Nur 3065 Exam 4 Questions & Accurate Answers Passed 100%

NUR 3065 EXAM 4 QUESTIONS &
ACCURATE ANSWERS PASSED 100%

Cranial Nerve I: Olfactory - CORRECT ANSWER o SENSORY
o Assess smell with eyes closed
o Normal = able to identify smells correctly

Cranial Nerve II: Optic - CORRECT ANSWER o SENSORY
o Inspect visual acuity
♣ Use Snellen chart
♣ Normal = 20/20 vision
o Inspect visual fields - peripheral vision tested by confrontation
♣ When looking straight ahead, wiggle fingers out to in, cover 1 eye, ask when the
moving object is spotted
♣ Normal = visual fields intact by confrontation

Cranial Nerve III, IV, VI: Oculomotor, Trochlear, and Abducens - CORRECT ANSWER
o MOTOR

o Inspect extraocular muscles function using the diagnostic positions test
♣ EOM's test - follow in an H or Vs
• Normal =
-EOM's intact in 5 cardinal fields of gaze
-Gaze is conjugate; simultaneous movement of both eyes, without nystagmus

♣ CN III = EOM
♣ CN IV = up, down, and inward movements
♣ CN VI = lateral movements

o Inspect pupil size and constriction
♣ Normal pupil size = equal, resting size is 3 to 5 mm

o Assess pupillary light reflex test
♣ Penlight from side to side, check same eye-direct and other
eye-consensual/simultaneous pupil constriction or reaction to light

o Accommodation test
♣ Focus far away to dilate pupils, then bring finger close to pt.'s nose 4 inches, check
for pupils to constrict and converge - axes move in

o PEERLA = pupils equal, round, react to light, and accommodation with consensual
response

,o Abnormal - CN VI = nerve palsy

Cranial Nerve V: Trigeminal - CORRECT ANSWER o MOTOR AND SENSORY
o Palpate for TMJ
♣ Ask pt. to clench teeth or chew, check jaw muscle strength
♣ Normal = strength equal bilateral, TMJ without pain or crepitus

Cranial Nerve VII: Facial - CORRECT ANSWER o MOTOR AND SENSORY
o Motor - pt. can smile, frown, raise eyebrow, puff cheeks symmetrically
o Ask pt. if they can identify taste (sweet, salty, sour, bitter) on anterior 2/3 of tongue
o Abnormal - Bell's Palsy (nerve paralysis)
♣ Facial paralysis
♣ Self-limiting; will resolve in approximately 6 weeks
♣ Usually follows trauma, infection (cannot wrinkle forehead)

Cranial Nerve VIII: Acoustic - CORRECT ANSWER o SENSORY
o Assess hearing acuity
o Whisper word at 2 feet
♣ Normal = voices sounds were audible, and words correctly identified

o Rinne test (compares air and bone conduction); Weber test (tuning fork); Romberg
test (pt. close eyes and remain still)

Cranial Nerve IX and X: Glossopharyngeal and Vagus - CORRECT ANSWER o
MOTOR AND SENSORY
o Inspect and palpate and uvula rise midline on phonation
♣ Normal = soft palate intact, uvular midline
o Ask pt. to swallow, say 'ahh', use tongue blade, uvula rises

Cranial Nerve XI: Spinal - CORRECT ANSWER o MOTOR
o Palpate muscle strength with head/neck movement and shoulder shrug
♣ Normal = 5/5 bilaterally as client moves against resistance

Cranial Nerve XII: Hypoglossal - CORRECT ANSWER o MOTOR
o Inspect tongue when extended
♣ Ask pt. to stick out their tongue, check position
♣ Normal = midline without deviation
o Abnormal - nerve palsy

Head - CORRECT ANSWER o Headaches
o Injury
o Dizziness/syncope

Neck - CORRECT ANSWER o Pain
o Limited ROM

,o Enlarged or tender nodes
o Goiter

Mouth and Throat - CORRECT ANSWER o Mouth pain or toothache
o Bleeding gums
o Lesions in mouth or tongue
o Sore throat
o Dysphagia

Nose and Sinuses - CORRECT ANSWER o Discharge
o Severe/unusual/frequent colds
o Sinus pain
o Nosebleeds
o Allergies

Ears - CORRECT ANSWER o Earaches
o Infections
o Discharge
o Vertigo
o Tinnitus

Eyes - CORRECT ANSWER o Blurring
o Decreased acuity
o Blind spots
o Floaters
o Eye pain
o Glaucoma
o Cataracts

Identify the anatomical locations of the lymph nodes/chains of nodes present in the
head and neck. - CORRECT ANSWER • Preauricular (1)
o In front of ear

• Posterior auricular (2)
o Superficial to the mastoid process, behind the ear
o Mastoid skull bone

• Occipital (3)
o Base of the skull

• Submental (4)
o Behind the dip of the mandible (jaw bone)

• Submandibular (5)
o Halfway between the tip and angle of the mandible

, • Jugulodigastric (6)
o (tonsillar) under the angle of the mandible

• Superficial cervical (7)
o Overlying the sterno-mastoid muscle

• Deep cervical chain (8)
o Deep under the sterno-mastoid muscle

• Posterior cervical (9)
o Posterior triangle along the edge of the trapezius muscle

• Supraclavicular (10)
o Just above and behind the clavicle

• Palpate all 10 nodal areas; use gentle pressure and slight circular motion; palpate both
sides simultaneously
o Note - location, size, shape, mobility, tenderness
• Normal findings... palpate as movable, discrete, soft, non-tender

• Enlargements...
o Lymphadenopathy > 1 cm
o Bilateral or unilateral
o If nodal enlargement - check the area they drain for S/S of inflammation, neoplasm

Identify the normal range of motion of the neck. - CORRECT ANSWER • Flexion,
extension
• Hyperextension
• Lateral bending
• Rotation

Tracheal Deviation: - CORRECT ANSWER • when your trachea is pushed to one side
of your neck by abnormal pressure in your chest cavity or neck
o Masses push trachea away from affected area
o Atelectasis causes pull toward affected area
o Pneumothorax is the most frequently reported cause of tracheal deviation from
pressure buildup

Lymph Adenopathy: - CORRECT ANSWER is palpable enlargement of >/= lymph
nodes; disease of the lymph nodes

Thyromegaly: - CORRECT ANSWER a disorder in which the thyroid gland; the thyroid
gland in the neck becomes abnormally enlarged
o Most commonly known as goiter
o Most often caused by iodine in the diet