Health Assesment Exam 2

What technique is used to assess eye movement?

6 Cardinal Fields of Gaze

What is consensual pupillary reaction?

pupillary constriction in response to light shone on the opposite eye

What should be used when testing a patient's visual acuity?

Snellen chart

What is nystagmus?

involuntary, rhymical, and rapid eye movements (horizontal, vertical, or rotary)

What is migraine?

headache characterized by severe head pain, sensitivity to light (photophobia), dizziness, and nausea, vomiting

A sinus infection is characterized by ____ secretion or discharge?

Purulent

What is turbinates?

small structures inside the nose that cleanse and humidify air that passes through the nostrils into the lungs; usually deep pink in color

What happens during skull fracture?

clear or blood drainage thru nose and/or ears affecting the sphenoid and ethmoid bones

In children LESS than three years of age, pull the earlobe ___ and ___

Down;back

In children MORE than three years of age, pull the earlobe ___ and ___

Up;back

When assessing cranial nerve 7 (VII) for facial symmetry, what should you ask the pt to do?

to smile, purse lips, close eyes, wrinkle forehead and chin, puff cheeks

What parts of the eye are assessed in cranial nerve 3 (III)?

pupils, extraocular muscles, eyelids

pupils, extraocular muscles, eyelids

Cranial nerves 3, 4, 6 (III, IV, VI)

What is tinnitus

ringing or buzzing in the ears

What is hemoptisis?

coughing up blood

What is heart failure?

heart cannot pump enough blood

what is hyperglycemia?

high blood sugar

What is mammography?

x-ray imaging of the breast

What is cholecystectomy?

surgical removal of the gallbladder

What is prostatectomy?

surgical removal of the prostate

When assessing cranial nerve 12 (XII), what should you ask pt to do?

stick tongue out, move tongue

cyanosis

Abnormalities in skin color:
skin turns blue because of lack of oxygen

jaundice

Abnormalities in skin color:
skin turns yellow, usually sign of liver disease

erythema

Abnormalities in skin color:
skin turns red because of increased blood flow

petechaie

Abnormalities in skin color:
pinpoint bleeding, usually < 1cm

Ecchymosis

Abnormalities in skin color:
macula patch; blood pools under skin, usually > 1cm

hematoma (tumor)

Abnormalities in skin color:
pool of clotted blood forming in tissue, organ or body space

Why should we be concerned about lesions?

to identify skin cancer
(more than 6mm in size, variations in color, bleed easily, itchy)

True or false:
You should assess sclera or mucosa if dark green or bright yellow.

True

How to detect if a pt has contractures?

they have limited range of motions

Stage 1

Stages of pressure ulcers:

non-blanchable discoloration, reddened-to-darker; epidermis is compromised

Stage 2

partial thickness; blister formed, w/ reddened oozing wound bed; reaching dermis

Stage 3

Stages of pressure ulcers:

full thickness; oozing slough; reaching hypodermis (fat)

Stage 4

Stages of pressure ulcers:

can reach muscle, bone, tendons, ligaments; tunneling; undermining

Characteristics of Breath Sounds:
Bronchial

- location: trachea
- high, loud pitch
- inspiration shorter than expiration

Characteristics of Breath Sounds:
Bronchovesicular

- location: (anterior) 1st and 2nd intercostal space at sternal border
- location: (posterior) T4 media to scapula
- moderate, medium pitch
- inspiration equal to expiration

Characteristics of Breath Sounds:
Vesicular

- location: peripheral lung fields
- low, soft pitch
- inspiration greater than expiration

Why do clubbing of fingers occur?

because of hypoxia (chronic low blood oxygen levels)

Characteristics of Adventitious Sounds:
wheezing

- musical, high pitched sounds
- heard more commonly during expiration
- occlusion of bronchioles

Characteristics of Adventitious Sounds:
rhonchi

- low pitched snoring sounds
- heard primarily during expiration
- coughing may clear
- occlusion of bigger bronchi

Characteristics of Adventitious Sounds:
fine crackles

- popping and crackling noises
- better heard at end of inspiration
- may be heard in congestive heart failure and pulmonary fibrosis

Characteristics of Adventitious Sounds:
coarse crackles

- bubbling sounds
- heard during inspiration and expiration
- often a sign of adult respiratory distress syndrome (ARDS), early congestive heart failure, asthma or pulmonary edema.

Characteristics of Adventitious Sounds:
pleura friction rub

- low pitched, coarse rubbing or grating sound
- sounds like 2 surfaces rubbing together
- heard throughout inspiration and expiration
- loudest over the lower anterolateral surface

Signs of respiratory distress

- tachypnea
- shortness of breath
- retractions (intercoastal, infra/supra clavicular, infrasternal)
- cyanosis
- nasal flaring
- irritability
- changes in state of consciousness or behavior
- somnolence (drowsiness, restlessness)

When performing an ophthalmoscopic examination, the nurse examines the patient's right eye:

with the nurse's right eye and the patient's left eye with the nurse's left eye

What is the purpose of assessing a patients vision confrontation?

peripheral vision

A nurse hears inspiratory and expiratory wheezes bilaterally. What is the meaning of this finding?

narrowed airways

A nurse hears bronchovesicular sounds in the posterior chest on either side of the spine. This finding indicates

pleural effusion

The student nurse is reviewing the pathophysiology of inspiration. The primary muscles of inspiration are the diaphragm and the _____

external intercostal muscles

The nurse auscultates prolonged expiration with expiratory wheezing and diminished breath sounds while assessing a patient. What disorder does the nurse suspect?

Asthma