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Nursing Skills
Test 4- HEENT
| Question | Answer |
|---|---|
| What body parts are include in the HEENT exam? (11) | Skull, Face, Eyes, Ears, Nose & Sinuses, Mouth and Pharynx, trachea, thyroid gland, lymph nodes |
| During an HEENT exam, what would you ask them about their subjective history? (Name as many as you can) | Headaches, Head Injury, Visual changes, eye injuries, Use of corrective lenses,Hearing changes, hearing aids Eye and ear infections, Hoarseness, difficulty swallowing Oral care practices Surgeries, Allergies, Chronic illnesses, Occupational exposure ,His |
| A person whose head and all major organs of the head are in a normal condition and without significant abnormalities | Normoceohalic |
| A usually congenital condition in which an abnormal accumulation of fluid in the cerebral ventricles causes enlargement of the skull and compression of the brain, destroying much of the neural tissue. | Hydrocephalic |
| Occurs when the head is abnormally large; this includes the scalp, the cranial bone, and the contents of the cranium. | Macrocephaly |
| When is head circumference measured? (2) | As part of normal infant assessment to the age of 2 years; and any time it appears unusually large or small |
| When completing a head assessment, what else are you looking for other than size?(4) | Symmetry, Edema, masses, Hair |
| When looking at the face, what do you inspect for? (7) | Color, Symmetry, Distribution of facial hair, Edema, bruising, facial muscles, cranial nerve testing |
| When accessing the head, what do you palpate for? (3) | Masses, pain, instability, |
| Palpate the TMJ as client | Opens and closes mouth, should be smooth movement not clunky |
| Inspection of the eyes includes what five things | External and internal structures, Visual acuity, Extra ocular movements, Pupillary reaction, Peripheral vision |
| Eyelashes should curl | Outward |
| Where on the eye do you inspect for edema? (2) | Lids, lacrimal gland |
| What are six abnormal findings of a visual eye external eye inspection? | Drooping of eyelids (ptosis), inward (entropin) or outward (extropion) turning of lower lid, redness, drainage |
| When a light is shone in one eye, what should happen? | They will both constrict, the second does so my consensual reflex |
| When the eyes focus on finger 4-6” from nose and then as the finger gets closer to nose, what are eyes doing? | Accommodating and coming closer together |
| What does PERRLA mean? | Pupils Equal, Round, and Reactive to Light and Accommodation |
| What are abnormal findings of the internal eye? (6) | Redness, irregular size or shape, cloudiness (cataract), unequal response, inability to accommodate or converge |
| What three things could be the cause of pupil dilation or constriction at inappropriate time? | Glaucoma, meds or injury |
| The “cardinal positions” are six positions of gaze which allow comparisons of the Horizontal, vertical, and diagonal ocular movements produced by the six extra ocular muscles. There are six positions. | Six cardinal fields of vision |
| When testing peripheral vision you stand ___ ft. from patient at _____. | Two, eye |
| When testing peripheral vision, have patient cover one and you cover | Your eye opposite the patient’s covered eye |
| When testing peripheral vision, tell patient to fix gaze on | Your nose |
| When testing peripheral vision, how your arm out to one side and move your finger into _____until______ | Visual fields from various points, patient can see your fingers (you should both be able to see at the same time) |
| What do you use the Snellen chart for | Testing visual acuity |
| The snellen chart should be ___ feet away from the patient | 20 |
| Should the client keep their corrected lenses on if available during visual acuity check? | Yes |
| If the client does not have corrected lenses with them during visual acuity check, what else could they use? | Pinhole correction |
| How many times so you test each eye individually during the visual acuity test? | Twice and then do both eyes at the same time |
| What does 20/20 mean? | Normal” can read at 20’ what the normal person can read at 20’ |
| What does 20/50 minus 1 mean? | Missed one item on 20/50 line |
| What do you document when performing the visual acuity test? | “with correction” or “with pinhole correction” or “without correction” |
| Myopia | Nearsighted |
| Hyperopia | Farsighted |
| Presbyopia | Diminished ability to focus |
| Astigmatism | Inability to focus due to irregular curvature of the lens or cornea |
| Infants sight is | Myopic |
| Older adults have _____ tearing, lens becomes more ___ and often becomes ____ | Diminished, more, presbyoptic |
| Assemble the ophthalmoscope. Begin with light setting at the ____ light & the lens wheel at ___. | Large white, 0 |
| ___ the room when using an ophthalmoscope. Have pt. ___ glasses prn. Allow time for pt pupils to ___. | Darken, remove, dilate |
| When using an ophthalmoscope, sit ____ and have him look____. | Facing patient, straight ahead |
| Keep both your eyes____ when looking through the scope viewer of ophthalmoscope. | Open |
| When using an ophthalmoscope, use your ____ hand/right eye to examine pts right eye. Use your ____ hand & left eye to examine pts left eye | Right, left |
| When assessing the internal eye with ophthalmoscope, begin about ___” away from the pt & about ___ degrees lateral to his/her line of vision. | 10”, 15 |
| When using the ophthalmoscope, shine the light on the ____ and observe for -__. | Pupil, red reflex |
| What do you need to do to get the internal eye structures in clear vision? | Move ophthalmoscope toward the pupil until very close, rotate the lens wheel until the internal eye structures are clear. |
| How do you locate the optic disc using ophthalmoscope? | Follow blood vessels toward the midline |
| How do you locate the macula using ophthalmoscope? | Look toward patient’s temple for a small circular structure |
| When using the ophthalmoscope to look at the internal eye, what would we expect to see in a normal eye? (5) | Uniform red reflex, clear, yellow optic disc, reddish retina and light red arteries |
| When using ophthalmoscope to look at internal eye, what would be considered abnormal? (4) | Cloudy lens, changes in size, shape, color of vessels (hypertension, diabetes) |
| Infants sight is | Nearsighted |
| Peripheral vision is fully developed | At birth |
| By 2-3 months, the infant has voluntary control of eye_____ and the _____ begin to carry tears. | Muscles, lacrimal ducts |
| By___ months the infant can distinguish colors. | Eight |
| By ___ months an infant’s eyes are able to perceive a single message. This means that the eye muscles are___. | Nine, coordinated |
| What happens to ability to tear as we age | It is diminished |
| As we age, what happens to corneal sensitivity | It is decreased, may not be able to sense injury |
| As we age, the lens becomes more ___ and near vision becomes ____ | Rigid, impaired |
| What causes scattering of light and sensitivity to light as we age? (2) | Increased lens density and degeneration of cells in iris and cornea |
| What tool is used to inspect the canal and inner ear? | Otoscope |
| What tool is used to determine hearing acuity? | Tuning fork |
| External canal contains ______ and _____ | Hair follicles and cerminous glands |
| The ear is innervated by the ____ nerve | Trigeminal ( 5th cranial) |
| When inspecting the ear, what should be noted? (6) | Note position, size/proportion, shape, presence of lesions or scars, redness, swelling |
| Pain with movement of the ___ or ___ are indicative of infection of the external canal. | Pinna, tragus |
| How is the whisper test conducted? | Cover one ear, whisper (or use ticking watch) 1-2 feet from patient (out of their line of vision to prevent lip reading) |
| What tool is used to determine the type of hearing loss? | A tuning fork |
| problem with sound transmission through outer and middle ear | Conductive loss |
| Caused by inner ear damage | Sensorineural loss |
| Combination of conductive and sensorineural loss | Mixed loss |
| How do you conduct weber test? | Hold tuning fork at its base and strike against your hand to cause vibration, Place base at center of patient’s head, ask where hearing is heard best |
| A Weber Test is normal if… | heard in both ears or localized to top of head – “negative Weber test” or “no lateralization” |
| A Weber Test shows a conductive loss if … | heard better in affected ear (bone transmits sound better) – “lateralizes to right/left ear” |
| A Weber test shows a sensorineural loss of | heard better in unaffected ear (inner ear disorders, nerve damage, noise exposure, ototoxic drugs) |
| When conducting the Rinne test, strike the tuning fork against | Your hand |
| How do you test for bone conduction/BC as a part of the Rinne test? | Hold base against mastoid process and ask patient to tell you when sound is no longer heard |
| How do you test for air conduction/AC as a part of the Rinne test? | Immediately place the still vibrating tuning fork close to the external canal and ask whether patient can still hear the sound |
| A Rinne test is considered normal when | AC is reported to be greater than BC |
| In conductive hearing loss, BC will be ______ AC | Equal to or greater than |
| Hold otoscope in ___ hand to inspect right ear | Right |
| To inspect ear, what do you do to Pinna | Up and back for adult, down and back for child less than three years old |
| Insert otoscope with patient’s head tilted_______. | Away from you |
| When examining the ear with the otoscope, what should you look for? (5) | Wax, foreign bodies, redness, swelling, lesions |
| The ear canal itself should be | Smooth |
| What should you to if you see a foreign body in the ear | Stop exam and notify provider |
| A normal tympanic membrane should be (4) | Intact, translucent, shiny and with reflected cone of light |
| Redness or bulging indicates | Middle ear infection otitis media |
| As child grows,_____ lengthens and pharyngeal orifice moves ______ as a result ear infections are _____. | Eustachian tube, inferiorly, less frequent |
| What two common things in children can often occlude the Eustachian tube? | Enlarged tonsils and adenoids |
| Tympanic membrane may be more difficult to visualize in infants age? Because of what three reasons | Under six months, more horizontal, may be red from crying, less conical in shape so light reflex diffuse |
| By age ___ months, infant should turn head toward sound & respond to parent’s voice | 6-Apr |
| By age ___ months, infant should respond to his/her name and follow sounds | 10-Jun |
| People in the age group 65-85 will have a ____ % hearing loss. | 33% |
| People in the age group 85 and older will have a____% hearing loss. | 50% |
| As ______ begins to degenerate, hearing begins to degenerate. | Hair cells in the organ of Corti |
| What type of hearing loss usually occurs first? | Sensorineural |
| As we age, we lose the ability to hear ___ frequency sounds first and then ____ frequency sounds. | High, low |
| When inspecting the external nose and nares, what should we look for? (6) | Swelling, trauma, deformities, Symmetry of nares, Deviation or disruption of septum |
| How do you test for patency of the nose? | Occluding one nare and have patient inhale and exhale |
| What are three types of tools that can be used to inspect the internal nose? | Use otoscope, penlight, or nasal speculum to inspect each nostril |
| What three things should we check for when looking at the internal nose? | Mucous membrane color, presence of drainage or growths |
| What should a normal nostril look like? (2) | Should be smooth and pink |
| What could we find during inspection of the nostrils that could be indicative of allergies or chronic inflammation? (3) | Redness, pale, Boggy turbinates |
| Is it normal for sinuses to feel tender or swollen? | No, that would be abnormal |
| When looking at the mouth and pharynx, what structures should be included? (7) | Inspect lips, tongue, teeth, gums, hard & soft palate, posterior pharynx |
| Normal lips will be (3) | Pink, moist and smooth |
| Normal tongue and mucous membranes will be (4) | pink, moist, no lesions or swelling |
| Normal gums will be (2) | Pink and smooth |
| Normal teeth will be (2) | Intact, no discolorations |
| Normal tonsils will be (3) | Small, pink, symmetric |
| Normal uvula will be (2) | At the midline and mobile |
| What are abnormal findings of the mouth and pharynx (7)? | Pallor, Cyanosis, Swelling, Lesions, Bleeding gums, Tongue with white or bright red coating |
| What grade would tonsils have that are flat fit into the tonsillar fossa? | 0 |
| What grade would tonsils have that are protruding? | 1+ |
| What grade would tonsils have that are halfway between tonsillar pillars and uvula? | 2+ |
| What grade would tonsils have that nearly touch the uvula? | 3+ |
| What grade would tonsils have that touch each other “kissing tonsils”? | 4+ |
| When looking at neck muscles, assess for | Musculature |
| When completing musculature assessment of the neck, in what ways should client position head?(4) | Have client flex chin to chest and each shoulder, hyperextend backwards, rotate |
| When completing lymph node assessment of the neck, how should client position himself? | client should relax and flex neck slightly forward |
| What should you use to palpate neck? | Pads of fingers |
| If lymph nodes are palpable they should be (3) | small, soft, and moveable |
| Is tenderness in the lymph nodes normal? | No |
| In what three instances do we see enlarged lymph nodes? | Infection, autoimmune disorders, cancer |
| Palpate the trachea for (2) | Alignment and position |
| Describe a normal trachea | Midline at suprasternal notch |
| Describe an abnormal trachea | Unequal space between trachea and sternocleidomastoid muscle |
| From what position should the thyroid be palpated | From behind or in front of patient |
| When positioning your hands to inspect the thyroid, where should they be on patient’s neck? | Lower half |
| In order to be able to palpate the thyroid, what should you ask patient to do? | Swallow |
| What is the size of a normal thyroid? | A little large than the size of your thumb pad |
| How should a normal thyroid feel? (4) | Small, smooth, soft and move freely |
| What happens to the size of earlobes in an older adult (2)? | More prominent and elongated |
| What happens to the size of nose in an older adult? (2) | More prominent and larger due to unabated cartilage formation |
| What happens to the sense of smell in older adult? | Decreased |
| What happens to motor function of tongue? | Altered (could cause issues swallowing) |
| At what age to the number of taste buds begin to decrease? | 45 |
| Describe the thyroid gland of an older adult | Nodular |
| The lymph nodes in an older adult are ___ in size and ____ to palpate | Smaller, easier |
| Posterior fontanels close at | 8 weeks |
| Anterior fontanels close at | 18-24 months |
| Baby ( deciduous teeth) erupt at | 6-24 months |
| Permanent teeth begin to appear between | 6-18 years |
Created by:
anastasia158
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