Shared Flashcard Set

Details

HEENT & Nervous System
Study Guide Qs for Becky
111
Nursing
Undergraduate 1
11/17/2012

Additional Nursing Flashcards

 


 

Cards

Term
What are gross hearing tests?
Definition
The whisper test.
Term
What is the whisper test?
Definition
Have patient cover ear opposite of the one being tested. Stand 1-2 ft behind patient and whisper. Note pt's ability to hear words.
Term
What is the Weber test?
Definition
This is a test of lateralization of sound throgh bone conduction. If patient cannot hear the sound equally between both ears, you must perform the Rinne test to determine which ear is most affected.
Term
What is the Rinne test?
Definition
Used to compare air conduction and bone conduction. Place vibrating tuning fork on pt's mastoid process. Note time til pt no longer hears fork. Quickly bring vibrating fork infront of ear. Note time til pt no longer hears fork. Compare the times between the two ears.
Term
What is the tonsil grading scale?
Definition
It is a scale used to assess the tonsils. Grades are scaled from 0 to 4+:
0 - Not very enlarged.
1+ - Tonsils extend to arches
2+ - Tonsils extend just beyond arches
3+ - Tonsils approximate the uvula
4+ - Tonsils meet midline, "kiss"
Term
Describe the process for examining the ear with otoscope.
Definition
This process is used to assess the external ear canal and the tympanic membrane (TM). Assess the ear canal for patency, color, drainage, lesions and foreign objects. Assess the TM for color, intactness, landmarks, and mobility.
Term
What is the normal color for the Tympanic Membrane?
Definition
Pearly grey.
Term
What is stereognosis?
Definition
The ability to recognize the form of solid object by touch.
Term
What is graphesthesia?
Definition
The ability to recognize outlines, written on skin.
Term
Describe two-point discrimination
Definition
Ability to discern that two nearby objects touching the skin are truly two distinct points.
Term
What is point localization?
Definition
Ability to sense and locate the area being stimulated.
Term
What is extinction?
Definition
The ability to recognize that both sides of the body are being touched at once.
Term
What is the Glasgow Coma Scale?
Definition
A neurological scale that assess the conscious state of a person. Get between 3 (deeply unconsious person) to 15 (awake and alert person) points.
Term
What is the Red Reflex?
Definition
To check for the reflection of light off the retina. Check for presence of opacities (opaqueness).
Term
What does the eyelid do?
Definition
Protects eye from injury and distributes lubicration over the eye globe.
Term
What do the lacrimal glands do?
Definition
They're located in the pper lid just below the orbital rim. Produces tears to moisturize the globe and wash away foreign bodies.
Term
What is the sclera?
Definition
Underlies the blbar conjuctiva and gives the eyeball its white color. A tough avascular laer that gives the eye its structure and sape, which is important for transmission of visual images to the back of the eye for interpretation.
Term
What is the cornea?
Definition
The anterior outermost layer of the eyeball, which covers the pupil and iris and extends to the limbus. Contains sensory innervation for pain, thus providing an early warning system for eye injury. Avascular and transparent.
Term
What is the Anterior chamber?
Definition
The area between the cornea and the iris. filled with a clear fluid called aqueos humor.
Term
What is the iris?
Definition
A circular muscular tissue that forms the colored part of the eye. The aperture of the iris forms the pupil and controls the amount of light entering the retina.
Term
What are the pupils?
Definition
The pupule is the aperture of the iris.
Term
What is Anisoconia?
Definition
The unequal size of the pupils.
Term
What is the conjunctiva?
Definition
A mucuos membrane that lines the eyelids and the outermost portion of the globe. It provides lubrication.
Term
What are the steps for examining the eye?
Definition
Perform head to toe exam to check for signs of diseases of other organs that might affect the eye. Then test for visiual distance and color. Test extraocular muscles ability. Inspect external eye structures. With opthalmoscope, inspect red light reflex, optic disc, retina and vessels. Then palpate eyeball for consistency and lacrimal ducts for tenderness.
Term
What are the lips?
Definition
Muscular folds that surround the mouth; contain sensory receptors and are very sensitive.
Term
What is the buccal mucosa?
Definition
Moist mucuos membrane of the cheeks that assists with eating.
Term
What is gingivae?
Definition
Help to anchor teeth, part of oral mucosa, cover alveolar bone.
Term
What is the pharynx?
Definition
The pharynx is the muscular tube. It is divided into the nasopharynx, oropharynx, and laryngopharynx.
Term
What are the palates?
Definition
Hard palate (forms the floor of the nasal cavity) and soft palate (posterior to hard palate, elevates during swallowing to prevent food and saliva from entering the nasopharynx).
Term
What are the tonsils?
Definition
Lymphatic tissue that prevents infection. It is divided into the palatine, lingual, and pharyngeal.
Term
What are the salivary glands?
Definition
Secrete saliva, which contains amylase to convert starch to maltose.
Term
What are the Stensen's ducts?
Definition
Drains the parotid gland, enters the oral cavity through the buccal mucosa, opposite the second upper molar.
Term
What is the lingual frenulum?
Definition
Attaches the tongue to the floor of the mouth.
Term
What are the Wharton's ducts?
Definition
Drains submandibular and sublingual salivary glands, enters te oral cavity under the tongue on the floor of the mouth.
Term
What are the parotid glands?
Definition
Salivary glands anterior to the ear. Secretions help lubricate food to faciliate chewing and swalling.
Term
What are the submandibular glands?
Definition
Located at the posterior corner of the mandible. Assess these glands by looking under the chin. Look for edema/redness.
Term
What are the sublingual glands?
Definition
Located below te floor of the mouth.
Term
What do you assess for when assessing the nares?
Definition
Look for position, deformity, septal deviation, discharge and flaring. Palpate for patency, deformity and tenderness. Also check for epistaxis (nose bleed) and rhinorrea (copious drainage from nose).
Term
What are tests for visual acuity?
Definition
Snellen eye chart. Ishihara's embedded color vision test. And peripheral vision testing.
Term
What tests are used to test extraocular movement?
Definition
The corneal light reflex test. The conver/uncover test. and the Cardinal Feilds of Gaze test.
Term
Explain the process for assessing the external structures of the eye:
Definition
Check general appearance; Assess eyelashes for crusting or infestation; Assess eyelids for edema or lesions; Assess eyeball for protrusion; Assess lacrimal gland and nasolacrima duct for swelling, redness, and drainage; Assess conjuntiva for color and foreign objects; Assess sclera for color; Assess cornea and lens for corneal and blink reflex, as well as for clarity and abrasions; Assess iris for color and shape; Assess pupils for size and eqaulity. Test their reaction to light; Test eye accommodation for various eye distances; Assess anterior chamber of eye for pus or blood and for size and shape; Palpate eyeball for firmness and tenderness; Palpate lacrimal glands for tenderness.
Term
What is PERRLA?
Definition
Used to assess the pupils. It stands for: PUPILS are EQUAL, ROUND, and REACT to LIGHT with ACCOMADATION.
Term
What are the developmental considerations for older adults when assessing the eyes?
Definition
Older adults tend to develop presbyopia - descreased ability to focus clearly. May also develop ectropian (sagging of lower lid) or entropion (turning inward of eyelid). Laxity of eyelids leads to poor drainage of tears.
Term
What is ectropion?
Definition
Sagging of lower lid.
Term
What is entropion?
Definition
Turning inward of eyelid.
Term
What is presbyopia?
Definition
Decreased ability to focus clearly.
Term
What are the developmental considerations for older adult's ears?
Definition
Hearing loss is extremely common, called presbycusis, hearing loss associated with age.
Term
What is the tympanic membrane?
Definition
Divides external ear from middle ear: transmits sound waves. It is normally a cloudy grey color.
Term
Where does one assess for DTRs?
Definition
Biceps, triceps, brachioradialis, patellar, and achilles.
Term
What is the grading scale for DTRs?
Definition
4+ - Brisk, hyperactive
3+ - brisker than average
2+ - average
1+ - diminished
0 - no response.
Term
What is the procedure for testing the biceps reflex?
Definition
Rest pt's elbow in your nondominant hand with thumb over biceps tendon. Strike your thumbnail. Watch for flexion.
Term
What is the procedure for testing the triceps reflex?
Definition
Lift arm out and flex it at the elbow. Support the arm with nondominant hand. Strike triceps tendon 1-2 inches above olecranon process from behind. Watch for contraction.
Term
What is the procedure for the brachioradialis reflex?
Definition
Strike styloid process of radius. Watch for flexion at elbow and supination of forearm.
Term
Describe a normal lymph node?
Definition
Less than 1 cm in size. Round shape. Soft consistency. Mobile. Nontender. Well defined.
Term
Describe an infected lymph node
Definition
Enlarged. Round. "Boggy". Well defined, mobile and tender.
Term
Describe a malignant lymph node
Definition
Enlarged, irregular shape, hard, irregular borders, immobile, and nontender.
Term
Describe how to assess the thyroid gland.
Definition
Locate the thyroid isthmus below the cricoird cartilage. Inspect for enlargement. To palpate right lobe, slide fingers to the right and gently displace trachea to right. Palpate galnd as patient swallows. Then auscultate the thyroid with the bell for vascular sounds. There should be no vascular sounds.
Term
What are abnormal findings for the thyroid gland?
Definition
Enlarged thyroid: could indicate tumor or goiter. Or tender thyroid: may indicate inflammatory process such as acute thyroiditis.
Term
What is the buccal mucosa?
Definition
Moist mucous mebrane of the cheeks that asists with eating.
Term
What is the labial frenulum?
Definition
The skin that connects the lips to the gums.
Term
What is the lingual frenulum?
Definition
The skin that attaches the tongue to the floor of the mouth.
Term
What is diplopia?
Definition
Visual impairment in whcih you see double vision.
Term
What is tinnitus?
Definition
Ringing or booming sensation in one or both ears. Caused by external stimulus.
Term
What are the nasolabial folds?
Definition
Two skin folds that run from the side of the nose to the corners of the mouth.
Term
What are the palpebral fissures?
Definition
The opening between the margins of the upper and lower eyelids.
Term
What is acromegaly?
Definition
Enlargement of the skeletal bones in the face, hands and feet.
Term
What is nasal flaring?
Definition
When the nostrils widen when you breath. Often a sign of difficulty breathing.
Term
What is periorbital swelling?
Definition
Swelling of the area surrounding the socket of the eye.
Term
What is geographic tongue?
Definition
An inflammatory disorder on the dorsal surface of the tongue characterized by numerous and continually changing areas of the loss and regrwoth of the filiform papillae.
Term
What is malocclusion?
Definition
An abnormal contact between the teeth of the upper jaw and those of the lower jaw.
Term
What is lymphadenopathy?
Definition
Any disorder characterized by a localized or generalized enlargement of the lymphnodes or lymph vessels.
Term
What is torticollis?
Definition
An abnormal condition in which the head is inclined to one side as a result of contraction of the muscles.
Term
What is strabismus?
Definition
Cross eyes.
Term
What is ectropion?
Definition
The rolling outward of the margin of an eyelid.
Term
What is entropion?
Definition
The infolding of the margin of an eyelid.
Term
What is extraocular movement?
Definition
Movements of the eye in a conjugate (parallel) manner.
Term
What is corneal light reflex?
Definition
It determines if the eyes are being maintained in a consulate (parallel) position.
Term
What are direct pupillary reaction?
Definition
Same side response to a focused beam of light
Term
What is concensual pupillary reaction?
Definition
Opposite side response to a focused beam of light.
Term
What is anisocoria?
Definition
Inequality of the size of the pupils.
Term
What is a fundoscopic exam?
Definition
Visual inspection fo the interior eye
Term
What is pailledema?
Definition
Edema of the optic disc.
Term
What is presbycusis?
Definition
Diminished hearing acuity in older adults. Specifically high pitched sounds.
Term
What is exopthalmus?
Definition
Protrusion of the eyeball from the orbit. Can be caused by a tumor or thyroid problems.
Term
What is ptosis?
Definition
Drooping of the upper eyelid.
Term
What is Hordelum?
Definition
Medical for stye of the eye.
Term
What is stye?
Definition
An inflammed swelling of the edge of an eyelid caused by a bacterial infection.
Term
What is arcus senilis?
Definition
An opaque circle around the corner of the eye.
Term
What is microtia?
Definition
Abnormal smallness of the auricle of the ear.
Term
What is macrotia?
Definition
Excessive enlargement of the auricle of the ear.
Term
What is cheilitis?
Definition
Inflammation of the lips.
Term
What is cerumen?
Definition
Ear wax.
Term
What is the 1st cranial nerve?
Definition
Olfactory - sense of smell.
Term
What is the 2nd cranial nerve?
Definition
Optic - sense of sight.
Term
What is the 3rd cranial nerve?
Definition
Oculomotor - controls movement of the eye and dilation.
Term
What is the 4th cranial nerve?
Definition
Trochlear - extraocular movements.
Term
What is the 5th cranial nerve?
Definition
Trigeminal - facial sensation and motor, muscles of mastication.
Term
What is the 6th cranial nerve?
Definition
Abducen - extraocular movements.
Term
What is the 7th cranial nerve?
Definition
Facial - motor, facial muscles, sensory taste of anterior tongue.
Term
What is the 8th cranial nerve?
Definition
Acoustic - hearing.
Term
What is the 9th cranial nerve?
Definition
Glossopharyngeal - swalling, voice, gag, taste posterior tongue.
Term
What is the 10th cranial nerve?
Definition
Vagus - swallowing, voice, gag.
Term
What is the 11th cranial nerve?
Definition
Accessory - motor neck muscles
Term
What is the 12th cranial nerve?
Definition
Hypoglossal - motor, tongue muscle
Term
What are symptoms of a sinus infection?
Definition
Sinus pressure or pain.
Term
Describe the assessment of the salivary glands.
Definition
Inspect the stensen's ducts (on the cheeks), and the wharton's ducts (under the tongue). Also, palpate the parotid glands (in front of the ear) and submandibular and sublingual (under the mandible).
Term
What are the normal findings for the glands?
Definition
Parotid glands are nonpalpable and nontender. Submandibular and sublingual glands may be palpable but should be nontender, supple, and soft.
Term
How do you assess level of consciousness?
Definition
Test orientation to time, place and person. Awake, alert, and oriented to time, place, and person (AAO x3).
Term
How do you test for mental status?
Definition
Assess their memory (immediate, recent, and remote memory), general knowledge, vocabulary, mathmetical, though process, and abstract reasoning/judgement. You do these by asking questions such as: What is your name? Who is the current US President? etc.
Term
How do you assess for sensory function?
Definition
Assess pt's sensory function by using tests of light touch, pain, temperature, vibration, position sense, stereognosis, graphesthesia, two point discrimination, point localization, and extinction.
Term
How do you assess the nervous system?
Definition
You assess the cerebral function, cranial nerve function, sensory function, and reflexes. Specifically this includes testing behavior, LOC, mental status/memory, mathematical skills and abstract thinking. It also includes communication (Speech and language) as well as visual recognition.
Supporting users have an ad free experience!