Nursing Health Assessement Exam 4

Front 1

List the 12 Cranial Nerves

Back 1

Olfactory, Optic, Oculomotor, Trochlear, Trigeminal,Abducens, Facial, Acoustic, Glossopharyngeal, Vagus, Spinal Accessory, Hypoglossal

Front 2

List the 12 cranial nerves function, sensory, motor, or both

Back 2

1 sensory 2 sensory 3 motor 4 motor 5 both 6 motor 7 both 8 sensory 9 both 10 both 11 motor 12 motor

Front 3

How many spinal nerves are there and what are they called?

Back 3

31 pair, dermatomes

Front 4

List some risk factors for CVA. (10/12)

Back 4

Older,African American,Obesity,Males,Familyhx,Pain meds,HTN,Previous CVA,TIA,DM,CAD,smoking

Front 5

Give the minimal distance to the area for 2-point discrimination.

· Palm of hand
· Upper arms
· Fingertips
· Forearms

Back 5

·Palm of hand- 8-12 mm or inch
· Upper arms – 3 inches
· Fingertips – 2-8mm
· Forearms – 1 1/2 inches

Front 6

What lobe of the brain is responsible for sensation?

Back 6

Parietal

Front 7

What would be a positive/abnormal finding for the Babinski’s test?

Back 7

Dorsiflexion of the great toe

Front 8

What DTR’s do we perform in our check off assessment?

Back 8

1. biceps
2. Triceps
3. Brachioradialis
4. Patellar
5. Achilles
6. Babinski’s

Front 9

What would be an abnormal finding of stereognosis test and what is it an indicator of?

Back 9

Unable to identify object in hand. Parietal lobe dysfunction or sensory nerve tract

Front 10

Where does brain activity cease when a pt is in a coma?

Back 10

There is no activity above the brain stem

Front 11

Write the DTR scoring with the correct description…

______ brisk, clonus
______ Sluggish / diminished
______ No response
______ Active / expected
______ slightly hyperactive

Back 11

__4+____ brisk, clonus
__1+____ Sluggish / diminished
__0 ____ No response
__2+____ Active / expected
__3+____ slightly hyperactive

Front 12

What score is considered abnormal when assessing a client with the Glascow Coma Scale?

Back 12

Less than 14 is considered abnormal

Front 13

List some risk factors for hearing loss… (4/6)

Back 13

Environmental noise, Autoimmune disease,Medications,hx of congenital hearing loss,Family hx, Age

Front 14

What does tenderness of the mastoid area indicate?

Back 14

Mastoiditis

Front 15

What is the description of cerumen of dark and white skinned individuals?

Back 15

Moist, sticky, and dark

Front 16

What is the description of cerumen for Asians, Native Americans, and Alaskans?

Back 16

Sparse, flaky, dry, and light

Front 17

What tests would you perform to evaluate CN VIII and explain abnormals…

Back 17

1.Whispered Test – under 50% of words repeated
2.Finger Rub test – if unable to hear, high frequency hearing loss
3.Weber’s Test – if not heard equally in both ears
4.Rinne test – if bone conduction is less than ½ of air conduction

Front 18

What FHP is used in the assessment of CN’s?

Back 18

Cognitive / Perceptual

Front 19

What tests do you perform for coordination?

Back 19

Rapid movements
Finger to nose
Finger to thumb
Heel to shin

Front 20

What arteries supply 80% of the blood to the brain?

Back 20

Carotid

Front 21

What arteries supply 20% of the blood to the brain?

Back 21

vertebral

Front 22

What 2 components make up the Autonomic Nervous System, describe.

Back 22

Sympathetic Nervous System – fight or flight response
Parasympathetic Nervous system – breed and feed

Front 23

What components make up the CNS?

Back 23

Brain and Spinal Cord

Front 24

What components make up the PNS?

Back 24

Cranial Nerves
Spinal Nerves

Front 25

List and give a description of the ABCd’s of pain

Back 25

A – affect – crying, anger

B – behavioral – what are they doing?

C – cognitive – what does this pain mean?

D – description – sharp, throbbing, rating

Front 26

What is the proper degree of ear position and alignment? How else would you measure proper ear alignment?

Back 26

10o and on a plane with occipit line

Front 27

What does the Romberg test look for?

Back 27

Tests for balance or equilibrium problems

Front 28

In older adults, how does hearing loss generally proceed?

Back 28

High frequency hearing loss to lower frequency hearing loss

Front 29

List and describe some common problems with the ears and auditory system

Back 29

obstructed ear canal – excessive cerumen,Foreign body,otitis externa (swimmers ear), Acute otitis media (infection of middle ear),Conductive hearing loss (air conduction),Sensorineural hearing loss (nerve of inner ear)

Front 30

What are some abnormal conditions of the eye?

Back 30

· Cataracts
· Glaucoma
· Macular degeneration

Front 31

Describe how the following cultures possibly react to pain. Asians - hispanics –
Native Americans - Japanese –
Kenyans - Italians -

Back 31

Asians - stoic hispanics – vocal Native Americans - stoic Japanese – stoic
Kenyans - stoic Italians - vocal

Front 32

Name the 4 lobes of the brain and their functions

Back 32

1.Frontal – motor, Broca’s area, awareness of self, emotion
2.Parietal – sensory, senses, touch, shapes and texture
3.Temporal – auditory, language comprehension
4.Occipital – visual

Front 33

For what Snellen or Rosenbaum reading do you refer your pt to the optometrist?

Back 33

Greater than 20/30

Front 34

What is presbyopia?

Back 34

Loss of elasticity of the lens of the eye

Front 35

Give the terms and abbreviations for the following….

Right eye

Left eye

Each eye

Back 35

Right eye – oculus dexter - OD

Left eye – oculus sinister - OS

Each eye – oculus uterque - OU

Front 36

What 3 FHP’s can be used for Mental Status / Pain?

Back 36

·Cognitive / Perceptual
·Coping – Stress Tolerance
·Self Perception – Self Management

Front 37

What rating is considered legally blind?

Back 37

20/200

Front 38

What tests do we perform for meningeal inflammation? Please describe how each is performed

Back 38

Kernig’s – lying flat, flex hip and extend knee
Brudinski’s – lying flat, flexion of neck

Front 39

What would be an abnormal finding of the above tests?

Back 39

Pain or reaction of the fetal position

Front 40

What are Deep Tendon Reflex’s?

Back 40

Spinal cord segmental responses

Front 41

What is esotropia?

Back 41

Inward (medially) deviation of the eye

Front 42

What is exotropia?

Back 42

Outward (laterally) deviation of the eye

Front 43

What does and abnormal light reflection indicate?

Back 43

Weak extraocular muscles

Front 44

What test do you perform if the light reflection is asymmetrical?

Back 44

Cover / uncover test

Front 45

What is perception and how does it affect mental status?

Back 45

The perception of a recent life even determines a person’s emotional or psychological reaction to it.

Front 46

What is known as the emotional brain?

Back 46

Limbic system

Front 47

What are the 3 neurotransmitters that regulate mood and maintain arousal?

Back 47

· Norepinephrine
· Serotonin
· Dopamine

Front 48

Holmes Readjustment Scale – what does it measure for

Back 48

· Mental health / stress

Front 49

In the Holmes Readjustment Scale, what levels are considered “good” and describe its findings.

Back 49

· Under 150 with a 1 in 3 chance of developing a serious illness in 2 years

Front 50

What other scales can you use for a mental health assessment?

Back 50

· Beck Depression
· Yesavage Geriatric Depression Scale

Front 51

What would you include in your exam of a depressed client?

Back 51

· Posture
· Movement
· Dress
· Hygiene
· Speech
· B/P
· H/R
· RR
· Weight
· UBW%
· Orientation tests
· Short memory
· Calculation
· Language
· Judgment
· Abstract

Front 52

How do we rate pain?

Back 52

On a scale of 1-10 with 0 being no pain and 10 being worst pain ever felt

Front 53

How do we, as nursing students and future nurses, view a patient’s pain?

Back 53

Pain is whatever a client says it is whenever a client says it occurs

Front 54

What chemicals are released at the time of pain?

Back 54

Prostaglandins

Front 55

List the risk factors for depression (4/5)

Back 55

1. Female (2:1)
2. Age (adolescents, adults btwx 24-44)
3. Genetics
4. Psychosocial environment (abuse, alcoholism, losses)
5. Personal characteristics (low self esteem, pessimistic

Front 56

List the risk factors for anxiety (3/3)

Back 56

1. Genetics
2. Physical health (sleep deprivation)
3. Psychosocial environment (finances, health, school work)
a. (****hahahahah ANY NURSING STUDENT AT USF

Front 57

List the type of pain for the following descriptions:

Back 57

· Phantom pain - true pain, produced by stimulation of a nerve
· Chronic pain - > 6 months
· Referred pain - pain in same spinal cord segment
· Acute pain - < 6 months, usually due to tissue damage

Front 58

What is the condition called in which the eyes are not directed at the same object or point?

Back 58

Strabismus

Front 59

What condition can cause yellowing of the sclera?

Back 59

Jaundice

Front 60

What condition is caused by opacity of the crystalline lens?

Back 60

Cataracts

Front 61

What is glaucoma?

Back 61

Increase in intraocular pressure

Front 62

What superficial reflexes do we perform in our check off assessment (one currently and one previously)?

Back 62

Babinski’s and Abdominal

Front 63

What governing body do we use for our Pain standards?

Back 63

JCAHO

Front 64

What is the Gate theory of pain?

Back 64

That is the gate can be blocked by other stimulus, the pain will not be felt or as severe.

Front 65

What are the 4 steps of pain explain each.

Back 65

1. Transduction – stimulus causes tissue damage releasing action potential and sensitizing substances
2. Transmission – action potential from site of damage to spinal cord
3. Perception – conscious experience of pain
4. Modulation – brain tries to inhibit impulses

Front 66

What 3 scales do we use to assess pain?

Back 66

1. McGill Pain Questionnaire
2. Analog Scales
3. FACES

Front 67

What are some indicators of Pain in older adults?

Back 67

· Fatigue
· Lethargy
· Anorexia

Front 68

Under what conditions in older adults can pain go under detected?

Back 68

· Dementia
· Denial
· Distraction

Front 69

Pain is an expected part of aging

Back 69

False?