Exam 2: NR 304/ NR304 Health Assessment II Exam Review| Complete Guide with Verified Answers| 100% Correct (2023/ 2024)
QUESTION
What should one test
... [Show More] for with the pupillary light reflex?
Answer: - PERRLA
QUESTION
What does PERRLA stand for?
Answer: - Pupil Size
- pupils Equal
- pupils Round
- pupils Reactive to Light
- pupils Accommodate
QUESTION
What test should be used to assess cranial nerve VI?
Answer: - abducens
QUESTION
What does the cranial nerve V assessment asses for?
Answer: - Motor function
- Light touch sensory fucntion
QUESTION
How does one assess the sensory function portion of the cranial nerve V
assessment?
Answer: - Have person close eyes
- touch w/ a wisp to designated areas on person face
- have client state when they feel the light touch
QUESTION
What are some locations that should be assessed during the light touch sensation assessment of cranial nerve V?
Answer: - Face
- Forehead
- Cheeks
- Chin
QUESTION
What does the motor function assessment of Cranial nerve V entail?
Answer: - Mastication by palpating temporal and masseter muscles as person clenches teeth
QUESTION
What should you palpate to test mastication of cranial nerve V?
Answer: - temporal muscles
- masseter muscles
QUESTION
How does one assess cranial nerve VII?
Answer: Asking client to puff out the follow- ing:
- Puff cheeks
- Frown
- Smile
- Raise eye brows
QUESTION
What should one do while the client is puffing their cheeks during a cranial nerve VII assessment?
Answer: - Press cheeks in
QUESTION
What test is performed to assess cranial nerve VIII?
Answer: - Whisper voice test
QUESTION
How does one assess the cranial nerve IX motor function?
Answer: - depress tongue with tongue blade
- have client say "AHH"
- Touch posterior pharyngeal wall w/ tongue blade
QUESTION
What should one assess cranial nerve IX for motor function?
Answer: - Pharyngeal movement
- Uvula should rise in midline
- Soft palate should rise in midline
- tonsillar pillar should move medially
QUESTION
How should the gag reflex sound in a cranial nerve IX assessment?
Answer: - smooth
- not strained
QUESTION
How does one assess cranial nerve X?
Answer: - have patient tilt head slightly back
- have them swallow
QUESTION
What does cranial nerve X assessment assess?
Answer: - clients ability to manage saliva
QUESTION
How does one asses cranial nerve XI?
Answer: - Have client rotate head against resistance
- Have client shrug shoulders against resistance
QUESTION
What muscles does the cranial nerve XI assess?
Answer: - sternomastoid
- Trapezius
QUESTION
How does one assess cranial nerve XII?
Answer: - Inspect tongue
- Aske client to say "Light, Tight, Dynamite"
QUESTION
What should a nurse note for cranial nerve XII?
Answer: - Lingual speech ( enunci- ation of L, T, D, N) [Show Less]