Nursing 360 FINAL

condensed pathway of blood

-vena cava -R atrium -tricuspid valve -R ventricle -pulmonic valve -pulmonary arteries -lungs -pulmonary veins -L atrium -mitral valve -L ventricle -aortic valve

You auscultate a patient to rule out a pericardial friction rub. Which assessment technique is most appropriate: A) listen with the diaphragm, patient sitting up and leaning forward, breath held in expiration B) listen using the bell with the patient leaning forward C) listen at the base during normal respiration D) listen with the diaphragm, patient turned to the left side

A

the manubriosternal angle is: A) the articulation of the manubrium and the body of the sternum B) a hollow, U-shaped depression just above the sternum C) also known as the breastbone D) a term synonymous with costochondral junction

A

clinical manifestations of an aneurysm

-thrill of bruit may be noted over aneurysm -often severe pain with abdominal arotic aneurysms -aortic arch aneurysms usually present with dysphagia and hoarseness

pathogenesis of PVT

-thrombus dislodges -travels to RT side of heart -to the lungs -occludes pulmonary artery -alveoli collapse -leads to atelectasis

cataracts

opacity of crystalline lens from denaturation of lens protein a/m/b cloudy or blurred vision, headlight glare, diplopia

measurement general survey

weight, height, BMI, waist to hip ratio

psoriasis

well-circumscribed, raised lesions, silvery scales

sclera

white coating on the outside of the eyeball

vitiligo

white patches on skin

tophi

whitish/yellow small hard nontender nodules on or near the helix; seen with gout

jaundice

yellowish coloring

vesicular lung sounds

over peripheral lung fields

bronchial breath sounds

over tracheal areas

vertigo is defined as

spinning

koilonychia

spoon nails

hyperresonant percussion note

very low and very loud booming sound ex) COPD, emphysema

hypothermia

very low body temperature

components of the bony labyrinth

vestibule, semicircular canals, cochlea

physical abuse

violence

larynx is also known as the

voice box

BACTERIAL VAGINOSIS

CAUSED BY AN ALTERATION OF NORMAL VAGINAL FLORA WITH OTHER BACTERIA

CIRRHOSIS

CHRONIC DEGENERATIVE LIVER DISEASE

cranial nerves for eye movement

CN III, IV, and VI

nerves that the facial muscles are innervated by

CN V - trigeminal CN VII - facial

ROM of neck uses which cranial nerve

CN XI - spinal accessory

pulmonary venous thromboembolism

obstruction of pulmonary arterial bed by dislodged undissolved matter

what is a general survey

overview look of the whole person by observation

excoriation

spots of scratched away skin due to excessive itching

heart failure

occurs when either ventricle fails to pump blood efficiently into aorta or pulmonary arteries

myocardial infarction

occurs when myocardial ischemia is sustained resulting in death of myocardial cells

left-to-right CHD

oxygenated blood from the left side of the heart or aorta flows back into the right side - acyanotic

systole

ventricles contract creating pressure that closes AV valves which prevents backflow into atria

diastole

ventricles relax and fill with blood from left and right atria

hyperthermia

very high body temperature

(2) palates of mouth

hard and soft

percussion

helps determine position, size, density, and other characteristics of an organ via palpable vibration

glaucoma is caused by

increased ocular pressure

psychological abuse

mental anguish

anterior chamber

middle layer; filled with aqueous humor to maintain eye pressure

ciliary body

middle layer; lies beneath the iris, produces aqueous humor

otitis externa

(Swimmers ear) outer ear infection a/m/b swollen, red external ear, may have purulent drainage, painful, pruritic

bulla

(burn, blister) vesicle >1cm

CLINICAL MANIFESTATIONS OF HYDROCELE

-SCROTAL ENLARGEMENT -EDEMA ON ANTERIOR SIDE OF TESTIS -LIGHT RED GLOW OF TRANSILLUMINATION INDICATES PRESENCE OF FLUID

aphthous ulcer

(canker sore) painful ulceration with white base and red halo

varicella

(chickenpox) lesions that appear as macules that progress to papules, vesicles, and then crust over. very pruritic

conjunctivitis

(pink eye) inflammation of conjunctiva; pruritic, red, mattery, sticky discharge, usually viral

candidiasis

(thrush) oral infection a/m/b soft white plaques on buccal mucosa and tongue, able to scrape off - seen in immunocompromised persons

tachypnea

-increase in respiratory rate, >24 breaths -can be due to nervousness, fever

Functions of the respiratory system

-maintenance of heat exchange -maintenance of acid-base balance -removal of CO2 -supplies oxygen for energy production

clinical findings of bronchitis

-productive cough with purulent sputum -normal palpation -normal percussion -crackles with possible wheezing for auscultation, prolonged expiration

hypoventilation

-shallow breathing -inadequate alveolar ventilation in relation to metabolic demands -leads to hypoxemia and respiratory acidosis

respiratory considerations with the pediatric patient

-smaller and immature -often hear hyperresonance in infants

atrial kick

-starlings law - rubber band effect -25% extra blood for cardiac output

AGE CONSIDERATIONS FOR ABDOMEN - GERIATRICS

1. SUBCUTANEOUS FAT DEPOSITS 2. ORGANS MAY BE EASIER TO PALPATE

PERCUSSION OF ABDOMEN

1. TYMPANY OVER MOST 2. DULLNESS OVER ORGANS, BONES, MASSES 3. HYPERRESONANCE = AIR

AUSCULTATING ARTERIAL AND VENOUS VASCULAR SOUNDS IN THE ABDOMEN

1. USE BELL OF STETHOSCOPE 2. NORMAL = NO SOUNDS 3. ABNORMAL = BRUIT, VENOUS HUM

pallor

paleness/white

salivary glands

parotid, submandibular, and sublingual

(3) salivary glands

parotid, submandibular, sublingual

function of oropharynx

passageway for food and air, location of tonsils

CLINICAL FINDINGS OF CERVICAL CANCER

-ABNORMAL VAGINAL BLEEDING -LESION MAY BE VISIBLE

function of nasopharynx

passageway of air, closes during swallowing to prevent aspiration

left lung has ____ lobes

2

function of laryngopharynx

passageway of food

alopecia areata

patches of hair loss

diastolic murmur is always ________ and indicative of a problem

pathologic

sensorineuroal hearing loss

pathologic disorder of the inner ear, CN VIII, or auditory areas of the cerebral cotex

order of auscultating the heart

Aortic, Pulmonic, Erb's point, Tricuspid, Mitral

apnea

pause in breathing greater than 10 seconds

confrontation test evaluates

peripheral vision

levels of auditory system

peripheral, brainstem, cerebral cortex

telangiectases

permanently dilated, small blood vessels (spider veins)

nonverbal cues

physical appearance, posture, gestures, facial expression, eye contact, voice, touch

BLEEDING AFTER MENOPAUSE IS USUALLY ___________

CANCER

position of ear for pediatric otoscope exam

pinna down

position of ear for adult otoscope exam

pinna up and back

splinter hemorrhages

pinpoint hemorrhages under the nail

consensual light reflex

simultaneous constriction of the opposite pupil the light is being shined onto

discrete lesion

single defined lesion

ROM of neck is tested by

pushing up with shoulders and side to side with head

HEMORRHOIDS

DILATED VEINS OF HEMORRHOIDAL PLEXUS RESULTING FROM INCREASED PORTAL VENOUS PRESSURE

herpes zoster

(Shingles) acute, painful, linearly grouped vesicles that follow a dermatome

hordeolum

(Stye) an acute infection originating in sebacious gland of eyelid; painful, red, and edematous

CANDIDA VAGINITIS

FUNGAL (YEAST) INFECTION

PROSTATE CANCER IS MORE OFTEN FOUND IN ______ MEN

OLDER

GASTROESOPHAGEAL REFLUX (GERD)

REFLUX OF ACIDIC GASTRIC CONTENTS INTO LOWER ESOPHAGUS

halitosis

bad breath

macula is located towards the _____

outside of eye

kyphosis

"hunch back" posterior curvature of the thoracic spine - impairment of cardiopulmonary function

barrel chest

"stocky" lateral diameter more 1:1 than 1:2

pathway of blood

- VENA CAVA move deoxygenated blood -enters R ATRIUM -moves oxygen from the R atrium through the TRICUSPID VALVE - into R VENTRICLE -R ventricle contracts, pushing blood through the PULMONIC VALVE -into PULMONARY ARTERIES to travel to the lungs -blood is reoxygenated in LUNGS -returns via PULMONARY VEINS - to the L ATRIUM -L atrium contracts to push blood through the MITRAL VALVE - into the L VENTRICLE -L ventricle contraction forces blood through the AORTIC VALVE

clinical findings of pneumonia

-(I) cough, fever, tachy, dyspnea, SOB, increased sputum -(pal) decreased chest expansion on affected side, increased tactile fremitus -(per) dull over lobar pneumonia -(A) crackles/rhonchi and wheezes

pulse amplitude scale

-0+ = absent -1+ = barely palpable -2+ = normal -3+ = full volume -4+ = bounding

pitting edema scale

-1+ = little pit; 2mm -2+ = 4mm pit; rebound in few seconds -3+ = 6mm pit; rebounds in 10-20 seconds -4+ = 8mm pit; rebounds in >30 seconds

CLINICAL MANIFESTATIONS OF INTESTINAL OBSTRUCTION

-ABD PAIN -VOMITING -DEHYDRATION -ELECTROLYTE DEPLETION -ABD DISTENTION -CONSTIPATION

IBD: CROHN'S DISEASE CLINICAL MANIFESTATIONS

-ABDOMINAL PAIN -DIARRHEA -FATIGUE -WEIGHT LOSS -NAUSEA/VOMITING

CLINICAL MANIFESTATIONS OF PID (WOMEN)

-ACUTE OR CHRONIC -SIGNIFICANT PAIN -FEVER, CHILLS -DYSPAREUNIA (PAINFUL INTERCOURSE)

HOW OFTEN FOR PAP SMEARS

-AGES 21-30: EVERY 3 YEARS -AFTER 30: EVERY 5 YEARS WITH ADDED HPV SCREEN

CLINICAL MANIFESTATIONS OF COLON CANCER

-BLACK, TARRY STOOLS -OBSTRUCTION -ABD PAIN/CRAMPING -CHANGE IN CALIBER OF STOOL -CHANGE IN BOWEL HABITS

PEDICULOSIS PUBIS

-CRABS/ PUBIC LICE -SEVERE PRURITIS IN PERINEAL AREA -EXCORIATION AND ERYTHEMA

PEPTIC ULCER DISEASE

-DEEP EROSION OF THE MUSCOSA OF THE UPPER GI TRACT BY GASTRIC ACID AND PEPSIN -DUODENAL: 80%, UPPER PORTION OF SMALL INTESTINE -GASTRIC: AFFECTS STOMACH LINING

CLINICAL MANIFESTATIONS OF CELIAC DISEASE

-DIARRHEA/STEATORRHEA (FAT IN STOOL) -N/V -ABD PAIN -INCREASED APPETITE WITH NO WEIGHT GAIN -MALNUTRITION

CLINICAL FINDINGS OF EPIDIDYMITIS

-DULL, UNILATERAL SCROTAL PAIN -SCROTUM BECOMES ERYTHEMATOUS AND EDEMATOUS -FEVER -DYSURIA -HYDROCELE MAY BE SEEN WITH TRANSILLUMINATION

HERPES GENITALIS

-DYSURIA -PAIN -FEVER -VESICLES -ULCERATIONS

CLINICAL MANIFESTATIONS OF PANCREATITIS

-EPIGASTRIC OR LUQ PAIN THAT OFTEN RADIATES TO BACK -N/V -DECREASED BOWEL SOUNDS -ABD DISTENTION -FEVER -TACHY/HYPOTENSION -DEHYDRATION

RISK FACTORS OF ACUTE PANCREATITIS

-EXCESS ALCOHOL INTAKE -BILIARY OBSTRUCTION (GALLSTONES) -HIGH TRIGLYCERIDE LEVELS -HYPERCALCEMIA

CLINICAL FINDINGS OF HEMORRHOIDS

-EXTERNAL ORIGINATE OUTSIDE RECTUM AND APPEAR AS FLAPS OF TISSUE -INTERNAL ORIGINATE ABOVE INTERIOR SPHINCTER

CLINICAL FINDINGS OF NEPHROLITHIASIS

-FEVER -HEMATURIA -FLANK PAIN RADIATING TO GROIN AND GENITALS

CLINICAL MANIFESTATIONS OF APPENDICITIS

-FEVER -N/V -RLQ, PERIUMBILICAL PAIN

PROSTATITIS CLINICAL FINDINGS

-FEVER, CHILLS, BACK PAIN, OBSTRUCTIVE SX -ENLARGED PROSTATE -RECURRENT UTIs, PAIN, DYSURIA -URGENCY AND FREQUENCY

UTERINE LEIOMYOMAS

-FIBROIDS -BENIGN UTERINE TUMORS THAT CAN OCCUR SINGULARLY OR IN MULTIPLES

MECHANICAL INTESTINAL OBSTRUCITON

-FOLLOWING A SURGERY -HERNIA -TUMOR -CONSTIPATION -INTUSSESEPTION

IBD: ULCERATIVE COLITIS CLINICAL MANIFESTATIONS

-GI BLEEDING -DIARRHEA -WEIGHT LOSS/ANOREXIA -NAUSEA AND VOMITING -ABDOMINAL PAIN: LLQ

PROSTATE CANCER

-HARD AND IRREGULAR PROSTATE -URINARY OBSTRUCTION -FREQUENCY, URGENCY, DYSURIA, NOCTURIA

CLINICAL MANIFESTATIONS OF GERD

-HEARTBURN -EPIGASTRIC OR CHEST PAIN -REGURGITATION -DYSPHAGIA

INFLAMMATORY BOWEL DISEASE: ULCERATIVE COLITIS

-INFLAMMATION AND DAMAGE OF THE MUCOSA AND SUBMUCOSA, STARTS WITH RECTUM AND MOVES UP -PROBABLY AUTOIMMUNE -CAN HAVE PEAKS AND REMISSIONS

TRICHOMONAS

-INHABITS VAGINA AND LOWER URINARY TRACT -MALODORUS GREENISH-YELLOW DISCHARGE -VERY ITCHY VAGINAL IRRITATION -"STRAWBERRY PATCHES" ON CERVIX AND VAGINA

CLINICAL MANIFESTATIONS OF PEPTIC ULCER DISEASE

-IRON DEFICIENCY ANEMIA -PROJECTILE VOMITING -EPIGASTRIC PAIN/ BURNING OR CHEST PAIN -NAUSEA -WEIGHT LOSS

CLINICAL MANIFESTATIONS OF DIVERTICULITIS

-LLQ PAIN -FEVER -TACHYCARDIA -CONSTIPATION -ELEVATED WBC

CLINICAL FINDINGS OF BACTERIAL VAGINOSIS

-MALODORUS, THIN, WHITE, VAGINAL DISCHARGE -VULVAR ITCHING AND IRRITATION -PH >4.5

treatment of MI

-MONA -morphine -oxygen -nitroglycerin -aspirin

clinical manifestations of MI

-severe pain lasting longer than 5 minutes -may radiate to left shoulder, jaw, or arm -heart sounds distant with thready pulse -problem with "plumbing"

PREMENSTRUAL SYNDROME CLINICAL FINDINGS

-MOOD SWINGS, DEPRESSION, IRRITABILITY, ANXIETY, RESTLESSNESS, ANGER -DIFFICULTY CONCENTRATING, CONFUSION, FORGETFULNESS, ACCIDENT PRONE -EXCESSIVE ENERGY OR FATIGUE, NAUSEA, CHANGES IN APPETITE, INSOMNIA, BACK PAIN, HEADACHES, MUSCULAR PAIN, BREAST TENDERNESS, FLUID RETENTION

ENDOMETRIAL CANCER

-MOST COMMON GYNECOLOGIC MALIGNANCY -MOST OFTEN POSTMENOPAUSE -CARDINAL SYMPTOM IS ABNORMAL UTERINE BLEEDING AFTER MENOPAUSE

CLINICAL MANIFESTATIONS OF ACUTE CHOLECYSTITIS

-N/V -FEVER -ELEVATED LIVER FUNCTION TESTS -RUQ ABD PAIN AND EPIGASTRIC PAIN -HEART BURN -JAUNDICE

FUNCTIONAL INTESTINAL OBSTRUCTION

-NEUROLOGICAL, SPINAL CORD INJURY -INTESTINE SHUTTING DOWN POST SURGICALLY -NARCOTICS

CLINICAL FINDINGS OF OVARIAN CYSTS

-OFTEN ASYMPTOMATIC -TENDERNESS AND DULL SENSATION OR FEELING OF HEAVINESS IN PELVIS -SUDDEN ONSET OF ABD PAIN IF RUPTURED

RISK FACTORS FOR COLON CANCER

-OLDER AGE -FAMILY HISTORY -HIGH FAT DIET -LOW FIBER DIET -ADENOMATOUS POLYPS -ULCERATIVE COLITIS -CROHN DISEASE

SYPHILIS

-OPEN SORES AND PAINLESS LESIONS -CAN BE CONGENITAL -CHRONIC AND NOT CURABLE

TESTICULAR CANCER

-PAINLESS TESTICULAR MASS -HARD, IRREGULAR MASS IS FELT

CLINICAL MANIFESTATIONS OF CIRRHOSIS

-PALPABLE HARD LIVER - ASCITES -JAUNDICE -DARK URINE -CLAY COLORED STOOLS -SPLEEN ENLARGEMENT

ENDOMETRIOSIS CLINICAL FINDINGS

-PELVIC PAIN -DYSMENORRHEA -HEAVY OR PROLONGED MENSTRUAL FLOW -PALPABLE SMALL, FIRM, NODULAR-LIKE MASSES

CLINICAL FINDINGS OF RECTAL AND ANAL CANCER

-RECTAL BLEEDING -POTENTIALLY PALPABLE NODULAR RAISED EDGES

CLINICAL FINDINGS OF RECTAL POLYPS

-RECTAL BLEEDING -SMALL, SOFT NODULES

CLINICAL FINDINGS OF RECTAL PROLAPSE

-RECTAL BLEEDING, MASS, CHANGE IN BOWEL HABITS -BULGE OUTSIDE OF ANUS

HPV (WOMEN)

-SCREENED WITH PAP SMEARS -GENITAL WARTS (CAULIFLOWER-LIKE) -COMMON LINK TO CERVICAL CANCER

CLINICAL FINDINGS OF CANDIDA VAGINITIS

-SOMETIMES ASYMPTOMATIC -VULVAR PRURITUS -THICK, CHEESY, WHITE VAGINAL DISCHARGE -VAGINAL SORENESS AND EXTERNAL DYSURIA -ERYTHEMA AND EDEMA TO LABIA AND VULVAR SKIN

WHEN TO START SCREENING FOR COLON CANCER

-START AT AGE 50, THEN EVERY 10 YEARS -COLONOSCOPY, HEMOCCULT CARDS -IF FAMILY HISTORY, START 10 YEARS PRIOR TO DIAGNOSIS OF FAMILY MEMBER -IF POLYPS, DO EVERY 3-5 YEARS

CLINICAL FINDINGS OF TESTICULAR TORSION

-SUDDEN ONSET OF SEVERE PAIN AND SCROTAL SWELLING -TESTICLE BECOMES VERY TENDER -SCROTUM BECOMES EDEMATOUS AND OFTEN DISCOLORED -ELEVATION OF TESTICLE ON AFFECTED SIDE -NO CREMASTIC REFLEX

CLINICAL MANIFESTATIONS OF UTI

-URETHRITIS: FREQUENCY, URGENCY, DYSURIA -CYSTITIS: FREQUENCY, URGENCY, DYSURIA, BACTERIURIA, FEVER -PYELONEPHRITIS: FLANK PAIN, DYSURIA, NOCTURIA, FREQUENCY, FEVER

CHLAMYDIA

-URINARY SYMPTOMS -CERVICAL DISCHARGE -BLEEDING -TENDERNESS

CLINICAL FINDINGS OF UTERINE LEIOMYOMAS

-USUALLY ASYMPTOMATIC -PELVIC PRESSURE AND HEAVINESS -URINARY FREQUENCY -DYSMENORRHEA -PELVIC OR BACK PAIN -ABDOMINAL ENLARGEMENT

CERVICAL CANCER

-USUALLY CAUSED BY HPV INFECTION

OVARIAN CANCER CLINICAL FINDINGS

-USUALLY NO SX UNTIL ADVANCED STAGES -ABDOMINAL DISTENTION OR FULLNESS -OVARIAN MASS -NO SCREENING

CAUSES OF CIRRHOSIS

-VIRAL HEPATITIS -BILIARY OBSTRUCTION -ALCOHOL ABUSE

GONORRHEA

-YELLOWISH-GREEN VAGINAL DISCHARGE -VAGINAL ITCHING/BURNING -URETHRITIS -URETHRAL DISCHARGE -DYSURIA

ventricular septal defect

-abnormal opening in the wall between the two ventricles -heard best at apex -may hear diastolic murmur -can lead to valve problems especially on the left side

cheyne-stokes respiration

-associated with CHF, renal failure, OD -waxing and waning

clinical findings of TB

-asymptomatic in early stages -initial fatigue, anorexia, weight loss, fever -later find increasingly frequent cough, mucopurulent sputum, blood tinged sputum, and apical crackles

atrial septal defect

-blood flow between atria -unoxygenated blood mixing with oxygenated blood -usually closes within the first hour of life -feeding problems -may hear a systolic murmur or feel a thrill -best heard at base

respiratory considerations with the elderly patient

-bones thin, costal cartilage calcifies -diaphragm weakens

Angina Pectoris

-chest pain or discomfort caused by myocardial ischemia -goes away with rest

key points of possible Sx of TB

-cough lasting more than 3 weeks -weight loss -loss of appetite -hemoptysis -weakness/fatigue -fever -night sweats

adventitious sounds

-crackles (rales) -wheeze (rhonchi) -atelectatic crackles

bradypnea

-decrease in respiratory rate, <10 breaths -can be due to meds (usually pain meds)

respiratory considerations with the pregnant patient

-diaphragm increases up to 4cm -increases tidal volume

clinical manifestations of pulmonary venous thromboembolism

-dyspnea and CP -tachy, productive cough, anxiety, diaphoresis -heart failure, shock -crackles, wheezes

patent ductus arteriosus (PDA)

-failure of closure of the fetal ductus arteriosus -widened pulse pressure, bounding peripheral pulses, thrill at left sternal border -murmur similar to machinery -usually closes 2-3 days after birth

hyperventilation

-increase in rate and depth -alveolar ventilation that exceeds metabolic demands -leads to respiratory alkalosis

LIVER BORDER SHOULD DESCEND DOWNWARD ___-____ INCHES

0.75 TO 1.25 INCHES

stages of TB

1) inflammatory response 2)scar tissue forms 3) reactivation of healed lesion that multiplies 4) erodes into the bronchus and air filled cavity

cardiac auscultation routine

1) note rate and rhythm 2) identify S1 and S2 3) assess S1 and S2 separately 4) listen for extra heart sounds 5) listen form murmurs

OVULATION USUALLY CEASES ______ YEARS BEFORE MENOPAUSE

1-2 YEARS

posterior fontanel closes when

1-2 months

7 F'S OF ABDOMINAL DISTENTION

1. FAT 2. FETUS 3. FLUID (ASCITES) 4. FLATULENCE 5. FECES 6. FIBROID TUMOR 7. FATAL TUMOR

FUNCTIONS OF THE GI SYSTEM

1. INGESTION 2. DIGESTION 3. ABSORPTION 4. ELIMINATION

ORDER OF GATHERING OBJECTIVE DATA FROM THE ABDOMEN

1. INSPECT 2. AUSCULTATE 3. PALPATE 4. PERCUSS

AUSCULTATING ABDOMEN

1. LIGHT TOUCH OF STETHOSCOPE DIAPHRAGM 2. IRREGULAR, HIGH PITCHED, GURGLING SOUNDS

AGE CONSIDERATIONS FOR ABDOMEN - PEDS

1. PROTUBERANT BELLIES 2. LIVER MORE PALPABLE 3. FLEX KNEES UP FOR PALPATION

heart is typically located between the ___ and ___ intercostal spaces

2nd and 5th

right lung has ____ lobes

3

pupil should be how big

3-5mm

how many permanent teeth do adults have

32

ratio of pulse rate to respiratory rate

4:1

cone of light should be at ___ o'clock in right ear

5

AVERAGE AGE FOR MENOPAUSE...

50, CAN BE HEREDITARY

normal heart rate

60-100bpm

cone of light should be at ___ o'clock in left ear

7

what percentage of all sensory info reaches the brain via the eyes?

70%

anterior fontanel closes when

9mo-2yrs

acute bronchitis

<3 months

chronic bronchitis

>3 months

A patient has a barrel-shaped chest, characterized by: A) equal anteroposterior transverse diameter and ribs being horizontal B) anteroposterior transverse diameter of 1:2 and an elliptic shape C) anteroposterior transverse diameter of 2:1 and ribs being elevated D) ateroposterior transverse diameter of 3:7 and ribs sloping back

A

Pulse oximetry measures: A) arterial oxygen saturation of hemoglobin B) venous oxygen saturation of hemoglobin C) combined saturation of arterial and venous blood D) carboxyhemoglobin levels

A

When auscultating the heart, your first step is to: A) identify S1 and S2 B) listen for S3 and S4 C) listen for murmurs D) identify all four sounds on the first round

A

Which description would differentiate a split S2 from S3: A) S3 is lower pitched and is heard at the apex B) S2 is heard at the left lower sternal border C) the timing of S2 varies with respirations D) S3 is heard at the base; the timing varies with respirations

A

Which of the following assessments best confirms symmetric chest expansion? A) placing hands on the posterolateral chest wall with thumbs at the level of T9 or T10 and then sliding the hands up to pinch a small fold of skin between the thumbs B) inspection of the shape and configuration of the chest wall C) placing the palmar surface of the fingers of one hand against the chest and having the person repeat the words "99" D) percussion of the posterior chest

A

Which of these tests would the nurse use to check the motor coordination of an 11-month-old infant? A) Denver II B) Stereognosis C) Deep tendon reflexes D) Rapid alternating movements

A (To screen gross and fine motor coordination, the nurse should use the Denver II with its age-specific developmental milestones. Stereognosis tests a person's ability to recognize objects by feeling them, and is not appropriate for an 11-month-old infant. Testing of the deep tendon reflexes is not appropriate for checking motor coordination. Testing rapid alternating movements is appropriate for testing coordination in adults.)

The nurse is reviewing a patient's medical record and notes that he is in a coma. Using the Glasgow Coma Scale, which number indicates that the patient is in a coma? A) 6 B) 12 C) 15 D) 24

A (A fully alert, normal person has a score of 15, whereas a score of 7 or less reflects coma on the Glasgow Coma Scale.)

A patient has been diagnosed with a ganglion cyst over the dorsum of his left wrist. He asks the nurse, "What is this thing?" The nurse's best answer would be, "It is: A) a common benign tumor." B) a tumor that will have to be watched because it may turn malignant." C) caused by chronic repetitive motion injury." D) a skin infection that will need to be drained."

A (A ganglionic cyst is a common benign tumor; it does not become malignant, and it does not need to be drained. It is not caused by chronic repetitive motion injury.)

In the assessment of a 1-month-old infant, the nurse notices a lack of response to noise or stimulation. The mother reports that in the last week he has been sleeping all the time, and when he is awake all he does is cry. The nurse hears that the infant's cries are very high pitched and shrill. What should be the nurse's appropriate response to these findings? A) Refer the infant for further testing. B) Talk with the mother about eating habits. C) Nothing; these are expected findings for an infant this age. D) Tell the mother to bring the baby back in a week for a recheck.

A (A high-pitched, shrill cry or cat-sounding screech occurs with central nervous system damage. Lethargy, hyporeactivity, hyperirritability, and parent's report of significant change in behavior all warrant referral. The other options are not correct responses.)

A 21-year-old patient has a head injury resulting from trauma and is unconscious. There are no other injuries. During the assessment what would the nurse expect to find when testing the patient's deep tendon reflexes? A) Reflexes will be normal. B) Reflexes cannot be elicited. C) All reflexes would be diminished but present. D) Some would be present depending on the area of injury.

A (A reflex is a defense mechanism of the nervous system. It operates below the level of conscious control and permits a quick reaction to potentially painful or damaging situations.)

To assess the head control of a 4-month-old infant, the nurse lifts the infant up in a prone position while supporting his chest. The nurse looks for what normal response? A) Raises head and arches back B) Extends arms and drops head down C) Flexes knees and elbows with back straight D) Holds head at 45 degrees and keeps back straight

A (At 3 months of age, the infant raises the head and arches the back as if in a swan dive. This is the Landau reflex, which persists until 1 1/2 years of age. The other responses are incorrect.)

The nurse should use which test to check for large amounts of fluid around the patella? A) Ballottement B) Tinel sign C) Phalen's test D) McMurray's test

A (Ballottement of the patella is reliable when larger amounts of fluid are present. The Tinel's sign and the Phalen's test are used to check for carpal tunnel syndrome. The McMurray's test is used to test the knee for a torn meniscus.)

A patient states, "I can hear a crunching or grating sound when I kneel." She also states that "it is very difficult to get out of bed in the morning because of stiffness and pain in my joints." The nurse should assess for signs of what problem? A) Crepitation B) A bone spur C) A loose tendon D) Fluid in the knee joint

A (Crepitation is an audible and palpable crunching or grating that accompanies movement and occurs when articular surfaces in the joints are roughened, as with rheumatoid arthritis. The other options are not correct.)

The nurse is examining a 6-month-old infant and places the infant's feet flat on the table and flexes his knees up. The nurse notes that the right knee is significantly lower than the left. Which of these statements is true of this finding? A) This is a positive Allis sign and suggests hip dislocation. B) The infant probably has a dislocated patella on the right. C) This is a normal finding for the Allis test for an infant of this age. D) The infant should return to the clinic in 2 weeks to see if this has changed.

A (Finding one knee significantly lower than the other is a positive Allis sign and suggests hip dislocation. Normally the tops of the knees are at the same elevation. The other statements are not correct.)

A patient tells the nurse that she is having a hard time bringing her hand to her mouth when she eats or tries to brush her teeth. The nurse knows that for her to move her hand to her mouth, she must perform which movement? A) flexion. B) abduction. C) adduction. D) extension.

A (Flexion, or bending a limb at a joint, would be required to move the hand to the mouth. Extension is straightening a limb at a joint. Moving a limb toward the midline of the body is called adduction; abduction is moving a limb away from the midline of the body.)

In a person with an upper motor neuron lesion such as a cerebrovascular accident, which of these physical assessment findings should the nurse expect to see? A) Hyperreflexia B) Fasciculations C) Loss of muscle tone and flaccidity D) Atrophy and wasting of the muscles

A (Hyperreflexia, diminished or absent superficial reflexes, and increased muscle tone or spasticity can be expected with upper motor neuron lesions. The other options reflect a lesion of lower motor neurons.)

The functional units of the musculoskeletal system are the: A) joints. B) bones. C) muscles. D) tendons.

A (Joints are the functional units of the musculoskeletal system because they permit the mobility needed for the activities of daily living. The skeleton (bones) is the framework of the body.)

A woman who is 8 months pregnant comments that she has noticed a change in posture and is having lower back pain. The nurse tells her that during pregnancy women have a posture shift to compensate for the enlarging fetus. This shift in posture is known as: A) lordosis. B) scoliosis. C) ankylosis. D) kyphosis.

A (Lordosis compensates for the enlarging fetus, which would shift the center of balance forward. This shift in balance in turn creates strain on the low back muscles, felt as low back pain during late pregnancy by some women. Scoliosis is lateral curvature of portions of the spine; ankylosis is extreme flexion of the wrist, as seen with severe rheumatoid arthritis; and kyphosis is an enhanced thoracic curvature of the spine.)

To test for gross motor skill and coordination of a 6-year-old child, which of these techniques would be appropriate? A) Ask child to hop on one foot. B) Have the child stand on his head. C) Have child touch his finger to his nose. D) Have the child make "funny" faces at the nurse.

A (Normally a child can hop on one foot and can balance on one foot for about 5 seconds by 4 years of age, and can balance on one foot for 8 to 10 seconds at 5 years of age. Children enjoy performing these tests. Failure to hop after 5 years of age indicates incoordination of gross motor skill. Touching the finger to the nose checks fine motor coordination. Having the child make "funny" faces tests cranial nerve VII. It is not appropriate to ask a child to stand on his or her head.)

While obtaining a history of a 3-month-old infant from the mother, the nurse asks about the infant's ability to suck and grasp the mother's finger. What is the nurse assessing? A) Reflexes B) Intelligence C) Cranial nerves D) Cerebral cortex function

A (Questions regarding reflexes include such questions as "What have you noticed about the infant's behavior," "Do the infant's sucking and swallowing seem coordinated," and "Does the infant grasp your finger?" The other responses are incorrect.)

During the assessment of an 80-year-old patient, the nurse notices that his hands show tremors when he reaches for something and his head is always nodding. There is no associated rigidity with movement. Which of these statements is most accurate? A) These are normal findings resulting from aging. B) These could be related to hyperthyroidism. C) These are the result of Parkinson disease. D) This patient should be evaluated for a cerebellar lesion.

A (Senile tremors occasionally occur. These benign tremors include an intention tremor of the hands, head nodding -as if saying yes or no-, and tongue protrusion. Tremors associated with Parkinson disease include rigidity, slowness, and weakness of voluntary movement. The other responses are incorrect.)

The nurse is testing the deep tendon reflexes of a 30-year-old woman who is in the clinic for an annual physical examination. When striking the Achilles and quadriceps, the nurse is unable to elicit a reflex. The nurse's next response should be to: A) ask the patient to lock her fingers and "pull." B) complete the examination and then test these reflexes again. C) refer the patient to a specialist for further testing. D) document these reflexes as "0" on a scale of 0 to 4+.

A (Sometimes the reflex response fails to appear. It is too soon to document this as "absent" reflexes. Try further encouragement of relaxation, varying the person's position or increasing the strength of the blow. Reinforcement is another technique to relax the muscles and enhance the response. Ask the person to perform an isometric exercise in a muscle group somewhat away from the one being tested. For example, to enhance a patellar reflex, ask the person to lock the fingers together and "pull.")

The ankle joint is the articulation of the tibia, the fibula, and the: A) talus. B) cuboid. C) calcaneus. D) cuneiform bones.

A (The ankle or tibiotalar joint is the articulation of the tibia, fibula, and talus. The other bones listed are foot bones, but not part of the ankle joint.)

The nurse knows that determining whether a person is oriented to his or her surroundings will test the functioning of which of these structures? A) Cerebrum B) Cerebellum C) Cranial nerves D) Medulla oblongata

A (The cerebral cortex is responsible for thought, memory, reasoning, sensation, and voluntary movement. The other options structures are not responsible for a person's level of consciousness.)

The wife of a 65-year-old man tells the nurse that she is concerned because she has noticed a change in her husband's personality and ability to understand. He also cries and becomes angry very easily. The nurse recalls that the cerebral lobe responsible for these behaviors is the _____ lobe. A) frontal B) parietal C) occipital D) temporal

A (The frontal lobe has areas concerned with personality, behavior, emotions, and intellectual function. The parietal lobe has areas concerned with sensation; the occipital lobe is responsible for visual reception; and the temporal lobe is concerned with hearing, taste and smell.)

The nurse is checking the range of motion in a patient's knee and knows that the knee is capable of which movement(s)? A) Flexion and extension B) Supination and pronation C) Circumduction D) Inversion and eversion

A (The knee is a hinge joint, permitting flexion and extension of the lower leg on a single plane. The knee is not capable of the other movements listed.)

When performing a musculoskeletal assessment, the nurse knows that the correct approach for the examination should be: A) proximal to distal. B) distal to proximal. C) posterior to anterior. D) anterior to posterior.

A (The musculoskeletal assessment should be done in an orderly approach, head to toe, proximal to distal, from the midline outward. The other options are not correct.)

During an assessment of a 62-year-old man the nurse notices the patient has a stooped posture, shuffling walk with short steps, flat facial expression, and pill-rolling finger movements. These findings would be consistent with: A) parkinsonism. B) cerebral palsy. C) cerebellar ataxia. D) muscular dystrophy.

A (The stooped posture, shuffling walk, short steps, flat facial expression, and pill-rolling finger movements are all found in parkinsonism.)

Of the 33 vertebrae in the spinal column, there are: A) 5 lumbar. B) 5 thoracic. C) 7 sacral. D) 12 cervical.

A (There are 7 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 3 to 4 coccygeal vertebrae.)

During the history, a patient tells the nurse that "it feels like the room is spinning around me." The nurse would document this as: A) vertigo. B) syncope. C) dizziness. D) seizure activity.

A (True vertigo is rotational spinning caused by neurologic dysfunction or a problem in the vestibular apparatus or the vestibular nuclei in the brainstem. Dizziness is a lightheaded, swimming sensation. Syncope is a sudden loss of strength or a temporary loss of consciousness. Seizure activity is characterized by altered or loss of consciousness, involuntary muscle movements, and sensory disturbances.)

The nurse is teaching a class on osteoporosis prevention to a group of postmenopausal woman. A participant shows that she needs more instruction when she states, "I will: A) start swimming to increase my weight-bearing exercise." B) try to stop smoking as soon as possible." C) check with my doctor about taking calcium supplements." D) get a bone-density test soon."

A (Weight-bearing exercises include walking, low-impact aerobics, dancing, or stationary cycling. Swimming is not considered a weight-bearing exercise. The other responses are correct.)

A 59-year-old patient has a herniated intervertebral disk. Which of the following findings should the nurse expect to see on physical assessment of this individual? A) Hyporeflexia B) Increased muscle tone C) A positive Babinski's sign D) The presence of pathologic reflexes

A (With a herniated intervertebral disk or lower motor neuron lesion there is loss of tone, flaccidity, atrophy, fasciculations, and hyporeflexia or areflexia. No Babinski's sign or pathologic reflexes would be seen. The other options reflect a lesion of upper motor neurons.)

PREMENSTRUAL SYNDROME

A GROUP OF RECURRENT SYMPTOMS ASSOCIATED WITH MENSTRUAL CYCLE

MENOPAUSE

A PERMANENT CESSATION OF MENSES AND IS CONSIDERED COMPLETE AFTER WOMAN EXPERIENCES AN ENTIRE YEAR WITH NO MENSES

S2 indicates

closure of aortic and pulmonic valves

S1 indicates

closure of the mitral and tricuspid valves, beginning of systole

grouped lesion

clusters of lesions

pneumothorax

collapse of the lung (partial or complete)

Match numbers to letters: A)apex B)base C)lateral left D)lateral right E)posterior apex 1)rests on the diaphragm 2) C7 3) sixth rib, midclavicular line 4) fifth intercostal 5) 3 to 4 cm above the inner third of the clavicles

A) 5 B) 1 C) 3 D) 4 E) 2

match the numbers to letters: A) normal chest B) barrel chest C) pectus excavatum D) pectus carinatum E) scoliosis F) kyphosis 1) AP = transverse diameter 2) exaggerated posterior curvature of thoracic spine 3) lateral S-shaped curvature of the thoracic and lumbar spines 4) sunken sternum and adjacent cartilages 5) elliptic shape with an AP to transverse diameter in the ratio of 1:2 6) forward protrusion of the sternum with ribs sloping back at either side

A) 5 B) 1 C) 4 D) 6 E) 3 F) 2

Match the numbers to letters. A) tough, fibrous, double-walled sac that surrounds and protects the heart B) thin layer of endothelial tissue that lines the inner surface of the heart chambers and valves C) Reservoir for holding blood D) ensures smooth, friction-free movement of the heart muscle E) muscular pumping chamber F) muscular wall of the heart 1) pericardial fluid 2) ventricle 3) endocardium 4) myocardium 5) pericardium 6) atrium

A) 5 B) 3 C) 6 D) 1 E) 2 F) 4

atelectasis

collapsed alveoli caused by external pressure

HYDROCELE

ACCUMULATION OF FLUID IN SCROTUM

WHAT IS CONSIDERED INFERTILITY

ACTIVELY TRYING FOR ONE YEAR WITHOUT SUCCESS OF PREGNANCY

ACUTE CHOLECYSTITIS

ACUTE INFLAMMATION OF THE GALLBLADDER, BILE DUCT BECOMES OBSTRUCTED

AREAS TO LISTEN FOR VASCULARITY IN ABDOMEN

AORTA, RENAL, ILIAC, AND FEMORAL

types of hearing loss

conductive and sensorineural (perceptive)

function of the bony labyrinth

conducts sound to CNVIII(acoustic) and transmits signals for balance and position

function of the eustachian tube

connects middle ear to nasopharynx

bronchophony

consolidated lung tissue has better sound transmission and so "99" is heard more clearly (not normal)

egophony

consolidated lung tissue makes an auscultated "E" sound like "A"

Select the best description of bronchovesicular breath sounds: A) high-pitched, of longer duration on inspiration than expiration B) moderate-pitched, inspiration equal to expiration C) low-pitched, inspiration greater than expiration D) rustling sound, like the wind in the trees

B

miosis

constricted and fixed pupils

Select the best description of the tricuspid valve: A) left semilunar valve B) right AV valve C) Left AV valve D) right semilunar valve

B

Select the correct description of the left lung: A) narrower than the right lung with three lobes B) narrower than the right lung with two lobes C) wider than the right lung with two lobes D) shorter than the right lung with three lobes

B

tuberculosis

contagious, bacterial infection caused by Mycobacterium tuberculosis

The examiner is palpating the apical impulse. Which is a normal-sized impulse: A) less than 1cm B) approximately 1x2cm C) 3cm D) varies depending on the size of the person

B

The nurse auscultates the pulmonic valve area in which region: A) second right interspace B) second left interspace C) left lower sternal border D) fifth interspace, left midclavicular line

B

To use the technique of egophony, ask the patient to: A) take several deep breaths and then hold for 5 seconds B) say "eeeee" each time the stethoscope is moved C) repeat the phrase "99" each time the stethoscope is moved D) whisper a phrase as auscultation is performed

B

skin self examination ABCDE

Asymmetry Border Color Diameter - 5/6 mm Elevation and Enlargement

Atrial systole occurs: A) during ventricular systole B) during ventricular diastole C) concurrently with ventricular systole D) independently of ventricular function

B

When assessing the carotid artery, the nurse should palpate: A) bilaterally at the same time while standing behind the patient B) medial to the sternomastoid muscle, one side at a time C) for a bruit while asking the patient to hold his/her breath briefly D) for unilateral distention while turning the patient's head to one side

B

You are auscultating breath sounds on a patient. Which of the following best describes how to proceed? A) hold the bell of the stethoscope against the chest wall; listen to the entire right field and then the entire left field B) hold the diaphragm of the stethoscope against the chest wall; listen to one full respiration in each location, being sure to do side to side comparisons C) listen from the apices to the bases of each lung field using the bell of the stethoscope D) select the bell or diaphragm depending on the quality of sounds heard; listen for one respiration in each location, moving from side to side

B

You assess a patient who reports a cough. The characteristic timing of the cough of chronic bronchitis is described as: A) continuous throughout the day B) productive cough for at least 3 months of the year for 3 consecutive years C) occurring in the afternoon or evening because of exposure to irritants at work D) occurring in the early morning

B

You will hear a split in S2 most clearly in which area: A) apical B) pulmonic C) tricuspid D) aortic

B

A woman who has had rheumatoid arthritis for years is starting to notice that her fingers are drifting to the side. The nurse knows that this condition is commonly referred to as: A) radial drift. B) ulnar deviation. C) swan neck deformity. D) Dupuytren's contracture.

B (Fingers drift to the ulnar side because of stretching of the articular capsule and muscle imbalance caused by chronic rheumatoid arthritis. Radial drift is not seen.)

cutaneous pain

skin surface pain

A 40-year-old man has come into the clinic with complaints of "extreme tenderness in my toes." The nurse notices that his toes are slightly swollen, reddened, and warm to the touch. His complaints would suggest: A) osteoporosis. B) acute gout. C) ankylosing spondylitis. D) degenerative joint disease.

B (Acute gout occurs primarily in men over 40 years of age. Clinical findings consist of redness, swelling, heat, and extreme tenderness. Gout is a metabolic disorder of disturbed purine metabolism, associated with elevated serum uric acid. See Table 22-1 for descriptions of the other terms.)

An imaginary line connecting the highest point on each iliac crest would cross the _____ vertebra. A) first sacral B) fourth lumbar C) seventh cervical D) twelfth thoracic

B (An imaginary line connecting the highest point on each iliac crest crosses the fourth lumbar vertebra.)

The ability that humans have to perform very skilled movements such as writing is controlled by the: A) basal ganglia. B) corticospinal tract. C) spinothalamic tract. D) extrapyramidal tract.

B (Corticospinal fibers mediate voluntary movement, particularly very skilled, discrete, purposeful movements, such as writing. The corticospinal tract -also known as the pyramidal tract- is a newer, "higher" motor system that humans have that permits very skilled and purposeful movements. The other responses are not related to skilled movements.)

The nurse is assessing the neurologic status of a patient who has a late-stage brain tumor. With the reflex hammer, the nurse draws a light stroke up the lateral side of the sole of the foot and inward, across the ball of the foot. In response, the patient's toes fan out, and the big toe shows dorsiflexion. The nurse interprets this result as: A) a negative Babinski's sign, which is normal for adults. B) a positive Babinski's sign, which is abnormal for adults. C) clonus, which is a hyperactive response. D) the Achilles reflex, which is an expected response.

B (Dorsiflexion of the big toe and fanning of all toes is a positive Babinski's sign, also called "upgoing toes." This occurs with upper motor neuron disease of the corticospinal -or pyramidal- tract and is an abnormal finding for adults.)

During an examination, the nurse notices severe nystagmus in both eyes of a patient. Which of these conclusions by the nurse is correct? A) This is a normal occurrence. B) This may indicate disease of the cerebellum or brainstem. C) This is a sign that the patient is nervous about the examination. D) This indicates a visual problem, and a referral to an ophthalmologist is indicated.

B (End-point nystagmus at an extreme lateral gaze occurs normally. The nurse should assess any other nystagmus carefully. Severe nystagmus occurs with disease of the vestibular system, cerebellum, or brainstem.)

A patient's annual physical examination reveals a lateral curvature of the thoracic and lumbar segments of his spine; however, this curvature disappears with forward bending. The nurse knows that this abnormality of the spine is called: A) structural scoliosis. B) functional scoliosis. C) herniated nucleus pulposus. D) dislocated hip.

B (Functional scoliosis is flexible; it is apparent with standing and disappears with forward bending. Structural scoliosis is fixed; the curvature shows both when standing and when bending forward.)

A patient tells the nurse that "all my life I've been called 'knock knees.'" The nurse knows that another term for "knock knees" is: A) genu varum. B) genu valgum. C) pes planus. D) metatarsus adductus.

B (Genu valgum is also known as "knock knees" and is present when there is more than 2.5 cm between the medial malleoli when the knees are together.)

During an assessment of a 22-year-old woman who has a head injury from a car accident 4 hours ago, the nurse notices the following change: pupils were equal, but now the right pupil is fully dilated and nonreactive, left pupil is 4 mm and reacts to light. What does finding this suggest? A) Injury to the right eye B) Increased intracranial pressure C) Test was not performed accurately D) Normal response after a head injury

B (In a brain-injured person, a sudden, unilateral, dilated, and nonreactive pupil is ominous. Cranial nerve III runs parallel to the brainstem. When increasing intracranial pressure pushes the brainstem down -uncal herniation-, it puts pressure on cranial nerve III, causing pupil dilation. The other responses are incorrect.)

The nurse knows that testing kinesthesia is a test of a person's: A) fine touch. B) position sense. C) motor coordination. D) perception of vibration.

B (Kinesthesia, or position sense, is the person's ability to perceive passive movements of the extremities. The other options are incorrect.)

The assessment of a 60-year-old patient has taken longer than anticipated. In testing his pain perception the nurse decides to complete the test as quickly as possible. When the nurse applies the sharp point of the pin on his arm several times, he is only able to identify these as one "very sharp prick." What would be the most accurate explanation for this? A) Patient has hyperesthesia as a result of the aging process. B) This is most likely the result of the summation effect. C) The nurse was probably not poking hard enough with the pin in the other areas. D) The patient most likely has analgesia in some areas of arm and hyperalgesia in others.

B (Let at least 2 seconds elapse between each stimulus to avoid summation. With summation, frequent consecutive stimuli are perceived as one strong stimulus. The other responses are incorrect.)

An 80-year-old woman is visiting the clinic for a checkup. She states, "I can't walk as much as I used to." The nurse is observing for motor dysfunction in her hip and should have her: A) internally rotate her hip while she is sitting. B) abduct her hip while she is lying on her back. C) adduct her hip while she is lying on her back. D) externally rotate her hip while she is standing.

B (Limitation of abduction of the hip while supine is the most common motion dysfunction found in hip disease. The other options are not correct.)

An 85-year-old patient comments during his annual physical that he seems to be getting shorter as he ages. The nurse should explain that decreased height occurs with aging because: A) long bones tend to shorten with age. B) of the shortening of the vertebral column. C) there is a significant loss of subcutaneous fat. D) there is a thickening of the intervertebral disks.

B (Postural changes are evident with aging; decreased height is most noticeable and is due to shortening of the vertebral column. Long bones do not shorten with age. Intervertebral disks actually get thinner with age. Subcutaneous fat is not lost but is redistributed to the abdomen and hips.)

A patient is able to flex his right arm forward without difficulty or pain but is unable to abduct his arm because of pain and muscle spasms; the nurse should suspect: A) crepitation. B) rotator cuff lesions. C) dislocated shoulder. D) rheumatoid arthritis.

B (Rotator cuff lesions may cause limited range of motion and pain and muscle spasm during abduction, whereas forward flexion stays fairly normal. The other options are not correct.)

In obtaining a history on a 74-year-old patient the nurse notes that he drinks alcohol daily and that he has noticed a tremor in his hands that affects his ability to hold things. With this information, what should the nurse's response be? A) "Does your family know you are drinking every day?" B) "Does the tremor change when you drink the alcohol?" C) "We'll do some tests to see what is causing the tremor." D) "You really shouldn't drink so much alcohol; it may be causing your tremor."

B (Senile tremor is relieved by alcohol, although this is not a recommended treatment. The nurse should assess whether the person is abusing alcohol in an effort to relieve the tremor.)

The nurse places a key in the hand of a patient and he identifies it as a penny. What term would the nurse use to describe this finding? A) Extinction B) Astereognosis C) Graphesthesia D) Tactile discrimination

B (Stereognosis is the person's ability to recognize objects by feeling their forms, sizes, and weights. Astereognosis is an inability to identify objects correctly, and it occurs in sensory cortex lesions. Tactile discrimination tests fine touch. Extinction tests the person's ability to feel sensations on both sides of the body at the same point.)

During an interview the patient states, "I can feel this bump on the top of both of my shoulders—it doesn't hurt but I am curious about what it might be." The nurse should tell the patient, "That is: A) your subacromial bursa." B) your acromion process." C) your glenohumeral joint." D) the greater tubercle of your humerus."

B (The bump of the scapula's acromion process is felt at the very top of the shoulder. The other options are not correct.)

During an assessment of the cranial nerves, the nurse finds the following: asymmetry when the patient smiles or frowns, uneven lifting of eyebrows, sagging of the lower eyelids, and escape of air when the nurse presses against the right puffed cheek. This would indicate dysfunction of which of these cranial nerves? A) Motor component of IV B) Motor component of VII C) Motor and sensory components of XI D) Motor component of X and sensory component of VII

B (The findings listed reflect a dysfunction of the motor component of cranial nerve VII, the facial nerve.)

clinical manifestations of pleural effusion

dyspnea, intercostal bulging, tachy, dry cough, cyanosis, absent tactile fremitus, dull percussion, tracheal shift away from affected side

The nurse is examining the hip area of a patient and palpates a flat depression on the upper, lateral side of the thigh when the patient is standing. The nurse interprets this finding as the: A) ischial tuberosity. B) greater trochanter. C) iliac crest. D) gluteus maximus muscle.

B (The greater trochanter of the femur is palpated when the person is standing, and it appears as a flat depression on the upper lateral side of the thigh. The iliac crest is the upper part of the hip bone; the ischial tuberosity lies under the gluteus maximus muscle and is palpable when the hip is flexed. The gluteus muscle is part of the buttocks.)

Which of these statements concerning areas of the brain is true? A) The cerebellum is the center for speech and emotions. B) The hypothalamus controls temperature and regulates sleep. C) The basal ganglia are responsible for controlling voluntary movements. D) Motor pathways of the spinal cord and brainstem synapse in the thalamus.

B (The hypothalamus is a vital area with many important functions: temperature controller, sleep center, anterior and posterior pituitary gland regulator, and coordinator of autonomic nervous system activity and emotional status. The cerebellum controls motor coordination, equilibrium, and balance. The basal ganglia control autonomic movements of the body. The motor pathways of the spinal cord synapse in various areas of the spinal cord, not the thalamus.)

A mother of a 1-month-old infant asks the nurse why it takes so long for infants to learn to roll over. The nurse knows that the reason for this is that: A) there must be a demyelinating process occurring with her infant. B) myelin is needed to conduct the impulses, and the neurons of a newborn are not yet myelinated. C) the cerebral cortex is not fully developed, so control over motor function occurs gradually. D) the spinal cord is controlling the movement because the cerebellum is not yet fully developed.

B (The infant's sensory and motor development proceeds along with the gradual acquisition of myelin because myelin is needed to conduct most impulses. Very little cortical control exists, and the neurons are not yet myelinated. The other responses are not correct.)

The nurse is assessing a patient's ischial tuberosity. To palpate the ischial tuberosity, the nurse knows that it is best to have the patient: A) stand. B) flex the hip. C) flex the knee. D) in the supine position.

B (The ischial tuberosity lies under the gluteus maximus muscle and is palpable when the hip is flexed.)

The two parts of the nervous system are the: A) motor and sensory. B) central and peripheral. C) peripheral and autonomic. D) hypothalamus and cerebral.

B (The nervous system can be divided into two parts—central and peripheral. The central nervous system includes the brain and spinal cord. The peripheral nervous system includes the 12 pairs of cranial nerves, the 31 pairs of spinal nerves, and all their branches.)

During the neurologic assessment of a "healthy" 35-year-old patient, the nurse asks him to relax his muscles completely. The nurse then moves each extremity through full range of motion. Which of these results would the nurse expect to find? A) Firm, rigid resistance to movement B) Mild, even resistance to movement C) Hypotonic muscles as a result of total relaxation D) Slight pain with some directions of movement

B (Tone is the normal degree of tension -contraction- in voluntarily relaxed muscles. It shows a mild resistance to passive stretch. Normally, the nurse will notice a mild, even resistance to movement. The other responses are not correct.)

clinical manifestations of pneumothorax

dyspnea, tachy, CP, dry cough, asymmetric lung expansion, decreased tactile fremitus, hyperresonance, decreased breath sounds

otorrhea

ear discharge

otalgia

earaches

types of sweat glands

eccrine and apocrine

A patient has been diagnosed with osteoporosis and asks the nurse, "What is osteoporosis?" The nurse explains to the patient that osteoporosis is defined as: A) increased bone matrix. B) loss of bone density. C) new, weaker bone growth. D) increased phagocytic activity.

B (After age 40, loss of bone matrix -resorption- occurs more rapidly than new bone formation. The net effect is a gradual loss of bone density, or osteoporosis. The other options are not correct.)

MULTIPLE RESPONSE The nurse is assessing the joints of a woman who has stated, "I have a long family history of arthritis, and my joints hurt." The nurse suspects that she has osteoarthritis. Which of these are symptoms of osteoarthritis? Select all that apply. A) Symmetric joint involvement B) Asymmetric joint involvement C) Pain with motion of affected joints D) Affected joints are swollen with hard, bony protuberances E) Affected joints may have heat, redness, and swelling

B, C, D (In osteoarthritis, asymmetric joint involvement commonly affects hands, knees, hips, and lumbar and cervical segments of the spine. Affected joints have stiffness, swelling with hard bony protuberances, pain with motion, and limitation of motion. The other options reflect signs of rheumatoid arthritis.)

MULTIPLE RESPONSE A 69-year-old patient has been admitted to an adult psychiatric unit because his wife thinks he is getting more and more confused. He laughs when he is found to be forgetful, saying "I'm just getting old!" After the nurse completes a thorough neurologic assessment, which findings would be indicative of Alzheimer's disease? Select all that apply. A) Occasionally forgetting names or appointments B) Difficulty performing familiar tasks, such as placing a telephone call C) Misplacing items, such as putting dish soap in the refrigerator D) Sometimes having trouble finding the right word E) Rapid mood swings, from calm to tears, for no apparent reason F) Getting lost in one's own neighborhood

B, C, E, F (Difficulty performing familiar tasks, misplacing items, rapid mood swings, and getting lost in one's own neighborhood can be warning signs of Alzheimer's disease. Occasionally forgetting names or appointments, and sometimes having trouble finding the right word are part of normal aging.)

ERUCTATION

BELCHING

OVARIAN CYSTS

BENIGN CYSTIC GROWTHS WITHIN OVARY, MAY BE SOLITARY OR MULTIPLE, CAN OCCUR UNILATERALLY OR BILATERALLY

ENDOMETRIOSIS

BENIGN, PROGRESSIVE DISEASE PROCESS CHARACTERIZED BY PRESENCE AND GROWTH OF UTERINE TISSUE OUTSIDE THE UTERUS

HYPERACTIVE

BORBORYGMUS

HEMATOCHEZIA

BRIGHT RED BLOODY STOOL

A murmur is best heard after S1 and before S2. This murmur would be classified as: A) diastolic (possibly benign) B) diastolic (always pathologic) C) systolic (possibly benign) D) systolic (always pathologic)

C

A pleural friction rub is best detected by: A) observation B) palpation C) auscultation D) percussion

C

Absence of diaphragmatic excursion occurs with: A) asthma B) an unusually thick chest wall C) pleural effusion or atelectasis of the lower lobes D) age-related changes in the chest wall

C

On examining a patient's nails, you note that the angle of the nail base is >160 degrees and that the nail base feels spongy to palpation. These findings are consistent with: A) Acute respiratory distress syndrome B) normal findings for the nails C) CHD and COPD D) atelectasis

C

The function of the pulmonic valve is to: A) divide the left atrium and left ventricle B) guard the opening between the right atrium and right ventricle C) protect the orifice between the right ventricle and the pulmonary artery D) guard the entrance to the aorta from the left ventricle

C

The precordium is: A) a synonym for the mediastinum B) the area on the chest where the apical impulse is felt C) the area on the anterior chest overlying the heart and great vessels D) a synonym for the area where the superior and inferior venae cavae return unoxygenated venous blood to the right side of the heart

C

The stethoscope bell should be pressed lightly against the skin so that: A) chest hair doesn't simulate crackles B) high-pitched sounds can be heard better C) the bell does not act as a diaphragm D) the bell does not interfere with amplification of heart sounds

C

When examining for tactile fremitus, it is important to: A) ask the patient to breath quickly B) ask the patient to cough C) palpate the chest symmetrically D) use the bell of the stethoscope

C

turgor

elasticity of skin

what do the external intercostals do for breathing

elevate ribs

The articulation of the mandible and the temporal bone is known as the: A) intervertebral foramen. B) condyle of the mandible. C) temporomandibular joint. D) zygomatic arch of the temporal bone.

C (The articulation of the mandible and the temporal bone is the temporomandibular joint. The other responses are not correct.)

what do the sternomastoid muscles do for breathing

elevate sternum

what do the scalenus muscles do for breathing

elevate upper ribs

A patient has a severed spinal nerve as a result of trauma. Which of these statements is true in this situation? A) Because there are 31 pairs of spinal nerves, there is no effect if only one is severed. B) The dermatome served by this nerve will no longer experience any sensation. C) The adjacent spinal nerves will continue to carry sensations for the dermatome served by the severed nerve. D) This will only affect motor function of the patient because spinal nerves have no sensory component.

C (A dermatome is a circumscribed skin area that is supplied mainly from one spinal cord segment through a particular spinal nerve. The dermatomes overlap, which is a form of biologic insurance. That is, if one nerve is severed, most of the sensations can be transmitted by the spinal nerve above and spinal nerve below.)

A teenage girl has arrived complaining of pain in her left wrist. She was playing basketball when she fell and landed on her left hand. The nurse examines her hand and would expect a fracture if the girl complains: A) of a dull ache. B) that the pain in her wrist is deep. C) of sharp pain that increases with movement. D) of dull throbbing pain that increases with rest.

C (A fracture causes sharp pain that increases with movement. The other pains do not occur with a fracture.)

The nurse is assessing a 1-week-old infant and is testing his muscle strength. The nurse lifts the infant with hands under the axillae and notices that the infant starts to "slip" between the hands. The nurse should: A) suspect a fractured clavicle. B) suspect that the infant may have a deformity of the spine. C) suspect that the infant may have weakness of the shoulder muscles. D) consider this a normal finding because the musculature of an infant this age is undeveloped.

C (An infant who starts to "slip" between the nurse's hands shows weakness of the shoulder muscles. An infant with normal muscle strength wedges securely between the nurse's hands. The other responses are not correct.)

When taking the history on a patient with a seizure disorder, the nurse assesses whether the patient has an aura. Which of these would be the best question for obtaining this information? A) "Does your muscle tone seem tense or limp?" B) "After the seizure, do you spend a lot of time sleeping?" C) "Do you have any warning sign before your seizure starts?" D) "Do you experience any color change or incontinence during the seizure?"

C (Aura is a subjective sensation that precedes a seizure; it could be auditory, visual, or motor. The other questions are not correct regarding asking about an aura.)

A patient who has had rheumatoid arthritis for years comes to the clinic to ask about changes in her fingers. The nurse will assess for signs of what problems? A) Heberden's nodes B) Bouchard's nodules C) Swan neck deformities D) Dupuytren's contractures

C (Changes in the fingers caused by chronic rheumatoid arthritis include swan neck and boutonniere deformities. Heberden's nodes and Bouchard's nodules are associated with osteoarthritis. Dupuytren's contractures occur because of chronic hyperplasia of the palmar fascia and causes contractures of the digits)

A man who was found wandering in a park at 2 AM has been brought to the emergency department for an examination because he said he fell and hit his head. During the examination, the nurse asks him to use his index finger to touch the nurse's finger, then his own nose, then the nurse's finger again (which has been moved to a different location). The patient is clumsy, unable to follow the instructions, and overshoots the mark, missing the finger. The nurse should suspect which of the following? A) Cerebral injury B) Cerebrovascular accident C) Acute alcohol intoxication D) Peripheral neuropathy

C (During the finger-to-finger test, if the person has clumsy movement with overshooting the mark, either a cerebellar disorder or acute alcohol intoxication should be suspected. The person's movements should be smooth and accurate. The other options are not correct.)

A mother brings her newborn baby boy in for a checkup; she tells the nurse that he doesn't seem to be moving his right arm as much as his left and that he seems to have pain when she lifts him up under the arms. The nurse suspects a fractured clavicle and would observe for: A) a negative Allis test. B) a positive Ortolani's sign. C) limited range of motion during the Moro's reflex. D) limited range of motion during Lasègue's test

C (For a fractured clavicle, the nurse should observe for limited arm range of motion and unilateral response to the Moro's reflex. The other tests are not appropriate for this problem.)

The nurse suspects that a patient has carpal tunnel syndrome and wants to perform the Phalen's test. To perform this test, the nurse should instruct the patient to: A) dorsiflex the foot. B) plantarflex the foot. C) hold both hands back to back while flexing the wrists 90 degrees for 60 seconds. D) hyperextend the wrists with the palmar surface of both hands touching and wait for 60 seconds.

C (For the Phalen's test, the nurse should ask the person to hold both hands back to back while flexing the wrists 90 degrees. Acute flexion of the wrist for 60 seconds produces no symptoms in the normal hand. The Phalen's test reproduces numbness and burning in a person with carpal tunnel syndrome. The other actions are not correct for testing for carpal tunnel syndrome.)

During an examination, the nurse asks a patient to bend forward from the waist and notices that the patient has lateral tilting. When his leg is raised straight up, he complains of a pain going down his buttock into his leg. The nurse suspects: A) scoliosis. B) meniscus tear. C) herniated nucleus pulposus. D) spasm of paravertebral muscles.

C (Lateral tilting and sciatic pain with straight leg raising are findings that occur with a herniated nucleus pulposus. The other options are not correct.)

The nurse is explaining the mechanism of the growth of long bones to a mother of a toddler. Where does lengthening of the bones occur? A) Bursa B) Calcaneus C) Epiphyses D) Tuberosities

C (Lengthening occurs at the epiphyses, or growth plates. The other options are not correct.)

The nurse is performing a neurologic assessment on a 41-year-old woman with a history of diabetes. When testing her ability to feel the vibrations of a tuning fork, the nurse notices that the patient is unable to feel vibrations on the great toe or ankle bilaterally, but she is able to feel vibrations on both patellae. Given this information, what would the nurse suspect? A) Hyperalgesia B) Hyperesthesia C) Peripheral neuropathy D) Lesion of sensory cortex

C (Loss of vibration sense occurs with peripheral neuropathy -e.g., diabetes and alcoholism-. Peripheral neuropathy is worse at the feet and gradually improves as the examiner moves up the leg, as opposed to a specific nerve lesion, which has a clear zone of deficit for its dermatome.)

A patient is being assessed for range of joint movement. The nurse asks him to move his arm in toward the center of his body. This movement is called: A) flexion. B) abduction. C) adduction. D) extension.

C (Moving a limb toward the midline of the body is called adduction; abduction is moving a limb away from the midline of the body. Flexion is bending a limb at a joint; extension is straightening a limb at a joint.)

The nurse is examining a 3-month-old infant. While holding the thumbs on the infant's inner mid thighs and the fingers outside on the hips, touching the greater trochanter, the nurse adducts the legs until the nurse's thumbs touch and then abducts the legs until the infant's knees touch the table. The nurse does not notice any "clunking" sounds and is confident to record a: A) positive Allis test. B) negative Allis test. C) positive Ortolani's sign. D) negative Ortolani's sign.

C (Normally this maneuver feels smooth and has no sound. With a positive Ortolani's sign, the nurse will feel and hear a "clunk" as the head of the femur pops back into place. A positive Ortolani's sign reflects hip instability. The Allis test also tests for hip dislocation, but is done by comparing leg lengths.)

A 14-year-old boy who has been diagnosed with Osgood-Schlatter disease reports painful swelling just below the knee for the past 5 months. Which response by the nurse is appropriate? A) "If these symptoms persist, you may need arthroscopic surgery." B) "You are experiencing degeneration of your knee, which may not resolve." C) "Your disease is due to repeated stress on the patellar tendon. It is usually self-limited, and your symptoms should resolve with rest." D) "Increasing your activity and performing knee-strengthening exercises will help to decrease the inflammation and maintain mobility in the knee."

C (Osgood-Schlatter disease is painful swelling of the tibial tubercle just below the knee. It is most likely due to repeated stress on the patellar tendon. It is usually self-limited, occurring during rapid growth and most often in males. The symptoms resolve with rest. The other responses are not appropriate.)

During a neonatal examination, the nurse notices that the newborn infant has six toes. This finding is documented as: A) unidactyly. B) syndactyly. C) polydactyly. D) multidactyly.

C (Polydactyly is the presence of extra fingers or toes. Syndactyly is webbing between adjacent fingers or toes. The other terms are not correct.)

A patient is complaining of pain in his joints that is worse in the morning, is better after he has moved around for awhile, and then gets worse again if he sits for long periods of time. The nurse should assess for other signs of what problem? A) Tendinitis B) Osteoarthritis C) Rheumatoid arthritis D) Intermittent claudication

C (Rheumatoid arthritis is worse in the morning when arising. Movement increases most joint pain, except in rheumatoid arthritis, in which movement decreases pain. The other options are not correct.)

A patient is not able to perform rapid alternating movements such as patting her knees rapidly. The nurse should document this as: A) ataxia. B) astereognosis. C) the presence of dysdiadochokinesia. D) loss of kinesthesia.

C (Slow clumsy movements and the inability to perform rapid alternating movements occur with cerebellar disease. The condition is termed dysdiadochokinesia. Ataxia is uncoordinated or unsteady gait. Astereognosis is the inability to identify an object by feeling it. Kinesthesia is the person's ability to perceive passive movement of the extremities, or the loss of position sense.)

During an assessment of an 80-year-old patient, the nurse notices the following: inability to identify vibrations at the ankle and to identify position of big toe, slower and more deliberate gait, and slightly impaired tactile sensation. All other neurologic findings are normal. The nurse should interpret that these findings indicate: A) cranial nerve dysfunction. B) lesion in the cerebral cortex. C) normal changes due to aging. D) demyelinization of nerves due to a lesion.

C (Some aging adults show a slower response to requests, especially for those calling for coordination of movements. The findings listed are normal in the absence of other significant abnormal findings. The other responses are incorrect.)

The nurse is caring for a patient who has just had neurosurgery. To assess for increased intracranial pressure, what would the nurse include in the assessment? A) Cranial nerves, motor function, and sensory function B) Deep tendon reflexes, vital signs, and coordinated movements C) Level of consciousness, motor function, pupillary response, and vital signs D) Mental status, deep tendon reflexes, sensory function, and pupillary response

C (Some hospitalized persons have head trauma or a neurologic deficit from a systemic disease process. These people must be monitored closely for any improvement or deterioration in neurologic status and for any indication of increasing intracranial pressure. The nurse should use an abbreviation of the neurologic examination in the following sequence: level of consciousness, motor function, pupillary response, and vital signs.)

A 68-year-old woman has come in for an assessment of her rheumatoid arthritis, and the nurse notices raised, firm, nontender nodules at the olecranon bursa and along the ulna. These nodules are most commonly diagnosed as: A) epicondylitis. B) gouty arthritis. C) olecranon bursitis. D) subcutaneous nodules.

C (Subcutaneous nodules are raised, firm, and nontender and occur with rheumatoid arthritis in the olecranon bursa and along the extensor surface of the ulna.)

While assessing a 7-month-old infant, the nurse makes a loud noise and notices the following response: abduction and flexion of arms and legs; fanning of fingers, and curling of index and thumb in a C position followed by infant bringing in arms and legs to body. What does the nurse know about this response? A) This could indicate brachial nerve palsy. B) This is an expected startle response at this age. C) This reflex should have disappeared between 1 and 4 months of age. D) It is normal as long as movements are symmetric bilaterally.

C (The Moro reflex is present at birth and disappears at 1 to 4 months. Absence of the Moro reflex in the newborn or persistence after 5 months of age indicates severe central nervous system injury. The other responses are incorrect.)

A 30-year-old woman tells the nurse that she has been very unsteady and has had difficulty in maintaining her balance. Which area of the brain would the nurse be concerned about with these findings? A) Thalamus B) Brainstem C) Cerebellum D) Extrapyramidal tract

C (The cerebellar system coordinates movement, maintains equilibrium, and helps maintain posture. The thalamus is the main relay station where sensory pathways of the spinal cord, cerebellum, and brainstem for synapses on their way to the cerebral cortex. The brainstem consists of the midbrain, pons, and medulla and has various functions, especially concerning autonomic centers. The extrapyramidal tract maintains muscle tone for gross automatic movements, such as walking.)

A patient is visiting the clinic for an evaluation of a swollen, painful knuckle. The nurse notices that the knuckle above his ring on the left hand is swollen and that he is unable to remove his wedding ring. This joint is called the _____ joint. A) interphalangeal B) tarsometatarsal C) metacarpophalangeal D) tibiotalar

C (The joint located just above the ring on the finger is the metacarpophalangeal joint. The interphalangeal joint is located distal to the metacarpophalangeal joint. The tarsometatarsal and tibiotalar joints are found in the foot and ankle. See Figure 22-10 for a diagram of the bones and joints of the hand and fingers.)

When the nurse is testing the triceps reflex, what is the expected response? A) Flexion of the hand B) Pronation of the hand C) Extension of the forearm D) Flexion of the forearm

C (The normal response of the triceps reflex is extension of the forearm. The normal response of the biceps reflex causes flexion of the forearm. The other responses are incorrect.)

A patient with lack of oxygen to his heart will have pain in his chest and possibly the shoulder, arms, or jaw. The nurse knows that the statement that best explains why this occurs is which of these? A) There is a problem with the sensory cortex and its ability to discriminate the location. B) The lack of oxygen in his heart has resulted in decreased amount of oxygen to the areas experiencing pain. C) The sensory cortex does not have the ability to localize pain in the heart, so the pain is felt elsewhere. D) There is a lesion in the dorsal root that is preventing the sensation from being transmitted normally.

C (The sensory cortex is arranged in a specific pattern, forming a corresponding "map" of the body. Pain in the right hand is perceived at a specific spot on the map. Some organs are absent from the brain map, such as the heart, liver, and spleen. Pain originating in these organs is referred because no felt image exists in which to have pain. Pain is felt "by proxy" by another body part that does have a felt image. The other responses are not correct explanations.)

The area of the nervous system that is responsible for mediating reflexes is the: A) medulla. B) cerebellum. C) spinal cord. D) cerebral cortex.

C (The spinal cord is the main highway for ascending and descending fiber tracts that connect the brain to the spinal nerves, and it mediates reflexes.)

While gathering equipment after an injection, a nurse accidentally received a prick from an improperly capped needle. To interpret this sensation, which of these areas must be intact? A) Corticospinal tract, medulla, and basal ganglia B) Pyramidal tract, hypothalamus, and sensory cortex C) Lateral spinothalamic tract, thalamus, and sensory cortex D) Anterior spinothalamic tract, basal ganglia, and sensory cortex

C (The spinothalamic tract contains sensory fibers that transmit the sensations of pain, temperature, and crude or light touch. Fibers carrying pain and temperature sensations ascend the lateral spinothalamic tract, whereas those of crude touch form the anterior spinothalamic tract. At the thalamus, the fibers synapse with another sensory neuron, which carries the message to the sensory cortex for full interpretation. The other options are not correct.)

To palpate the temporomandibular joint, the nurse's fingers should be placed in the depression _____ of the ear. A) distal to the helix B) proximal to the helix C) anterior to the tragus D) posterior to the tragus

C (The temporomandibular joint can be felt in the depression anterior to the tragus of the ear. The other locations are not correct.)

The nurse is doing an assessment on a 29-year-old woman who visits the clinic complaining of "always dropping things and falling down." While testing rapid alternating movements, the nurse notices that the woman is unable to pat both her knees. Her response is very slow and she misses frequently. What should the nurse suspect? A) Vestibular disease B) Lesion of cranial nerve IX C) Dysfunction of the cerebellum D) Inability to understand directions

C (When a person performs rapid, alternating movements, slow, clumsy, and sloppy responses occur with cerebellar disease. The other responses are incorrect.)

The nurse is testing superficial reflexes on an adult patient. When stroking up the lateral side of the sole and across the ball of the foot, the nurse notices the plantar flexion of the toes. How should the nurse document this finding? A) Positive Babinski sign B) Plantar reflex abnormal C) Plantar reflex present D) Plantar reflex "2+" on a scale from "0 to 4+"

C (With the same instrument, the nurse should draw a light stroke up the lateral side of the sole of the foot and across the ball of the foot, like an upside-down "J." The normal response is plantar flexion of the toes and sometimes of the whole foot. A positive Babinski sign is abnormal and occurs with the response of dorsiflexion of the big toe and fanning of all toes. The plantar reflex is not graded on a 0 to 4+ scale.)

The nurse is teaching a class on osteoporosis prevention to a group of postmenopausal women. Which of these actions is the best way to prevent or delay bone loss in this group? A) Taking calcium and vitamin D supplements B) Taking medications to prevent osteoporosis C) Performing physical activity, such as fast walking D) Assessing bone density annually

C (Physical activity, such as fast walking, delays or prevents bone loss in perimenopausal women. The faster the pace of walking, the higher the preventive effect on the risk of hip fracture. The other options are not correct.)

vesicle

elevated and fluid filled <1cm

plaque

elevated, firm, rough lesion with flat surface, >1cm

hyperthyroidism clinical manifestations

goiter, exopthalmos, weight loss, heat intolerance, nervousness, tachy, diaphoresis

HDL is _____ cholesterol

good

most common hyperthyroidism disease

graves disease - autoimmune

NEPHROLITHIASIS

FORMATION OF STONES IN KIDNEY PELVIS, COMPOSED OF CALCIUM SALTS, URIC ACID, CYSTINE, OR STRUVITE

facilitation

guiding the conversation to keep it on track

toxic alopecia

hairloss from a chemical agent

lens

middle layer; refracts and focuses light onto the retina

A young swimmer comes to the sports clinic complaining of a very sore shoulder. He was running at the pool, slipped on some wet concrete, and tried to catch himself with his outstretched hand. He landed on his outstretched hand and has not been able to move his shoulder since then. The nurse suspects: A) joint effusion. B) tear of rotator cuff. C) adhesive capsulitis. D) dislocated shoulder.

D (Dislocated shoulder occurs with trauma involving abduction, extension, and external rotation -e.g., falling on an outstretched arm or diving into a pool)

valve between the left atrium and left ventricle

mitral (AV) valve

Fibrous bands running directly from one bone to another that strengthen the joint and help prevent movement in undesirable directions are called: A) bursa. B) tendons. C) cartilage. D) ligaments.

D (Fibrous bands running directly from one bone to another that strengthen the joint and help prevent movement in undesirable directions are called ligaments.)

polycystic lesion

more than one cyst, movable fluid filled space

The nurse has completed the musculoskeletal examination of a patient's knee and has found a positive bulge sign. The nurse interprets this finding to indicate: A) irregular bony margins. B) soft tissue swelling in the joint. C) swelling from fluid in the epicondyle. D) swelling from fluid in the suprapatellar pouch.

D (For swelling in the suprapatellar pouch, the bulge sign confirms the presence of fluid. The other options are not correct.)

microaneurysms

small, discrete, round red dots localized dilations of a small vessel; seen with diabetic retinopathy

In assessing a 70-year-old patient who has had a recent cerebrovascular accident, the nurse notices right-sided weakness. What might the nurse expect to find when testing his reflexes on the right side? A) Lack of reflexes B) Normal reflexes C) Diminished reflexes D) Hyperactive reflexes

D (Hyperreflexia is the exaggerated reflex seen when the monosynaptic reflex arc is released from the influence of higher cortical levels. This occurs with upper motor neuron lesions -e.g., a cerebrovascular accident-. The other responses are incorrect.)

basal cell carcinoma

most common form of skin cancer; nodular, pigmented lesion with depressed center and rolled borders

anteroposterior diameter should be ____ than the transverse diameter

smaller than; 1:2 ratio

ABORTIONS

NUMBER OF MISCARRIAGES/ELECTIVE ABORTIONS

GRAVIDA

NUMBER OF PREGNANCIES

RECTAL AND ANAL CANCER

OCCURS WHEN MALIGNANT TUMOR GROWS WITHIN RECTAL MUCOSA, ANAL CANAL, OR ANUS

PARIETAL ABDOMINAL PAIN

OUTSIDE TISSUES/ OVERLYING INFLAMMATION

nasal polyps

smooth gray nodules which can be caused by chronic allergic rhinitis

clinical manifestations of lung cancer

most common initial symptom is persistent cough, CP, pleural effusion, airway obstruction, weight loss, congestion, wheezing, hemoptysis

After examining a patient, you make the following notation: increased respiratory rate, chest expansion decreased on left side, dull to percussion over left lower lobe, breath sounds louder with fine crackles over left lower lobe. These findings are consistent with: A) bronchitis B) asthma C) pleural effusion D) lobar pneumonia

D

On auscultating a patient, you note a coarse, low-pitched sound during both inspiration and expiration. this patient reports pain with breathing. These findings are consistent with: A) fine crackles B) wheezes C) atelectatic crackles D) pleural friction rub

D

The examiner has estimated the jugular venous pressure. Identify the finding that is abnormal: A) patient elevated to 30 degrees, internal jugular vein pulsation at 1cm above sternal angle B) patient elevated to 30 degrees, internal jugular vein pulsation at 2cm above sternal angle C) patient elevated to 40 degrees, internal jugular vein pulsation at 1cm above sternal angle D) patient elevated to 45 degrees, internal jugular vein pulsation at 4cm above sternal angle

D

The second heart sound is the result of: A) opening of the mitral and tricuspid valves B) closing of the mitral and tricuspid valves C) opening of the aortic and pulmonic valves D) closing of the aortic and pulmonic valves

D

While the nurse is taking the history of a 68-year-old patient who sustained a head injury 3 days earlier, he tells the nurse that he is on a cruise ship and is 30 years old. The nurse knows that this finding is indicative of: A) a great sense of humor. B) uncooperative behavior. C) inability to understand questions. D) decreased level of consciousness.

D (A change in consciousness may be subtle. The nurse should notice any decreasing level of consciousness, disorientation, memory loss, uncooperative behavior, or even complacency in a previously combative person. The other responses are incorrect.)

Which of these statements about the peripheral nervous system is correct? A) The cranial nerves enter the brain through the spinal cord. B) Efferent fibers carry sensory input to the central nervous system through the spinal cord. C) The peripheral nerves are inside the central nervous system and carry impulses through their motor fibers. D) The peripheral nerves carry input to the central nervous system by afferent fibers and away by efferent fibers.

D (A nerve is a bundle of fibers outside the central nervous system. The peripheral nerves carry input to the central nervous system by their sensory afferent fibers and deliver output from the central nervous system by the efferent fibers.)

The nurse is providing patient education for a man who has been diagnosed with a rotator cuff injury. The nurse knows that a rotator cuff injury involves the: A) nucleus pulposus. B) articular process. C) medial epicondyle. D) glenohumeral joint.

D (A rotator cuff injury involves the glenohumeral joint, which is enclosed by a group of four powerful muscles and tendons that support and stabilize it. The nucleus pulposus is located in the center of each intervertebral disk. The medial epicondyle is located at the elbow.)

When the nurse asks a 68-year-old patient to stand with feet together and arms at his side with his eyes closed, he starts to sway and moves his feet farther apart. The nurse would document this finding as a(n): A) ataxia. B) lack of coordination. C) negative Homans' sign. D) positive Romberg sign.

D (Abnormal findings for Romberg test include swaying, falling, and widening base of feet to avoid falling. Positive Romberg sign is loss of balance that is increased by closing of the eyes. Ataxia is uncoordinated or unsteady gait. Homans' sign is used to test the legs for deep vein thrombosis.)

A 70-year-old woman tells the nurse that every time she gets up in the morning or after she's been sitting she gets "really dizzy" and feels like she is going to fall over. The nurse's best response would be: A) "Have you been extremely tired lately?" B) "You probably just need to drink more liquids." C) "I'll refer you for a complete neurologic examination." D) "You need to get up slowly when you've been lying or sitting."

D (Aging is accompanied by a progressive decrease in cerebral blood flow. In some people this causes dizziness and a loss of balance with position change. These people need to be taught to get up slowly. The other responses are incorrect.)

A 32-year-old woman tells the nurse that she has noticed "very sudden, jerky movements" mainly in her hands and arms. She says, "They seem to come and go, primarily when I am trying to do something. I haven't noticed them when I'm sleeping." This description suggests: A) tics. B) athetosis. C) myoclonus. D) chorea.

D (Chorea is characterized by sudden, rapid, jerky, purposeless movements that involve the limbs, trunk, or face. Chorea occurs at irregular intervals, and the movements are all accentuated by voluntary actions.)

The nurse notices that a woman in an exercise class is unable to jump rope. The nurse knows that to jump rope, one's shoulder has to be capable of: A) inversion. B) supination. C) protraction. D) circumduction.

D (Circumduction is defined as moving the arm in a circle around the shoulder.)

When assessing muscle strength, the nurse observes that a patient has complete range of motion against gravity with full resistance. What Grade should the nurse record using a 0 to 5 point scale? A) 2 B) 3 C) 4 D) 5

D (Complete range of motion against gravity is normal muscle strength and is recorded as Grade 5 muscle strength.)

The nurse is explaining to a patient that there are "shock absorbers" in his back to cushion the spine and to help it move. The nurse is referring to his: A) vertebral column. B) nucleus pulposus. C) vertebral foramen. D) intervertebral disks.

D (Intervertebral disks are elastic fibrocartilaginous plates that cushion the spine like shock absorbers and help it move. The vertebral column is the spinal column itself. The nucleus pulposus is located in the center of each disk. The vertebral foramen is the channel, or opening, for the spinal cord in the vertebrae.)

A professional tennis player comes into the clinic complaining of a sore elbow. The nurse will assess for tenderness at the: A) olecranon bursa. B) annular ligament. C) base of the radius. D) medial and lateral epicondyle.

D (The epicondyles, the head of radius, and tendons are common sites of inflammation and local tenderness, or "tennis elbow." The other locations are not affected.)

When reviewing the musculoskeletal system, the nurse recalls that hematopoiesis takes place in the: A) liver. B) spleen. C) kidneys. D) bone marrow.

D (The musculoskeletal system functions to encase and protect inner vital organs, support the body, produce red blood cells in the bone marrow, and store minerals.)

During the history of a 78-year-old man, his wife states that he occasionally has problems with short-term memory loss and confusion: "He can't even remember how to button his shirt." In doing the assessment of his sensory system, which action by the nurse is most appropriate? A) The nurse would not do this part of the examination because results would not be valid. B) The nurse would perform the tests, knowing that mental status does not affect sensory ability. C) The nurse would proceed with the explanations of each test, making sure the wife understands. D) Before testing, the nurse would assess the patient's mental status and ability to follow directions at this time.

D (The nurse should ensure validity of the sensory system testing by making sure the patient is alert, cooperative, comfortable, and has an adequate attention span. Otherwise, the nurse may obtain misleading and invalid results.)

A 50-year-old woman is in the clinic for weakness in her left arm and leg that she has noticed for the past week. The nurse should perform which type of neurologic examination? A) Glasgow Coma Scale B) Neurologic recheck examination C) Screening neurologic examination D) Complete neurologic examination

D (The nurse should perform a complete neurologic examination on persons who have neurologic concerns -e.g., headache, weakness, loss of coordination- or who have shown signs of neurologic dysfunction. The Glasgow Coma scale is used to define a person's level of consciousness. The neurologic recheck examination is appropriate for persons with demonstrated neurologic deficits. The screening neurologic examination is performed on seemingly well persons who have no significant subjective findings from the history.)

The nurse is testing the function of cranial nerve XI. Which of these best describes the response the nurse should expect if the nerve is intact? The patient: A) demonstrates ability to hear normal conversation. B) sticks tongue out midline without tremors or deviation. C) follows an object with eyes without nystagmus or strabismus. D) moves the head and shoulders against resistance with equal strength.

D (These are the expected normal findings when testing cranial nerve XI -spinal accessory nerve-: The patient's sternomastoid and trapezius muscles are of equal size; the person can rotate the head both ways forcibly against resistance applied to the side of the chin with equal strength; the patient can shrug the shoulders against resistance with equal strength on both sides. Checking the patient's ability to hear normal conversation checks the function of CN VIII. Having the patient stick out the tongue checks the function of CN XII. Testing the eyes for nystagmus or strabismus is done to check CN III, IV, and VI.)

During an assessment of a 32-year-old patient with a recent head injury, the nurse notices that the patient responds to pain by extending, adducting, and internally rotating his arms. His palms pronate and his lower extremities extend with plantar flexion. Which of these statements about these findings is accurate? A) This indicates a lesion of the cerebral cortex. B) This indicates a completely nonfunctional brainstem. C) This is a normal response that will go away in 24 to 48 hours. D) This is a very ominous sign and may indicate brainstem injury.

D (These findings are all indicative of decerebrate rigidity, which is a very ominous condition and may indicate a brainstem injury.)

A man who has had gout for several years comes to the clinic with a problem with his toe. On examination, the nurse notices the presence of hard, painless nodules over the great toe; one has burst open with a chalky discharge. This finding is known as: A) a callus. B) a plantar wart. C) a bunion. D) tophi.

D (Tophi are collections of sodium urate crystals resulting from chronic gout in and around the joint that cause extreme swelling and joint deformity. They appear as hard, painless nodules -tophi- over the metatarsophalangeal joint of the first toe and they sometimes burst with a chalky discharge)

The nurse is examining a 2-month-old infant and notices asymmetry of the infant's gluteal folds. The nurse should assess for other signs of what disorder? A) Fractured clavicle B) Down syndrome C) Spina bifida D) Hip dislocation

D (Unequal gluteal folds may accompany hip dislocation after 2 to 3 months of age, but some asymmetry may occur in healthy children. Further assessment is needed. The other responses are not correct.)

A 78-year-old man has a history of a cerebrovascular accident. The nurse notes that when he walks his left arm is immobile against the body with flexion of the shoulder, elbow, wrist, and fingers and adduction of the shoulder. His left leg is stiff and extended and circumducts with each step. What type of gait disturbance is this individual experiencing? A) Scissors gait B) Cerebellar ataxia C) Parkinsonian gait D) Spastic hemiparesis

D (With spastic hemiparesis, the arm is immobile against the body. There is flexion of the shoulder, elbow, wrist, and fingers and adduction of the shoulder, which does not swing freely. The leg is stiff and extended and circumducts with each step. Causes of this type of gait include cerebrovascular accident.)

turbinates

mucosa projections within the nasal cavity

DYSPHAGIA

DIFFICULTY SWALLOWING

ESOPHAGEAL VARICES

DISTENDED, TORTUOUS COLLATERAL VEINS THAT DEVELOP FROM PROLONGED ELEVATION OF PRESSURE

fontanels

soft spots on babies which allow for expansion and growth of the brain

BENIGN PROSTATIC HYPERPLASIA (BPH)

ENLARGEMENT OF PROSTATE, FEELS SMOOTH FIRM AND RUBBERY, PROJECTS MORE THAN 1CM INTO RECTUM

3 REGIONS OF ABDOMINAL CAVITY

EPIGASTRIC, UMBILICAL, AND HYPOGASTRIC (SUPRAPUBIC)

CHRONIC ESOPHAGEAL IRRITATION CAN LEAD TO...

ESOPHAGEAL CANCER

LITHOTOMY POSITION

FEET IN STIRRUPS, KNEES APART WITH ADEQUATE DRAPING, BUTTOCKS ON EDGE OF EXAM TABLE, ARMS AT SIDES OR ACROSS CHEST

PYROSIS

HEARTBURN

CLINICAL MANIFESTATIONS OF ESOPHAGEAL VARICES

HEMATEMESIS, MELENA

DIVERTICULITIS

HERNIATION OF THE MUCOSA AND SUMBUCOSA THROUGH THE COLON WITH INFLAMMATION DUE TO INCREASING INTRALUMINAL PRESSURE

OVARIAN CANCER

HIGHEST MORTALITY RATE OF GYNECOLOGIC CANCERS

PARAPHIMOSIS

INABILITY TO RETURN FORESKIN OVER GLANS

EPIDIDYMITIS

INFLAMMATION OF EPIDIDYMUS AND VAS DEFERENS - USUALLY ASSOCIATED WITH STD

PROSTATITIS

INFLAMMATION OF PROSTATE GLAND

IBD: CROHN'S DISEASE

INFLAMMATION OF THE GI TRACT EXTENDING THROUGH ALL LAYERS OF THE INTESTINAL WALL, INCREASED RISK FOR COLON CANCER

BALANITIS

INFLAMMATION OF THE GLANS

ACUTE PANCREATITIS

INFLAMMATION OF THE PANCREAS: -SUDDEN AND PAINFUL -FLOW OF PANCREATIC DIGESTIVE ENZYMES INTO DUODENUM -DIGESTIVE ENZYMES ACT ON PANCREAS ITSELF

APPENDICITIS

INFLAMMATION OF THE VERMIFORM APPENDIX

VISCERAL ABDOMINAL PAIN

INTERNAL ORGANS

CELIAC DISEASE

INTOLERANCE OF GLUTEN THAT CAUSES BOWEL INFLAMMATION AND MALABSORPTION - THOUGHT TO BE AUTOIMMUNE

EPIDSPADIA

URETHRA OPENS ON DORSAL SIDE OF PENIS

HYPOSPADIAS

URETHRAL MEATUS LOCATED ON VENTRAL SIDE OF PENIS

PYELONEPHRITIS

UTI OF RENAL PELVIS

right sided HF manifestations

JVD, dependent peripheral edema, S3 at sternal left lower border, systolic murmur, and weight gain

WHEN A PATIENT REPORTS THAT A CERTAIN SPOT IN THE ABDOMEN IS TENDER, IT IS BEST TO PALPATE THAT SPOT _____

LAST

left sided heart failure causes

LV MI, HTN, aortic or mitral valve stenosis

URETHRITIS

UTI OF URETHRA

CYSTITIS

UTI OF URINARY BLADDER

during assessment, the nurse knows that expected assessment findings in the normal adult lung include the presence of:

muffled voice sounds and symmetric tactile fremitus

deep somatic pain

musculoskeletal pain

ABNORMAL INSPECTION OF ABDOMEN

MARKED PULSATIONS, VISIBLE PERISTALSIS, CULLEN'S SIGN, PROMINENT DILATED VEINS, HERNIAS, DISTENTION, MARKED CONCAVITY, BULGING

COMPONENTS OF UPPER GI TRACT

MOUTH, ESOPHAGUS, STOMACH

HYPOACTIVE

NO SOUNDS FOR 5 MINUTES

PARA

NUMBER OF LIVE BIRTHS

hypothyroidism is also known as

myxedema

current health aspects

Onset Location Duration Characteristics Aggravating/alleviating factors Relieving Timing Setting/severity

REFERRED ABDOMINAL PAIN

PAIN FELT IN ONE SPOT BUT ORIGINATING IN ANOTHER SPOT

DYSURIA

PAIN WITH URINATION

INTESTINAL OBSTRUCTION

PARTIAL OR COMPLETE BLOCKAGE OF THE INTESTINAL LUMEN OF THE SMALL (90%) OR LARGE BOWEL

PELVIC INFLAMMATORY DISEASE (PID) (WOMEN)

POLYMICROBIAL INFECTION OF UPPER REPRODUCTIVE TRACT

COLON CANCER

PRIMARY MALIGNANT NEOPLASM OF THE COLON

CYSTOCELE

PROLAPSE OF THE BLADDER

RECTOCELE

PROLAPSE OF THE RECTUM

RECTAL POLYP

PROTRUDING GROWTH FROM RECTAL MUCOSA

RECTAL PROLAPSE

PROTRUSION OF RECTAL WALL THOUGH ANUS

external nasal bones

nasal, frontal, maxillary

presbyopia

near vision is decreased

paget's disease of bone

softens, thickens, and deforms bone

COMPONENTS OF LOWER GI TRACT

SMALL AND LARGE INTESTINES, RECTUM, ANUS

eye muscles

Superior rectus - cnIII Lateral rectus - cnVI Inferior rectus - cnIII Inferior oblique - cnIII Medial rectus - cnIII Superior oblique - cnIV

ANORECTAL FISSURE

TEAR OF ANAL MUCOSA CAUSING INTENSE PAIN, ITCHING, AND RECTAL BLEEDING

TESTICULAR TORSION

TWISTING OF TESTICLE AND SPERMATIC CORD, CUTTING OFF BLOOD SUPPLY - CONSIDERED A SURGICAL EMERGENCY

NORMAL BOWEL SOUNDS

TYPICALLY NOTED 5-30 TIMES A MINUTE

nodule

solid elevated lesion >1cm

PHIMOSIS

VERY TIGHT FORESKIN THAT CANNOT BE RETRACTED OVER GLANS

HEMATEMESIS

VOMITING BLOOD

T or F: intercostal retractions, nasal flaring, and pursed lip breathing indicate airflow obstruction and poor ventilation

True

SECONDARY AMENORRHEA

WHEN YOUVE HAD YOUR PERIOD (MENARCHE) AND THEN IT STOPS, #1 REASON IS PREGNANCY

TESTICULAR CANCER IS MORE OFTEN FOUND IN ______ MEN

YOUNGER

chronic cough

a cough lasting more than 2 months

episodic cough

a cough lasting no longer than 2-3 weeks

hydrocephalus

abnormal accumulation of CSF

hirsutism

abnormal hair growth in females

pleural effusion

accumulation of serous fluid in pleural space between visceral and parietal pleurae

accommodation

adaptation of the eye for near vision; look away the pupils dilate, look up close and they constrict

physical appearance general survey

age, sex, level of consciousness, skin color, facial features, signs of distress

pathways of hearing

air conduction and bone conduction

spontaneous pneumothorax

air enters pleural space through lung wall rupture

traumatic pneumothorax

air enters via opening or injury in chest wall

what is the visceral pleura

an envelope between the lungs and chest wall that help with expansion and constriction

leukoplakia

chalky, thick, raised patches with well-defined borders - PRECANCEROUS - does not scrape off

reason for seeking care is also known as

chief complaint

chalazion

nodule of meibomian gland in eyelid; firm, nontender

trachea

anterior to the esophagus; 10-11cm long

when auscultating, the right side is heard more _______ while the left side is heard more ________

anterior; posterior

valve between the left ventricle and the aorta

aortic (semilunar) valve

S1 is loudest at the _____ of the heart

apex

when listening to heart sounds, you can hear S1 best at the:

apex of the heart

Fill in the blanks. S1 is best heard at the ______ of the heart, whereas S2 is loudest at the ______ of the heart. S1 coincides with the pulse in the ______ and coincides with the _______ wave if the patient is on an ECG monitor.

apex; base; carotid artery; R

whisper pectoriloquy

ask the pt. to whisper "1,2,3" (healthy lung areas should not be able to make this out) -frequencies more able to be transmitted in abnormal lungs

red reflex

at 4 inches away, the opthalmoscope should reflect light off the retina to produce a "red" pupil

LDL is _____ cholesterol

bad

S2 is loudest at the ____ of the heart

base

fingertip palpation

best for fine tactile discrimination

base of finger palpation

best for vibrations

S4

best heard over tricuspid or mitral areas with client on L side, often seen with uncontrolled HBP

where is the carotid artery pulse located

between the trachea and sternomastoid muscle

tension headache

bilateral, frontal or occipital, band like pain, gradual onset, can last for several days

steps of a health history

biographical data, reason for seeking care, current health or history of current illness, past health, family history, review of systems, functional assessment

dizziness is defined as

blackout

S3 is due to

blood hitting off the sides of the heart chamber; usually in early to mid diastole; best heard at apex

cyanosis

blusish-gray

limbus

border between the cornea and sclera

ecchymosis

bruise

Asthma

chronic reactive airway (inflammatory) disorder resulting in reversible bronchoconstriction and air hunger in response to triggers

lichenification

chronic scaling, itching, overgrowth of tissue

seborrheic dermatitis

chronic scaly, white/yellowish plaques usually on and around scalp

nasal cavity function

clean, warm, and moisten inhaled air

pupillary light reflex

normal constriction of pupils when a light shines on the retina

Valvular Heart Disease (VHD)

can be acquired or congenital disorder of heart valve; most common causes include rheumatic fever and endocarditis

bilateral edema is usually _________ in nature

cardiac

veins

carry deoxygenated blood via system of blood vessels EX. pulmonary vein carries oxygenated

arteries

carry oxygenated blood via branching blood vessels to capillary beds EX. pulmonary artery carries unoxygenated

right sided heart failure causes

caused by backflow related to left sided HF, acute RV MI, or PE, pulmonary HTN

acute glaucoma

caused by increased ocular pressue; a/m/b oval pupil, dilated pupil, cloudy vision, acute eye pain, halos around light

cochlea

central hearing apparatus

what does the peripheral auditory system do

converts sound vibrations into electrical impulses

canthus

corners of the eyes

clinical manifestations of asthma

cough, anxiety, tachy, dyspnea, SOB, decreased fremitus, wheezing, prolonged expiration

clinical manifestations of atelectasis

cough, dyspnea, tachy, O2 sat decrease, decreased chest expansion on affected side, dull percussion

bulbar conjunctiva

covers and protects the anterior portion of the white sclera

cheilitis

cracking or fissures in the corners of mouth

strabismus

cross-eyes, lazy eyes

normocephalic

normal head size

scar

normal tissue replaced with collagen

optic disc is located towards the _____

nose

epistaxis

nose bleed, most common site is Kiesselbach's plexus

nares

nostrils

iritis

dark red halo arouund iris and cornea; can cause photophobia, ciliary flushing, blurred vision, and pain

left sided heart failure

decreased pumping ability leads to fluid accumulation leading to fluid back up in the left atrium to lungs

visceral pain

deep internal pain - organs

sunken eyeballs indicate

dehydration/malnutrition

what do the external oblique and the abdominal rectus do for breathing

depress lower ribs and compress viscera

what do the internal intercostals do for breathing

depress the ribs

annular or circular lesion

describes circular shape of lesion

emphysema

destruction of alveolar walls that causes permanent abnormal enlargement of air spaces

mydriasis

dilated and fixed pupils

acute pain

dissipates after injury heals

which question is most likely to elicit information about a medical emergency?

do spots move in front of your eyes?; may indicate retinal detachment

chronic pain

does not stop when injury heals

diplopia

double vision

crust

dried drainage or blood

hypothyroidism clinical manifestations

dry skin and hair, periorbital edema, weight gain, fatigue

subconjunctival hemorrhage

due to increased ocular pressure

palperbral fissure

elliptical opening between the eyelids

jugular veins

empty unoxygenated blood directly into the superior vena cava

cyst

encapsulated and fluid filled, mobile, and usually larger in size

acromegaly

enlarged extremities that result from excess hGH production in the pituitary gland

function of mouth

entry of digestive tract, airway for respiratory system

three layers of skin

epidermis, dermis, and subcutaneous

impetigo

erythematous macule that turns into a vesicle or bullae, then forms a honey colored crust. contagious bacterial infection.

types of strabismus

esotropia and exotropia

keloid

excessive scar tissue

the nurse knows that the bronchovesicular breath sounds are:

expected near the major airways

flatness percussion note

extremely dull ex) bone

ptosis

eyelid drooping over pupil

palpebrae

eyelids

behavior general survey

facial expression, mood and affect, speech, dress, personal hygiene

physical neglect

failure to provide basic services

psychological neglect

failure to provide stimulation

financial neglect

failure to use assets

zosteriform lesion

falls along a nerve line or dermatome

left sided HF manifestations

fatigue, SOB, DOE, nocturnal dyspnea, displaced apical pulse, palpable thrill, S3, systolic murmur at apex

subcutaneous layer

fatty tissue

tactile (vocal) fremitus

feel for vibrations when the client says "99" - assessing for fluid buildup

palpation

feeling something to assess the patient

referred pain

felt in one location but is actually originated in another

Lanugo

fine hair layer on premature infants and very underweight people

Macule

flat, <1cm

purpura

flat, reddish purple nonblanchable discoloration of skin, >3mm and flat

BP

force of blood against arterial walls

(4) paranasal sinuses

frontal, maxillary, ethmoid, and sphenoid

cranial bones

frontal, parietal, occipital, and temporal

how to test CNX

gag reflex

mobility general survey

gait and ROM

what herbals increase bleeding risk

garlic and gingko

dead space

space filled with air but does not take part in gas exchange (about 150mL)

how to test CN IX

have client say "ahh" soft palate and uvula should rise

pediculosis capitis

head lice

scale

heaped keratinized cell, flaky/scaly

TSH is _____ in hypothyroidism

high; thyroid hormone is underactive

indirect percussion

hitting your own finger which is resting on the patient

costal angle

how wide/narrow a chest cavity is, 90 degrees or less is normal

during percussion, the nurse knows that a dull percussion note elicited over a lung lobe most likely results from:

increased density of lung tissue

paronychia

infection of cuticle

pneumonia

infection of terminal bronchioles and alveoli in one or both lungs

acute otitis media

infection of the middle ear a/m/b otalgia, fever, hearing loss, bulging red TM, loss of light reflex

sinusitis

inflammation and infection of sinuses a/m/b reddened and swollen nasal mucosa and turbinates, fever, sweats, fatigue, purulent drainage

bronchitis

inflammation of bronchial tree r/t excessive mucus secretions

otitis media with effusion (OME)

inflammation of middle ear space resulting in accumulation of serous fluid in middle ear a/m/b popping, hearing loss, fullness, fluid/air bubbles, retracted TM

blepharitis

inflammation of the eyelash follicles

folliculitis

inflammation of the hair follicle; pustules with an erythematous base

acute rhinitis

inflammation of the nasal mucosa a/m/b clear, watery discharge, inflammation, dark red turbinates

contact dermatitis

inflammatory reaction of skin with vesicles that weep, ooze, crust

retina

innermost portion of the eye that receives visual stimuli and transmits images to the brain for processing

financial abuse

intentional misuse of resources

what does the cerebral cortex auditory system do

interprets the meaning of the sound to determine response

esotropia

inward laziness of eye

what happens to the diaphragm as you breath in

it descends and contracts

how to test for near vision

jagger, rosenbaum, or newspaper 14in from eyes

scoliosis

lateral S-shaped curvature of the thoracic and lumbar spine - severe cases may cause reduced lung volume

fissure

linear crack from epidermis to dermis

palpebral conjunctiva

lines the eyelid

auscultation

listening, usually through a stethoscope

aneurysm

localized dilation of artery caused by weakness in arterial wall

what does the brainstem auditory system do

locates the direction of a sound in space and sound identification

target lesion

looks like a target

ulcer

loss of epidermis and dermis

erosion

loss of part of the epidermis, superficial

tympany percussion note

loud, high pitched sound ex) abdomen

resonant percussion note

low, loud, hollow sound ex) lung sounds

TSH is _____ in hyperthyroidism

low; thyroid hormone is overactive

diaper dermatitis

macularpapular reddened patches with poorly defined borders

Kaposi's Sarcoma

malignant neoplasm often seen with AIDS; dark, bluish purple lesions that start on lower extremities that are painful and pruritic

3 bones of ear

malleus, incus, and stapes

candidiasis

manifests in dark, warm, moist places. Large patch of scaly red rash with sharply demarcated borders

functional assessment is based off of

maslow's hierarchy of needs

hematoma

masses of accumulated blood within a tissue, organ, or body space

function of tongue

mastication, swallowing, cleansing, speech, and taste

systolic pressure

max pressure against the artery during left ventricular contraction

conductive hearing loss

mechanical dysfunction of external or middle ear

choroid

middle layer; lines the recessed portion of the eyeball between the sclera and retina

what may contribute to sensorineural hearing loss?

ototoxic drugs or gradual nerve degeneration

exotropia

outward laziness of eye

bronchovesicular lung sounds

over major bronchi

lymph nodes

preauricular, posterior auricular (mastoid), occipital, submental, submandibular, anterior superficial cervical, posterior superficial cervical

diastolic pressure

pressure between contractions

function of external auditory canal

protection and to alter the sound waves before reaching the TM

exopthalmos

protruding of the eye

allergic rhinitis

pruritic nose and eyes, nasal congestion, sneezing, cough, pale and smooth turbinates

trichotillomania

pulling out own hair

valve between the right ventricle and the pulmonary artery

pulmonic (semilunar) valve

pustule

pus filled cavity

papule

raised, <1cm

confluent lesion

rash is running, no specific borders

3 qualities of pulse

rate, rhythm, force

empathy

recognizing the others emotions

squamous cell carcinoma

red, scaly patch with demarcated borders, soft, mobile, and elevated

atopic dermatitis

red, weeping, crusted lesions that are usually on extremities and is pruritic

erythema

redness

what is review of systems

relatively head to toe examination of the body and body systems

qualities of respirations

relaxed, non-labored, automatic

reflection

repeat part of what the client says to provide better clarity

predominant note over lung fields is _____

resonance

internal layer of the eye includes the (4)

retina, optic disc, retinal vessels, macula

JVD is indicative of:

right sided heart failure

jugular veins are an important indicator of:

right-sided heart function

Congenital Heart Disease (CHD) types

right-to-left and left-to-right

tinnitus

ringing in ears

Tinea infections

ringworm, athletes foot, circular well demarcated lesions with clear center; fungal

linear lesion

scar or scratch - in a line

acute respiratory distress syndrome (ARDS)

severe, generalized injury of the alveolar-capillary membrane

nystagmus

shaking/bouncing of the eye, lateral is normal, vertical is abnormal

body structure general survey

stature, nutrition, symmetry, posture, position, body build, contour, obvious physical deformities

during an examination of the anterior thorax, the nurse is aware that the trachea bifurcates anteriorly at the _______

sternal angle

neck muscles

sternocleidomastoid and trapezius

what kind of data is given in the reason for seeking care

subjective

dermatitis

superficial inflammatory conditions of skin

wheal

superficial raised red lesion

diaphoresis

sweating

timing of carotid pulse is very close to ventricular _______

systole

pulse pressure

systolic-diastolic

clinical manifestations of ARDS

tachypnea, shallow breaths, productive cough, use of accessory muscles, "shock state," possible crackles/rhonchi

vital signs general survey

temp, pulse, respirations, BP, O2 sat

Bell's palsy

temporary form of facial paralysis that occurs with damage to CN VII; may be caused by the herpes simplex virus

alveoli

terminal "ends" to the respiratory tree that form an outcrop of sacs or ducts within the lung parenchyma

corneal light reflex (hirschberg test)

tests for strabismus

diagnostic positions test

tests six cardinal fields of gaze, look for nystagmus

what does 20/30 mean

the client can see at 20 feet what a normal person can see at 30 feet

dull percussion note

thud ex) densities, organs

petechiae

tiny red or brown pinpoint lesions <3mm

otomycosis

tiny, multiple white and/or black dots on ear drum or canal walls due to a fungal infection

function of the iris

to expand and contract the pupil, to regulate the amount of light that reaches the retina

function of turbinates

to increase internal nasal surface area

what is the purpose of an interview

to obtain subjective data

purpose of the skull

to protect the brain and spinal cord

epidermis layer

top layer with no blood vessels, basal cell layer and horny cell layer

before inserting the otoscope into a client's ear, you should palpate the

tragus and pinna

functions of the middle ear (3)

transmits sound vibrations, protection from intense vibration, equalize air pressure

function of the tympanic membrane

transmits sound waves through vibration

beau's line

transverse grooves in nails, usually from trauma

tension pneumothorax

trapped air in pleural space increases leading to a compressed lung and shifting mediastimum to unaffected side

valve between the right atrium and right ventricle

tricuspid (AV) valve

down syndrome

trisomy 21, genetic disorder where a person has 47 chromosomes instead of 46

lung cancer

uncontrolled growth of anaplastic cells in lung

clinical manifestations of emphysema

underweight with barrel chest, SOB, minimal exertion, use of accessory muscles, chronic cough, decreased breath sounds, hyperresonance

cluster headache

unilateral, behind the eye, excruciating, typically lasts 30 mins to 2 hours but will repeat

right-to-left CHD

unoxygenated blood from the right side of the heart enters the left side and systemic circulation - cyanotic

diaphragm

used for high pitched sounds

bell

used for low pitched sounds

snellen eye chart

used to test central vision acuity

summary

validating the education that's been done

VHD - incompetent valve

valve does not close completely

VHD - stenotic valve

valve does not open completely

malignant melanoma

variation in color of a nevi which may involve flaking, scaling, or drainage - ABCDE's

dermis layer

vascular, connective, and elastic tissue

cocaine and nicotine decrease oxygen supply due to:

vasoconstriction