NURS1921 Exam IV: HEENT Assessment

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NURS1921 Exam IV: HEENT Assessment
2011-10-23 23:35:55
NURS1921 Exam IV HEENT Assessment

Based on lecture by Mrs. Robertson
Show Answers:

  1. What should be inspected when assessing the head and face?
    • Symmetry
    • Position and alignment
    • Lesions, redness, edema or drainage
    • Inspect then palpate scalp & hair
    • Facial Expression
  2. What should be inspected when assessing the neck?
    • Muscle symmetry
    • Trachea
    • Neck veins
    • Carotid arteries
    • Enlarged lymph nodes
    Pupil equal, Round react to light and accomodate
  4. How are extraocular movements assessed?
    • 6 cardinal fields of vision
    • Assessing CNIV: Trochlear
  5. What is the Romberg Test used to assess?
    • Vestibular function
    • Pos. means there is a vestibular disorder
  6. How is the whisper test conducted?
    Whisper something from about 2 ft. behind pt.
  7. How is tongue movement assessed?
    • Have pt. stick our their tongue and move it from side to side.
    • Assessing CNXII: Hypoglossal
  8. How is the gag reflex assessed?
    • Use a tongue depressor or swab to elicit gag reflex
    • Assessing CNX: Vagus
    • NPO if gag reflex isn't working properly
  9. Considerations for older adults
    • Visual acuity, peripheral vision and accommodation to darkness decreases
    • Conjunctiva of eye may appear yellowed
    • Skin around the eye may darken, eyes may appear sunken
    • Generalized hearing loss, beginning with high-frequency sounds
    • Earlobe elongates
    • Sense of smell and taste diminished (sweel/salty first)
    • Oral mucosa is drier