160 Exam 2

kyphosis

- posterior curvature (convexity) of the thoracic spine normal with aging

How are deep tendon reflexes (DTR) scored? What is normal?

0 = No response 1+ = Sluggish or diminished 2+ = Active or expected response 3+ = Slightly hyperactive, more brisk than normal; not necessarily pathologic 4+ = Brisk, hyperactive with intermittent clonus associated with disease 2+ is normal

What is the pulse amplitude scale? What is normal?

0+ Absent 1+ Diminished, barely palpable 3+ Full volume 4+ Full volume, bounding hyperkinetic

the nurse is auscultation a patients heart sounds. which area is best for hearing the sounds of the mitral valve? 1 - 5th left intercostal space at the midclavicular lines 2 - 2nd left intercostal space at the sternal border 3 - 4th left intercostal space at the left sternal border 4 - 2nd right intercostal space at the sternal border

1 - 5th left intercostal space at the midclavicular lines

which CN is the nurse testing by touching a cotton wisp on the patients forehead, cheeks, and chin? 1 - CN V 2 - CN IV 3 - CN VI 4 - CN VII

1 - CN V

which test would the nurse perform to assess cerebellar function in a patient? select all that apply. one, some, or all may be correct 1 - Romber test 2 - Extinction test 3 - Sterognosis test 4 - Point location test 5 - FInger-to-nose test

1 - Romber test 5 - FInger-to-nose test

after conducting a cardiac exam, the nurse concludes that the patient has normal cardiopulmonary functioning. which finding contributed to the conclusion? select all that apply. one, some, or all responses may be correct. 1 - absence of cardiac murmur 2 - second heart sounds (S2) louder at the base of the heart 3 - a louder first sounds (S1) at the base 4 - a diminished second heart sound (S2) at the apex 5 - absence of equal and bilateral breath sounds

1 - absence of cardiac murmur 2 - second heart sounds (S2) louder at the base of the heart

Which type of bowel sounds does the nurse expect to find in a patient diagnosed with paralytic ileus? 1 - absent 2 - hypoactive 3 - hyperactive 4 - normoactive

1 - absent

Which response would the nurse provide when asked to explain the reason for changes in bowel movements? select all that apply. one, some, or all responses may be correct 1 - eating different foods can affect bowel movements 2 - it is rare for medications to affect bowel movements 3 - not getting enough activity can alter bowel movements 4 - some people have a change in bowel movements when stressed 5 - a bowel infection is the main reason for bowel movement changes

1 - eating different foods can affect bowel movements 3 - not getting enough activity can alter bowel movements 4 - some people have a change in bowel movements when stressed

An older adult patient has ben admitted with possible angina. for which sign or symptom other than chest pain would the nurse assess? select all that apply. one, some, or all responses may be correct 1 - fatigue 2 - weakness 3 - nausea 4 - hyponatremia 5 - drug interactions

1 - fatigure 2 - weakness 3 - nausea also could be experience shortness of breath, chest pain, or chest tightness

which planta reflex response is normal in an adult patient? 1 - flexion of the toes 2 - extension of the great toe 3 - extension of the lower leg 4 - flexion of the elbow

1 - flexion of the toes

which function do bones have in the body? select all that apply. one, some, or all may be correct 1 - hematopoiesis 2 - organ protection 3 - facilitate movement 4 - support for soft tissues 5 - reinforce respiratory passages

1 - hematopoiesis 2 - organ protection 3 - facilitate movement 4 - support for soft tissues

The nurse performs which action to prepare the patient for an abdominal exam? Select all that apply. one, some, or all responses may be correct 1 - keep the room warm 2 - ask the patient to be in a prone position 3 - ask the patient to keep their knees straightened 4 - ask the patient to empty their bladder 5 - warm the stethoscope endpiece before using

1 - keep the room warm 4 - ask the patient to empty their bladder 5 - warm the stethoscope endpiece before using

Pain in the RUQ of the abdomen would reflect pathology in which organ? select all that apply. one, some, or all responses may be correct 1 - liver 2 - stomach 3 - cecum 4 - gallbladder 5 - duodenum

1 - liver 4 - gallbladder 5 - duodenum

which assessment fidning in an older female patient would indicate possible osteoporosis? 1 - loss of height 2 - uneven shoulder and hip levels 3 - morning joint pain and stiffness 4 - muscle atrophy with a waddling gait

1 - loss of height

a patient who has undergone mastectomy surgery for cancer of the right breast has significant edema in the right arm. the nurse suspects the patient will be diagnosed with which condition? 1 - lympedema 2 - chronic hypotension 3 - deep vein thrombosis 4 - superficial varicose veins

1 - lympedema

which is considered a risk factor for coronary artery disease? select all that apply. one, some, or all responses may be correct 1 - male sex 2 - obesity 3 - smoking 4 - hypotension 5 - overexertion 5 - diabetes mellitus

1 - male sex 2 - obesity 3 - smoking 5 - diabetes mellitus

which factor would the nurse educator include when teaching a group of new nurses in a long-term care setting about risk factors for stroke? select all that apply. one, some, or all responses may be correct 1 - obesity 2 - diabetes 3 - hypotension 4 - active lifestyle 5 - tobacco use

1 - obesity 2 - diabetes 5 - tobacco use

which risk factor for stroke is modifiable? select all that apply. one, some, or all responses may be correct 1 - obesity 2 - age 3 - hypertension 4 - gender 5 - hypercholesteremia

1 - obesity 3 - hypertension 5 - hypercholesteremia

Which assessment finding would indicate that a patient is experiencing a kidney infection or stones? 1 - pain when percussing the costovertebral angle 2 - flat diaphram when percussing the upper liver border 3 - tense abdominal muscles when palpating the abdomen 4 - pain upon inspiration when palpating the RUQ

1 - pain when percussing the costovertebral angle

which factor would the nurse include when preparing a teaching plan for a patient education class on osteoporosis for aging adults? select all that apply. one, some, or all responses may be correct 1 - postmenopausal, fair-skinned women 2 - calcium deficiency 3 - very tall people 4 - vitamin D deficiency 5 - oversecretion of estrogen

1 - postmenopausal, fair-skinned women 2 - calcium deficiency 4 - vitamin D deficiency

which range-of-motion technique would the nurse use to help confirm a suspected nerve root compression? 1 - straight leg raises 2 - adduction of the hips 3 - dorsiflexion of the feet 4 - hyperextension of the knees

1 - straight leg raises

Which statement regarding a bowel assessment is correct? Select all that apply. one, some, or all responses may be correct 1 - the nurse should inspect, auscultate, palpate, and then percuss 2 - the abdomen should move smoothly and evenly with respirations 3 - normal bowel sounds may occur between 5-30 times per minute 4 - auscultate for 5 minutes before confirming the absence of bowel sounds 5 - use the pads of the fingertips to depress the abdomen 1 cm for light palpation

1 - the nurse should inspect, auscultate, palpate, and then percuss 2 - the abdomen should move smoothly and evenly with respirations 3 - normal bowel sounds may occur between 5-30 times per minute 4 - auscultate for 5 minutes before confirming the absence of bowel sounds 5 - use the pads of the fingertips to depress the abdomen 1 cm for light palpation

Which sounds does the nurse expect when percussing over the intestines? 1 - tympany 2 - dullness 3 - resonance 4 - hyperresonance

1 - tympany

which assessment finding of the affected area does the nurse anticipate when reviewing the chart of a patient with suspected peripheral arterial disease in the lower extremities? select all that apply. one, some, or all responses may be correct 1 - weak pulses 2 - loss of foot hair 3 - frequent leg pruritus 4 - visible varicose veins 5 - prolonged capillary refill

1 - weak pulses 2 - loss of foot hair 5 - prolonged capillary refill

Describe the pitting edema scale.

1+ barely perceptible pit - 2mm 2+ deeper pit, rebounds in a few seconds - 4mm 3+ deep pit, rebounds in 10-20 seconds - 6mm 4+ deeper pit, rebounds in >30 seconds - 8mm

1. Which patient's description of pain is consistent with injury to a bone? 1. "Deep, dull, and boring" 2. "Cramping even when not moving" 3. "Intermittent, sharp, and radiating" 4. "Tingling with pins and needles sensation with movement"

1. "Deep, dull, and boring"

4. Which question gives the nurse additional information about a patient's report of his hands shaking for the last 2 months? 1. "Does the shaking occur when your hands are at rest or when you are picking up an item?" 2. "Do you experience any abnormal sensations, such as tingling or coldness, at the same time?" 3. "What actions do you take to relieve the shaking when it occurs?" 4. "Have you ever experienced this shaking before?"

1. "Does the shaking occur when your hands are at rest or when you are picking up an item?"

7. The nurse asks a patient to stand with her feet together, her arms placed at her sides, and her eyes closed. The nurse then observes the patient moving her foot to maintain balance and opening her eyes. Based on this finding, which additional assessment does the nurse perform to confirm an abnormality with balance? 1. Ask the patient to walk in tandem, putting the heel of one foot directly against the toes of the other foot. 2. Ask the patient to sit down and alternatively tap the thighs with your hands using rapid supination and pronation movements. 3. Place a vibrating tuning fork in the patient's ankle and ask when she no longer detects the vibration. 4. With the patient in a seated position, support one lower leg while sharply dorsiflexing the foot and maintain it in flexion.

1. Ask the patient to walk in tandem, putting the heel of one foot directly against the toes of the other foot.

5. While assessing the range of motion of the patient's knee, the nurse expects the patient to be able to perform which movements? 1. Flexion, extension, and hyperextension 2. Circumduction, internal rotation, and external rotation 3. Adduction, abduction, and rotation 4. Flexion, pronation, and supination

1. Flexion, extension, and hyperextension

6. A patient reports joint pain interfering with sleep and morning joint stiffness for the first hour after getting out of bed. Considering this report, what abnormal findings does the nurse anticipate during the examination? 1. Hot, painful, deformed, and edematous wrists and peripheral interphalangeal joints bilaterally 2. Decreased range of motion of one hip and knee, with pain on flexion and crepitus during movement of these joints 3. Erythema in one great toe, ankle, and lower leg that is painful to the touch 4. Abrupt onset of local tenderness, edema, and decreased range of motion of the shoulder and hip bilaterally

1. Hot, painful, deformed, and edematous wrists and peripheral interphalangeal joints bilaterally

4. Which organs is the nurse assessing during palpation of the right upper quadrant of the abdomen? 1. Liver and gallbladder 2. Stomach and spleen 3. Uterus, if enlarged, and right ovary 4. Right ureter and ascending colon

1. Liver and gallbladder

8. What is the most accurate technique for detecting a venous thrombosis at the bedside? 1. Measure the thigh circumference to detect an increase from the baseline. 2. Dorsiflex the calf and notice if the patient complains of pain. 3. Elevate one leg above the level of the heart to determine if the veins empty. 4. Palpate the pulses distal to the areas of the suspected thrombosis.

1. Measure the thigh circumference to detect an increase from the baseline.

2. The nurse is interviewing a patient with a history of flank pain, fever, and chills. Which examination technique is most appropriate for this patient? 1. Percussion of the costovertebral angle 2. Deep palpation of the lower abdomen 3. Palpation of the kidney for contour 4. Auscultation of the lower quadrants of the abdomen

1. Percussion of the costovertebral angle

which advice would the nurse provider to a patient at risk for coronary artery disease to prevent further complications? select all that apply. one, some, or all responses may be correct 1 - increase fluid intake 2 - avoid smoking cigarettes 3 - avoid a sedentary lifestyle 4 - use compression garments 5 - reduce the intake of fatty foods

2 - avoid smoking cigarettes 3 - avoid a sedentary lifestyle 5 - reduce the intake of fatty foods

while assessing a patient with venous insufficiency, the nurse finds that the patient has edema in lower extremities. the nurse will assess for which other symptoms of venous insufficiency? 1 - lesion with black eschar on the feet 2 - brownish-bronze leg skin pigmentation 3 - pain in the legs when walking, relieved with resting 4 - decreased posterior tibial and dorsalis pedis pulses

2 - brownish-bronze leg skin pigmentation

which disorder does the nurse suspect a patient is experiencing when the patient says, "Ive been having severe leg pain when i go for my afternoon walk or climb a few flights of starirs. but it goes away when i rest"? 1 - arthritis 2 - claudication 3 - diabetes 4 - hyperthyroidism

2 - claudication

which condition, if present in the patient's history, would prompt the nurse to assess for peripheral neuropathy? select all that apply. one, some, or all may be correct 1 - meningioma 2 - diabetes mellitus 3 - cervical spondylosis 4 - shoulder dislocation 5 - nutritional deficiency

2 - diabetes mellitus 5 - nutritional deficiency

which description will the nurse use when explaining grade 3 muscle strength? 1 - full range of motion, but not against gravity 2 - full range of motion against gravity and no resistance 3 - full range of motion against gravity and some resistance 4 - full range of motion against gravity and full resistance

2 - full range of motion against gravity and no resistance

Which abdominal assessment finding is consistent with ascites? 1 - crusting skin and erythema 2 - glistening, taut skin 3 - bluish periumbilical color 4 - deeply sunken umbilicus

2 - glistening, taut skin

which technique would the nurse use to assess CN VII? select all that apply. one, some, or all may be right 1 - watch the jaw movement while child is chewing 2 - observe the child smiling, frowning, and crying 3 - have the child puff out their cheeks 4 - ask the child to show their teeth 5 - use the snellen eye chart for visual acuity

2 - observe the child smiling, frowning, and crying 3 - have the child puff out their cheeks 4 - ask the child to show their teeth

the nurse is assessing an older adult patient for peripheral vascular complications of the lower extremities. which nursing action is appropriate during a peripheral vascular exam of the lower extremities? 1 - assessing the weight of the patient 2 - palpating the pulses of the patient 3 - percussing the lungs of the patient 4 - assessing the body temperature of the patient

2 - palpating the pulses of the patient

which instruction would the nurse give to a patient while performing the Romberg test? 1 - walk heel to toe across the room 2 - stand with your feet together and eyes open. now, close your eyes 3 - run the heel of your right foot down your left shin starting at your knee 4 - hold your hands away from your sides, and turn your hands back and forth rapidly

2 - stand with your feet together and eyes open. now, close your eyes

which test is the nurse performing when the patient is asked to recognize the object after a paper clip is placed on the patient's palm while their eyes are closed? 1 - graphesthesia 2 - stereognosis 3 - extinction 4 - discrimination

2 - stereognosis

which motor function would the nurse describe when teaching about the glossopharngeal nerve? 1 - tasting of food 2 - swallowing and gagging 3 - lateral movement of the eye 4 - muscular movement of the tongue

2 - swallowing and gagging CN IX

after measuring pitting edema in a patient, the nurse documents it as 4+. which finding supports the nurse's documentation? select all that apply. one, some, or all may be correct 1 - the patient has moderate pitting 2 - the patient has very deep pitting 3 - the patient has no palpable pedal pulses 4 - the patient has indentation of long duration 5 - the patient has indentation of short duration

2 - the patient has very deep pitting 4 - the patient has indentation of long duration

which statement is correct regarding the difference between the arterial and venous systems? 1 - the walls of the arteries are thinner, and the walls of the veins are thicker 2 - the pressure inside arteries is high, the pressure inside veins is lower 3 - the arteries contain valves, the veins are devoid of valves 4 - the arteries transport blood to the heart, and the veins transport blood away from the heart

2 - the pressure inside arteries is high, the pressure inside veins is lower

What is normal capillary refill time?

2 seconds or less

2. A patient complains of pain in the calf when walking. Which question should the nurse ask for further data? 1. "Does your calf also swell when this pain occurs?" 2. "Does the pain go away when you stop walking?" 3. "Do you become short of breath when you're walking?" 4. "Do you feel dizzy when the pain occurs?"

2. "Does the pain go away when you stop walking?"

4. When a patient complains of chest pain, which question is pertinent to ask to gain additional data? 1. "What were you doing when the pain first occurred?" 2. "What does the pain feel like?" 3. "Do you have shortness of breath?" 4. "Has anyone in your family ever had a similar pain?"

2. "What does the pain feel like?"

10. You had to yell his name to get him to open his eyes; he could not tell you his name or location, and he could raise his hands when asked. Using the Glasgow Coma Scale (see Fig. 15.23), what score would you give to this patient? 1. 12 2. 13 3. 14 4. 15

2. 13

9. A nurse inspects the abdomen for skin color, surface characteristics, and surface movement. What part of the abdominal assessment does the nurse perform next? 1. Palpate lightly for tenderness and muscle tone 2. Auscultate for bowel sounds 3. Palpate deeply for masses or aortic pulsation 4. Percuss for tones

2. Auscultate for bowel sounds

3. While assessing a patient's bicep muscle strength, the nurse applies resistance and asks the patient to perform which motion? 1. Extension of the arm 2. Flexion of the arm 3. Adduction of the arm 4. Abduction of the arm

2. Flexion of the arm

9. What is the expected patient response when assessing the function of CN XI (spinal accessory)? 1. Demonstrates full, active range of motion of the neck 2. Moves shoulders against resistance equally 3. Follows an object with eyes without nystagmus 4. Sticks out tongue without tremor or deviation

2. Moves shoulders against resistance equally

1. During a health history, a patient reports having difficulty swallowing. Based on this report, which assessment technique does the nurse use to collect more data about the patient's ability to swallow? 1. Ask the patient to puff out her cheeks, purse her lips, and blow out. 2. Observe the soft palate when the patient says "ahh." 3. Observe the patient while she swallows water from a paper cup. 4. Wearing gloves, grasp the patient's tongue and palpate all sides.

2. Observe the soft palate when the patient says "ahh."

8. A patient complains of her jaw popping when chewing. Which examination techniques are appropriate for the nurse to use with this patient? 1. Inspecting the musculature of the face and neck for symmetry. 2. Observing the range of motion of and palpating each temporomandibular joint for movement, sounds, and pain 3. Asking the patient to move her chin to her chest, hyperextend her head, and move her head from the right side to the left side 4. Asking the patient to open her mouth as widely as possible and inspecting the lower jaw for redness, edema, or broken teeth

2. Observing the range of motion of and palpating each temporomandibular joint for movement, sounds, and pain

6. When assessing an adult's liver, the nurse percusses the lower border and finds it to be 5 cm below the costal margin. What is the nurse's appropriate action at this time? 1. Document this as an expected finding for this adult 2. Palpate the upper liver border on deep inspiration 3. Palpate the gallbladder for tenderness 4. Use the hooking technique to palpate the lower border of the liver

2. Palpate the upper liver border on deep inspiration

6. Where does a nurse palpate the posterior tibial pulse? 1. Behind the knee in the popliteal fossa 2. The inner aspect of the ankle below and slightly behind the medial malleolus 3. Over the dorsum of the foot between the tendons of the first and second toes 4. The outer side of the ankle below and slightly behind the lateral malleolus

2. The inner aspect of the ankle below and slightly behind the medial malleolus

which name is given to the angular motion when the arm is moved away from the midline of the body? 1 - adduction 2 - extension 3 - abduction 4 - flexion

3 - abduction

a bedridden patient with hypertension reports sudden sharp pain in the legs. the nurse finds the patients legs to be warm, red, and edematous. which class of medication would be most beneficial for the patient? 1 - analgescis 2 - antibiotics 3 - anticoagulants 4 - antihypertenisves

3 - anticoagulants prolonged bed rest = higher risk of getting blood clots

which technique would the nurse use to auscultate the abdomen? 1 - push the stethoscope against the skin 2 - auscultate the abdomen after palpation 3 - auscultate using the diaphragm endpiece 4 - begin auscultation from the LUQ

3 - auscultate using the diaphragm endpiece

which state describes the function of the lymphatic system? 1 - it helps in tissue oxygenation 2 - it filters the blood to engulf bacteria 3 - it removes fluid from interstitial spaces 4 - it is part of the immune system

3 - it removes fluid from interstitial spaces

crushing pain in the center of the chest may indicate which serious condition? 1 - stroke 2 - pulmonary edema 3 - myocardial infarction 4 - bleeding stomach ulcer

3 - myocardial infarction

after asking a patient to move the mandible side to side, the nurse hears an audible clicking sound. when the patient does not voice pain, which action would the nurse take? 1 - inquire about tobacco use 2 - document arthritic changes 3 - recognize a normal finding 4 - schedule a bone density test

3 - recognize a normal finding

which term can be used to describe the pacemaker of the heart? 1 - lymph node 2 - ranvier node 3 - sinoatrial node 4 - atrioventricular node

3 - sinoatrial node

the nurse has taught a patient the physiologic changes that occur in the body because of cigaretet smoking. which statement by the patient indicates the need for the nurse to conduct further instruction? 1 - smoking constricts the arteries 2 - smoking increases the heart workload 3 - smoking decreases blood pressure 4 - if i have quit smoking before, it is possible to stop now

3 - smoking decreases blood pressure

The nurse should auscultate the abdomen for at least __________________ ______________________ before documenting absent bowel sounds.

3-5 minutes

3. A patient reports a gnawing, burning pain in the midepigastric area that is aggravated by bending over or lying down. Which additional question does the nurse ask as part of a symptom analysis? 1. "Do you have a family history of this type of pain?" 2. "How long ago did you eat?" 3. "Is the pain worse after eating or when your stomach is empty?" 4. "Have you noticed any yellow coloring in your eyes or on your skin?"

3. "Is the pain worse after eating or when your stomach is empty?"

10. A patient reports having abdominal fullness and having vomited several times yesterday and today. What question is appropriate for the nurse to ask in response to this information? 1. "Has there been a change in the amount of the distention?" 2. "Did you have heartburn before the vomiting?" 3. "What did the vomitus look like?" 4. "Have you noticed a change in the color of your urine or stools?"

3. "What did the vomitus look like?"

3. A nurse who is auscultating a patient's heart hears a harsh sound, a raspy machine-like blowing sound, after S1 and before S2. How does this nurse document this finding? 1. An opening snap 2. A diastolic murmur 3. A systolic murmur 4. A pericardial friction rub

3. A systolic murmur

10. With the patient in a supine position, how does a nurse assess the external rotation of the patient's right hip? 1. Asking the patient to move the right leg laterally with the right knee straight 2. Asking the patient to flex the right knee and turn medially toward the left side (inward) 3. Asking the patient to place the right heel on the left patella 4. Asking the patient to raise the right leg straight up and perpendicular to the body

3. Asking the patient to place the right heel on the left patella

5. Using deep palpation of a patient's epigastrium, a nurse feels a rhythmic pulsation of the aorta. Based on this finding, what is the nurse's most appropriate response? 1. Auscultate this area using the bell of the stethoscope. 2. Percuss the area for tones. 3. Document this as an expected finding. 4. Ask the patient if there is pain in this area.

3. Document this as an expected finding.

5. How does a nurse determine jugular vein pulsations? 1. Raises the head of the bed about 90 degrees and looks for the jugular vein pulsation parallel to the sternocleidomastoid muscle as the bed is slowly lowered 2. Looks for jugular vein pulsations at the jaw line as the patient turns from supine to a side-lying position 3. Elevates the head of the bed until the external jugular vein pulsation is seen above the clavicle 4. Positions the patient supine and asks him or her to cough; inspects for jugular vein pulsations during the cough

3. Elevates the head of the bed until the external jugular vein pulsation is seen above the clavicle

3. During a symptom analysis, the patient reports a pain that radiates from the right lateral thigh, over the knee, and around to the right medial ankle. The nurse refers to the dermatome map (see Fig. 15.8) to determine that the patient's description of pain is consistent with dysfunction of which spinal nerve? 1. Second lumbar (L2) 2. Third lumbar (L3) 3. Fourth lumbar (L4) 4. Fifth lumbar (L5)

3. Fourth lumbar (L4)

7. The nurse is comparing the right and left legs of a patient and notices that they are asymmetric. Which additional data does the nurse collect at this time? 1. Passively moves each leg through range of motion and compares the findings 2. Observes the patient's gait and legs as he or she walks across the room 3. Measures the length of each leg and compares the findings 4. Palpates the joints and muscles of each leg and compares the findings

3. Measures the length of each leg and compares the findings

10. While inspecting the legs of a male patient, the nurse notices that the skin is shiny and taut with little hair growth. Which additional data would the nurse find to indicate that this patient has peripheral arterial disease? 1. Pitting edema of one or both feet or legs 2. Increased circumference in the thighs bilaterally 3. Pale, cool legs with diminished-to-absent dorsalis pedis pulses 4. Pain when legs are dependent that is relieved when legs are elevated

3. Pale, cool legs with diminished-to-absent dorsalis pedis pulses

7. Which finding does the nurse expect during auscultation of the heart? 1. A low-pitched blowing sound is heard over the apex of the heart. 2. A high-pitched vibration is heard over the base of the heart. 3. The S1 heart sound is louder at the apex of the heart. 4. The S3 heart sound sounds like "Ken-tuck-y."

3. The S1 heart sound is louder at the apex of the heart.

6. Which patient behavior indicates to the nurse that the patient's facial cranial nerve (CN VII) is intact? 1. The patient's eyes move to the left, right, up, down, and obliquely. 2. The patient moistens the lips with the tongue. 3. The sides of the mouth are symmetric when the patient smiles. 4. The patient's eyelids blink periodically.

3. The sides of the mouth are symmetric when the patient smiles.

which grade would the nurse enter in the medical record of a patient whose deep tendon reflexes are very brisk and hyperactive with clonus? 1 - 1+ 2 - 2+ 3 - 3+ 4 - 4+

4 - 4+

Pain at McBurney's point is associated with which condition? 1 - Colitis 2 - Volvulus 3 - Renal Calculi 4 - Appendicitis

4 - Appendictis pain near the umbilicus and ends in the RLQ at McBurneys

which test would the nurse use to determine the patient's level of consciousness following a head-on motor vehicle accident? 1 - grey-turner sign 2 - Hamman sign 3 - mini-mental status exam 4 - Glasgow coma scale

4 - Glasgow coma scale

which pulse point will be palpated signularly by the nurse? 1 - popliteal 2 - radial 3 - femoral 4 - carotid

4 - carotid

a parent explains, "my daughter doesn't stand properly because of a difference in the height of her shoulders." which finding supports the nurse's suspicion of scoliosis? 1 - joint tenderness 2 - limited arm range of motion 3 - spasm of the paravertebral muscles 4 - humping of the ribs on one side while bending

4 - humping of the ribs on one side while bending

which finding is indicative of a pulse deficit? 1 - BP is 140/82 mm Hg in the left arm, 138/80 mm Hg in the right arm 2 - the difference between the systolic blood pressure and the diastolic blood pressure is 36 mm Hg 3 - the radial pulse has an amplitude of 3+, while the ulnar pulse has an amplitude of 1+ 4 - the radial pulse is counted at 82 beats/min, while the apical pulse is counted at 90 beats/min

4 - the radial pulse is counted at 82 beats/min, while the apical pulse is counted at 90 beats/min

Which assessment findings require further evaluation? select all that apply. one, some, or all responses may be correct 1 - pulse rate of 78 beats/min 2 - respiratory rate of 16 breaths/min 3 - oxygen saturation reading of 95% 4 - use of accessory muscles while breathing 5 - patient's oral mucosa is very light pink color

4 - use of accessory muscles while breathing 5 - patient's oral mucosa is very light pink color

1. A patient reports severe abdominal pain and pain in the right shoulder that gets worse after eating fried foods. What question does the nurse ask to gather more data about the possibility of cholelithiasis? 1. "Has your abdomen been distended?" 2. "Have you experienced fever, chills, or sweating?" 3. "Have you vomited up any blood in the last 24 hours?" 4. "Has the color of your urine or stools changed?

4. "Has the color of your urine or stools changed?

2. As a patient is walking into the exam room, the nurse notices his unsteady gait. What findings does the nurse anticipate during the neurologic exam? 1. When the patient stands with his feet together and eyes closed, his upright posture is maintained. 2. The nurse notices no patient response after striking the right patellar tendon with a reflex hammer. 3. The patient is able to move the heel of one foot down the shin of the other leg while lying supine. 4. A tremor is observed in his hands while he touches his finger to his thumb on the same hand.

4. A tremor is observed in his hands while he touches his finger to his thumb on the same hand.

7. Which is an abnormal sound the nurse would detect when auscultating the abdomen using the bell of the stethoscope? 1. High-pitched gurgles 2. Borborygmi 3. Venous hum 4. Absent bowel sounds

4. Absent bowel sounds

2. How does the nurse determine if a patient's musculoskeletal examination is normal? 1. By reading the examination findings documented in the patient's chart 2. By comparing findings from other patients in the same age group 3. By reading descriptions in health assessment books 4. By comparing the patient's left side with the right side

4. By comparing the patient's left side with the right side

8. What is the earliest and most sensitive indication of altered cerebral function? 1. Memory impairment 2. Loss of deep tendon reflexes 3. Inability to communicate 4. Change in level of consciousness

4. Change in level of consciousness

9. When a nurse asks a patient to place the right arm behind the head, the nurse is assessing for which range of motion? 1. Flexion of the elbow 2. Hyperextension of the shoulder 3. Internal rotation and adduction of the shoulder 4. External rotation and abduction of the shoulder

4. External rotation and abduction of the shoulder

5. Which technique does the nurse use to assess the triceps reflex? 1. Holds the patient's relaxed arm with the elbow extended while striking the appropriate tendon with a reflex hammer 2. Holds the patient's relaxed forearm with the hand slightly pronated while striking the appropriate tendon with a reflex hammer 3. Holds the patient's relaxed arm with elbow flexed at a 90-degree angle, places a thumb over the appropriate tendon, and strikes the thumb with the reflex hammer 4. Holds the patient's relaxed arm with elbow flexed at a 90-degree angle in one hand and strikes the appropriate tendon just above the elbow with a reflex hammer

4. Holds the patient's relaxed arm with elbow flexed at a 90-degree angle in one hand and strikes the appropriate tendon just above the elbow with a reflex hammer

9. Each patient has had consistent blood pressure readings during the last three clinic visits. Which patient has a blood pressure consistent with expected findings? 1. Ms. J, whose blood pressure has been 140/90 2. Mr. Q, whose blood pressure has been 130/76 3. Ms. Y, whose blood pressure has been 120/80 4. Mr. P, whose blood pressure has been 110/78

4. Mr. P, whose blood pressure has been 110/78

4. The nurse assessing the patient's muscle strength finds that the patient has full resistance to opposition. Using Table 14.1, how would this finding be documented? 1. Poor or 2/5 2. Fair or 3/5 3. Good or 4/5 4. Normal or 5/5

4. Normal or 5/5

1. The nurse is listening to the patient's heart at the 2nd LSB. Which area is being auscultated? 1. Erb's point 2. Mitral area 3. Aortic area 4. Pulmonic area

4. Pulmonic area

8. Which technique does the nurse use to palpate a patient's abdomen? 1. Asks the patient to breath slowly though the mouth 2. Uses the heel of the hand to perform deep palpation 3. Uses the left hand to lift the rib cage away from the abdominal organs 4. Uses the pads of the fingertips to depress the abdomen.

4. Uses the pads of the fingertips to depress the abdomen.

Bowel sounds should be heard every __________ to ________________ seconds.

5-15 seconds

List the Cranial Nerves: roman numeral, name, sensory, motor or both and how to assess each one CN 6

Abducens Motor: Lateral eye movement

Describe Allis' sign and the Barlow-Ortolani maneuver in newborns.

Allis' sign - assessment for hip dislocation, infant lying supine, flex knees with the feet flat on the table and align the femurs Barlow Ortolani maneuver - adduct the legs, exerting downward pressure, then abduct them, moving knees apart and down towards the table apply upward pressure with the fingers on the greater trochanter

Who is most at risk for varicose veins?

women, obese, someone with peripheral venous disease

Describe Neurological Screening in a Healthy Patient.

• ASSESS mental status and level of consciousness. • ASSESS speech. • NOTICE cranial nerve functions. • OBSERVE gait. • ASSESS extremities for muscle strength and tone.

Discuss inspection for the cardiac system. Head to Toe s & s.

• INSPECT for general appearance, skin color, and breathing effort. • INSPECT the anterior chest wall. • PALPATE the apical pulse. • AUSCULTATE the apical pulse. • AUSCULTATE the heart. • CALCULATE the pulse deficit. • INTERPRET the electrocardiogram. • PALPATE temporal and carotid pulses. • INSPECT the jugular veins. • MEASURE the blood pressure. • INSPECT the upper extremities • PALPATE the upper extremities. • PALPATE upper-extremity pulses. • INSPECT the lower extremities. • PALPATE the lower extremities. • PALPATE lower-extremity pulses.

what are the characteristics and where is the pain located for Peptic ulcer?

Burning, cramping Epigastrium Gastric: 1-2 h after meals Duodenal: 2-4 h after meals, pain in back

Characteristics and location of Esophageal reflux

Burning, tight sensation, squeezing Midepigastric to xiphoid; radiates to neck, ear, or jaw

what are the characteristics and where is the pain located for Appendicitis

Colicky Umbilical moving to RLQ

what are the characteristics and where is the pain located for Gastritis?

Constant, burning Epigastric

Characteristics and location of Acute pericarditis

Constant, sharp, stabbing pain Substernal, radiates to left shoulder, neck, or arms

what are the characteristics and where is the pain located for gastroenteritis?

Cramping Diffuse

what are the characteristics and where is the pain located for Irritable bowel syndrome

Cramping, recurrent, sharp, burning LLQ

List the Cranial Nerves: roman numeral, name, sensory, motor or both and how to assess each one CN 7

Facial Motor: Movement of facial expression muscles except jaw, close eyes, labial speech sounds (b, m, w, and rounded vowels) Sensory: Taste on the anterior two-thirds of tongue, sensation to pharynx Parasympathetic: Secretion of saliva and tears

List the Cranial Nerves: roman numeral, name, sensory, motor or both and how to assess each one CN 9

Glossopharyngeal Motor: Voluntary muscles for swallowing and phonation (guttural speech sounds) Sensory: Sensation of nasopharynx, gag reflex, taste on the posterior one-third of tongue Parasympathetic: Secretion of salivary glands, carotid reflex

Briefly explain the Romberg test. What is a positive Romberg? What part of the brain does it test?

Have the patient stand with feet together, arms resting at sides with eyes open, and then eyes closed. Stand close to the patient with arms ready to "catch" the patient if he or she begins to fall off balance. There will be slight swaying, but the upright posture and foot position should be maintained. cerebellum

what are the characteristics and where is the pain located for Gastro-esophageal reflux?

Heartburn, regurgitation, angina relieved by antacids Mid-epigastric May radiate to jaw

Characteristics and location of Myocardial infarction (MI)

Heavy pressure, squeezing, crushing; burning, not relieved with rest, position change or nitrates Substernal, radiates to arms, neck, jaw

List the Cranial Nerves: roman numeral, name, sensory, motor or both and how to assess each one CN 12

Hypoglossal Motor: Tongue movement for speech sound articulation (l, t, n) and swallowing

Review muscle strength table.

No evidence of contractility- 0 Evidence of slight contractility-1 Complete range of motion with gravity eliminated-2 Complete range of motion with gravity-3 Complete range of motion against gravity with some resistance-4 Complete range of motion against gravity with full resistance-5

How is an urgent assessment done for PVS conditions?

Palpate the pulse to confirm its presence and then compare pulse strength between the feet.

Define stereognosis.

Place a small, familiar object in the patient's hand, e.g., a key, paper clip, or coin, and ask him or her to identify it. The object should be properly identified.

Characteristics and location of Stable angina

Pressure, burning, heaviness, crushing Usually located substernally, can radiate to left arm, neck, jaw, shoulders

List the Healthy People 2020 health promotion goals for the abdominal system. (colorectal cancer) Primary prevention: Secondary prevention:

Primary prevention: An individual can lower the risk of developing colorectal cancer by managing controllable risk factors such as diet and physical activity Secondary prevention: Men and women of average risk should be screened from ages 45 to 75. Adults aged 76-85 should consult their care provider about screening. Screening tests can be used to find polyps or colorectal cancer.

Describe S1 & S2. Which valves are involved in each?

S1 - closing of the tricuspid and mitral valves lubb sounds S2- closing of the aortic and pulmonary valve dubb

Briefly, what could cause S3 & S4 heart sounds? (advanced practice)

S3 - when blood in the atria rapidly fills the ventricles, ub, CHF S4 - when atrial contraction completes the filling of the ventricles, a fourth sound may be heard, ub, heard at the beginning, past damage to heart muscle, stiff ventricle

Electrical system of the heart. What is the pacemaker of the heart?

SA node (sinoatrial node)

what are the characteristics and where is the pain located for cholecystitis or cholelithiasis

Severe, progressing to constant RUQ or epigastric radiates to R shoulder

List the Cranial Nerves: roman numeral, name, sensory, motor or both and how to assess each one CN 11

Spinal accessory Motor: Turn head, shrug shoulders, some actions for phonation

what are the characteristics and where is the pain located for Ectopic pregnancy

Sudden onset, persistent pain Lower quadrants referred to shoulder

what are the characteristics and where is the pain located for Intestinal obstruction

Sudden onset, severe, colicky Referred to epigastrium, umbilicus

what are the characteristics and where is the pain located for Pancreatitis

Sudden onset, steady, severe, knifelike LUQ, epigastric; radiates to back

List the Cranial Nerves: roman numeral, name, sensory, motor or both and how to assess each one CN 5

Trigeminal Motor: Jaw opening and clenching, chewing and mastication Sensory: Sensation to cornea, iris, lacrimal glands, conjunctiva, eyelids, forehead, nose, nasal and mouth mucosa, teeth, tongue, ear, facial skin

List the Cranial Nerves: roman numeral, name, sensory, motor or both and how to assess each one CN 4

Trochlear Motor: Downward, inward eye movement

List the Cranial Nerves: roman numeral, name, sensory, motor or both and how to assess each one CN 10

Vagus Motor: Voluntary muscles of swallowing and phonation Sensory: Sensation behind ear and part of external ear canal Parasympathetic: Secretion of digestive enzymes; peristalsis; carotid reflex; involuntary action of heart, lungs, and digestive tract

Characteristics and location of Costochondritis

Variable Rib cage or sternum, confined to one area

What are the Wernicke and Broca areas of the brain responsible for?

Wernicke - located in left temporal lobe, responsible for comprehension of spoke and written langue Broca - involves in the formulation of words

Write out (use several sentences) the documentation of a normal abdominal assessment:

abdomen is smooth, flat, and lighter color than extremities with smooth, symmetric contour and no visible peristalsis. umbilicus midline and rectus abdominis muscles prominent when head raised. bowel sounds present with no vascular sounds. no tenderness, masses, or aortic pulsations to light or deep abdominal palpation. umbilical ring reels round with no irregularities or bulges. tympany in all quadrants. liver span 3 inches. unable to percuss spleen. liver border smooth. gallbladder, spleen, and kidneys are not palpable

What are some causes of hypoactive bowel sounds?

abdominal surgery narcotics late bowel obstruction

Describe normal urine characteristics. Normal color and amount per hour.

amber colored at least 30 mL/hr

lordosis

anterior curvature (concavity) of the spine normal with pregnant women and toddlers

What are the 5 areas to auscultate?

aortic valve - 2nd ICS, RSB pulmonic valve - 2nd ICS, LSB Erb's Point - 3rd ICS, LSB tricuspid valve - 4th ICS, LSB mitral valve - 5th ICS, LMCL APE To MAN

Discuss a child's cardiac considerations.

apical pulse - felt in 4th or 5th ICS just medial to MCL examine within 24 hours of birth and again at 2-3 days infant needs to be quite and done for a full 1 minute small diaphragm and bell palpate the femoral and brachial pulses and assess capillary refill pulse O2 is mandatory with newborn screening to check for critical congenital heart defects

Differentiate venous and arterial insufficiency.

arterial - produces pain that worsens with activity, especially prolonged walking venous - intensifies with prolonged standing or sitting in one position

Describe the procedure for lightly palpating the abdomen. What are you assessing for?

ask patient to bend their knees to relax the abdominal muscle. palpate all quadrants. using fingertips to go 1 cm. keep fingers together and lift the hand from one area to another (don't slide) palpate over the area of pain last (if patient reported abdominal pain

Discuss orientation assessment. How do you assess orientation?

ask patient to tell their full name, his present location, and todays date

Discuss older adult musculoskeletal changes.

assess for balance and gait, risk for falls

what are advanced practice techniques for abdominal assessment?

assess the abdomen for fluid assess for abdominal pain caused by inflammation assess for abdomen for a floating mass

Describe palpation of the heart.

assessing the arterial pressure, measuring blood pressure, palpating any thrills on the chest, and palpating for the point of maximal impulse

Borborygmi

audible sounds produced by hyperactive peristalsis

Differentiate bone pain, muscle pain, and nerve pain.

bone -deep, dull, boring muscle - sore, achy, crampy, tender, pain with movement nerve - shooting, stabbing or burning sensation

How and where do bones grow and elongate?

bone develops by replacing hyaline cartilage Activity in the epiphyseal plate enables bones to grow in length (this is interstitial growth). Appositional growth allows bones to grow in diameter.

Discuss medication Digoxin.

can cause slow pulse rates

What is the first sign of impaired cerebral function/ neurological deterioration?

change in level of consciousness

Discuss Indicators of Significant Changes in Neurological Status.

change in level of consciousness, loss of person, place, time

When is urgent assessment needed for cardiac issues?

chest pain, peripheral edema, unexplained sudden weight gains, SOB, irregular pulse rate or rhythm, dizziness, or poor peripheral circulation

List Levels of Consciousness.

confusion delirium lethargy obtundation stupor coma

Define heart murmur.

created by turbulent blood flow, produces prolonged extra sounds heard during systole and diastole, blowing/swishing, can be outgrown, innocent - no problems new development - usually involves valves, stenosis

Discuss ethnic and gender differences in musculoskeletal system.

curvatures in femurs -Caucasians - femoral curve -Indians - anterior curve Africans Americans - straight men - larger/stronger bones, less likely to have problems

arteries

deliver oxygen-rich blood from the heart to the tissues of the body muscular tube lined by smooth tissue the pressure inside arteries is high

What are some causes of hyperactive bowel sounds?

diarrhea early bowel obstruction Gastroesophageal reflux

What is pulse pressure? What is normal?

difference between systolic and diastolic pressure normal - between 30 and 40 mm Hg

Define dorsiflexion and plantar flexion. Which joint does the action occur in?

dorsiflexion - pointing the toes toward the face plantar flexion - point toes toward the ground occurs in the foot

The expected percussion tone over a full bladder is___________________________.

dullness

peripheral vascular disease

edema, dark staining skin

what is ascites?

excess fluid inside abdominal cavity

How do you locate the femoral, dorsalis pedis and the posterior popliteal pulses?

femoral - palpate below the inguinal ligament, midway between the symphysis pubis and anterior superior iliac crest, and move your fingers inward toward the pubic hair. dorsalis pedis - palpate lightly over the dorsum of the foot between the extension tendons of the first and second toes posterior popliteal pulses - palpate the popliteal artery behind the knee in the popliteal fossa

2 tests for testing of ascites?

fluid wave test shifting dullness

Which part of the brain contains the vital autonomic centers for respiratory, cardiac, and vasomotor function?

frontal lobe

Explain how consciousness is assessed, including use of stimulation?

glasgow coma scale

Describe older adults PVS changes.

increased arterial resistance contributes to hypertension reduced elasticity of arteries impairs peripheral blood flow orthostatic hypotension may contribute to falls

What is the difference in the plantar reflex/Babinski sign with babies and why?

it is normal for the dorsiflexion of big toe and the smaller toes fan out.

Describe scoliosis and testing performed. At what age is screening recommended?

lateral curvature of the spine 11-12 yrs compare shoulders and hips, bend over

Patients with a stroke (CVA) in the ______________hemisphere of brain are more likely to have language deficits.

left

Discuss carotid arteries

left common carotid artery right common carotid artery

what organs are in the LUQ?

left lobe of liver, spleen, stomach body of pancreas left adrenal gland portion of left kidney portions of transverse and descending colon

what organs are in the RUQ?

liver gallbladder pylorus duodenum head of pancreas right adrenal gland portion of right kidney portions of ascending and transverse colon

what are 3 causes of ascites?

liver failure kidney failure cirrhosis

Discuss osteoporosis and reduction recommendations.

loss of bone density and decreased bone formation, silent disease, loss of height, spontaneous fracture from brittle bone, develop kyphosis balanced diet rich in calcium and vitamin D, engage in weight bearing exercise, avoid smoking and excessive alcohol, DEXA

Define bruit.

low pitched blowing sounds usually heard during systole that indicates turbulent blood flow from an occlusion of the vessel

what organs are in the LLQ?

lower pole of left kidney sigmoid colon portion of descending colon bladder (only if distended) left ureter left ovary and salpinx uterus (only if enlarged) left spermatic cord

what organs are in the RLQ?

lower pole of right kidney cecum and appendix portion of ascending colon bladder (only if distended) right ureter right ovary and salpinx uterus (only if enlarges) right spermatic cord

Child abdominal assessment

lying flat, follow same procedure as for adults, although percussion is not typically performed normal : symmetric, soft, and rounded. There is synchronous abdominal and chest movement with breathing. Diastasis rectus (a gap between the rectus muscles) may be noted during crying. Visible pulsations in the epigastric areas are common. abnormal: distention or masses as well as concave, sunken, or flat appearance, or abdominal wall defects.

What is the significance of Angle of Louis?

marks the point at which the costal cartilages of the 2nd rib articulate with the sternum

A patient who has a CVA in the right side of the brain will have _________ and ________ deficits on the _________________ side of the body.

motor sensory left

Spinal cord injury at _________________ may not be able to breath on their own. May be dependent on a ventilator the rest of their lives.

neck, C1, C2, C3, C4, C5

Are jugular veins normally visible?

no

what are routine techniques for abdominal assessment?

observe patients general appearnace, behavior, and positoin inspect the abdomen auscultate the abdomen palpate the abdomen lightly palpate the abdomen deeply

With the abdomen assessment, what order is the assessment done that is different from other body systems?

observe, inspect, auscultate and then palpate

Discuss auscultation of the heart.

occurs in 5 areas on the anterior chest light pressure if hard to hear - ask patient to hold breath

List the Cranial Nerves: roman numeral, name, sensory, motor or both and how to assess each one CN 3

oculomotor motor - raise eyelids, most extraocular movements parasympathetic - pupillary constriction, change lens shape

List some risk factors for CVA

older adults males, then equal after menopause family hx face - african americans previous CVS or TIAs diabetes, A Fib HTN, hyperlipidemia, smoking, obesity, alcohol

List the Cranial Nerves: roman numeral, name, sensory, motor or both and how to assess each one CN 1

olfactory sensory: smell reception and interpretation

Explain the Glascow Coma Scale (GCS). What are the ranges of scores from highest to lowest? What are the three areas tested?

only with altered consciousness tests eye response, verbal response, motor response

List the Cranial Nerves: roman numeral, name, sensory, motor or both and how to assess each one CN 2

optic sensory: visual acuity and visual fields

How do you palpate carotid pulse?

palpate along the medial edge of the sternocleidomastoid muscle in the lower third of the neck to assess amplitude.

what are special circumstances techniques for abdominal assessment?

percuss the abdomen, liver, and spleen palpate the liver, gallbladder, spleen, and kidneys percuss the kidneys

Where, how, and why are the kidneys percussed for tenderness?

perform when patient reports pain in the back (flank pain) patient is seated 2 different ways 1 - direct percussion - tap each costovertebral angle with the bottom of the dominant fist 2 - place the palmar surface of the nondominant hand over the CVA and tap the top of the hand with dominant hand

Define oriented X 4:

person, place, time, why are you here

Explain Babinski reflex or plantar sign. What is a positive?

plantar reflex Using the end of the handle on the reflex hammer, stroke the lateral aspect of the sole of the foot from heel to ball, curving medially across the ball of the foot. The expected findings should be plantar flexion of all toes. positive - dorsiflexion of the great toe

What is PMI?

point of maximal impulse using with apical pulse - over the apex of the heart at the 5th ICS, LMCL

List the main goals of Healthy People 2020 related to cardiovascular disease. Which are primary and which are secondary?

primary: -Smoking cessation -Nutrition: Plant-based or Mediterranean-like diet high in vegetables, fruits, nuts, whole grains, lean vegetable or animal protein (preferably fish) and vegetable fiber -Blood lipid management: Total cholesterol less than 190 mg/dL -Weight: Achieve and maintain a desirable body weight (body mass index [BMI] between 18.5 and 24.9) -Physical activity: At least 150 min a week of at least moderate-intensity physical activity such as brisk walking secondary: BP screening, Lipid Level screening

What are the 6 P's of neurovascular assessment?

pulselessness, pain, pallor, paresthesia, paralysis or paresis, polar

Describe PERRLA. Know cranial nerves involved with visual acuity, eye movement & pupillary response.

pupils equal round reactive light accommodation CN 3, 4, & 6

Differentiate receptive aphasia and expressive aphasia.

receptive - inability to comprehend the speech of others and of oneself (Wernicke) expressive - inability to spontaneously communicate or translate ideas into meaningful speech or writing (Broca's)

List & explain heart rhythms.

regular - equal spacing between beats irregular - without any pattern

discuss Juglar veins

right internal jugular vein right external jugular vein, left external jugular vein, left internal jugular vein

Describe how to do a head to toe musculoskeletal assessment including inspection, palpation, the limbs and joints involved.

routine • INSPECT skeleton and extremities. • PALPATE muscles. • PALPATE bones and joints. • ASSESS range of motion of each joint. • ASSESS muscle tone. • ASSESS muscle strength and compare sides. special circumstances • ASSESS for nerve root compression. advanced practice • ASSESS for carpal tunnel syndrome. • ASSESS for rotator cuff damage. • ASSESS knee effusion. • ASSESS for knee stability. • ASSESS for meniscal damage or tear. • ASSESS for hip flexion contractures.

older adult abdominal assessment

same as a younger adult normal - may have increased fat deposits, even with decreased subc fat may feel soft = decreased muscle done abnormal - distension from fluid or gas, asymmetry from hernias, constipation or bowel obstruction, or hypoactive bowel sounds.

Discuss the older adult's cardiac changes.

same as younger adults

With inspection, what are the normal findings?

skin may be lighter there due to lack of exposure skin should be smooth (scars, silver-white striae, and very faint vascular network is normal) umbilicus should be centrally located contours - flat (athletic/muscular), rounded (subcut fat/poor muscle tone) or scaphoid (thin adults) upper midline pulsation (thin patients) move smoothly and evenly with respirations females - exhibt thoracic movements during inhaltion males - exhibit abdominal movements during inhalation

How does the CNS change in OLDER ADULTS?

slowed responses, move slowly, show decline in function, deviation of gait from midline, difficulty with rapidly alternating movements, some loss of reflexes and sensations

Describe the order that blood flows through the heart.

superior vena cava & inferior vena cava -> right atrium -> right atrioventricular valve -> right ventricle -> pulmonary valve -> lungs -> left atrium -> mitral valve -> left ventricle -> aortic valve -> aorta -> body

What position should your patient be in to do an abdominal assessment?

supine

Blood pressure, what is normal?

systolic <120 diastolic <80

peripheral areterial disease

taunt, shiny, pink skin no edema

veins

the pressure inside veins is lower carry blood toward the heart

What are cardiac thrills, lifts, retractions and heaves?

thrills - may occur with a murmur from a disorder of the aortic or pulmonic valve lifts/heaves - may indicate ventricular hypertrophy retractions - may indicate pericardial disease or right ventricular hypertrophy

Which sense of orientation is lost first?_______________ Second________________ Third__________

time, place, person

The normal percussion tone for the abdomen is_______________________________.

tympany caused by presence of gas

Define lymphedema.

unilateral edema, occlusion of lymph channels or surgical removal of lymph channels

Explain the Mini Mental Status Exam (MMSE). What does it assess? What are the parts?

used to test cognitive function among the elderly, includes tests of orientation, attention, memory, language, and visual-spatial skills

What are some reasons the right and left thigh & calf circumferences may be unequal?

venous thromboses edema chronic venous stasis

What is occurring with the chambers & valves of the heart during diastole?

ventricles are relaxed and fill with blood from atria. accomplished when pressure of the blood in atria becomes higher than the pressure in the ventricles. the aortic valve and pulmonary valve are closing

What is occurring with the chambers & valves of the heart during systole?

ventricles contract, creating a pressure that closed the AV valves, preventing the backflow of blood into the atria also forces the semilunar valves to open, resulting in ejection of blood into the aorta (from Left Ventricle) and pulmonary arteries (from right ventricle) when blood is ejected, pressure decreases, causing semilunar valve to close

List the Cranial Nerves: roman numeral, name, sensory, motor or both and how to assess each one CN 8

vestibulocochlear Sensory: Hearing and equilibrium