Quiz 2: NURS190 / NURS 190 (Latest 2026 / 2027 Update) Physical Assessment | Questions & Answers | Grade A | 100% Correct – WCU

Quiz 2: NURS190 / NURS 190 (Latest 2026 / 2027 Update) Physical Assessment | Questions & Answers | Grade A | 100% Correct – WCU Q: Nurses know how you're feeling by... Answer looking at your eyes Q: Eyes are Answer the window to the outside world; most important assessment Q: Cranial nerve I is the.... Answer extension of diencephalon Q: Cranial nerve II is the... Answer extension of keylacephalon Q: Cranial nerve III and IV are located in... Answer the midbrain Q: Cranial nerves V, VI, VII, VIII are located in the... Answer pons Q: Cranial nerves IX, X, XI, and XII are located in the... Answer brain stem Q: The farther you go down the brainstem = Answer the worst the conditions will be Q: If you have a global stroke and it affects cranial nerves IX, X, XI, and XII it is Answer bad news Q: You receive information from the outside world through cranial nerve _____, this nerve receives the information and takes it the the _________ and it goes into a whole bunch of ______ and goes to the _______ side of the brain to take information so you would respond with your __________ ________. Answer II, midbrain, nuclei, opposite, contralateral eye Q: Information that goes in ipsilateral also goes to __________. That's why when we shine the flashlight in one eye _______ ______ _______. Answer contralateral, both pupils constrict Q: Which nerves respond to the eye constricting? Answer Parasympathetic nerve, cranial nerve III Q: Why is it important for us to know that both eyes respond? Answer You have to know that if you create a barrier here, and you take your flashlight here, and you shine your flashlight in one eye, you are going to see all the information of the flashlight in the other eye as well Q: Constriction, imagery =....Will see... Answer corneal light reflex....identical information in both eyes Q: It is __________ to see identical information in both eyes. Answer normal Q: When something happens to the pt, because all these nuclei are located centrally in the brain, pts tend to present with...Which nerves are affect? Answer deficits with the eye examination (i.e PERRLA)...cranial nerve III and IV I.e. stroke Q: Cranial nerve III innervates ________ ______, so if there is a stroke of the midbrain you are going to see a pt that presents with... Answer levator palpebrae, droopy eyelid Q: Cranial nerve III is associated with....this would give you a ________ that your eye is _______ and ______ = ____________. Answer Palsy; gaze, coming down, looking out, abnormal Q: Abnormal findings with stroke Answer 1. Ptosis 2. Sudden acute vision loss 3. Angina of the eye = retinal artery stenosis Q: Ptosis = Dysfunction of which CN? Answer drooping of the eye; If the pt didn't have it in the morning but they have it now = concern; dysfunction of cranial nerve III Q: Nystagmus Answer Involuntary rapid eye movements; not good, severity depends on the caliber of the lesion Q: Cranial nerve has... Answer sensory and motor components Q: Bell's Palsy deals with cranial nerve Answer VII Motor components of cranial nerve VII Answer temporal, oculer, cervical, buccal, mandibular Sensory components of cranial nerve VII Answer taste (change in taste), hearing (change in hearing) VII innervates ______ ________ Answer subpedius muscle in the ear, do you have a change in your sense of hearing, do you have a change of taste, can cause droopiness of the eye (Palsy) IV, V, VI are ______ so you are going to have..... oculomotors, gaze problems #1 cause of geriatric blindness in the world...What kind of vision loss and why do they go blind? macular degeneration; degeneration of the macular which contains all the sensory nerves Macular degeneration -Seen more in caucasians, there is no cure for it, that is why people go blind -Usually start with dry degeneration -They lose central vision loss, peripheral vision is intact (two black dots in front of your eye) -Anti veg-F injection = you don't go from dry to wet which is the end stage of that disease -Legally blind Leading cause of blindness in the world? Diabetic retinopathy Microvascular damage Retinopathy Nephropathy Neuropathy Macrovascular damage MI Stroke PAD Cataract assessment -you see this light film in the elderly population; you can get it surgical fixed -White patches in the lens of their eyes, lens becomes warped over the years -Cannot tell colors their vision is distorted Physical assessment of the eye with elderly always presents with two findings: 1. Dryness of the eye (presbyopia) 2. Inability to focus How do you talk to a blind person Stand in front of them and remain eye contact Physical assessment of the eye or ear. You always want to make sure that you always ask them if... they wear any visual aid, or hearing aid Medical emergency = Which one is worse? Acute glaucoma; closed glaucoma Glaucoma = increased ocular pressure, if it is not treated you can go blind; pupil is oval shaped and dilated, cornea appears cloudy with circumcorneal redness, pain is sudden and accompanied by halos around lights and a decrease in vision The posterior chamber drains into the anterior chamber and if that pathway is closed or narrowed you are going to have symptoms of... Glaucoma which is extreme pain in the eye, and pain in the abdomen -Pain in the abdomen because of the vagus nerve = medical emergency Physical assessment of the nose look pt in face, use flashlight to detect any dry blood, dry mucous membrane Runny nose = rhinorrhea, happens during allergy season Nose bleeds that do not stop are... bad 99% of nosebleeds are mechanical Pathologic nosebleed that does not stop = epistaxis; cannot be fixed in doctors office Cranial nerve VIII regulates _______. Test it by... hearing; whispering a set of words in the patient's ear one at a time; VII has a sensory component to hearing Elder people have hearing problems... -middle ear (usually otitis media or otosporosis) -outer ear (usually cerumen or wax, needs to be removed carefully), -inner ear problem Otitis media is seen a lot in...Presents with... -Pediatric patients, ear pain, fever, bulging ear drum Otitis externa = Swimmer's ear, tender to touch, red, erythema, swelling of the auricle and ear canal and scanty drainage, may be accompanied by itching, fever, and enlarged lymph nodes Romberg test a test of proprioception (the body knowing its position without needing to see it), have pt stand with their eyes closed, assess for any swaying, this is because they're sense of proprioception is altered, this is from neuropathy Stomping gait = Romberg positive Clear liquid from the ear = cerebrospinal fluid; test by taking gaze and putting it on the ear, you will see a yellow halo Always assess the head, make sure its.. atraumatic, normal cephalic, check the ears, check the nose for bleeding, ears for discharge = in the clear Air conduction is ________ than bone conduction. Ex. 30 for air conduction and 15 for bone conduction = greater; normal because ration 2:1 Rinne test use a tuning fork, put the base of the tuning fork on the mastoid bone and you feel the vibration, when you don't feel the vibration you bring it to your ear and you'll hear it; this shows that air conduction is greater than bone conduction, ask the pt to tell you when the sound is no longer heard Weber test tests for inner ear, sensoryneuro; you tap your tuning fork in the middle of the forehead, the vibration must be felt in both ears, if it is not felt in both ears, it means it is lateralizing to one ear, means hearing loss is detected Black dots or spots are known as _______. They are considered _________. floaters, normal Halos around lights are associated with... cataracts, glaucoma, digoxin drug toxcitiy If nystagmus occurs during test, there could be a... weakness in the extraocular muscles or cranial nerve III cranial III nerve damage results in unilaterally dilated pupil, there is no reaction to light, ptosis may be seen ear drainage may indicate an infection bloody or purulent drainage of the ear could indicate otitis media or infection of the middle ear serous drainage of the ear could indicate allergic reaction aspirin can cause ringing in the ears (tinnitus) When the patient says "aah" this movement is related to the proper functioning of cranial nerves IX and X Abnormal findings in Weber test sound lateralizes to (right or left) ear Hearing and balance are functions of cranial nerve VIII The sense of taste are cranial nerves VII and IX Movement of the tongue is cranial nerve XII Epistaxis a nosebleed may follow trauma such as a blow to the nose or may accompany another alteration in health such as rhinitis, hypertension, or blood coagulation disorder Bilateral subconjunctival hemorrhage is caused by ruptured blood vessels and can be associated with hypertension Causative factor of nystagmus weakness in the extraocular muscles Which test measures intraocular pressure? Tonometry Esophoria is when the eye turns inward during the cover test The nurse notes there is a lack of convergence when testing a client's accommodation. Which cranial nerves should the nurse recognize are potentially dysfunctional? III, IV, VI Clinical manifestations of rhinitis nasal mucosa with presence of thin, watery discharge, sneezing, nasal congestion Presence of black, furry-looking coated on the tongue is related to an overgrowth of fungus due to the inhibition of normal bacteria due to antibiotic use Testing olfactory nerve = CN I vision exam/snellen chart = CN II Testing eyes, PERRLA,controlspupillaryconstrictionanddilation = CN III 6 cardinal fields of gaze = CN III, IV, VI facial nerves and TMJ = CN V and VII Whisper and Romberg test = CN VIII Gag reflex, swallow, and tongue movement = CN IX, X, XII What are cataracts? Cloudy lens in eye What are the causes of cataracts? Aging, genetics, DM, smoking, eye injury, surgery, sun exposure, corticosteroids What is a stye? Painful lump from bacterial infection A stye is also known as hordeolum What is ptosis? Drooping upper eyelid What are the causes of ptosis? Levator muscle stretching, aging, eye injury, surgical complication What is ocular melanoma? Growth of pigment-making cells in the eye What is retinoblastoma? Eye cancer causing white pupil and misaligned eyes What is strabismus? Crossed eyes causing double vision and loss of depth perception What are the causes of strabismus? Eye muscle problems, DM, thyroid disease, CVA, MG, brain tumor, TBI, post-op complication Thyroid eye disease is also known as Exophthalmos What is thyroid eye disease? Eye protrusion, dryness, and vision changes due to hyperthyroidism. What are the causes of thyroid eye disease? Immune system attacking thyroid gland, causing eye muscle swelling What is anisocoria? Unequal pupil size What are the causes of anisocoria? Nervous system problem, viral infection, eye damage Astigmatism Blurred or distorted vision due to imperfection in curvature of eye's cornea or lens Conjunctivitis Irritation of conjunctiva causing red, swollen, & discharge in one or both eyes Conjunctivitis is also known as Pink eye Crow's feet Wrinkles at corners of the eyelids due to facial muscles movement Blepharitis Inflammation of eyelids causing redness, burning, or soreness with flakes or oily particles Cauliflower ear External ear swelling and purple due to blunt blow to external ear Subperichondrial hematoma is also known as Cauliflower ear Acute otitis media Earache, n/v/d, fever, hearing loss due to viral or bacterial infection Eardrum perforation Hole in eardrum causing sudden pain, bleeding from the ear, and hearing loss due to ear infections or sudden change in pressure Deviated septum Off-center bone and cartilage that divides the nose in half causing difficulty breathing and interfering with sinus drainage due to injury or trauma Gingivitis Inflammation of the gums causing bleeding and discomfort due to plaque-induced, meds, vit C deficiency, or infections What is Leukoplakia? White or gray patches inside mouth or on the tongue (thick, develop over time) *sores more likely cancerous What are the types of Leukoplakia? Hairy (immunocompromised, painless, fuzzy white) What are the causes of Leukoplakia? Irritation (rough teeth, rough places on dentures, smoking, holding chewing tobacco), Epstein Barr virus What is the treatment for Leukoplakia? Local or systemic antivirals (prevent replication), podophyllum resin solution & topical tretinoin can improve white patches (appearance) What is Gingival hyperplasia? Overgrowth of gingival tissue w/out inflammation What is the cause of Gingival hyperplasia? Meds (phenytoin, nifedipine) What is Tonsilitis? Red, swollen, & purulent exudate w/ tonsils, pain w/ swallowing, fever, HA What are the causes of Tonsilitis? Viral or Bacterial Which prefix relates to tongue? Gloss 3 multiple choice options If a patient answers correctly for what year is it. What are they oriented to? Time 3 multiple choice options What assessment technique goes with eyes, ears, nose, mouth, and throat? Palpation 2 multiple choice options If the patient answers correctly the reason they are here. What are they oriented to? Situation 3 multiple choice options If the patient answers correctly with their name. What are they oriented to? Self 3 multiple choice options Which prefix relates to the mouth? Oro 3 multiple choice options Is a patient answers correctly for where they are. What are they oriented to? Place 3 multiple choice options What assessment technique goes with eyes, ears, nose, mouth and throat? Inspection 2 multiple choice options What is the definition of myopia? Nearsightedness 3 multiple choice options What is the definition of mydriasis? Pupil dilation What is the definition for hyperopia? Farsightedness 3 multiple choice options What is the definition of miosis? Pupil constriction 3 multiple choice options Which term describes bulging of the eyes? Exophthalmos 3 multiple choice options Which term describes drooping of the eyelid? Ptosis 3 multiple choice options Which people size is an expected finding? 5 mm 3 multiple choice options What is the grade range for tonsils? 0-4+ 3 multiple choice options Tonsils occupying less than 25% of the lateral dimension of the oropharynx would be graded as 1 + 3 multiple choice options Tonsils occupying more than 50% but less than 75% of the lateral dimension of the oropharynx would be graded as 3 + 3 multiple choice options What finding is consistent with conjunctivitis Red conjunctiva 2 multiple choice options Yellow discoloration of the hard palate is a sign of Jaundice 3 multiple choice options What are the signs of gingivitis Redness, swelling, and bleeding 3 multiple choice options What are the signs of gingival hyperplasia? Overgrowth of the tissue 3 multiple choice options Assessment findings with the ears colon watery drainage after a trauma. What unexpected finding could be present? Skull fracture 3 multiple choice options Assessment finding with the ears colon consistently turning the head towards sound. What unexpected finding could be present? Hearing deficit 3 multiple choice options What is an expected finding with the tongue? Tongue is moist, rough, and red 1 multiple choice option Which unexpected finding is consistent with white nasal drainage? Eating too much Dairy 3 multiple choice options What color nasal drainage is consistent with a patient presenting with signs of bronchitis? Brown 3 multiple choice options Which unexpected finding is consistent with green nasal drainage? Sinusitis 3 multiple choice options Which one isn't associated with the tongue Gingival hyperplasia 3 multiple choice options How far away should a patient be from the Rosenbaum chart? 12 in 3 multiple choice options Which test is used to assess for distance vision? Snellen chart 2 multiple choice options With the corneal light reflex what is the nurse assessing? Misalignment 3 multiple choice options What test is the nurse conducting when she shines the light into one eye and comparison with the other eye? Consensual constriction 3 multiple choice options What is a unilateral black curtain coming down with the sight of vision a sign of Detached retina 3 multiple choice options What is cloudy vision a sign of? Cataracts 3 multiple choice options What is central vision loss a sign of? Macular degeneration 3 multiple choice options What is peripheral vision loss a sign of? Glaucoma 3 multiple choice options What is the purpose of Performing the "H" or "Wagon pinwheel" method with the eyes? Extraocular muscles 3 multiple choice options What is an expected finding with an ophthalmoscope? Hyperpigmented center in the macula 3 multiple choice options What is an expected finding with an otoscope? Pearly grey tympanic membrane 3 multiple choice options What part of the body is being assessed with the Weber and Rinne test? Ears 3 multiple choice options A nurse is having the patient stand with their eyes closed to assess position sense. What is the name of this test? Romberg 3 multiple choice options