306 Midterm

Positive obturator sign

Indicates right hypogastric pain suggesting irritation of the obturator muscle by an inflamed appendix

Pneumonia

Infection of lung parenchyma from the respiratory bronchioles to the alveoli

A nurse is preparing to palpate a client's spleen. Which position would the nurse use to facilitate palpation?

Right-side lying

The LLQ contains all of the following structures except: A. Urinary bladder B. Sigmoid colon C. Spleen D. Descending colon

C

A client experiences increasing difficulty taking in a deep breath. For which health problem should the nurse focus when assessing this client?

COPD

COPD

overdistention of air spaces distal to terminal bronchioles, with destruction of alveolar septa and chronic obstruction of the airways

Psoriasis

overgrowth of oil on the skin or manifested plaques; on outside surfaces of body (elbows)

Odynophagia

painful swallowing

LUQ organs

pancreas, aorta, transverse colon, spleen, stomach

Wheal

raised red skin lesion due to interstitial fluid; allergic reaction; localized skin edema

Incontinence secondary to medications

sedatives, tranquilizers, anticholinergics, sympathetic blockers, and potent diuretics cause any type of incontinence

Plaque

(psoriasis) raised elevation that is more than 1 cm

Burrow

(scabies) slightly raised tunnel in the skin; little bugs burrow their way into the skin; very itchy; usually just on the epidermis

Pitting edema scale

1+: 2 mm 2+: 4 mm 3+: 6 mm 4+: 8 mm

The nurse notes that a client's lower left leg swelling is alleviated when the extremity is elevated. Which stage of lymphedema is this client experiencing?

1st stage

Recognizing the patient's feelings without agreeing with them is a form of: A. Validation B. Empathy C. Reassurance D. Transition

A

The nurse is assessing a 79-year-old client's posterior thorax during a focused respiratory assessment. The nurse should attribute what assessment finding to age-related changes? A. Slight kyphosis B. Audible wheeze C. Asymmetrical chest expansion D. Inaudible posterior lung sounds

A

Which of the following would be most important for a nurse when developing critical thinking skills? A. Maintenance of an open mind B. Reliance on current situation C. Quick decision making D. Static knowledge base

A

Which of the following would be most important for the nurse to remember when auscultating the thorax? A. Listen at each site for at least one complete respiratory cycle B. Be alert to the client's comfort and offer rest periods C. Have the client breathe deeply through the mouth D. Auscultate the base at the level of the sixth rib

A

Asthma

A chronic allergic disorder characterized by episodes of severe breathing difficulty, coughing, and wheezing

The patient is complaining of low back pain. Which of the following would be appropriate questions to ask? (Select all that apply.) A. "Can you point with one finger to where it hurts the worst?" B. "On a scale of 1 to 20, with 10 being the worst pain ever, what number is the pain right now?" C. "Have you tried taking any over-the-counter medication for the pain?" C. "Do you remember falling or twisting?"

A,B,C,D

Atopic Eczema

Appears mainly on flexor surfaces; silvery scaly patches

A nurse experiences difficulty with palpation of the dorsalis pedis pulse in a client with arterial insufficiency. What is an appropriate action by the nurse based on this finding?

Assess adequacy of blood flow using a Doppler device

A nurse auscultates a client's lungs and hears fine crackles. What is an appropriate action by the nurse? A. Listen again with the bell of the stethoscope B. Have the client breathe through the mouth C. Instruct the client to cough forcefully D. Assess for the use of accessory muscles

C

A client reports sharp and stabbing chest pain that worsens with deep breathing and coughing. A cardiac cause to this pain is ruled out. The description of the pain is consistent with what respiratory condition? A. Asthma B. Pneumonia C. Rales D. Pleurisy

D

Auscultation of a 23-year-old client's lungs reveals an audible wheeze. What pathological phenomenon underlies wheezing? A. Fluid in the alveoli B. Blockage of a respiratory passage C. Decreased compliance of the lungs D. Narrowing or partial obstruction of an airway passage

D

Edema is produced by four mechanisms

Increased plasma volume from sodium retention; increased capillary membrane permeability, related to burns, snake bites, angioedema, allergic reactions; low plasma protein levels caused by renal disorders; blockage or inadequate removal of lymphatic fluid (lymphedema)

A client complains of epigastric pain and tarry stools. The nurse should suspect what as the underlying cause?

Gastric ulcer

The nurse auscultates the base of the lungs to assess for what reason?

It is where fluid occurs with pulmonary edema

When performing a physical examination for a client with scoliosis, which physical characteristic should the nurse expect to find during the assessment?

Lateral deviation of the spinous processes

Cyst

Nodule that has some expressible material in it

Anxiety with Hyperventilation

Overbreathing, with resultant respiratory alkalosis and fall in the partial pressure of carbon dioxide in the blood

The colon originates in the:

RLQ

When assessing the breath sounds of a newly admitted patient, the nurse notes increased transmission of voice sounds over the right lung. What would this indicate to the nurse?

The lung has become airless

Mrs. LaFarge, 60 years old, presents with urinary incontinence. She cannot get to the bathroom quickly enough when she senses the need to urinate. She has normal mobility. Which is most likely?

Urge incontinence

Ulcer

a deeper loss of epidermis and dermis; may bleed and scar

Tinea versicolor

a fungal infection that causes painless, discolored areas on the skin; usually on chest or neck

Fissure

a linear crack in the skin, often resulting from excessive dryness

Papule

a raised elevation that is less than 1 cm

Pleural effusion

abnormal accumulation of fluid between the pleurae

Diffuse Interstitial Lung Disease

abnormal and widespread infiltration of cells, fluid, and collagen into interstitial spaces between alveoli; many causes

Secondary lesions

acne with pitting and scars; nodules are starting to present

Positive Murphy's sign indicates:

acute cholecystitis

Stress Incontinence

momentary leakage os small amounts of urine with coughing, laughing, and sneezing while the person is in an upright position

RLQ organs

cecum, appendix, ascending colon

Seborrheic Keratosis

common benign lesions on adults; yellowish to brown raised lesions that feel slightly greasy and velvety or warty and have a "stuck on" appearance

The pancreas of an adult client is located

deep in the upper abdomen and is not normally palpable

LLQ organs

descending and sigmoid colon

Dysphagia

difficulty swallowing

Ureteral colic

dramatically different from kidney pain; severe, colicky pain originating at the CVA and radiating around the trunk into the lower quadrant of the abdomen and groin, or possibly into the upper thigh, testicle, or labium. Results from sudden distention of ureter. Ask about any fever, chills, or hemturia.

Left-sided heart failure

elevated pressure in pulmonary capillary bed with movement of fluid into interstitial spaces and alveoli, decreased compliance (increased stiffness) of the lungs, increased work of breathing

Chronic bronchitis

excessive mucus production in bronchi, followed by chronic obstruction of airways

Pustule

filled with pus; acne

Scale

flakes of dead exfoliated epidermis; color may be white, gray, or silvery; texture may be fine or thick

Obturator sign

flex the patient's right thigh at the hip, with the knee bent, and rotate the leg internally at the hip.

Rovsing sign

for referred rebound tenderness; press deeply and evenly in the left lower quadrant then quickly withdraw your fingers

RUQ organs

gallbladder, liver, duodenum

Bulla

greater than 1 cm; skin infection is association with an allergic reaction to a medication

Keloid

hypertrophic scarring that extends beyond the borders of the initiating injury; see a lot on ear or chest when people get tattoos or get a mole removed

functional incontinence

incontinence on the way to the toilet or only in the early morning

What produces pleuritic pain with deep inspiration?

inflammation of the pleura

urge incontinence

involuntary urine loss preceded by an urge to void. The volume tends to be moderate

Afib

it is beating and functional, but it is going quicker and is abnormal. High risk of stroke, must be on blood thinners

Spontaneous pneumothorax

leakage of air into pleural space through blebs on visceral pleura, with resulting partial or complete collapse of the lung

Petechia/Purpura

manifestations of blood outside the vessels; indicative of a bleeding disorder; can happen when people are coughing a lot or in women who give birth

Nodule

marble-like lesion larger than 0.5 cm; deeper and firmer in the skin

Primary lesions

mild, moderate, and severe cystic acne

Actinic Keratosis

seen on sun exposed skin of older adults; superficial, flattened papules covered by a dry scale

Crust

skin condition that starts to ooze and then it crusts over (impetigo); can come from strep throat if there is a break on the skin

Biliary colic

sudden obstruction of the cystic duct or common bile duct by a gallstone

Acute pulmonary embolism

sudden occlusion of part of pulmonary arterial tree by a blood clot that usually originates in deep veins of legs or pelvis

Psoas sign

suggests irritation of the psoas muscle by an inflamed appendix; place hand just above patient's right knee and ask patient to raise that thigh against your hand. Alternatively, ask patient to turn onto left side. Then extend the patient's right leg at the hip. Flexion of the leg at the hip makes the psoas muscle contract; extension stretches it.

Lichenification

thickening of the epidermis in response to a long-term skin condition (seen a lot in people with eczema)

What is harder to localize: visceral or parietal pain?

visceral

Overflow incontinence

when intravesicular pressure overcomes urethral resistance, continuous dripping or dribbling incontinence ensues