Nur 203 Final
Positioning of patient for a womans exam:
For the examination, place the woman in the lithotomy position with the examiner at the stool. Help the woman into supine position with feet in stirrups and knees apart, and buttocks at the edge of the examining table. Ask the woman to lift her hips as you guide them to the edge of the table. Elevate her head to a 45 degree angle so you can see her face.
Sequence of complete health exam:
General survey, vital signs, skin/nails/hair, head and neck, ears/nose/throat, eye, thorax and lungs, breast, musculoskeletal system, cardiovascular system, abdomen, peripheral vascular system, nervous system, women's focused examination, men's focused examination
Testing Cranial nerves nine and ten: motor or sensory?
Glossopharyngeal and Vagus nerve: Have the person say "ahhh" as they stick out their tongue and the uvula should rise midline. Cranial nerve IX Glossopharyngeal (Motor) pharynx (phonation and swallowing) (Sensory)- taste on posterior one third of the tongue, pharynx (gag reflex) Cranial nerve X Vagus- Motor (talking, swallowing) Pharyngeal movement, Gag reflex -(Sensory)- general sensation from carotid body/ sinus, pharynx, viscera, Taste posterior 1/3rd of the tongue
14) Indicate under which body system you would document the following symptoms collected during the review of symptoms?
Headache: Neurological
Testing Cranial nerve twelve: sensory or motor?
Hypoglossal nerve: (motor) tongue movement (side to side) Have the person say the following, "light, tight, dynamite."
Define cultural competence:
Implies that the caregiver understands and attends to the total context of the individual's situation, including awareness of immigration status, stress factors, other social factors, and cultural similarities and differences.
How could pain affect vital signs?
Increased blood pressure, increased heart rate, increased respiratory rate.
Age and developmental considerations:
Infants: the testes develop in the abdominal cavity near the kidneys. During the later months of gestation the testes migrate, pushing the abdominal wall in front of them and dragging the vas deferens, blood vessels, and nerves behind. Adolescent: The first sign is the enlargement of the testes. Next pubic hair appears, and then penis size increases. Adults/Aging Adults: In the aging male the amount of pubic hair decreases and turns gray. Penis size decreases. Because of decreases tone of the dartos muscles, the scrotal contents hang lower. The testes decrease in size and are less firm.
Normal/abnormal findings of a breast exam:
Normal: Usually nodes are not palpable, although you may feel a small, soft, nontender node in the central group. Expect some tenderness when palpating high in the axilla. Note any enlarged and tender lymph nodes. Abnormal: Nodes enlarged with any local infection of the breast, arm, or hands and with breast cancer metastases.
How to assess midline trachea:
Normally the trachea is midline, palpate for any tracheal shift. Place your index finger on the trachea in the sternal notch and slip it off to each side. The space should be symmetrical on both sides. Note any deviation from the midline.
What does nutritional screening include?
Nutritional screening is the first step in assessing nutritional status. Parameters used for nutritional screening typically include weight and weight history, diet information, and routine laboratory data. Types of nutritional screenings include comprehensive nutritional assessment, 24 hour recall, food frequency questionnaire and food diaries.
Testing Cranial nerve three (motor and sensory), four (motor), and six (motor):
Oculomotor, Trochlear, and Abducens nerves: Check pupils for size, regularity, equality, direct and consensual light reaction, and accommodation. CN III (motor and sensory) extraocular muscle movement via opening eyelid, pupil constriction, lens shape, CN IV (Motor) moving eyes down and inward, CN VI (motor) PERRLA, Cardinal positions of gaze (fingers moving in 6 ways)
Testing Cranial nerve one: Sensory or Motor?
Olfactory nerve (sensory) : With the person's eyes close, occlude one nostril and present an aromatic substance. Use a familiar scent like toothpaste or peppermint.
Testing Cranial nerve two: Sensory or motor?
Optic nerve (sensory): Test visual acuity and visual fields by confrontation test.
Technique to assess carotid arteries
Palpate only one carotid artery at a time to avoid compromising arterial blood to the brain. Feel the contour and amplitude of pulse. Normally contour is smooth with a rapid upstroke and slower downstroke, and the normal strength is 2+ or moderate. Findings should be same bilaterally.
Normal lung sounds:- Bronchial
Pitch: High, Amplitude: Loud, Duration: Inspiration < Expiration, Quality: Harsh, hollow tubular, Normal location: Trachea and larynx.
Normal Lung Sounds: Vesicular
Pitch: Low, Amplitude: Soft, Duration: Inspiration > Expiration, Quality: Rustling, like the sound of the wind in the trees, Normal Location: Over peripheral lung fields
Normal lung sounds- Bronchovesicular:
Pitch: Moderate, Amplitude: Moderate, Duration: Inspiration = Expiration, Quality: Mixed, Normal location: Over major bronchi.
PMI
Precordial Movements are the contractions of the heart normally felt in most people. Subtle differences can be observed to give clinical cues of heart diseases.
cerebellar function tests
RAM test, Finger to Nose test, Heel to shin test Rapid Alternating Movement: (RAM) Ask the person to pat the knees with both hands, lift up, turn hands over, and pat the knees with the back of the hands. Then ask the person to do this faster. Normally this is done at a rhythmic pace. Finger - Nose- Finger- Test: With the person's eyes open, ask that he or she use the index finger to touch your finger and then his or her own nose. Heel-to-shin-test: test lower extremity coordination by asking the person, who is in a supine position, to place the heel on the opposite knee and run it down the shin from the knee to the ankle.
Regions and quadrants of the abdomen
Right Upper Quadrant- Gallbladder, Liver, Duodenum, Upper portion of your right kidney, Part of your colon, Part of your pancreas. Right Lower Quadrant- Appendix, Right ureter, Part of your colon, Lower portion of your right kidney, Right ovary (for females). Left Upper Quadrant- Stomach, Pancreas, Spleen, Part of your liver, Upper portion of your left kidney, Part of your colon, Left Lower Quadrant- Left ureter, Part of your colon, Lower portion of your left kidney, Part of your colon, Left ovary (for females
Tanner Sexual Maturity Rating Scale:
The stages of development are documented in Tanner's sexual maturity rating. There are five stages which include the enlargement of the testes and growth of pubic hair.
Normal heart sounds with coordinating valve closures
"Normal heart sounds: The first heart sound (S1) occurs with closure of AV valves and thus signals the beginning of systole. Mitral component of first sound (M1) slightly precedes tricuspid component (T1) but you usually hear these two components fused as one sound. You can hear S1 over all precordium, but loudest at apex.The second heart sound (S2) occurs with closure of semilunar valves and signals end of systole. The aortic component of the second sound (A2) slightly precedes pulmonic component (P2). Although heard over all precordium, S2 loudest at base.
Importance of self-care, ADLS-
(Activities of Daily Living) Allows the healthcare provider to assess the patient's mental status and their level of self care
45) Which glands should be palpated during a vaginal examination of a female?
(pg 729) a) Herbeden's and Bouchard's b) Skene's and Bartholin's c) Anterior and Posterior d) Minora and Majora B
ROM appropriate documentation
+5 if full ROM, even and smooth movement
Normal lung sounds: Name and sound
- Bronchial, Pitch: High, Amplitude: Loud, Duration: Inspiration < Expiration, Quality: Harsh, hollow tubular, Normal location: Trachea and larynx. - Bronchovesicular: Pitch: Moderate, Amplitude: Moderate, Duration: Inspiration = Expiration, Quality: Mixed, Normal location: Over major bronchi. - Vesicular: Pitch: Low, Amplitude: Soft, Duration: Inspiration > Expiration, Quality: Rustling, like the sound of the wind in the trees, Normal Location: Over peripheral lung fields
Abnormal Lung Sounds: Wheezes (Sibilant)
- Wheeze (Sibilant): Description: High pitched, musical squeaking sound that sounds polyphonic. Predominant in expiration but may occur in inspiration as well.
PQRST of pain assessment-
-Precipitating or palliative -Quality or quantity -Region or radiation -Severity scale -Timing Subjective questions to ask, Where is your pain? When did your pain start? What does your pain feel like?... (pain ch slide 4)
Abnormal Lung Sounds: (Sonorous rhonchi, low- pitched)
-Wheeze (Sonorous rhonchi, low- pitched): Description: Low pitched, monophonic single note, musical snoring, moaning sounds, they are heard throughout the cycle. Although they are more prominent on expiration. - Stridor: High pitched, monophonic, inspiratory, crowing sound Know what these sound like
Tonsil appearance and rating
1+ normal, 2+ slightly above normal, 3+ almost touching, 4+ touching
Normal lung sounds: Name and Location
1. Bronchial (Tracheal) Normally heard over the trachea and larynx. Should not be heard over the lung fields. 2. Vesicular Expected sounds heard over the lung felds. Expected finding: "Clear to auscultation." 3. Bronchovesicular Over bronchioles and lungs.
Flow of blood through the heart
1.From the liver through inferior vena cava to right atrium. (superior vena cava drains venous blood from the head and upper extremities) 2.From RA, venous blood travels through tricuspid valve to right ventricle. 3.From RV venous blood flows through the pulmonic valve to pulmonary artery. 4.Pulmonary artery delivers deoxygenated blood to the lungs. 5.Lungs oxygenate blood 6.Pulmonary veins return fresh blood to LA 7.From LA arterial blood travels through mitral valve to LV 8.LV ejects blood through the aortic valve into the aorta 9.Aorta delivers oxygenated blood to the body.
profile sign in nails
160 degree profile, any more would be considered clubbing
Clubbing-
180 degrees on the fingernails is a sign of of the heart or lungs which cause chronically low blood levels of oxygen. Diseases which cause malabsorption, such as cystic fibrosis or celiac disease can also cause clubbing
Cone of light
5 o'clock in right ear 7 o'clock in left ear
Know normal, overweight, obese parameters
< 18.5 BMI is underweight, 18.5 - 24.9 Normal weight, 25- 29.9 overwight, 30.0 - 39.9 obesity
Pleural friction rub:
A very superficial sound that is coarse and low pitched; it has a grating quality as if two pieces of leather are being rubbed together. Mechanism: Cause when pleurae become inflamed and lose their normal lubricating fluid.
Which is a normal respiratory rate for an adult?
A. 24-40 B. 22-34 C. 18-30 D. 12-16 D.
19) What is the most commonly auscultated breath sound?
A. Bronchial B. Bronchial Vesicular C. Vesicular D. Crackles
31) The nurse is performing a measurement of diaphragmatic excursion on a 24 year-old male athlete. The patient's measurement is 4cm. The nurse's next best action is to:
A. Call the physician immediately to notify him B. Alert the patient to this abnormal finding C. Document the findings in the chart, since these are normal D. Ask the patient to call his family to discuss the findings over the phone C
The nurse notes on examination of the scrotum a soft "bag of worms" feeling, what is the most likely scrotal abnormality?
A. Epididymitis B. Hydrocele C. Testicular torsion D. Varicocele D*
30) The following type of health history should be collected by the nurse on all patients new to the hospital or office setting?
A. Focused B. Specialized C. Comprehensive D. Objective c
26) An adolescent boy's parents are asking you as the nurse during a pediatric well check visit in the outpatient setting, how long puberty will take (the complete change from a preadolescent to an adult). The best response is:
A. One years B. Two years C. Three years D. Four years C
24) The nurse is asked to perform a bimanual examination on a female patient admitted to the hospital for pelvic pain. The nurse knows that the best positioning of the provider during this technique is:
A. Seated B. Lateral to the patient C. On the right side of the bed D. Standing D
The nurse is preparing to do a hip examination on a 40 year old male in an outpatient clinic setting. He/She knows that the best positioning for the patient to appropriately assess hip range of motion.
A. Siting B.Standing C.Supine D.Lateral Recumbent C*
20) Using the Tanner Sex Maturity Rating Scale, identify which stage the following characteristics of adolescent males would be categorized: Few straight slightly darker hairs at base of the penis. Hair is long and downy. Little or no penis enlargement. Testes and scrotum begin to enlarge. Scrotal skin reddens and changes in texture.
A. Stage II B. Stage III C. Stage IV D. Stage V A
The physical examination findings and laboratory testing are considered what type of data?
A. Subjective B. Objective Objective
The chief complaint and review of systems from the health history is considered what type of data?
A. Subjective B. Objective subjective
When performing a rectal and anus examination, what is the best positioning of the patient?
A. Supine B. Lateral decubitus C. Sitting D. Standing B*
15) When assisting the nurse practitioner during a pelvic exam a nulliparous female patient, the cervix appears pink, smooth, and doughnut shaped with a small circular hole in the middle. Which is the most appropriate for the nurse to recognize?
A. That these are normal findings for a nulliparous female B. That these are normal findings for a parous female c. That these findings may indicate early pregnancy. D. That these findings may indicate cervical cancer A.
When percussing over lung tissue the nurse should note what sound?
A. Tympany- (A hollow drum-like sound that is produced when a gas-containing cavity is tapped sharply. Tympany is heard if the chest contains free air (pneumothorax) or the abdomen is distended with gas). B. Resonance- (low pitched clear hollow sound that predominates in the lung tissue of a healthy adult) C. Hyperresonance- a lower pitched booming sound found when too much air is present D. Hyporresonance B*
22) Which site of the female breast is the location of most breast tumors?
A. Upper Inner Quadrant B. Upper Outer Quadrant C. Lower Inner Quadrant D. Lower Outer Quadrant b
A 38 year old African American male is admitted to the hospital with an asthma exacerbation. The nurse admitting the patient would anticipate which type of lung sounds?
A. Vesicular = are soft and low pitched with a rustling quality during inspiration and are even softer during expiration. B. Crackles = Discontinuous, high pitched, short crackling sounds heard during inspiration that are not cleared by coughing C. Wheezes = high-pitched musically whistling sound made while you breathe mostly during expiration, but in some extreme cases during inspiration D. Friction rub = (pleural) superficial sound that is course and low pitched, has a grading quality as if two pieces of leather are being rubbed together C*
23)The best validated technique to detect a breast mass during a clinical breast exam is which of the following?
A. Wedge B. Vertical strip C. Spokes on a wheel D. Horizontal strip B
25) Palpable vibration of the chest wall that results from speech or other verbalizations is referred to as?
A. Whispered pectoriloquy B. Vocal resonance C. Tactile fremitus D. Stridor c
18) When do the testicles typically descend along the inguinal canal into the scrotum?
A. before birth B. immediately after birth C. Within 4 weeks D. by the age of 12 months A
The portion of the health history that the provider "detects" or observes during the examination can be referred to as which type of data?
A. subjective B. objective objective
Reinforcement:
Another technique to relax the muscles and enhance the response. Ask the person to perform an isometric exercise in a muscle group somewhat away from the one being tested.
Testing Cranial nerve eleven: sensory or motor?
Accessory nerve: Check equal strength by asking the person to rotate the head forcibly against resistance. (Motor) Movement of the sternomastoid and trapezius muscles
Positioning of patient and provider during a male genitourinary system exam:
Ask the male to stand and lower undershorts down to the knees. The examiner should be sitting, or the male can be supine on the table for the initial exam and then stand to check for a hernia.
Alert and oriented x 3? What does this mean? How do you assess?
Asking the patient if they know their name, where they are, and the date/time
Appropriate techniques to assess nose, mouth, throat
Assess the nostrils with the otoscope with patients head tilted back, occlude one nostril at a time with one finger, palpate sinuses with thumbs bilaterally, When touching areas with bodily fluids like the mouth use gloves, shine a pen light in the mouth to grade tonsils
Cardinal fields of gaze test
Assessment of the positions to which the eye may normally be moved by the extraocular muscles
ABCDEs of the skin
Asymmetry, Boarder, Color, Diameter greater than 6mm pencil or eraser size, Elevation
Age and developmental considerations during a womans exam:
At birth: the external genitalia are engorged because of the presence of maternal estrogen. The ovaries are located in the abdomen during childhood. The uterus is small with a straight axis and no anteflexion. At puberty: estrogens stimulate the growth of cells in the reproductive tract and the development of secondary sex characteristics. The first signs of puberty are breast development and pubic hair development. The pregnant woman: the greatest change is the shape of the uterus. The nonpregnant uterus has a flattened pear shape. Throughout pregnant it becomes an oval shape. The aging woman: Menopause usually occurs at 48-51 years. The ovaries stop producing progesterone and estrogen. The uterus shrinks in size as well.
BMI:
BMI is a practical marker of optimal weight for height and an indicator of obesity or undernutrition. It is calculated by Weight (pounds) divided by Height (inches)2 multiplied by 703
Best way to approach / ask about sexual relationships for a womans exam:
Begin with open ended questions to assess individual needs. Include appropriate questions as a routine. Communicate that you accept individual's sexual activity and believe that it is important. "Are you in a relationship involving sex now?" "Do you have more than one sexual partner?" "What is your sexual preference?"
Patient positioning during a breast exam:
Begin with the woman sitting up and facing you. You may use a short gown, open at the back, and lift it up to the woman's shoulder during inspection. During palpation when the woman is supine, cover one breast with the gown while examining the other.
How to test EOMs
Cardinal positions test Extraocular muscles- out of the orbit or beyond the eye, six different ways the moves, up and down, laterally, inward, oblique move them up and in or up and in, moved by the cranial nerves. CN Three- all other movement and constriction of the pupil. CN Four- down. Cranial nerve six- side. Nystagmus- vibration or twitch of the eye
Components of the interview CC, HPI, ROS:
Chief complaint (CC) This is a brief, spontaneous statement in the person's own words that describe the reason for the visit. History of present illness (HPI) For the well person, this is a short statement about the general state of health: "I feel healthy right now." For the ill person, this section is a chronological record of the reason for seeking care, from the time the symptoms first started until now. Your final summary of any symptom the person has should include the location, character or quality, quantity or severity, timing, setting, aggravating or relieving factors, associated factors, and patient's perception. Review of systems (ROS) The purpose of this section are 1) to evaluate the past and present health state of each body system, 2) To double check in case any significant data were omitted in the present illness section, 3) To evaluate health promotion practices.
Indicate under which body system you would document the following symptoms collected during the review of symptoms?
Cough: Respiratory system
Indicate under which body system you would document the following symptoms collected during the review of symptoms?
Decreased appetite: Gastrointestinal
DTRS (location, normal findings, and documentation)
Deep tendon reflexes are graded on a 4 point scale. 4+ very brisk, hyperactive with clonus, indicative of disease. 3+ Brisker than average, may indicate disease, probably normal. 2+ Average, normal. 1+ Diminished, low normal, or occurs only with reinforcement. 0+ is no response. Biceps reflex: Support the person's forearm on yours, this position relaxes and partially flexes the person's arm. Place your thumb on the bicep tendon and strike a blow on your thumb. You can feel as well as see the normal response, which is a contraction of the biceps muscle and flexion of the forearm. Triceps reflex: Tell the person to let the arm "just go dead" as you suspend it by holding the upper arm. Strike the triceps tendon directly just above the elbow. The normal response is an extension of the forearm. Brachioradialis Reflex: Hold the person's thumb to suspend the forearms in relaxation. Strike the forearm directly, about 2 to 3 cm above the radial styloid process. The normal response if flexion and supination of the forearm. Quadriceps Reflex: Let the lower legs dangle freely to flex the knee and stretch the tendons. Strike the tendon directly just below the patella. Extension of the lower leg is the expected response. Achilles Reflex: Position the person with the knee flexed and the hip externally rotated. Hold the foot in dorsiflexion and strike the achilles tendon directly. Feel the normal response as the foot plantar flexes against your hand.
Best provider techniques for a breast exam:
Direct the woman to change position while you check the breast for skin retraction signs. First ask her to lift her arms slowly over the head. Both breasts should move symmetrically. Next ask her to push her hands on her hips and to push her two palms together. These maneuvers contract the pectoralis major muscle. A slight lifting of both breasts occur. Ask the woman with large, pendulous breast to lean forward while you support her forearms. Note the symmetric free forward movement of both breasts. Use the pads of your first three fingers and make a gentle rotary motion on the breast. Vary your pressure so you are palpating light, medium, and deep tissue in each location.
Reassessment of the Hospitalized Adult doesn't require....
Doesn't require full head to toe physical examination during every 24 hour stay.
Medical terms for subjective symptoms of the ears
Earaches, Infections, Discharge, Hearing loss, Environmental noise, Tinnitus, Vertigo, Self-care behaviors
How do you assess the level of consciousness? Cognition?
Eyes (Pupillary response, eye opening), verbal response (responsive, ability to speak/ form words), motor response (can follow commands, responds to pain)
Nonverbal behaviors of pain-
Facial grimacing, guarding, restlessness, stillness, diaphoresis (sweaty, clamy), sleeping, change in vitals (increase bp, resp rate, heart rate)
Testing Cranial nerve seven: Sensory or motor?
Facial nerve: With the person's eyes closed, test light touch sensation with a cotton wisp. Have the person say "now" whenever they feel it. Also, have the person smile, frown, close eyes, lift eyebrows, puff out cheeks. (Motor)Smile, frown, close eyes tightly, lift eyebrows, show teeth, and puff cheeks (Sensory) Taste (taste test with a tongue blade and salt or sugar) on anterior 2/3 of the tongue
Assessment techniques of the anus, rectum and prostate:
Left lateral, lithotomy, and standing
Crackles Coarse:
Loud, low-pitched, bubbling and gurgling sounds that start in early inspiration and may be present in expiration. May decrease somewhat by suctioning or coughing but will reappear shortly. Sounds like opening a velcro fastener.
Cardiac landmarks
Mediastinum contains all of the chest organs except the lungs, Right and left cardiac borders, Great vessels Organs located in the mediastinum include the heart, the aorta, the thymus gland, the chest portion of the trachea, esophagus, lymph nodes and important nerves. Heart and great vessels are located between lungs in middle third of thoracic cage, called mediastinum. Great vessels lie bunched above the heart. Superior and inferior vena cava returns deoxygenated venous blood to the right side of the heart. Pulmonary artery leaves the right ventricle, bifurcates, and carries the venous blood to the lungs Pulmonary veins return the freshly oxygenated blood to the left side of the heart and the aorta carries it out to the body.
Percussion over abdomen
Should be tympanic over the abdomen, except over the liver/ ribs
SBAR for staff communication
Situation Background Assessment Recommendation Situation = Providing specific information relative to patient's issue. Background = Providing context and assessment data relative to patient issue.Assessment = Nurse's interpretation of data relative to patient issue. Recommendation = Expectations of physician's orders relative to patient issue.
Normal findings of the prostate gland:
Size = 2.5 cm long by 4 cm wide; should not protrude more than 1 cm into the rectum. Shape = Heart shape, with palpable groove. Surface = Smooth, Consistency = Slightly movable, Sensitivity = Nontender to palpation
Atelectatic crackles:
Sounds like fine crackles but do not last and are not pathologic; disappear after first few breaths Mechanism: When sections of alveoli are not fully aerated, they deflate and accumulate sections.
Tanner rating scale:
Tanners rating scale is the five stages of pubic hair development. This is helpful in teaching girls the expected sequence of sexual development.
Testicular self-exam:
The procedure by which a man checks the appearance and consistency of his testes Encourage self care by teaching every male (from 13/14 years old through adulthood) how to examine his own testicles. A good time to examine id during the shower or bath, when your hands are warm and soapy and the scrotum is warm. Hold the scrotum in the palm of your hands and gently feel each testicle using your thumb and first two fingers. If you notice a firm, painless lump contact your doctor. TSE= T= timing, once a month, S = shower, warm water relaxes scrotal sac, E = examine, check for changes, report changes immediately.
Know how to obtain appropriate vitals and measurements (i.e. height, weight):
Temperature: Place the thermometer at the base of the tongue in either of the posterior sublingual pockets - not in front of the tongue. Instruct the person to keep his of her lips closed. Usually less than 20 to 30 seconds to read a measurement. Pulse: Use the pads of your first three fingers, palpate the radial pulse at the flexor aspect of the wrist laterally along the radius bone. If the rhythm is regular, count the number of beats in 30 seconds and multiply by two. Respirations: Maintain your position of counting the radial pulse and unobtrusively count the respirations. Count for 30 seconds, but count for a minute if you suspect an abnormality. Blood Pressure: The person may be sitting or lying down, with the bare arm supported at heart level. When sitting, the patient's feet should be flat on the floor because BP has a false high measurement when legs are crossed. Palpate the brachial artery and inflate the cuff until the artery pulse is obliterated. Note that number. When you inflate the cuff to auscultate the blood pressure, you will add 20 to 30 mm Hg to the number you noted to identify maximal inflation level. This maximal inflation pressure helps you avoid missing an auscultatory gap, which is a period when Korotkoff sounds disappear during auscultation. Deflate the cuff quickly and completely, then wait 15 to 30 seconds before reinflating so that the blood trapped in the veins can dissipate. Place the bell or diaphragm of the stethoscope over the site of the brachial artery, making a light but airtight seal. Rapidly inflate the cuff to maximal inflation level that you determined. Then deflate the cuff slowly and evenly, about 2 mm hg per heartbeat. Note the points at which you hear the first appearance of sound, the muffling of sound, and the final disappearance of sounds.
Romberg:
Testing equilibrium Ask the person to stand up with feet together and arms at the sides. Once in a stable position, ask him or her to close the eyes and to hold the position. Wait about 20 seconds. Normally a person can maintain posture and balance even, although slight swaying may occur.
Anatomy anus, rectum and prostate:
The anal canal is the outlet of the gatrointestinal (GI) tract. The anal canal is surrounded by two concentric layers of muscles, the sphincters. The internal sphincter is under involuntary control by the autonomic nervous system. The external sphincter surrounds the internal sphincter but also has a small section overriding the tip of the internal sphincter at the opening. It is under voluntary control. The anal columns are folds of mucosa. These extend vertically down from the rectum and end in the anorectal junction. The rectum is 12 cm long, is the distal portion of the large intestine. It extends from the sigmoid colon, at the level of the 3rd sacral vertebra. The prostate gland lies in front of the anterior wall of the rectum and 2 cm behind the symphysis pubis.
Self-breast technique and timing:
The best time to perform a self breast examination is right after the menstrual period, when the breast are the smallest and least congested. At home she can palpate while in the shower, where soap and water assist palpation. Press the three middle fingers in a circular motion and use three levels of pressure. Follow an up and down pattern. Note any lumps.
Anatomy of the breast
The breast lie anterior to the pectoralis major and serratus anterior muscles. The superior lateral corner of the breast tissue, called the axillary tail of Spence, projects up and laterally into the axilla. The nipple is just below the center of the breast. The areola surrounds the nipple for a 1-2 cm radius.
Anatomy during a womans exam:
The external genitalia are called the vulva, or pudendum. The mons pubis is a round, firm pad of adipose tissue covering the symphysis pubis. The labia majora are two rounded folds of adipose tissue extending from the mons pubis down and around the perineum. Inside the labia majora are two smaller, darker folds of skin, the labia minora. The labia minora are joined posteriorly by a transverse fold, the frenulum. The clitoris is a small, pea shaped erectile body, homologous with the male penis and highly sensitive to tactile stimulation.
Normals for inspection and palpation of the head, face, neck:
The head: Note the general size and shape. Normocephalic is the term that denotes a round, symmetrical skull that is appropriate related to body size. To assess shape, place your fingers in the person's hair and palpate the scalp. The skull normally feels symmetric and smooth. There is no tenderness to palpation. The face: Inspect the face, noting the facial expression and its appropriateness to behavior or reported mood. Expect symmetry of eyebrows, palpebral fissures, nasolabial folds, and sides of mouth. The neck: Head position is centered in the midline, and accessory neck muscles should be symmetric. The head should be held erect and still. Note any limitation of movement during active motion for range of motion.
Testing Cranial nerve five: sensory or motor?
Trigeminal nerve: Palpate the temporal and masseter muscles as the person clenches their teeth. (Motor) Muscles of mastication. (Sensory) light touch to face, forehead, cheeks and chin, corneal reflex
Know the normal assessment of lymphatics:
Use a gentle circular motion of your finger pads, palpate the lymph nodes. - Preauricular, in front of the ear. - Posterior auricular (mastoid), superficial to the mastoid process. - Occipital, at the base of the skull. - Submental, midline, behind the tip of the mandible. - Submandibular, halfway between the angle and tip of the mandible. - Jugulodigastric, under the angle of the mandible. - Superficial cervical, overlying the sternomastoid muscle. - Deep cervical, deep under the sternomastoid muscle. - Posterior cervical, in the posterior triangle along the edge of the trapezius muscle - Supraclavicular, just above and behind the clavicle, at the sternomastoid muscle.
Indicate under which body system you would document the following symptoms collected during the review of symptoms?
Vertigo: HEENT (head ears eyes nose throat) Ears
Testing Cranial nerve eight: Sensory or motor?
Vestibulocochlear (Acoustic): (sensory) Perform the whisper test.
Snellen eye chart-
Visual acuity for distance, 20 feet away, numerator and denominator, 20/25 top number distance the person is away bottom number is what distance a normal person can see at the same distance. -1 (the minus number is for how many they miss, if they miss 3 they didn't correctly read the row. Less than 3 is ok)
Abnormal lung sounds
Wheezing = bronchial constriction (LA) Rhonchi = large amount of secretion (midlung) Stridor = obstruction in (UA)
Confrontation-
When a finger moves toward the eyes the pupils will converge and constrict
drainage pathways
When nodes are enlarged, check the area they drain for the source of the problem. Explore the area proximal (upstream) to the enlarged node. All head and neck structures eventually drain into the deep cervical chain.
When is it appropriate to collect history from someone other than the patient?
When the patient is not mentally competent or does not speak the same language
Be familiar with the three pain scales
Wong-Baker faces pain rating scale- ages +3, Descriptor Scale- pain thermometer scale with verbal description from "no pain to pain as bad as it could be), Numeric rating scale- 0-10
How to initiate sexual history questionary during a male exam:
Your questions should be objective and matter of fact. Communicate that you accept individual's sexual activity and believe that it is important. " Are aspects of sex satisfactory to you and your partner?" "What is the sexual preference - relationship with a woman, a man, or both?" " Do you and your partner use a condom or contraceptive?"
48) Upon removal of the Pedersen speculum, the nurse notes thick, white, curdlike discharge clinging to the vaginal wall of a female patient in an OB/Gyn office. Which is the best statement by the nurse to the patient given these findings?
a) "This type of discharge is normal for most women of your age and no intervention is necessary." b) "I recommend you shower more frequently paying particular attention to the vaginal area." c) "We are going to collect a sample of the discharge to send to the lab for further evaluation today if that is okay with you?" d) "Let's start you on oral contraceptive today, it is evident you are sexually active." c
38) A female patient is coming in for her first clinical breast examination. She asks the nurse how long a thorough breast examination should take. The appropriate response by the nurse is:
a) 1 minute per breast b) 3 minutes per breast c) 5 minutes per breast d) 7 minutes per breast B
36) The nurse knows that female breasts extend between which two ribs?
a) 1st and 5th b) 2nd and 6th c) 3rd and 7th d) 4th and 8th B
27) When the nurse pushes her finger in the inguinal canal of a male client he/she feels a bump on the fingertips when asking the patient to bear down. This finding likely indicates:
a) A normal finding b) A hernia c) A testicular torsion d) A hydrocele B
52) This includes the attitudes, knowledge, and skills necessary for providing quality care to diverse populations.
a) Acculturation b) Cultural competence c) Naturalistic d) Heritage B
35) An audible and palpable crunching or grating that accompanies movement of articular surfaces is referred to as:
a) Articulation b) Crepitus c) Rales d) Thrill b
28) The best technique for the nurse to assess retraction when examining breast tissue on a female patient is to:
a) Ask the patient to relax and remain in a sitting position b) Ask the patient to lie supine with arms at her sides c) Ask the patient to lift her arms slowly over her head from sitting d) Ask the patient to cross her arms and lean forward c
51) You are evaluating a patient for the first time who has no history of nutrition-related problems. What should your initial screening include?
a) Calorie count of nutrients b) Complete physical exam c) Food diary d) Measurement of height, weight, and BMI D
43) Which maneuver would assist the patient with contracting the pectoralis major muscle when examining a patient with breast implants?
a) Clenching her teeth b) Pushing her psalms together c) Rolling to her side d) Crossing her arms in front of her body B
21) When performing a straight right leg test on a patient, the maneuver reproduces pain to the back and down the patient's right leg. If lifting an affected leg reproduces sciatic pain, this confirms the presence of which abnormality.
a) Diabetic Neuropathy b) Leg Length Discrepancy c) Herniated Disc d) Spinal Mass c
17) When the nurse is collecting the review of systems from a pregnant 34 year-old female, the patent reports numbness and tingling along the first, second, and third digits of bilateral hands, especially at night when sleeping. An appropriate test the nurse can perform to elicit this sensation during the physical exam is the:
a) Finkelstein's sign b) Lachman's test c) Tinel's sign = It is performed by lightly tapping (percussing) over the nerve to elicit a sensation of tingling or "pins and needles d) McMurray's test = rotational testing of the legs c
41) The nurse is collecting a history on a patient presenting to the emergency room with a chief complaint of sore throat. What type of history should be collected?
a) Focused b) Specialized c) Comprehensive d) Objective A
42) The physician is evaluating an inpatient at the hospital and asks the nurse to retrieve the goniometer to complete the assessment. The nurse knows that the goniometer will assist the physician to evaluate which body system:
a) Genitourinary b) Cardiovascular c) Respiratory d) Musculoskeletal D
44) A squatted duck walk during a sport physical examination is most helpful for the nurse when examining which joint?
a) Hip b) Knee c) Ankle d) Spine B
16) The nurse is examining the cervical spine of an adolescent during a routine visit to the family practice office. He/she asks the patient to lift the chin toward the ceiling, touch each ear toward the corresponding shoulder, and turn the chin toward each shoulder. The motion the nurse failed to examine to assess complete range of motion is:
a) Hyperextension b) Rotation c) Flexion- chin to chest d) Lateral bending c
47) Noting the size, contour, color, presence of swelling and any masses or deformities of every joint during the musculoskeletal exam is part of which assessment technique?
a) Inspection b) Palpation c) Percussion d) Auscultation A
40) Identification of cryptorchidism (undescended testicle) is important early in life because of all of the following except:
a) Late identification can cause infertility b) Late identification can increase the risk of testicular cancer c) Late identification can cause erectile dysfunction d) Late identification can cause decreased spermatogenesis C
34) The nurse is assessing range of motion of a patient's spine. He/she asks the patient to bend forward and touch the toes, bend backward, and bend sideways. The motion the nurse failed to examine for complete range of motion is:
a) Lateral bending b) Hyperextension c) Rotation d) Flexion c
39) While the nurse is listening with a stethoscope over the chest, the patient says "ee" and this sounds like an "a" when auscultating the posterior chest. What does this likely suggest?
a) Normal findings b) Consolidation in the lung, such as pneumonia c) Bronchial constriction such as with asthma d) Respiratory distress B
49) Asking the patient to turn their palms upward when performing a musculoskeletal exam of the upper extremities is referred to as which motion?
a) Pronation b) Supination c) External rotation d) Internal rotation B
37) At this stage of breast bud development according to the Sexual Maturity Rating in Girls, the areola and nipple form a secondary mound over the breast.
a) Stage II b) Stage III c) Stage IV d) Stage V C
32) Using the Tanner Sex Maturity Rating Scale, identify which stage the following characteristics of adolescent males would be categorized: Pubic hair growth spread over medial thighs and adult size and shape penis and scrotum.
a) Stage II b) Stage III c) Stage IV d) Stage V D
46) What position is best suited for the patient when the nurse is to perform the hernia exam on a male?
a) Supine b) Lateral recumbent c) Sitting d) Standing D
50) When an examining an adolescent during a wellness visit the nurse completes a Snellen screening and reports the patient's visual acuity is 20/40. What does this mean?
a) The patient can read from 20 feet what a person with normal vision can read at 40 feet. b) The patient can read from 40 feet what a person with normal vision can read at 20 feet. c) The patient can read the entire chart from 40 feet. d) The patient can read the chart from 20 feet with the left eye, and from 40 feet with the right eye. A
33) A 70 year-old male is complaining of dribbling with urination, nocturia, and a change in the force of stream. What might the nurse suspect is the most likely cause?
a) These symptoms may indicate a STI b) These symptoms may indicate an enlarging prostate c) These symptoms may indicate a urinary tract infection d) These symptoms may indicate bladder cancer B
29) A sexually active parous female presents for her pap smear wellness examination. The nurse is prepping the examination tray for the physician conducting the exam. The nurse should provide which size Pedersen speculum to maintain patient comfort?
a. Pediatric b. Small c. Medium d. Large c.
The portion of the health history where the patient "tells" the provider their symptoms can be referred to as which type of data?
a. Subjective B. objective A*
Base and apex of heart
base- top apex- bottom
- Crackles Fine:
discontinuous, high-pitched, short crackling, popping sounds heard during inspiration that are not cleared by coughing Mechanism: Inspiratory crackles: inhaled air collides with previously deflated airways.
Normal anticipated findings in an abdomen assessment-
even skin tone, no bumps lesions or protrusions, the liver and kidneys are not inflamed/ no pain, no pain over the abdomen, no CVA tenderness
Health promotion activities across the lifecycle-
exercise like yoga or running
Glasgow Coma Scale-
eyes, verbal, motor Max- 15 pts, below 8= coma
Sequence of Complete Health History
move from "head to toe" Maximize patient's comfort, Avoid unnecessary changes in position, Enhance clinical efficiency, Brief teaching acceptable
visual acuity test
near vision test using Jaegar chart (aka mini Snellen chart), a handheld vision screener
The Fifth Vital Sign
pain
Normal TM and landmarks
pinna (top of ear), tragus (ear flap), mastoid process (low, behind ear)
tandem walking:
placing the heel of one foot in front of and touching the toes of the other foot and repeating the process to walk in a straight line; used as a test of gait, sobriety
PERRLA
pupils equal, round, reactive to light and accommodation
Quadrants of the breast:
upper outer upper inner lower outer lower inner The breast may be divided into four quadrants by imaginary horizontal and vertical lines intersecting at the nipple. In the upper outer quadrant note the axillary tail of spence, the cone shaped breast tissue that projects up into the axilla, close to the pectoral group of axillary lymph nodes. The upper outer quadrant is the site of most breast tumors.
Differentiate dizziness, vertigo, syncope-
vertigo you're spinning, dizziness the rooms spinning, syncope sensation of falling but not/ light headedness
Pain is
what the patient says it is!
Expected findings (inspection, palpation, tactile fremitus, percussion, auscultation)
with inspection symmetric, no bumps, lesions or masses, no chest deformities palpation no lumps, lesions or pain, tactile fremitus no increased vibration (meaning there is no fluid in the lungs), percussion, auscultation- no bruit or extra sounds
