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134 Cards in this Set
- Front
- Back
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What may dry and coarse hair indicate?
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hypothyroidism
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What may an increase in the silkiness and fineness of hair indicate?
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hyperthyroidism
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What things do you inspect the scalp for?
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inflammation
pustular eruption cysts warts moles insect bites flaking scaling |
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overproduction of sebum from the sebaceous glands of the hair follicles
causes greasy, scaly patches on the scalp |
seborrhea
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What causes seborrhea?
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stress and tension
(there is also a genetic predisposition) |
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What things do you inspect and palpate the skull for?
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tenderness
masses depressions lesions size shape |
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What things do you inspect the face for?
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size
shape symmetry any tics or abnormal movements |
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What 2 things do you inspect on the face to determine whether it is symmetrical or not?
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palpebral fissures
naso-labial folds |
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cranial nerve that innervates the nasal and oral mucosa, facial skin, and corneal reflex through its sensory branches
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trigeminal nerve (CN V)
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How do you test the sensory function of the trigeminal nerve?
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Touch the patient's face with the sharp and dull ends of a safety pin and have the patient tell you whether it is sharp or dull.
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How do you test the motor function of the trigeminal nerve?
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Ask the patient to clench his teeth while you palpate the temporal muscles (temporal area) and masseter muscles (jaw area) and note the strength of muscle contraction.
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How do you test the motor function of the facial nerve?
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Ask the patient to smile, frown, close both eyes, wrinkle forehead, puff out cheeks, and raise eyebrows. Observe for asymmetry and weakness.
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Where is skin color best assessed?
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In areas of least pigmentation:
sclera conjunctiva nail beds lips buccal mucosa tongue palms soles |
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Where is cyanosis best assessed?
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buccal mucosa
nailbeds |
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Where is jaundice best assessed?
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sclera
hard palate posterior aspect of tongue skin |
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How does pallor appear in a light-skinned person?
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whitish-gray
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How does pallor appear in a dark-skinned person?
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ashen gray or as a loss of red glow tones
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Where is pallor best assessed?
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nailbeds
lips mucous membranes conjunctiva |
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What part of the hand do you use to assess skin temperature?
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the dorsum (back)
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Skin turgor is an indication of:
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hydration status (it denotes the skin's elasticity)
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Where is skin turgor best assessed?
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sternum
forehead **beneath the clavicle in an older adult |
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skin lesion that is solely a color change, flat and circumscribed, of less than 1 cm
(ex. freckles, flat nevi) |
macule
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skin lesion that you can feel caused by superficial thickening in the epidermis
is solid, elevated, circumscribed, and less than 1 cm diameter) (ex. elevated nevus, wart) |
papule
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macule that is larger than 1 cm
(ex. mongolian spot, measles rash) |
patch
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skin lesion in which papules coalesce to form surface elevation wider than 1 cm; a plateaulike, disk-shaped lesion
(ex. psoriasis, lichen planus) |
plaque
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type of skin lesion that is solid, elevated, hard or soft, and larger than 1 cm
it may extend deeper into dermis than papule (ex. xanthoma, fibroma, intradermal nevi) |
nodule
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type of skin lesion that is superficial, raised, transient, and erythematous
has a slightly irregular shape due to edema ex. mosquito bite, allergic reaction |
wheal
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type of skin lesion that is larger than a few cm in diameter, firm or soft, deeper into dermis
may be benign or malignant (ex. lipoma, hemangioma) |
tumor
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type of skin lesion in which wheals coalesce to form extensive reaction
intensely pruritic |
urticaria (hives)
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encapsulated fluid-filled cavity in dermis or subcutaneous layer, tensely elevating skin
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cyst
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elevated cavity containing free fluid, up to 1 cm
a "blister" clear serum flows if wall is ruptured ex. herpes simplex, early chicken pox, contact dermititis |
vesicle
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type of skin lesion that is larger than 1 cm diameter and usually single chambered
superficial in epidermis it is thin walled, so it ruptures easily ex. friction blister, burns, contact dermatitis |
bulla
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type of skin lesion with turbid fluid in the cavity
circumscribed and elevated ex. impetigo, acne |
pustule
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What is the ABCDE mnemonic for the abnormal characteristics of lesions?
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Asymmetry
Border Irregularity Color Diameter greater than 6 mm Elevation and Enlargement |
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What may bilateral exophthalmos indicate?
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Graves disease
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What may unilateral exophthalmos indicate?
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a tumor or lesion
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What causes alopecia of the eyebrows?
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fungal infection
scaling lesions |
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What may cause ptosis of the eyelids?
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CN III (oculomotor) damage because it allows the lid to open and remain open
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What cranial nerve closes the eyelid?
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facial (CN VII)
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eversion of the eyelids common in the aging process and in scarring from eye injuries
only serious if it results in irritation to the cornea |
ectropion
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inversion of the eyelids
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entropion
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fatty substance the lubricates the eyelids
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sebum
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What deveops when the sebaceous glands of the eye become infected?
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stye (hordeolum)
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What are the signs of infection in the eyelids?
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crusting
scaling hair loss |
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comprises the nasolacrimal ducts, lacrimal gland, ducts, and sacs
primary function is to create tears that keep the eyes moist and clean |
lacrimal apparatus
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openings in the inner canthus of the upper and lower eyelids
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puncta
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transparent membrane over the sclera
it appears a whitish color because of the sclera beneath it |
bulbar conjunctiva
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lines the inner surface of the upper and lower eyelids and is reddish (full of tiny blood vessels) in color
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palpebral conjunctiva
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What does paleness of the palpebral conjunctiva indicate?
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anemia or chronic diseases
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inflammation of the bulbar conjunctiva
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conjunctivitis (pink eye)
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What color may the sclera appear in dark-skinned individuals?
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gray-blue
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What is the normal size of the pupils?
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3-5 mm for an adult
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What does PERRLA stand for?
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Pupils Equal, Round, React to Light, and Accomodation
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What 3 cranial nerves are associated with pupillary reaction to light and pupillary reaction to accomodation?
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oculomotor (III)
trochlear (IV) abducens (VI) |
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What can affect the pupil's reaction to light?
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increased intracranial pressure (IICP)
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In the test for pupillary reaction to light, normally the illuminated eye ________ and the other pupil ______ simultaneously.
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constricts
constricts (this is the direct and consensual reaction to light) |
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the eye's adaptation to near vision
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accomodation
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What happens to the eyes when you bring an object toward the nose?
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pupils constrict and eyes converge
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When you pause at each position in the Cardinal positions of gaze test, you are looking for:
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nystagmus (abnormal rhythmic oscillations of the eyes)
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In the Cover-Uncover test, you are looking for:
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any movement in the once covered eye as it attempts to refocus on the designated object
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In the Corneal Light Reflex (Hirshberg Test), the cornea should reflect the light in exactly the same place in both eyes. An asymmetrical reflex indicates:
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strabismus (deviating eye, cross-eyed, squinting) due to muscle weakness
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How do you test for diplopia (double vision)?
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Have the patient identify how many fingers you are holding up.
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The corneal reflex test, in which you touch the patient's cornea with a wisp of cotton to see if they blink, involves the sensory function of which cranial nerve?
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trigeminal (CN V)
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Which cranial nerve is involved in the visual fields (confrontation), visual acuity, and color discrimination tests?
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optic nerve (CN II)
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What does the visual fields (confrontation test) test for?
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glaucoma
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chart used to test a person's long distance visual acuity
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Snellen chart
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When performing an ophthamoscopic exam, where shoud the nurse stand?
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in front of the patient, about 10 inches and 15 degrees to the right of the patient's line of vision
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Moving the diopters on the ophthalmoscope compensates for:
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nearsightedness and farsightedness
(red #s are for nearsightedness and black #s are for farsightedness) |
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What are you looking for with the ophthalmoscope?
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red reflex
retinal vessels optic disc general background of retina macula |
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caused by the reflection of light off the inner retina
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red reflex
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What does the red reflex indicate?
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that the lens is free of opacity (cataract) and cloudiness
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What do retinal arteries look like in comparison to retinal veins?
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retinal arteries will be a lighter brighter red
veins will be larger and darker |
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a round, yellowish orange to creamy pink structure seen by the ophthalmoscope
it should be lighter than the retinal background |
optic disc
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What is located within the optic disc?
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physiologic cup (it is a brighter yellow than the rest of the disc)
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What should the general background of the retina look like?
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light red to dark brown-red depending on the person's skin color
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located temporal to the optic disc
the area of the retina with the greatest visual acuity and greatest sensitivity to light |
macula
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What do you inspect the external ear for?
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size
configuration location angle of attachment to the head |
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What do you inspect the external ear canal for?
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color
intactness buildup of cerumen general hygiene discharge redness swelling *also palpate for nodules and tenderness |
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What do you use to inspect the internal ear canal and tympanic membrane?
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otoscope
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For an adult or older child, pull the ear ___________ when inserting the otoscope.
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up and back
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For an infant or child under 3, pull the ear _________ when inserting the otoscope.
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down
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What do you inspect the internal ear canal for?
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redness
swelling lesions foreign bodies discharge |
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What color should the tympanic membrane be?
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shiny, pearly gray or light pink and free of lesions
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What does a deep pink or red tympanic memebrane indicate?
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inflammation (otitis media)
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What does a blue tympanic membrane indicate?
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accumulation of blood
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What does bulging of the tympanic membrane indicate?
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fluid or pus behind the membrane (otitis media)
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What does a sunken tympanic membrane indicate?
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dehydration
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What is the cone of light on the tympanic membrane?
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a reflection of the otoscope light
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Where will the cone of light be located in the right ear?
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5 o' clock
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Where will the cone of light be located in the left ear?
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7 o' clock
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What are the 4 tests you can perform to test the sensory function of the acoustic nerve (CN VIII)?
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whisper test (voice test)
Weber-lateralization test Rinne test Schwabach test |
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In the Weber-lateralization test, a conductive hearing loss will cause the sound to be lateralized to:
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the impaired ear because solids such as cerumen and exudate conduct sound better
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In the Weber-lateralization test, a sensori-neural hearing loss will cause the sound to be lateralized to:
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the good ear
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problem in exterior/middle ear
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conductive hearing loss
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inner ear problem
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sensori-neural hearing loss
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test that compares air and bone conduction
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Rinne Test
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What should the ratio of air conduction to bone conduction be?
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sound should be heard twice as long by air conduction
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What happens in the Rinne test when the patient has a conductive hearing loss?
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the bone conduction will be longer than air conduction because the vibration through the middle ear is blocked and vibration through bone bypasses obstruction
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What should the external portion of the nose be inspected for?
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deviations in size, shape, and color
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How do you assess the patency of the nares?
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by asking the patient to occlude one ala nasi while breathing through the other
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What should the nasal cavity be inspected for?
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Mucosa should be moist, pink, and free of swelling, lesions, and drainage.
Middle and inferior turbinates should be the same color as the nasal mucosa. Look for areas of pallor, redness, swelling, or polyps. Note any areas of rhinitis (inflammation ) or epistaxis (bleeding from nose). |
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What will the mucous membranes of the nose look like in a person with allergies such as hayfever?
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swollen
boggy pale or grayish |
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If you note any nasal drainage, what should you describe about it?
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color
consistency (frothy, watery, tenacious) amount (scant, moderate, copious) odor |
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When you are examining the nose, what sinuses should you palpate?
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frontal (either side of the nose under the eyebrows)
maxillary (lower part of the cheekbones) |
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How do you test the sensory function of the olfactory nerve (CN I)?
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Instruct the patient to close his eyes and occlude one ala nasi. Provide a familiar scent for the person to smell.
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An absence of smell may result from:
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excessive smoking
sinus condition cocaine use |
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What should you inspect the lips for?
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symmetry
color edema fissures herpes simplex |
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What should you palpate the lips for?
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moistness
induration (hardness) intactness lesions |
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In a dark skinned person, the mucosa of the mouth will appear:
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patchy brown
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How many teeth do adults have?
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32
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What do you use to inspect and palpate the tongue?
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a gloved hand and a piece of gauze
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What should you inspect the floor of the mouth for?
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cyanosis
pallor lesions nodules |
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The floor of the mouth is a common site for:
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oral cancer
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When the patient says "Ah", what rises in the mouth?
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the uvula and soft palate
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When the uvula and soft palate rise when a person says "Ah", this tells us that which cranial nerve is intact?
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vagus (CN X)
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What does the pharynx of a smoker look like?
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yellowish red with small nodules
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The gag reflex and taste test on the posterior third of the tongue involve what two cranial nerves?
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glossopharyngeal (CN IX)
vagus (CN X) |
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When the gag reflex is absent, what is suspected?
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a lesion
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What test checks the sensory function of the facial nerve (CN VII)?
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taste test on the anterior 2/3 of the tongue
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What test checks the motor function of the hypoglossal nerve (CN XII)?
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Instruct the person to move the tongue from side to side and touch the roof of the mouth.
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What should you inspect the neck for?
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color
symmetry masses enlargement of the thyroid or lymph nodes abnormal pulsations impaired range of motion lesions scars |
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Name the lymph nodes in the head and neck that you feel for:
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submental
submandibular tonsilar preauricular postauricular occipital posterior cerivical anterior cervical supraclavicular infraclavicular |
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Delimitation of the lymph nodes means:
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whether they are discrete or matted together
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Tender lymph nodes suggest:
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infection
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Hard, fixed lymph nodes suggest:
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malignancy
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To check the thyroid, tell the patient to swallow a sip of water. The thyroid and cartilage should:
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rise as the person swallows
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an enlarged thryoid gland
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goiter
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What should you do if the thyroid is visibly enlarged?
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do NOT palpate it!
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Why do you inspect and palpate the trachea?
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for any deviation from the midline
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What causes deviation of the trachea?
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mass
atelectasis aneurysm pneumothorax |
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What muscles does the spinal accessory nerve innervate?
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trapezius
sternocleidomastoid |
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a blowing sound that indicates a distortion of a blood vessel that could interfere with blood flow
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bruit
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What do you auscultate the carotid arteries for?
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bruits
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If the thyroid gland feels enlarged, auscultate the thyroid for:
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bruits (they will occur due to accelerated blood flow through the gland)
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