health 4 questions

condyloma acuminatum

(genital warts) associated with tannish, brown to purplish white lesions that are macular or papular.

Shoulders have forward flexion of ____ and backward extension of up to _____

180 degrees, 50 degrees

When assesing the ROM of a clients ankle the nurse would place the client through which movements

Dorsiflexion, plantar flexion, inversion, eversion.

the nurse observes that the urinary meatus is on the dorsal side of the penis of a newborn. this would be

Epispadias, describes when the urinary meatus opens on the dorsal aspect of the penis as opposed to being centrally located.

example of a manisfestation of gout

Gout is an alteration of purine metabolism that produces tophi, erthyema, pain and edema.

the nurse is performing a vaginal examination and assesses wart like lesions on the vulva, the may indicate what health problem.

HPV.

The nurse is examining an elderly patient and noted an exaggerated curvature of the the thoracic spine, nurse would document this as?

Kyphosis, an exaggerated convex curvature of the spine that occurs because of a congenital abnormality, fractures, arthritic conditions, or stds.

For each symptom of musculoskeletal problems ask the following

Location, Quality, Severity, Onset, Timing, Aggravating and alleviating factors.

the nurse is examining the spine of a client who is experiencing an extreme curvature of the lumbar area. how would the nurse document this?

Lordosis, an exaggerated curvature of the spine.

a woman gave birth a month ago and has red, warm, swollen and tender left breast with a temperature of 100 degrees, and reports fatigue and chills. nursing diagnosis would be

Mastitis is an infection in the beast that manifests as a red, warm, swollen, breast, with accompanying fever.

This client has a history of gouty arthritis and reports pain and swelling of the elbow. the nurse concludes that these manisfestatoins are consistent with?

Olecranon bursitis which is an inflammation and swelling of the elbow.

the nurse finds a crusty, scaly lesion on the right breast at the nipple, the client might have which health problem

Paget's disease, which is a malignant lesion of the nipple with discharge and scaly erosion

a 30 year old uncircumcised male is unable to retract the foreskin so the glans of the penis can be assessed during examination. this nurse would document this as

Phimosis, the term used to describe the inability to retract the foreskin of the penis.

Nurse finds a brown spot below the right breast. it has a nipple located in the center. this finding should be documented as

Supernumarary nipple, which has an appearance of a mole but it is benign.

When assessing ROM of cervical spine ask client to

Touch chest with chin (flexion), look upward toward the ceiling (hyperextension). try to teach each should with ear on the same side (lateral flexion)

during examination of a female older adult, nurse notices a blue cyanotic cervix, the client should be evaluated for what

a client may experience a cyanotic cervix when she has congestive heart failure.

spermatocele

a cyst located in the epididymis.

Decreased bone density by osteoporosis is caused by

a faster rate of bone resoprrtion than that of new bone growth.

the nurse palpates a round, fluid-filled cyst on the dorsum of the wrist. the nurse interprets this finding as consistent with

a ganglion

An enlarged or swollen TMJ appears as

a rounded protuberance

Scoliosis

a spinal curvature to right or left, can lead to an exaggerated thoracic convexity on affected side; because body compensates a plumb line dropped from T1 falls between the gluteal cleft, because unequal leg length may contribute to scoliosis, legs should be measured with client supine from anterior superior iliac spine to medial malleolus.

If client cannot perform abduction without lifting or shrugging affected shoulder and has pain, tenderness and muscle atrophy

a torn rotator cuff may be present.

a pregnant women in her third trimester has yellow discharge coming from her breasts, nurses initial action is to

after about the 4th month of pregnancy colostrum may be released from the breasts. it is a thin yellow liquid that is a precursor to milk.

Signs of benign prostatic hyperplasia

an enlarged prostate gland that may cause the client to experiene frequency, hesistancy, dribbiling, difficulty initiating urinary stream, a weak stream, and urinary retention or incontinence.

the nurse is assessing an 80 year old man that complains of nocturia, what findings may be present on a prostate exam?

as prostate gland enlarges with age it becomes firm, fixed and hard, although the gland is enlarged small nodules are not present,

To test ROM of TMJs

ask client to open mouth widely to determine if it opens with ease, push out lower jaw and move lower jaw side to side.

prostatitis

associated with thin watery, blood-tinged drainage.

Asymmetrical breast, lesions, dimpling or retraction may be signs of

breast cancer

client presents to the emergency room with pain, redness, warmth and swelling in the left breast. the nurse will evaluate this client for

breast infectoin.

Breasts in older adults

breasts lose elasticity of subcutaneous tissue and skin turgr and become pendulous and flat, nipples may invert or retract, tissue may feel cordlike and thickening may be present.

hemangioma

bright red, raised lesion 2-10 cm in diameter, caused by a cluster of immature capillaries.

a 50 year old man with history of cardiovascular disease reports that his breast are getting bigger as he gets older. Nurses best response

cardiac glycosides such as digoxin can cause gynecomastia in males.

when assessing a pediatric clients skin rash the nurse notes that the rash consists of small, red, fluid filled vessicles that began on the trunk and progressed to the face, arms and legs. client most likely has.

chicken pox or varicella bein as groups of small, red, fluid filled vesicles usually on the trunk and progress to the face, arms and legs.

the nurse finds enlarged nail beds and spongy quality at the nail base during assessment of a client with COPD, nurse would document this as

clubbing

Palpation methods for breast exams include

concentric circles, vertical strip method, pie method, back and forth technique, and bimanual palpation.

when testing range of motion of a client's shoulder, the nurse hears a grating sound. The nurse should document which of the following assessment findings?

crepitus.

risk factors for testicular cancer are

cryptorchidism, age 20-40, family history of cancer, mump orchitis, inguinal hernia, maternal history of using DES

which nursing diagnosis has the highest priority for a client who has a skin tone change from normal to cyanosis.

cyanosis or pallor usually indicates a low level of plasma oxygenm which places the client at risk for inefective tissue perfusion.

a 20 year old female asks why her breasts feel bumpy a few days during the month, the best response is

cyclic hormonal changes may cause cyclic breast nodules,

Age related musculoskeletal changes likely to be present in a 72 year old

decreased bone density and possible osteoporosis, decrease in height and kyphosis, slight flexion of hip and knees when the client is standing, decrease in size and quantity of muscle fibers and increased connective tissue, resulting in fibrous or stringy muscles, less elastic tendons, and reduction reaction time. Changes in synovial fluid fragmentation of connective tissue and scarring and calcification of joint capsules, frayed, thin, and cracked joint cartilage, with possible underlying bone erosion, less shock absorbency, and decreased flexibility and ROM. a bowlegged stance caused by reduced muscle control which alters the normal angle of the hip.

Older adult bone changes include

decreased calcium absoprtion and reduced osteoblast production

older adult skin changes

decreased skin elasticity and increased wrinkling, dryness of skin and hair due to decrease in sebum production, decrease in perspiration due to decreased in sweat glands, decrease in vascularity may cause paleness in light skinned, and a dull, gray or darker appearance in dark skin. hair thins and becomes gray, nails appear thicker, harder and more brittle, peeling, yellow or opaque and oddly shaped.

Subluxation, partical dislocation of a joint is accompanied by

deformity and misalignment of the forearm.

Swelling, deformity, atrophy, and misalignment of shoulders suggest

degenerative joint disease, trauma (sprain or strain), or inflammatory conditions such as rheumatoid arthritis, bursitis, or tendonitis.

varicocele

enlargement of spemartic cord veins that leads to a soft compressible mass in scrotum, mass result in infertility

risk factors for prostate cancer

family history of prostatic cancer, age, African American descent

major functions of the skin include

feels touch, pressure, temperature, and pain, protects body and internal structures from damage and loss of fluids and electrolytes. regulates body temperature. repairs surface wounds, synthesized vitamin d. allows of identification through facial contours, skin and hair color and fingerprints.

Breast cancer risk factors are

female, increasing age, immediate relative with breast cancer, menstruation prior to age 12, caucasian race, sedentary lifestyle, obesity, increased alcohol intake, nulliparity, pregnancy after age 30, or lack of breastfeeding, use of oral contraceptives or hormonal replacement therapy. presence of BRCA1 and 2 gene.

Keratin

fibrous protein that gives epidermis its tough, protective qualities.

ecchymosis

flat irregularly shaped lesion of varying size with no pulsation. begins a bluish-purple mark that changes to greenish-yellow colow, in darker skins it varies from blue to deep purple and in darkest skin it appears as a darkened area. caused by a release of blood from superficial vessel into surrounding tissue due to trauma, hemophilia, liver disease or deficiency in vitamin c or k

Venous lake

flat, blue lesion with radiating, cascading, or linear veins extending from the center, size ranges from 3 to 25 cm, caused by a type of vascular dilation caused by increased intraveneous pressure in superficial veins.

spider angioma

flat, bright red dot with tiny radiating blood vessels ranging in size from a pinpoint to 2cm, caused by a type of telangiectasis (vascular dilation) caused by elevated estrogen levels, pregnancy, estrogen therapy, vitamin B deficiency, or liver disease.

port wine stain

flat, irregularly shaped lesion ranging in color from pale red to deep red. caused by a large, flat mass of blood vessels on the skin surface

Petechiae

flat, red or purple rounded freckles, 1-3 mm in diameter, caused by minute hemmoraghes resulting from fragile capillaries caused by septiciemias, liver disease, or vitamin c or k deficiency and anticoagulant therapy.

purpura

flat, reddish blue irregularly shaped extensive patches of varying size, caused by bleeding disorders, scurvy, and capillary fragility in older adults, senile purpura.

the nurse is inspecting a female clients external genitalia and notes cauliflower like lesions, these lesions are consistent with which health problem

genital warts are cauliflower-life papules on the genitalia and result from infection with HPV.

the nurse is assessing the client's knee for ballottement. after having the client lie supine with the leg in extension, the nurse should take which action?

grasp the thigh above the knee and push fluid in the suprapatellar bursa to move between the femur and patella.

Gouty Arthritis may be present if

great toe is swollen, hot, red and very painful.

Example of Flexion in Knee ROM

have client bend each knee against chest as far as possible.

Shoulders ROM

have client shrug shoulders by flexing them forward and upward, check internal and external rotation.

what action would the nurse take to examine the temporomandibular joint?

have the client open and close the mouth while palpating the joint in front of the tragus.

Shoulder discomfort from ROM may resulft from conditions that increase intraabdominal pressure such as

hiatal hernia or GI disease.

Are there any areas of the breast where cancer is more likely to occur?

in the upper outer quadrant, the incidence of breast cancer is highest in the upper out quadrant of the breasts, including the tail of spence. if the mass is on the tail of spence, it must then be distinguished from enlarged lymph nodes.

candida occurs

in warm moist areas and is associated with red papular lesions that occasionally become pus filled.

Carpal tunnel syndrome occurs when

inflammed wrist tissues cause pressure on median nerve, which innervates the hand. Experience Phalens sign which is wrist pain and tingling and numbness that can radiate to the arm, shoulder, neck, or chest within 60 seconds. also have weakness when attempting opposition of the thumb.

To best detect skin color changes when assessing a dark skinned client the nurse should inspect which areas of the body

inspect areas of the body with less pigmentation such as the lips, oral mucosa, sclera, palms of hands, and conjunctivae of the inner eyelids.

When performing an assessment of the client presenting with a musculoskeletal problem, which action should the nurse take first?

inspect the area of pain or inflammation

Chancroid

is a cauliflower like reddish-pink lesion

To determine information about a vaginal infection the nurse should gather data related to

itching is associated with infections such as vaginitis, dematitis, lice, and candidiasis.

Osteoarthritis is characterized by

joint cartilage becomes frayed, thin, and and cracked, leading to erosion of underlying bone, with less shock absorbency of joints and decreased flexibility and ROM.

Dermis

layer of connective tissue that lies just below the epidermis, composed of lymph vessels, blood vessels, and nerve fibers.

senile lentigines

liver spots, hyper pigmented freckles on the backs of hands and the arms.

Subcatenous tissue is made up of

loose connective tissue that stores fat cells for energy, protects body against trauma, and insulates the body from heat loss. cutaneous or sweat glands which include eccrine glands, apocrine glands, and sebaceuous oil glands.

to test ROM of hands and fingers

make a tight fist with each hand with fingers folded into palm and thumb across knuckles (thumb flexion). open first and stretch fingers ( extension, straightening a limb at a joint)

Genital Herpes

manifests as painful pustules and vesicles and is associated with fever, dysuria, and other viral symptoms.

characteristics associated with a benign breast lesion

may be tender to touch, are well-defined and have regular borders. they are usually firm and not mobile.

in assesing a clients hair, the nurse notes the texture is very coarse, dry, and brittle, what condition should the nurse consider a potential cause for this

metabolic disorders such as hypothyroidism and nurtritional deficencies may cause the hair to become very dull, coarse, dry and brittle.

An example of abduction and adduction is during the hip ROM test

move leg away from midline then as far as possible toward the midline. abduction is the term used when a body part is moved away from body midline, addicution is when a body part is moved toward the midline of the body.

Hydrocele

nontender accumulation of fluid in the scrotum

A ganglion is

often painless, round, fluid filled mass that arises from tendon sheaths or dorsum of wrist and hand; if it is more prevalent with wrist flexion it does not interfere with ROM or joint function

the nurse is examining the breast of a 15 year old girl, she asks why her right breast is larger than her left

one breast may grow faster than the other throughout the period of adolescence.

When assesing the breasts of a 60 year old woman the nurse palpates the breasts and notes breast tissue that is pendulous with loss of elasticity, nurse would document this as

pendulous breast tissue is a normal change that occurs with age.

Gonorrhea

penile discharge associated with purulent white to green discharge.

ROM test for Ankles and Feet

point foot toward nose (dorsiflexion), and then toward floor (plantar flexion), turn sole of the foot outward at ankle (eversion) and then inward (inversion), curl toes downward (plantar flexion), spread toes as far as possible (abductoin) and the bring does together (adduction).

haemophilus infections

produce painful, pinkish red lesions

Fungal skin infection

produces an itchy, red rash in warm moist areas,

Syphilis

produces an ulcerated round or oval nontender lesion that has a red halo and is edematous

to detect dimpling or contour of breasts have client

raise hands over head or placing them on hips

hematoma

raised irregularly shaped lesion similar to ecchymosis, except that is elevates the skin and looks like swelling caused by leakage of blood into the skin and subcutaneous tissue as a result of trauma or surgical incision

cherry angiomas

small, bright red spots that increase in number with age.

when examining the scrotal sac of a 30 year old the nurse would document this as a normal finding

testes usually have a firm, smooth, and possible rubbery feeling. the scrotal sac should have rugae and hsould feel like skin, and have a darker pigmentation that other areas of the skin.

the best breast assessment technique for an obese female

the bimanual technique is used to support the breast and permit the breast to be compressed between the hands.

the order of a BSE

the client should be taught to inspect the breast then the axilla by looking in a mirror with arms elevated and the hands on hips. after inspection the client should be taught to palpage the breast, axilla, and nipple using finger pads systematically. this should be performed monthly.

The assessment techniques used when assessing a females breasts

the first step in breast examination is inspection of breasts and then axillae, the second step is palpation of the breast and then the axillae.

To test cranial nerve V the nurse would have the client

the mouth is open and closed and the jaw is pushed in and out and moved side to side.

when examining the cervical ROM of a client the nurse should act the client to perform which movements?

touching the chin to the shoulder measures flexion, looking toward the ceiling measures hyperextension, touching the ear to the same shoulder measures lateral flexion.

Characteristics associated with malignant breast lesions

usually solid, dense, hard and nontender with irregular and poorly defined borders.

hypospadias

when the urerthal opening is on the ventral aspect or underside of the penis

an inguinal hernia is caused

when there is weakening of the abdominal muscles which allows the intestine to protrude through the abdominal muscles which allows the intestine to protrude through the abdominal muscle into the inguinal canal.