Exam (elaborations)
NURS 125 - FINAL REVIEW
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NURS 125 - FINAL REVIEW
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FinalNURS 125 - FINAL REVIEW
1. Preauricular lymph nodes: in front of the ear
2. Posterior auricular (mastoid) lymph node: superficial to the mastoid process
3. Occipital lymph node: at base of skull
4. submental lymph node: midline, behind the tip of the mandible
5. submandibular lymph node: halfway between the angle and the tip of the
mandible
6. tonsillar lymph node: under the angle of the mandible
7. superficial cervical lymph node: overlying the sternomastoid muscle
8. deep cervical lymph node: under the sternomastoid muscle
9. posterior cervical lymph node: in the posterior triangle along the edge of the
trapezius muscle
10. Supraclavicular lymph node: just above and behind the clavicle, at the ster-
nomastoid muscle
11. Subjective data for the head and neck assessment: headache, head injury,
dizziness, neck pain, limited ROM, lumps or swelling, history of head or neck surgery.
12. Questions to ask about past head injury.: Onset, setting, dizziness or light-
headness, seizures, loss of consciousness before fall, duration, location, any symp-
toms after, change in LOC.
13. Loss of consciousness before a fall: loss of consciousness before a fall may
have cardiovascular cause (example - heart block).
14. Palliative actions for migraines: with migraines, people lie down to feel better
15. Palliative action for cluster headaches: with cluster headaches, people need
to move (like pace) to feel better.
16. Presyncope: a light headed, swimming sensation of a feeling of falling caused
by decreased blood flow to the brain or heart. Is a part of dizziness.
17. Vertigo: a sense of rotational spinning often from a labyrinthine- vestibular
disorder.
18. subjective vertigo: person feels like he or she is spinning
19. objective vertigo: feels like the room is spinning
20. Disequilibrium: is a shakiness or instability when walking related to muscu-
loskeletal disorder or multisensory deficits
21. dysphagia: difficulty in swallowing or inability to swallow
22. Inspection and palpation of the head: size and shape, temporal area, and
facial structures
23. normocephalic: refers to round symmetric skull that is appropriately related to
body size
,Final
24. palpation of temporal artery: artery is above the zygomatic bone between the
eye and top of the ear.
25. temporal arteritis: artery looks tortuous, feels hardened, is tender
, Final
26. TMJ joint: located just below the temporal artery and anterior to the targus.
Palpate the joint as the patient opens the mouth. Movement should be smooth, with
no limitation or tenderness.
27. Inspection and palpation of the neck: Symmetry, Range of motion, Lymph
nodes, Trachea, and Thyroid gland
28. Abnormal findings with neck symmetry: head tilt occurs with muscle spasm.
Rigidity of the head and neck occurs with arthritis.
29. Range of motion of the neck: patient to touch the chin to chest, turn head
to right and left, touch ear to shoulder, extend neck backwards. Motion should be
smooth and controlled.
30. Cranial nerve that control the neck: Spinal accessory nerve (XI)
31. palpation of lymph nodes: use gentle circular motion of fingertips to palpate
lymph nodes. Normally are not palpable. Begin at the preauricular lymph node and
systematically work down to the supraclavicular.
32. circumstances that cause enlarged lymph nodes: acute infections, chronic
inflammation, cancerous nodes, HIV, Neoplasm in the thorax or abdomen, hodgkin's
lymphoma.
33. lymphadenopathy: is enlargement of lymph nodes >1 cm, caused by infection,
allergy, or neoplasm.
34. palpation of trachea: place index finger on the trachea and slip it off to each
side; should be midline, symmetric and not deviated
35. tracheal tug: rhythmic downward pull that is synchronous with systole and oc-
curs with aortic arch aneurysm. In peds population, can be caused from respiratory
distress.
36. inspection of thyroid gland: position a light to shine across neck to show
swelling. Ask patient to drink water. Thyroid tissue normally moves up with a swallow.
37. Auscultation of thyroid: If thyroid is enlarged, auscultate gland using a stetho-
scope. The presence of a bruit indicates an abnormal increase in blood flow to the
area.
38. palpation of thyroid gland: Posterior approach: Stand behind patient, patient
to sit up straight with head forward and right. Use fingers of left hand to push trachea
to the right. Use right hand to feel thyroid as patient swallows.
39. assessing infants skull: measure infants head size with tape at each visit up
to age 2. Then yearly up to age 6.
40. newborn heads measure about 32-38 cm: normally 2 cm larger than chest
circumference
41. caput succedaneum: edematous swelling and ecchymosis of the presenting
part of the head caused by birth trauma
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