NSE 103 FINAL EXAM QUESTIONS WITH CORRECT ANSWERS LATEST UPDATE 2026

NSE 103 FINAL EXAM QUESTIONS WITH CORRECT ANSWERS LATEST UPDATE 2026 What are the main components of the ophthalmic system? - Answers Eyelids, eyebrows, palpebral fissures; pupil, iris, sclera, lens, cornea, conjunctiva, and canthus; lacrimal apparatus; extraocular eye muscles; retina and optic nerve. Which cranial nerve is primarily responsible for visual acuity? - Answers CN II (optic nerve). What should be asked about corrective lenses during assessment? - Answers When they began, reasons for wearing, frequency of wear, issues, last eye specialist appointment, and vision changes since last appointment. What are some visual impairments to note? - Answers Blurry vision, double vision, floaters, halos around lights, blind spots, difficulty seeing at night. What types of eye discharge should be noted? - Answers Clear (normal), persistent watery (allergies, blocked duct, infection), yellow/green/white (infection). What conditions can lead to dry or gritty eyes? - Answers Insufficient tears, aging, hormones, medications, environment, and diseases affecting blinking. What should be noted about discoloration and pruritus in the eyes? - Answers Reddened or yellow whites of eyes, itching, bumps, and open sores should be assessed. What is blepharitis? - Answers Blepharitis is characterized by red, swollen, irritated eyelids. What does a brief scan in eye assessment involve? - Answers Quickly recognizing signs, changes, and deterioration. What are observable cues of vision impairment? - Answers Eyeglasses, cane, prosthesis, patch, using hands for guidance, bumping, squinting, and difficulty maintaining eye contact. What is the normal alignment of the eyeball? - Answers Normally aligned, not protruding or sunken. What are common lesions found during eye assessments? - Answers Hordeolum, chalazia, and intraocular hemorrhage. What should be noted about the cornea, lens, and sclera during an assessment? - Answers Cornea should be smooth, lens and cornea clear, sclera white or soft greyish-blue in darker skin. What is the normal appearance of the conjunctiva? - Answers Transparent, slightly pink, with visible vessels and no lesions/swelling/foreign bodies. What should be prioritized in cases of eye trauma? - Answers Any sudden change in vision, eye pain, and signs of infection. What should be assessed when evaluating a patient with false eyelashes? - Answers Look for signs of inflammation. What is ptosis and what can cause it? - Answers Ptosis is the drooping of the eyelid, which can be age-related or congenital. What is the pupillary light reflex and how is it assessed? - Answers It assesses cranial nerves II and III by shining a penlight in the eyes and observing for direct and consensual responses. What does PERRLA stand for in ocular assessments? - Answers Pupils Equal, Round, Reactive to Light and Accommodation. What indicates a 'blown' pupil and why is it serious? - Answers A 'blown' pupil is dilated, fixed, and unresponsive, indicating potential brain herniation. What is the wiggle finger method used for? - Answers To assess peripheral vision. Stand 3-4 feet away, have the client fixate on your nose, stretch arms to superior quadrants, wiggle one finger, and the client points to the moving side. Repeat for other quadrants. Normal is correct identification; abnormal is not seeing the wiggle or incorrect identification. How is the counting finger method performed? - Answers Stand 3-4 feet away, cover opposite eyes, and hold up 1-5 fingers in superior, lateral, and inferior fields. Ask how many fingers are seen. Repeat for the other eye. Normal is accurate reporting; abnormal is difficulty seeing or identifying fingers. Which cranial nerves innervate extraocular eye movements? - Answers Cranial Nerves III (oculomotor), IV (trochlear), and VI (abducens). What is the diagnostic positions test for extraocular eye movement? - Answers Stand 3-4 feet away at the same level. The client focuses on your nose. Normal is midline gaze; abnormal is deviation in any direction. How should the client follow your finger during the diagnostic positions test? - Answers The client should keep their head still and follow your finger through six cardinal positions of gaze, holding each position for 2 seconds and returning to center each time. What is the procedure for the ocular fundus reflex test? - Answers The client looks at a distant point with dim lights. Both examiner and client remove eyeglasses. Use medium circle light at the lowest brightness. How is the ophthalmoscope held during the examination? - Answers Hold it in the dominant hand against the orbital/cheek bone on the dominant side, looking through the aperture. Stand 15 degrees lateral with the opposite hand on the client's forehead. What does the objective assessment include regarding the external eye? - Answers General inspection, symmetry, alignment, lesions, discharge, cornea/lens/sclera, conjunctiva. What methods are used for peripheral vision assessment? - Answers Comparison, wiggle finger, and counting finger methods. What does the ophthalmoscope examination assess? - Answers Ocular fundus reflex and fundus test. What health promotion strategies are emphasized for eye health? - Answers Smoking cessation, healthy diet, exercise, environmental considerations, and hygiene. What are common symptoms to look for in an objective eye assessment? - Answers Redness, discoloration, swelling, discharge, and lesions. What are the main components of the vestibulocochlear system? - Answers The external ear (auricle/pinna), middle ear, inner ear, and the vestibulocochlear nerve (cranial nerve VIII). What is the significance of lymph nodes around the ears during assessment? - Answers They are often assessed during ear examination as part of lymphatic assessment. What common symptoms should be assessed in a subjective evaluation of the vestibulocochlear system? - Answers Pain, hearing impairment, dizziness, vertigo, pruritus, discolouration, discharge (otorrhea), tinnitus, and other vestibulocochlear-related symptoms. What mnemonic can be used for subjective health assessment related to the vestibulocochlear system? - Answers The PQRSTU mnemonic. Why is it important to ask about medications during a subjective assessment? - Answers Some medications can be ototoxic, affecting hearing and balance. What are the two types of hearing loss that should be differentiated during assessment? - Answers Sensorineural hearing loss (related to CN VIII, inner ear, brain) and conductive hearing loss (related to blockage). What is the difference between dizziness and vertigo? - Answers Dizziness is light-headedness, while vertigo is a spinning sensation. What should be included in the objective assessment of the vestibulocochlear system? - Answers Inspection and palpation of the external ear, otoscopic examination, and hearing assessment. What should be observed during the brief scan of the objective assessment? - Answers Grimacing, holding the ear, reaction to greeting, speech volume/clarity, and lipreading. What are the key aspects to inspect during the otoscopic examination? - Answers External canal for inflammation, discharge, foreign bodies, earwax, and tympanic membrane for colour, contour, discharge, and integrity. What are the immediate priorities of care in vestibulocochlear assessment? - Answers Sudden hearing loss and vertigo, ear discharge following head trauma, ear pain and signs of infection, and foreign objects in the ear. What are some signs of infection in the ear that require immediate attention? - Answers Erythema, swelling, discharge, and ear pain. What are the main components of the nervous system? - Answers Central Nervous System (CNS: brain and spinal cord), Peripheral Nervous System (PNS: 12 paired cranial nerves and 31 paired spinal nerves), and the Autonomic Nervous System. What are the signs of paresis, paralysis, and paraesthesia? - Answers Paresis is weakness, paralysis is inability to move, and paraesthesia is abnormal sensations like tingling or numbness. What is the SAFE mnemonic for fall risk assessment in seizure patients? - Answers Safe environment, Assist with mobility, Fall risk reduction, Engage client/family. What does the Mini-Mental State Exam (MMSE) evaluate? - Answers Cognitive function and detects impairment. What is the purpose of the Montreal Cognitive Assessment Test (MoCA)? - Answers To detect mild cognitive impairment, especially when memory issues are present but MMSE/SMMSE results are normal. What is the Glasgow Coma Scale (GCS) used for? - Answers To assess the level of consciousness and track changes in traumatic brain injury (TBI) or other conditions affecting consciousness. What is the range of the Glasgow Coma Scale (GCS) scores? - Answers The GCS scores range from 3 (unresponsive) to 15 (fully responsive). How is TBI classified according to GCS scores? - Answers TBI is classified as Severe (≤8), Moderate (9-12), and Mild (13-15). What is the sensory function of CN I (Olfactory)? - Answers CN I is responsible for the sense of smell. How is CN I tested? - Answers Test nasal patency, then present familiar smells under an open naris while occluding the other naris. What is the normal finding when testing CN I? - Answers The normal finding is the ability to identify smell bilaterally. What is the sensory function of CN II (Optic)? - Answers CN II is responsible for visual acuity, visual fields, and pupillary light reflex afferent. What is the procedure for testing peripheral vision with CN II? - Answers Use confrontational visual field exam by comparing the client's vision to the examiner's at eye level. What is the sensory and motor function of CN III (Oculomotor)? - Answers CN III controls pupil innervation, lens shape, upper eyelid movement, and most eye movements. What is the normal finding when observing eyelids for CN III? - Answers Normal findings include equal palpebral fissures and no sclera visible above the iris. What is the significance of new onset or sudden loss of vision? - Answers It is an emergency (e.g., stroke or retinal detachment) that requires immediate attention. What is the purpose of the Pupillary Light Reflex test? - Answers To assess pupils for shape, equality, size, and response to light. What cranial nerves are involved in the Pupillary Light Reflex? - Answers Cranial Nerves II (Optic) and III (Oculomotor). What is the normal size range for pupils? - Answers 2-8 mm, depending on light conditions. What indicates a normal accommodation response? - Answers Convergence of eyes inward and pupillary constriction when focusing on a near object. Which cranial nerve is primarily responsible for accommodation? - Answers Cranial Nerve III (Oculomotor). What is the procedure for testing Extraocular Eye Movement (EOM)? - Answers Client follows a finger through an 'H' pattern while keeping their head still. What are the signs of normal Extraocular Eye Movement? - Answers Smooth, conjugate movement with no nystagmus or double vision. What are the characteristics of normal eyelids? - Answers Equal palpebral fissures bilaterally. What are some signs of abnormal eyelids? - Answers Drooping or retraction of the eyelid. What does PERRLA stand for in pupil assessment? - Answers Pupils Equal, Round, Reactive to Light and Accommodation. What are the signs of abnormal pupils? - Answers No/sluggish light reflex, unequal size/shape. What indicates normal Extraocular Movement? - Answers Smooth, conjugate movement with no double vision. What are the signs of abnormal Extraocular Movement? - Answers Disconjugate movement, nystagmus, or double vision. What is the function of Cranial Nerve IV (Trochlear)? - Answers Motor control for downward and inward eye movement. What is the function of Cranial Nerve V (Trigeminal)? - Answers Sensory for facial dermatomes and motor for temporal/masseter muscles. What are the signs of damage to Cranial Nerve V? - Answers Asymmetrical facial sensation, delayed/absent corneal reflex, weakness in jaw clenching. What is the procedure for testing sensory function of Cranial Nerve V? - Answers Touch forehead, maxillary, and mandible areas bilaterally with cotton. What is the function of Cranial Nerve VI (Abducens)? - Answers Motor control for horizontal outward eye movement. What are the signs of damage to Cranial Nerve VI? - Answers Inability to track outward, double vision. What is the function of Cranial Nerve VII (Facial)? - Answers Sensory for taste on the anterior 2/3 of the tongue and motor for facial expressions. What are the signs of damage to the facial nerve (CN VII)? - Answers Asymmetrical facial movement, inability to close the eye, drooping of the eye/mouth, and decreased/absent taste. How is motor function of the facial nerve tested? - Answers Observe symmetry at rest and ask the patient to raise eyebrows, close eyes tightly (try to open), smile/frown, and puff cheeks. What indicates normal motor function in facial movements? - Answers Symmetrical movement. What indicates abnormal motor function in facial movements? - Answers Asymmetry, inability to perform movements such as closing the eye or puffing cheeks. How is sensory function of the facial nerve assessed? - Answers Apply a familiar substance (sugar/salt in water) to the anterior 2/3 of the tongue and ask the patient to identify it. What are the signs of damage to the vestibulocochlear nerve (CN VIII)? - Answers Decreased/absent hearing, tinnitus, vertigo, and balance issues. What is the purpose of the Finger/Thumb Rub Test for hearing? - Answers To assess cochlear function by occluding one ear and rubbing fingers near the other ear to see if the patient can hear. What is the Whisper Voice Test used for? - Answers To assess cochlear function by whispering numbers/letters and asking the patient to repeat. What indicates abnormal results in the Whisper Voice Test? - Answers The patient is unable to repeat the whispered numbers/letters. What does the Past Pointing Test assess? - Answers Vestibular function by having the patient extend arms forward and return to touch the examiner's hands with eyes closed. What indicates normal results in the Past Pointing Test? - Answers The patient touches the examiner's hands (negative past pointing). What are the signs of damage to the glossopharyngeal nerve (CN IX)? - Answers Decreased/absent taste (posterior), diminished/absent gag reflex, asymmetrical palate/uvula, dysphagia, dysphasia, and hoarseness. How is the gag reflex tested? - Answers By tapping the lateral pharynx near the tonsillar pillars or lateral posterior soft palate with a tongue depressor. What indicates normal gag reflex? - Answers Gag response present with pharynx constricting and uvula/soft palate rising symmetrically. What does the 'Ahh' test assess? - Answers The symmetrical rise of the soft palate and uvula when the patient says 'ahh'. What are the signs of damage to the vagus nerve (CN X)? - Answers Asymmetrical rise of the palate/uvula, absent gag reflex, and difficulty swallowing or speaking. What is the function of the spinal accessory nerve (CN XI)? - Answers Motor function for neck and shoulder movement, specifically the sternocleidomastoid and trapezius muscles. What are the signs of damage to the spinal accessory nerve? - Answers Asymmetry/atrophy of neck muscles, misaligned shoulders, and decreased range of motion/resistance in neck/shoulders. What is the normal finding when inspecting neck and shoulders for CN XI? - Answers Symmetrical neck muscles and shoulders with full range of motion. What are the normal findings when testing neck and shoulders during a neurological assessment? - Answers Symmetrical neck/shoulders, full range of motion (ROM), and full resistance bilaterally. What is the primary function of CN XII - Hypoglossal? - Answers Motor function for tongue movement and strength. What are signs of damage to the hypoglossal nerve? - Answers Inability to stick tongue out midline, tremor, decreased movement/strength. How is the hypoglossal nerve tested? - Answers Open mouth, stick tongue out (note midline/deviation/tremors), move side to side, and push tongue against cheek for resistance. What are normal findings for hypoglossal nerve testing? - Answers Tongue midline, no deviation/tremors, full movement, able to resist pressure. What does motor function and cerebellar testing evaluate? - Answers Spinal nerves, spinal column, cerebellum, brain (muscle tone, strength, movement, coordination, balance). What is the first step in motor function and cerebellar testing? - Answers Inspect and palpate muscles for bulk, symmetry, and involuntary movements. What does the Romberg test assess? - Answers Proprioception and balance by observing swaying when standing with feet together, first with eyes open, then closed. What is the procedure for the Finger-to-Nose test? - Answers Extend arms and touch nose with index finger, alternating arms, with eyes open then closed. What is the normal procedure for pain sensation testing? - Answers Sharp/smooth discrimination; the patient indicates 'sharp' or 'smooth' when touched. What is the normal procedure for light touch sensation testing? - Answers Using a cotton ball or light touch, the patient says 'now' when felt. How is vibration sensation tested? - Answers Using a tuning fork on bony prominences, the patient indicates when vibration is felt and when it stops. What does kinesthetic and position sensation testing involve? - Answers Moving one digit (finger/toe) up/down randomly and having the patient identify the direction. What is stereognosis in fine tactile discriminative sensation testing? - Answers Identifying a familiar object placed in hand with eyes closed. What is graphesthesia in fine tactile discriminative sensation testing? - Answers Drawing a letter/number on the palm and asking the patient to identify it with eyes closed. What is the Deep Tendon Reflex (DTR) Scale? - Answers A scale measuring reflex responses from 0+ (no response) to 4+ (sustained/very brisk). What does a score of 4+ on the DTR scale indicate? - Answers Sustained/very brisk response, possibly with clonus present. How is the triceps DTR tested and what is the normal response? - Answers Support the upper arm, tap the triceps tendon above the elbow; normal response is slight elbow extension. What is the procedure for testing the brachioradialis DTR and its normal response? - Answers Forearm rests on legs, tap tendon 5cm above wrist; normal response is slight forearm supination and elbow flexion. How is the patellar DTR tested and what is the expected response? - Answers Client seated with legs dangling, tap patellar tendon below kneecap; normal response is leg extension. What is the procedure for testing the Achilles DTR and its normal response? - Answers Client seated with foot dorsiflexed or prone with foot dangling, tap Achilles tendon; normal response is plantar flexion. What is the Babinski reflex and what does it indicate? - Answers Stroke the plantar side of the foot; normal adult response is plantar flexion of toes, abnormal response (Babinski's sign) is dorsiflexion of the big toe and fanning of other toes, indicating upper motor neuron lesion. What components make up the Upper GI tract? - Answers Oral cavity, esophagus, stomach, duodenum. What components make up the Lower GI tract? - Answers Small and large intestine, rectum, anus. What are the accessory glands and organs of the GI system? - Answers Salivary glands, liver, pancreas, gallbladder. Which lymphatic organs are associated with the GI system? - Answers Tonsils, spleen, appendix. What is xerostomia? - Answers Dry mouth. What does hematemesis indicate? - Answers Blood in vomit, with bright red suggesting upper GI bleed and coffee grounds indicating old blood. What position should a client be in for an oral cavity examination? - Answers Upright position. What should be inspected on the lips during an oral cavity assessment? - Answers Inspect for swelling, color (pink to brown tones), lesions, malformations (e.g., cleft lip), moisture, and texture. What are the normal findings for lips during an oral assessment? - Answers Moist, no cracking/lesions/swelling, pink/brown, no discoloration. Which areas should be inspected in the oral mucosa? - Answers Insides of lips, buccal mucosa, tongue (dorsal, ventral), floor of mouth, hard and soft palate, pharynx, and salivary gland openings. What should be noted about the oral mucosa during inspection? - Answers Moisture, color (pink, note cyanosis/pallor), lesions, swelling, nodules, malformations, and halitosis. What are the normal findings for the oral mucosa? - Answers Moist, pink, no discoloration/lesions/nodules/swelling, tonsils visible but not enlarged. What should be inspected regarding teeth and gums? - Answers Tooth color (white, yellowing/browning), missing/chipped/broken teeth, and gum color (pink, note redness). What are the normal findings for teeth and gums? - Answers White teeth, no loose/missing/chipped/broken teeth, pink gums, no swelling/bleeding/pain. What position should the client be in for an abdominal assessment? - Answers Supine with head on pillow, arms by side, knees bent. What should be noted during the inspection of the abdomen? (GI) - Answers Level of consciousness, facial expression, presence of jaundice, and any medical equipment. What should be observed for during abdominal inspection? - Answers Symmetry, bulging, and peristaltic movement. What are the characteristics to note about abdominal shape and contour? - Answers Symmetrical/asymmetrical shape; contour can be flat, rounded, concave (indicating dehydration/malnutrition), or distended (indicating air, fluid, constipation, obstruction, IBS, malnutrition, or ascites). What does a distended abdomen often feel like? - Answers A distended abdomen is often firm. What is the normal visibility of peristaltic movement? - Answers Peristaltic movement is normally not visible. What are the normal and abnormal findings for bowel sounds? - Answers Normal: present in all four quadrants; Absent after 5 minutes in each quadrant may indicate obstruction, peritonitis, or perforation. What is the frequency range for normoactive bowel sounds? - Answers Normoactive bowel sounds are 5-30 sounds per minute. What are signs of hypoactive and hyperactive bowel sounds? - Answers Hypoactive: 5 sounds/min (may indicate sleep, post-surgery, narcotics, constipation); Hyperactive: 30 sounds/min (may indicate after eating, diarrhea, early obstruction). What is rebound tenderness and when should it be assessed? - Answers Rebound tenderness is pain on release of pressure in the right lower quadrant and should be assessed in suspected appendicitis. What are the positioning options for inspecting the perianal region in different age groups? - Answers Supine with legs flexed (infants/toddlers), left lateral with right leg flexed (older children/adults), lithotomy (women) standing leaning over table (men). What does a normal gag reflex indicate during cranial nerve testing? - Answers Normal: pharynx constricts, uvula and soft palate move upward. How do you test the gag reflex for CN IX and CN X? - Answers Tap near lateral pharynx/tonsillar pillars or lateral posterior soft palate with a tongue depressor and penlight. What is assessed when inspecting the soft palate and uvula during cranial nerve testing? - Answers Symmetry at rest, elevation when the client says 'ahh', and midline position of the uvula. What are the normal findings for soft palate and uvula inspection? - Answers Soft palate elevates symmetrically, uvula remains midline and elevates. What should be observed during swallowing assessment for CN X? - Answers Observe swallowing or ask the client to sip water to assess for dysphagia. What factors should be considered in a nutritional assessment? - Answers Individual needs, culture, food security, and social determinants of health. What does Nutrition Canada's Food Guide recommend? - Answers A diverse mix of foods (vegetables, fruit, whole grains, proteins), limit sugar/salt/high calorie/saturated fats/processed foods, and water as drink of choice. How is tongue movement assessed in cranial nerve testing for CN XII? - Answers Ask the client to open their mouth, stick their tongue out, and move it side to side. What are the abnormal findings when assessing tongue movement? - Answers Deviation, tremors, decreased or absent movement. How is tongue strength assessed for CN XII? - Answers Place fingers on the cheek and ask the client to push their tongue against the cheek, then repeat on the other side. What is peripheral edema and what causes it? - Answers Peripheral edema is swelling from excess fluid in dependent locations, caused by inadequate pumping leading to blood backup. What personal and family history should be inquired about during a cardiovascular assessment? - Answers Hypertension, high cholesterol, heart attack, heart failure, valve issues, and age of diagnosis/death. What indicates a hypertensive crisis during a cardiovascular assessment? - Answers Angina and shortness of breath/other symptoms with very high blood pressure (180/110 mm Hg). What is the normal finding when using the bell of the stethoscope on the carotid arteries? - Answers No bruit. What does the presence of a bruit suggest during carotid artery assessment? - Answers Partial obstruction. What should you do if a bruit is heard during carotid artery assessment? - Answers Do NOT palpate. How should you palpate the carotid arteries? - Answers Gently palpate one carotid artery at a time in the middle third of the neck. What are the key aspects to assess when palpating the carotid artery? - Answers Force (1+-3+), symmetry, and quality (quick upstroke, slow downstroke). What is the normal finding for carotid artery palpation? - Answers 2+ equal bilaterally, smooth contour. What position should the client be in for jugular vein inspection? - Answers Supine with head of bed at 30-45 degrees. What is the normal appearance of the right external jugular vein during inspection? - Answers Flat or not visible. How can you distinguish between jugular and carotid pulses? - Answers Jugular varies with breathing, is non-palpable, and has a double diffuse wave; carotid is one quick palpable wave. What does a distended or bulging jugular vein indicate? - Answers Elevated central venous pressure (CVP) due to fluid retention or right ventricular dysfunction. What should be inspected in the precordium? - Answers Base (2nd intercostal space), left sternal border (2nd-5th ICS), and apex (5th ICS, midclavicular line) for impulses and heaves. What is a normal finding during the inspection of the precordium? - Answers No impulses observed. What indicates increased cardiac workload during precordium palpation? - Answers Pulsations or heaves. What should be assessed during palpation of the precordium? - Answers Thrills (vibratory sensations) indicating turbulent blood flow. What is the normal finding for the apical impulse? - Answers Gentle tap, short duration, 1-2 cm², may not be felt. What does an abnormal apical impulse indicate? - Answers Potential hypertrophy, overload, or failure. What are the 5 Ps of acute limb ischemia to watch for in arterial issues? - Answers Pain, Pallor, Pulselessness, Paresthesia, Paralysis. What should be observed during the inspection of hands and arms in a PVS assessment? - Answers Color, edema, limb circumference discrepancy, lesions, ulcers, and nail color. What aspects should be inspected in the feet and legs? - Answers Color, hair distribution (loss on toes suggests PAD), size and edema (compare bilaterally), lesions and ulcers, and vascularity (varicose veins). What pulses should be palpated in the feet and legs? - Answers Dorsalis pedis and posterior tibial bilaterally, popliteal behind the knee, and femoral inferior to the inguinal ligament. What are the signs of deep vein thrombosis (DVT)? - Answers Unilateral leg pain, swelling, warmth, and erythema. What are some risk factors for deep vein thrombosis (DVT)? - Answers Immobility, prolonged sitting, etc. What is the Doppler ultrasonic stethoscope used for? - Answers To detect pulsatile blood flow when peripheral pulses are difficult to palpate. What is a key difference in pain symptoms between arterial and venous issues? - Answers Arterial pain is sharp and cramping, relieved by rest; venous pain is aching and heavy. How do pulses differ between arterial and venous symptoms? - Answers Arterial pulses are decreased or absent distal to blockage; venous pulses are present but may be difficult to palpate. What skin color changes are associated with arterial symptoms? - Answers Pallor on elevation and dependent rubor (redness when lowered). What skin temperature is typical for arterial symptoms? - Answers Cool to touch. Where do arterial ulcers typically occur? - Answers On toes, dorsal foot, lateral malleolus; they are well-defined, dry, and deep. Where do venous ulcers typically occur? - Answers On the medial malleolus; they have an irregular shape, shallow, and exudative base. What is the primary function of the respiratory system? - Answers Gas exchange, facilitating oxygenation and removing carbon dioxide. What structures are included in the upper respiratory tract? - Answers Nasal cavity, paranasal sinuses, pharynx, and larynx. What structures are included in the lower respiratory tract? - Answers Trachea, bronchi, respiratory units, lungs, pleural membranes, pleural cavity, pulmonary artery and vein, diaphragm. What are common problems associated with the respiratory system? - Answers Sinusitis, nasal polyps, asthma, pneumonia, cancer, cystic fibrosis, bronchitis, emphysema, COPD, and respiratory viruses. What is dyspnea? - Answers Difficulty breathing, characterized by shortness of breath and feeling unable to catch one's breath. What should be noted about sputum characteristics during a cough assessment? - Answers Thickness, color (clear, yellow, green, pink-tinged, bloody), and whether it is productive or dry. What does chest and nasal congestion indicate? - Answers Mucus accumulation in the chest/lungs and/or nasal cavity, often associated with cough and runny nose. What are the pleural membranes? - Answers Visceral and parietal membranes that surround the lungs. What are common sensations associated with sinus pain/pressure? - Answers Inflammation, infection, blockage, nasal congestion/discharge, headaches, earaches, and pain around the ear/neck. What does wheezing indicate? - Answers Wheezing is a whistling sound or noisy breathing during inspiration and/or expiration, associated with airway narrowing, inflammation, and bronchospasm. What symptoms indicate a potential anaphylaxis reaction? - Answers Wheezing, allergies and exposure, pruritus, rash/hives, difficulty swallowing, facial/lip swelling, nausea. What are the characteristics of chest pain that should be assessed? - Answers Sensation, discomfort, tenderness, tightness, or sharp pain in the chest, which may worsen with breathing and coughing. What are the prioritized steps in a brief scan for respiratory distress? - Answers 1. Assess airway patency. 2. Assess presence of breathing and respiratory rate. 3. Assess work of breathing and signs of respiratory distress. What signs indicate airway obstruction? - Answers Secretions, snoring, stridor, difficulty breathing, coughing, drooling, wet voice, unable to speak. What is the significance of nasal flaring in infants? - Answers Nasal flaring is common in infants/young children and may indicate respiratory distress. What does a tripod position indicate in a patient? - Answers A tripod position, where the patient leans forward with hands/forearms on legs/surface, often indicates respiratory distress. What colour changes should be assessed during a respiratory evaluation? - Answers Assess for cyanosis or pallor in lips, mucous membranes, fingernails, and conjunctiva, which indicate hypoxemia. What are the signs of clubbing in fingernails? - Answers Clubbing is indicated by a nail angle flattening to ≥180 degrees, softening of the nail bed, and enlargement of fingertips. What should be done if capillary refill is sluggish? - Answers A sluggish return (3 seconds) suggests issues with oxygenated blood perfusion. What areas should be assessed during a thoracic examination? - Answers Posterior/lateral thorax from shoulders/axillary to the bottom of the rib cage; anterior thorax from lung apices (above clavicles) to bases (bottom of rib cage). What should be done to maintain privacy during a thoracic examination? - Answers Close doors/curtains, use draping, and expose only necessary areas. What should be inspected on the external surface of the nose? - Answers Color (should match the face, no redness/discoloration), symmetry, swelling, and malformations. What is a normal finding for the nasal cavity and mucosa? - Answers Color should be pinkish red, with no discharge, bleeding, swelling, or foreign bodies. How should nasal patency be assessed? - Answers Occlude one naris and ask the client to sniff deeply through the other; note ability to breathe inwards without obstruction. What should be done if lesions or sinus pain are present during a nasal examination? - Answers Conduct a focused assessment and report to a physician/NP; sinus pain may require decongestants, antibiotics, or antihistamines. What should be noted when assessing the symmetry of the thorax? - Answers Compare left/right sides for symmetry and chest expansion; assess if expansion is equal during breathing. How can a clinician test for chest expansion during a thoracic examination? - Answers Place thumbs on either side of the vertebra at T9/T10, pinch skin between thumbs, and ask the client to take a deep breath; thumbs should move equally apart/together. What should be done if a client has nasal obstruction or absent sniff? - Answers Investigate for mucous, foreign body, or assess for respiratory distress. What are the signs of a cutaneous nose lesion that requires prompt intervention? - Answers An open sore that does not heal within 4-6 weeks is a concern and needs close examination. What is the normal adult ratio of anteroposterior to transverse diameter? - Answers Approximately 1:2. What position should the patient be in during auscultation? - Answers The upright position. What should be noted about air entry during auscultation? - Answers Quality (good, decreased, absent) and equality of air entry should be compared bilaterally. What defines bronchovesicular breath sounds? - Answers Moderate loudness, equal inspiration and expiration, located in the upper thorax near vertebrae and bronchi. What are vesicular breath sounds? - Answers Quiet, low-pitched sounds with inspiration greater than expiration, found in the periphery of lung fields. What are bronchial breath sounds? - Answers Hollow, harsh sounds with expiration greater than inspiration, typically heard over the trachea. What are adventitious sounds? - Answers Abnormal sounds that indicate issues in the lungs, including wheezes, stridor, and crackles. What are wheezes, and what do they indicate? - Answers Continuous musical sounds indicating bronchoconstriction, associated with conditions like asthma or emphysema. What is stridor, and when is it concerning? - Answers A high-pitched wheezing sound indicating partial upper airway obstruction; requires immediate response. What do crackles indicate, and how are they characterized? - Answers Interrupted popping or bubbling sounds indicating fluid accumulation, characterized as fine, moderate, or coarse. What does crepitus indicate during a thoracic assessment? - Answers It indicates subcutaneous emphysema, which can result from trauma, surgery, or infection. What is Tactile Vocal Fremitus and how is it assessed? - Answers It is the vibration on the chest wall from vocalization, assessed by placing the ulnar or palmar surface of fingers on the chest while the patient says a low-frequency word. What is the normal finding for Tactile Vocal Fremitus? - Answers Fremitus should be equal left to right and is harder to feel at the bases. What abnormal sounds can be detected during percussion? - Answers Dull sounds (indicating fluid/solid matter) and hyperresonance (indicating hyperinflation). What is the best way to assess for Tactile Vocal Fremitus? - Answers Ask the client to say a low-frequency word while palpating the chest. (say "foodie") What technique is used for tactile vocal fremitus? - Answers Use the ulnar surface of hands or base of palmar fingers on 3-5 locations each side anteriorly, asking the client to say 'foodie' or 'coin'. What is the procedure for percussion in respiratory assessment? - Answers Perform upright, indirect percussion at 4-8 locations each side anteriorly, starting from the apices down to the bases, comparing side to side. What sound should be noted over the heart during percussion? - Answers A dull sound over the heart in the 2nd-5th intercostal space on the left side. What are common respiratory symptoms to assess in patients? - Answers Dyspnea, cough, wheezing, congestion, and chest pain. What is the primary survey approach in clinical assessment? - Answers A systematic assessment that includes Airway, Breathing, Circulation, Disability, and Exposure. What vital signs indicate clinical deterioration? - Answers Partial airway obstruction, poor peripheral circulation, unexpected fluid loss, decreased urine output, changes in Glasgow coma scale, abnormal respiratory rate, low or high SpO2, low systolic BP, and altered mentation. What does the 'Breathing' component of the primary survey evaluate? - Answers It measures the respiratory rate, evaluates work of breathing, and measures O2 saturation. What does the 'Circulation' component of the primary survey include? - Answers Palpating pulse (rate/rhythm), measuring BP (auscultation), and assessing urine output. What does the 'Disability' component of the primary survey assess? - Answers Level of consciousness (LOC), speech changes, pain, symmetry/weakness/balance, and vision changes. What does the 'Exposure' component of the primary survey involve? - Answers Measuring temperature, inspecting skin integrity, checking for pressure injuries, and observing wounds and mobilization ability. What is the primary function of the musculoskeletal (MSK) system? - Answers The MSK system serves as the body's framework and supportive structure. What additional roles does the MSK system play? - Answers The MSK system is involved in hemopoiesis, and mineral and fat storage. What are the main components of the MSK system? - Answers The main components include the skull and facial bones, vertebral column, thoracic cage, clavicle and scapula, upper and lower limb bones, and hip/pelvic bones. Where is cartilage found in the body? - Answers Cartilage is found in areas such as the nose, ears, costal cartilage, and articular cartilage in joints. How does the neurological system influence the MSK system? - Answers The neurological system influences muscle function, which is innervated by cranial and spinal nerves. What are common MSK problems? - Answers Common MSK problems include back pain, repetitive strain injury (RSI), osteoarthritis, rheumatoid arthritis, sprains, and bone fractures. What are common symptoms associated with the MSK system? - Answers Common symptoms include pain, headache, stiffness, muscle tightness, numbness, weakness, muscle twitches, fatigue, mobility issues, redness, swelling, local temperature change, deformities, and psychological distress. What signs indicate a severe headache requiring immediate intervention? - Answers Signs include sudden onset, confusion, trouble seeing/speaking/walking, fainting, and numbness/weakness. What specific questions should be asked regarding joint stiffness? - Answers Questions should cover which joints are affected, when it began, time of day it's worst, whether it's constant or intermittent, what makes it better or worse, treatment, and use of mobility aids. What should be assessed regarding muscle spasms? - Answers Assess quality, region, frequency, timing, what makes it better or worse, associated symptoms, treatment, and understanding of the cause. What factors should be considered in assessing mobility, balance, and weakness? - Answers Consider limitations with walking/standing/sitting, concerns with balance/weakness, use of mobility aids, quality of concerns, region, timing, what makes it better or worse, treatment, understanding of the cause, and impact on daily life. What does the SAFE mnemonic stand for in fall risk reduction? - Answers SAFE stands for Safe environment, Assist with mobility, Fall risk reduction, Engage the client and family. What symptoms should be assessed using the PQRSTU method in musculoskeletal (MSK) evaluations? - Answers Redness, swelling, temperature changes, deformities, injury details, quality, region, timing, and other MSK symptoms like fatigue, numbness, dizziness, or flu-like symptoms. What personal and family history questions should be asked during an MSK assessment? - Answers Inquire about chronic conditions affecting muscles, bones, and joints, and familial history of conditions such as arthritis, lupus, gout, and fibromyalgia. What is the significance of a sudden, very severe headache in an MSK assessment? - Answers It may indicate a life-threatening condition like an aneurysm, especially if accompanied by symptoms like reduced consciousness, disorientation, eye pain, light sensitivity, or blurred vision. What are the steps involved in conducting a brief scan of the MSK system? - Answers 1. Assess footwear and presence of mobility aids. 2. Assess posture and balance. 3. Look for tremors or deformities. 4. Check limb symmetry and gait. 5. Document findings descriptively. What general principles should be followed in an objective MSK assessment? - Answers Conduct after the subjective assessment, focus on inspection, palpation, range of motion (ROM), and manual muscle testing (MMT), compare findings bilaterally, and adapt positions as needed. What should be avoided during an objective assessment if trauma to the neck or back is suspected? (MSK) - Answers Do not conduct range of motion (ROM) or manual muscle testing (MMT). What should be assessed during the inspection of each body region in an MSK assessment? - Answers Colour, symmetry, swelling, masses, deformities, length of limbs, and involuntary muscle contractions. What should be assessed during palpation in an MSK assessment? - Answers Temperature, pain, masses, swelling, deformities, palpable fluid, and size/contour of muscles, starting with the unaffected side. What is the sequence of assessment during an objective MSK evaluation? - Answers Conduct the assessment in a sequential order to minimize position changes, using a cephalocaudal or proximal to distal approach. What is the role of manual muscle testing (MMT) in an objective assessment? - Answers To evaluate the strength and function of muscles. What should be noted about the client's posture during the brief scan? (MSK) - Answers Any abnormal findings such as hunched posture or unequal weight bearing. What does Range of Motion (ROM) assess? - Answers The joint's mobility (active, assisted active, passive), including the range, quality of movement, crepitus, and pain. What is Manual Muscle Testing (MMT) used for? - Answers To evaluate muscle strength against resistance using a grading scale, ensuring joint stabilization and proper alignment. What is the MRC scale in Manual Muscle Testing? - Answers A grading scale from 0 to 5 used to assess muscle strength. What is a key consideration when a client has full active ROM? - Answers Their MMT is at least 3/5. What additional assessment does MMT of the neck include? - Answers Assessment of Cranial Nerve XI. What health promotion questions should be asked regarding activity/exercise? (MSK) - Answers Current activity levels, types of exercise, meaning of an active lifestyle, and any concerns. What strategies can help prevent falls? - Answers Regular checkups, safe home environment, nutritious meals, exercise, and managing medications. What is important to document in clinical judgment? - Answers Subjective data and objective assessment findings, including inspection, palpation, ROM, and MMT. What should be documented for each joint assessed? - Answers ROM specifics if limited, MMT findings, whether they are equal bilaterally, and any pain experienced. Subjective Assessment of Integumentary System - Answers Perform a subjective assessment of the integumentary system by asking relevant questions about symptoms like pruritus, rashes, nevi, skin discolouration, ulcers, nail changes, and alopecia, using mnemonics like PQRSTU. Objective Assessment of Integumentary System - Answers Prepare for and conduct an objective assessment of the integumentary system including inspection and palpation of the skin, nails, and hair. Inspecting Skin for Colour Variations - Answers Inspect the skin for colour variations such as pallor, cyanosis, erythema, brawny discolouration, jaundice, and vitiligo, noting how these may present in different skin tones. Inspecting Skin for Nevi - Answers Inspect the skin for nevi using the ABCDE mnemonic. Inspecting Skin for Lesions - Answers Inspect the skin for primary and secondary lesions and describe their characteristics. Inspecting and Palpating Hair - Answers Inspect and palpate the hair for colour, texture, distribution, and lesions. Primary Lesions - Answers Develop as a direct result of a pathological process and are not modified by scratching or infection. Secondary Lesions - Answers Evolve from a primary lesion either through its natural progression or as a result of external factors like scratching or infection. Macule - Answers A flat (non-palpable) spot, typically discoloured (hyperpigmented or erythematous), less than 1 cm. Example: freckle, café au lait spot. Papule - Answers An elevated, solid, palpable, circumscribed growth, less than 1 cm in diameter. Example: elevated mole, mosquito bite. Wheal - Answers A swollen, inflamed skin patch that itches or burns, generally 3 mm or larger. Example: hives. Vesicle - Answers A small, fluid-filled sac with a thin wall. Usually appears in groups. Example: herpes simplex blister. Ulcer - Answers A loss of parts of the tissue (crater-like), exposed with some healing formation. Example: venous insufficiency ulcer. Pustule - Answers A pus-filled, circumscribed, elevated lesion. May have redness/swelling at the site. Example: pimple. Keloid - Answers A thick, raised patch of skin (scar tissue). Results from excessive collagen formation during healing. Fissure - Answers A crack or split of the outer layer of the skin. Tumour - Answers An abnormal growth, palpable, typically larger than nodules ( 2 cm). Can be benign or malignant. Example: lipoma, skin cancer. Scale - Answers An accumulation of dried fragments of stratum corneum that are shed from the skin. Often flaky in appearance. A - Asymmetry (integumentary) - Answers Moles that are asymmetrical/irregular in shape (one side does not match the other) are a warning sign. B - Border irregularity (integumentary) - Answers Mole borders that are irregular or jagged in appearance.