A&P
State the 4 cranial bones
Frontal
Parietal
Occipital
Temporal
Mandible has hinge joint
Maxilla is stationary
State an expected variation of the head
Slight asymmetry
Aging client = dry, brittle hair and thinning.
Expect = Symmetrical eyes and nares, round with prominences in frontal, parietal and occipital bones + mastoid process. Proportional with the body, that is midline with the trunk. Skin uniform in color and smooth without lesions or edema.
Unexpected: significant asymmetry, lumps, protrusion, sunken areas, ecchymotic areas, lesions, redness, hair loss, edema, tense facial expressions, hirsutism, small oval white particles.
What is the level of consciousness? (one per table)
1.65-year-old. MVA. Awakens to shaking, falls asleep shortly after. (table 1, 2)
2.40-year-old, drug overdose. Awakens to sternal rubs. (table 3, 4)
3.45-year-old. CABG. Awakens to the door opening. (table 5, 6)
4.80-year-old. Hemorrhagic stroke. Does not awaken to sternal rubs or nailbed pinching. (table 7)
1.Lethargic
2.Stuporous
3.Alert
4.Comatose
A nurse performed an assessment and suddenly the client has facial drooping. What is the nurses' next action(s)?
1. Perform a FAST assessment (facial-CN 5/7; arm-extremity strength x10 seconds, speech with orientation/comprehension, time-this began/call help).
2. Obtain VS. Notify the provider if the nurse suspects a stroke.
3. Risk for falls - fall safety precautions: call for help, call button within reach, frequent checks, bed low, floor mats, bed alarm if not following commands, clear and safe environment (throw rugs, cords, toys)
A nurse plans to assess the 6 P's of a neurovascular assessment to rule out compartment syndrome. Which items will the nurse assess? (Select all that apply)
A. Pulses
B. Sensation
C. Movement
D. Color
E. Pressure
F. Pain
A-F
•Pulses for pulselessness
•Sensation for Paresthesia
•Movement for paralysis
•Color for pallor
•Pressure
•Pain
State one component and its function of the eye
Eyelids - protect from injury, light, dust
Eyelashes/Eyebrows - filter dust, dirt
Lacrimal gland - secretes tears for moisture
Conjunctivae - mucous membraneslining eyeball and eyelids
Cornea - transparent layer covering iris/pupil
Sclera - tough, protective white covering majority of the eyeball
Iris - eye color, contains muscles for pupil dilation
Pupil- regulate amount of light
Pupillary light reflex - expected constriction when bright light shines onto the retina
Lens - bends light rays towards retina by adjusting its thickness
6 muscles - coordinated eye movement, innervated by 3 CN: 3, 4, 6 (Oculomotor, Trochlear, Abducens)
State two (2) unexpected findings of the eyes.
Exophthalmos: bulging eyes
Strabismus: cross eye
Eyebrows ending before the temporal canthus
Brows not moving when attempted
Eyebrow scaling or flaking
Eyelid redness, edema, dropping, not closing the eyelids
Sclera discoloration (green or yellow)
Subconjunctival hemorrhage
Conjunctivitis
Pupils unequal in size, not PERRLA, cloudy, 1-3 mm or 7-9 mm in "normal" light
What is the Glasgow Coma Scale?
1.59-year old. PE. Opens both eyes when spoken to, obeys commands, and oriented conversation.
2.20-year old. Alcohol intoxication. Opens both eyes to sound, obeys commands, and inappropriate words during conversation.
3.30-year old. Motorcycle accident. Eyes open to pain, abnormal flexion, and incomprehensible sounds.
4.65-year-old (yo). SA. Never opens eyes, no motor response, no verbal response.
5. 21-yo. Head injury. Eye open to pain, withdraws extremities, inappropriate words
6. 32-yo. Anaphylaxis. eyes open to speech, shifts arm away from the pain, confused conversation
7. 45-yo. hemorrhagic stroke. Opens eyes to pain, decerebrate posturing, no sounds produced even with pain.
Measure Eye-opening, Motor response, and Verbal response (3-15 points)
1.15 (4+6+5)
2.12 (3+6+3)
3.7 (2+3+2)
4.3 (1+1+1)
5. 9 (2+4+3)
6. 12 (3+5+4)
7. 5 (2+2+1): Abnormal extension
A nurse performed an assessment and suddenly the client complains of sudden vision difficulties. What is the nurses' next action(s)?
1. Assess for any foreign body in the sclera and conjunctiva: observe for tearing, redness, edema.
2. Assess eye drainage, pupil size, shape, and response to light.
3. VS
4. Notify provider, document. *if trauma without foreign body, apply an eye patch until provider evaluates!
5. Risk for falls: maintain light, call light in reach, clear pathways.
A nurse is going to test cranial nerve VII, which assessment is most appropriate?
A. Direct and consensual pupillary reaction to light.
B. Corneal reflex by touching the cornea with a wisp of cotton.
C. Vision by using Snellen eye chart.
D. Have the client smile and clench their teeth.
D. Have the client smile and clench their teeth.
A: CN III (pupillary reflex)
B: Corneal reflex
C: CN II, distance vision assessing for myopia (struggle with) or hyperopia (good)
State one component and its function of the ears
External ear (auricle or pinna) transfers sound waves into the external auditory canal.
Cerumen - prevents foreign matter from reaching TM.
Tympanic Membrane (TM) separates external and middle ear
Middle ear - contains malleus, incus, stapes that work together when TM vibrates. Also contains eustachian tube opening (middle ear connection with nasopharynx).
E-tube - pressure equalization between middle ear and environment. Yawning or swallowing closes.
Inner ear - balance and equilibrium - CN 8 (auditory)
Cochlea with Organ of Corti - allows hearing to occur d/t transmission of electrical impulses to the brain.
State an expected finding of the ear.
Auricle appears symmetric in size & placement.
The color is uniform with the rest of the face.
Intact without lumps, edema, or lesions.
Cerumen may be noticed at the canal's opening. It may be gray-yellow, tan, or black in color, and its texture is moist and waxy or dry and flaky.
Expected variation: family trait of small, large, or atypical shape.
Tonsils are rated on a scale of 0-4+. Describe each of the following rating (one per table)
0
1+
2+
3+
4+
0: Absent
1+ (normal): Tonsils are hidden behind the tonsillar pillars
2+: Tonsils extend to the edges of the tonsillar pillars
3+: Tonsils extend beyond the edges of the tonsillar pillars but not to the midline. Complications?
4+: Tonsils extend to the midline and may touch. Complications?
A nurse is going to perform an assessment on a client who called the nurses' station complaining of ear pain. What is the nurses' next action(s)?
1. Wash hands upon entering the room.
2. Obtain subjective data, observing closely how the client is hearing and speaking
3. Inspect: Auricle and outer ear.
4. Palpate: external ear and mastoid area, pinna, and tragus.
5. VS, Document, notify provider of unexpected findings.
A client reports an inability to move their tongue. Which assessment would be the most appropriate for the nurse to perform?
A. Test the hypoglossal nerve
B. Test the facial nerve.
C. Test for sensory function.
D. Test the trochlear nerve.
A. Tongue movement is controlled by the hypoglossal CN XII
B. Assesses cheek puffing, eyebrow-raising, clenching teeth; taste on anterior tongue.
C. Does not assess motor function.
D. Trochlear is CN IV (eye movement aka cardinal fields of gaze, along III and VI)
State one cranial nerve that innervates the nose or oral cavity
CN - 1: olfactory (nose)
CN - 5, 7, 9, 10, 12
5: Trigeminal (movement of oral cavity)
7: Facial (taste, facial movement, salivary stimulation)
9: Glossopharyngeal (Taste, gag, swallow)
10: Vagus (rise of soft palate, uvula movement)
12: Hypoglossal (tongue movement)
State one unexpected finding of the nose and sinuses.
Allergies: Pale mucosa with clear discharge
URI: Bright red mucosa with mucoid discharge
Bacterial Infection: Bilateral yellow or green discharge. Unilateral foreign body if foul-smelling, yellow or green discharge.
Skull fracture: unilateral watery discharge, assess for HALO sign
A nurse needs to fully assess the eyes. State one test the nurse will perform.
Snellen (E, numbers, pictures): Distance: CN 2
Jaeger, Rosenbaum: Near, can use newspaper: CN II
Cardinal fields of gaze (Extraocular movements): H or wheel: CN 3, 4, 6
PERRLA: CN III
Accommodation
Corneal light reflex
Ishihara test: Cones of the eye "color" assessment
Peripheral vision (subjective d/t assessing own opposite eye that is also covered)
A nurse completed the subjective questions and vital signs on a client whose chief complaints is sinus issues. What is the nurses' next action(s)?
1. Inspect nasal mucosa with penlight, observing drainage color, consistency, and smell.
2. Palpate for obstruction by pressing on each side of the nares while the client inhales with their nose.
-Frontal and Maxillary Sinuses with light illumination.
3. Document, notify provider, educate client appropriately.
The nurse assesses the client's optic nerve with the Snellen chart. The results are 20/25, the client asks "what does that mean?" The nurse's best response would be:
A. "You can read at 25 feet what most people read at 20 feet."
B. "Your left eye can see the chart at 20 feet while the right eye can see it at 25 feet."
C. "You can read at 20 feet what most people can read at 25 feet."
D. "You can read the chart perfectly with both eyes."
C. Numerator = client; denominator = others. This client may be myopic "nearsighted"
State 1 lymphatic node of the head/neck, and demonstrate its location by palpating it on yourself.
Preauricular / Parotid
Posterior auricular
Occipital
Posterior / Deep cervical chain
Supraclavicular
Anterior cervical chain (superficial)
Submental
Submandibular (submaxillary)
Retropharyngeal (tonsillar)
State one unexpected finding of the mouth.
B12 deficiency: Smooth or dark red swollen tongue
Gingivitis: swelling of the gums with redness and bleeding
Liver disorder: yellow discoloration of the hard palate
Infection: petechiae, lesions, edema, or drainage
Thrush (Fungal): Soft white plaques that can be rubbed off, leaving a red open area.
Tonsillitis: red, edematous uvula and pillars with yellow exudate, c/o sore throat.
Canker sore or aphthous ulcer: painful round ulcer with a white base and red halo surrounding the white area.
The nurse is going to fully assess the ears. State one test the nurse will perform.
Otoscope: full inspection
Whisper test
Weber: midline of the skull with tuning fork
Rhine: Mastoid process with tuning fork (bone conduction), then air conduction
Romberg: Balance with eyes open and closed.
Cranial Nerve 8: Auditory (acoustic, or vestibulocochlear)
A client is in ER triage and has a lump on the front of their neck. What is the triage nurses' next action(s)?
1. Inspect and react to any respiratory distress (stridor, inability to speak a sentence, difficulty swallowing, accessory muscle usage).
- HELP! (get to a room)
-HOB elevate, VS (Sa02), oxygen supplementation
2. Obtain subjective data.
3. Auscultate the trachea for stridor d/t obstruction of airway.
-NPO until provider assesses. Document.
The nurse is assessing the client's lips and notes a bluish tinge. This finding would indicate to the nurse that the client may be experiencing which problem?
A. Beginning of a canker sore.
B. Lack of dental care.
C. Inflammation of the lips.
D. Hypoxia
D. Hypoxia.
B may result in gingivitis.
C findings would be redness, swelling, or tenderness