Cranial Nerves
This cranial nerve lets you raise your eyebrows, puff your cheeks, and smile.
What is Cranial Nerve VII (Facial)?
During a normal respiratory assessment, the nurse expects this sound to be heard over most of the lung fields.
What is vesicular breath sounds?
This heart sound is created by the closure of the mitral and tricuspid valves.
What is S1?
This pulse is located behind the knee and can be difficult to palpate.
What is the popliteal pulse?
This area of the breast extends into the axilla and is a common site for breast cancer development.
What is the Tail of Spence?
This nerve controls most of the eye’s motor movement—upward, downward, and inward gaze.
What is Cranial Nerve III (Oculomotor)?
intercostal muscles are drawn inward between the ribs and indicates airway obstruction
What are chest retractions
This jugular finding reflects right atrial pressure and may be distended in heart failure.
What is jugular vein distention?
These vessels return blood to the heart through muscle contraction and one-way valves.
What are veins?
These small bumps on the areola are sebaceous glands that become more prominent during pregnancy.
What are Montgomery glands?
When you ask the client to stick out their tongue, this cranial nerve allows it to move midline.
What is Cranial Nerve XII (Hypoglossal)?
When assessing the nails, a normal nail bed angle is approximately this many degrees; a larger angle may indicate chronic hypoxia and clubbing.
What is 160 degrees
This abnormal heart sound, often called the “ventricular gallop,” may be heard in fluid overload or heart failure.
What is S3?
This scale is commonly used to document the strength of peripheral pulses.
What is the 0–3+ pulse scale?
(0 = absent, 1+ weak, 2+ normal, 3+ bounding)
During a breast exam, the nurse asks the client to sit with arms raised, hands on hips, and leaning forward to check for this sign of possible malignancy.
What is retraction or dimpling?
This cranial nerve depresses the eye so you can look down and inward, using the superior oblique muscle.
What is Cranial Nerve IV (Trochlear)?
This bluish discoloration of the skin, lips, or nail beds indicates inadequate oxygenation and is best assessed in the mucous membranes of dark-skinned clients.
What is cyanosis?
This sound, heard with the bell of the stethoscope over the carotid artery, suggests turbulent blood flow.
What is a carotid bruit?
This condition occurs when lymphatic drainage is blocked, causing unilateral swelling.
What is lymphedema?
This condition results from blocked or damaged lymphatic drainage after a mastectomy and causes swelling of the affected limb.
What is lymphedema?
This cranial nerve helps elevate the shoulders and turn the head against resistance.
What is Cranial Nerve XI (Spinal Accessory)?
This low-pitched, grating sound heard during both inspiration and expiration occurs when the pleura become inflamed and rub together.
What is a pleural friction rub?
hese extra heart sounds are caused by rapid ventricular filling or atrial contraction and are best assessed with the patient in the left lateral position.
What are S3 and S4?
Cool skin, weak pulses, pale color, and pain with elevation describe this type of insufficiency.
What is arterial insufficiency?
This abnormal breast finding presents as thickened, pitted skin resembling an orange peel and may indicate lymphatic obstruction from cancer.
What is peau d’orange?