Chapter 15, 16, 17 | Eyes, Ears, Nose, Mouth, Throat | NURS 122

flashcard on the cranial nerves?

bony orbital cavity

surrounds the eyes and cushioned the eye with fat

eyelids (palpebrae)

protects the eye and control the light entry

conjunctiva

transparant membrane covering the sclera and lining the eyelids

lacrimal apparatus

system of structures the produces and drains tears to ensure moisture and remove debris

palpebral fissues

elliptical opening between eyelids

canthus

junction of the upper and lower eyelids

• inner canthus contains the caruncle which secrete sebaceous materials

caruncle

1. located in the inner canthus

2. secrete sebaceous materials

meibomian glands

1. located in the tarsal plates

2. secrete oils to prevent tear evaporation

what part of the eyes is involve in light refraction? (outermost to inner most)

1. cornea

2. aqueous humor

3. lens

4. vitreous humor

what is the neural pathway of the visual pathway starting from the eye to the brain?

1. retina

2. optic nerve

3. optic chiasm (where the fibers cross - lateralization of vision)

4. occipital lobe

what is the image orientation on the retina?

images on the retina are inverted and reversed

pupillary light reflex

constriction of the pupul in response to light

accomodation (reflex)

adjustments for near and far vision via lens curvature

sherpath

auricle

external ear

vestibule

a space or cavity that serves as the entrance to a passage way (e.g., vestibule of the ear)

semicircular canal

any of the three bony fluid-filled loops in the osseous labyrinth of the internal ear, associated with the sense of balance

cochclear

spiral tunnel with two full and three quarter-turns resembling a tiny snail shells that is associated with the sense of hearing

what are the ossicles of the ear?

1. malleus

2. incus

3. stapes

what are the three antomic division of the pharynx?

1. nasopharynx

2. oropharynx

3. laryngopharynx

the bony arch of the hard plate and the soft palate from the _______ of the mouth

roof

the tongie is secured to the oral cavity by the __________

frenulum

nares

anterior opening of the nose

septum

cartilaginous divider between the two anterior cavities (vestibules)

choana

posterior opening leading to the nasopharynx

turbinates

parallel curved bony structures covered by a vascular mucous membrane which forms the lateral walls of the nose and protrude into the nasal cavity

cribriform plates

bony plate on the roof of the nose

kiesselbach plexus

convergence of small fragule artries and veins in the nasal septum

what are the four paranasal sinuses and their general functions

1. maxillary

2. frontal

3. ethmoid

4. sphenoid

all of these provide humidification, filtration, voice resonance, skull lightening, thermal insulation, and shock absorption

on the _________ and the ________ sinuses are accesible for examination

maxillary; frontal

what are the main functions of the ears and associated structure)?

1. transmission of sounds impulses (cochlear)

2. responding to changes in movement vestibule of inner ear)

3. interpretation of sounds waves (tympanic membrane

4. drainage of fluid into the posterior aspect of the inferior nasal turbinate (eustachian tube)

what are the function of the nose?

1. olfaction

2. respiration

3. warming of air

4. humidification of air

5. filtering of the air

6. resonance of laryngeal sounds

which part of the pharynx does food, saliva, and liquid pass through on its way to the stomach?

oropharynx and laryngopharynx

what is the function of the salivary glands?

1. identify fastes

2. moisten the mouth

3. reduce the incidence of dental caries

4. start digestion of starch

The inner ear is composed of which of the following structures?

Auricle

Cochlea

Tympanic membrane

Stapes

cochlea

when asking about a patient history of present illness in relation to the ear, nose and mouth, what are the factors that the student should inquire the patient about?

1. symptoms (onset, duration, location, associated symptoms)

2. aggravating/alleviating factors

3. effort to treat

4. medication (e.g., analgesic, NSAIDS, narcotics, etc)

5. characteristics/severity/predisposing factors of the illness

what are some type of medication that can help alleviate symptoms of ear and nose illness?

1. analgesics

2. NSAIDs

3. narcotics

4. thyroid preparation

what are some type of medications that can help alleviate symptoms of the mouth and oropharynx illness?

1. analgesics

2. NSAIDs

3. narcotics

4. phenytoin

5. cyclosporine

6. calcium channel blockers

7. mouth rinse

8. lozenges

when asking about the patient’s medical-surgical history regarding the ears, what should the student nurse ask about?

1. history of ear infections

2. history of surgery to the ea

3. history of labyrinthitis (inflammation or dysfunction of the labyrinthine canals of the inner ear - resulting in vertigo)

when asking about the patient’s medical-surgical history regarding the nose, what should the student nurse ask about?

1. history of previous nasal trauma/fracture

2. history of chronic nosebleeds

3. history of pharyngitis

4. history of nasal surgery

5. history of postnasal drip

6. history of recurrent or chronic sinusitis

7. history of recurrent/chronic sinusitis

8. history of allergies

when asking about the patient’s medical-surgical history regarding the mouth/throat, what should the student nurse ask about?

1. history of frequent, documented strep infections

2. history of tonsillectomy (surgical excision of the palatine tonsil)

3. history of adenoidectomy (surgical removal of the lymphoid tissues in the nasopharynx)

why would someone chose to have a tonsillectomy?

some people may chose to remove their palatine tonsil to prevent recurrent tonsillitis

why would someone chose to have a adenoidectomy?

removal of the lymphoid issues in the nasopharynx may be performed because the adenoids are enlarged, chronically infected or causing obstruction

what are the factors that the student nurse should ask about when inquiring about patient’s family history of ears, nose, and throat illness?

1. allergies

2. hearing loss (e.g., Meniere disease)

3. hereditary renal diseases

what are some personal/social history that might predispose the patient to higher likelihood of developing ears, nose, and/or thorat infections?

1. environmental hazards (e.g., chemical exposure

2. nutritions

3. oral care patterns

4. tobacco/alcohol use

5. recreational drug use

6. protective devices

The nurse should ask the patient with ear pain about which associated symptoms as part of a history of present illness?

Select all that apply.

• Fever

• Ear drainage

• Decreased hearing ability

• Previous ear pain

• Association with exercise

Fever

The nurse should ask about fever as part of the history of present illness related to the patient’s ear pain.

Ear drainage

The nurse should ask about any ear drainage as part of the history of present illness related to the patient’s ear pain.

Decreased hearing ability

The nurse should ask about the ability to hear as part of the history of present illness related the patient’s ear pain.

Previous ear pain

Previous ear pain is part of the medical-surgical history, not history of present illness.

Association with exercise

Association of the ear pain with exercise is part of the personal/social history, not history of present illness.

Which questions should the nurse ask a patient with hearing loss regarding timing of symptoms as part of the history of present illness?

Select all that apply.

• “Did the hearing loss begin suddenly?”

• “How long has the hearing loss lasted?”

• “Are you sensitive to loud noises?”

• “Are you experiencing any pain?”

• “Is the hearing loss constant or intermittent?”

“Did the hearing loss begin suddenly?”

The nurse should ask whether the hearing loss was sudden or gradual when assessing the timing of symptoms as part of the history of present illness.

“How long has the hearing loss lasted?”

The nurse should ask how long the hearing loss lasted when assessing the timing of symptoms as part of the history of present illness.

“Are you sensitive to loud noises?”

The nurse should ask about sensitivity to noise to assess associated symptoms, not the timing of symptoms.

“Are you experiencing any pain?”

The nurse should ask about pain to assess associated symptoms, not the timing of symptoms.

“Is the hearing loss constant or intermittent?”

The nurse should ask whether the hearing loss is constant or intermittent when assessing the timing of symptoms as part of the history of present illness.

The nurse should ask the patient presenting with dental pain which questions as part of the history of present illness?

Select all that apply.

• “Do you wear dentures?’

• “Have you noticed any areas of irritation?”

• “How long have you had the pain?”

• “Do you have any family history of dental disease?”

• “How often do you see a dentist?”

• “Do you wear dentures?’

  The nurse should ask the patient with dental pain if he or she wears dentures as part of the personal/social history.

  “Have you noticed any areas of irritation?”

  The nurse should ask the patient with dental pain about any irritation he or she is experiencing related to the dentures as part of the history of present illness.

  “How long have you had the pain?”

  The nurse should ask the patient with dental pain about the duration of the pain as part of the history of present illness.

  “Do you have any family history of dental disease?”

  Asking the patient with dental pain about a family member’s dental disease is part of the family history and is not a part of the history of present illness.

  “How often do you see a dentist?”

  The nurse should ask the patient with dental pain about his or her dental visits as part of the personal/social history, not history of present illness.

The nurse should ask the patient presenting with nasal drainage which questions regarding the history of present illness?

Select all that apply.

• Associated symptoms of sneezing and congestion

• Parent or family member with seasonal allergies

• Color and amount of drainage

• Unilateral or bilateral

• Seasonality

Associated symptoms of sneezing and congestion

The nurse should ask about associated symptoms as part of the history of present illness.

Parent or family member with seasonal allergies

The nurse should ask about seasonal allergies but as part of the family history, not history of the present illness.

Color and amount of drainage

The nurse should ask about drainage characteristics as part of the history of present illness.

Unilateral or bilateral

The nurse should ask about laterality as part of the history of present illness.

Seasonality

The nurse should ask about seasonality as part of the history of present illness.

what factors should he student nurse note when inspecting the auricles and mastoid?

1. size, shape, symmetry

2. color

3. positions

4. preauricular area

5. external auditory canal

what factors should he student nurse note when palpating the auricles and mastoid?

1. mobility

2. consistency

what factors should he student nurse note when examining the inside of the ear?

1. audiotory canals

2. landmarks, color, contour, and mobility of the tympanic membrane

what are some different hearing examination that can be done?

1. whispered voice

2. Weber test

3. Rinne Test

the use of ________ is the preferred screening for hearing loss

audiometry

what are the different factors that the student nurse should assess for when examining the mouth and lips?

1. symmetry

2. color

3. condition

what are the different factors that the student nurse should assess for when examining the teeth and tongue?

1. occlusion

2. color

3. conditions

4. size

5. symmetry

6. color, coating, size, and presence of ulcerations of the dorsal surface of the tongue

7. ventral surface and floor of the mouth

8. lateral borders

9. number of teeth

10. texture

11. movement

what are the different factors that the student nurse should assess for when examining the oral mucosa and gums?

1. color

2. sweeling

3. symmetry

4. ulcerations

5. conditions

6. bleeding

7. loose teeth

8. tenderness

what are the different factors that the student nurse should assess for when examining the uvula and oropharynx?

1. color

2. landmark

3. movements

4. tonsils

5. posterior wall of pharynx

The nurse should assess for which findings by palpating the nose?

Select all that apply.

• Masses

• Tenderness

• Nasal flaring

• Shape and size

• Position of bones and cartilage

• Masses

• Tenderness

• Position of bones and cartilage

When inspecting the dorsum of the tongue, the nurse should note which features?

Select all that apply.

• Size

• Color

• Coating

• Ulcerations

• Tenderness

• Size

• Color

• Coating

• Ulcerations

what are the normal assessment findings for inspection of the ears?

1. auricles equal size/similar appearance

2. Darwin tubercle

3. same color as facial skin

4. top of auricle aligns or above inner canthus of the eye

5. auricle in vertical position

6. preauricular pits

7. skin tags

8. smooth skin

9. no discharge or odor

what are the normal assessment findings for the palpation of the ears?

1. firm and mobile auricle

2. flexible auricle readily recoil

3. no tenderness in postauricular or mastoid area

4. pre/postauricular lymph nodes not palpable

what is the normal assessment findings for otoscopic examination?

1. minimal cerumen (color/texture varies)

2. visible umbo, handle of malleus, and light reflex

3. translucent, pearly gray tympanic membrane

4. tympanic membrane slightly conical, concave umbo

5. tympanic membrane moves in and out with positive and negative pressure from pneumatic attachment

wha is the normal assessment findings for hearing screening?

1. patients respond appropriately to questions

2. patient repeats whispered words, numbers, letters more than 50% of the time

what is the normal assessment finding for the Weber Test?

sound heard equally in both ears when ears not occluded, sound heard better in non occluded ear

what is the normal assessment finding for the Rinne Test?

measurement of air conduction twice as long as measurement of bone conduction

what is the normal assessment finding (inspection & palpation) for the nose?

1. smooth

2. columella (directly midline, width not greater than diameter of naris)

3. color same as facial skin

4. nares oval shapes, symmetrical

5. patent bilaterally

6. firm, stable

7. patient is able to smell

what is the normal assessment finding (inspection & palpation) for the nasopharynx?

1. close to midline

2. thicker anteriorly than posteriorly

3. inferior and middle turbinate visible

4. possible film of clear discharge on septim

5. hairs in vestibule

what is the normal assessment finding (inspection & palpation) for the nasopharynx?

1. nontender

2. no swellng

what are the normal assessment findings for the teeth?

1. ivory, yellow-stained or brown

2. 32 teeth firmly anchored

what are the normal assessment findings for the tongue?

1. midline, no fasciulations

2. dull red color, moist, glistening

3. anterior: smooth with papillae and small fissures

4. posterior: slightly uneven.rugose, thinner mucosa

5. ventral surface: pink, smooth, large veins visible

6. wharton ducts on either side of frenulum

7. patient can taste

what are the normal assessment finding of the buccal mucosa?

1. whiteish yellow or whitish pink Stense duct

2. fordyce spots may be present

what are the normal assessment findings of the palate of the mouth?

1. hard palate: whitish, dome-shaped, tranverse rugae

2. soft palate: pinker, continuous with hard palate

3. uvula midline

4. torus palatinus: bony protuberance at midline

5. soft palate rises symmetrically with “ah”

6. uvula remains midline with “ah”

what are the normal assessment finding fo the throat and tonsils?

1. tonsils blend into pink pharynx

2. possible crypts in tonsils for debris collection

3. posterior oropharynx: smooth glistening pink

4. small lymphatic tissues spots and blood vessels

5. gag reflex present bilaterally

what are some mouth and throat changes associated with aging?

1. decreased salivary flow

2. thinning buccal mucosa

3. fissures/varicosities on tongue

4. malocclusion, missing teeth, dentures

5. the sense of taste begins to deteriorate at 50 years of age

what are some ear/nose changes associated with aging?

1. may have hearing aid

2. coarse hair on auricle

3. scleroic changes to tympanic membrane

4. presbycusis (conductive hearing loss)

5. cerumen impaction

nose/sinuses

1. dry mucosa

2. increased hairs on vestibules

3. decreased sense of smell in adults over age 60

true or false: nose flaring on inspiration is an abnormal finding?

true

true or false: polyps of the nose or sinuses is an abnormal finding

true

hyperemia

an excess of blood in part of the body caused by increase blood flow as in inflammatory response, local relaxation of arterioles, or obstruction of the outflow of blood from an area

rhinorrhea

AKA runny nose - excessive nasal discharge

During the examination of the ears, which finding is expected?

Auricle scales

Low-set ears

Flexible earlobes

Tenderness on palpation

Flexible earlobes

What ear assessment finding should be considered part of the normal aging process?

Tinnitus

Epistaxis

Angioedema

Presbycusis

Tinnitus

Tinnitus, or ringing in the ears, is an unexpected finding at any age.

Epistaxis

Epistaxis, or nasal bleeding, is not part of the ear assessment and not a normal part of the aging process.

Angioedema

Angioedema is not part of the ear assessment and not a normal part of the aging process.

Presbycusis

Presbycusis, or sensorineural hearing loss, is an expected finding in older adults.

Which of the following are normal findings of a mouth and throat examination?

Select all that apply.

• Uvula at midline

• Dorsal surface of tongue glistening

• Lips symmetrical vertically but not horizontally

• Hard palate continuous with soft palate

• 32 teeth, firmly anchored

• Uvula at midline

• Dorsal surface of tongue glistening

• Hard palate continuous with soft palate

• 32 teeth, firmly anchored

Which of the following are normal findings of a nose examination?

Select all that apply.

• Columella directly midline

• Septum thicker posteriorly than anteriorly

• Hairs in vestibule

• Inferior and middle turbinates visible

• Nares asymmetrical

Columella directly midline

The columella should be directly midline.

Septum thicker posteriorly than anteriorly

The septum should be thicker anteriorly than posteriorly.

Hairs in vestibule

There should be hairs in the vestibule.

Inferior and middle turbinates visible

The inferior and middle turbinates should be visible.

Nares asymmetrical

The nares should be symmetrical.

Which mouth and throat assessment findings should be considered abnormal?

Select all that apply.

• Nodule on the palate, not at the midline

• Tonsils that project beyond the tonsillar pillars

• Intact gag reflex

• Asymmetrical lips

• Red spots at the Stensen duct

Nodule on the palate, not at the midline

A nodule on the palate that is not at the midline is an abnormal finding in an assessment of the mouth and throat.

Tonsils that project beyond the tonsillar pillars

Tonsils that project beyond the tonsillar pillars is an abnormal finding in an assessment of the mouth and throat.

Intact gag reflex

Intact gag reflex is a normal finding in an assessment of the mouth and throat.

Asymmetrical lips

Asymmetrical lips are an abnormal finding on assessment of the mouth and throat.

Red spots at the Stensen duct

Red spots at the Stensen duct is an abnormal finding on assessment of the mouth and throat.

vertigo

illusion of rational movement by a patient, caused by disorder of the inner ear

• should documentL spontaneous episode of dizziness that is severe, difficulty walking, nausea and vomiting, and headaches

Meniere disease

1. sudden onset of vertigo

2. hearing loss

3. whistling/roaring sound in the affected ear

4. sensitivity to sound

5. fullness in ears

6. nausea and vomiting

what are some behavior associated with conductive hearing loss?

1. turns volume up on TV, radio

2. speech sounds muffled in noisy environment

3. asks to have information repeated

4. speaks softly

what are some behavior associated with sensorineural hearing loss?

1. people mumble

2. difficulty understanding speech

3. speaks loudly

4. unable to hear in crowded room

The nurse assesses a patient complaining of difficulty swallowing that began 1 month ago. The nurse notes the presence of enlarged tonsils, dry mucous membranes, and white spots on the tonsils. Which assessment information should the nurse document as history of present illness related to the ears, nose, and throat (ENT) assessment?

Select all that apply.

• Enlarged tonsils

• Difficulty swallowing

• White spots on the tonsils

• Dry mucous membranes
  

• Difficulty swallowing

• Dry mucous membranes

A patient with a history of dental caries reports pain with chewing. The patient smokes 1 pack of cigarettes each day and reports no dental visits for several years. The nurse notes a foul odor from the mouth and multiple discolored teeth. Which subjective assessment data should the nurse document as personal/social history related to a mouth assessment?

Foul mouth odor

Pain with chewing

History of dental caries

Patient’s cigarette habit

Patient’s cigarette habit

Which information suggestive of a thyroid condition should be documented under family history?

Tachycardia

Neck pain on palpation

Spouse with Graves disease

Father with Graves disease

Tachycardia

Tachycardia is objective data, not part of the family history.

Neck pain on palpation

Neck pain on palpation, as determined by the nurse, is objective data, not part of the family history.

Spouse with Graves disease

The patient’s spouse with Graves disease is not considered part of the family history because there is no genetic relationship between the patient and his or her spouse.

Father with Graves disease

The patient’s father with Graves disease is family history suggestive of a thyroid condition.

The nurse has a 36-year-old patient who is complaining of ear pain and difficulty hearing. The patient reports a family history of hearing loss. The patient has ear drainage and a retracted tympanic membrane on examination. Which should the nurse document as objective data related to the ear assessment?

Difficulty hearing

Ear pain

Ear drainage and retracted tympanic membrane

Family history of hearing loss

Ear drainage and retracted tympanic membrane

A patient with a history of ear trauma complains of right ear pain and muffled hearing. The nurse notes loss of high- and low-frequency sounds. Which objective information should be documented as a part of the ear assessment?

Select all that apply.

• Ear pain

• Muffled hearing

• History of ear trauma

• Loss of low-frequency sounds

• Loss of high-frequency sounds

Ear pain

The patient’s ear pain is history of present illness, not objective data.

Muffled hearing

The patient’s muffled hearing is history of present illness, not objective data.

History of ear trauma

The patient’s history of ear trauma is medical-surgical history, not objective data.

Loss of low-frequency sounds

Loss of low-frequency sounds, as determined by the nurse, is objective data related to the ear assessment.

Loss of high-frequency sounds

Loss of high-frequency sounds, as determined by the nurse, is objective data related to the ear assessment.

_____ to _____ mm is considered to be the most normal size pupil

2; 3

true or false: pupil are equal, round, reactive to light, and accommodating

true: PERRLA

fixation

a reflex direction of eye toward an object attrating a person’s attraction

slide 12

diabetic retinopathy

abnormal growth of blood vessels in the retina obstructing vision