Nursing Health Assessment Final Exam

-Facial (facial movement and taste) -Tested by having the patient make various facial expressions What is CN VII and its test? -Auditory/ Acoustic/ Vestibulocochlear (hearing and equilibrium) -Tested by using the Whisper test and with a tuning fork for the Weber and Rinne tests What is CN VIII and its test? -Glossopharyngeal (swallowing, tongue sensation, and taste) -Tested by having the patient open his or her mouth to say "ah" and checking for rising of the soft palate with phonation What is CN IX and its test? -Vagus (swallowing, vocal cords) -Tested by having the patient open his or her mouth to say "ah" and checking for rising of the soft palate with phonation What is CN X and its test? -Spinal accessory (head and shoulder movement) -Tested by shrugging the shoulders against resistance and turning the head side to side against resistance What is CN XI and its test? -Hypoglossal (tongue movement) -Tested by having the patient stick his or her tongue out midline and moving it side to side What is CN XII and its test? -Appearance (ie. posture, body movements, clothing, grooming, hygiene) -Behavior (ie. level of consciousness, facial expression, speech, mood and affect) -Cognition (ie. orientation, attention span, immediate recall, recent memory, remote memory) -Thought processes ABCT What are the components of headings of the mental status exam and objective data? -Awake -Alert -Oriented -Time and space What are the components of Level of Consciousness (LOC)? The Romberg Test is a cerebellar function test in which the patient stands with his or her feet together and arms at the sides first with eyes open and then with eyes closed. If a patient needs to move his or her feet apart to stay balanced or if the patients falls, then the result is considered a positive Romberg. A negative Romberg, which is considered the normal and desired result, would be when the patient may sway slightly but can still maintain posture and balance. What is the Romberg Test? The Glasgow Coma Scale is a scale to assess Level of Consciousness (LOC) by addressing eye opening, motor response, and verbal response. Patients are scored on a scale of 3-15; a score of 7 or less indicates a coma. What is the Glasgow Coma Scale, and what score indicates a coma? PHQ-2, PHQ-9, and MMSE (Mini-Mental State Exam). What are the screening tests for depression? a depression screening that asks 2 questions about depressed mood and anhedonia (lack of interest). PHQ-2 serves as a screening tool for possible use of the full PHQ-9 tool. What is the Patient Health Questionnaire-2 (PHQ-2)? a depression screening that asks a series of 9 questions, requiring adding column totals that relate to the frequency of the occurrence of symptoms. The higher the patient scores on the PHQ-9, the greater the likelihood of functional impairment or clinical diagnosis of depression. What is the Patient Health Questionnaire-9 (PHQ-9)? an involuntary trembling of a limb or body part. What is a tremor? paleness, which indicates decreased blood flow caused by inadequate circulation. In light skin, the skin will simply appear pale and white. In darker patients, skin tone will appear lighter than normal. In light brown skin, the skin may appear more yellowish-brown. In dark skin, the skin will have less red tones and appear ashen. What is pallor, and what does it look like in different skin tones? the elasticity of the skin. tested by pinching up the skin at the tops of the hands and feet in adults and at clavicles or sternum for elders. The skin should spring back to normal when it is released. If there is tenting, which is when the skin stays pinched up, this could be a sign of dehydration. What is skin turgor, and how is it tested in adults vs. elders?