Assessment Skill Set (Including Cranial Nerves)

Front 1

What is the difference between a shift assessment / head-to-toe assessment and a focus assessment?

Back 1

A focus assessment is one that is focused on the patient's presenting issue. A shift assessment / head-to-toe assessment is an assessment of the entire patient.

Front 2

Define inspection.

Back 2

Assessing using your sense of vision to inspect.

Examples of when this is used include skin irritation, wound healing, pupil dilation, Etc.

Front 3

Define palpation.

Back 3

Assessing using touch.

Examples of when this is used include temperature of the skin, feeling for masses, assessing for tenderness upon palpation, etcetera.

Front 4

Define percussion.

Back 4

Assessing using the fingers and striking with the other hand to listen to changes in Pitch.

Examples of when this is utilized include approximate heart location, lungs, Etc.

Front 5

Define auscultation.

Back 5

Assessing using a stethoscope to listen to different sounds in the body.

Examples of when this is used include bowel sounds, heart sounds, lung sounds, Etc.

Front 6

Define olfaction.

Back 6

Assessing using your sense of smell.

Examples of when disses used include assessment of urine, feces, drainage, Etc.

Front 7

Describe how pupillary reflexes are assessed.

Back 7

Dim the room light. Have the patient look straight ahead. Use your pen light side to side and see if the pupils constrict to adjust for light, bilaterally.

Have the patient focus on a distant object. Then have the patient focus on a near object such as a pen, and see if the pupils accommodate for distance.

Front 8

Normal pupils are ____, ____, and ____ in ____ and ____.

Back 8

Round

Clear

Equal

Size

Shape

Front 9

In a cardiovascular assessment, identify eight areas of subjective data you will ask the patient.

Back 9

Dyspnea on exertion

Chest pain / discomfort

Palpitations

Excessive fatigue

Nausea

Leg pain / cramps

Lightheadedness

Weakness

Front 10

What is a bruit? What causes it? How is it assessed?

Back 10

A bruit is an audible vascular sound associated with turbulent blood flow.

It can indicate pathology, such as atherosclerotic stenosis.

Is assessed by auscultation with a stethoscope at the heart, cervical arteries and veins, and AV connections. They may be palpated as a thrill AKA vibration.

Front 11

Describe the technique for assessing jvd. What does excessive pressure signify?

Back 11

Place the patient in a Supine position with the head of the bed elevated 30 degrees. Visually examine the neck on both sides, with the patient's head turned in the opposite direction.

Excessive pressure can signify cardiovascular / valve diseases, COPD, tension pneumothorax, cardiac tamponade, pericarditis, and others.

Front 12

Describe the method for assessing pitting edema.

Back 12

The nurse would press and area form leave for 5 seconds and then release. The depth of the indentation that remains after the nurse releases the area determines its severity. The nurse can also use a tape measure to measure the circumference of the extremity in order to compare down the road.

Front 13

In describing edema, what measure can be used?

Back 13

1+ = 2mm

2+ = 4mm

3+ = 6mm

4+ = 8mm

Front 14

Why are peripheral pulses palpated bilaterally?

Back 14

Peripheral pulses should be symmetric in quality and quantity. Palpating then bilaterally, except the Carotid pulses, allows for comparison to check for any potential issues.

Front 15

When palpating peripheral pulses, what scale is used? How are they defined?

Back 15

0= no detectable pulse

1+= weak pulse, which likely indicates arterial impairment

2+= normal pulse, no arterial disease, no reduction in arterial flow

3+= full pulse, greater than expected, possible high blood pressure / autonomic neuropathy

4+= bounding pulse, much greater than expected, probable autonomic neuropathy, possible aneurysm

Front 16

Compare and contrast venous and arterial insufficiency in regards to color.

Back 16

In venous insufficiency, the color is normal or cyanotic; darker discoloration is present when more severe.

In arterial insufficiency, the color is pale; when extremity is elevated, it worsens. Dusky red when extremity is lowered.

Front 17

Compare and contrast venous and arterial insufficiency in regards to edema.

Back 17

In venous insufficiency, edema is common because the blood struggles to leave.

In arterial insufficiency, edema is uncommon because blood is having trouble arriving.

Front 18

Compare and contrast venous and arterial insufficiency in regards to pulse.

Back 18

In venous insufficiency, pulses are present.

In arterial insufficiency, pulses are decreased or absent.

Front 19

Compare and contrast venous and arterial insufficiency in regards to skin changes.

Back 19

In venous insufficiency, brown pigmentation around the ankles is present.

In arterial insufficiency, skin is thin and shiny, with decreased hair growth and thickened nails.

Front 20

Compare and contrast venous and arterial insufficiency in regards to temperature.

Back 20

In venous insufficiency, skin temperature is normal to touch.

In arterial insufficiency, skin temperature is cool to the touch.

Front 21

What is the potential significance of a discrepancy in bilateral pulse assessment?

Back 21

It may include peripheral vascular disease, deep vein thrombosis, other obstructions / circulatory problems.

Front 22

How are bowel sounds assessed?

Back 22

Before palpation, but during / after a visual inspection, use a stethoscope to oscillate the patient's abdomen in each of the four quadrants. The patient should be lying Supine and flat. If you don't believe you have heard bowel sounds, make sure to listen to each quadrant for 5 minutes each.

Front 23

Normal bowel sounds occur irregularly every ___ to ___ seconds.

Back 23

5 to 15

Front 24

What may hypoactive for absent bowel sounds indicate?

Back 24

Bowel obstruction, necrotizing vowel, or other issues affecting peristalsis. This would be an expected finding if a patient is recently post-op due to sedation.

Front 25

What observations are made when assessing a patient's gait?

Back 25

Stability / coordination / balance

Speed

Use of assistive devices or improvised assistive devices such as Walls, Furniture, Etc.

Foot dragging

Weakness

Shuffling

Limping

Position of the upper body during ambulation

Front 26

How is the patient's level of Consciousness assessed?

Back 26

Arouseability

Identifying their name

Identifying their location

Identifying the day of the week / date / year

Stating the reason for being in the hospital

Front 27

As LOC declines, what signs / symptoms May a patient exhibit?

Back 27

They may not answer questions, become irritable, become unwilling to cooperate, have a short attention span, increased difficulty to wake up, Etc.

Front 28

The diaphragm of a stethoscope can be used to auscultate:

Back 28

Breath sounds

Heart sounds

Blood pressure with manual cuff

Front 29

The bell of a stethoscope is used to auscultate:

Back 29

Heart murmurs

Some bowel sounds

Front 30

Before beginning a head-to-toe assessment, which things should you do?

Back 30

Perform hand hygiene, explain the procedure, provide for privacy and comfort, and check ID band. Raise the bed to a working level.

Front 31

During a head-to-toe assessment, how can you assess pain?

Back 31

Whether it is present or not present, it's location, description, and treatment. If the patient is in pain, they may have difficulty participating in the head to toe assessment.

Front 32

During a head-to-toe assessment, how do you assess psychosocial issues?

Back 32

Ask patient if they have any fears or anxieties, monitor their behavior, ask who their support person is, ask if they are employed and what they do for work, as well as their living situation.

Front 33

During a head-to-toe assessment, how can you assess neurological function?

Back 33

If they're alert and oriented times 4, if their face is symmetrical, their speech, Vision, head, neck, ears, nose, tongue, oral cavity, grips, CMS, numbness, tingling, pupils (shape, size, accommodation for light and distance)

Front 34

During a head-to-toe assessment, how do you assess respiratory function?

Back 34

If the patient is using oxygen or uses oxygen at home, if they have a cough and if it's productive, listen to anterior and posterior lung sounds, ask about work of breathing, check chest rise symmetry, check mucous membranes for color and moisture, examine nail beds for their color and shape.

Front 35

During a head-to-toe assessment, how can you assess cardiovascular function?

Back 35

Skin color, CRT, heart sounds including the aortic, pulmonic, tricuspid and mitral, apical pulse rate, jvd, pulses including temporal, carotid, brachial, radial, ulnar, femoral, popliteal, posterior tibial, and dorsalis pedis, edema, whether it's pitting or non pitting, hair growth, calf tenderness, and IV site (redness, swelling, pain, patency, warmth)

Front 36

During a head-to-toe assessment, how can you assess gastrointestinal function?

Back 36

Visually inspect the abdomen, auscultate bowel sounds, palpate the abdomen, ask the patient about any distension, as well as their diet type, appetite, any occurrences of nausea, vomiting, diarrhea, constipation, gas, note the presence of any drains and the type, ask the patient about their last bowel movement including when their last BM was, color, and consistency.

Front 37

During a head-to-toe assessment, how can you assess genitourinary health?

Back 37

Ask the patient when they last urinated, note if it was from a void or through a catheter, the urine's Clarity, color, odor, ask the patient about any Dysuria, changes in urgency, frequency, or the presence of any dribbling or bladder distention. Ask the patient if they have had a steady stream of urine, note any redness, discharge, or itching in the private area. Do a visual assessment. Note any abnormalities, wounds, sores, etc. Ask the patient about their last menstrual period if it applies.

Front 38

During a head-to-toe assessment, what can you evaluate in regards to musculoskeletal function?

Back 38

Range of motion, and whether it's active or passive, the patient's previous level of function, upper and lower extremity strength or weakness, joint swelling, stiffness, or tenderness, assess a patient's gait, ask if they use any assistive devices, check to see if they are on a special bed, or are in restraints.

Front 39

During a head-to-toe assessment, how can you assess the patient's integumentary system?

Back 39

Visually inspect the skin, check the color and temperature, and note any moisture in the skin, assess for turgor, rash, petechiae, ecchymosis, as well as the presence of any tattoos, body piercings, wounds, dressings, old incisions / scars, examine pressure areas and bony prominences, assess for redness, edema, ecchymosis, drainage, and accommodation of any wounds, as well as any areas of non blanchable redness. MAKE SURE TO ASSESS THE PATIENT'S POSTERIOR SIDE AS WELL.

Front 40

Upon finishing a head-to-toe assessment, what should you do?

Back 40

Make sure that the bed is low and locked, that the side rails are up, the call light is Within Reach, and the room is tidy.

Front 41

What equipment do you need in order to performing a head-to-toe assessment?

Back 41

Gloves

Thermometer

Watch with a second hand

Stethoscope

BP cuff

Penlight

Tape measure / ruler

Tongue blade

Front 42

Back 42

Front 43

What is the landmark for the listening to the aortic heart sound?

Back 43

The right sternal border at the second intercostal space

Front 44

What is the landmark for the mitral heart sound?

Back 44

The fifth intercostal space, midclavicular line. It is where the apical heart rate is taken.

Front 45

What is the landmark for the pulmonic heart sound?

Back 45

Left sternal border, 2nd intercostal space.

Front 46

Where is the landmark for the tricuspid heart sound?

Back 46

The fourth intercostal space, left sternal border

Front 47

What are the priorities during assessment?

Back 47

Airway

Breathing

Circulation

Focused assessment

Front 48

The first cranial nerve is the ___ nerve. It isn't routinely tested. It should be tested however, if a patient has a head injury or reports an impaired or absent sense of ___.

Back 48

Olfactory

Smell

Front 49

The second cranial nerve is the ___ nerve. It plays the leading role in regards to ____.

Back 49

Optic

Visual acuity and visual fields

Front 50

How can you assess cranial nerve 1?

Back 50

Have the patient close their eyes and presenting a familiar, non pungent irritating substance, such as coffee and see if they can identify it.

Front 51

How can you assess cranial nerve 2?

Back 51

For acuity, you can use a Snellen chart, but if one is not available you can use a newspaper. If they can't do that, hold up several fingers and ask them to tell you how many there are. To test near Vision, you can ask them to read the paper upon handing it to them.

For visual Fields, stand facing the patient, an arm's length away. Have the patient cover their right eye while you cover your left. Ask the patient to look at your uncovered eye. Hold a brightly colored objects in your other hand and extend that arm out, slowly moving from the periphery to the center of the visual field. Have the patience saying now when they first see the object. You should both notice it at the same time. Assess in different directions.

Front 52

The third cranial nerve is the ___ nerve. It controls ___ and ____.

Back 52

Oculomotor

Pupil size

Eye/eyelid movement (with CN 4--trochlear & 5--abducens)

Front 53

How can you assess cranial nerve 3?

Back 53

Pupil accommodation

Have the patient look different directions or track your fingers

Check for extraocular movements or rapid involuntary movements of the eyeballs

Drooping of the eyelids

Front 54

The fifth cranial nerve is the ____ nerve. It has 3 branches and they control ____.

Back 54

Trigeminal

Facial sensation and motor function

Front 55

What are the three branches of cranial nerve 5?

Back 55

Ophthalmic

Maxillary

Mandibular

Front 56

How can you assess cranial nerve 5?

Back 56

Have the patient close their eyes then gently rub the patient's face (forehead, cheeks, and chin) with a piece of cotton and have them saying now when they feel the stimulus.

Front 57

The seventh cranial nerve is the ____. It controls the ____ and the movement of the ____.

Back 57

Facial

Corneal reflex

Lips and cheeks

Front 58

How can you assess cranial nerve 7?

Back 58

Observe the face at rest noting signs of weakness such as a drooping mouth. And ask the patient to smile, frown, open their eyes wide, razor eyebrows, show their teeth, puff out their cheeks, purse their lips.

You can also assess their sense of taste, by placing salt or sugar on the sides of the tongue and see if they can identify it.

Front 59

The eighth cranial nerve is the ___. It controls ____ and ____.

Back 59

Acoustic

Hearing

Equilibrium

Front 60

How can you assess cranial nerve 8?

Back 60

Have a patient cover one ear and hold a ticking watch or have your fingers together a few inches from the other ear. Do the same with the other ear.

If you suspect heading loss, in order to determine if it's conductive (caused by a defect in the middle or outer ear) or sensorineural (due to inner ear or acoustic nerve damage), strike a tuning fork and place it on top of the patient's head centering it. If it is conductive hearing loss the sound will be louder in the affected ear. If the problem is sensorineural, they'll hear it better in the unaffected ear. (The Weber test)

To test to the vestibular portion, ask the patient if they're experiencing dizziness, vertigo, or loss of balance.

Front 61

The ninth cranial nerve is the ____ and it stimulates the ____. The tenth cranial nerve is the ___ and it stimulates the ____.

Back 61

9th: glossopharyngeal; sensation to the pharynx, the tonsils, and the posterior third of the tongue.

10th: vagus; muscles of the pharynx, larynx, and palate.

Front 62

The 9th and 10th cranial nerves can be assessed together by ____.

Back 62

Eliciting the gag reflex

Can also have the patient say ahh while you look in their mouth. The uvula should rise but not deviate either side. Then ask the patient to swallow. If they're both intact, they should be able to do so without difficulty.

Speech is also controlled in part by the vagus nerve. Listen to the patient talk. If their voice sounds nasal they may have pharyngeal paralysis. Hoarseness or inability to make high-pitch sounds can signal vocal cord weakness.

Front 63

The eleventh cranial nerve is the ____ and it controls the ____.

Back 63

Spinal accessory nerve

Sternocleidomastoid and trapezius muscles

Front 64

You can assess cranial nerve 11 by:

Back 64

Having the Patient turn their head while you hold your hand against their cheek and Shrugged their shoulders while you press down on them

Front 65

The 12th cranial nerve is the ____ and it controls the ___.

Back 65

Hypoglossal nerve

Tongue's movement

Front 66

You can assess cranial nerve 12 by:

Back 66

Noticing that patient has difficulty forming words (dysarthria), such as seen in stroke patients. With a lesion of central nerve 12, the tongue deviates to the weaker side.

Front 67

On Old Olympus towering top, a Finn and German viewed some hops.

This is a:

A. Rhyme used to test facial nerve function

B. Mneumonic Device for the names of the cranial nerves

C. Device for testing the motor portion of the trigeminal nerve

D. Tool used to determine if a cranial nerve is sensory or motor

Back 67

B. Mnemonic device for the names of cranial nerves

Front 68

Damage to the hypoglossal nerve will result in ___.

A. Dysarthria

B. Tinnitus

C. Menstrual irregularities

D. Unequal pupil size

Back 68

A. Dysarthria

Front 69

Which nursing assessment is most appropriate when evaluating the second cranial nerve?

A. Have the patient identify odors.

B. Test the patient's balance.

C. Check the patient's gag reflex.

D. Have the patient read a newspaper aloud.

Back 69

D. Have the patient reading newspaper aloud.

Front 70

Which is not a branch of the trigeminal nerve?

A. The acoustic branch

B. The maxillary branch

C. The mandibular branch

D. The ophthalmic branch

Back 70

A. The acoustic branch

Front 71

The nurse checking a patient's pupillary response to light is testing the

A. Olfactory nerve

B. Optic nerve

C. Oculomotor nerve

D. Optic and oculomotor nerves

Back 71

C. Oculomotor nerve

Front 72

Which Finding may indicate damage to the vagus nerve?

A. Inability to make a high-pitched sound

B. Absence of the corneal reflex

C. Drooping of the mouth

D. Inability to shrug the shoulders

Back 72

A. Inability to make a high-pitch sound

Front 73

Non-obstructive anosmia is related to dysfunction of the

A. Olfactory nerve

B. Oculomotor nerve

C. Abducens nerve

D. Vagus nerve

Back 73

A. Olfactory nerve

Front 74

Which test can be used during the physical exam to determine whether unilateral hearing loss is conductive or sensorineural?

A. Audiometry

B. The Whisper test

C. The watch tick test

D. The Weber test

Back 74

D. The Weber test

Front 75

The consensual pupillary response is tested by

A. Asking patients if they have trouble closing their eyes

B. Directing a light toward one eye and observing the pupil of the opposite eye

C. Instructing the patient to cover one eye While You observe the opposite eye for extraocular movements

D. Evaluating the ability of the patient's eyes to converge

Back 75

B. Directing a light toward one eye and observing the pupil of the opposite eye

Front 76

When assessing a patient who has a hypoglossal nerve lesion, the nurse can expect to find that the patient's

A. Uvula does not rise

B. Eyelids droop

C. Tongue deviates to one side

D. Gait is unsteady

Back 76

C. Tongue deviates to one side

Front 77

Which substance is not appropriate for testing the patients sense of smell?

A. Ammonia

B. Coffee

C. Cinnamon

D. Vanilla

Back 77

A. Ammonia

Front 78

The most appropriate way to evaluate the motor portion of the trigeminal nerve is to

A. Ask the patient to move their head from side to side.

B. Assess a patient's ability to pick up small objects.

C. Instruct the patient to clench their teeth while you palpate the temples and jaw.

D. Have the patient look up, down, and sideways.

Back 78

C. Instruct the patient to clench their teeth while you palpate the temples and jaw.

Front 79

Which cranial nerve allows the eyes to look downward toward the nose?

Back 79

The trochlear nerve

Front 80

Salt is placed on the side of the patient's tongue to evaluate the ___.

Back 80

Facial nerve

Front 81

Cranial nerve 11 supplies

Back 81

The muscles of the shoulders and neck

Front 82

Which of the following does not control eye movement?

A. The optic nerve

B. The oculomotor nerve

C. The trochlear nerve

D. The abducens nerve

Back 82

A. The optic nerve

Front 83

One way to test the vestibular function of the acoustic nerve is to

A. Check the auditory studies.

B. Ask the patient if they experience dizziness.

C. Have the patient shrug their shoulders.

D. Perform the watch tick test.

Back 83

B. Ask the patient if they experience dizziness.

Front 84

Bell's Palsy is a condition involving which cranial nerve?

Back 84

The facial nerve -- cranial nerve number 7

Front 85

When checking the gag reflex, the nurse is testing the ____ and ____ nerves.

Back 85

Glossopharyngeal and vagus nerves