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How is CN I assessed?
Patient clears nose to remove mucus, occludes one nostril, and identifies a scented object the nurse is holding.
What could an abnormality in CN I be due to?
- An olfactory tract lesion, tumor
- Lesion of the frontal lobe
- Nasal/sinus issue
- Smoking, cocaine
Ptosis may present in what condition?
A patient's eyes show smooth and coordinated movement in the superior rectus, inferior rectus, and inferior oblique directions. Which cranial nerve was assessed?
A patient's eyes show smooth and coordinated movement in the superior oblique direction. What cranial nerve was assessed?
A patient's eyes show smooth and coordinated movement in the lateral rectus directions. What cranial nerve was assessed?
The presence of nyastagmus may indicate __________________________
How do I know a patient has nyastagmus?
Patient shows rhythmic oscillation of the eyes
The presence of paralytic strabismus may indicate __________________________
Paralysis of the oculomotor, trochlear, or abducens nerves
What is an Argyll Robertson pupil?
When the pupil has an absent light reflex (but a present acommodation reflex
The presence of an Argyll Robertson pupil suggests _______________________
CNS syphilis, meningitis, brain tumor, alcoholism
If a patient's pupils remain dilated at 6-7 mm, what could be the cause?
Oculomotor nerve paralysis
What could cause constricted, fixed pupils?
Narcotics abuse or damage to the pons
What could cause a unilaterally dilated pupil that is unresponsive to light or accommodation?
Damage to the oculomotor nerve
What could cause constricted pupils unresponsive light or accommodation?
Lesions of the sympathetic nervous system
How is the trigeminal CN assessed?
Ask the patient to clench their teeth while you palpate the temporal and masseter muscles for contraction.
Asymmetric strength of the masseter and temporal muscles could be due to ___________________________________
Lesion or injury of the trigeminal nerve
What should the nurse tell the patient before assessing the sensory function of the trigeminal CN?
"I am going to touch your forehead, cheeks, and chin with the sharp or dull sensation. Also tell me where you feel it"
Inability to feel or correctly identify facial stimuli occurs with lesions of what CN?
If the nurse lightly touches the patient's cornea with a fine wisp of cotton, and the patient does not blink (absent corneal reflex), what nerve(s) could have a lesion?
Trigeminal CN or the motor part of the facial nerve
What type of pain would someone with a positive blumberg's sign test feel?
Sharp, stabbing pain as the examiner releases pressure from the abdomen
What does a positive blumberg's sign suggest?
Peritoneal irritation (as from appendicitis)
What type of reaction would be felt in a positive roysing sign?
Pain in the RLQ during pressure in the LLQ
What does a positive roysing sign suggest?
What type of reaction is felt in a positive murphy's sign?
Accentuated sharp pain that causes client to hold their breath (inspiratory arrest)
How would I assess for ascites?
Fluid waves are present if movement of a fluid wave against the resting hand suggests large amounts of fluid present
What does a positive murphy's sign suggest?
How should I assess for ascites?
To assess for psoas, what should. I ask the patient to do?
The nurse should ask the patient to lie on their left side. Hyperextend the client's right leg.
What would indicate the presence of psoas?
Pain in the right lower quadrant upon hyperextension of the right leg
How does a nurse assess for obturator?
The nurse would support the patient's right knee and ankle. Flex hip and knee, and rotate the leg internally and externally
How would the nurse know if there is an obturator?
Pain in the RLQ would present. Irritation of the obturator muscle d/t appendicitis or a perforated appendix.
I have a deep, constant, throbbing pain? It is pressure like pain in 1i specific area of the face and neck. What kind of headache do I have?
If I have a sinus headache, where does it hurt?
in 1 area of the face or along eyebrow ridge and below cheekbone
In what patterns is a sinus headache usually seen?
Sudden movements of the head, bending forward, lying down, sudden temperature change, in the morning
I have stabbing pain, accompanied by tearing, eyelid drooping, reddened eyes, and a runny nose. What type of headache do I have?
Characteristics of a tumor related headache
Varies with location of tumor, variable in intensity, felt in the morning; usually subsides later in the day; no prodromal stage, may be aggravated by coughing, sneezing, or sudden head movements
Characteristics of a meningitis related headache
Headache that moves into the neck causing neck pain with head flexion
Abnormal facial expressions: Moon-face with reddened cheeks and increased facial hair
Abnormal facial expressions: Expothalamos
Abnormal facial expressions: Dull, puffy face, edema around the eyes; dry, coarse, and sparse hair
Hypothyroidism and myxedema
Abnormal facial expressions: Tightened-hard face with thinning facial hair?
Abnormal facial expressions: Mask-like facial appearance; (+shuffling gait, rigid muscles, diminished reflexes)
What changes may be found upon palpation of the thyroid in an older adult?
Thyroid feels more nodular or irregular or found lower in the neck (fibrotic changes)
Potential causes of a nose ulcer
Cocaine use, trauma, chronic infection, chronic nose picking
If a patient cannot sniff through nostril that is not occluded, what are some potential causes?
Swelling, rhinitis, foreign object obstruction
Reddish lips may be d/t:
Ketoacidosis, carbon monoxide poisoning, COPD w/ polycythemia, or edema (allergic reactions)
Red, swollen gums that bleed easily may be d/t:
Gingivitis, vitamin C deficiency (scurvy), leukemia
Blue-black or grey-white line along the gum line suggests:
Chalky, white raised patches in the buccal mucosa suggests:
Leukoplakia may be d/t:
Chronic irritation, heavy smoking and alcohol use, precancerous
White spots lying over reddend mucosa suggest:
Early sign of measles (Koplik spots)
Brown patches in side cheeks suggest:
Black hairy tounge suggests:
Hyposalivation, heavy smoking and alcohol, antibiotics
A red, shiny, tongue suggests:
Niacin or vitamin B12 deficiency
A red, shiny, tongue without papillae suggests:
Niacin or vitamin B12 deficiency, anemia, antineoplastic therapy
Raised, white, feathery areas on side of tongue that are NOT removable suggest:
Hairy leukoplakias (HIV & AIDS)
White, removable plaques suggest:
Thick, white plaques on soft palate suggest:
A very small tongue suggests:
An atrophied tongue or fasciculations suggest:
Hypoglossal CN damage
List abnormal findings of the tonsils
Red, enlarged (2+, 3+, 4+), covered w/ exudate and white patches of yellow/white
Bright red & swelling = infection
White exudate = infectious mono, leukemia, diphtheria
Tenderness in the frontal or maxillary sinus suggests:
Allergies, acute bacterial rhinosinusitis
Large amounts of exudate in the sinuses suggest:
Viral upper respiratory infection, crepitus felt upon palpation over maxillary sinus
Receding gums become ischemic and undergo fibrotic changes as a part of normal aging. What are the clinical implications of this
Tooth surfaces may be worn from prolonged use; may be more susceptible to periodontal disease & tooth loss; teeth may appear longer due to gingival recession
Assessment of the eyes should examine ____________, __________________, ________________, _____________
- Visual acuity
- Pupillary response and accommodation
- Visual fields
- Extraocular movement
- Corneal light reflex test
Difference in size of pupils (brain injury)
Drooping upper eyelid (associated w/ diseases like myasthenia gravis)
Mydriasis may be d/t:
CNS injury, circulatory collapse, deep anesthesia
What does arcus senilis cause?
Lipid deposits in the edge of the cornea
Benign lesions on the eyelids (yellowish)
Superficial scratch on the cornea
Inflammation of the conjunctiva
Halos around light suggest:
What condition forms a white arc around limbus and is a normal part of aging? (Has no effect on vision)
Are visual floaters a normal occurrence in adults over 40 years old?
Congenital excessive enlargement of the external ear
Enlarged preauricular and postauricular lymph nodes suggests:
Non-tender, hard, cream colored nodules on the helix that contain uric acid crystals (tophi) suggest:
Blocked sebaceous glands suggest:
Ulcerated, crusted nodules that bleed suggest:
A pale, blue ear color suggests:
White spots in the ear suggest:
Scarring from infection
Foul-smelling, sticky yellow discharge and/or reddened-swollen canals suggests:
Otitis externa, impacted foreign body
Bloody purulent discharge of the internal ear suggests:
Otitis media with ruptured tympanic membrane
Impacted cerumen blocking the view of canal suggests:
Conductive hearing loss
Findings in external otitis:
Purulent, bloody drainage; redness, swelling of pinna and ear canal; itching, fever, enlarged tender regional lymph nodes
Findings in otitis media w/ perforation of the tympanic membrane:
Purulent drainage associated w/ pain and popping sensation; bloody, clear, or pus-like
Findings in otitis externa:
Pain when the pinna and tragus are moved
, purulent otorrhea (ear drainage), "Swimmer's ear"
Difference between conductive and sensorineural hearing
Conductive hearing: refers to sound waves transmitted by the external and middle ear
Sensorineural hearing: Sound waves transmitted by inner ear
Purpose of the Weber test:
Evaluate the conduction of sound waves through bone to help distinguish between conductive and sensorineural hearing
How is the Weber test performed?
Strike tuning fork with the back of the hand and place it at the center of the patient's head or forehead; ask if pt hears the sound better in one ear or same in both ears
What would indicate conductive or sensorineural hearing loss in a Weber test?
Conductive hearing loss is present if the pt "hears" sound in poor ear
Sensorineural hearing loss is present in hearing loss if the pt hears sound in good ear
Purpose of the Rinne test:
Compare ear and bone conduction sounds and determine cause of hearing loss
How is the Rinne test performed?
Strike a tuning fork and place base of the fork by mastoid process (ear) and ask pt to tell you when sound is no longer heard
What result of the Rinne test suggests conductive hearing loss?
BC > AC
What result of the Rinne test suggests sensorineural hearing loss?
AC > BC **
What are the major causes of distension below the umbilicus?
Full bladder, uterine enlargement, ovarian tumor/cyst
What are the major causes of a distended/protuberant abdomen?
Fat, feces, fetus (pregnancy), fibroids, flatulence, fluid
What are the major causes of distension above the umbilicus?
Masses of pancreas, gastric dilation
What would the percussion tone of a pregnant woman's abdomen sound like?
Tympany over intestines and dullness over uterus
What is the percussion tone over fat
What is the percussion tone over feces
Dullness over feces
What is the percussion tone over flatus
Tympany over area
What is the percussion tone over ascitic fluid
Dullness over fluid (bottom of abdomen and flanks), tympany over intestines (top of abdomen)
Separation between the 2 rectus abdominis muscles; appears as a midline ridge
An incisional hernia appears as a bulge near _______________________________
Surgical scar on abdomen
What organs should produce tympanic sounds when percussed?
Stomach and intestines
What organs should produce dullness when percussed?
Liver, spleen, non-evacuated descending colon
Hyperresonance in the abdomen suggests:
An enlarged area of dullness usggests:
Enlarged liver or spleen
An enlarged, nontender liver suggests:
An enlarged, tender liver suggests:
CHF, acute hepatitis, abcess
An enlarged nodular liver suggests:
Cancer, late cirrhosis, syphilis
A liver that is higher than normal suggests:
Abdominal mass, ascites, paralyzed diaphragm
A liver that is lower than normal suggests:
Decreased or absent bowel sounds suggest:
Total obstruction (!)
Hyperactive (>30/min) bowel sounds suggest:
How many bowel sounds should be heard within 1 minute?
Normal Rinne test result
AC > BC
Testing the gag reflex tests function of which CNs?
Glossopharyngeal and Vagus CNs
How is the spinal accessory nerve tested?
- Pt shrugs shoulders against resistance to assess trapezius muscle
- Pt turns head against resistance (first R, then L) to assess sternocleidomastoid muscles
"Light, tight, dynamite" is used to assess which CN?
This type of gait is wide-based, staggering and unsteady. The romberg test result is positive
This type of gait is shuffling , turns accomplished in very stiff manner, with stooped-over posture w/ flexed hips and knees
This type of gait is a stiff, short gait with thights overlapping each other with each step
Type of gait with flexed arm held close to body while pt drags toe of leg or circles it stiffly outward and forward
Gait in which patient lifts foot and knee high with each step, then slaps foot down hard; cannot walk on heels
Footdrop is seen in pt's with:
Abnormally small head
Large and thick skull and facial bones
Acorn-shaped, enlarged skull bones suggests:
Horizontal jerking movements suggest:
Head tilted to one side suggests:
Unilateral vision, hearing deficiency, shortening of sternocleidomastoid muscle
Hard, thick tender temporal artery with inflammation suggests:
Temporal arteritis (Acute, urgent condition that can lead to blindness)
Limited ROM, swelling, tenderness, crepitation in the temporal arteries suggests:
TMJ (Temporomandibular joint) syndrome
Enlarged, warm, tender, firm, moveable lymph nodes suggest:
Clumped lymph nodes suggest:
Enlarged, firm, non-tender, mobile (involves occipital nodes) suggest:
Hard, > 3 cm, unilateral, non-tender, fixed, matted lymph nodes suggest:
Rubbery, discrete, gradually appearing lymph nodes suggest:
Hard, non-tender, left supraclavicular node (Virchow's/Sentinel node) suggests:
Thoracic or abdominal cancer
Headache that is dull, tight, and diffuse
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