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NU 325 Health Assessment Exam 2 Study Guide
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NU 325 Health Assessment Exam 2 Study Guide
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NU 325 Health Assessment Exam 2 Study GuideA nursing diagnosis appropriate for a patient with ear problems
includes Correct Answers disturbed sensory perception
A patient presents with a complaint of drooping of his eyes,
cheeks, and mouth on one side. This finding is most likely
associated with pathology of which cranial nerve? Correct
Answers Cranial nerve VII
A school nurse is performing annual vision screening for
seventh grade students. Which of the following charts would the
nurse most likely be using? Correct Answers Snellen's chart
acne Correct Answers Over 90% of males and 80% of females
will have acne by age 21; the psychological effect is more
significant than the physical effect. Self-treatment is common.
Causes are increased sebum production and epithelial cells that
do not desquamate normally.
Acute airway obstruction is a situation that should be Correct
Answers quickly assessed and treated.
Acute infection Correct Answers acute onset, <14 days'
duration; nodes are bilateral, enlarged, warm, tender, and firm
but freely movable.
An adolescent male presents with complaints of nosebleeds. The
nurse would further asses for Correct Answers nasal trauma
,An outcome that is appropriate for a patient with hearing
impairment is Correct Answers Patient explains plan to
accommodate hearing impairment.
Anisocoria Correct Answers unequal pupil size
anterior fontanel normally closes Correct Answers the
diamond-shaped fontanel closes between 9 months and 2 years
Antihelix Correct Answers the inner rim of the ear
Antitragus Correct Answers small eminence on the upper
margin of the lobe
apocrine sweat glands Correct Answers produce a thick, milky
secretion and open into the hair follicles. They are located
mainly in the axillae, anogenital area, nipples, and navel and are
vestigial in humans. They become active during puberty, and
secretion occurs with emotional and sexual stimulation.
Bacterial flora residing on the skin surface react with
________________ sweat to produce a characteristic musky
body odor. The functioning of these glands decreases in the
aging adult.
assessment for skin turgor Correct Answers -Pinch large fold
of skin on the chest under the clavicle - mobility is ease of rise
and _______________ is ability to return to place promptly -
infants skin should snap back immediately
-older adults should show tenting
,Bifid uvula Correct Answers The uvula looks partly severed
and may indicate a submucous cleft palate, which feels like a
notch at the junction of the hard and soft palates. This may
affect speech development because it prevents necessary air
trapping. The incidence is more common in American Indians.
bulbar conjunctiva Correct Answers overlays the eyeball, with
the white sclera showing through
Cancerous nodes Correct Answers -are hard, >3 cm, unilateral,
nontender, matted, and fixed.
-A single enlarged, nontender, hard, left supraclavicular node
may indicate neoplasm in thorax or abdomen (Virchow node)-
Painless, rubbery, discrete nodes that gradually appear occur
with Hodgkin lymphoma, commonly in the cervical region.
Candidiasis Correct Answers A white, cheesy, curdlike patch
on the buccal mucosa and tongue. It scrapes off, leaving a raw,
red surface that bleeds easily. Termed thrush in the newborn. It
is an opportunistic infection that occurs after the use of
antibiotics and corticosteroids and in immunosuppressed people.
capillary refill test Correct Answers -color should refill nail in
less that 3 secs.
-push down on nail bed or back of hand
-Indicates status of peripheral circulation
Cleft lip Correct Answers Maxillofacial clefts are the most
common congenital deformities and are associated with
phenytoin (Dilantin), maternal smoking and alcohol use,
benzodiazepines, and corticosteroids. Early treatment preserves
, the functions of speech and language formation and deglutition
(swallowing).
Cleft palate Correct Answers A congenital defect, the failure
of fusion of the maxillary processes. Wide variation occurs in
the extent of cleft formation, from upper lip only, palate only,
uvula only, to cleft of the nostril and the hard and soft palates.
clubbing Correct Answers -180 degrees or greater
-indicates cardiovascular disease or COPD
CN III, IV, and VI Correct Answers Tests to check:
•Corneal Light Reflex
•Diagnostic Position Test
cranial nerve I Correct Answers -Olfactory Nerve
-identifyimg two different scents
(usually not tested during routine exam
Cranial Nerve II Correct Answers -Optic nerve
-Direct and Consensual pupillary light reflex test
Cranial Nerve III Correct Answers -Oculomotor nerve
-Direct and Consensual pupillary light reflex test
Cranial nerve IX Correct Answers -Glossopharyngeal nerve
-Test by touching the posterior wall with the tongue blade elicits
the gag reflex.
cranial nerve V Correct Answers Trigeminal nerve
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