Health assessment exam 2

Eyelashes equally distributed; no drainage Eyebrows evenly distributed; no scaly or flaky skin; symmetrical Cornea clear with no opacities Lens transparent with no opacities Pupils equal in size Iris blue, green, brown, or hazel in color, smooth; controls diameter and size of pupil Sclera is white Conjunctiva is pink and moist Lacrimal duct clear with no swelling Palpebral fissures equal bilaterally No abnormal involuntary movement

Normal findings when inspecting the eye should consist of:

Lips are symmetric Upper lip is everted Pink, moist No lesions, swelling, or cracking of skin

Normal findings when inspecting the lips should include:

20/20

Normal vision acuity is:

Electrocardiogram

This test provides vital information about the heart's electrical conduction system; records the electrical activity of the heart; helps diagnose abnormal heartbeats, heart rhythm, and tissue ischemia: 1. Troponin test 2. Echocardiography 3. Electrocardiogram 4. Creatinine kinase-MB

Suprapubic

Using the nine-region abdominal mapping, in what quadrant is the bladder located? a. Suprapubic b. Epigastric c. Umbilical d. Left inguinal

Conducting the Whispered Voice Test

What test assess for impaired or high-frequency of hearing:

Assess the palpebral fissures.

You are assessing a patient's eyes and note that the left eyelid is drooping. What assessment should you perform next? 1. Assess the nasolacrimal folds. 2. Assess the conjunctiva for drainage. 3. Assess the palpebral fissures. 4. Assess the pupil reaction.

a, c, d

You are auscultating an apical pulse on a patient. What characteristics should you assess? (Select all that apply.) a. Beats per minute b. Location c. Amplitude d. Rhythm e. Pulsations

a, c, d

You are auscultating lungs sounds. Identify the normal lungs sounds in an adult patient. (Select all that apply.) a. Vesicular b. Rhonchi c. Bronchovesicular d. Tracheal e. Stridor

Size Shape Color Symmetry Landmarks

You should assess both ears for:

d

You start to lightly palpate a patient's abdomen and she starts giggling and says she is very ticklish. What should you do? a. Stop light palpation and start deep palpation. b. Skip this assessment technique and move to percussion. c. Warm both hands and use the bimanual technique. d. Have her rest her hand on top of your hand while you palpate.

1:1

Your patient has had chronic obstructive pulmonary disease for the past 20 years. What would you expect her anterior-posterior chest ratio to be? a. 1:1 b. 1:2 c. 2:2 d. 2:1

An anal fissure

____ is a tear in the anus that can cause pain, itching and bleeding: 1. An anal fissure 2. A hemorrhoid 3. Excoriation 4. A lesion

Sight

____ occurs when the eyes and brain work together to detect, translate, and interpret incoming visible spectrum electromagnetic radiation:

Bronchovesicular

________ lung sounds are heard between the scapulae posteriorly. 1. Bronchovesicular 2. Vesicular 3. Bronchial 4. Tracheal

carbon dioxide

_______________ is released from the lungs at the alveoli tissue level to maintain the acid-base balance. 1. carbon dioxide 2. oxygen 3. nitrogen 4. carbon monoxide

cataract

clouding of the lens of the eye

Virtual colonoscopy

Has emerged as an alternative to the traditional gold standard, optical colonoscopy, for screening asymptomatic adults and is considered the best radiological diagnostic test for imaging colorectal

nearsightedness

Myopia is called:

circulatory musculoskeletal neurological

Name the systems that work to maintain the respiratory system:

Pupils constrict (accommodation) and both eyes converge simultaneously

Normal finding when assessing for tesing of accomodation consist of:

No tenderness firm consisency

Normal findings for palpating the ear should consist of:

Pupil is round and black Both pupils are equal size Diameter is 2 to 8 mm Both eyes have a consensual response to direct light

Normal findings when inspecting pupil size & consensual response should consist of:

Color of teeth white to ivory color Clean, and free of debris Smooth edges 32 teeth or 28 teeth if wisdom teeth have been removed

Normal findings when inspecting teeth should include:

Equal size and shape bilaterally; normal size (4 cm to 10 cm) Color same as facial skin Symmetrical Angle of attachment < 10 degrees No deformities, inflammation, nodules, or drainage

Normal findings when inspecting the ear should include:

cauliflower ear

Occurs from repeated trauma or hitting the ear,; a blood clot form or there is damage to the cartilage causing a change in shape and structure of the ear, usually seen in wrestlers or people who participate in contact sports:

Clubbing of nail plates

Occurs with chronic lack of oxygen or hypoxia. The tips of the fingers and nails change in shape and size:

Auricles (pinna) Tragus Ear lobes Mastoid process

Palpate the ear by palpating the:

Tenderness Masses or depressions

Palpate the head for:

Flexible sigmoidoscopy every 5 years Colonoscopy every 10 years Double-contrast barium enema every 5 years Computed tomography virtual colonoscopy every 5 years

People who are 50 years of age and older should be screen for one of these testing according to schedule:

2, 3, 4, 1

Put the sequence for abdominal assessment in order: 1. Palpation 2. Inspection 3. Auscultation 4. indirect percussion

1, 2, 3

The major function of the lungs is gas exchange and the delivery of oxygen to all parts of the body. The other body systems that maintain the respiratory system include which of the following? Select all that apply. 1. Circulatory system 2. Musculoskeletal system 3. Neurological system 4. Gastrointestinal system

True

The mandible bone of the face is considered the largest and strongest bone. True or False

Protection

The most important function of the cranial vault is: A. Lubrication B. Facial appearance C. Protection D. Movement

Symmetry of the face.

The nasal labial folds and the palpebral fissures of the face are measured to assess for: a. Appearance of the face. b. Symmetry of the face. c. Edema of the face. d. Involuntary movements of the face.

1:2

The normal AP- to transverse ratio is _____________. 1. 1:2 2. 2:1 3. 1:1 4. 1:3

empty their bladder

The nurse asks the patient about pain prior to beginning the abdominal exam. What else does the nurse ask the patient?_______ 1. empty their bladder 2. smoked in the past 30 minutes 3. had anything to eat or drink in the past 30 minutes 4. had any caffeine in the past 30 minutes

renal colic pain

This usually result from kidney stone; the stone may partially or totally obstruct the ureter; it may remain in one place or travel down the urinary tract:

pupils Equal Round & Reactive to light (directly and consensually) with noted Accommodation

What does PERRLA stand for:

Creatinine kinase-MB

What enzyme increases when cardiac tissue is damaged due to decreased oxygenation; usually elevates 3 to 4 hours after cardiac damage: 1. Troponin 2. Creatinine kinase-MB 3. Triglycerides 4. Cholesterol

Myocardium

What is the layer of the heart that is the thick, middle layer? 1. Epicardium 2. Endocardium 3. Myocardium 4. Pericardium

To assess for nasal passageway occlusion

What is the purpose of assessing the patency of the nose? 1. To assess for nasal passageway occlusion 2. To assess for tenderness, inflammation, or deviation 3. To assess appearance and symmetry 4. To assess for normal size and shape

Conjunctiva

What is the thin membrane covering the front of the eye and eyelids called? a. Conjunctiva b. Tarsal plates c. Lacrimal ducts d. Aqueous humor

Eustachian tube

What part of the ear connects the middle ear to the pharynx? a. Auricle b. Labryrinth c. Eustachian tube d. Semilunar canals

Put on gloves and inspect lips for: Symmetry Color Moisture Lesions Swelling

When inspecting the lips you should:

millimeters

When measuring the size of each pupil you should measure it in:

Use the finger pads of both hands, palpate: Earlobes Corner of the eyes Temporal arteries Zygomatic arch - ask patient to open and close mouth

When palpating the face you should:

exophthalmos

abnormal protrusion of the eyeball

Mixed hearing loss

this hearing loss includes both conductive and sensorineural hearing loss:

Tenderness swelling lumps nodules

Abnormal findings when palpating the ear may consist of:

Colonoscopy

This procedure allows for tissue samples to be biopsied and polyps (abnormal growths) to be removed. This is the gold standard to detect colon cancer:

Tympanometry testing

This test assess the movement of the tympanic membrane and disorders of the middle ear:

Tophi

Is hard, whitish, or cream-colored, nontender deposits of uric acid crystals indicative of gout:

phrenic nerve

Controls the diaphragm; it originates from cranial nerves C3-C5.

Barium enema

This test is useful to identify several different pathologies such as diverticula, tumors, polyps, rectal bleeding, or complaints of abdominal pain:

Microtia (small ear)

Is a congential deformity acquired while a baby is developing in the womb; it is usually not hereditary. Less than 4 cm (approximately 1.5 inches) in vertical height:

peak flow meter

This measures your Peak Expiratory Flow Rate (PEFR):

Comprehensive

Is a dilated eye exam to look directly at the retina and internal structures of the eye:

Stool analysis

Is a examination of feces for volume, odor, shape, color consistency, and presence of mucus, pathogens and substance:

cornea abrasion

scratch on the cornea

Audiometric testing

Is a hearing evaluation to assess conductive and sensorineural hearing loss at different high and low frequencies:

LASIK

Is a laser eye surgery to reshape the cornea to correct farsightedness, nearsightedness, or an astigmatism:

hordeolum (or a stye)

Is a localized inflammation and/or infection of the hair follicles of the eyelid or the meibomian glands:

Red, inflamed or bleeding mucosa; lesions Tenderness with palpation Aphthous stomatitis Gingivitis Gingival hyperplasia Periodontal disease Thrush

Abnormal findings may consist of when inspecting and palpating the buccal mucosa should include

Pupils are unequal in size or both dilated or constricted and fixed Anisocoria Mydriasis Miosis Horner's Syndrome

Abnormal findings when inspecting pupil size & consensual response may consist of:

Asymmetrical Lesions Cysts Drainage Color is blue, red, white, or pale. Cauliflower ear Microtia Macrotia Tophi

Abnormal findings when inspecting the ear may include:

myopia

A 14-year-old high school student complains of difficulty reading his text books because the "print is a little blurry." The result of a Snellen vision test is 20/20. Which condition would the nurse suspect: .a. Hyperopia b. Presbyopia c. Myopia d. Photophobia

Pterygium

A 67-year-old lawyer comes to the clinic for an annual examination. He denies any history of eye trauma or recent visual changes. Inspection of his eyes reveals a triangular thickening of the bulbar conjunctiva across the outer surface of the cornea. He has a normal pupillary reaction to light and accommodation. Based on this description, what is the most likely diagnosis? 1. Cataract 2. Pterygium 3. Glaucoma

b

A 75-year-old female client states "when I eat meals, I feel like food gets stuck in my throat." What is an appropriate nursing action? a. Tell the patient to cut up her food in smaller pieces. b. Notify the physician and anticipate a referral to speech therapy for a swallow evaluation. c. Ask the patient specifically what foods she has difficulty swallowing. d. Encourage the patient to drink more fluids to soften the food she eats.

Diastasis recti

A bulging in the mideline are of the abdomen which occurs when there is separation of the two halves of the rectus abdominals muscles in the midline at the linea alba: 1. Hernia 2. Diastasis recti 3. Ascites 4. Cullen's Sign

scaploid abdomen

A condition in which the anterior abdominal wall is sunken and presents a concave rather than a convex contour.

diaphragm

A dome-shaped muscle that lies at the bottom of the chest cavity; it is the principal muscle of respiration. It separates the thoracic and abdominal cavities.

c

A patient's vision is recorded as 20/30 using the Snellen eye chart. A correct interpretation of this finding would be: a. The patient can read from 30 feet what a person with normal vision can read 20 feet. b. The patient can read from 20 feet with left eye and 30 feet with right eye c. The patient can read at 20 feet what a person with normal vision can read 30 feet. d. The patient can read from 20 feet with right eye and 30 feet with left eye.

Conjunctivitis

A patient comes to see you complaining of a headache and pain below the eye sockets. You place each of your thumbs beside the patient's nose and press. By doing this, you are assessing: a. Blepharitis b. Chalazion .c. Conjunctivitis .d. Hordeolum

Maxillary sinuses

A patient comes to see you complaining of a headache and pain below the eye sockets. You place each of your thumbs beside the patient's nose and press. By doing this, you are assessing: a. Sphenoid sinuses b. Frontal sinuses c. Maxillary sinuses d. Ethmoid sinuses

tachycardia

A patient has a heart rate of 110 BPM. This is called____________________________.

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.

Ptosis Blepharitis Blocked lacrimal duct Cataract Conjunctivitis Corneal abrasion Exophthalmos Hordeolum Sceleral jaundice (icterus). Pterygium Periorbital edema

Abnormal findings when inspecting the eye should may consist of:

Cullen's Sign

A superficial bleeding under the skin (ecchymosis) around the umbilicus and may indicate intra-abdominal bleeding: 1. Ascites 2. Hernia 3. Cullen's Sign 4. A lesion

Lips are inverted Swelling, erythema, lesions, cracking of skin Angular cheilitis Angioedema Pallor of the lips Herpes simplex virus

Abnormal findings when inspecting the lips may consist of:

Loose, broken, painful teeth Malocclusion of the teeth

Abnormal findings when inspecting the teeth may consist of:

The higher the denominator means poorer distant visual acuity. Myopia Hyperopia Presbyopia Legal Blindness

Abnormal findings for visual acuity can consist of:

Pain Tenderness Mass Depression Involuntary movements Macrocephaly

Abnormal findings when palpating and inspecting the head may consist of:

Pupils do not constrict or converge

Abnormal finding when assessing for tesing of accomodation may consist of:

Individual repeats fewer than half of the six letters or numbers correctly or did not hear what you whispered

Abnormal findings for the Whispered Voice Test can include:

. Barrel chest

Anterior posterior-to transverse ratio is 1:1, and the costal angle is greater than 90 degree; increase in the costal angle may be a sign of chronic obstructive pulmonary disease: 1. Barrel chest 2. Pectus excavatum 3. Pectus carinatum

True

Any patient complaints of chest pain is an emergency. True or False

Bronchial breath sounds

Are heard over the trachea and larger bronchi; expiratory sounds are louder and last longer than inspiratory sounds and have a pause between them; high-pitched, hollow, tubular breath sounds.

Borborygmus

Are loud, gurgling sounds made by the movement of gas through the intestine:.

Otalgia (ear pain) and otorrhea (ear drainage)

Are the most common complaints for which individuals seek medical care for their ears:

Angular cheilitis

Is the inflammation at the corner of the mouth ; sore, cracked corners of the lips; commonly caused by yeast infection, dry mouth, or vitamin D deficiency: 1. Angioedema 2. Herpes simplex virus 3. Angular cheilitis

Echocardiography

Is a noninvasive ultrasound (US) that uses high frequency sound waves of various intensities to help diagnose cardiovascular disorders: Allows visualization of the size, shape, position, thickness, and movement of cardiac structures: 1. Echocardiography 2. Holter monitior 3. Exercise stress test 4. Electrocardiogram

Dyspepsia

Is a term that is used to describe a vague feeling of fullness and chest discomfort, indigestion, or burning in the chest or upper abdomen, especially after eating:

Ascities

Is an abnormal cumulation of fluid in the peritoneal cavity: 1. Diastasis recti 2. Ascites 3. A lesion 4. Hernia

Tinnitus

Is the perception of sound when no actual external noise is present; it is commonly referred to as "ringing in the ears:

Individual repeats at least three of the six letters or numbers correctly

Normal findings for the Whispered Voice Test includes:

130-159 mg/dl

Borderline high for Low-Density Lipoprotein (LDL) is:

Holter monitior

Is an ambulatory test for 24 hours; the patient wears a monitor that records the cardiac electrical impulses; the monitoring is read and interpreted by a cardiologist: 1. Echocardiography 2. Holter monitior 3. Exercise stress test 4. Electrocardiogram

Xerostomia

Is considered a dry mouth with decreased saliva. Many medications can cause dry mouth.

Caucasians & African Americans

Cancers of the larynx and pharynx are most common in which racial or ethnic groups? 1. Caucasians & African Americans 2. Latinos and Asians 3. Asians and Italians 4. African Americans and Latinos

1, 2, 4

Characteristics of bilirubin include which of the following? Select all that apply 1. It is a by-product of red blood cell (RBC) catabolism. 2. It deposits yellow pigment in the skin and sclera at elevated levels. 3. A decrease is known as icterus. 4. It is produced by the liver, spleen, and bone marrow.

sensorineural hearing loss

Is considered inner hearing loss, when there is damage to the (cochles), a person speech may sound unclear or muffled. Most common permanent hearing loss:

Conductive hearing loss

Is considered middle hearing loss. Involves reduction in sound level or the ability to hear faint sounds; Wax impaction is the most common cause of this type of hearing loss:

Expiratory dyspnea

Is difficulty breathing associated with chronic obstructive lung disease; wheezing is usually present

Cardiac dyspnea

Is difficulty breathing related to an inadequate cardiac output.

Angioedema

Is edema of the lips; usually related allergic reaction: 1. Angioedema 2. Herpes simplex virus 3. Angular cheilitis

Pyrosis

Is indigestion/heartburn usually described as a "burning sensation" in the epigastric area radiating up to the throat:

GERD

Is motility disorder characterized by heartburn and reflux or gastric content into the lower esophagus:

Dysuria

Is painful or difficult urination indicative of an inflammatory condition or pathology of the urinary tract:

Pericardium

Is the fluid-filled fibrous sac that surrounds the heart; the fluid helps to provide lubrication while the heart is contracting and relaxing; it is attached to the diaphragm

Pink, smooth, moist, no lesions, swelling, or bleeding Tight margin around each tooth No tenderness with palpation

Normal findings should consist of when inspecting and palpating the buccal mucosa should include:

A, C, D

During the health history, a 79-year-old patient keeps leaning forward and turning the left side of the face towards you. What question(s) should you ask the patient? (Select all that apply.) a. Are you having difficulty hearing me? b. Are you having difficulty understanding the questions? c. Do you have any ringing or buzzing in your ears? d. What was your occupation?

a, b, c, d, e

During the health history, the patient states that she has been wearing contact lenses for the past five years. What questions should you ask? (Select all that apply.) a. Do you wear contact lenses? b. Are they soft or hard? c. Do you sleep with them on? d. Do you have any problems with wearing contact lenses? e. Do you experience redness or irritation?

True

Fecal Occult Test is used to determine colerectal cancer: True or False

True

Fecal Occult Test is used to identify hidden blood stool: True or False

Past medical history Cataracts Glaucoma Macular degeneration Eye surgery Laser-assisted in situ keratomileusis (LASIK)

Health history for the eye exam should consist of:

Reduce the prevalence and severity of disorders of hearing and balance; smell and taste; and voice; speech, and language:

Healthy People 2020 goal for hearing is to:

Improve the visual health of the nation through prevention, early detection, timely treatment, and rehabilitation

Healthy People 2020 goal for vision is to:

Reduce the number of new cancer cases, as well as the illness, disability, and death caused by cancer

Healthy people 2020 gaol for colon cancer

Understanding Function in our daily lives

Hearing enhances our quality of life by helping with:

less than 40 mg/dL

High-Density Liproprotein optimal level for men is:

less than 50 mg/dl

High-Density Liproprotein optimal level for women is:

farsightedness

Hyperopia is called:

Size Shape Configuration Movement

Inspect the patient's head for:

Endocardium

Is the thin inner layer of the heart.

Epicardium

Is the thin, outer layer of the heart.

T wave

Is ventricular repolarization; cells return to their normal polarity; atria and ventricles relax

Visual acuity

Measure a patient's vision to see details at near and far distances:

True

Men have a higher incidence of Coronary Artery Disease than women until women reach menopause. True or False

Symmetrical, midline, and round Normacephalic Erect and still No pain, tenderness, masses, or depressions during palpation

Normal finding when palpating and inspecting the head should include:

Macrotia

Refers to ears that are oversized or large ears that aren't in proportion to the head greater than 10 cm.

QRS

Represents electrical impulses traveling through the ventricular myocardium: ventricular depolarization; ventricles are contracting.

P wave

Represents normal atrial depolarization (cell interiors become positively charged); atria are contracting.

50

Screening for colorectal cancer can be a yearly fecal occult blood test after age ____? 1. 50 2. 45 3. 60 4. 55

Inspecting the ears Palpating the ears Assessing hearing Assessing the internal ear (Advanced)

Sequence of Assessment for the ears

Inspecting the eye Assess visual acuity Assess ocular motility Assess pupil size and consensual response Assess for accommodation.

Sequence of Assessment for the eyes should consist of:

conversational hearing

Start assessing a person's hearing during the first encounter, noting whether "_____ _____ " is intact.

2, 4

The extraocular structures of the eye include which of the following? Select all that apply. 1. Sclera 2. Conjunctiva 3. Optic nerve 4. Lacrimal glands 5. Iris

Left ventricle; aorta

The heart is a double pump. The left atria pumps blood to the ___________; the left ventricle pumps blood to the _____________. a. Left ventricle; aorta b. Left ventricle; lungs c. Right ventricle; lungs d. Aorta; lungs

Presbyopia

The inability to focus on near objects-age related changes in Lens are called:

respiratory system

The major function of the lungs is gas exchange and the delivery of oxygen to all parts of the body.

Exercise stress test

This test monitors the heart function and rhythm while running on a treadmill. The patient is hooked up to an EKG monitor during the test and is closely monitored: 1. Echocardiography 2. Electrocardiogram 3. Troponin test 4. Exercise stress test

True

Syncopal episodes are when the patient has fainted and lost consciousness. True or False

50 until the age 75

The American Cancer Society recommends that people beginscreening for colon cancer at the age:

snellen test

The ___________assesses the patient's ability to see far distances

dysphagia

The aide reports to the nurse that the patient coughs when he drinks liquids and appears to be having difficulty swallowing solid foods. The medical term for difficulty swallowing is:________

Less than 150

The desirable level for triglycerides are:

less than 200 mg/dl

The desirable total cholesterol level is:

tenderness, swelling, and inflammation.

The purpose of palpating the face is to assess for:

vesicular

The nurse is auscultating a patient's lungs. In the bottom of the posterior lung fields, the nurse hears soft low sounds where inspiration is longer or louder than expiration. What are these lung sounds called? a. Adventitious b.. Bronchial .c. Bronchovesicular d. vesicular

2, 3

The nurse is auscultating bowel sounds. Which of the following steps are correct? Select all that apply. 1. Place the diaphragm of the stethoscope on the abdomen at the right upper quadrant. 2. Assess intensity, pitch, and frequency of bowel sounds. 3. Auscultate in all four abdominal quadrants. 4. Auscultate for a full minute before documenting that there are no bowel sounds.

Erb's point

The nurse is listening to heart sounds. The nurse hears S1 equally to S2 at the LSB, 3rd ICS. This spot is known as ____________.

Sigmoidoscopy

This noninvasive procedure is able to screen for colon cancer and polyps (abnormal growths) in the rectum and sigmoid colon:

False

The nurse teaches her patient ways to promote respiratory health by encouraging the patient to get vaccinated every 5 years against influenza. True or False

less than 70 mg/dl

The optimal level for Low-Density Lipoprotein (LDL) is:

Bronchoscopy

The patient has a chronic cough and is spitting up blood. What diagnostic test do you anticipate the doctor will order to visualize the bronchial tree? a. Thoracentesis b. Arterial blood gases c. Lung biopsy d. Bronchoscopy

Troponin level

The patient has had some blood work done. The results show cardiac tissue damage due to decreased oxygenation. The laboratory values were elevated levels 7 days after cardiac tissue damage. Which laboratory test did the patient have? 1. Creatine kinase-MB 2. Troponin level 3. Total cholesterol level 4. High density lipoprotein (HDL-C)

Listen for at least 5 minutes

The patient is complaining that he has been constipated for the past 6 days but has very small bouts of diarrhea. You auscultate for bowel sounds and do not hear any sounds. What should you do? a. Call the doctor immediately b. Listen for at least 5 minutes c. Palpate the abdomen to stimulate peristalsis d. Document hypoactive bowel sounds

Oxygen supply to the heart is insufficient

The patient reports chest pain with exertion. He states the pain feels like "someone is sitting on my chest." What is the etiology for this chest pain? a. Compression of the rib cage b. Lack of blood supply to the extremities c. Oxygen supply to the heart is insufficient d. Muscle contractions to the thoracic area

11.5 pack-years

The patient reports that he has been smoking a half of a pack of cigarettes daily for 23 years. What is his pack-year history? a. 23 pack-years b. 16.5 pack-years c. 11.5 pack-years d. 10.5 pack-years

Rhinorrhea

The patient reports that he has clear nasal drainage especially during the spring months. What is this nasal drainage called? a. Epistaxis b. Xerostomia c. Sinusitis d. Rhinorrhea

Gallbladder

The patient states that he has pain in his RUQ after eating a fatty meal for the past month. He denies nausea and vomiting. What organ do you suspect is the source of this pain? a. Liver b. Stomach c. Gallbladder d. Pancreas

Tension

The patient states that she has frequent headaches. The patient explains that the headaches are a feeling of pressure in the front of the head. The patient also tells you "It feels like someone is tightening a band on my head." What type of headache is this patient describing? a. Migraine b. Cluster c. Sinus d. Tension

Paroxysmal nocturnal dyspnea

The patient tells the nurse that he cannot sleep at night because he will wake up and sit up in bed to relieve the shortness of breath. The nurse suspects this is: a. Cardiac dyspnea b. Expiratory dyspnea c. Orthopnea. d. Paroxysmal nocturnal dyspnea

electrical conduction, bundle of his

The physician has ordered an Electrocardiogram (EKG) on a patient. The nurse knows this is used to assess the heart's____. This system is as follows: Starts at the SA node, then to the AV node, down to ________ and out to the Purkinje fibers.

the accommodation reflex of the eye

The purpose for testing for accommodation is to assess for:

the pupillary light reflex that controls the diameter of the pupil, and to assess the integrity of the optic pathways (consensual pupil response)

The purpose inspecting the pupil size & consensual response is to assess:

inflammation, lesions, or abnormalities Equipment: Tongue blade and penlight

The purpose of inspecting and palpating the buccal mocosa is to assess for:

normal size and shape of the head Equipment needed: gloves

The purpose of inspecting and palpating the head is to assess for:

the structures of the mouth for redness, inflammation, lesions, or abnormalities Equipment: Penlight, gloves, tongue blade, sterile gauze

The purpose of inspecting and palpating the mouth is to assess for:

to assess the anterior eye structures

The purpose of inspecting the eyes is:

facial appearance and symmetry

The purpose of inspecting the face is to assess for:

shape and integrity of the lips

The purpose of inspecting the lips is to assess for:

position of teeth number of teeth and integrity of teeth

The purpose of inspecting the teeth is to assess for:

tenderness

The purpose of palpating the ear is to assess for:

Hyperactive

These are loud, high-pitched sounds:

Hypoactive

These are slow, decreased sounds:

Pectus excavatum

This is a congenital deformity; sternun is abnormally depressed or sunken into the chest: 1. Barrel chest 2. Pectus excavatum 3. Pectus carinatum

Pectus carinatum

This is a deformity of the chest; sternun protrudes out from the chest: 1. Barrel chest 2. Pectus excavatum 3. Pectus carinatum

Tonometry

This is a device to measure intraocular pressure

vertigo

This is a feeling that the environment is moving may feel like you are spinning, tilting or falling:

Darwin's Tubercle

This is a painless congenital deviation that is a small, cartilaginous protuberance on the helix of the ear:

Absent

This mean there are no sounds present:

Legally blind

When a person visual acuity is 20/200 or greater that person is considered to be:

1

When inspecting the anus . How will the male patient present who will have a prostate be examine: 1. Standing and bending over, and holding onto the exam table 2. Side lying 3. Prone 4. Lithotomy

Draw an imaginary line from the external canthus of the eye to the top of the helix. Draw an imaginary line perpendicular to the ear. Assess the angle of attachment.

When inspecting the ear you should:

Assess symmetry Assess distribution of hair and for scaly, flaky, skin Using a light source, inspect Cornea for smoothness and clarity Lens for clarity, color and shape Assess sclera for color

When inspecting the eyebrows

Inspect the eyelashes for dtribution and drainage

When inspecting the eyelashes you should:

Observe that the eyelids open and close completely Assess for any drainage.

When inspecting the eyelids:

Inspect the conjunctiva Use your thumbs to slide the bottom eyelids down to assess the mucosa of the lower conjunctiva Ask the patient to look up Inspect the color of the mucosa Inspect the lacrimal duct Wearing gloves, inspect and palpate the lacrimal duct for any swelling or excessive tearing Assess palpebral fissures Assess the distance of the upper lid to the lower lid for symmetry Compare the palpebral fissures on each side of the face Inspect for abnormal involuntary eye movements

When inspecting the eyes you should:

Appearance of the face Symmetry Nasolabial folds Palpebral fissures Facial expression Involuntary movements Condition and texture of the skin Edema

When inspecting the face you should assess for:

Dentures, caps, or missing teeth Color of teeth Tooth decay Ask patient to clench teeth and assess for malocclusion, malposition of the teeth

When inspecting the teeth you should assess for:

ptosis

drooping of the eye

blepharitis

inflammation of the eyelid