N308 Test 2

Eyes

100

Explain the difference between direct and consensual light reflex

What is direct light reflex occurs when the pupil constricts when a light is shined into it, and consensual is when the opposite eye also constricts

200

Name the purpose of two eye tests and how to perform them

What is Snellen, confrontation, cardinal positions, cover/uncover test, PERRLA

300

Name the eye cranial nerves, and what each does

What is II: vision III:eye opening, pupil constriction IV: eyes move inward and downward VI: lateral eye movement

400

Name two normal eye findings in the older adult

ptosis, decreased tears, presbyopia, decreased visual acuity

500

Which of the following would be considered normal when assessing a 30 year old patient's eyes? (select all that apply) A. presbyopia B. pupils diverge and constrict when testing accomodation C. conjunctiva is light pink D. Pupils are enlarge readily, reflect with light, and accomodate E. the patient's eyes track a moving finger without oscillating

C, E

Ears

100

name the three bones of the middle ear

malleus, incus, stapes

200

explain the difference between conductive, sensorineural, and mixed hearing loss

conductive: issue with the physical ear (excessive cerumen, scarring on tympanic membrane, etc.) sensorineural: issue with cranial nerve VIII mixed: conductive + sensorineural

300

What are 4 subjective questions that you can ask a patient regarding their ears?

earaches, infections, discharge, hearing loss, environmental noise, tinnitus, vertigo, sound protection

400

Explain the difference between the tympanic membranes of a patient with otitis media and a patient with otitis media with effusion

Otitis media: redness and bulging, along with pain and fever otitis media with effusion: amber yellow tympanic membrane from serum buildup in the middle ear

500

Which of the following would the nurse note as a cause for concern regarding an ear assessment? (select all that apply) A. a positive Romberg test B. the patient wears noise-cancelling headphones while at shooting range C. the patient uses Q tips to keep the ears free from cerumen and fluid buildup D. patient leans forward and looks at nurses mouth during conversation E. the tympanic membrane is gray

A, C, D

Neuro

100

Demonstrate decerebrate posture

upper extremities extended, internal rotation, lower extremities extended, plantar flexion

200

What movements result from stimulating the brachioradialis reflex?

supination and flexion of the wrist

300

What does the Glasgow Coma Scale measure?

eye opening, verbal response, and motor response

400

Name the three sensory functions that the spinothalamic tract is responsible for, and explain how you would test each.

Pain, temperature, light touch What is the posterior column tract responsible for?

500

A 24 year old patient with a history of multiple concussions explains difficulty differentiating between smells. Which of the following are primary appropriate actions by the nurse? (select all that apply) A. place an abrasive smell, such as an alcohol wipe, under the patient's nose to see if he is capable of smelling stronger scents B. test stereognosis and the patient's ability to discriminate sharp from dull C. call the doctor to report this finding D. test cranial nerves, with special attention to CN II E. inspect the patient's nares and alignment of septum

B, E

Musculoskeletal

100

Correctly demonstrate the following muscle movements: -eversion -dorsiflexion -supination

eversion: turn foot with sole facing outward dorsiflexion: toes toward nose supination: palms up (like holding soup)

200

While attempting to take an patient's blood pressure, she is resistive to movement and her arms remain stiffly flexed. She reports extreme pain when extending her bicep. What abnormal finding is she experiencing? A. dislocation B. subluxation C. contracture D. ankylosis E. crepitis

C. contracture (ankylosis is stiffness of a JOINT, she is experiencing shortening of her muscle which causes her pain)

300

A patient has full ROM against gravity, but has difficulty moving his extremities when resistance is applied to his muscles. How would you grade this? A. 6 B. 4 C. 3 D. 1 E. -1

B 0-5 scale 5: full ROM against gravity and full resistance 4: full ROM against gravity and some resistance 3: full ROM with gravity 2: Passive motion 1: slight contraction 0: no contraction

400

A 38 y.o. female presents to the physicians office for pain in her wrists. What are three appropriate actions by the nurse to gather objective data?

-inspect size of joint, comparing two wrist joints -palpate the joint for swelling or deformity -perform active ROM by having pt make a fist, flex and hyperextend the wrist, etc. -test muscle strength (hand grasps, move against resistance, etc.) -Phalen or Tinel test (explain procedure)

500

A 1 year old child is coming in for his check up. Which of the following signs would the nurse note as abnormal? A. genu varum B. natural inversion of the feet C. positive Ortolani's sign D. lumbar curvature of the spine E. positive Babinski sign

B (talipes equinovarus aka clubfoot) C clunking showing congenital hip dislocation

Cranial Nerves

100

For which cranial nerve would you have a patient smile, frown, and puff out their cheeks?

VII (facial)

200

How would you test cranial nerves IX and X?

have pt say ahh and observe how the tonsils and uvula move

300

A patient who is unable to clench her teeth and whose tongue does not protrude midline has issues with which cranial nerves?

V, VII

400

Name which cranial nerves are both sensory and motor (hint: there's 5)

III, V, VII, IX, X

500

Older adults commonly can have issues with which cranial nerves? (select all that apply) A. I B. III, IV, VI C. VII D. IX, X E. XI

A. decreased sense of smell B. decreased pupillary reflexes C. decreased muscle tone in face E. decreased muscle tone and strength