topic 7 - 316

what is the most accurate measure of visual acuity?

snellen chart

normal snellen result?

20/20 vision

what does 20/40 vision mean?

the patient sees at 20 feet what a person with normal vision sees at 40

if a pt cannot read the largest snellen letter, what should the nurse do?

move close and record the distance

how is near vision tested?

jaeger card held 14 inches from the eyes

normal near vision result

14/14

what test assesses extraocular muscle function

six cardinal positions of gaze

what abnormalities are assessed during EOM testing?

nystagmus, lid lag, and muscle weakness

what is nystagmus?

involuntary rhythmic eye movement

what conditions can cause pathologic nystagmus

stroke, multiple sclerosis, brain tumor, vestibular disorders

what is lid lag

upper eyelid lags behind eyeball when looking downward

lid lad is commonly associated with what disorder

hyperthyroidism (graves disease)

normal conjunctiva findings

clear, moist, pink over lower lid, white over sclera

what does excessive tearing suggest

nasolacrimal duct obstruction

what are brown scleral macules in african americans

normal pigmentation variation

what eye finding is associated with jaundice

yellow sclera

what does PERRLA stand for

pupils equal, round, reactive to light and accommodation

what cranial nerves are involved in the light reflex

CN II and CN III

what is the direct light reflex

constriction of the illuminated pupil

what is the consensual light reflex

constriction of the opposite pupil when light is shone into one eye

what is the normal accommodation response

pupillary constriction and eye convergence

what is anisocoria

unequal pupil size

what is miosis

constricted pupils

what is mydriasis

dilated pupils

what is presbyopia

loss of accomodation causing difficulty seeing near objects

four common causes of vision loss in older adults

catarcts, glaucoma, diabetic retinopathy, macular degeneration

what causes glaucoma

increased intraocular pressure causing optic nerve damage

what causes cataracts

lens opacity due to protein clumping

what causes age related macular degeneration?

degeneration of macular cells causing loss of central vision

what is conductive hearing loss?

problem in outer middle ear preventing sound transmission

causing of conductive hearing loss?

cerumen impaction, otitis media, perforated TM, otosclerosis

what is sensorineural hearing loss

damage to the inner ear, CN VIII, or auditory pathways

causes of sensorineural hearing loss

presbycusis, noise exposure, ototoxic drugs, meniere disease

what is presbycusis

high frequency hearing loss

what is otosclerosis

fixation of the stapes causing conductive hearing loss

what screeing test is used for hearing

whispered voice test

how is the whispered voice test formed

stand behind the patient, mask opposite ear, whisper 2-syllable words

normal whispered voice test result

correct repetition of whispered words

what is vertigo?

false sensation of spinning or movement

what part of the ear is responsible for balance

vestibular system of the inner ear

common symtoms associated with vertigo?

nausea, vomiting, imbalance, nystagmus

normal skull shape

normocephallic, round, and symmetric

normal facial assessment finding?

symmetric facial structures and movements

what abnormal facial finding is associated with bell palsy

unilateral facial paralysis from lower motor neuron lesion

what facial finding is associated with parkinson disease

masklike face, staring gaze, drooling

most common normal lymph node finding

not palpable

characteristics of normal lymph nodes

small soft mobile discrete nontender

abnormal lymph node findings

enlarged, hard, fixed, matted, tender

which lymph node is most concerning if enlarged

sypraclavicular node

normal tracheal position

midline

what should be assessed during neck ROM

flexion, extension, rotation and laterl bending

normal thyroid findings?

smooth, soft, symmetric, non tender

what should an enlarged thyroid be assessed for

bruit

normal external nose finding

symmetric and midline

how is nasal patency assessed

Occlude one nostril and ask the patient to sniff. repeat on the other side

what is epistaxis

nosebleed

during a nosebleed should the patient lean forward of backward

forward

why lean forward during a nosebleed

prevent aspiration and swallowing blood

which sinuses are palpated during assessment

frontal and maxillary sinuses

normal sinus assessment finding?

no tenderness

sinus tenderness suggests what condition?

sinusitis or infection

normal gums

pink/coral, stippled tight and well defined

normal tongue findings?

pink, moist, smooth, no lesions

what is leukoedema

benign gray white buccal mucosa finding common in african americans

what are fordyce granules

small yellow white papules normal finding

tonsil grade 1+

visible and small

tonsil grade 2+

halfway between pillars and uvula

tonsil grade 3+

touching the uvula

tonsil grade 4+

touching each other

normal tonsil findings?

pink, symmetric, no exudate, usually 1+ to 2+

what cranial nerves are tested by the gag reflex

CN IX and CN X