Exam 2 Ch. 14
A female client tells the nurse that she may be experiencing premenstrual syndrome. An appropriate question for the nurse to ask the client is
"Do you experience mood swings or bloating?"
A client visits the clinic for a routine examination. The client tells the nurse that she has become constipated because she is taking iron tablets presvribed for anemia. The nurse has instructed the client about the use of iron preparations and possible constipation. The nurse determines that the clinet has understood the instructions when she says
"I can decrease the constipation if I eat foods high in fiver and drink water."
Pediculosis pubis
"crabs"
Average HR 2-6 years
(103) 68-138
Average HR 1-2 years
(110) 70-150
Average 10-114 years
(85) 55-115
Average HR 6-10 years
(95) 65-125
pallor
(loss of color) arterial insufficiency, decreased blood supply, and anemia. Pallid tones vary from pale to ashen.
S1
- Coordinates with S wave - tricuspid and mitral, apex of the heart - Carotids - systole
S2
- Semilunar valves - base in the upper chest - T - diastole
RUL
1-4th Rib anteriorly T1-T3 posteriorly
LUL
1-7 anteriorly T1-T3 posteriorly
Order of Assessment of Heart
1. HR and Rhythm 2. Z pattern 3. Assess for murmurs
Clubbing
180 degrees and above from hypoxia
Normal peripheral pulse
2+
Expansion of ribs should be
2-3 inches
Micuspid Area
3rd-5th midsternal line point of max HB
Ventricular HR
40 beats/min takes over when SA node is sick (60 beats/min)
LLL
5-7 anteriorly Mostly posterior and lateral T3-T10 posteriorly
RLL
5-7 anteriorly Mostly posterior and lateral T3-T10 posteriorly
Blood from the lower trunk and legs drains upward into the inferior vena cava. The percentage of the body' blood volume that is contained in the veins is nearly
70%
Average HR 6-12 months
75-155 (115)
Average HR first 6 months
80-180 (130)
Average HR of Birth Infants
90-190 (140)
Rib slope should be
<90 degrees downward
Cullen's sign
A bluish or purple discoloration around the umbilicus indicates intra-abdominal bleeding
Annular lesion
A round of scalloped lesion in which the center has cleared, leaving a thin, ring like, raised, erythematous border. Example: "ringworm"
Raynaud Disease
A vasospastic disorder, primarily affects the hands, characterized by color change from pallor, to cyanosis, to rubor' attacks precipitated by cold or emotional upset and relieved by warmth
Paralytic test
Absent or high-pitched bowel sounds
Lichenification
Accentuation of normal skin lines resembling tree bark, commonly caused by excessive scratching.
Dysplastic nevus
An atypical mole
Positive psoas sign
Assessed by raising right leg from hip
Peptic ulcer disease
Bacterium Helicobacter pylori
Corona
Base of the glans
The portion of the stethoscope used to assess for murmurs
Bell
Grey-Turner's sign
Bluish or puplish discoloration on the abdominal flanks. Abdominal bleeding
Contusion
Bruise
Ecchymosis/ecchymose
Bruise or bruising
Ballottement test
Can identify a amass or enlarged organ in an ascitic abdomen
Chadwick sign
Cervix appears blue rather than pink
Valsalva maneuver
Client holds breath and bears down
Herpes progenitalis
Clusters of pimple-like clear vesicles that erupt and become ulcers painful
The skin plays a vital role in temperature maintenance, fluid and electrolyte balance, and synthesis of vitamin
D
Libido
Desire for sexual activity
Crust
Dried secretions from a primary skin lesion
Proctosigmoidoscopy
Exam of the rectum and sigmoid colon using a sigmoidoscope
Right Middle Lobe of Lung
Extends from 4th- 6th rib laterally and anteriorly and extends back to midaxillary line
Risk factors for Peripheral Vascular Disease
Family history Personal history Excessive intake of salt/smoking
Contours of abdomen
Flat Scaphoid Proturberent Rounded
Checking for arterial insufficiency
Have client lie down on back while you support client's legs (12 in) above heart level. Have client flap feet up and down at anles for 60 seconds then skit up and dangle legs. Feet should be white with color returned in 10 seconds.
Tricuspid/ Mitral Area
Herb's Point 3rd intercostal space
urticaria
Hives; pruritic wheals, often transient and allergic in origin.
Geriatric variations in lungs and thorax
Increase in normal respiratory rate (16-25) increased kyphosis increased diaphragmatic breathing hyperresonance of thorax Decreased breath sounds
Intestinal obstruction
Increased peristaltic waves
Murphy sign
Inspiratory arrest or causes client to hold breath. Used for cholecytis in RUQ
Chars of Arterial Insufficiency
Intermittent claudication to sharp, unrelenting extent Pulses: diminished or absent Dependent rubor Pallor foot Dry, shiny skin Ulcers are deep and circular Minimal edema
Left kidney (lower pole)
LLQ
Left ovary and tube
LLQ
Left spermatic cord
LLQ
Left ureter
LLQ
Sigmoid colon
LLQ
Left adrenal gland
LUQ
Left kidney
LUQ
Left ureter
LUQ
Pancreas (body and tail)
LUQ
Spleen
LUQ
Splenic flexure of colon
LUQ
Stomach
LUQ
To palpate the spleen of an adult client, the nurse should begin the abdominal assessment of the client at the
LUQ
Transverse ascending colon
LUQ
Tricuspid Area
Left sternal border, 5th intercostal space
Pulmonic Area Location
Left- 2nd intercostal space
Excoriation
Lesion resulting from scratching or excessive rubbing of the skin or a discrete lesion
The nurse is planning a presentation about coronary heart disease for a group of middle-aged adults. What should be included in the nurse's teaching plan?
Lowering elevated cholesterol and BP decreases the risk of heart attack
systemic lupus erthematosus
Malar rash (butterfly rash) across the bridge of nose and cheeks, more in females than males and more common in black and Hispanic people
Margination
Margination is the shape of the lesion as it is seen in cross section. It describes the transition zone between normal and abnormal skin. Margination is generally stated to be sharp or diffuse.
Apical Impulse
Mitral area (5th intercostal space midclavicular line) Left ventricle moving out during systole Usually small impulses while palpating Role on left side if can't feel
Carotid Arteries
No blowing or swishing sounds hear Pulses are equally strong a 2+ is normal Smooth and rapid on the upstroke and slower and less abrupt on the downstroke When auscultating use bell
Os
Opening in center of cervix
Red, scaly, crusty areas on breasts
Paget's disease
Common Concerns of PVS/Lymphatics
Pain aching or heavy feeling/ intermittent claudication (severe pain in calf while walking) Skin changes Varicosities edema cramping numbness and tingling sensations or cold decreased functional ability
Chars of Venous Insufficiency
Pain is achy and cramping Pulses: Present but difficult to palpate Skin is thickened Ulcers are superficial and around the medial malelous Leg edema is moderate to severe
Edema associated with chronic venous insufficiency
Pitting Usually unilateral Skin ulceration may be present
Hernia
Protrusion of the bowel through weakened muscles
Appendix
RLQ
Ascending colon
RLQ
Cecum
RLQ
Right kidney (lower pole)
RLQ
Right ovary and tube
RLQ
Right spermatic cord
RLQ
Right ureter
RLQ
To palpate for tenderness of an adult clinet's appendix, the nurse should begin the abdominal assessment at the client's
RLQ
Where to begin auscultaion of the abdomen?
RLQ near the ileocecal valve
Ascending and transverse colon
RUQ
Duodenum
RUQ
Gallbladder
RUQ
Hepatic Flexure of colon
RUQ
Liver
RUQ
Pancreas (head)
RUQ
Pylorus
RUQ
Right adrenal gland
RUQ
Right kidney (right upper pole)
RUQ
Right ureter
RUQ
To percuss the liver of an adult client, the nurse should begin the abdominal assessment oat the client's
RUQ
Cholecystitis
RUQ pain or tenderness
Scale
Rapid turnover of epidermal layer, resulting in accumulation and delayed shedding of outermost epidermis. Also: small, thin flakes of epithelial cells. Example: dandruff
Chancres
Red oval ulcerations caused by syphilis
Rebound tenderness
Release of pressure quickly after deep palpation
Aortic Area Location
Right Midclavicular Line 2nd intercostal space
A female client tells the nurse that she has pain while urinating. Besides obtaining a urinalysis, the nurse should asses the client for
STDs
Trichomonas vaginitis
STI protozoan infection with secretions that are foul smelling
Bartholin glands
Secrete mucus to aid in lubrication during intercourse
Braden Scale Assesses
Sensory perception, moisture, activity, mobility, nutrition, and friction and shear
Copper Red Hair Color in African American Children
Severe Malnutrition
Ascites
Shifting dullness and fluid wave tests
Jugular Vein
Should not be visibly distended with the client sitting upright Pressure- should not be distended, bulging or protruding at 45 degrees or greater
Syphilitic chancre
Silvery-white papule that develops a red, oval ulceration painless
Brawny skin
Skin that is dark and leathery
The nurse assessing an older adult bedridden client in her home. While assessing the client's buttocks, the nurse observes that a small area of the skin is broken and resembles an erosion. The nurse should document the client's pressure ulcer as
Stage II
Hollow organs
Stomach, gall bladder, S and L intestines, bladder, uterus
Dullness posteriorly can be heard
T10 and below
valves of Houston
Three semilunar transverse folds within the rectal interior
During the gynecologic exam, the nurse observes that the client has a yellow-green frothy vaginal discharge. The nurse should plan to test the client for possible
Trichomonas vaginalis infection
While assessing the anal area of an adult client, the nurse detects redness and excoriation. The nurse determines that this sign is most likely due to
a fungal infection
The nurse is assessing a dark-skinned client who has been transported to the emergency room by ambulance. When the nurse observes that the client's skin appears pale, with blue-tinged lips and oral mucosa, the nurse should document the presence of
a great degree of cyanosis
scrotal hernia
a loop of bowel protrudes into the scrotum to create what is known as an indirect inguinal hernia fingers cannot get above the mass
While assessing the nails of an adult client, the nurse observes Beau lines. The nurse should ask the client if he has had
a recent illness
Confluent:
a term used to describe lesions that "run together"
The abdominal contents are enclosed externally by the abdominal wall musculature-- three layers of muscle extending from the back, around the flanks, to the front. The outer muscle layer is the external
abdominal oblique
varicocele
abnormal dilation of the veins in the spermatic cord
amenorrhea
absence of menstruation
atrophic vaginitis
after menopause the discharge may be bloody causes itching burning dryness and painful urination
The posterior tibial pulse can be palpated at the
ankle
The nurse is preparing to assess the cardiovacular system of an adult client with emphysema. The nurse anticipates that there may be some difficulty palpating the client's..
apical pulse
Cancer of the glans penis
appears as hardened nodule or ulcer on the glans painless occurs primarily in uncircumsized men
The nurse is assessing an older adult client who has lost 2.27 kg (5 lb) since her last visit 1 year ago. The client tells the nurse that her husand died 2 months ago. The nurse should further asses the client for
appetite changes
The nurse is preparing to use a Doppler ultrasound probe to detect blood flow in the femoral artery of an adult client. The nurse should
apply K-Yjelly to the client's skin
the apocrine glands are dormant until puberty and are concentrated in the axillae, the perineum, and the
areola of the breat
Secondary lesions
arise from changes in primary lesions
Primary lesions
arise from normal skin due to irritation or disease
While assessing the peripheral vascular system of an adult client, the nurse detects cold clammy skin and loss of hair on the client's legs. The nurse suspects that the client may be experiencing
arterial insufficiency
very thin skin
arterial insufficiency or those on steroid therapy
To assess for anemia in a dark-skinned client, the nurse should observe the client's skin for a color that appears
ashen
Before beginning the exam of the genitalia of an adult male client, the nurse should
ask the client to empty his bladder
The nurse is planning to assess the abdomen of an adult male client. Before the nurse begins the assessment, the nurse should
ask the client to empty his bladder.
Bruit is
associated with occlusive arterial disease
The semilunar valves are located
at the exit of each ventricle at the beginning of the great vessels
Assessment technique most often associated with evaluation of the cardiovascular system
auscultation
The nurse is performing a speculum exam on an adult woman. The nurse is having difficulty inserting the speculum because the client is unable to relax. The nurse should ask the client to
bear down
The nurse is planning to inspect the anal area of an adult female client. To assess for any bulges or lesions, the nurse should as the client to
bear down.
S3
benign finding commonly heard at the beginning of the diastolic pause in children, adolescents, and young adults. Pathological after 40
The bicuspid, or mitral, valve is located
between the left atrium and the left ventricle
A client visits the clinic and tells the nurse that her stools have been pale for the past 2 days and her skin has been itching. The nurse should refer the client to a physician for possible
biliary disease
While assessing an adult client's feet for fungal disease using a Wood light, the nurse documents the presence of a fungus when the fluorescence is
blue
Direct inguinal hernia
bowel herniates from behind and through the external inguinal ring. It rarely travels down into the scrotum
indirect inguinal hernia
bowel herniates through internal inguinal ring and remains in the inguinal canal or travels down into the scrotum
femoral hernia
bowel herniates through the femoral ring and canal. It never travels into the scrotum, and the inguinal canal is empty. Mostly in women
The nurse suspects that a male client may have a hernia. The nurse should further assess the client for
bowel sounds at the bulge
The major artery that supplies blood to the arm is the
brachial artery
After palpating the radial pulse of an adult client, the nurse suspects arterial insufficiency. The nurse should next assess the client's
brachial pulse
cystocele
bugling in the anterior vaginal wall caused by thickening of the pelvic musculature. The bladder prolapses into the vagina
The S4 sound
can be hear during diastole
Peau d'orange
carcinoma
While palpating the apex, left sternal border, and base in an adult client, the nurse detects a thrill. The nurse should further assess the client for
cardiac murmur
While assessing the skin of an older adult client, the nurse observes that the client has small yellowish brown patches on her hands.. The nurse should instruct the client that these spots are
caused by aging of the skin in older adults
The nurse is assessing an African American client's skin. After the assessment, the nurse should instruct the client that African American persons are more susceptible to
chronic discoid lupus erythematosus
hydrocele
collection of serous fluid in the scrotum outside the testes within the tunica vaginalis appears as swelling
The nurse is planning to perform the Trendelenburg test on an adult client. The nurse should explain to the client that this test is used to determine the
competence of the saphenous vein valves
The external sphincter of the anus is
composed of skeletal muscle
Spoon Nails
concave, iron deficient anemia
The P-wave phase of an ECG represents
conduction of the impulse throughout the atria
During assessment of the gentialia of an adult male, the client has an erection. The nurse should
continue the exam in an unhurried manner
The nurse plans to assess an adult client's kidneys for tenderness. The nurse should assess the area at the
costovertebral angle
The nurse has assessed a male client and determines that one of the testes is absent. The nurse should explain to the client that this condition is termed
cryptochidism
The nurse is asses the genitalia of a female client and detects a bulging anterior wall in the vagina. The nurse should plan to refer the client to a physician for
cystocele
thickened nails
decreased circulation and onychomycosis
An older adult client visits the clinic complaining of urinary incontinence. The nurse should explain to the client that this is often due to
decreased urethral elasticity
The pancreas of an adult client is located
deep in the upper abdomen and is not normally palpable
hair follicles, sebaceous glands, and sweat glands originate from the
dermis
Hyperthyroidism
diaphoresis
Part of the stethoscope used to auscultate normal heart sounds
diaphragm
dyspnea
difficulty breathing
Orthopnea
difficulty breathing while laying down
The nurse is caring for a female client during her first postoperative day after a temporary colostomy. The client refuses to look a the colostomy bag or the area. A priority nursing diagnosis for this client is
disturbed body image related to temporary colostomy
A client visits the clinic because she has missed one period and suspects she is pregnant. While assessing the client, the nurse detects a solid, mobile, tender, unilateral adnexal mass. The client's cervix is soft. The nurse suspects that the client may be experiencing
ectopic pregnancy
longitudinal ridging of the nails
elderly
The Cowper glands
empty into the urethra
cyst
encapsulated fluid filled or semi solid mass
The nurse is assessing the genitalia of an adult male client when he tells the nurse that his testes are swollen and painful. The nurse should refer the client to a physician for possible
epididymitits
A male client tells the nurse that his occupation requires heavy lifting and a great deal of strenous activity. The nurse should assess the client for
erectile dysfunction
The outer layer of the vaginal wall is under the direct influence of
estrogen
A 25-year-old client asks the nurse how often he should have a testicular exam. After instructing the client about the American Cancer Society's guidelines, the nurse determines that the client has understood the instruction when he says he should have a testicular exam
every 4 years
Hirsutism
facial hair on females. From Cushing's disease and results from an imbalance of adrenal hormones or a side effect of steroids
cryptorchidism
failure of one or both testicles to descend into scrotum
The major causes of abdominal distension
fat feces fetus fibroids flatulence fluid
A primary function of hair in the nose and eyelashes is to serve as a
filter for dust
An adult male client visits the clinic and tells the nurse that he believes he has athlete's foot. The nurse observes that the client has linear cracks in the skin on both feet. The nurse should document the presence of
fissures
The nurse is preparing to palpate the epitrochlear lymph nodes of an adult male client. the nurse should instruct the client to
flex his elbow about 90 degrees
A female client visits the clinic and complains to the nurse that her skin feels "dry." The nurse should instruct the client that skin elasticity is related to adequate
fluid intake
If a male client is uncircumcised, the glans of the penis is covered by the
foreskin
phimosis
foreskin is so tight that it cannot be retracted over the glans
paraphimosis
foreskin is so tight that, once retracted, it cannot be returned back over the glans
Normal skin variations
freckles vitiligo depigmentation of the skin striae- stretch marks seborrheic keratosis- warty lesion scar mole- nevus cutaneous tag cutaneous horn cherry angioma
A client visits the clinic and tells the nurse that her stools have been black for the past 3 days. The nurse should assess the client for
gastrointestinal bleeding
While assessing the genitalia of a female client, the nurse observes moist fleshy lesions on the client's labia. The nurse should refer the client to a physician for possible
genital warts
The nurse is caring for a client who is employed as a typist and has a family history of peripheral vascular disease. The nurse should instruct the client to reduce her risk factors by
getting regular exercise
The corpora spongiosum extends distally to form the acorn-shaped
glans
The visible portion of the clitoris is termed the
glans
Yellow Nail Syndrome
grow slowly and curved seen in AIDS and respiratory syndromes
During assessment of an adult client, which of the following lifestyle practices would indicate to the nurse that the client may be at high risk for HIV/AIDS? A client who
has anal intercourse with other males
menorrhagia
heavy menstruation
The rectum is lined with folds of mucosa, and each fold contains a network of arteries, veins, and visceral nerves. When these veins undergo chronic pressure, the result may be
hemorrhoids
While assessing an adult male client, the nurse detects pimple-like lesions on the client's glans. The nurse explains the need for a referral to the client. The nurse determines that the client has understood the instructions when the client says he may have
herpes infection
While performing a gynecologic exam, the nurse observes small, painful, ulcer-like lesions with red bases on the client's labia. The nurse should refer the client to a physician for possible
herpes simplex virus infection
An adult client tells the nurse that his father died of a massive coronary attack at the age of 65. The nurse should explain to the client that one of the risk factors for coronary heart disease is
high serum level of low-density lipoproteins
Sibilant wheezing
high-pitched musical sounds continuous or primarily on expiration
Fine crackles
high-pitched, short, popping sounds
The nurse is about to palpate the carotid arteries. The nurse should ask the client to
hold her breath
A 53-year-old client tells the nurse that she thinks she is starting the menopausal phase of her life. The nurse should instruct the client that she may experience
hot flashes
A 20-year-old visits the outpatient center and tells the nurse that he has been experiencing sudden generalized hair loss. After determining that the client has not received radiation or chemotherapy, the nurse should further assess the client for signs and symptoms of
hypothyroidism
Dry, flaky, rough skin
hypothyroidism
While assessing the nails of an older adult, the nurse observes early clubbing. The nurse should further evaluate the client for signs and symptoms of
hypoxia
During assessment of an elderly male client, the client tells the nurse that he has had difficulty urinating for the past few weeks. The nurse should refer the client to the physician for possible
impotence
A 45- year old male client tells the nurse that he has had problems in having an erection for the last couple of weeks but is "doing better now." The nurse should explain to the client that
impotence in males should be investigated
The nurse assesses a hospitalized adult client and observes that the client's jugular veins are fully extended. The nurse contacts the client's physician because the client's signs are indicative of
increased central venous pressure
Localized area of tissue necrosis caused by prolonged anoxia
infarct
During assessment of the vaginal area of an adult client, the client tells the nurse that she has had pain in her vaginal area. The nurse should further assess the client for
infection
While assessing the cervix of an adult client, the nurse observes a yellowish discharge from the cervix. The nurse should further asses the client for a/an
infection
epididymitis
infection of the epidydimis
Excessive generalized hair loss
infection, nutritional deficiencies, hormonal disorders, thyroid or liver disease, drug toxicity, hepatic or renal failure
orchitis
inflammation of the testis frequently associated with mumps
testicular tumor
initially a small, firm, nontender nodule on the testis
The only layer of the skin that undergoes cell division is the
innermost layer of the epidermis
The nurse is preparing to asses the abdomen of a hospitalized client 2 days after abdominal surgery. The nurse should first
inspect the abdominal area
The nurse assessing the peripheral vascular system of an older adult client. The client tells the nurse that her legs "seem cold all the time and sometimes feel tingly." The nurse suspects that the client may be experiencing
intermittent claudication
The nurse is assessing the abdomen of an adult client and observes a purple discoloration at the flanks. The nurse should refer the client to a physician for possible
internal bleeding.
The external sphincter and internal sphincter of the rectum are divided by the
intersphincteric groove
While assessing the abdominal sounds of an adult client, the nurse hear high-pitched tingling sounds throughout the distended abdomen. The nurse should refer the client to a physician for possible
intestinal obstruction
Pruritis
itching
The inguinal canal in male client is located
just above and parallel to the inguinal ligament
An Aftrican American female client visits the clinic. She tells the nurse that she had her ears pierced several weeks ago, and an elevated, irregular, reddened mass has now developed at the ear lobe. The nurse should document a
keloid
The nails are composed of
keratinized epidermal cells
The sigmoid colon is located in this area of the abdomen: the
left lower quadrant
zosteriform
linear along a nerve route
Solid organs
liver, spleen, pancreas kidneys
Paronychia of the nails
localized infection
terminal hair
longer, generally darker, and coarser on scalp and eyebrows
Sonorous wheezing
low-pitched snoring sound hear continuously or on expiration
Coarse crackles
low-pitched, bubbling, moist sounds
Pleural friction rub
low-pitched, dry, grating sound that is continuous
A client visits the clinic and tells the nurse that she had a mastectomy 2 years ago. The nurse should assess the client for
lymphedema
While assessing an adult client, the nurse observes freckles on the client's face. The nurse should document the presence of
macules
A client visits the clinic for a routine physical examination. The nurse prepares to assess the client's skin. The nurse asks the client if there is a family history of skin cancer and should explain to the client that there is a genetic component with skinn cancer, especially
malignant melanoma
While assessing an adult client's abdomen, the nurse observes that the client's umbilicus is deviated to the left. The nurse should refer the client to a physician for possible
masses
Ovarian cancer
masses that are cancerous are usually solid, irregular, non-tender, and fixed
The prostate gland consists of two lobes separated by the
median sulcus
Bladder
midline
prostate gland
midline
uterus
midline
While assessing an adult client, the nurse detects opening snaps early in diastole during auscultation of the heart. The nurse should refer the client to a physician because this is usually indicative of
mitral valve stenosis
half and half nails
nails that are half white on the upper proximal half and pink on the distal half. Seen in chronic renal disease
nodules and tumors
nodules are .5-2 cm and tumors are greater than 2 cm
Edema associated with lymphedema
nonpitting usually bilateral
Montgomery turbercles
normal on breasts
The nurse detects paradoxical pulses in an adult client during an examination. The nurse should explain to the client that paradoxical pulses are usually indicative of
obstructive lung disease
An adult white client visits the clinic for the first time. During assessment of the client's skin, the nurse should assess for central cyanosis by observing the client's
oral mucosa
Squamous cell carcinoma is associated with
overall amount of sun exposure
Candidal Vaginitis
overgrowth of yeast
dyspareunia
painful intercourse in the female
dysmenorrhea
painful menstruation
dysuria
painful urination
The nurse is planning to assess a client's abdomen for rebound tenderness. The nurse should
palpate deeply while quickly releasing pressure
The nurse is assessing the bowel sounds of an adult client. After listening to each quadrant, the nurse determines that bowel sounds are not present. The nurse should refer the client to a physician for possible
paralytic ileus
Rectocele
part of the rectum protrudes into the vagina
Vellus hair
peach fuzz present over much of the body
Vesicular
peripheral lung fields low-pitched breezy, soft, long on inspiration and short on expiration
The nurse assesses an adult male client's abdomen and observes diminished abdominal respiration. The nurse determines that the client should be further assessed for
peritoneal irritation
The outermost layer of the vaginal wall is composed of
pink squamous epithelium and connective tissue
To palpate the spleen of an adult client, the nurse should
place the right hand below the left costal margin
While assessing an adult client, the nurse observes an elevated, palpable, solid mass with a circumscribed border that measures 1 cm. The nurse documents this as a
plaque
While assessing the anus of an adult client, the nurse detects the presence of small nodules. The nurse should refer the client to a physician for possible
polyps
The sinoatrial node of the heart is located on the
posterior wall of the right atrium
The anterior chest area that overlies the heart and great vessels is called the
precordium
pustule
puss filled vesicule or bulla
To asses an adult client for possible appendicitis and a postive psoas sign, the nurse should
raise the client's right leg from the hip
Photosensitivity
rash that appears after exposure to the sun
The nurse has assessed the heart sounds of an adolescent client and detects the presence of an S3 heart sound at the beginning of the diastolic pause. The nurse should instruct the client that she should
recognize that this finding is normal in adolescents
While auscultating an adult client's heart rate and rhythm, the nurse detects an irregular pattern. The nurse should
refer the client to a physician
A male client tells the nurse that he has received a diagnosis of hernia. He vistits the clinic because he is nauseated and has extreme tenderness on the left side. The nurse should
refer the client to an emergency room
Turgor
return of the skin to its normal state. Older client's skin loses its turgor from loss of elasticity
The colon originates in this abdominal area: the
right lower quadrant
A client who is an active outdoor swimmer recently received a diagnosis of discoid systemic lupus erythematosus. The client visits the clinic for a routine exam and tells the nurse that she continues to swim in the sunlight 3 times a week. She has accepted her patchy hair loss and wears a wig on occasion. A priority nursing diagnosis of the client is
risk for ineffective health maintenance related to deficient knowledge of effects of sunlight on sin lesions.
acanthosis nigricans
roughening and darkening of skin in localized areas, especially the posterior neck
Mons pubis
round firm pad of adipose tissue that covers the symphysis pubis
Normal bronchovesicular
scapular area posteriorly and 1-2 ICS anteriorly moderate-pitched, mixed, moderate loud, equal on inspiration and expiration.
A dark-skinned client visits the clinic because he "hasn't been feeling well." To assess the client's skin for jaundice, the nurse should inspect the client's
sclera
Normal Lesions for Older Clients
seborrheic or senile keratoses, senile lengtigines, cherry angiomas, purpura, and cutaneous tags and horns
The prostate functions to
secrete a milky substance that neutralizes female acidic secretions.
Skene glands
secrete mucus to lubricate and maintain moist vaginal environment
pitting
seen with psoriasis
diastasis recti
separation of the ab muscles
Nummular lesions
sharply marginated, round lesions that are coin sized (3 to 10 cm in diameter) and coin shaped
Genital warts
single or multiple, moist, fleshy papules painless
spermatocele
sperm filled cystic mass located on epididymis
audible variation between closure of two valves
splitting
Koilonychia of nails
spoon-shaped nails that may be seen with trauma to cuticles or nail folds or in iron deficiency anemia, endocrine or cardiac disease
The nurse is instructing a group of high school students about risk factors associated with various skin cancers. The nurse should instruct the group that
squamous cell carcinomas are most common on the body sites with heavy sun exposure
A client visits the clinic because she experienced bright hematemesis yesterday. The nurse should refer the client to a physician because this symptom is indicative of
stomach ulcers
The primary function of the gallbladder is to
store and excrete bile
An older adult client visits the clinic for a gynecologic exam. The client tells the nurse that she has been told that she has uterine prolapse. The nurse should further assess the client for
stress incontinence.
Connecting the skin to underlying structures is/are the
subcutaneous tissue
The testes in the male scrotum are
suspended by the spermatic cord
The skin fold of the labia majora are composed of adipose tissue, sebaceous glands, and
sweat glands
An adult male client visits the outpatient center and tells the nurse that he has been experiencing patchy hair loss. the nurse should further asses the client for
symptoms of stress
While inspecting the genitalia of a male client, the nurse observes a chancre lesion under the foreskin. The nurse has explained this obseration to the client. The nurse determines that the client understands the need for a referral when the client says that chandre lesions are associated with
syphilis
event of the heart when contraction of the ventricles forces blood into major vessels
systole
Bacterial vaginosis
the cause of bacterial vaginosis is unknown but produces fish like odor and white grey secretions
epispadias
the urethral meatus is located on the top of the glans occurs rarely congenital defect
To auscultate Erb Point, the nurse should place the stethoscope at the
third to fifth intercostal space at the left sternal border
Palpable murmur described as feeling like the throat of a purring cat
thrill
Normal Bronchial sounds
tracheal and thorax high-pitched harsh or hollow loud short on inspiration and long on expiration
While assessing an adult client's abdomen, the nurse observes that the client's umbilicus is enlarged and everted. The nurse should refer the client to a physician for possible
umbilical hernia
hypospadias
urethral meatus is located underneath the glans congenital defect
A male client visits the clinic and tells the nurse that he has had a white discharge from his penis for the past few days. The nurse should refer the client to a physician for possible
urethritis
During a physical exam of an adult client, the nurse is preparing to auscultate the client's abdomen. The nurse should
use the diaphragm of the stethoscope
To asses an adult client's skin turgor the nurse should
use two fingers to pinch the skin under the clavicle
While transilluminating the scrotal contents in a male adult client, the nurse does not detect a red glow. The nurse should refer the client to a physician for possible
varicocele
Short, pale, and fine hair that is present over much of the body is termed
vellus
During a physical examination, the nurse detects warm skin and brown pigmentation around an adult client's ankles. The nurse suspects that the client may be experiencing
venous insufficiency
While inspecting the skin color of a male client's legs, the nurse observes that the client's legs are slightly cyanotic while he is sitting on the edge of the examination table. The nurse should refer the client to a physician for possible
venous insufficiency
torsion of spermatic cord
very painful condition caused by twisting of spermatic cord
The nurse is preparing to examine the skin of an adult client with a diagnosis of herpes simplex. The nurse plans to measure the client's symptomatic lesions and measure the size of the client's
vesicles
Vesicules and bullas
vesicules are less than .5 cm and bullas are greater than .5 cm
The skin folds of the labia majora and the labia minora form a boat-shaped area termed the
vestibule
A client's skin color depends on melanin and carotene contained in the skin, and the
volume of blood circulating in the dermis
The nurse is preparing a speculum examination on an adult woman. To lubricate the speculum before insertion, the nurse should use
warm tap water
cyanosis
white skin to appear blue, especially in the perioral, nail bed, and conjuctival areas. Dark skin may appear blue, dull and lifeless in the same areas Central cyanosis is in the oral mucosa
