NR 509 Assessment Study Guide Solutions

NR 509 Assessment Study Guide Solutions First step obtain - Ans:-patient consent to video and assessment Face most note - Ans:-head is midline and symmetrical no discoloration or lesions Palpation of Lymph nodes on face and neck - Ans:-preauricular lymph nodes-at front of ear postauricular lymph nodes-back of ear occipital lymph nodes-back of head tonsillar lymph nodes-move forward under jaw submandibular lymph nodes-under jaw submental lymph nodes-under chin Now palpate the cervical Lymph nodes - Ans:-pre-cervical lymph nodes-run hands down neck toward collarbone post-cervical lymph nodes-directly posterior to this ©GRACEAMELIA 2024/2025 ACADEMIC YEAR. ALL RIGHTS RESERVED FIRST PUBLISH OCTOBER 2024 Page 2/18 supraclavicular lymph nodes-run hands over clavicle make sure to note no tenderness, enlargement and they are equal bilaterally Cranial Nerve V: Trigeminal Nerve 1st component: motor 2nd component: sensory - Ans:-clench jaw assess masseter muscle note strength, no distortions, and equal bilaterally 2nd component: close eyes and touch forehead, each cheek, nose, and chin make sure they are able to tell you where you're touching Cranial Nerve V11: Facial Nerve Have client do a series of - Ans:-facial expressions 1. smile note equal and symmetrical 2. frown 3. raise eyebrows 4. puff cheeks-equal bilateral 5. pucker lips-want a nice tight pucker ©GRACEAMELIA 2024/2025 ACADEMIC YEAR. ALL RIGHTS RESERVED FIRST PUBLISH OCTOBER 2024 Page 3/18 Note intact: if able to perform and equal and symmetrical bilaterally Inspect the Ears 1. note the outer ear 2. use an otoscope to look inside for adult pull ear - Ans:-1. equal and symmetrical no nodules or lesions or discoloration 2. up and back and note external auditory canal is clear, no redness, drainage, effusion (full of fluid) swelling and absent of cereum and tympanic membrane is bright or pearly grey do same with other ear Palpate the ears 1. palpate the 2. next palpate the - Ans:-1. pinna (top of the ear) note absence of nodules or tenderness 2. tragus (inner ear triangle) note absence of tenderness Cranial nerve VIII: the Acoustic Nerve 1. this will assess (blank) you will use the Whisper test - Ans:-1. patient's hearing have them cover one ear and whisper something "123 or 456" into the opposite ear and have them repeat back to you. Do this on both ears Note hearing is intact bilaterally ©GRACEAMELIA 2024/2025 ACADEMIC YEAR. ALL RIGHTS RESERVED FIRST PUBLISH OCTOBER 2024 Page 4/18 assess Eyes 1. first look at - Ans:-1. the conjunctiva (pull-down bottom eyelids); note pink, clear with lesions or discoloration or drainage and sclera is white/clear bilaterally Cranial II: Optic Nerve 1. you'll be testing central 2. IF they can read off the lowest lines then - Ans:-1. vision to do this pull out pocket Snellen Chart stand 6 ft away and have pt read off of lowest line covering one eye have patient cover other eye and repeat and then perform