Portage Learning NURS 100 Final Exam Study Guide
Head to Toe
Head & Neck ● Lymph nodes (10)
Eyes ● Inspect for color, shape, symmetry, position, & alignment of eyes
○ Corneal light reflex: light appears equally in the same spot
on both pupils; strabismus (cross eye)
● Conjunctiva & sclera
○ Bulbar conjunctiva: delicate mucous membrane that
covers the exposed surface of the sclera (white)
○ Palpebral conjunctiva: membrane that lines the
anterior portion of sclera (uniformly pink)
● Lids: Lacrimal apparatus
○ Nasolacrimal sac: upper dilated end of the nasolacrimal duct;
is lodged in a deep groove formed by the lacrimal bone &
frontal process of the maxilla
● Confrontation
○ Peripheral vision
○ Pt can see fingers enter visual field (180 degrees)
● CN 2 Optic: S (visual acuity)
○ Snellen (far vision): myopia/nearsightedness
○ Rosenbaum (arms length): hyperopia/farsightedness
○ Ishihara (color vision)
■ od/os/ou
● PERRLA
○ Pupils
○ Equal
○ Round
○ Reactive to Light
■ CN 3 Oculomotor: M
,Portage Learning NURS 100 Final Exam Study Guide
■ Pupillary constriction (bringing light in from the side)
○ Accommodation
■ Constrict & converge (focus on something, then
refocus on pen)
● Cardinal Positions of gaze (nystagmus or involuntary
rapid eye movements, drifting)
○ CN 3 Oculomotor: M
○ CN 4 Trochlear: M
○ CN 6 Abducens: M
● Cataracts: cloudy or opaque areas in the ocular lens, temporary
○ Risk factors: Increasing age, Diabetes, high BP
● Glaucoma: a group of eye conditions that can cause blindness; often
caused by an abnormally high pressure in your eye; permanent
○ Risk factors: having high internal eye pressure
(intraocular pressure)
● Terms (exam 4)
○ Wk 9 terms: https://quizlet.com/585839860/week-9-terms-
flash-cards/
Ears ● Inspect & palpate auricles for redness, swelling, tenderness
● Inspect external canal for redness, swelling, drainage, cerumen,
foreign bodies
● Otitis externa: inflammation of external ear; allergic reaction to
beauty/personal care products
● Otitis media: inflammation of middle ear; common in pt’s with
environmental/seasonal allergies
● Weber (lateralization)
○ Vibration and sound equal bilaterally
● Rinne (AC>BC 2:1)
○ Pt unable to hear or feel the sensation in one ear during
Weber
○ Conduction: air conduction to bone conduction, hear it
twice as long as you should be able to feel it
❖ Whisper
➢ Able to identify words
Nose ● Inspect nares for symmetry, lesions, tenderness
● Inspect internal nares for inflammation, drainage
,Portage Learning NURS 100 Final Exam Study Guide
○ Make sure septum is midline, not deviated
○ Septal deviation: a condition in which the nasal septum (the
bone and cartilage that divide the nasal cavity of the nose in
half) is significantly off center, or crooked, making breathing
difficult
○ Palpate pt’s nose assessing for pain, tenderness, swelling &
deformity?
● CN 1 Olfactory: S
○ Can smell ⅔ odors
○ Patency: air is moving freely within nasal cavity
● Palpate sinuses
○ Frontal: superior orbital rim above eyebrow
○ Maxillary: superior aspect of the cheek bones (around eyes)
● Terms
○ Epistaxis: Nosebleed
○ Nasal flaring: Occurs when the nostrils widen while
breathing; often a sign of trouble breathing
○ Nasal discharge: Excess drainage, ranging from a clear fluid
to thick mucus, from the nose and nasal passages;
rhinorrhea
Mouth ● Inspect
&
Throat ○ Lips: color, moisture, cracking, lesions,
○ Oral mucosa: color, moisture, lesions (moist & pink)
○ Gums: color, swelling, retraction of gingiva, lesions (pink,
smooth moist)
○ Teeth: decay, alignment
● Glossopharyngeal 9 & Vagus 10: B
○ Soft palate/uvula movement
■ Smooth, moist, pink, rises w vocalization
■ Uvula is midline
○ Speech quality
○ Swallow
■ Dysphagia: difficulty swallowing
○ Gag reflex
○ Only 9: verbalize taste
● Hypoglossal 12: M
○ Color, saliva, symmetry, open areas
○ Ease & equality of tongue movement
, Portage Learning NURS 100 Final Exam Study Guide
○ Strength of tongue
● Tonsils: color, exudate, lesions
● Thyroid assessment
● Throat pain
● Swollen lymph nodes
● Thrush: An infection in which the fungus Candida albicans
accumulates in the mouth
Cardiovascul ● Inspect/palpate color, temperature, texture of skin, hair distribution
ar in extremities
● Observe the neck and precordium for visible pulsations
○ Precordium: portion of the body over the heart and
lower thorax, APEToMan
● Capillary refill < 3 seconds
● S1: best heard at apex (loudest in mitral); closure of mitral &
tricuspid valves; “LUB”; low pitched & dull; beginning of
ventricular
systole
● S2: best heard in aortic area at base of heart; closure of aortic &
pulmonic valves; “DUB”; end of ventricular systole; shorter, higher-
pitched, louder sound than S1
● S3: ventricular gallop; may be cardinal sign of heart failure in adults;
best heard at apex with pt lying on left side; low-pitched; the y
sound in “Ken-tuck-y”; follows S2; may also be associated with such
conditions as pulmonary edema, atrial-septal defect, acute MI and
last trimester of pregnancy
● S4: atrial gallop; heard over tricuspid or mitral areas with pt on left
side; heard in elderly, or those with HTN, aortic stenosis, or a history
of MI; commonly describe as sounding like; “Ten-nes-see”
○ Murmurs: regurgitation of blood between atrium &
ventricles (valve isn't closing all the way)
○ Thrills: palpable vibration: usually valvular dysfunction
○ Heaves: lifting of the chest wall felt during palpation
○ Bruits: abnormal “swooshing or blowing” heard over blood
vessel; stenosis or occlusion
■ Feel a thrill, hear a bruit
❖ APETM
➢ Aortic: 2nd intercostal space R sternal border
➢ Pulmonic: 2nd intercostal space L sternal border
➢ Erb's point: 3rd intercostal space L sternal border
Head to Toe
Head & Neck ● Lymph nodes (10)
Eyes ● Inspect for color, shape, symmetry, position, & alignment of eyes
○ Corneal light reflex: light appears equally in the same spot
on both pupils; strabismus (cross eye)
● Conjunctiva & sclera
○ Bulbar conjunctiva: delicate mucous membrane that
covers the exposed surface of the sclera (white)
○ Palpebral conjunctiva: membrane that lines the
anterior portion of sclera (uniformly pink)
● Lids: Lacrimal apparatus
○ Nasolacrimal sac: upper dilated end of the nasolacrimal duct;
is lodged in a deep groove formed by the lacrimal bone &
frontal process of the maxilla
● Confrontation
○ Peripheral vision
○ Pt can see fingers enter visual field (180 degrees)
● CN 2 Optic: S (visual acuity)
○ Snellen (far vision): myopia/nearsightedness
○ Rosenbaum (arms length): hyperopia/farsightedness
○ Ishihara (color vision)
■ od/os/ou
● PERRLA
○ Pupils
○ Equal
○ Round
○ Reactive to Light
■ CN 3 Oculomotor: M
,Portage Learning NURS 100 Final Exam Study Guide
■ Pupillary constriction (bringing light in from the side)
○ Accommodation
■ Constrict & converge (focus on something, then
refocus on pen)
● Cardinal Positions of gaze (nystagmus or involuntary
rapid eye movements, drifting)
○ CN 3 Oculomotor: M
○ CN 4 Trochlear: M
○ CN 6 Abducens: M
● Cataracts: cloudy or opaque areas in the ocular lens, temporary
○ Risk factors: Increasing age, Diabetes, high BP
● Glaucoma: a group of eye conditions that can cause blindness; often
caused by an abnormally high pressure in your eye; permanent
○ Risk factors: having high internal eye pressure
(intraocular pressure)
● Terms (exam 4)
○ Wk 9 terms: https://quizlet.com/585839860/week-9-terms-
flash-cards/
Ears ● Inspect & palpate auricles for redness, swelling, tenderness
● Inspect external canal for redness, swelling, drainage, cerumen,
foreign bodies
● Otitis externa: inflammation of external ear; allergic reaction to
beauty/personal care products
● Otitis media: inflammation of middle ear; common in pt’s with
environmental/seasonal allergies
● Weber (lateralization)
○ Vibration and sound equal bilaterally
● Rinne (AC>BC 2:1)
○ Pt unable to hear or feel the sensation in one ear during
Weber
○ Conduction: air conduction to bone conduction, hear it
twice as long as you should be able to feel it
❖ Whisper
➢ Able to identify words
Nose ● Inspect nares for symmetry, lesions, tenderness
● Inspect internal nares for inflammation, drainage
,Portage Learning NURS 100 Final Exam Study Guide
○ Make sure septum is midline, not deviated
○ Septal deviation: a condition in which the nasal septum (the
bone and cartilage that divide the nasal cavity of the nose in
half) is significantly off center, or crooked, making breathing
difficult
○ Palpate pt’s nose assessing for pain, tenderness, swelling &
deformity?
● CN 1 Olfactory: S
○ Can smell ⅔ odors
○ Patency: air is moving freely within nasal cavity
● Palpate sinuses
○ Frontal: superior orbital rim above eyebrow
○ Maxillary: superior aspect of the cheek bones (around eyes)
● Terms
○ Epistaxis: Nosebleed
○ Nasal flaring: Occurs when the nostrils widen while
breathing; often a sign of trouble breathing
○ Nasal discharge: Excess drainage, ranging from a clear fluid
to thick mucus, from the nose and nasal passages;
rhinorrhea
Mouth ● Inspect
&
Throat ○ Lips: color, moisture, cracking, lesions,
○ Oral mucosa: color, moisture, lesions (moist & pink)
○ Gums: color, swelling, retraction of gingiva, lesions (pink,
smooth moist)
○ Teeth: decay, alignment
● Glossopharyngeal 9 & Vagus 10: B
○ Soft palate/uvula movement
■ Smooth, moist, pink, rises w vocalization
■ Uvula is midline
○ Speech quality
○ Swallow
■ Dysphagia: difficulty swallowing
○ Gag reflex
○ Only 9: verbalize taste
● Hypoglossal 12: M
○ Color, saliva, symmetry, open areas
○ Ease & equality of tongue movement
, Portage Learning NURS 100 Final Exam Study Guide
○ Strength of tongue
● Tonsils: color, exudate, lesions
● Thyroid assessment
● Throat pain
● Swollen lymph nodes
● Thrush: An infection in which the fungus Candida albicans
accumulates in the mouth
Cardiovascul ● Inspect/palpate color, temperature, texture of skin, hair distribution
ar in extremities
● Observe the neck and precordium for visible pulsations
○ Precordium: portion of the body over the heart and
lower thorax, APEToMan
● Capillary refill < 3 seconds
● S1: best heard at apex (loudest in mitral); closure of mitral &
tricuspid valves; “LUB”; low pitched & dull; beginning of
ventricular
systole
● S2: best heard in aortic area at base of heart; closure of aortic &
pulmonic valves; “DUB”; end of ventricular systole; shorter, higher-
pitched, louder sound than S1
● S3: ventricular gallop; may be cardinal sign of heart failure in adults;
best heard at apex with pt lying on left side; low-pitched; the y
sound in “Ken-tuck-y”; follows S2; may also be associated with such
conditions as pulmonary edema, atrial-septal defect, acute MI and
last trimester of pregnancy
● S4: atrial gallop; heard over tricuspid or mitral areas with pt on left
side; heard in elderly, or those with HTN, aortic stenosis, or a history
of MI; commonly describe as sounding like; “Ten-nes-see”
○ Murmurs: regurgitation of blood between atrium &
ventricles (valve isn't closing all the way)
○ Thrills: palpable vibration: usually valvular dysfunction
○ Heaves: lifting of the chest wall felt during palpation
○ Bruits: abnormal “swooshing or blowing” heard over blood
vessel; stenosis or occlusion
■ Feel a thrill, hear a bruit
❖ APETM
➢ Aortic: 2nd intercostal space R sternal border
➢ Pulmonic: 2nd intercostal space L sternal border
➢ Erb's point: 3rd intercostal space L sternal border
