormal finding which indicates sensorineural hearing loss or conductive hearing loss depending on which ear reports lateralization.
What is gynectomastia?
The appearance of breast tissue in males. May be seen in boys after birth, 12-14 years of age, and peaks around the ages of 50-80 (1 in 4 men in this age range have breast enlargement. Certain medications such as anabolic steroids can also cause this.
Where are the maxillary sinuses located?
The maxilla (cheekbone) along the side walls of the nasal cavity
Why should the nurse wear gloves when assessing the head and scalp?
The nurse should wear gloves when palpating the head and scalp as hair can obscure any open wounds which non-gloved hands could come into contact with.
Describe the purpose of performing the Rhomberg test and how to conduct this test? What is a normal finding?
The purpose of performing the Rhomberg test is to assess balance. This test is conducted by having the patient stand together with arms at side initially and then having them close their eyes. Should be able to maintain position for 20 seconds without swaying or moving legs.
What color should the sclera of the eye be upon exam? What term is used for a yellowed appearance? What could this yellowing indicate?
The sclera should be white upon exam. A yellowed appearance of the sclera is known and jaundice and can indicate liver impairment and indicates that there is a high level of bilirubin in the blood.
Which area of the breast has the most incidences of cancer?
The upper outer portion which connects to the axillary tail of spence
What is epispadias?
The urethral meatus is located on top of the glans (dorsal side) and occurs rarely as a result of a congenital defect
Describe the steps to the whisper test.
The whisper test assesses hearing by standing behind the patient and whispering a 2-syllable word while the patient covers their left ear and then having them repeat the word. The test is then performed on the opposite side the same way using a different 2-syllable word.
Who has greater health risk: someone with an apple shape or pear shape?
Those who have an apple shape as there are larger fat stores around the waist
How is a hydrocele usually identified?
Through transillumination, if it is blood which is causing swelling of the scrotum instead this will not be illuminated
How do you assess the functioning of cranial nerve 8?
Through whisper test, webber, or rhine test
What is the function of Cranial Nerve 1 (Olfactory)?
To carry smell impulses from nasal mucous membranes to brain ("you only have 1 nose). Is a SENSORY function
What is the function of cranial nerve 2?
To carry visual impulses from the eye to the brain. Is a SENSORY function
What is the adam's test used for?
To test for scoliosis. Involves client bending over and touching toes to assess for any lateral curvature in spine
How are tonsils graded on a numeric scale and what does each numeric value represent in relation to physical finding?
Tonsils are graded on a scale of +1 to +4. +1 indicates tonsils are visible, +2 indicates tonsils are midway between tonsillar pillar and uvula, +3 indicates tonsils are touching uvula, and +4 indicates tonsils are touching eachother.
What is BMI an estimate of?
Total body fat
What is the name of cranial nerve 5?
Trigeminal nerve
What is the name of cranial nerve 4?
Trochlear nerve
True or False: Prebuscysis is a normal sign of aging which usually occurs around 50 years of age.
True
True or False: Dimpling or retraction of the breasts is abnormal
True. This finding can indicate malignancy. Observe by having clients raise hands above head, placing hands on hips, and then cuffing hands.
How does cryptorchidism appear?
Undescended testes which is when scrotum appears undeveloped and testes cannot be palpated. Is a failure of the testes to descend into the scrotum
How do you test the function of cranial nerve 2?
Use Snellen chart to assess vision in both eyes
If you a nurse teaching a patient how to palpate during a breast exam what you tell them?
Use the first three finger tip pads are they are most sensitive to structural changes
How do you palpate breast tissue?
Using the pads of the three middle fingers. Can use the circular method, wedge method, and vertical strip method to palpate
What is the name of cranial nerve V (10)?
Vagus nerve ("Nothing open in Vegas until 10")
What is the name for cranial nerve 8?
Vestibulocochlear/Acoustic nerve
Discuss some physical findings noted upon inspection that could indicate hyperthyroidism
Weight loss, hair loss, emotional lability, tachycardia, hyperactive reflexes, thyroid enlargement upon palpitation
What is a hydrocele?
When serous fluid collects in the scrotum. Appears as swelling in the scrotum and is usually painless. Usually confirmed through transillumination, if there is blood in the scrotal sac instead it will not transilluminate
How does use of the otoscope differ between young children (under 3 years of age) and those older than age 3 years?
When using the otoscope on a child under 3 years of age the ear lobe should be pulled down and back to assess. Children older than 3 should be assessed by pulling the pinna up and back.
What is Paget's disease? What would you expect to see with a breast exam?
Would see redness, mild scaling, and flaking of the nipple early and then it would disappear but this does not mean the disease is gone. Other symptoms include tingling, itching, increased sensitivity, burning, discharge, and pain.
What age group of men does testicular cancer effect?
Younger men in their 20-40s, the risk decreases over the age of 55
What is normal serum albumin?
3.5-5.5 gm/dL. Indicates protein stores. Under 2.1 indicates severe depletion. More sensitive indicator of protein stores compared to pre-albumin
How much of the diet should be made up of carbs?
55-60% of total calories
What is considered an underweight BMI?
<18.5
How do hydroceles appear?
Appear with transillumination and an enlarged scrotum
What is a person with a large body build who gains weight easily defined as?
Endomorph
What can triceps skin fold determine?
Evaluates subcutaneous fat stores. If under 90% indicates moderate malnourishment and over 130 indicates obesity
What movement will the knee joint make?
Flexion and extension
What is the function of cranial nerve 11 (spinal accessory nerve)?
Performs MOTOR function by moving trapezius and sternocleidomastoid muscles (shoulder muscles). "Cranial nerve 11 makes your shoulders go to heaven"
What is a good pneumonic to remember sensory, motor or both functions for cranial nerves?
Some Say Money Matters, But My Brother Says Big Boobs Matter More
What is the function of cranial nerve 9 (glosspharyngeal nerve)?
The sensory component is to provide taste to posterior 1/3 of tongue. The motor component is to gag/swallow. Is BOTH a sensory and motor function nerve.
Describe typical, "normal" characteristics of lymph nodes. Also, what are some "red flags" or abnormal findings when palpating the lymph nodes?
Typical "normal" characteristic findings of lymph nodes are that they are usually difficult to palpate and not tender or visible. Enlarged lymph nodes, enlarged non-tender lobe which is fixed to the body
Which test is used to assess prebuscysis?
Whisper test