NURS 5220 Exam 2 (2026/2027) (PDF) | Advanced Health Assessment

NURS 5220 Exam 2 (2026/2027) (PDF) | Advanced Health Assessment Aaron sign - ANSWER Pain or distress occurs in the area of the patient's heart or stomach on palpation of McBurney's point Appendicitis Ballance sign - ANSWER Fixed dullness to percussion in left flank, and dullness in right flank that disappears on change of position Peritonitis Blumberg sign - ANSWER rebound tenderness peritonitis, appendicitis Cullen sign - ANSWER bruising around umbilicus pancreatitis or ectopic pregnancy Cranial Nerve I (one) - ANSWER Olfactory Sense of smell Sensory Test for odor identification (rule out nasal obstruction) Cranial Nerve II (two) - ANSWER Optic Sensory and visual acuity Test for visual acuity Test visual fields Perform ophthalmologic exam Cranial Nerve III (three) - ANSWER Oculomotor Motor Evaluated with IV and VI Eye movement, pupil size, eyelid opening Inspect eyelid for drooping Inspect pupil size and equality Test consensual response and accommodation Test extra-ocular eye movement So tested thru PERLA and six cardinal fields Eyelid dooping/palsy is cranial nerve III Cranial Nerve IV (four) - ANSWER Trochlear Motor Evaluated with III and VI Eye movement, pupil size, eyelid opening Inspect eyelid for drooping Inspect pupil size and equality Test consensual response and accommodation Test extra-ocular eye movement So tested thru PERLA and six cardinal fields Cranial Nerve V (five) - ANSWER Trigeminal Mixed (both sensory and motor) Jaw strength, ask to clench teeth Inspect face for atrophy or tremors Palpate jaw for tone and strength Test for pain and sensation Test corneal reflex Cranial Nerve VI (six) - ANSWER Abducens Motor Evaluated with III and IV Eye movement, pupil size, eyelid opening Inspect eyelid for drooping Inspect pupil size and equality Test consensual response and accommodation Test extra-ocular eye movement So tested thru PERLA and six cardinal fields Cranial Nerve VII (seven) - ANSWER Facial Mixed (both sensory and motor) Facial expressions and taste Inspect facial symmetry Test tongue for salt and sweet Assess smile, frown, puff out cheeks Cranial Nerve VIII (eight) - ANSWER Acoustic Sensory Hearing and balance Test hearing (whisper test) Compare bone and air conduction Test for sound lateralization Cranial Nerve IX (nine) - ANSWER Glossopharyngeal Mixed (both sensory and motor) Taste and swallowing Test tongue for sour and bitter Test gag reflex and swallowing Cranial Nerve X (ten) - ANSWER Vagus Mixed (both sensory and motor) Swallowing and speech Inspect palate and uvula for symmetry Inspect for swallow difficulty Evaluate guttural speech sounds Cranial Nerve XI (eleven) - ANSWER Spinal accessory Motor Muscle strength Test trapezius and sternocleidomastoid muscle strength Shrug shoulders against resistance Cranial Nerve XII (twelve) - ANSWER Hypoglossal Motor Tongue strength Inspect tongue for tremors, symmetry, atrophy Test tongue movements Test tongue strength Evaluate lingual speech sounds Assessing cranial nerves in infants - ANSWER In infants, cranial nerves can be assessed by observing: CN II, III, IV, and VI can be assessed by looking for optical blink reflex, gaze and tracking, doll's eye CN V is evaluated with rooting and sucking reflex CN VII look at facial expression, forehead wrinkling, smiling CN VIII look at acoustic blink reflex, doll's eye manuever CN IX, X evaluate swallow and gag reflex CN XII evaluate sucking and swallowing ability, tongue position with pinch test Types of agnosia: Visual - ANSWER Occipital lobe Types of agnosia: Auditory - ANSWER Temporal lobe (lateral + superior) Types of agnosia: Tactile - ANSWER Parietal lobe Types of agnosia: Body parts and relationships - ANSWER Parietal lobe (posterio-inferior) Types of aphasia: Auditory receptive - ANSWER Temporal lobe (Wernicke's area) Types of aphasia: Expressive speaking - ANSWER Inferior posterior frontal area (Broca's) Types of aphasia: Visual receptive - ANSWER Parietal-occiptal Broca's aphasia - ANSWER Expressive type of aphasia characterized by intact reading comprehension, impaired writing skills, and using only nouns and verbs in speech Broca area (frontal lobe) contains the motor cortex, which is associated with speech formation, as well as decision making, problem solving, the ability to concentrate, and short-term memory Which part of the brain contains the Wernicke's speech area? - ANSWER Temporal lobe The temporal lobe is responsible for perception and interpretation of sounds as well as localizing their source. It contains the Wernicke speech area, which allows a person to understand spoken and written language. It is also involved in the integration of behavior, emotion, and personality, as well as long-term memory Types of aphasia: Expressive writing - ANSWER Posterior frontal What are characteristics of delirium? - ANSWER Characteristics of delirium include a sudden onset of cognitive impairment, illogical flow of ideas, and hallucinations that fluctuates during the day and last hours or days What are characteristics of Parkinson's? - ANSWER Slumped posture and a lack of facial expression may indicate depression or a neurologic condition such as Parkinson disease Shuffling gait What does the limbic system regulate? - ANSWER Emotions The limbic system mediates certain patterns of behavior that determine survival (e.g., mating, aggression, fear, and affection). Reactions to emotions such as anger, love, hostility, and envy originate here, but the expression of emotion and behavior is mediated by connections between the limbic system and the frontal lobe What tool tracks cognitive changes over time? - ANSWER Mini-Mental Status Exam (MMSE) Deep tendon reflexes: Biceps - ANSWER Elbow flexion C5 & 6 Deep tendon reflexes: Brachioradial - ANSWER Forearm pronation and elbow flexion C5 & 6 Deep tendon reflexes: Triceps - ANSWER Elbow extension C6, 7, 8 Deep tendon reflexes: Patellar - ANSWER Lower leg extension L2, 3, 4 Deep tendon reflexes: Clonus - ANSWER Rhythmic oscillating movements Ankle Associated with upper motor neuron disease Deep tendon reflexes: Plantar - ANSWER S1 & 2 Deep tendon reflex scoring - ANSWER 0 no response 1+ sluggish or diminished 2+ active or expected response 3+ more brisk than expected, slightly hyperactive 4+ brisk, hyperactive, with intermittent or transient clonus Tinel sign - ANSWER Medial nerve tingling, carpal tunnel Brudzinski's sign - ANSWER Involuntary flexion of the hips and knees when the neck is passively flexed; indicates meningeal irritation Kernig's sign - ANSWER Evaluated by flexing the leg at the knee and hips and then attempting to straighten the leg Pain in the lower back and resistance to straighten is a positive Kernig sign May indicate meningeal irritation Multiple sclerosis - ANSWER a progressive autoimmune disorder characterized by a combination of inflammation and degeneration of the myelin of the brain's white matter leading to decreased brain mass and obstructed transmission of nerve impulses Seizure disorder (epilepsy) - ANSWER a chronic disorder characterized by recurrent, unprovoked seizures secondary to an underlying brain abnormality Encephalitis - ANSWER acute inflammation of the brain and spinal cord involving the meninges, often due to a virus Meningitis - ANSWER inflammation of the meninges of the brain and spinal cord Intracranial tumor - ANSWER Abnormal growth within the cranial cavity that may be a primary or metastatic cancer Pseudotumor cerebri - ANSWER a clinical syndrome of intracranial hypertension that mimics brain tumors Stroke (Brain attack or CVA) - ANSWER a sudden interruption of blood supply to a part of the brain or the rupture of a blood vessel, spilling blood into the spaces around brain cells Myasthenia gravis - ANSWER Autoimmune disorder that affects the neuromuscular junction involved with muscle activation, autoantibodies directed against the acetylcholine receptors in the neuromuscular junction cause destruction and inflammatory changes in the postsynaptic membranes that lead to muscle dysfunction Guillain-Barre syndrome - ANSWER Postinfectious disorder following a nonspecific gastrointestinal or resp infection that causes an acute neuromuscular paralysis Trigeminal neuralgia (Tic Douloureux) - ANSWER Recurrent paroxysmal sharp pain that radiates into one or more branches of the fifth cranial nerve Bell palsy - ANSWER Acute paralysis or weakness of one side of the face that may have partial or complete resolution Peripheral neuropathy - ANSWER Disorder of the peripheral nervous system that results in motor and sensory loss in the distribution of one or more nerves Cerebral palsy - ANSWER Group of permanent disorders of movement and posture development associated with non-progressive disturbances that occurred in the development of the infant brain Myelomeningocele (spina bifida) - ANSWER a congenital vertebral defect (commonly at the lumbar or sacral level) that allows the spinal cord contents to protrude Shaken baby syndrome - ANSWER a severe form of child abuse resulting from the violent shaking of infants younger than 1 year of age Parkinson disease - ANSWER A slowly progressive degenerative neurological disorder in which motor function is primarily affected along with behavioral and cognitive problems Normal pressure hydrocephalus - ANSWER syndrome simulating degenerative disease that is caused by noncommunicating hydrocephalus (dilated ventricles with intracranial pressure WNL) Post polio syndrome (progressive post poliomyelitis muscular atrophy) - ANSWER The reappearance of neurologic signs 10 or more years after an acute poliomyelitis infection Thelarche - ANSWER Onset of breast development in girls, typically occurs after age 8 and is accompanied by other signs of puberty including a growth spurt Breast abnormalities: fibrocystic changes - ANSWER Benign fluid filled cyst formation caused by ductal enlargement Breast abnormalities: fibroadenoma - ANSWER Benign tumors composed of stromal and epithelial elements that represent a hyperplastic or proliferative process in a single terminal ductal unit Breast abnormalities: malignant breast tumors - ANSWER Ductal carcinoma arises from epithelial lining of ducts; lobular carcinoma originates in glandular tissue of the lobes