Hello Head & Neck
The most common site of oral cancer and should be examined by the nurse when conducting an oral exam.
What is under the tongue?
This visual emergency may manifest in the client suddenly seeing floaters, flashing lights or a curtain over their vision.
What is a detached retina?
This is utilized to assess risk for developing a pressure ulcer. Risk factors include immobility, increased moisture, shearing and decreased nutrition.
What is the Braden Scale?
To assess hydration of a client the nurse would utilize the following technique.
What is pinching the skin over the clavicle to check for slow recoil?
A patient is complaining of difficulty breathing when lying flat in bed. The nurse would document this abnormal finding as this.
What is orthopnea?
The nurse is conducting a throat exam and notes the tonsils to touch the uvula. When grading the tonsils the nurse notes this in the documentation.
What is Grade III?
0- removed
+1 barely visible
+2 between pillars and uvula
+3 touching uvula
+4 touching each other
Hold your finger or a pencil 12-15 inches away from client's face. Ask the client to focus on it while you move towards the client. A normal response is the pupils constrict.
What is testing for accomodation?
There are 2 types of this bluish skin color. One resulting from a cardiopulmonary problem and the other from vasoconstriction. To differentiate the nurse would assess the oral mucosa.
What is central and peripheral cyanosis?
What is Acrocyanosis?
(Persistant cyanosis is indicative of a congenital heart defect)
The nurse knows to assess the apical pulse at this anatomical position.
State the exact location.
What is midclavicicular at the fifth intercostal space?
The patient you are caring for has been admitted for Cushing Syndrome due to an increased cortisol level. You would expect the patient to present with the following appearance. (List 2 of the 3 characteristics)
What is moon shaped face, reddened face and facial hair?
When reviewing the medical record of an older client the nurse notes the patient to have presbycusis. The nurse knows this means the following.
What is bilateral, gradual hearing loss?
A dark skinned client would be assessed for erythema by utilizing this assessment technique.
Certain medications such as anti-hypertensives, anti-histamines and chemotherapy may cause xerostomia otherwise known as this.
What is dry mouth?
In order to assess the pulse of a newborn the nurse would utilize one of these two methods.
What is assess the brachial pulse or listen to the apical pulse?
A patient presents with "the worst headache of their life", nausea/vomiting and appears in severe pain. The nurse would be concerned for the following condition.
What is an intracranial hemorrhage?
The nurse asks the patient to cover one eye while the nurse observes for movement of the eye in an abnormal fashion.
What is the Cover Test?
A pressure ulcer is noted to be covered with slough and eschar would be assigned this stage by the nurse.
What is unstageable?
(The wound be is not visible due to slough and therefore can not be assigned a stage).
The systolic pressure is a reflection of the pressure in the arteries as the heart does this.
What is contracting?
A 4 day old infant presents to the pediatrician for a fever of 102. This condition is assumed until otherwise proven.
What is meningitis?
When the nurse is assessing these, use the flat pads of your fingers and gently palpate the surface. An abnormal finding would be a sunken or bulging area.
What are the fontanelles?
-The posterior fontanelle closes around 2-4 months.
- The anterior fontanelle may remain open until 18 months of age.
Testing for this can be done by holding your finger 12-15 inches from the patients eyesight and moving closer to the patient. A normal response would be pupil constriction.
What is testing for accommodation?
An elevated, palpable containing serous fluid and measuring 1cm on the right, upper back.
What is a bulla?
(Vesicle is noted to be less then 0.5cm and bulla are noted to be greater then 0.5cm)
After taking a patients radial pulse the nurse notes the pulse to be 108 and irregular. The next assessment the nurse would conduct would be this.
Name the 5 assessment indicators noted in the APGAR scoring.
What is
Activity / Pulse / Grimace / Appearance / Respiration