NR302 / NR 302 Exam 2 (New 2026/2027 Update) Health Assessment I |Verified Questions and Answers| 100% Correct | A Grade -Chamberlain

NR302 / NR 302 Exam 2 (New 2026/2027 Update) Health Assessment I |Verified Questions and Answers| 100% Correct | A Grade -Chamberlain Q. During a cardiovascular assessment, the nurse knows that a thrill is: ANSWER Vibration that is palpable.That signifies turbulent blood flow and accompanies loud murmurs. Q. The nurse educator is preparing an education module for the nursing staff on the epidermal layer of skin. Which of these statements would be included in the module? ANSWER Replaced every 4 weeks. Q. The nurse educator is preparing an education module for the nursing staff on the dermis layer of skin. Which of these statements would be included in the module? The dermis: ANSWER Contains sensory receptors. Q. The nurse is examining a patient who tells the nurse, "I sure sweat a lot, especially on my face and feet but it doesn't have an odor." The nurse knows that this condition could be related to: ANSWER Eccrine glands. Q. The nurse is bathing an 80-year-old man and notices that his skin is wrinkled, thin, lax, and dry. This finding would be related to which factor in the older adult? ANSWER An increased loss of elastin and a decrease in subcutaneous fat Q. The nurse is reviewing the anatomy and physiologic functioning of the heart. Which statement best describes what is meant by atrial kick? ANSWER The atria contract toward the end of diastole and push the remaining blood into the ventricles. Q. During an examination, the nurse finds that a patient has excessive dryness of the skin. The best term to describe this condition is: ANSWER Xerosis Q. A 13-year-old girl is interested in obtaining information about the cause of her acne. The nurse should share with her that acne: ANSWER Is caused by increased sebum production. Q. When listening to heart sounds, the nurse knows the valve closures that can be heard best at the base of the heart are: ANSWER Aortic and pulmonic. Q. The nurse keeps in mind that a thorough skin assessment is extremely important because the skin holds information about a person's: ANSWER Circulatory status. Q. A patient comes in for a physical examination and complains of "freezing to death" while waiting for her examination. The nurse notes that her skin is pale and cool and attributes this finding to: ANSWER Peripheral vasoconstriction. Q. A patient comes to the clinic and tells the nurse that he has been confined to his recliner chair for approximately 3 days with his feet down and he asks the nurse to evaluate his feet. During the assessment, the nurse might expect to find: ANSWER Distended veins Q. The second heart sound (S2) occurs: ANSWER with the closure of the semilunar (aortic and pulmonic) valves and signals the end of systole. it is loudest at the base of the heart. Q. Which of these statements describes the closure of the valves in a normal cardiac cycle? ANSWER The tricuspid valve closes slightly later than the mitral valve. Q. The component of the conduction system referred to as the pacemaker of the heart is the: ANSWER Sinoatrial (SA) node. Q. The electrical stimulus of the cardiac cycle follows which sequence? ANSWER Jaundice Q. The findings from an assessment of a 70-year-old patient with swelling in his ankles include jugular venous pulsations 5 cm above the sternal angle when the head of his bed is elevated 45 degrees. The nurse knows that this finding indicates: ANSWER Elevated pressure related to heart failure. Q. A 42-year-old woman complains that she has noticed several small, slightly raised, bright red dots on her chest. On examination, the nurse expects that the spots are probably: ANSWER Senile angiomas Q. A 65-year-old man with emphysema and bronchitis has come to the clinic for a follow-up appointment. On assessment, the nurse might expect to see which finding? ANSWER Clubbing of the nails Q. A 35-year-old pregnant woman comes to the clinic for a monthly appointment. During the assessment, the nurse notices that she has a brown patch of hyperpigmentation on her face. The nurse continues the skin assessment aware that another finding may be: ANSWER Chloasma. Q. During an assessment, the nurse palpates a thrill and lift at the fifth left intercostal space midclavicular line. In the same area, the nurse also auscultates a blowing, swishing sound right after the S1. These findings would be most consistent with: ANSWER These findings are consistent with mitral regurgitation. Q. A 70-year-old woman who loves to garden has small, flat, brown macules over her arms and hands. She asks, "What causes these liver spots?" The nurse tells her, "They are: ANSWER "Clusters of melanocytes that appear after extensive sun exposure." Q. The nurse notices that a patient has a solid, elevated, circumscribed lesion that is less than 1 cm in diameter. When documenting this finding, the nurse reports this as a: ANSWER Papule. Q. The nurse just noted from the medical record that the patient has a lesion that is confluent in nature. On examination, the nurse expects to find: ANSWER Lesions that run together. Q. A patient has had a "terrible itch" for several months that he has been continuously scratching. On examination, the nurse might expect to find: ANSWER Lichenification. Q. A physician has diagnosed a patient with purpura. After leaving the room, a nursing student asks the nurse what the physician saw that led to that diagnosis. The nurse should say, "The physician is referring to the: ANSWER "Confluent and extensive patch of petechiae and ecchymoses on the feet." Q. Heart failure causes: ANSWER Decreased cardiac output when the heart fails as a pump and the circulation becomes backed up and congested. Q. The nurse is assessing the skin of a patient who has acquired immunodeficiency syndrome (AIDS) and notices multiple patchlike lesions on the temple and beard area that are faint pink in color. The nurse recognizes these lesions as: ANSWER Kaposi's sarcoma. Q. A 45-year-old farmer comes in for a skin evaluation and complains of hair loss on his head. His hair seems to be breaking off in patches, and he notices some scaling on his head. The nurse begins the examination suspecting: ANSWER Tinea capitis. Q. Sign and Symthoms of Heart Failure ANSWER dyspnea, orthopnea, paroxysmal nocturnal dyspnea, decreased blood pressure, dependent and pitting edema; anxiety; confusion; jugular vein distention; and fatigue Q. The nurse is assessing for inflammation in a dark-skinned person. Which technique is the best? ANSWER Assessing the oral mucosa for generalized erythema Q. The nurse is preparing for a certification course in skin care and needs to be familiar with the various lesions that may be identified on assessment of the skin. Which of the following definitions are correct? Select all that apply. ANSWER Petechiae: Tiny punctate hemorrhages, 1 to 3 mm, round and discrete, dark red, purple, or brown in color. Vesicle: Known as a friction blister Nodule: Solid, elevated, and hard or soft growth that is larger than 1 cm Q. A physician tells the nurse that a patient's vertebra prominens is tender and asks the nurse to reevaluate the area in 1 hour. The area of the body the nurse will assess is: ANSWER At the level of the C7 vertebra. Q. When examining the face of a patient, the nurse is aware that the two pairs of salivary glands that are accessible to examination are the ___________ and ___________ glands. ANSWER Parotid; submandibular Q. During a cardiac assessment the nurse finds the following: jugular vein pulsations 4 cm above the sternal angle when the patient is elevated at 45 degrees, blood pressure 98/60 mm Hg, heart rate 130 beats per minute, ankle edema, difficulty breathing when supine, and an S3 on auscultation. Which of these conditions best explains the cause of these findings? ANSWER Heart failure During an assessment, the nurse notes that the patient's apical impulse is laterally displaced and is palpable over a wide area. This finding indicates: Volume overload, as in heart failure. The nurse is aware that the four areas in the body where lymph nodes are accessible are the: Head and neck, arms, inguinal area, and axillae. When the nurse is auscultating the carotid artery for bruits, which of these statements reflects the correct technique? While lightly applying the bell of the stethoscope over the carotid artery and listening, the patient is asked to take a breath, exhale, and briefly hold it. A patient reports excruciating headache pain on one side of his head, especially around his eye, forehead, and cheek that has lasted approximately to 2 hours, occurring once or twice each day. The nurse should suspect: Cluster headaches A patient complains that while studying for an examination he began to notice a severe headache in the frontotemporal area of his head that is throbbing and is somewhat relieved when he lies down. He tells the nurse that his mother also had these headaches. The nurse suspects that he may be suffering from: Migraine headaches A 19-year-old college student is brought to the emergency department with a severe headache he describes as, "Like nothing I've ever had before." His temperature is 40° C, and he has a stiff neck. The nurse looks for other signs and symptoms of which problem? Meningeal inflammation The nurse is preparing for a class on risk factors for hypertension and reviews recent statistics. Which racial group has the highest prevalence of hypertension in the world? Blacks A patient has come in for an examination and states, "I have this spot in front of my ear lobe on my cheek that seems to be getting bigger and is tender. What do you think it is?" The nurse notes swelling below the angle of the jaw and suspects that it could be an inflammation of his: Parotid gland. The nurse suspects that a patient has hyperthyroidism, and the laboratory data indicate that the patient's T4 and T3 hormone levels are elevated. Which of these findings would the nurse most likely find on examination? Tachycardia A patient's thyroid gland is enlarged, and the nurse is preparing to auscultate the thyroid gland for the presence of a bruit. A bruit is a __________ sound that is heard best with the __________ of the stethoscope. Soft, whooshing, pulsatile; bell During an admission assessment, the nurse notices that a male patient has an enlarged and rather thick skull. The nurse suspects acromegaly and would further assess for: Coarse facial features. A patient visits the clinic because he has recently noticed that the left side of his mouth is paralyzed. He states that he cannot raise his eyebrow or whistle. The nurse suspects that he has experienced a cerebrovascular accident (CVA) or stroke. A woman comes to the clinic and states, "I've been sick for so long! My eyes have gotten so puffy, and my eyebrows and hair have become coarse and dry." The nurse will assess for other signs and symptoms of: Myxedema (hypothyroidism) During an examination of a female patient, the nurse notes lymphadenopathy and suspects an acute infection. Acutely infected lymph nodes would be: Firm but freely movable. During an assessment of an infant, the nurse notes that the fontanels are depressed and sunken. The nurse suspects which condition? Dehydration A patient has a normal pupillary light reflex. The nurse recognizes that this reflex indicates that: Constriction of both pupils occurs in response to bright light. The nurse is assessing a patient with possible cardiomyopathy and assesses the hepatojugular reflux. If heart failure is present, then the nurse should recognize which finding while pushing on the right upper quadrant of the patient's abdomen, just below the rib cage? The jugular veins will remain elevated as long as pressure on the abdomen is maintained. The nurse is reviewing in age-related changes in the eye for a class. Which of these physiologic changes is responsible for presbyopia? Loss of lens elasticity Which of these assessment findings would the nurse expect to see when examining the eyes of a black patient? Dark retinal background The nurse is preparing to assess the visual acuity of a 16-year-old patient. How should the nurse proceed? Use the Snellen chart positioned 20 feet away from the patient. A patient's vision is recorded as 20/30 when the Snellen eye chart is used. The nurse interprets these results to indicate that: The patient can read at 20 feet what a person with normal vision can read at 30 feet. A patient is unable to read even the largest letters on the Snellen chart. The nurse should take which action next? Shorten the distance between the patient and the chart until the letters are seen, and record that distance. During an assessment of the sclera of a black patient, the nurse would consider which of these an expected finding? Presence of small brown macules on the sclera When assessing the pupillary light reflex, the nurse should use which technique? Shine a light across the pupil from the side, and observe for direct and consensual pupillary constriction. The nurse is assessing a patient's eyes for the accommodation response and would expect to see which normal finding? Convergence of the axes of the eyes A patient comes into the clinic complaining of pain in her right eye. On examination, the nurse sees a pustule at the lid margin that is painful to touch, red, and swollen. The nurse recognizes that this is a: Hordeolum (stye) The nurse needs to pull the portion of the ear that consists of movable cartilage and skin down and back when administering eardrops. This portion of the ear is called the: Auricle. The nurse is reviewing the structures of the ear. Which of these statements concerning the eustachian tube is true? It helps equalize air pressure on both sides of the tympanic membrane. A patient with a middle ear infection asks the nurse, "What does the middle ear do?" The nurse responds by telling the patient that the middle ear functions to: Conduct vibrations of sounds to the inner ear. The nurse is assessing a patient who may have hearing loss. Which of these statements is true concerning air conduction? Air conduction is the normal pathway for hearing. During an interview, the patient states he has the sensation that "everything around him is spinning." The nurse recognizes that the portion of the ear responsible for this sensation is the: Labyrinth. A 31-year-old patient tells the nurse that he has noticed a progressive loss in his hearing. He says that it does seem to help when people speak louder or if he turns up the volume of a television or radio. The most likely cause of his hearing loss is: Otosclerosis. During an assessment of a 20-year-old Asian patient, the nurse notices that he has dry, flaky cerumen in his canal. What is the significance of this finding? This finding: Is a normal finding, and no further follow-up is necessary. The nurse is taking the history of a patient who may have a perforated eardrum. What would be an important question in this situation? "Is there any relationship between the ear pain and the discharge you mentioned?" A 31-year-old patient tells the nurse that he has noticed pain in his left ear when people speak loudly to him. The nurse knows that this finding: Is a characteristic of recruitment. The nurse is performing an otoscopic examination on an adult. Which of these actions is correct? Pulling the pinna up and back before inserting the speculum The nurse is assessing a 16-year-old patient who has suffered head injuries from a recent motor vehicle accident. Which of these statements indicates the most important reason for assessing for any drainage from the ear canal? Bloody or clear watery drainage can indicate a basal skull fracture. In performing a voice test to assess hearing, which of these actions would the nurse perform? Whisper a set of random numbers and letters, and then ask the patient to repeat them. In an individual with otitis externa, which of these signs would the nurse expect to find on assessment? Enlarged superficial cervical nodes During an examination, the patient states he is hearing a buzzing sound and says that it is "driving me crazy!" The nurse recognizes that this symptom indicates: Tinnitus. The nurse is testing the hearing of a 78-year-old man and is reminded of the changes in hearing that occur with aging that include which of the following? Select all that apply. Progression of hearing loss is slow. The aging person may find it harder to hear consonants than vowels. Sounds may be garbled and difficult to localize. The primary purpose of the ciliated mucous membrane in the nose is to: Filter out dust and bacteria. The tissue that connects the tongue to the floor of the mouth is the Frenulum. The salivary gland that is the largest and located in the cheek in front of the ear is the _________ gland. Parotid TA 25-year-old woman in her fifth month of pregnancy has a blood pressure of 100/70 mm Hg. In reviewing her previous examination, the nurse notes that her blood pressure in her second month was 124/80 mm Hg. In evaluating this change, what does the nurse know to be true? This decline in blood pressure is the result of peripheral vasodilatation and is an expected change. The nurse is assessing an 80-year-old patient. Which of these findings would be expected for this patient? Decreased ability to identify odors While obtaining a health history, a patient tells the nurse that he has frequent nosebleeds and asks the best way to get them to stop. What would be the nurse's best response? "Sit up with your head tilted forward and pinch your nose." A 92-year-old patient has had a stroke. The right side of his face is drooping. The nurse might also suspect which of these assessment findings? Dysphagia A 72-year-old patient has a history of hypertension and chronic lung disease. An important question for the nurse to include in the health history would be: "Have you noticed any dryness in your mouth?" The nurse is using an otoscope to assess the nasal cavity. Which of these techniques is correct? Avoiding touching the nasal septum with the speculum The nurse is palpating the sinus areas. If the findings are normal, then the patient should report which sensation? Firm pressure In assessing a 70-year-old man, the nurse finds the following: blood pressure 140/100 mm Hg; heart rate 104 beats per minute and slightly irregular; and the split S2 heart sound. Which of these findings can be explained by expected hemodynamic changes related to age? Increase in systolic blood pressure When examining the mouth of an older patient, the nurse recognizes which finding is due to the aging process? Smooth glossy dorsal surface. The sac that surrounds and protects the heart is called the: Pericardium. The direction of blood flow through the heart is best described by which of these? Right atrium right ventricle pulmonary artery lungs pulmonary vein left atrium left ventricle In assessing a patient's major risk factors for heart disease, which would the nurse want to include when taking a history? Smoking, hypertension, obesity, diabetes, and high cholesterol becoming a nurse characteristics grit, integrity, courage, knowledge, attentive and resourceful optimal nutritional status equals sufficient nutrients undernutrition less than body requirements overnutrition more than body requirements how does nutrition impact the Branden scale? skin breakdown from poor nutrition, fundamental needs of patients not being taken care of, friction and shear, nutrition, mobility, moisture, activity and the lower the number the higher the risk subjective data of nutrition what do you eat with a 24 diet recall, alcohol, water and lifespan/cultural needs and variations metabolic syndrome or insulin resistance syndrome waist circumference greater than 40 inches (102 cm) in men or greater than 35 inches (88 cm) in women, blood pressure greater than 130/85, triglyceride greater than 150 mg/dL, high-density lipo-protein greater than 40 mg/dL in men or greater than 50 mg/dL in women, and glucose greater than 100 mg/dL you are at risk for metabolic syndrome if? you have 3 or more of the categories of waist circumference, blood pressure, triglyceride, high-density lipo-protein and glucose what comes along with metabolic syndrome? CAD and diabetes what are abnormal findings caused by nutritional deficiencies? spongy or scorbutic gums, rickets, magenta tongue, cheilosis/angular stomatitis, pitting edema, obesity, marasmus, kwashirorkor spongy or scorbutic gums deficiency of vitamin C, gums are swollen, ulcerated and bleeding. deficiency defects in oral epithelial basement membrane and peridontal collagen fiber synthesis Rickets Vitamin D and calcium deficiencies in children and adults, children have disorders of cartilage cell growth, enlargement of epiphyseal growth plates while adults have osteomalacia osteomalacia softening of bones magenta tongue or glossitis Riboflavin deficiency Pale tongue attributable to iron deficiency Beefy red-colored tongue Vitamin B complex deficiency Cheilosis or angular stomatitis erythema, scaling, and shallow and painful fissures at the corners of the mouth occur with excess salivation and Candida infection, often seen in edentulous persons and those with poorly fitting dentures, causing folding in corners of mouth, which creates a warm, moist environment favoring growth of yeast Pitting edema bilateral dependent pitting edema occurs with heart failure, diabetic neuropathy and hepatic cirrhosis while unilateral edema occurs with occlusion of deep vein, both bilateral and unilateral edema occur with lymphatic obstruction obesity over nutrition, and having a BMI of greater than 40 maramus protein-calorie malnutrition, decrease in BMI and cachexia is present. kwashiorkor protein malnutrition, ascites, no protein, decreased albumin (keeps water in) and peristaisnes ascites the accumulation of fluid in the peritoneal cavity, causing abdominal swelling. ecomosis bruise petechaie skin prick white dots, decreased platelets, make purpura (looks like bruise), confluence, and hive like with wheels perfusion capillary refull document greater than 3 seconds, muddy sclera, black skin look at roof of mouth vesicle group like in shingels wheel or petechiae hives what is anthropometric measures (quantitative) height, weight, BMI, waist to hip ratio and nutrition assessment form what are laboratory studies? hemoglobin/hematocrit, cholesterol, and serum albumin underweight BMI less than 18.5 for adults, less than 5th percentile for children normal weight BMI 18.5-24.9 for adults, healthy between 5-85th percentile for children overweight BMI 25-29.9 for adults, between the 85-95 percentile for children obesity BMI 30-39.9 greater than 95th percentile for children extreme obesity greater than 40 waist to hip ratio equation waist circumference divided by hip circumference BMI equation weight (in kg) divided by height (in meters) squared or waist to hip ratio indication for android or upper body obesity 1.0 or greater in men or 0.8 or greater in women nursing diagnoses for malnutrition deficient knowledge:nutrition, feeding self-care deficit, impaired swallowing, imbalanced nutrition : more than body requirements, imbalanced nutrition: less than body requirements and risk for constipation how to assess skin, hair and nails? inspection, palpation and nursing diagnosis of impaired skin integrity data analysis about subjective data changes in color(pigmentation) or moles, brusing, dryness or diaphoresis, pruritis (chronic kidney disease), rashes or lesions, medications, hair loss or alopecia, environmental and occupational hazards, and self-care behaviors relevant health history about subjective data previous disease, allergies objective data with skin, hair and nails cleanliness, odor, color (tone) and pigmentation, vascularity, bruising, temperature, moisture, texture, thickness, mobility, edema and lesions turgor mobility, decreased with edema, poor turgor is evident in severe dehydration or extreme weight loss, the pinched skin recedes slowly or "tents" and stands by itself edema four point scale 1+ mild pitting, with sling indentation, no perceptible swelling of the leg, then 2+ moderate pitting, indentation subsides rapidly, 3+ deep pitting, indentation remains for a short time, leg is very swollen, 4+ very deep pitting, indentation lasts a long time, leg is very swollen what does edema show in the dependent body parts (feet, ankles, and sacral areas) where the skin looks puffy and tight, makes the hair follicles more prominent thus you notes a pigskin or orange peel look unilateral edema consider a local or peripheral cause bilateral edema or edema that is generalized over the whole body consider a central problem such as heart failure or kidney failure primary skin lesions wheal or vesicle secondary lesions crust or fissure vascular lesions petechiae assess all lesions for what? color, elevation (flat, raised, pedunculated), configuration and pattern (grouped or confluent), location and distribution and exudate Pallor includes what? anemia, shock, local arterial insufficiency, albinism, and vitiligo anemia pallor decreased hematocrit, appears as generalized pallor in light skin, and yellow-brown in brown skin, appears ashen gray, dull in black skin and chick areas with least pigmentation such as conjunctivae, mucous membranes shock pallor decreased perfusion, vasoconstriction and appears the same as anemia local arterial insufficiency pallor appears marked localized pallor (lower extremities, especially when elevated) in light skin and ashen gray, dull, cool to palpation in dark skin albinism pallor total absence of pigment melanin throughout the integument, appears whitish pink in light skin and tan, cream, or while in dark skin cyanosis is and the types increased amount of unoxygenated hemoglobin and central and peripheral central cyanosis chronic heart and lung disease cause arterial desaturation, appears dusky blue in light skin, appears dark but dull,lifeless, only severe cyanosis is apparent in skin-check conjunctivae, oral mucosa, and nail beds in dark skin patients peripheral cyanosis exposure to cold, anxiety, appears nail beds dusky in light skin and dark skin patients types of erythema hyperemia, polycythemia, carbon monoxide poisoning, and venous stasis hyperemia erythema increased blood flow through engorged arterioles such as in inflammation, fever, alcohol intake and blushing, appears red, bright pink in light skin and purplish tinge but difficult to see, palpate for increased warmth with inflammation, taut skin and hardening of deep tissues in dark skin polycythemia increased red blood cells, capillary stasis, appears ruddy blue in face, oral mucosa, conjunctiva, hands, and feet in light skin and well concealed by pigment, check for redness in lips for dark skin patients carbon monoxide posioning appears bight cherry red in face and upper torso in light skin patients and cherry-red color in nail beds, lips and oral mucosa venous stasis erythema decreased blood flow from area, engorged venules, appears dusky rubor of dependent extremities, a prelude to necrosis with pressure sore in light skin patients and easily masked, use palpation for warmth or edema for dark skin patients jaundice is what? increased serum bilirubin, more than 2 to 3 mg/100 mL from liver inflammation or hemolytic disease such as after severe burns, and some infections how is jaundice presented in light skin yellow in sclera, hard palate, mucous membranes and then over the skin how is jaundice presented in dark skin check sclera for yellow near limbus, do not mistake normal yellowish fatty deposits in the periphery under the eyelids for jaundice, jaundice best noted in junction of hard and soft palate and also palms what are the types of jaundice? carotenemia and uremia carotenemia jaundice increased serum carotene from ingestion of large amounts of carotene-rich foods, appears yellow-orange in forhead, palms, soles, nasolabial folds but no yellowing in sclera or mucous membranes in light skin and yellow-orange in palms and soles in dark skin uremia jaundice renal failure causes retained urochrome pigments in the blood, appears orange-green or gray overlying pallor of anemia, may also have ecchymoses and purpura in light skin and easily masked, rely on laboratory and clinical findings in dark skin brown-tan types addison disease and cafe au lait spots addison disease cortisol deficiency stimulates increased, appears bronzed appearance an "eternal tan" most apparent around nipples, perineum, genitalia, and pressure points in light skin and easily masked, rely on laboratory and clinical findings cafe au lait spots caused by increased melanin pigment in basal cell layer and tan to light brown, irregularly shaped, oval patch with well-defined borders how to collect objective data for skin, hair and nails vellus hair and terminal hair, check for color, cleanliness, texture, distribution and lesions how to collect objective data for nails check hygiene, color, ridges, capillary refill less than or greater than 3 seconds, shape and contour seen with clubbing nails indicate what? CAD, chronic lung disease, COPD, and decreased oxygen levels melanoma assessment ABCDE, asymmetry, border irregularity, color variation, diameter greater than 6 mm (size of pencil eraser) and elevation or evolution what to always note in melanoma assessment? new pigmented lesions, bleeding of a mole, ugly duckling sign ugly duckling sign suspicious lesion stands out as looking differed compared with neighboring nevi normal clubbing 160 degrees curved nail clubbing 160 degrees or less early clubbing 180 degrees lifespan considerations with assessments infants, children, pregnant female, aging adult, and cross cultural differences pertinent to skin and nails what is normal for pregnant females chloasma (facial pigment) and linea nigra (tendon from 6 pack turns brown) what is normal for the aging adult factors impacting risk for skin disease and breakdown what is subjective data for head, face, neck and regional lymphatics head injury with loss of consciousness, headaches, dizziness, neck pain, lumps or swelling and history of head or neck surgery what is objective data for the head, face, neck and lymphatics symmetry of face, skull, temporal artery and temporal mandibular joint (TMJ), range of motion of neck and muscle strength assessment, lymphatics, assess trachea, assess thyroid, bruit what does symmetry of face test for cranial nerve 7 or VII what does range of motion of neck test for flexion, extension, and assess for pain with flexion which is related to nuchal rigidity nuchal rigidity neck stiffness, photophobia (intolerance of bright light) and headache, It is a sign of irritation of the meninges, such as seen in meningitis, subarachnoid hemorrhages and various other diseases. what does checking muscle strength assessment test for cranial nerve XI, eleven F.A.S.T. means facial changes, arm drift, speech and timing lymph nodes that are movable and hurt are a sign of infection lymph nodes that are immovable and don't hurt are a sign of cancer dysphagia is difficulty swallowing how is bruit auscultated with an enlarged thyroid and use the bell of the stethoscope and not present normally how is bruit heard low sound, blowing and swishing sound children have what type of lymph nodes prominent lymph nodes and lymphoid tissue begins atrophy prior to adolescence lymph nodes in assessment preauricular, posterior auricular, occipital, jugulodigastric, submandibular, submental, superficial cervical, posterior cervical, deep cervical chain, supraclavicular lifespan considerations for head, face, neck and lymphatics infants and children have fontanels, and tonic neck reflex and aging adult have senile tremors fontanels should look full and bulging, not smooth here but elsewhere on the baby skull will be smooth tonic neck reflex primitive reflex that disappears within 3-4 months, when supine and head is turned to one side extension of same arm and leg, flexion of opposite arm and leg senile tremors benign or intention tremors of the face, jaw, protrusion of the tongue which is common with aging what subjective data should the nurse collect about eyes? wear contacts, double vision, vision loss, last eye appointment, occupational work (working on a computer for long periods), changes in eyes with watering objective data for visual acuity tests for which cranial nerve cranial nerve II, two or optic nerve how to test for distance vision snellen chart how to test for near vision or presbyopia jaeger card how to test for peripheral vision confrontation test how to test for color vision test embedded color test what does the numerator always mean always 20 over denominator with higher number meaning the worse the vision how to collect objective data for eyes distance vision, near vision, peripheral vision, color vision, EOM's which are extraoculomotor muscles and Pupillary response or PERRLA what are the EMO's tests diagnostic positions tests or six cardinal fields of gaze, corneal light reflex, assessing for strabismus and nystagmus diagnostic positions tests or six cardinal fields of gaze test for which cranial nerves cranial nerves III, IV, and VI, or three, four and six how to test for corneal light reflex hirschbergs test strabismus seen with a white dot from light, Disorder in which the eyes don't look in exactly the same direction at the same time. nystagmus when eyes wiggle in middle, associated with MS, a vision condition in which the eyes make repetitive, uncontrolled movement PERRLA means Pupils, Equal size, Round shape, React to Light (direct and consensual response) and Accommodation Accommodation for PERRLA Pupils constrict in response from far to near focus red reflex is assessed through what use of ophthalmoscope red reflex is when red glow fills the pupil caused by reflection of lights off the healthy inner retina an absence of red reflex is called white glow in infants and children which could indicate retinoblastoma what are abnormal findings for eyeballs exophthalmos and peri-orbital edema exophthalmos or protruding eyes a forward displacement of the eyeballs and widened palpebral fissures, lid lag which the upper lid rests well above the limbus and white sclera is visible and acquired bilateral is associated with thyrotoxicosis peri-orbital edema lids are swollen and puffy, lid tissues are loosely connected, so excess fluid is easily apparent, occurs with local infections, crying, systemic conditions as congestive heart failure, renal failure, allergy and hypothyroidism abnormal finding for eyelids ptosis and xanthelasma ptosis or drooping upper lid occurs from neuromuscular weakness (myasthenia gravis), oculomotor cranial nerve III damage or sympathetic nerve damage (horner syndrome) or is congenital, a positional defect that gives the person a sleepy appearance and impairs vision xanthelasma soft, raised yellow plaques occurring on the lids at the inner canthus, commonly occur around the 50s and more frequently in women, occur with both high and normal blood levels of cholesterol and have no pathologic significance abnormal findings in lens cataract cataract types central gray opacity or nuclear cataract and star shaped opacity or cortical cataract central gray opacity or nuclear cataract shows an opaque gray surrounded by a black background as it forms in the center of lens nucleus, looks like a black center against the red reflex, begins after 40 years old, develops slowly, gradually obstructs vision star-shaped opacity or cortical cataract shows as asymmetric, radial, white spokes with black center, looks like black spokes are evident against the red reflex, forms in the outer cortex of lens progressing faster than nuclear cataract abnormal findings in pupils anisocoria anisocoria or unequal pupil size although this exists normally in 5% of the population, consider central nervous system disease abnormal findings in conjunctiva's inflammation and edema, related to pink eye which leads to lymphadenopathy to enlargement of lymph nodes and reaction to infection conjunctivitis infection of conjunctiva, pink eye, has red, beefy looking vessels at periphery but is usually clearer around iris, commonly from viral or bacterial infection, allergy or chemical irritation, symptoms are itching, burning, foreign body sensation, and eyelids stuck together on awakening, person will have normal vision normal pupil size and reaction to light allergic conjunctivitis upper lid, conjunctiva and cornea are inflamed from seasonal allergen or persistent allergen, symptoms are eye itching redness, watering, discomfort, does not obscure vision, signs are diffuse redness of conjunctiva, lid swelling, upper tarsal surface that shows velvety thickening, redness, small papillae iritis or circumcorneal redness deep, dull red halo around the iris and cornea, redness is more prominent at the periphery, pupil shape may be irregular from swelling of iris, person has marked photophobia,constricted pupil, blurred vision, and throbbing pain primary angle closure glaucoma acute narrow angle glaucoma shows circumcorneal redness around the iris with dilated pupil, pupil is oval, dilated, cornea looks steamy, acute glaucoma occurs with sudden increase in intraocular pressure from blocked outflow from anterior chamber, person has sudden clouding of vision, sudden eye pain, halos around lights and needs emergency treatment hypothyroidism hair dry, coarse, sparse, lateral eyebrows that are thin, periorbital edema and puffy dull face hyperthyroidism protruding eyes and enlarged thyroid gland glaucoma increased pressure in the eyeball increased intracranial pressure seen by inspection, ocular pressure from nerve increased papilledema swelling and redness of the optic disc, serious sign of increase intracranial pressure (ICP), visual acuity is not affected, causes venous stasis in the globe showing redness, congestion and elevation of the disc the nurse determines that a patient has 20/40 vision which means what the patient can read from a distance of 20 feet what a person with normal vision can read at a distance of 40 feet when assessing a patients pupils for accommodation, the RN should interpret which findings as normal constriction and convergence to determine a patients visual acuity, the RN would use what snellen chart, confrontation test, and jaeger card for distance, near vision and color vision what to never use when cleaning ears Q tips subjective data for the ears earaches, infections, discharge, hearing loss (presbycussis), changes in hearing, hearing aids, environmental noise, tinnitus, vertigo, and self care behaviors presbycussis normal hearing loss with aging tinnitus ringing or buzzing in ears vertigo when it feels like the room is spinning Hearing accounts for what sensory and motor actions hearing as sensory and equilibrium as motor normal objective data findings for the ears cerumen (earwax), and hair abnormal objective data findings for the ears erythema or discoloration, otorrhea (ear discharge), blood, foreign bodies otorrhea ear discharge tympanic membrane assessment using the otoscope appearance shiny, translucent, pearly gray color, flat position, intact membrane integrity tympanic membrane assessment using the otoscope what to do with adult and older children pull pinna up and back tympanic membrane assessment using the otoscope what to do with infant and children under three pull pinna down cone of light occurs where in the normal right ear 5 o'clock cone of light occurs where in the normal left ear 7 o'clock what is common with toddlers and their ears develop otitis media which will present with pain, redness, swelling, and toddler will be tugging at ear chance that it could rupture how to assess for hearing acuity whisper test, Weber test or Rinne test whisper test determines ability to hear whispered sounds from two feet away Weber test a vibrating tuning fork in contact with the top of the head should be heard equally well in both ears, associated with conductive hearing loss Rinne Test using a tuning fork, compare bone conduction to air conduction, with normal results air conduction greater than bone conduction what does assessing the hearing acuity assess? cranial nerve VIII or eight subjective data for nose, mouth and throat discharge, sinus pain, epistaxis, rhinorrhea, sore throat, bleeding gums, xerostomia, toothache, dysphagia, smoking, alcohol consumption, and self-care behaviors eipstaxis nose bleed xerostomia dry mouth, can be side effect from meds rhinorrhea mucus, a condition where the nasal cavity is filled with a significant amount of mucus fluid. when mucus is clear in color it means allergies when mucus is yellow/green in color it means infection objective data for the external nose and sinuses includes testing cranial nerve one with scents, patency of nostrils, percuss and palpate the frontal and maxillary sinuses objective data for the internal nose and sinuses includes inspect using speculum, mucosa pink and moist and septum is in the midline objective data for the mouth and throat includes teeth, oral (buccal) mucosa, gums, movement of tongue, rise of soft palate, uvula mid-line, swallow, gag, pharynx and tonsils what is a cultural consideration with African-Americana patients with objective data from the mouth and throat leukoedema leukoedema benign, milky, bluish-white opaque appearance of the buccal mucosa that occurs commonly in African Americans the movement of the tongue affects which cranial nerve cranial nerve XII, 12 the rise of soft palate, uvula mid-line, swallow and gag affects which cranial nerve cranial nerves IX, and X, so 9 and 10 cranial nerve One (I) olfactory, nose, smell cranial nerve two (II) optic, eyes, sight, snellen chart and visual field test cranial nerve three (III) oculomotor, P.E.R.R.L.A. cranial nerve four (IV) trochlear, extraocular eye muscles, EMO, superior oblique cranial nerve five (V) trigeminal, face/forehead sensations and chewing, corneal reflex cranial nerve six (VI) abducens, lateral eye muscles cranial nerve seven (VII) expressions in forehead, smile, taste, FAST (strokes) cranial nerve eight (VIII) acoustic, ears for hearing and balance cranial nerve nine (IX) glossopharyngeal, uluva, swallow and gag reflex cranial nerve ten (X) vagus, rise of the uvula, gag reflex and esophagus cranial nerve eleven (XI) accessory, shoulder and head movement check for meningitis cranial nerve twelve (XII) hypoglossal, tongue movement an assessment of a patients nose reveals bilateral pale and edmatous nasal mucosa with clear, watery rhinorrhea, this data most likely indicates what an allergic response which finding, if noted, when inspecting a patient's mouth would require immediate follow-up by the nurse leukoplakia candidiasis in adults candida species as normal oral flora is present in 60 % of healthy adults, overgrowth of candida occurs with steroid inhaler use, HIV infection, use of broad-spectrum antibiotics or cortiosteroids, leukemia, malnutrition or reduced immunity candidiasis or monilial infection a white, cheesy, curd-like patch on the buccal mucosa and tongue, it scrapes off, leaving a raw, red surface that bleeds easily, termed thrush in the newborn, is an opportunistic infection that occurs after the use of antibiotics and corticosteroids and in immunosuppressed people aphthous ulcer common canker sore, is a vesicle at first and then a small, round, punched out ulcer with a white base surrounded by a red halo, quite painful and lasts for 1 to 2 weeks, cause is unknown, although it is associated with stress, fatigue, and food allergy leukoplakia chalky white, thick, raised patch with well-defined borders, lesion is firmly attached and does not scrape off, may occur on the lateral edges of tongue, caused by chronic irritation and occurs with heavy smoking and alcohol use, lesions are precancerous, must refer to specialist leukoedema is normal for which culture African americans the nurse assesses that a patient is unable to stick out their tongue, the nurse suspects that which of the following cranial nerves is not functioning properly cranial nerve XII tweleve a 10 year old girl is being seen in the pediatric clinic for "fluid filled sores all around the mouth and nose, the sores are bothersome, ugly and little itchy impetigo