NR 509 Assessment Test Question and Answers
First step obtain
Answer: patient consent to video and assessment
Face most note
Answer: head is midline and symmetrical
no discoloration or lesions
Palpation of Lymph nodes on face and neck
Answer: preauricular lymph nodes-at front of ear
postauricular lymph nodes-back of ear
occipital lymph nodes-back of head
tonsillar lymph nodes-move forward under jaw
submandibular lymph nodes-under jaw
submental lymph nodes-under chin
Now palpate the cervical Lymph nodes
Answer: pre-cervical lymph nodes-run hands down neck toward collarbone
post-cervical lymph nodes-directly posterior to this
supraclavicular lymph nodes-run hands over clavicle
make sure to note no tenderness, enlargement and they are equal bilaterally
Cranial Nerve V: Trigeminal Nerve
1st component: motor
2nd component: sensory
Answer: clench jaw assess masseter muscle
note strength, no distortions, and equal bilaterally
2nd component: close eyes and touch forehead, each cheek, nose, and chin make sure they are able to
tell you where you're touching
Cranial Nerve V11: Facial Nerve
Have client do a series of
Answer: facial expressions
1. smile note equal and symmetrical
2. frown
3. raise eyebrows
4. puff cheeks-equal bilateral
5. pucker lips-want a nice tight pucker
Note intact: if able to perform and equal and symmetrical bilaterally
Inspect the Ears
1. note the outer ear
2. use an otoscope to look inside for adult pull ear
Answer:
1. equal and symmetrical no nodules or lesions or discoloration
, 2. up and back and note external auditory canal is clear, no redness, drainage, effusion (full of fluid)
swelling and absent of cereum and tympanic membrane is bright or pearly grey
do same with other ear
Palpate the ears
1. palpate the
2. next palpate the
Answer: 1. pinna (top of the ear) note absence of nodules or tenderness
2. tragus (inner ear triangle) note absence of tenderness
Cranial nerve VIII: the Acoustic Nerve
1. this will assess (blank) you will use the Whisper test
Answer: 1. patient's hearing have them cover one ear and whisper something "123 or 456" into the
opposite ear and have them repeat back to you. Do this on both ears Note hearing is intact bilaterally
assess Eyes
1. first look at
Answer: 1. the conjunctiva (pull-down bottom eyelids); note pink, clear with lesions or discoloration or
drainage and sclera is white/clear bilaterally
Cranial II: Optic Nerve
1. you'll be testing central
2. IF they can read off the lowest lines then
Answer: 1. vision to do this pull out pocket Snellen Chart stand 6 ft away and have pt read off of lowest
line covering one eye
have patient cover other eye and repeat and then perform using both eyes and repeat
2. Note patient's vision is normal 20/20 in left and right and bilaterally
Cranial Nerve II: Optic Nerve
1. Now you'll be testing
Answer: 1. peripheral vision; first have pt stand in front of you; place both your arms straight out over
their shoulders until they tell you they can't see them then bring them in toward their head until they
can see them in their peripheral vision
2. then move hands toward their center from their temple
3. then move hands toward their center starting from down below their waist
Note peripheral vision is normal
Cranial Nerve II: Optic Nerve
1. now you'll be testing
Answer: 1. pupil reaction to light
using ophthalmoscope turn light on; starting eye-level ask pt to stare at your nose move light from
peripheral to center on one eye; then do the same on the other
Note: pupils are equal, round bilaterally, note, size 2-3 mm, and constrict to light
Cranial Nerve III: Oculomotor
Cranial Nerve IV: Trochlear
Cranial Nerve VI: Abducens
1. you'll be checking for
First step obtain
Answer: patient consent to video and assessment
Face most note
Answer: head is midline and symmetrical
no discoloration or lesions
Palpation of Lymph nodes on face and neck
Answer: preauricular lymph nodes-at front of ear
postauricular lymph nodes-back of ear
occipital lymph nodes-back of head
tonsillar lymph nodes-move forward under jaw
submandibular lymph nodes-under jaw
submental lymph nodes-under chin
Now palpate the cervical Lymph nodes
Answer: pre-cervical lymph nodes-run hands down neck toward collarbone
post-cervical lymph nodes-directly posterior to this
supraclavicular lymph nodes-run hands over clavicle
make sure to note no tenderness, enlargement and they are equal bilaterally
Cranial Nerve V: Trigeminal Nerve
1st component: motor
2nd component: sensory
Answer: clench jaw assess masseter muscle
note strength, no distortions, and equal bilaterally
2nd component: close eyes and touch forehead, each cheek, nose, and chin make sure they are able to
tell you where you're touching
Cranial Nerve V11: Facial Nerve
Have client do a series of
Answer: facial expressions
1. smile note equal and symmetrical
2. frown
3. raise eyebrows
4. puff cheeks-equal bilateral
5. pucker lips-want a nice tight pucker
Note intact: if able to perform and equal and symmetrical bilaterally
Inspect the Ears
1. note the outer ear
2. use an otoscope to look inside for adult pull ear
Answer:
1. equal and symmetrical no nodules or lesions or discoloration
, 2. up and back and note external auditory canal is clear, no redness, drainage, effusion (full of fluid)
swelling and absent of cereum and tympanic membrane is bright or pearly grey
do same with other ear
Palpate the ears
1. palpate the
2. next palpate the
Answer: 1. pinna (top of the ear) note absence of nodules or tenderness
2. tragus (inner ear triangle) note absence of tenderness
Cranial nerve VIII: the Acoustic Nerve
1. this will assess (blank) you will use the Whisper test
Answer: 1. patient's hearing have them cover one ear and whisper something "123 or 456" into the
opposite ear and have them repeat back to you. Do this on both ears Note hearing is intact bilaterally
assess Eyes
1. first look at
Answer: 1. the conjunctiva (pull-down bottom eyelids); note pink, clear with lesions or discoloration or
drainage and sclera is white/clear bilaterally
Cranial II: Optic Nerve
1. you'll be testing central
2. IF they can read off the lowest lines then
Answer: 1. vision to do this pull out pocket Snellen Chart stand 6 ft away and have pt read off of lowest
line covering one eye
have patient cover other eye and repeat and then perform using both eyes and repeat
2. Note patient's vision is normal 20/20 in left and right and bilaterally
Cranial Nerve II: Optic Nerve
1. Now you'll be testing
Answer: 1. peripheral vision; first have pt stand in front of you; place both your arms straight out over
their shoulders until they tell you they can't see them then bring them in toward their head until they
can see them in their peripheral vision
2. then move hands toward their center from their temple
3. then move hands toward their center starting from down below their waist
Note peripheral vision is normal
Cranial Nerve II: Optic Nerve
1. now you'll be testing
Answer: 1. pupil reaction to light
using ophthalmoscope turn light on; starting eye-level ask pt to stare at your nose move light from
peripheral to center on one eye; then do the same on the other
Note: pupils are equal, round bilaterally, note, size 2-3 mm, and constrict to light
Cranial Nerve III: Oculomotor
Cranial Nerve IV: Trochlear
Cranial Nerve VI: Abducens
1. you'll be checking for
