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NUR 634 Advanced Health Assessment Midterm Exam/274 Q/A
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NUR 634 Advanced Health Assessment Midterm Exam/274 Q/A
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NUR 634 Advanced Health AssessmentMidterm Exam/274 Q/A
Subjective History Components - -chief complaint, HPI, PMH, family history,
social history, & review of systems: what patient tells you.
-Objective History Components - -General survey, vitals, physical exam,
diagnostic results, what you observe or see.
-Presbyopia - -age-related near-vision loss. Can see far away better.
-Examples of sudden, painful unilateral vision loss - -corneal ulcer, acute
closed angle glaucoma, uveitis, or traumatic hyphema.
-Examples of sudden, PAINLESS unilateral vision loss - -retinal detachment,
macular degeneration, or retinal vein occlusion.
-Olfactory (CN 1) - -smell, occlude each nostril
-Optic (CN 2) - -Vision-Snellen chart, an enlarged blind spot affects optic
nerve
caused by glaucoma, optic neuritis, and papilledema.
-Oculomotor Nerve (CN III) - -Test PERRLA, Paralysis if the pupil is dilated,
fixed to light and near accommodation with ptosis, lateral deviation of the
eye. Impaired ability to look up, down, or inward. (A conjugate gauze is a
normal gaze=both eyes move in same direction at same time). ptosis=CNIII
problem.
-Trochlear Nerve (CN IV) - -controls superior oblique muscle-moves eye
down towards nose, damage from head trauma or central lesions=diplopia.
Diplopia is also seen in cataracts, astigmatism, or CN III, IV, or VI neuropathy,
or myasthenia gravis, trauma, or lesions in brainstem or cerebellum.
-Trigeminal (CN V): - -Facial sensation, nasal and buccal mucosa, & teeth,
mastication muscles. Test corneal reflex, have pt clench teeth/palpate
masseter/temporal muscles, sharp/dull sensations on cheek/forehead.
-Abducens (CNVI) - -Movement of lateral rectus muscle, moves eye
laterally.
-Facial (CN VII) - -Facial muscles, taste anterior 2/3rd of tongue. Have pt
smile, show teeth, raise eyebrows, frown, close eyes tight, puff out cheeks.
Bell's Palsy.
, -Vestibulocochlear (CN VIII) - -Sensation to pharynx, posterior 1/3rd of
tongue, and tympanic membrane. Test gag reflex.
-Vagus Nerve (CN X) - -Supplies parasympathetic nerve fibers to viscera of
chest, abdomen, motor fibers to pharynx, larynx. *A deviated uvula without
swelling indicates vagus nerve lesion.
-Spinal Accessory (CN XI): - -Supplies motor fibers to sternocleidomastoid &
trapezius muscle, ask pt to shrug shoulders against your hands.
-Hypoglossal (CN XII): - -Tongue muscles, ask pt to move tongue all around.
-Glaucoma - -gradual loss of peripheral vision, optic nerve damage. Open
Angle=asymptomatic, bilateral, gradual increased cup-to-disk ratio from
increased intraocular pressure=notching of optic cup. Acute Closed Angle
rapid onset of sudden vision loss, unilateral, deep eye pain, dilated and fixed
pupil with cloudy cornea=emergency if increased intraocular pressure.
-Macular Degeneration - -gradual loss of central vision d/t damaged retina.
-Cataracts: - -gradual cloudiness/opacification of the lens from DM,
overexposure to sun, long-term steroid use, diuretics, poor diet, smoking,
ETOH, age, trauma, lead exposures=NO red reflex, Leukoria-white reflex
present, blurred/cloudy vision, halo around lights, diminished night vision,
diplopia, fall risk.
-Normal Retina: - -present red reflex, veins pulsate, arteries narrower.
Normal Cup/Disk ratio is 1/3, fovea is in middle of macula.
-AV Tapering - -vein "winds" or tapers down on either side of artery.
-AV Nicking - -vein stops abruptly on either side of artery, arteries indent
and displace veins, caused by HTN
-AV Banking - -vein is twisted on distal side of artery
-Subconjuncival Hemorrhage: - -red painless eye.
-Red & Painful eye - -Hyphema (blood in anterior chamber of eye),
episcleritis
(inflammation of episcleral vessels in RA or herpes), acute angle closer
glaucoma, or uveitis.
, -Amblyopia - -Reduction in vision causing loss of binocular vision from
cataracts or untreated strabismus (cross-eyed detected with cover-uncover
test or Hirschberg Test- will show asymmetric light reflex, pt c/o diplopia).
-Esotropia: - -eye drifts in
-Exotropia - -eye drifts out
-Hypertropia: - -eye drifts up
-Hypotropia - -eye drifts down
-Retinoblastoma - -rapidly developing cancer of the retina w/ absent red
reflex.
-Corneal Scar - -superficial grayish-white opacity in cornea.
-Tonic Pupil (Adele's Pupil): - -Pupil is large, regular, slow reaction to light
unilateral.
-Normal Optic Disk: - -yellowish-orange to creamy pink with sharp margins.
-Optic Atrophy - -death of optic nerve fibers=loss of disc vessels=white
appearance.
-Glaucomatous Cupping: - -the optic disk is pale with a backward
depression caused by
increased IOP.
-Papilledema - -the optic disk is pink and hyperemic.
-Ectropion - -outward turning of lower eyelid.
-Entropion: - -inward turning of lower eyelid.
-Superficial (Flame) Retinal Hemorrhages: - -small, linear, flame-shaped, red
streaks in fundus from HTN or DM, papilledema, & occluded retinal vein.
-Preretinal Hemorrhages - -blood anterior to the retina that obscures retinal
vessels.
-Deep Retinal Hemorrhages - -small, rounded, irregular red spots in deep
layer of retina
caused by diabetes.
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