Physical assessment Quiz 2 WCU
Focus Assessment: Visual acuity - ✔️✔️The degree of detail the eye can discern in an
image
Near vision = newspaper print - Rosenbaum
Snellen Chart = 20 ft in front of the patient
Eye assessment questions to ask - ✔️✔️"When was the last eye exam and findings?"
(2 years is recommended)
"Any medications for eye disorders?"
"Do you wear corrective glasses or contact lenses?"
"Have you ever been diagnosed with a disease of the eye?"
"Do you have any family history of eye disorders?"
CN I - ✔️✔️Olfactory (sensory)
smell
CN II - ✔️✔️Optic(sensory)
vision
CN III - ✔️✔️Oculomotor (motor)
eye movement, pupil constriction
CN IV - ✔️✔️Trochlear (Motor)
Down and inward movement of eye
CN V - ✔️✔️Trigeminal Nerve;
Both
Sensory--cutaneous sensations from face and mouth
Motor--opening jaw, chewing from maxillary and mandibular (mastication)
CN VI - ✔️✔️abducens(motor)
lateral eye movement
CN VII - ✔️✔️Facial (motor and sensory)
facial expression, taste
CN VIII - ✔️✔️Vestibulocochlear(sensory)
hearing and balance
CN IX - ✔️✔️glossopharyngeal (motor)
gag reflex, swallowing and speech
CN X - ✔️✔️Vagus(Sensory and motor)
, autonomic functions of viscera (glands, digestion, heart rate)
CN XI - ✔️✔️Accessory Nerve(Motor)
Moving head and swallowing
CN XII - ✔️✔️Hypoglossal(Motor)
Tongue movement
What does it mean when using the Snellen chart, the pt's vision is 20/30. - ✔️✔️The
patient can see at 20 ft what a person with normal vision can see at 30
Which CN is responsible for Vision (Snellen chart)? - ✔️✔️CN II (optic) Vision
Glaucoma - ✔️✔️Pt describes a change in vision, the loss of peripheral vision
presbyopia - ✔️✔️impaired vision as a result of aging
(farsightedness)
Astigmatism - ✔️✔️a condition in which the eye does not focus properly because of
uneven curvatures of the cornea; Pt will see floaters
hyperopia - ✔️✔️Condition in which a person can see things in the distance but has
trouble seeing at close range.
myopia - ✔️✔️nearsightedness
patient sees faraway objects as blurry
PERRLA - ✔️✔️pupils equal, round, reactive to light and accommodation
What condition could be occurring if pt's intraocular pressure is 26? - ✔️✔️Glaucoma
What should the tympanic membrane look like? - ✔️✔️pearly gray color
normal finding on the Rinne test - ✔️✔️AC>BC
air conduction is greater than bone conduction
Questions nurses should ask during ear assessment - ✔️✔️Do you use hearing
devices?
Are you taking any medications for the ears?
Are there any changes to your hearing?
Do you suffer from frequent ear infections?
Proper way to use the otoscope - ✔️✔️pull pinna up and back
Focus Assessment: Visual acuity - ✔️✔️The degree of detail the eye can discern in an
image
Near vision = newspaper print - Rosenbaum
Snellen Chart = 20 ft in front of the patient
Eye assessment questions to ask - ✔️✔️"When was the last eye exam and findings?"
(2 years is recommended)
"Any medications for eye disorders?"
"Do you wear corrective glasses or contact lenses?"
"Have you ever been diagnosed with a disease of the eye?"
"Do you have any family history of eye disorders?"
CN I - ✔️✔️Olfactory (sensory)
smell
CN II - ✔️✔️Optic(sensory)
vision
CN III - ✔️✔️Oculomotor (motor)
eye movement, pupil constriction
CN IV - ✔️✔️Trochlear (Motor)
Down and inward movement of eye
CN V - ✔️✔️Trigeminal Nerve;
Both
Sensory--cutaneous sensations from face and mouth
Motor--opening jaw, chewing from maxillary and mandibular (mastication)
CN VI - ✔️✔️abducens(motor)
lateral eye movement
CN VII - ✔️✔️Facial (motor and sensory)
facial expression, taste
CN VIII - ✔️✔️Vestibulocochlear(sensory)
hearing and balance
CN IX - ✔️✔️glossopharyngeal (motor)
gag reflex, swallowing and speech
CN X - ✔️✔️Vagus(Sensory and motor)
, autonomic functions of viscera (glands, digestion, heart rate)
CN XI - ✔️✔️Accessory Nerve(Motor)
Moving head and swallowing
CN XII - ✔️✔️Hypoglossal(Motor)
Tongue movement
What does it mean when using the Snellen chart, the pt's vision is 20/30. - ✔️✔️The
patient can see at 20 ft what a person with normal vision can see at 30
Which CN is responsible for Vision (Snellen chart)? - ✔️✔️CN II (optic) Vision
Glaucoma - ✔️✔️Pt describes a change in vision, the loss of peripheral vision
presbyopia - ✔️✔️impaired vision as a result of aging
(farsightedness)
Astigmatism - ✔️✔️a condition in which the eye does not focus properly because of
uneven curvatures of the cornea; Pt will see floaters
hyperopia - ✔️✔️Condition in which a person can see things in the distance but has
trouble seeing at close range.
myopia - ✔️✔️nearsightedness
patient sees faraway objects as blurry
PERRLA - ✔️✔️pupils equal, round, reactive to light and accommodation
What condition could be occurring if pt's intraocular pressure is 26? - ✔️✔️Glaucoma
What should the tympanic membrane look like? - ✔️✔️pearly gray color
normal finding on the Rinne test - ✔️✔️AC>BC
air conduction is greater than bone conduction
Questions nurses should ask during ear assessment - ✔️✔️Do you use hearing
devices?
Are you taking any medications for the ears?
Are there any changes to your hearing?
Do you suffer from frequent ear infections?
Proper way to use the otoscope - ✔️✔️pull pinna up and back
