EX 2
effects of aging on respiration
-Respiratory strength declines -Lungs lose elasticity -Decreased flexibility in rib cartilage -Bone density decreases
list the adventitious breath sounds
-fine crackles -coarse crackles -pleural friction rub -Wheezes (sibilant) -Rhonchi (sonorous) -stridor
function of lower respiratory tract
Transports air to lungs for gas exchange
what is the function of the abducens nerve
innervates lateral rectus muscle abducts eye
what is the function of the trochlea nerve
innervates superior oblique muscles
what is the function of the ocular motor nerve
innervates the rest: superior, inferior & medial rectus & inferior oblique muscles
which technology will be used for the treatment of electrical burns? a. skin substitutes b. electrical stimulation c. topical growth factors d. hyperbaric oxygen therapy
D. hyperbaric oxygen therapy
Signs of cyanosis
- bluish discoloration. - bluish nail beds or mucous membranes/lips. - digital clubbing. - bluish tongue RR > 30/min O2 sat <90%
ear changes in the elderly
- delayed electrical responses in brain (longer time to process and respond to information) - fine hairs lining ear canal become coarser and stiffer - decrease hearing - cerumen build up - cerumen becomes drier
what are normal eye changes in older adults
- eye sits deeper - eyebrows thin - conjunctiva thin, may yellow - iris: irregular pigmentation - decreased tear formation - vision may decline - smaller pupils (loss of accommodation, decreased night vision, decreased depth perception) - lens enlarge, transparency decrease
what are clues of hearing loss
- patiently leaning forward to hear - position a head with the good ear forward - concentrating on lip movements - asking questions to be repeated - using a loud or monotone voice
list the 3 salivary glands and their location
-parotid: below ear, over masseter -submandibular: lower mandible -sublingual: under tongue
tonsil grades
1+ visible 2+ halfway between tonsillar pillars and uvula 3+ touching the uvula 4+ touching each other +1, +2 are normal
During an examination, the nurse knows that the best way to palpate the lymph nodes in the neck is described by which statement? a. Using gentle pressure, palpate with both hands to compare the two sides. b. Using strong pressure, palpate with both hands to compare the two sides. c. Gently pinch each node between ones thumb and forefinger, and then move down the neck muscle. d. Using the index and middle fingers, gently palpate by applying pressure in a rotating pattern.
A
order of the 10 lymph nodes:
1. preauricular 2. posterior auricular 3. occipital 4. submental 5. submandibular 6. jugulodigastric 7. superficial cervical 8. deep cervical chain 9. posterior cervical 10. supraclavicular
The nurse is testing a patients visual accommodation, which refers to which action? a. Pupillary constriction when looking at a near object b. Pupillary dilation when looking at a far object c. Changes in peripheral vision in response to light d. Involuntary blinking in the presence of bright light
A
The nurse suspects that a patient has hyperthyroidism, and the laboratory data indicate that the patients T4 and T3 hormone levels are elevated. Which of these findings would the nurse most likely find on examination? a. Tachycardia b. Constipation c. Rapid dyspnea d. Atrophied nodular thyroid gland
A
Where is the apex of the lung located?
2-4 cm above clavicle
When examining the eye, the nurse notices that the patients eyelid margins approximate completely. The nurse recognizes that this assessment finding: a. Is expected. b. May indicate a problem with extraocular muscles. c. May result in problems with tearing. d. Indicates increased intraocular pressure
A
When performing the corneal light reflex assessment, the nurse notes that the light is reflected at 2 oclock in each eye. The nurse should: a. Consider this a normal finding. b. Refer the individual for further evaluation. c. Document this finding as an asymmetric light reflex. d. Perform the confrontation test to validate the findings
A
A patients laboratory data reveal an elevated thyroxine (T4) level. The nurse would proceed with an examination of the _____ gland. a. Thyroid b. Parotid c. Adrenal d. Parathyroid
A
A patients vision is recorded as 20/80 in each eye. The nurse interprets this finding to mean that the patient: a. Has poor vision. b. Has acute vision. c. Has normal vision. d. Is presbyopic.
A
During an examination, the nurse finds that a patient has excessive dryness of the skin. The best term to describe this condition is: a. Xerosis. b. Pruritus. c. Alopecia. d. Seborrhea.
A
While performing an assessment of a 65-year-old man with a history of hypertension and coronary artery disease, the nurse notices the presence of bilateral pitting edema in the lower legs. The skin is puffy and tight but normal in color. No increased redness or tenderness is observed over his lower legs, and the peripheral pulses are equal and strong. In this situation, the nurse suspects that the likely cause of the edema is which condition? a. Heart failure b. Venous thrombosis c. Local inflammation d. Blockage of lymphatic drainage
A Bilateral edema or edema that is generalized over the entire body is caused by a central problem such as heart failure or kidney failure. Unilateral edema usually has a local or peripheral cause
The nurse just noted from the medical record that the patient has a lesion that is confluent in nature. On examination, the nurse expects to find: a. Lesions that run together. b. Annular lesions that have grown together. c. Lesions arranged in a line along a nerve route. d. Lesions that are grouped or clustered together
A Confluent lesions (as with urticaria [hives]) run together. Grouped lesions are clustered together. Annular lesions are circular in nature. Zosteriform lesions are arranged along a nerve route.
A 75-year-old woman who has a history of diabetes and peripheral vascular disease has been trying to remove a corn on the bottom of her foot with a pair of scissors. The nurse will encourage her to stop trying to remove the corn with scissors because: a. The woman could be at increased risk for infection and lesions because of her chronic disease. b. With her diabetes, she has increased circulation to her foot, and it could cause severe bleeding. c. She is 75 years old and is unable to see; consequently, she places herself at greater risk for self injury with the scissors. d. With her peripheral vascular disease, her range of motion is limited and she may not be able to reach the corn safely
A A personal history of diabetes and peripheral vascular disease increases a persons risk for skin lesions in the feet or ankles. The patient needs to seek a professional for assistance with corn removal.
The nurse is performing an external eye examination. Which statement regarding the outer layer of the eye is true? a. The outer layer of the eye is very sensitive to touch. b. The outer layer of the eye is darkly pigmented to prevent light from reflecting internally. c. The trigeminal nerve (CN V) and the trochlear nerve (CN IV) are stimulated when the outer Test Bank - Physical Examination and Health Assessment 8e (by Jarvis) 194 surface of the eye is stimulated. d. The visual receptive layer of the eye in
A The cornea and the sclera make up the outer layer of the eye. The cornea is very sensitive to touch. The middle layer, the choroid, has dark pigmentation to prevent light from reflecting internally. The trigeminal nerve (CN V) and the facial nerve (CN VII) are stimulated when the outer surface of the eye is stimulated. The retina, in the inner layer of the eye, is where light waves are changed into nerve impulses
When examining a patients CN function, the nurse remembers that the muscles in the neck that are innervated by CN XI are the: a. Sternomastoid and trapezius. b. Spinal accessory and omohyoid. c. Trapezius and sternomandibular. d. Sternomandibular and spinal accessory
A The major neck muscles are the sternomastoid and the trapezius. They are innervated by CN XI, the spinal accessory.
A 45-year-old farmer comes in for a skin evaluation and complains of hair loss on his head. His hair seems to be breaking off in patches, and he notices some scaling on his head. The nurse begins the examination suspecting: a. Tinea capitis. b. Folliculitis c. Toxic alopecia. d. Seborrheic dermatitis.
A Tinea capitis is rounded patchy hair loss on the scalp, leaving broken-off hairs, pustules, and scales on the skin, and is caused by a fungal infection. Lesions are fluorescent under a Wood light and are usually observed in children and farmers; tinea capitis is highly contagious.
The nurse is examining a patient who tells the nurse, I sure sweat a lot, especially on my face and feet but it doesnt have an odor. The nurse knows that this condition could be related to: a. Eccrine glands. b. Apocrine glands. c. Disorder of the stratum corneum. d. Disorder of the stratum germinativum
A The eccrine glands are coiled tubules that directly open onto the skin surface and produce a dilute saline solution called sweat. Apocrine glands are primarily located in the axillae, anogenital area, nipples, and naval area and mix with bacterial flora to produce the characteristic musky body odor. The patients statement is not related to disorders of the stratum corneum or the stratum germinativum
What is torus palatinus?
A bony overgrowth at the midline of the hard palate.
a client is hospitalized with pressure injuries. which task(s) could be delegated to an unlicensed assistive personnel (UAP)? (select all that apply) a. empty wound drainage containers b. report changes in wound appearance c. apply prescribed dressings and medications d. access and record data about wound appearance e. choose dressing and therapies for wound treatment
A, B
The nurse is preparing for a certification course in skin care and needs to be familiar with the various lesions that may be identified on assessment of the skin. Which of the following definitions are correct? Select all that apply. a. Petechiae: Tiny punctate hemorrhages, 1 to 3 mm, round and discrete, dark red, purple, or brown in color b. Bulla: Elevated, circumscribed lesion filled with turbid fluid (pus) c. Papule: Hypertrophic scar d. Vesicle: Known as a friction blister e. Nodule: Solid, elevated, and hard or soft growth that is larger than 1 cm
A, D, E A pustule is an elevated, circumscribed lesion filled with turbid fluid (pus). A hypertrophic scar is a keloid. A bulla is larger than 1 cm and contains clear fluid. A papule is solid and elevated but measures less than 1 cm.
What are the 5As of smoking cessation?
Ask Advise Assess Assist Arrange
. Which of these assessment findings would the nurse expect to see when examining the eyes of a black patient? a. Increased night vision b. Dark retinal background c. Increased photosensitivity d. Narrowed palpebral fissures
B
A 22-year-old woman comes to the clinic because of severe sunburn and states, I was out in the sun for just a couple of minutes. The nurse begins a medication review with her, paying special attention to which medication class? a. Nonsteroidal anti-inflammatory drugs for pain b. Tetracyclines for acne c. Proton pump inhibitors for heartburn d. Thyroid replacement hormone for hypothyroidism
B
A male patient with a history of acquired immunodeficiency syndrome (AIDS) has come in for an examination and he states, I think that I have the mumps. The nurse would begin by examining the: a. Thyroid gland b. Parotid gland. c. Cervical lymph nodes. d. Mouth and skin for lesions
B
A patient comes to the clinic complaining of neck and shoulder pain and is unable to turn her head. The nurse suspects damage to CN ______ and proceeds with the examination by _____________. a. XI; palpating the anterior and posterior triangles b. XI; asking the patient to shrug her shoulders against resistance c. XII; percussing the sternomastoid and submandibular neck muscles d. XII; assessing for a positive Romberg sign
B
A patient has come in for an examination and states, I have this spot in front of my ear lobe on my cheek that seems to be getting bigger and is tender. What do you think it is? The nurse notes swelling below the angle of the jaw and suspects that it could be an inflammation of his: a. Thyroid gland. b. Parotid gland. c. Occipital lymph node. d. Submental lymph node
B
An older adult woman is brought to the emergency department after being found lying on the kitchen floor for 2 days; she is extremely dehydrated. What would the nurse expect to see during the examination? a. Smooth mucous membranes and lips b. Dry mucous membranes and cracked lips c. Pale mucous membranes d. White patches on the mucous membranes
B
During a skin assessment, the nurse notices that a Mexican-American patient has skin that is yellowishbrown; however, the skin on the hard and soft palate is pink and the patients scleras are not yellow. From this finding, the nurse could probably rule out: a. Pallor b. Jaundice c. Cyanosis d. Iron deficiency
B
The nurse is assessing a patient who has liver disease for jaundice. Which of these assessment findings is indicative of true jaundice? a. Yellow patches in the outer sclera b. Yellow color of the sclera that extends up to the iris c. Skin that appears yellow when examined under low light d. Yellow deposits on the palms and soles of the feet where jaundice first appears
B
The nurse is performing the diagnostic positions test. Normal findings would be which of these results? a. Convergence of the eyes b. Parallel movement of both eyes c. Nystagmus in extreme superior gaze d. Slight amount of lid lag when moving the eyes from a superior to an inferior position
B
The nurse is reviewing in age-related changes in the eye for a class. Which of these physiologic changes is responsible for presbyopia? a. Degeneration of the cornea b. Loss of lens elasticity c. Decreased adaptation to darkness d. Decreased distance vision abilities
B
The physician reports that a patient with a neck tumor has a tracheal shift. The nurse is aware that this means that the patients trachea is: a. Pulled to the affected side. b. Pushed to the unaffected side. c. Pulled downward. d. Pulled downward in a rhythmic pattern
B
A 52-year-old woman has a papule on her nose that has rounded, pearly borders and a central red ulcer. She said she first noticed it several months ago and that it has slowly grown larger. The nurse suspects which condition? a. Acne b. Basal cell carcinoma c. Melanoma d. Squamous cell carcinoma
B Basal cell carcinoma usually starts as a skin-colored papule that develops rounded, pearly borders with a central red ulcer. It is the most common form of skin cancer and grows slowly. This description does not fit acne lesions
A patient is unable to differentiate between sharp and dull stimulation to both sides of her face. The nurse suspects: a. Bell palsy. b. Damage to the trigeminal nerve. c. Frostbite with resultant paresthesia to the cheeks. d. Scleroderma.
B Facial sensations of pain or touch are mediated by CN V, which is the trigeminal nerve. Bell palsy is associated with CN VII damage. Frostbite and scleroderma are not associated with this problem
A patient says that she has recently noticed a lump in the front of her neck below her Adams apple that seems to be getting bigger. During the assessment, the finding that leads the nurse to suspect that this may not be a cancerous thyroid nodule is that the lump (nodule): a. Is tender. b. Is mobile and not hard. c. Disappears when the patient smiles. d. Is hard and fixed to the surrounding structures.
B Painless, rapidly growing nodules may be cancerous, especially the appearance of a single nodule in a young person. However, cancerous nodules tend to be hard and fixed to surrounding structures, not mobile
A 40-year-old woman reports a change in mole size, accompanied by color changes, itching, burning, and bleeding over the past month. She has a dark complexion and has no family history of skin cancer, but she has had many blistering sunburns in the past. The nurse would: a. Tell the patient to watch the lesion and report back in 2 months. b. Refer the patient because of the suggestion of melanoma on the basis of her symptoms. c. Ask additional questions regarding environmental irritants that may have caused this condition. d. Tell the patient that these signs suggest a compound nevus, which is very common in young to middle-aged adults
B The ABCD danger signs of melanoma are asymmetry, border irregularity, color variation, and diameter. In addition, individuals may report a change in size, the development of itching, burning, and bleeding, or a newpigmented lesion. Any one of these signs raises the suggestion of melanoma and warrants immediate referral
A patient reports excruciating headache pain on one side of his head, especially around his eye, forehead, and cheek that has lasted approximately to 2 hours, occurring once or twice each day. The nurse should suspect: a. Hypertension. b. Cluster headaches. c. Tension headaches. d. Migraine headaches
B Cluster headaches produce pain around the eye, temple, forehead, and cheek and are unilateral and always on the same side of the head. They are excruciating and occur once or twice per day and last to 2 hours each
A semiconscious woman is brought to the emergency department after she was found on the floor in her kitchen. Her face, nail beds, lips, and oral mucosa are a bright cherry-red color. The nurse suspects that this coloring is due to: a. Polycythemia. b. Carbon monoxide poisoning. c. Carotenemia. d. Uremia
B A bright cherry-red coloring in the face, upper torso, nail beds, lips, and oral mucosa appears in cases of carbon monoxide poisoning
The nurse is assessing the skin of a patient who has acquired immunodeficiency syndrome (AIDS) and notices multiple patchlike lesions on the temple and beard area that are faint pink in color. The nurse recognizes these lesions as: a. Measles (rubeola). b. Kaposis sarcoma. c. Angiomas. d. Herpes zoster
B Kaposis sarcoma is a vascular tumor that, in the early stages, appears as multiple, patchlike, faint pink lesions over the patients temple and beard areas. Measles is characterized by a red-purple maculopapular blotchy rash that appears on the third or fourth day of illness. The rash is first observed behind the ears, spreads over the face, and then spreads over the neck, trunk, arms, and legs. Cherry (senile) angiomas are small (1 to 5 mm), smooth, slightly raised bright red dots that commonly appear on the trunk in all adults over 30 years old. Herpes zoster causes vesicles up to 1 cm in size that are elevated with a cavity containing clear fluid.
The nurse is assessing a 1-month-old infant at his well-baby checkup. Which assessment findings are appropriate for this age? Select all that apply. a. Head circumference equal to chest circumference b. Head circumference greater than chest circumference c. Head circumference less than chest circumference d. Fontanels firm and slightly concave e. Absent tonic neck reflex f. Nonpalpable cervical lymph nodes
B, D, F
When examining the face of a patient, the nurse is aware that the two pairs of salivary glands that are accessible to examination are the ___________ and ___________ glands. a. Occipital; submental b. Parotid; jugulodigastric c. Parotid; submandibular d. Submandibular; occipital
C
During ocular examinations, the nurse keeps in mind that movement of the extraocular muscles is: a. Decreased in the older adult. b. Impaired in a patient with cataracts. c. Stimulated by cranial nerves (CNs) I and II. d. Stimulated by CNs III, IV, and VI
D
. A physician has diagnosed a patient with purpura. After leaving the room, a nursing student asks the nurse what the physician saw that led to that diagnosis. The nurse should say, The physician is referring to the: a. Blue dilation of blood vessels in a star-shaped linear pattern on the legs. b. Fiery red, star-shaped marking on the cheek that has a solid circular center. c. Confluent and extensive patch of petechiae and ecchymoses on the feet. d. Tiny areas of hemorrhage that are less than 2 mm, round, discrete, and dark red in color
C
A 42-year-old woman complains that she has noticed several small, slightly raised, bright red dots on her chest. On examination, the nurse expects that the spots are probably: a. Anasarca. b. Scleroderma. c. Senile angiomas. d. Latent myeloma.
C
A 70-year-old woman who loves to garden has small, flat, brown macules over her arms and hands. She asks, What causes these liver spots? The nurse tells her, They are: a. Signs of decreased hematocrit related to anemia. b. Due to the destruction of melanin in your skin from exposure to the sun. c. Clusters of melanocytes that appear after extensive sun exposure. d. Areas of hyperpigmentation related to decreased perfusion and vasoconstriction.
C
A mother brings in her newborn infant for an assessment and tells the nurse that she has noticed that whenever her newborns head is turned to the right side, she straightens out the arm and leg on the same side and flexes the opposite arm and leg. After observing this on examination, the nurse tells her that this reflex is: a. Abnormal and is called the atonic neck reflex. b. Normal and should disappear by the first year of life. c. Normal and is called the tonic neck reflex, which should disappear between 3 and 4 months of age. d. Abnormal. The baby should be flexing the arm and leg on the right side of his body when the head is turned to the right.
C
A patient, an 85-year-old woman, is complaining about the fact that the bones in her face have become more noticeable. What explanation should the nurse give her? a. Diets low in protein and high in carbohydrates may cause enhanced facial bones. b. Bones can become more noticeable if the person does not use a dermatologically approved moisturizer. c. More noticeable facial bones are probably due to a combination of factors related to aging, such as decreased elasticity, subcutaneous fat, and moisture in her skin. d. Facial skin becomes more elastic with age. This increased elasticity causes the skin to be more taught, drawing attention to the facial bones
C
A patients thyroid gland is enlarged, and the nurse is preparing to auscultate the thyroid gland for the presence of a bruit. A bruit is a __________ sound that is heard best with the __________ of the stethoscope. a. Low gurgling; diaphragm b. Loud, whooshing, blowing; bell c. Soft, whooshing, pulsatile; bell d. High-pitched tinkling; diaphragm
C
A visitor from Poland who does not speak English seems to be somewhat apprehensive about the nurse examining his neck. He would probably be more comfortable with the nurse examining his thyroid gland from: a. Behind with the nurses hands placed firmly around his neck. b. The side with the nurses eyes averted toward the ceiling and thumbs on his neck. c. The front with the nurses thumbs placed on either side of his trachea and his head tilted forward. d. The front with the nurses thumbs placed on either side of his trachea and his head tilted backward
C
A woman comes to the clinic and states, Ive been sick for so long! My eyes have gotten so puffy, and my eyebrows and hair have become coarse and dry. The nurse will assess for other signs and symptoms of: a. Cachexia. b. Parkinson syndrome. c. Myxedema. d. Scleroderma
C
During an admission assessment, the nurse notices that a male patient has an enlarged and rather thick skull. The nurse suspects acromegaly and would further assess for: a. Exophthalmos. b. Bowed long bones. c. Coarse facial features. d. Acorn-shaped cranium
C
The nurse needs to palpate the temporomandibular joint for crepitation. This joint is located just below the temporal artery and anterior to the: a. Hyoid bone. b. Vagus nerve. c. Tragus. d. Mandible
C
The nurse notices that an infant has a large, soft lump on the side of his head and that his mother is very concerned. She tells the nurse that she noticed the lump approximately 8 hours after her babys birth and that it seems to be getting bigger. One possible explanation for this is: a. Hydrocephalus. b. Craniosynostosis. c. Cephalhematoma. d. Caput succedaneum
C
When examining a patients eyes, the nurse recalls that stimulation of the sympathetic branch of the autonomic nervous system: a. Causes pupillary constriction. b. Adjusts the eye for near vision. c. Elevates the eyelid and dilates the pupil. d. Causes contraction of the ciliary body
C
which rationale is correct for the nurse to empty a Hemovac wound suction device when it is half full? a. emptying the unit is safer when it is half full b. accurate measurement of drainage is facilitated c. negative pressure in the unit lessens as fluid accumulates, interfering with further drainage d. fluid collecting in the unit exerts positive pressure, forcing drainage back up the tubing and into the wound
C
During an examination of a female patient, the nurse notes lymphadenopathy and suspects an acute infection. Acutely infected lymph nodes would be: a. Clumped. b. Unilateral. c. Firm but freely movable. d. Firm and nontender
C Acutely infected lymph nodes are bilateral, enlarged, warm, tender, and firm but freely movable. Unilaterally enlarged nodes that are firm and nontender may indicate cancer
A 35-year-old pregnant woman comes to the clinic for a monthly appointment. During the assessment, the nurse notices that she has a brown patch of hyperpigmentation on her face. The nurse continues the skin assessment aware that another finding may be: a. Keratoses. b. Xerosis. c. Chloasma. d. Acrochordons
C In pregnancy, skin changes can include striae, linea nigra (a brownish-black line down the midline), chloasma (brown patches of hyperpigmentation), and vascular spiders. Keratoses are raised, thickened areas of pigmentation that look crusted, scaly, and warty. Xerosis is dry skin. Acrochordons, or skin tags, occur more often in the aging adult
A patient comes to the clinic and tells the nurse that he has been confined to his recliner chair for approximately 3 days with his feet down and he asks the nurse to evaluate his feet. During the assessment, the nurse might expect to find: a. Pallor b. Coolness c. Distended veins d. Prolonged capillary filling time
C Keeping the feet in a dependent position causes venous pooling, resulting in redness, warmth, and distended veins. Prolonged elevation would cause pallor and coolness. Immobilization or prolonged inactivity would cause prolonged capillary filling time
A patient is especially worried about an area of skin on her feet that has turned white. The health care provider has told her that her condition is vitiligo. The nurse explains to her that vitiligo is: a. Caused by an excess of melanin pigment b. Caused by an excess of apocrine glands in her feet c. Caused by the complete absence of melanin pigment d. Related to impetigo and can be treated with an ointment
C Vitiligo is the complete absence of melanin pigment in patchy areas of white or light skin on the face, neck, hands, feet, body folds, and around orificesotherwise, the depigmented skin is normal
A patient comes in for a physical examination and complains of freezing to death while waiting for her examination. The nurse notes that her skin is pale and cool and attributes this finding to: a. Venous pooling. b. Peripheral vasodilation. c. Peripheral vasoconstriction. d. Decreased arterial perfusion.
C "?:K54Q5Q2 A chilly or air-conditioned environment causes vasoconstriction, which results in false pallor and coolness
A 60-year-old man is at the clinic for an eye examination. The nurse suspects that he has ptosis of one eye. How should the nurse check for this? a. Perform the confrontation test. b. Assess the individuals near vision. c. Observe the distance between the palpebral fissures. d. Perform the corneal light test, and look for symmetry of the light reflex.
C A 60-year-old man is at the clinic for an eye examination. The nurse suspects that he has ptosis of one eye. How should the nurse check for this? a. Perform the confrontation test. b. Assess the individuals near vision. c. Observe the distance between the palpebral fissures. d. Perform the corneal light test, and look for symmetry of the light reflex.
The nurse is assessing for inflammation in a dark-skinned person. Which technique is the best? a. Assessing the skin for cyanosis and swelling b. Assessing the oral mucosa for generalized erythema c. Palpating the skin for edema and increased warmth d. Palpating for tenderness and local areas of ecchymosis
C Because inflammation cannot be seen in dark-skinned persons, palpating the skin for increased warmth, for taut or tightly pulled surfaces that may be indicative of edema, and for a hardening of deep tissues or blood vessels is often necessary
The nurse notices that a patients palpebral fissures are not symmetric. On examination, the nurse may find that damage has occurred to which cranial nerve (CN)? a. III b. V c. VII d. VIII
C Facial muscles are mediated by CN VII; asymmetry of palpebral fissures may be attributable to damage to CN VII (Bell palsy).
During the aging process, the hair can look gray or white and begin to feel thin and fine. The nurse knows that this occurs because of a decrease in the number of functioning: a. Metrocytes. b. Fungacytes. c. Phagocytes. d. Melanocytes
D
A black patient is in the intensive care unit because of impending shock after an accident. The nurse expects to find what characteristics in this patients skin? a. Ruddy blue. b. Generalized pallor. c. Ashen, gray, or dull. d. Patchy areas of pallor
C Pallor attributable to shock, with decreased perfusion and vasoconstriction, in black-skinned people will cause the skin to appear ashen, gray, or dull
A patient has been admitted for severe psoriasis. The nurse expects to see what finding in the patients fingernails? a. Splinter hemorrhages b. Paronychia c. Pitting d. Beau lines
C Sharply defined pitting and crumbling of the nails, each with distal detachment characterize pitting nails and are associated with psoriasis
A physician tells the nurse that a patients vertebra prominens is tender and asks the nurse to reevaluate the area in 1 hour. The area of the body the nurse will assess is: a. Just above the diaphragm. b. Just lateral to the knee cap. c. At the level of the C7 vertebra. d. At the level of the T11 vertebra.
C The C7 vertebra has a long spinous process, called the vertebra prominens, which is palpable when the head is flexed
five days after a client has abdominal surgery the nurse assesses the client's incision site for signs of dehiscence. which clinical finding supports that client is experiencing wound dehiscence? a. increased bowel sounds b. loosening of intact sutures c. sudden increase in serosanguineous drainage d. purplish color of the incision
C. sudden increase in serosanguineous drainage
During an assessment of the sclera of a black patient, the nurse would consider which of these an expected finding? a. Yellow fatty deposits over the cornea b. Pallor near the outer canthus of the lower lid c. Yellow color of the sclera that extends up to the iris d. Presence of small brown macules on the sclera
D
. A 52-year-old patient describes the presence of occasional floaters or spots moving in front of his eyes. The nurse should: a. Examine the retina to determine the number of floaters. b. Presume the patient has glaucoma and refer him for further testing. c. Consider these to be abnormal findings, and refer him to an ophthalmologist. d. Know that floaters are usually insignificant and are caused by condensed vitreous fibers.
D
. The nurse is reviewing causes of increased intraocular pressure. Which of these factors determines intraocular pressure? a. Thickness or bulging of the lens b. Posterior chamber as it accommodates increased fluid c. Contraction of the ciliary body in response to the aqueous within the eye d. Amount of aqueous produced and resistance to its outflow at the angle of the anterior chamber
D
A 19-year-old college student is brought to the emergency department with a severe headache he describes as, Like nothing Ive ever had before. His temperature is 40 C, and he has a stiff neck. The nurse looks for other signs and symptoms of which problem? a. Head injury b. Cluster headache c. Migraine headache d. Meningeal inflammation
D
A man has come in to the clinic for a skin assessment because he is worried he might have skin cancer. During the skin assessment the nurse notices several areas of pigmentation that look greasy, dark, and stuck on his skin. Which is the best prediction? a. Senile lentigines, which do not become cancerous b. Actinic keratoses, which are precursors to basal cell carcinoma c. Acrochordons, which are precursors to squamous cell carcinoma d. Seborrheic keratoses, which do not become cancerous
D
A patient has a normal pupillary light reflex. The nurse recognizes that this reflex indicates that: a. The eyes converge to focus on the light. b. Light is reflected at the same spot in both eyes. c. The eye focuses the image in the center of the pupil. d. Constriction of both pupils occurs in response to bright light.
D
A woman is leaving on a trip to Hawaii and has come in for a checkup. During the examination the nurse learns that she has diabetes and takes oral hypoglycemic agents. The patient needs to be concerned about which possible effect of her medications? a. Increased possibility of bruising b. Skin sensitivity as a result of exposure to salt water c. Lack of availability of glucose-monitoring supplies d. Importance of sunscreen and avoiding direct sunlight
D
The nurse is assessing for clubbing of the fingernails and expects to find: a. Nail bases that are firm and slightly tender. b. Curved nails with a convex profile and ridges across the nails. c. Nail bases that feel spongy with an angle of the nail base of 150 degrees d. Nail bases with an angle of 180 degrees or greater and nail bases that feel spongy.
D
The nurse is bathing an 80-year-old man and notices that his skin is wrinkled, thin, lax, and dry. This finding would be related to which factor in the older adult? a. Increased vascularity of the skin b. Increased numbers of sweat and sebaceous glands c. An increase in elastin and a decrease in subcutaneous fat d. An increased loss of elastin and a decrease in subcutaneous fat
D
The nurse notices that a patient has a solid, elevated, circumscribed lesion that is less than 1 cm in diameter. When documenting this finding, the nurse reports this as a: a. Bulla. b. Wheal. c. Nodule. d. Papule
D
The nurse notices that a patients submental lymph nodes are enlarged. In an effort to identify the cause of the node enlargement, the nurse would assess the patients: a. Infraclavicular area. b. Supraclavicular area. c. Area distal to the enlarged node. d. Area proximal to the enlarged node.
D
A patient comes to the clinic and states that he has noticed that his skin is redder than normal. The nurse understands that this condition is due to hyperemia and knows that it can be caused by: a. Decreased amounts of bilirubin in the blood b. Excess blood in the underlying blood vessels c. Decreased perfusion to the surrounding tissues d. Excess blood in the dilated superficial capillaries
D Erythema is an intense redness of the skin caused by excess blood (hyperemia) in the dilated superficial capillaries
A 65-year-old man with emphysema and bronchitis has come to the clinic for a follow-up appointment. On assessment, the nurse might expect to see which finding? a. Anasarca b. Scleroderma c. Pedal erythema d. Clubbing of the nails
D Clubbing of the nails occurs with congenital cyanotic heart disease and neoplastic and pulmonary diseases. The other responses are assessment findings not associated with pulmonary diseases
The nurse educator is preparing an education module for the nursing staff on the dermis layer of skin. Which of these statements would be included in the module? The dermis: a. Contains mostly fat cells. b. Consists mostly of keratin. c. Is replaced every 4 weeks. d. Contains sensory receptor
D ` The dermis consists mostly of collagen, has resilient elastic tissue that allows the skin to stretch, and contains nerves, sensory receptors, blood vessels, and lymphatic vessels. It is not replaced every 4 weeks.
A patient has had a terrible itch for several months that he has been continuously scratching. On examination, the nurse might expect to find: a. A keloid. b. A fissure. c. Keratosis. d. Lichenification
D Lichenification results from prolonged, intense scratching that eventually thickens the skin and produces tightly packed sets of papules. A keloid is a hypertrophic scar. A fissure is a linear crack with abrupt edges, which extends into the dermis; it can be dry or moist. Keratoses are lesions that are raised, thickened areas of pigmentation that appear crusted, scaly, and warty
A patient complains that while studying for an examination he began to notice a severe headache in the frontotemporal area of his head that is throbbing and is somewhat relieved when he lies down. He tells the nurse that his mother also had these headaches. The nurse suspects that he may be suffering from: a. Hypertension. b. Cluster headaches. c. Tension headaches. d. Migraine headaches.
D Migraine headaches tend to be supraorbital, retroorbital, or frontotemporal with a throbbing quality. They are severe in quality and are relieved by lying down. Migraines are associated with a family history of migraine headaches.
The nurse is aware that the four areas in the body where lymph nodes are accessible are the: a. Head, breasts, groin, and abdomen. b. Arms, breasts, inguinal area, and legs. c. Head and neck, arms, breasts, and axillae. d. Head and neck, arms, inguinal area, and axillae
D Nodes are located throughout the body, but they are accessible to examination only in four areas: head and neck, arms, inguinal region, and axillae.
The nurse educator is preparing an education module for the nursing staff on the epidermal layer of skin. Which of these statements would be included in the module? The epidermis is: a. Highly vascular. b. Thick and tough. c. Thin and nonstratified. d. Replaced every 4 weeks
D The epidermis is thin yet tough, replaced every 4 weeks, avascular, and stratified into several zones
cranial nerves are part of what system
Peripheral Nervous System (PNS)
what is the pathway of hearing
Pinna --> Ear Canal --> Tympanum --> Ossicles --> Cochlea
Define dehiscense
Separation of the incisional edges
What is a bifid uvula?
a condition in which uvula is split either completely or partially; occurs in 10% of some American Indian groups
which color would the nurse anticipate when assessing a client's skin tears? a. red b. gray c. black d. yellow
a. Red
what is cranial nerve VI
abducens nerve
signs of hyperthyroidism
anxiety weight loss palpitations tachycardia heat intolerance fine, limp hair low TSH high T3
ABCDEs of melanoma
asymmetry, border, color, diameter, evolution
The nurse is conducting a visual examination. Which of these statements regarding visual pathways and visual fields is true? a. The right side of the brain interprets the vision for the right eye. b. The image formed on the retina is upside down and reversed from its actual appearance in the outside world. c. Light rays are refracted through the transparent media of the eye before striking the pupil. d. Light impulses are conducted through the optic nerve to the temporal lobes of the brain
b
for which purpose would the nurse use hypoallergenic tape or montgomery straps in postoperative skin care? a. conserving the client's energy b. protecting the fragile skin of an older client c. increasing oxygenation to the wound promote healing d. improving perfusion to the wound to promote healing
b. protecting the fragile skin of an older client
pressure changes can lead to
barotrauma
what muscle and nerve in the right eye are used to down and to the right
inferior rectus muscle CN III
what is chronically draining ear called
cholesteatoma (can erode auditory ossicles --> significant damage to hearing)
what is hereditary hemorrhage telangiectasia
chronic nosebleeds develops abnormal blood vessels
sign of infected parotid
chubby cheeks
structure and function of eustachian tube
connects middle ear to nasopharynx allows for pressure regulation of middle ear
while caring for a client with a portable wound drainage system, the nurse observes that the collection container is half full. the nurse empties the container. which nursing intervention would the nurse do next? a. circle the drainage on the dressing b. irrigate the suction tube with sterile saline c. clean the drainage port with an alcohol wipe d. compress the container before closing the port
d. compress the container before closing the port
how would the nurse classify a wound that exhibits some necrotic tissue with a semiliquid slough and exudate? a. red b. black c. green d. yellow
d. yellow
define dysphagia
difficulty swallowing
what is otalgia
ear pain
what is cerumen
ear wax
what is the function of the inferior rectus and what cranial nerve controls it
elevates downward adducts, rotates medially-inward CN III
what is the function of the superior rectus and what cranial nerve controls it
elevates upward adducts, rotates medially-inward CN III
another name for a tick bite
erythema migrans
sinuses NOT accessible for examination and their location
ethmoid sinuses = between the orbits sphenoid sinuses = deep within the skull in the sphenoid bone
signs of hypothyroidism
fatigue dry skin cold intolerance constipation course hair menstrual irregularity high TSH low T4
function of upper respiratory tract
filters, warms, and humidifies air
list the sinuses accessible to examine and their location
frontal sinus = in frontal bone above and medial to orbite maxillary sinuses = in maxilla (cheekbone) along side walls of nasal cavity
functions of respiration
gas exchange, communication, olfaction, acid-base balance, blood pressure regulation, blood and lymph flow, blood filtration, expulsion of abdominal contents
how to perform breath sounds
have patient breathe through mouth (deeper than usual) use diaphragm end of stethoscope to listen to full respiration at each location compare side-to-side
high TSH = Low TSH =
high TSH = hypothyroidism low TSH = hyperthyroidism
characteristics of inhalation
increased thoracic diameter thorax pressure causes slight negative pressure 500-800mL air enters lungs
what muscle and nerve in the right eye used to look up and towards the left
inferior oblique muscle CN III
what muscle and nerve in the right eye are used to look down and to the left
inferior rectus muscle CN III
what is used to test color vision
ishihara cards
why is under the floor of mouth used for oral medication
it is very vascular which allows for fast absorption
what test is used to test near vision
jaeger chart
what is the lacrimal apparatus made up of
lacrimal apparatus = lacrimal gland + lacrimal sac + naso-lacrimal duct
what muscle and nerve in the right eye are used to the right
lateral rectus muscle CN VI
what does the whisper test evaluate
loss of high frequency sounds
most common eye conditions for elderly
macular degeneration, glaucoma, cataracts, diabetic retinopathy f
what muscle and nerve in the right eye are used to left
medial rectus muscle CN III
what is titus median
middle ear infection
what is the function of the lateral rectus and what cranial nerve controls it
moves laterally-towards temple CN VI
what is the function of the medial rectus and what cranial nerve controls it
moves medially CN III
define epistaxis
nosebleed common during pregnancy
what is cranial nerve III
ocular motor nerve
expiration characteristics
passive process diaphragm, internal intercostal, abdominals relax lung pressure > atmospheric pressure air pushed from lungs, out chest, diaphragm relaxes
list the 3 levels of intervention
primary prevention : prevent disease secondary prevention: early detection of disease at curable stage tertiary prevention: reducing complications of existing or established medical dx
the bottom of the scapula is located at which rib
rib 8
what test is used to test distance vision
snellen test
Define Pectus Excavatum
sternum and cartilages sunken inward
Define Pectus Carinatum
sternum protrudes outward
what muscle and nerve in the right eye are used to look up and towards the right
superior rectus muscle CN III
difference in tonsils in the elderly
tonsils shrink with age
define edentulous
toothless
what is cranial nerve IV
trochlea nerve
what is the function of the superior oblique and what cranial nerve controls it
turns downward abducts, rotates laterally CN IV
what is the function of the inferior oblique and what cranial nerve controls it
turns upward abducts, turns laterally CN III
Acute Airway obstruction requires...
urgent attention
where are vertebra prominens
vertebrae C7
Define tactile fremitus
when vibrations are felt on the chest wall test: repetition of "99" by patient
