Nursing Health Assessment Chapter 10
Which head assessment finding may be an expected variant in a newborn?
Sunsetting sign
Which finding would the nurse note as normal on inspection of the neck?
Symmetry of the muscles
The nurse is assessing a patient's optic disc. What instrument would be best for this assessment?
The optic disc is viewed with an ophthalmoscope
A patient is complaining of difficulty hearing. Which structure of the ear stimulates the acoustic nerve?
The ossicle
What is periodontitis?
when inflammation causes erosion of gum tissue and loosening teeth
A nurse is obtaining a health history from a 52-year-old male patient with a red lesion at the base of the tongue. What additional data does the nurse specifically collect about this patient?
Alcohol and tobacco use
Which finding is expected when both eyes are examined for light reactivity?
Brisk bilateral reactivity
Which findings would be considered abnormal on examination of an infant's fontanels?
Bulging Depressed Anterior fontanel open at 2 years
How does the nurse assess a patient's consensual reaction?
By shining a light into the patient's right eye and observing the pupillary reaction of the left eye
Which findings are expected when assessing the tonsils?
Crypts with food particles
Which mouth and oropharynx assessment findings are expected for the child?
Deciduous teeth
Which age-related finding is expected in a 55 year old patient?
Decrease in sense of taste
What are the s/s of hydrocephalus in adults?
Decreased mental status and HA
What is periodontal disesae?
Deep pockets between the teeth and gingiva
What is peritonsillar abscess?
Displaced tonsil and uvula associated with sore throat radiating to the ear
Which findings are expected when the nasal septum is assessed?
Location close to midline of face Anterior septum thicker than posterior septum
Which ear assessment findings would be considered abnormal?
Vertigo Tinnitus Hearing loss
Which data from the health history of a 42-year-old man should be evaluated further as a possible risk for hearing loss?
"My primary hobby is carpentry work."
A 24-year-old female patient has a 2-day history of clear nasal drainage. Based on these data, which question is the most logical for the nurse to ask?
"Do you have allergies?"
During the history the patient indicates that her eyes have been red and itching. Which additional question does the nurse ask?
"Do you have seasonal allergies?"
A 32-year-old women has a 4-day history of sore throat and difficulty swallowing. The nurse observes tonsils covered with yellow patches. The tonsils are so large that they fill the entire oropharynx and appear to be touching. How does the nurse document these findings?
"Enlarged tonsils 4+ with yellow exudate."
The nurse suspects that a female patient is having trouble with the thyroid when the patient answers yes to which question?
"Have you noticed a change in your level of energy?"
Which eye finding is normal for a 3-year-old child?
20/40 visual acuity
What is Branchial cleft cyst?
A mass along anteromedial border of sternoclediomastoid muscle
What is Thyroglossal duct cyst?
A movable cystic mass in neck midline
The nurse is assessing a patient's mandible. The area between the sternocleidomastoid muscles and the mandible is anatomically known as the:
Anterior triangle
Which technique is used for palpating lymph nodes?
Apply gentle pressure over the nodes with the pads of the fingers
While talking with a patient, the nurse suspects that he has hearing loss. Which examination technique is the most accurate for assessing hearing loss?
Audiometry test
A patient describes a recent onset of frequent and serve unilateral headaches that last about 1 hour. Based on these symptoms, the nurse suspects which type of headache?
Cluster headaches
The nurse is aware that the greatest physical variation of ears among individuals of different races is:
Consistency and color of cerumen
Which eye reaction is a normal finding when light is briefly shone over the pupil?
Constriction
What is acute otitis media (AOM)?
infection of the middle ear
Which findings would be considered abnormal when the neck is assessed?
Edema Webbing Nuchal rigidity
Which eye assessment finding is associated with hyperthyroidism?
Exophthalmos
The student nurse is learning how to use the ophthalmoscope. When performing an ophthalmoscopic examination, examine the patient's right:
Eye with your right eye and the patient's left eye with your left eye
What is Dizziness?
Feeling faintness
Which finding would the nurse consider normal on assessment of the thyroid gland?
Firm and pliable
Which findings would be considered normal on palpation of the neck?
Firm thyroid gland tissue Right thyroid lobe slightly larger than left Movement of cricoid cartilage on swallowing
What is oral cancer?
Firm, nonmobile mass with cervical lymphadenpathy
Which finding is expected in assessment of the auricle of an infant?
Flexibility
During the examination of the ears, which finding is expected?
Flexible earlobes
Hyperthyroidism causes?
Grave's disease
What is presbycusis?
Hearing loss with aging
Which nasal assessment findings, suggestive of inhaled cocaine abuse, are considered abnormal?
Hyperemia Rhinorrhea Edema of the nasal mucosa
The nurse is asking the patient to stick out his tongue and move it back and forth. Which cranial nerve is the nurse testing?
Hypoglossal nerve (CN XII)
Which HA come with an aura?
Migraines
The nurse is documenting in the chart. For documentation purposes, which term is used to describe a head that is of average size and shape?
Normocephalic
When examining the eyes, which finding is indicative of extraocular muscle weakness?
Nystagmus
What causes Hydrocephalus in adults?
Obstruction, increased CSF production, or decreased CFS absorption
What is Exotropia?
Outward turning of the eye
When the sinuses are palpated, which findings would be considered abnormal?
Pain Swelling Tenderness Opaque glow on transillumination
Which finding would the nurse note as normal on palpation of the head?
Palpable ridge of sagittal fissure
What ear assessment finding would be considered part of the normal aging process?
Presbycusis
During a physical examination the nurse is unable to feel the patient's thyroid gland with palpation from an anterior approach. What is the appropriate action of the nurse at this time?
Recognize that this is an expected finding
S/S of closed angle glaucoma?
Sharp pain and seeing halo around lights
Which finding would the nurse note as normal on inspection of the head?
Slight asymmetry in facial features
Which findings would be considered abnormal on palpation of the head?
Slight depressions Asymmetrical salivary glands Thrill over temporal arteries
The nurse is treating a patient for a nosebleed. The patient complains of frequent nosebleeds. What could be a possible cause of the nosebleeds?
Snorting cocaine
What are the characteristics of lymph nodes in patients who have an acute infection?
They are enlarged and tender
Which head assessment findings would be considered abnormal?
Tics Pallor Alopecia
Which finding would the nurse note as normal when assessing the face?
Variations in shape
What is torticollis?
When the head is tilted toward the sternocleidomastoid
Which age-related color change is expected on assessment of the sclera of an older adult?
Yellow
The nurse examines a patient's auditory canal and tympanic membrane with an otoscope. Which finding is considered abnormal?
Yellow or amber color to the tympanic membrane
How long do Migraine HA last?
a few hours to 3 days
What is strabismus?
abnormal ocular alignment
What is hordeolum?
acute infection of sebaceous gland of eyelid caused by S. aureus
What causes presbycusis?
atrophy and deterioration of cells in the cochlea or atrophy, degeneration and stiffening of cochlear motion
What is aphthous uclers?
canker sores that appear as a round or oval lesion with a yellow/white center and red halo
what causes sensorineural hearing loss (SNHL)?
caused by structural changes, disorders of the ear, or problems with the auditory nerve
s/s of OME?
clogged sensation decreased hearing trouble with balance clicking/popping sounds retracted yellow/grey TM with limited mobility
s/s of cataract
cloudy/blurred vision, glare from headlights, poor night vision, red reflex is absent
What is Herpes simplex type 1
cold sores that are highly contagious viral infection spread by direct contact
s/s of conductive hearing loss
decreased hearing with muffled tones
What is Acute pharyngitis?
enlarged anterior cervical lymph nodes; swollen tonsils
s/s of hyperthyroidism
exophthalmos (bulging eyes)
What are s/s of AOM
fever vomiting decreased hearing
What is chalazion?
firm & non-tender nodule in eyelid following conjunctivitis
What are the s/s of hydrocephalus in infants?
increased ICP and enlarged head
what is conjunctivitis?
inflammation of conjunctiva, local infection where the eye is red with thick/sticky discharge on eyelids in AM
What is otis media with effusion (OME)?
inflammation of middle ear space with serous fluid in middle ear
What does Meniere's Disease indicate?
inner ear problems
s/s of corneal abrasion
intense pain, foreign body sensation, photophobia, red
what is conductive hearing loss?
interference of air conduction in middle ear
What is Esotropia?
inward turning of the eye
How long do Cluster HA last?
more than once a day for 1-2 hours
What is Non-paralytic strabismus?
muscle weakness, focussing difficulty
What is epistaxis?
nose bleeds
What causes Hydrocephalus in infants?
obstruction of CSF drainage
What is odynophagia?
pain with swallowing
What is paralytic strabismus?
paralysis of extraoccular muscles
The nurse is assessing a patient for confrontation. The confrontation test assesses:
peripheral vision
s/s of candidiasis?
soft white plaques on tongue, buccal mucosa or posterior pharynx
What is Vertigo?
the environment is whirling around
What is candidiasis?
thrush
What is corneal abrasion?
ulcer of corneal area caused by infection, incomplete closure of the eye, scratches, foreign bodies, over worn contacts
