 Amblyopia= lazy eye

 Strabismus= cross eye. Disorder in which the eyes don't look in exactly the same direction at the same time.
 Presbyopia=A gradual, age-related loss of the eyes' ability to focus actively on nearby objects. Cause by loss of
elasticity by lens
 Diplopia=double vision. is the perception of 2 images of a single object
 test central visual acuity with a Snellen. the corneal light reflex using the Hirschberg test
 glaucoma is the leading cause of preventable blindness
 opaque=less transparent
 epistaxis=bloody nose
 Dysphagia=Difficulty swallowing
 Pruritus or itch is defined as an unpleasant sensation of the skin that provokes the urge to scratch
 Palpation, or touch, can provide information about skin texture, including the presence of scaling and skin moisture,
including diaphoresis, or perspiration. Pruritus, or itching, is a subjective finding reported by the client, and pallor and
jaundice describe skin color, assessed through observation.
 Gynecomastia is an enlargement or swelling of breast tissue 
 Hypertrophy=enlargement of an organ or tissue from the increase in size of its cells.
 Hyperplasia=is an imbalance between cell proliferation and programmed cell death.
 Psoriasis=Thickening of the skin is dry, silvery, scaly patches.
 Tinnitus=Ringing, crackling, or buzzing in the ear.
 Presbycusis=Hearing loss
 Hyperacusis is a highly debilitating and rare hearing disorder characterized by an increased sensitivity to certain
frequencies and volume ranges of sound. Intolerance for sound levels that do not bother other people.
 Exophthalmos=Bulging eyeballs
 Ptosis= "Lid lag", drooping upper lid. Occurs with cranial nerve III damage or systemic neuromuscular weakness.
 Diplopia=2 images of a single object. Double vision
 Lacrimation=Tearing of the eyes
 Epiphora=Excessive tearing of the eyes
 Glaucoma=Increased ocular pressure, restricted fluid flow around the anterior chamber of the eye.
 Presbyopia=Inability to accommodate for near vision.
 Cataracts=An opacity in the lens. Cloudy, and clumping of proteins in the lens. cloudy lenses and blurred vision (not
glaucoma).
 Conjunctivae= eyelids. Good place to assess for pallor in dark skin people
 Macular Degenerations=Most common cause of blindness. Central vision is loss, peripheral vision is intact.
 Myopia=Nearsightedness
 Hyperopia=Farsightedness
 Blepharitis=Inflammation of the eyelids. Staphylococcal infection leads to red, scaly, and crusted lids. The eye burns,
itches, and tears.
 Chalazion=A firm, nontender nodule on the eyelid, arising from infection of the meibomian gland. Not painful unless
inflamed.
 Hordeolum (Stye)=A result of staphylococcal infection of hair follicles on the margin of the lids. The affected eye is
swollen, red, and painful.
 Periorbital Edema=Swollen, puffy lids. Occurs when crying, infection, and systemic problems including kidney failure,
heart failure, and allergy.

Petechiae =Tiny round brown-purple spots due to bleeding under the skin, may be in a
small area due to minor trauma or widespread due to blood-clotting disorder. They usually
appear on your arms, legs, stomach, and buttocks.
o The nurse is examining a dark-skinned client for the presence of
petechiae. The nurse will best observe these lesions in which body area?
Oral mucosa
 Adult Normal Chest/Expansion=Both should be symmetrical. Anteroposterior diameter < transverse diameter (1:2
ratio).
 Barrel Chest=The anteroposterior diameter is equal to the lateral diameter, and the ribs are horizontal. Occurs normally
with aging and accompanies COPD and emphysema. Costal angle > 90 degrees.
 Dyspnea=Change in this pattern producing SOB or difficulty breathing.
  Hemoptysis (blood) Sputum=Frank blood vs. streaks of blood
 White or Clear Sputum=Colds, bronchitis, viral infections
 The nurse is testing a client for astereognosis. The nurse should ask the client to
close the eyes and perform which action? Identify an object placed in the client's
hand.
 Yellow or Green Sputum=Bacterial infections
 Rust Colored Sputum=TB or pneumonia
 Pink or Frothy Sputum=Pulmonary edema, medications
 Orthopnea=Difficult breathing when supine
 Crepitus=A crunching feeling under the skin caused by air leaking into subcutaneous tissue. "Popping noise".
 Nail Clubbing=The nail appears more convex and wide. The nail angle is greater than 160 degrees. 160 is considered
normal. It occurs in chronic respiratory and cardiac conditions in which oxygenation is compromised (emphysema,
COPD).
 Pulmonary Edema=An abnormal accumulation of fluid in the interstitial tissue and alveoli of the lungs. Both cardiac
and noncardiac disorders can cause this. Can cause tachycardia, crackles, wheezes, and cyanosis. Frothy sputum or
hemoptysis. JVD, weight gain, S3, left-sided CHF.
 The patient has encephalitis and presents with a severe headache and fever. Which
additional assessment finding would the nurse monitor for?
o Nuchal rigidity occurs in patients with encephalitis. Encephalitis refers to inflammation of the brain. An aura
is associated with migraine headaches, not encephalitis. Runny nose is a sign of cluster headaches or
allergies, not encephalitis. Craniosynostosis is premature closing of one or multiple cranial sutures, resulting
in a malformed head, but craniosynostosis does not occur with encephalitis.

Normal vital sign ranges for the average healthy adult while resting are: Blood pressure:
90/60 mm Hg to 120/80 mm Hg. Breathing: 12 to 18 breaths per minute. Pulse: 60 to
100 beats per minute
A bruise often develops a purple or purple-blue appearance 12 to 36 hours after blunt-force trauma. A
new bruise is red. The color of bruises (and ecchymoses) generally progresses from purple-blue to bluish-
green to greenish-brown to brownish-yellow before fading away.

Kaposi's Sarcoma
A malignant tumor of the epidermis and internal epithelial tissues. Typically soft, blue to
purple, and painless. May be macular or papular and may resemble keloids or bruises.
Common in people who are HIV positive.

Congestive Heart Failure

Increased pressure in the pulmonary veins causes interstitial edema around the alveoli
and may cause edema of the bronchial mucosa. Pulmonary capillaries engorged.
Deflated alveoli. Increased respiratory rate, SOB (especially on exertion), orthopena,
peripheral edema, pallor. Normal tactile fremitus, skin cool and clammy. Resonance.
Normal breath sounds and voice sounds. Wheezes or crackles at the bases of the
lungs.
Using a tongue blade and penlight, inspect the lips, teeth and gums, tongue, and buccal mucosa.

• Inspect the palate and uvula. Also, check their integrity and mobility as the person says “ahhh.” This action also tests one
function of cranial nerve X.

• Next assess the throat. To do this, inspect and grade the tonsils, and inspect the pharyngeal wall, noting its color and any
exudates or lesions.

• Test cranial nerve XII by having the patient stick out the tongue.

I=  OLFACTORY (smell)

II= OPTIC (central & peripheral vision)

III= OCULOMOTOR (pupillary constriction)

IV= TROCHLEAR (eye movement down)

V= TRIGEMINAL  (face sensation & movement)

VI= ABDUCENS (eye movement to sides)

 VII= FACIAL  (facial movements & expression)

VIII= AUDITORY   (hearing)

IX=  GLOSSOPHARYNGEAL  (tongue movement & swallowing)

X=  VAGUS  (pharynx movement)

XI=  SPINAL ACCESSORY  (neck & shoulder movement)

XII=  HYPOGLOSSAL  (tongue movement)

Cranial Nerve I  - Olfactory

• Test sense of smell in those who report loss of smell, head trauma, and abnormal mental status, and
when presence of intracranial lesion suspected

• With person’s eyes closed, occlude one nostril and present familiar aromatic substance, e.g., coffee,
orange, vanilla, soap, or peppermint

• Normally person can identify an odor on each side of nose; normally decreased with aging; any
asymmetry in sense of smell is important

Abnormality

• Anosmia

Cranial Nerve II - Optic

(central & peripheral vision) 

• Test visual acuity and visual fields by confrontation test. Or SNELLEN CHART

• The nurse is preparing to test the visual acuity of a client, using a Snellen chart. Which
identifies the accurate procedure for this visual acuity test?

The right eye is tested, followed by the left eye, and then
both eyes are tested.

"Stand 20 ft (6 meters) from the chart and cover 1 eye."

Normal is 20/20 (distance in ft at which client is standing

from chart/distance in ft at which a normal eye could have
read that particular line)
• Using ophthalmoscope, examine ocular fundus to determine color, size, and shape of optic disc

Abnormalities

• Defect or absent central vision

• Defect in peripheral vision, hemianopsia

• Absent light reflex

• Papilledema

• Optic atrophy

• Retinal lesions

Cranial Nerves III, IV, VI –

Oculomotor, Trochlear, Abducens
(pupil constriction & eye movements) 
 • Check pupils for size, regularity, equality, direct and consensual light reaction, and
accommodation

• Assess extraocular movements (EOMs) by cardinal positions of gaze

• Assess for nystagmus (back & forth of eyes)

Abnormalities

CN III, oculomotor nerve

• Dilated pupil, ptosis, eye turns out and slightly down

• Failure to move eye up, in, down

• Absent light reflex

CN IV, trochlear nerve

• Failure to turn eye down or out

   CN VI, abducens nerve

• Failure to move laterally, diplopia on lateral gaze

Cranial Nerve V – Trigeminal

(face sensation & movement) 

• temporal and masseter muscles as person clenches teeth 

• Muscles should feel equally strong on both sides; try to separate jaws by pushing down on
chin; normally you cannot

• Sensory function: with person’s eyes closed, test light touch sensation by touching a cotton
wisp to designated areas on person’s face: forehead, cheeks, and chin 

• Tests all three divisions of CN V: ophthalmic, maxillary, and mandibular

Abnormalities

• Absent touch and pain, paresthesias

• No blink

• Weakness of masseter or temporalis muscles

Cranial Nerve VII – Facial

(facial movements & expression)

Motor function:

• Note mobility and facial symmetry as person responds to requests to smile, frown,
close eyes tightly (against your attempt to open them), lift eyebrows, show teeth

• Have person puff cheeks, then press puffed cheeks in, to see that air escapes equally
from both sides

Sensory function: (not tested routinely)

• Test only when you suspect facial nerve injury

 • When indicated, test sense of taste by applying cotton applicator covered with
solution of sugar, salt, or lemon juice to tongue and ask person to identify taste

Abnormalities

• Absent or asymmetric facial movement

• Loss of taste

Cranial Nerve VIII – Acoustic

(hearing)

• Test hearing acuity by ability to hear normal conversation and by whispered voice test

Abnormality

Decrease or loss of hearing

Cranial Nerves IX and X –

Glossopharyngeal and Vagus
(pharynx & larynx)

Motor function

• Depress tongue with tongue blade, and note pharyngeal movement as person says
“ahhh” or yawns; uvula and soft palate should rise in midline, and tonsillar pillars
should move medially

• Touch posterior pharyngeal wall with tongue blade, and note gag reflex; voice
should sound smooth, not strained

Sensory function

• Cranial nerve IX does mediate taste on posterior one third of tongue, but technically
too difficult to test

Abnormalities

CN IX, glossopharyngeal nerve

• No gag reflex

CN X, vagus nerve

• Uvula deviates to side

• No gag reflex

• Voice quality: hoarse or brassy, nasal twang or husky

• Dysphagia, fluids regurgitate through nose

Cranial Nerve XI – Spinal Accessory

(neck & shoulder movement) 

• Examine sternomastoid and trapezius muscles for equal size

 • Check equal strength by asking person to rotate head against resistance applied to side of
chin

• Ask person to shrug/elevate shoulders against resistance 

• These movements should feel equally strong on both sides

Abnormality

Absent movement of sternomastoid or trapezius muscles

Cranial Nerve XII – Hypoglossal

(tongue movement) 

• Inspect tongue; no wasting or tremors should be present

• Note forward thrust in midline as person protrudes tongue

• Ask person to say “light, tight, dynamite,” and note that lingual speech

(sounds of letters l, t, d, n) is clear and distinct

Abnormalities

• Tongue deviates to side, Slowed rate of tongue movement

Romberg test 

◦ YOU MUST HOLD YOUR ARMS ON EITHER SIDE OF THE PATIENT TO PREVENT FALLS!

◦ Ask person to stand up with feet together and arms at sides

◦ Have person close eyes and hold position for about 20 seconds

◦ Normal is person can maintain balance 

Positive Romberg = ataxia = lack of coordination 

Weber Test: turner fork. Uses

bone conduction to evaluate hearing in a person who hears
better in one ear than in the other. Put tuning fork midline of frontal bone or forehead.

Bell's Palsy

Temporary disorder affecting cranial nerve VII (facial) and producing a unilateral facial paralysis. May be caused by a
virus. Its onset is sudden, and it usually resolves spontaneously in a few weeks without residual effects.

Parkinson's Disease

A mask like or blank expression occurs. A result of a decrease in dopamine, a neurotransmitter.

Although usually it is not done in the screening examination, touching the posterior wall with the
tongue blade elicits the gag reflex. This tests cranial nerves IX and X, the glossopharyngeal and
vagus. Test cranial nerve XII, the hypoglossal nerve, by asking the person to stick out the tongue.
It should protrude in the midline.
The nurse is testing the coordinated functioning of cranial nerves III, IV, and VI. To do
this correctly, what should the nurse test?
 2. The 6 cardinal fields of gaze

In the pregnant patient, the resting pulse rate increases 10 to 20 beats/min and the blood pressure decreases. • In the older adult,
the systolic blood pressure rises and orthostatic hypotension may occur

Assessment of the infant’s chest and lungs includes inspection, palpation, and auscultation but no percussion.

In the pregnant woman, the thoracic cage and costal angle are wider. Respirations are deeper with a 40% increase in tidal volume.
• The 6-minute walk test (6 MWT) is used to measure respiratory function in older adults. Older adults may exhibit a barrel chest
and kyphosis, or outward curvature of the thoracic spine

human papillomavirus causes most cases of cervical cancer.

Diminished hair on the legs and skin that is cool to touch are symptoms of decreased arterial blood flow

The nurse is assessing a client who has a history of aortic regurgitation. Where should the nurse place the stethoscope diaphragm
to listen for this condition? 2nd intercostal space along the right sternal border.

What is the best place for the nurse to hear lower lobe lung sounds with a stethoscope? Posterior chest below the 3rd
intercostalspace

the nurse is assessing a client who has a history of mitral stenosis (murmur). How should the nurse assess this client with a
stethoscope to listen for this condition? Place the bell on the 5th intercostal space, left midclavicular line

Mitral stenosis=place patient on left hand side. Aortic regurgitation=patient sit up, lean forward, breath out and loud

When obtaining orthostatic vital signs, the nurse takes serial measurements of pulse and blood pressure. The order of positions
for obtaining orthostaticvital signs is lying, sitting, and then standing.

Prolonged exposure to loud occupational noise can cause

sensorineural hearing loss by damaging the cochlear hair cells.
Audiometry is the most reliable method of testing the acuity of
auditory sensory perception.

While palpating a client's breasts, the nurse detects a nontender,

solitary, round lobular mass that is solid and firm and slides easily
through the breast tissue . The findings of this breast exam are
consistent with which condition? Fibroadenoma are benign
tumors that are nontender masses that are round and lobular and
when palpated move easily through breast tissue and feel solid
and firm. They are diagnosed by palpation, ultrasound, and needle
biopsy.

Edema is caused by fluid accumulating in the interstitial spaces.

Dependent extremities such as the feet and ankles are more prone to peripheral edema caused by conditions such as heart failure,
so the nurse should assess the ankles for dependent edema.
Wheezes= asthma. Crackles=Pulmonary fibrosis. Breath sounds will be decreased or absent over the area of a pneumothorax.

The nurse is assessing for the presence of pallor in a dark-skinned client. What finding
should the nurse look for?
Loss of normal red tones in the skin
Kussmaul's respirations: Respirations that are increased in rate, Respirations that are
abnormally deep

The nurse is assessing for changes in skin color in a dark-skinned client. The nurse
finds which areas helpful in assessing for pallor or cyanosis? Select all that apply.
Sclerae, Tongue, Nail beds

Order of PPE Application

● Gown

● Mask

● Goggles/face shield

● Gloves

Order of PPE Removal

● Gloves

● Goggles/face shield

● Gown

● Mask
The nurse is caring for a pediatric client who just arrived at the emergency department
with an extremity fracture. The nurse uses the 5 "Ps" to assess the extent of the client's
injury. What are some of the 5 "Ps"? Select all that apply.
 1. Pallor
 2. Pain and point of tenderness
 3. Paralysis distal to the fracture site
 5. Sensation distal to the fracture site

The nurse is conducting a neurological assessment, including a health history, on a

client with a neurological disorder. The nurse observes that the client is having difficulty
answering the questions and should perform which action?

- Ask the client to give permission for a family member to stay during the interview.

The registered nurse (RN) is educating a new RN on conducting a problem-based or

focused assessment on a client. Which statement by the new RN indicates that the
teaching has been effective?

- "This is mostly used in a walk-in clinic or emergency department."

Romberg test= The functional status of the vestibular apparatus in the inner ear

The school nurse has conducted a class on testicular self-examination (TSE) at the local
high school. The nurse determines that the information was correctly interpreted if 1 of
the students states that which action should be performed?

- Roll the testicle between the thumb and forefinger.

The nurse is instructing a client how to perform a testicular self-examination (TSE). The
nurse should explain that which is the best time to perform this exam?
After a shower or bath. First thing in the morning

A nursing student is performing a respiratory assessment on a female adult client and is

assessing for tactile fremitus. Which action by the nursing student indicates a need for
further teaching?

- Palpating over the breast tissue to assess and compare vibrations from 1 side to the
other

The community health nurse is instructing a group of young female clients about breast
self-examination. The nurse should instruct the clients to perform the examination at
which time?
- 1 week after menstruation begins

A clinic nurse is preparing to evaluate the peripheral vision of a client by the

confrontational method. Which statement demonstrates that the client correctly
understands the instructions for the test?

- I will tell you when the small object is in my visual field."

- The examiner and client cover the eyes directly opposite to one another and stare at
each other's uncovered eye, and a small object is brought into the visual field.

A client's vision is tested with a Snellen chart. The results of the tests are documented
as 20/60. What action should the nurse implement based on this finding?

- Instruct the client that he or she may need glasses when driving.

The nurse is preparing to check the breath sounds of a client. When auscultating for
bronchovesicular breath sounds, the nurse should place the stethoscope over which
area?

- he major bronchi

The nurse is preparing to perform an abdominal examination on a client. The nurse

should place the client in which position for this examination?

- Supine with the head raised slightly and the knees slightly flexed

After performing an initial abdominal assessment on a client with nausea and vomiting,
the nurse should expect to note which finding?
 1. Waves of loud gurgles auscultated in all 4 quadrants
The nurse is performing an abdominal assessment and inspects the skin on the client's
abdomen. Which assessment technique should the nurse perform next?

- Listen to bowel sounds in all 4 quadrants.

The nurse is assessing a client for meningeal irritation and elicits a positive Brudzinski's
sign. Which finding did the nurse observe?
-The client passively flexes the hip and knee in response to neck flexion and reports
pain in the vertebral column.

The nurse is preparing to measure the apical pulse on an assigned client. The nurse
places the diaphragm of the stethoscope over which cardiac site?
 1. Mitral area

The nurse is making initial rounds on the nursing unit to check the condition of assigned
clients. The client complains of discomfort at the intravenous (IV) site, and the nurse
notes that the site is cool, pale, and swollen and that the solution is infusing slowly.
What action should the nurse take first?
 1. Stop the IV infusion.

The nurse is assessing a client with a history of cardiac problems. Where should the
nurse place the stethoscope to hear the first heart sound (S1) the loudest?

Over the fifth intercostal space in the left midclavicular line

The nurse is performing a neurological assessment on a client and notes a positive

Romberg's test. The nurse makes this determination based on which observation?

- A significant sway when the client stands erect with feet together, arms at the side,
and the eyes closed

A client with a diagnosis of asthma is admitted to the hospital with respiratory distress.
Which type of adventitious lung sounds should the nurse expect to hear when
performing a respiratory assessment on this client?
Wheezes

The nurse is testing a client for graphesthesia and asks the client to close his eyes. The
nurse should next ask the client to take which action?

- Identify 3 numbers or letters traced in the client's palm.

The nurse is testing a client for astereognosis. The nurse should ask the client to close
the eyes and perform which action?
- Identify an object placed in the client's hand.
The nurse is caring for a client immediately after removal of the endotracheal tube. The
nurse should report which sign immediately if experienced by the client? 
1. Stridor 
The nurse caring for a client with a pneumothorax and who has had a chest tube inserted
notes continuous gentle bubbling in the suction control chamber. What action is most
appropriate? 
1. Do nothing, because this is an expected finding. 

The nurse is caring for a client who suffered an inhalation injury from a wood stove. The
carbon monoxide blood report reveals a level of 12%. Based on this level, the nurse would
anticipate noting which sign in the client? 
2. Flushing

The nurse instructs a client to use the pursed-lip method of breathing and the client asks the
nurse about the purpose of this type of breathing. The nurse responds, knowing that
the primary purpose of pursed-lip breathing is to promote which outcome? 
4. Promote carbon dioxide elimination

1. The nurse is preparing to suction a client via a tracheostomy tube. The nurse should
plan to limit the suctioning time to a maximum of which time period? 
3. 10 seconds

2. The nurse is suctioning a client via an endotracheal tube. During the suctioning
procedure, the nurse notes on the monitor that the heart rate is decreasing. Which
nursing intervention is most appropriate? 
3. Stop the procedure and reoxygenate the client.

3. While changing the tapes on a tracheostomy tube, the client coughs and the tube
is dislodged. Which is the initial nursing action?
Grasp the retention sutures to spread the opening.

Which client is at risk for the development of a sodium level at 130 mEq/L (130
mmol/L)?
 1. The client who is taking diuretics

A student states that a client has palpable rushing vibration in the area of the pulmonic valve.
What should the instructor explain that the student is feeling?
A. A thrill