NUR306 final

Mydriasis

dilation of the pupil

Binaural interaction at the level of the brainstem permits - amplification of sound - identification and location of the direction of the sound - direction of sound toward the appropriate conduction pathway - interpretation of sound

identification and location of the direction of the sound

How would you test for damage to the glossopharyngeal and vagus nerves?

Swallow or checking gag reflex, tests CN IX glossopharyngeal & X Vagus (shrugging tests Accessory nerve CN XI) (sense of smell tests olfactory CN I) (Smiling tests facial nerve CN VII)

pes planus

abnormal flatness of the sole and arch of the foot

instruction/normal findings in a testicular self-exam? - a firm, smooth, egg-shaped organ can be palpated - each testicle is examined individually after relaxing the scrotal skin - a hard mass can be palpated on anterior or lateral aspect - the thumb and fingers of both hands can be used to apply firm and gentle pressure - a raised swelling that can be palpated on the superior aspect of the testicle is the epididymis

- a firm, smooth, egg-shaped organ can be palpated - each testicle is examined individually after relaxing the scrotal skin - the thumb and fingers of both hands can be used to apply firm and gentle pressure - a raised swelling that can be palpated on the superior aspect of the testicle is the epididymis

Which clients would experience impaired near vision? - A ct. with myopia - A ct. with presbyopia - A ct. with hyperopia - A ct. with retinopathy - A ct. with macular degeneration

- ct. with presbyopia -ct. with hyperopia

1) positive Kernig sign & positive Brudzinski sign indicate... and positive babinski sign indicates

1) meningitis 2) presence of CNS disease

which GCS score would the nurse give a client who does not open the eyes to any stimulus, only makes incomprehensible sounds and moans, and extends the arm at the elbow with adduction and internal rotation of the arm at the shoulder? 5 6 7 8

5 [1 point for not opening eyes to any stimuli] [2 points for incomprehensible sounds] [2 points for abnormal extension of the arm]

Which condition may be the cause of double vision (diplopia)? -Myasthenia gravis -Periorbital tumors -Conjunctival blood vessels rupture -Abnormalities of extraocular muscle actions

Abnormalities of extraocular muscle function. [MYASTHENIA GRAVIS may cause drooping of the upper eye lid margin (ptosis)] [PERIORBITAL TUMORS may result in exophthalmos, which causes a protrusion of the globe beyond it normal position within the bony orbit]

Which characteristic of urine changes in the presence of a UTI? -Clarity -Viscosity -Glucose level -Specific gravity

Clarity [cloudy urine usually indicates drainage associated w infection] [viscosity is NOT measurable in urine] [glucose levels aren't affected by UTIs] [Specific gravity yields info related to FLUID BALANCE]

Which finding would be expected in a client who has osteoarthritis that would not be present in clients with rheumatoid arthritis? - Ulnar drift - Heberden nodes - Swan-neck deformity - Boutonniere deformity

Heberden nodes (heberden nodules = bony or cartilaginous enlargements of the distal interphalangeal joints that are associated w osteoarthritis) (the other 3 occur with rheumatoid arthritis)

Which are general growth parameters for an adolescent client that the nurse will monitor during a health maintenance visit? - Height - Weight - Body mass - BP - Head circumference

Height, weight, body mass (BP is a vital sign, not a growth parameter. Head circumference is assessed until 36m)

What physical changes would the nurse observe in a client with malnutrition? -Hypotension -Dry, dull hair -Abdominal edema -Delayed wound healing -Depletion of muscle mass

Hypotension; Dry, dull hair; Abdominal edema; Delayed wound healing; Depletion of muscle mass [hypotension, dry dull hair, abdominal edema (seen with protein malnutrition), delayed wound healing, & depletion of muscle mass are ALL signs of malnutrition]

when performing an assessment on Trigeminal nerve function, how would the nurse identify function of this nerve? - observing pupil constriction - identifying corneal sensation - determining the ability to smell - determining the ability to shrug the shoulders

Identifying corneal sensation (CN V innervates the cornea) (pupil constriction = CN III) (ability to smell = CN I) (shoulder shrug = CN XI)

Which joint would be palpated to identify genu valgum? - Hip -Knee - Temporomandibular - Metacapophalangeal

Knee genu valgum aka knock-knees = condition where knees are poorly aligned (knee joint should be assessed for presence of effusion; hip joint assessed to determine mobility and pain in the groin or pain that radiates to knee; temporomandibular joint for weakness/pain in the face; metacarpophalangeal for hand function based on ROM)

which term would the nurse use to describe bone loss greater than normal but less than caused by osteoporosis? - Osteopenia - Osteomyelitis - Osteomalacia - Osteoarthritis

Osteopenia = bone loss that is more than normal but not yet at the level for a diagnosis of osteoporosis. (osteomyelitis = infection of bone or bone marrow) (osteomalacia = softening of bones due to calcium or vitamin D deficiency) (osteoarthritis = cartilage deterioration in the joints)

Which action would the nurse take to assess for ascites? - observe client for signs of respiratory distress - percuss client's abdomen and listen for dull sounds - palpate the lower extremities over the tibia and observe for pitting - auscultate for the absence of bowel sounds in the abdomen

Percuss the clients abdomen and listen for dull sounds (this would produce a dull sound is excess fluid is present (ascites)) (bowel sounds may still be heard with developing ascites, when it gets extensive bowel sounds may diminish) (respiratory distress may occur with ascites, but it's NOT EVIDENCE of it cuz it can be caused by many other conditions)

Which finding in the client's history will alert the nurse to the MOST likely cause of the sensorineural hearing loss? - Prolonged exposure to noise - Buildup of cerumen in the ear - Blockage of the ear from a foreign body - Perforation of the tympanic membrane

Prolonged exposure to noise. (causes sensorineural hearing loss) (Cerumen build up can cause obstruction leading to conductive hearing loss. Foreign bodies can cause infection and inflammation, leading to conductive hearing loss. Perforation of TM leads to higher risk for ear infections, which can cause conductive hearing loss)

what are iatrogenic risks?

adverse medication reactions; skin breakdown; hazards of immobility; delirium; learned helplessness, alteration in nutrition, hydration, sleep Iatrogenesis = harm brought forth by a healer or any unintended adverse reactions because of an intervention, not considered the natural course of the disease/injury.

Which condition would the nurse suspect when an older adult has a thin white ring around the margin of her iris? - Cataract - Arcus senilis - Conjunctivitis - Macular degeneration

arcus senilis (cataract = increased opacity of the lens that blocks light from entering the eye.) (redness indicates conjunctivitis) (macular degeneration = blurring of central vision from progressive degeneration of the center of the retina)

Which behavioral findings corresponds to intimate partner violence in young adolescents? (select all) - Attempting suicide - sexually acting out - pattern of substance abuse - fear of certain people or places - preoccupation with others' or ones' own genitals

attempting suicide & pattern of substance abuse (behavioral findings in children undergoing sexual abuse = sexually acting out, fear of certain ppl/places, and a preoccupation with genitalia)

a client reports right ear hearing loss. when performing a Weber test with a turning fork, the client hears the sound better with the right ear. Which condition would the nurse suspect from these results? -Normal hearing -mixed hearing loss -conduction hearing loss -sensorineural hearing loss

conductive hearing loss [in a weber test, conduction hearing loss often causes the turning fork to be heard better and more clearly in the impaired ear.] [ppl with sensorineural hearing loss will hear the sound better in the normal ear]

While assessing a pediatric client, an ophthalmologist notices the child is unable to focus on an object with both eyes simultaneously. Which other finding would confirm the diagnosis as strabismus? - impaired near vision - crossed appearance of eyes - elevated intraocular pressure - impaired extraocular muscles - degeneration of central retina

crossed appearance of eyes, impaired extraocular muscles (strabismus = condition in which both eyes do not focus on an object simultaneously, resulting in crossed eyes. caused by impaired extraocular muscles.)

A client is admitted with osteoarthritis. Which joints would the nurse expect the client to report as having first been involved? - Hips - Knees -Ankles - Shoulders - Metacarpals

hips, knees (osteoarthritis affects the weight bearing joints (hips and knees) first bc they bear the most weight.) (although ankles are weight bearing joints, there is less degeneration, so they're eventually affected)

what relates to what?: macular degeneration or glaucoma center vision difficult to see; seeing halos around light; inability to see objects in the periphery; dim light makes vision more difficult

macular degeneration: center vision difficult to see; dim light makes vision more difficult glaucoma: halos around light; inability to see objects in the periphery

S4 sound

occurs at the end of diastole, when the ventricle is resistant to filling. occurs just before S1. To auscultate for the S4 sound, listen at the left lower sternal border and in the mitral valve area. Listen with the bell with the patient in left lateral position.

In a pt. with a bowel obstruction, which assessment findings indicate the possible onset of peritonitis? - Diarrhea - Bradycardia - Rebound tenderness - Diminished bowel sounds - Rigid, board-like abdomen

rebound tenderness, diminished bowel sounds, rigid, board-like abdomen (classic signs of peritonitis = rebound tenderness, diminished/absent bowel sounds, and rigid board-like abdomen) (also pt. would experience constipation not diarrhea and the HR would be tachycardic)

which tests would be used to assess cortical sensory function? - stereognosis - romberg test - graphesthesia - finger-to-nose test -two-point discrimination

stereognosis, graphesthesia, two-point discrimination (two-point discrimination tests the ability to perceive a separation between fingers and toes)

torticollis

twisting of the neck in an unusual position to one side

which statement describes varicocele (veins become enlarged inside scrotum)? -varicocele occurs most often on the left side -the left testicle is larger when associated varicocele is present -testicular size increases with increasing duration of a varicocele -Dihydrotestosterone level increases with the duration of a varicocele

varicocele occurs most often on the left side. [left testicle is SMALLER when present] [testicular size DECREASES with increasing duration] [Dihydrotestosterone levels DECREASE with increasing duration]

How to calculate BMI

weight (kg) / height (m^2) (lbs to kgs = lbs/2.2) (in to cm = in x 2.5) (cm to m = move decimal 2 places to the left)

Which actions would be included in the assessment process by a nurse working in a school health promotion program for adolescents? 1. Conduct a school violence assessment 2. Assess the sleep pattern of the students 3. Try identifying individuals at risk for substance abuse 4. Identify the need for fluoride supplements to prevent dental caries 5. Inquire about the presence of guns in the home to reduce the incidence of homicide

1, 3, 5 (assessment of sleep pattern is performed in infants)

whats the correct technique for using an otoscope to examine the ears of an infant?

pull pinna down and back

Which questions would the nurse ask the client when obtaining their health history? - "Tell me about you food habits" - "Do you use alcohol or tobacco?" - "Have you sustained any personal loss recently?" - "Have you ever experienced any allergic reactions?" - "Does any family member have a long-term illness?"

"Tell me about your food habits." "Do you use alcohol or tobacco?" "Have you ever experienced any allergic reactions?" (other 2 would be asked while assessing FAMILY history)

what type of sound is expected with an intestinal obstruction in the descending colon? - tympany - borborygmi - abdominal bruit - pleural friction rub

Borborygmi = rapid, high-pitched bowel sounds, indicative of hyperperistalsis that occurs behind an intestinal obstruction (Tympany is percussed not auscultated, and in the presence of gas it'd be high pitched or musical)

which disorders could be responsible for excessive tearing? - chalazion - entropion - hordeolum - conjunctivitis - keratoconjunctivitis sicca

Chalazion, entropion, conjunctivitis (chalazion = inflammation of a sebaceous gland in eyelid manifested by excessive tearing and light sensitivity) (entropion = disorder of eyelid that causes pain and excessive tearing) (hordeolum = infection of the eyelid sweat glands that causes red, swollen, and painful eyes) (keratoconjunctivitis sicca = dry eye syndrome; causes decreased tear production)

match the factor being assessed to the test used to do so: factors: - Color disability - Peripheral vision - Intraocular pressure - Extraocular muscle function tests: - corneal light reflex & 6 cardinal positions of vision (CN's III, IV, VI ) - The Ishihara chart - Perimetry & confrontation test - Tonometry

Color disability (color blindness) & The Ishihara chart Peripheral vision & perimetry and confrontation test Intraocular pressure & tonometry extraocular muscle function & corneal light reflex & 6 cardinal positions of vision (CN's III, IV, VI )

What do these different mensing terms mean? Dysmenorrhea: MENOrrhagia: METROrrhagia:

Dysmenorrhea: pain with menses MENOrrhagia: heavy bleeding with menses METROrrhagia: bleeding between menses

S3 heart sound

caused by: ventricular filling occurs in diastole immediately after S2 when the AV valves open and atrial blood first pours into the ventricles. To auscultate for the S3 sound, listen to all auscultatory areas with both the diaphragm and the bell. If an extra sound is noted, listen carefully to note its timing and characteristics.

the tympanic membrane of an older adult may be... - thinner than that of a younger adult - whiter than that of a younger adult - pinker than that of a younger adult - more mobile than that of a younger adult

whiter than that of a younger adult.