Skin, Hair, Nails, Head, Neck, and Eye Assessment

Question 1

made under sterile conditions
and at very low to no risk for
infection. Usually skin or vascular
incisions

Answer 1

Clean wounds

Question 2

made under sterile conditions but involving the
respiratory, GI, genital, urinary tract without unusual contamination.

Answer 2

Clean-contaminated wound

Question 3

exposed to content of GIT or infected fluids from GUT

Answer 3

Contaminated wound

Question 4

exposed to contaminants or
exhibiting evidence of infection prior to surgery.

Answer 4

Infected wound

Question 5

*No inflammation
*No break in sterile technique
*Wound primarily closed/Not drained
*Aero- digestive, genitourinary & Biliary tract not entered
*Potential infection rate

Answer 5

Clean Wounds

Question 6

*Traumatic Wounds
*Acute inflammation present
*Major break in sterile technique
*Gross spillage/contamination from respiratory, gastrointestinal, biliary, or genitourinary tracts
*Potential infection rate 15%-20%

Answer 6

Contaminated wounds

Question 7

*No inflammation
*Minor break in sterile technique
*Aerodigestive or genitourinary tract entered without spillage
*Potential infection rate 8%-10%

Answer 7

Clean-contaminated wound

Question 8

*Old Traumatic wounds
*Clinical infection present
*Perforated Viscus
*40% expected infection rate
*Devitalized tissue

Answer 8

Class IV Wounds (dirty) or Infected Wounds

Question 9

an abnormal collection
of CSF in the ventricles of the brain causing enlargement of the cranium. (separation of cranial sutures, bulging fontanels and dilated veins across the scalp)

Answer 9

HYDROCEPHALUS

Question 10

developmental delays and congenital abnormalities are associated with maternal intake of alcohol during pregnancy. (microcepahly, flattened
check bones and upper lip, small eyes)

Answer 10

FETAL ALCOHOL SYNDROME (FAS)

Question 11

results from either extra chromosomes 21 or translocation of chromosomes 14 or 15 with 21 or 22. (microcephaly, flattened occipital bones, slanted small eyes,
depressed nasal bridge low set ears and protruding tongue).

Answer 11

DOWN SYNDROME (Trisomy 21)

Question 12

due to diet deficient in iodine. (puffy facial features and often a larger than normal tongue.

Answer 12

CONGENITAL HYPOTHYROIDISM

Question 13

premature closure
and ossification of the fontanels result in cranial deformities and microcephaly.

Answer 13

CRANIOSYNOSTOSIS

Question 14

congenital or acquired contraction of the sternocleidomastoid muscle causing the head to inclined to one side. (ROM is decreased)

Answer 14

TORTICOLLIS

Question 15

overproduction of growth
hormones resulting to thickening of the skin, subcutaneous tissue and facial bones and coarsening of facial features

Answer 15

ACROMEGALY

Question 16

paralysis usually unilateral of
the facial nerve (CN VII) can be transient or permanent. Common causes include trauma, compression and infection.

Answer 16

BELLS PALSY

Question 17

excessive
production of exogenous ACTH results in a round “moon” facies, fat deposits at the nape of the neck, “buffalo hump”, and sometimes a velvety discoloration around the neck (acanthosis nigricans).

Answer 17

CUSHING SYNDROME

Question 18

a degenerative
neurological disease which presents a masklike facial appearance, rigid muscles,
diminished reflexes and a shuffling gait.

Answer 18

PARKINSON DISEASE

Question 19

or brain attack.
Embolism, hemorrhage, or vasospasm in the brain results in ischemia of surrounding tissue and neurological damage. Symptoms depend on the part of the brain affected

Answer 19

CVA/STROKE

Question 20

hardening of the skin usually noted in the hands and face. Skin becomes firm and loses mobility seemingly fixed to underlying tissues

Answer 20

SCLERODERMA

Question 21

enlarged thyroid gland
(hyper/hypothyroidism)

Answer 21

GOITER

Question 22

severe hypothyroidism, presents periorbital swelling and edema of the face, hands, and feet.

Answer 22

MYXEDEMA

Question 23

Assessment of Visual Acuity

Answer 23

● Distance Vision
● Near Vision
● Color Vision

Question 24

the patient reads the letter 20 ft. away

Answer 24

Snellen test

Question 25

(pocket screener) or ask the
patient to read newsprint

Answer 25

Jaeger test

Question 26

Color vision (Identifying colors)

Answer 26

Ishihara Cards

Question 27

61-92 cm (2-3 ft.) directly in front of the patient. Examiner’s eye and
patient’s eye should be on the
same level but cover the other
side w/o pressure while the
examiner present 1-4 finger
midway between 4 quadrants

Answer 27

Static Confrontation

Question 28

examiner’s eye and patient’s
eye should be on the same level
but instruct the patient to say
“now” when the fingers 1st
come to view. Wiggle fingers
from a distal point moving them
towards the center.

Answer 28

Kinetic Confrontation

Question 29

test for strabismus. Instruct to stare
straight ahead at the bridge
of your nose. Stand in front
of the patient and shine a
penlight at the bridge of the
pt’s. nose.

Answer 29

Corneal Light Reflex
(Hirschberg test)

Question 30

for presence and amount of ocular deviation. The light level should be low, with no direct light sources shining in the pt’s. eyes. The extraocular muscles should have very little activity

Answer 30

Cover test

Question 31

allows to detect muscle defects
that cause misalignment or
uncoordinated eye movements.

Answer 31

Cardinal fields of gaze test

Question 32

inspect eyebrows,
lashes, and eyelids; note eye shape and symmetry.
▫ Lacrimal apparatus
▫ Bulbar conjunctiva
▫ Cornea and lens

Answer 32

Assessment of External Eyes

Question 33

▫ Iris
▫ Pupil – PERRLA

Answer 33

Assessment of Exterior Ocular Structure

Question 34

▫ Disc: cup disc, rims pink and healthy
▫ Vessels: signs of Arteriovenous (AV) nicking
▫ Macula: flat, good light reflex off the surface
▫ Periphery: lattice or tears

Answer 34

Assessment of Internal Ocular Structure

Question 35

Nearsightedness is a vision condition in which people can see close objects clearly, but objects farther away appear blurred.

Answer 35

Myopia

Question 36

Farsightedness is a common vision condition in which you can see distant objects clearly, but objects nearby may be blurry

Answer 36

Hyperopia

Question 37

a common and generally treatable imperfection in the curvature of the eye that causes blurred distance and near vision.

Answer 37

Astigmatism

Question 38

farsightedness
caused by loss of elasticity
of the lens of the eye,
occurring typically in
middle and old age.

Answer 38

Presbyopia

Question 39

Types of Strabismus

Answer 39

*Esotropia
*Exotropia
*Hypotropia
*Hypertropia

Question 40

Outward turning

Answer 40

Exotropia

Question 41

Inward turning

Answer 41

Esotropia

Question 42

Downward turning

Answer 42

Hypotropia

Question 43

Unward turning

Answer 43

Hypertropia