Health Assessment : Set 4

Craniosynostosis

severe deformity caused by premature closure of the sutures.

dyspnea

shortness of breath; difficulty breathing

Neck stiffness

limitation in ROM OCCURS: cervical arthritis, inflammation of neck muscles

Title VI of the Civil Rights Act 1964

limited English proficiency persons seeking health cannot be denied healthcare services

Zosteriform

linear arrangement along a unilateral nerve route

Anorexia

loss of appetite for food

Atrophy of muscles

loss of muscle mass OCCURS: disuse, muscle tissue damage, or motor nerve damage

orthostatic hypotension

low blood pressure occurring in some people when they stand up

resonance

low-pitched, clear, hollow sound that predominates in healthy lung tissue in adult

prone

lying on stomach

apgar scoring system

newborn's first respiratory assessment- measures the successful transition to extra uterine life; 1-minute apgar with a total score of 7-10 indicates newborn in good condition

Abdomen: The Aging Adult

- fat accumulation - salivation decreases - esophageal emptying delayed - gastric secretions decreases - increased incidence of gallstones - liver size decreases - frequent constipation

Non-Nursing Models

Body-Systems (medical model) Maslow's Hierarchy of Needs Minimum Data Set (MDS)

Palpate with patient relaxed, neck flexed.Follow sequence:

Inspect trachea for any deviation. Feel for any deviation. Spaces should be symmetric. Inspect the region below cricoid cartilage for thyroid. Ask patient to sip water and swallow; watch for thyroid movement.

Past Health questions

Childhood Illnesses, Accidents or Injuries, Serious or Chronic Illnesses, Hospitalizations, Operations, Obstetric History, Immunizations, Last examination date, Allergies, Current Medications

Cataracts

Clouding of lens

"Normal" eyelid and eyelash findings:

Eyelids should be symmetrical Eyelashes should be intact with an even distribution Upper eyelid should OVERLAP the superior portion of the iris Eyelids should completely close

Fissure

Linear crack with abrupt edges extends into denis, dry or moist

Most common childhood illnesses

Measles, mumps, rubella, chickenpox, whooping cough, strep throat, and frequent ear infections

pleura

Serous membranes that form the envelope between the lungs and the chest wall. The visceral pleura lines the outside of the lungs. Parietal pleura lines the inside of the chest wall and diaphragm.

Intraductal Papilloma

Serous or serosanguineous discharge which is spontaneous, unilateral, or from a single duct. Lesion consists of tiny tumors. Often there is a palpable nodule in underlying duct. Affect women from 40-60 years of age, most are benign.

Coarctation of aorta

Severe narrowing of the descending aorta, a congenital heart defect

Coarctation of Aorta

Severe narrowing of the descending aorta, a congenital heart deficit.

Magicoreligious (Cause of Illness)

The basic premise is that the world is seen as an arena in which supernatural forces dominate.

Ulticaria (Hive

Wheal's coalesce to form extensive reaction.

Nosocominal infection

an infection that is obtained while a patient is in a hospital or as a result of being in a hospital(unrelated to the patient's primary condition)

Dorsal

directed toward or located on the surface

Bloody Show

dislodging of thick cervical mucus plug at end of pregnancy, which is a sign of beginning or labor

abdominopelvic cavity

division of the anterior (ventral) cavity that houses the abdominal and pelvic viscera

Nodes

filter fluid before it is returned to the blood stream and filter out microorganisms that could be harmful to the body

Skin Turgor

skin resiliency and plumpness ASSESS: pinch up large fold of skin on anterior chest under clavicle -- reflects elasticity > 2 seconds

sucking tubercle

small pad in the middle of the upper lip from friction of breastfeeding/ bottle feeding

Clitoris

small, elongated erectile tissue in the female located at anterior juncture of labia minora

Lymph nodes

small, oval clumps of tissue located at intervals along the vessels

Epstein pearls

small, whitish glistening pearly papules along hard palate on gums

polyp

smooth, nontender gray nodule in nasal cavity due to chronic allergies

Dull sound

soft thud over dense organs

Goodell sign

softening of the cervix before pregnancy

Chvostek's sign

spasm of the facial muscles produced by sharply tapping over the facial nerve in front of the parotid gland and anterior to the ear; suggestive of latent tetany in patients with hypocalcemia

anatomical postion

standar reference position used fro describing locations and directions on the human body

Squamous cell carcinoma

start from actinic keratoses or de novo - devlop central ulcer and surround erythema OCCURS: hands or head, areas exposed to UV radiation LESS common, but grows rapidly

General inspection is:

the ability to see around the room and follow directions without squinting or craning forward to see

Assessment

the collection of data about an individual's health state

Colostrum

the first breast secretion at the end of pregnancy

Menarche

the first menstrual period

Visceral pain examples

ureteral colic, acute appendicitis, ulcer pain, cholecystitis

Arrhythmia

variation from the hearts normal rhythm

Pallor

vasoconstriction

Erythema

vasodilation

Five determining factors of BP

Cardiac output Peripheral vascular resistance Volume of circulating blood Viscosity Elasticity of vessel walls

Recreational drug use

Certain drugs can cause the pupils to dilate or constrict abnormally.

Cover-uncover test

Cover one eye; Watch the uncovered eye for a steady, fixed gaze. Uncover the first eye and observe the uncovered eye for any movement

Caries

Decay in the teeth

Dysphonia

Difficulty or discomfort in talking, with abnormal pitch or volume, caused by laryngeal disease. Voice sounds hoarse or whispered, but articulation and language are intact.

3+ Reflex

Exaggerated Response

Exophthalamos vs. Enophthalmos

Exophthalmos--protruding eyes Endophthalmos--sunken eyes

Cyst

Fluid filler cavity in dermis and subcutaneous - sebaceous cyst

Cranial Nerve I

Olfactory Function: Smell

P(Q)RSTU

Quality or Quantity- How does it look, feel, sound? How intense/severe is it?

Capacitance vessels

ability to stretch

tachycardia

abnormally rapid heartbeat (over 100 beats per minute)

egophony

auscultate chest while person phonates long "ee-ee-ee" sound. normal finding= you should hear eeee through stethoscope. abnormal= sounds changes to aaaa sound

S2 loudest?

base

Why do you auscultate the abdomen second

because percussion and palpation can increase peristalsis

wheezes

continuous musical sounds heard mainly over expiration

The nurse notices that a school-aged child has bluish-white, red-based spots in her mouth that are elevated approximately 1 to 3 mm. What other signs would the nurse expect to find in this patient? a. Pink, papular rash on the face and neck b. Pruritic vesicles over her trunk and neck c. Hyperpigmentation on the chest, abdomen, and back of the arms d. Red-purple, maculopapular, blotchy rash behind the ears and on the face

d. Red-purple, maculopapular, blotchy rash behind the ears and on the face

Which structure is located in the left lower quadrant of the abdomen? a... Liver b. Duodenum c. Gallbladder d. Sigmoid colon

d. Sigmoid colon

Which of these statements about the peripheral nervous system is correct? a. The CNs enter the brain through the spinal cord. b. Efferent fibers carry sensory input to the central nervous system through the spinal cord. c. The peripheral nerves are inside the central nervous system and carry impulses through their motor fibers. d. The peripheral nerves carry input to the central nervous system by afferent fibers and away from the central nervous system by efferent fibers.

d. The peripheral nerves carry input to the central nervous system by afferent fibers and away from the central nervous system by efferent fibers. A nerve is a bundle of fibers outside of the central nervous system. The peripheral nerves carry input to the central nervous system by their sensory afferent fibers and deliver output from the central nervous system by their efferent fibers. The other responses are not related to the peripheral nervous system.

To gain the trust of a young child, the examiner should: a. sit down and hold the child during the examination. b. focus on the child by asking him or her questions. c. ask the parent to stay in the waiting area. d. first focus on the parent as the child plays with a toy.

d. first focus on the parent as the child plays with a toy. Young children may be fearful of a new person and environment; the examiner should first focus on the parent while the child plays with a toy. The parent should hold the child in his or her lap during the health history and examination. The parent should remain in the examination room with a young child.

Areola

darkened area surrounding nipple

caries

decay in teeth

older adults

decreased vital capacity and increased residual lung volume, decreased alveoli therefore less surface area for gas exchange

Rectouterine Pouch

deep recess formed by the peritoneum between the rectum and cervix

DTR

deep tendon reflexes, measured on a scale from 1+ to 5+, 2+ is normal

Ischemia

deficient supply of oxygenated arterial blood to a tissue cause by obstruction of a blood vessel

Allen test

determining the patency of the radial and ulnar arteries by compressing one artery site and observing return of skin color as evidence of patency of the other artery

Tinel Sign

direct percussion of the median nerve at the wrist produces no symptoms in the normal hand. If positive test, percussion produces tingling and burning along distribution. Sign of carpal tunnel syndrome

Acromegaly

enlargement of the extremities

Hepatomegaly

enlargement of the liver

Nocturia

excessive urination at night

Nocturia

excessive urination during the night

Menorrhagia

excessively heavy menstrual flow

Tail of Spence

extension of breast tissue into the axilla

CNS responses to pain

fear, anxiety, fatigue

objective vertigo

feels like the room is spinning

Palpation techniques: fingertips

for fine tactile discriminations, such as skin texture, swelling, pulsatility, and presence of lumps

pectus carinatum

forward protrusion of sternum with ribs sloping back

Nocturia

frequent and excessive urination during the night due to heart failure

Rage

furious, loss of control. ex: person has expressed violent behavior to self or others.

Mobility

gait- normal walking Range of motion- full mobility of joints & well No involuntary movement

emphysema

gradually damages the air sacs (alveoli) in your lungs, making you progressively more short of breath.

Pedigree or genogram

graphic family tree that uses symbols to depict the gender, relationship, and age of immediate blood relatives in at least three generations, also highlights health issues and diseases of family members

Genital warts

growths or bumps in the genital area

barrel chest

has horizontal ribs and costal angle > 90 degrees

bronchial breath sound

high pitch, loud, normal location trachea and larynx, prolonged expiratory phase

stridor heard in children

high pitched inspiratory crowing heard without stethoscope, occurring with upper airway obstruction (croup, foreign body aspiration, acute epiglottis)

Endocrine responses to pain

increased adrenergic activity

physiologic dyspnea

increased awareness of need to breathe develops early in pregnancy

Lordosis

inward or concave curvature of the lumbar spine

Target

iris, concentric rings of color

Diffuse pain

localized, aching, cramping

clonus

muscular spasm involving repeated, often rhythmic, contractions.

Suprapubic

name of abdominal region just superior to pubic bone

GI responses to pain

nausea, vomiting, llieus

crackles only in upper lung fields in children

occur with cystic fibrosis

palpation

often confirms points noticed during inspection, applies sense of touch: texture, temp, moisture, swelling, etc...

Peritoneal friction rub--LIVER

over lower right rib cage, from abscess or metastatic tumor

Gingival Hyperplasia

overformation of gum tissue

pleural friction fremitus

palpable with inflammation of the pleura; makes a coarse grating sound when rubbed together during breathing

Function of the lacrimal apparatus:

provides constant irrigation to keep the conjuctiva and corna moist and lubricated.

Tinnitus

ringing or buzzing in the ears

Arteriosclerosis

rise in systolic blood pressure

Peritoneal friction rub

rough grating sound heard through the stethoscope over the site of peritoneal inflammation

anatomy

science that studies the form and composition of the bodes structures

Critical Thinking

simultaneously problem-solving while self improving one's own thinking ability

bradypnea

slow breathing, dec but regular rate <10 per minute; drug-induced depression, inc intracranial pressure, and diabetic coma

Bradycardia

slow heart rate, <50 beats per minute in the adult

tympany

sound heard over stomach

Edema

swelling of the legs or dependent body part due to increased interstitial fluid

The corneal light reflex assesses:

the parallel alignment of the eyes

Neuroanatomic pathway

the pathway of pain

Apex of the Heart

tip of the heart pointing down toward the 5th left intercostal space

Function of the venous system

to hold more blood when blood volume increases

Heart Auscultation

"All Pigs Eat Turkey Meat" A-aortic P-pulmonic E-Erb's point T-tricuspid valve M-mitral valve

Cancer lumps:

"BREAST" B- breast mass R- retraction E- edema A- axillary mass S- scaly nipple T- tender breast

What to say to initiate a domestic violence assessment

"Because domestic violence is so common in our society, we are asking all women the following questions."

Herpes Simplex

"Cold Sore" usually at the lip junction

How many pairs of cranial nerves?

12

How long do you auscultate bowel sounds

5 minutes

Palpable cervical lymph nodes decrease between what ages?

50-60

Prevalence of lactose intolerance statistics

7.72% for Whites 19.5% for African Americans 10% for Hispanics

Kaposi sarcoma spots/indicative of?

AIDS

CNS

Brain and Spinal Cord

Aphthous Ulcer (Af-tho-us)

Canker Sores

Right Lower Quadrant

Cecum-Appendix-Right ovary and tube (female)-Right ureter-Right spermatic cord (male)

Dyspnea

Difficult, labored breathing

Hyoid Bone

Is the highest, palpated high in the neck at the level of the floor of the mouth.

Hyperactive bowel sounds

Loud, gurgling sounds, "borborygmi," signal increased motility. They occur with early mechanical bowel obstruction (high-pitched), gastroenteritis, brisk diarrhea, laxative use, and subsiding paralytic ileus.

Rhinorrhea

Nasal mucosa is wollen and bright red with discharde

2+ Reflex

Normal Response

Pupillary light reflex

Normal constriction of the pupils when bright light shines on the retina

Abdominal Reflex

Normal response is the ipsilateral contraction of the abdominal muscles with an observed deviation of the umbilicus towards the stroke.

Sclera and ethnicities

Normally "china" white, but can be gray-blue/"muddy" wiht small brown macules (in A-A)

The most abnormal presentation of Jugular Venous Pressure:

Patient elevated to 45 degrees, internal jugular vein pulsation at 4 cm above sternal angle

Tachycardia

Rapid heart rate above 90 beats per minute in the adult

Microcephalic

Smaller than average head

Ambivalence

The existence of opposing emotions toward an object, idea, person. ex: a person feels love and hate toward another at the same time.

Atrophic Scar

The resulting skin level is depressed with loss of tissue

Subjective Data

Where is pain?

Naturalistic (Cause of Illness)

belief that human life is only one aspect of nature and part of the general order of the cosmos

A patient's abdomen is bulging and stretched in appearance. The nurse should describe this finding as: a. Obese. b. Herniated. c. Scaphoid. d. Protuberant.

d. Protuberant.

pulse pressure

difference between systolic and diastolic pressure and reflects the stroke volume

Lymphedema

high protein swelling of limb, commonly due to breast cancer treatment

supine

laying on back

Ongoing/Follow-up Database

used in all settings to monitor progress on short term or chronic health problems

Fluctuant Ovarian Mass-Ovarian Cyst

usually asymptomatic Smooth, round, fluctuant, mobile, nontender mass on ovary. Some cysts resolve spontaneously within 60 days but must be followed closely

reflex arc

(1) receptor: site of stimulus action (2) sensory neuron: transmits afferent impulses to CNS (3) integration center: synapse (4) motor neuron: conducts efferent impulses from the integration center to an effector organ (5) effector: muscle fiber/gland cell that responds to the efferent impulses (by contracting or secreting)

Muscloskeletal: The Aging Adult

- change in height (decrease) - distribution of sub-q fat changes - kyphosis - "lengthening of arm-trunk axis" - ROM, strength same with no muscloskeletal disease

How you would modify your interviewing technique when working with a hearing-impaired person?

-ask for preferred way of communication -complete health history may require a sign language interpreter -lip reading: face patient squarely and have good lighting -speak slowly and supplement your voice with hand gestures -written communication useful when health history forms available

Tonsil grading

1+: visible 2+: halfway between tonsillar pillars and uvula 3+: touching the uvula 4+: touching one another

Face

14 bones Maxilla Nasal Zygomatic (cheek) Lacrimal Mandible (jaw) All articulate at sutures except mandible (jaw)

1=Hypoesthesia 2=Anesthesia 3=Hyperesthesia

1=decreased touch sensation 2=absent touch sensation 3=increased touch sensation

During the assessment of deep tendon reflexes, the nurse finds that a patients responses are normal bilaterally. Indicate what number is used to indicate normal deep tendon reflexes when documenting this finding?

2+ Reflex

Know cranial nerves for extraocular movements: 3, 4, 6

3: Oculomotor (eye mvmt) 4: Trochlear 5: Trigeminal

Carotid bruit

A benign murmur heard just above the clavicles. It is slightly harsh, early or midsystolic, often louder on the left, and will disappear completely by carotid artery compression How to assess -- using the bell of your stethoscope and light pressure, listen over the carotid arteries for bruits. Palpate for thrills.

Jaundice

A yellowing of the skin and eyes due to rising amounts of bilirubin in the blood 1st noted: junction of hard/soft palate and sclera

Carcinoma: ABCDE

A(asymmetry) B(border irregularity) C(color variation) D(diameter) E(elevation/evolution)

7. A 14-year-old girl is anxious about not having reached menarche. When taking the history, the nurse should ascertain which of the following? The age: A) she began to develop breasts B) her mother developed breasts C) she began to develop pubic hair D) she began to develop axillary hair.

A) she began to develop breasts

41. A new mother calls the clinic to report that part of her left breast is red, swollen, tender, very hot, and hard. She has a fever of 101 F. She has also had symptoms of the flu, such as chills, sweating, and feeling tired. The nurse notices that she has been breastfeeding for 1 month. From her description, what condition does the nurse suspect? A) Mastitis B) Paget's disease C) Plugged milk duct D) Mammary duct ectasia

A. Mastitis

Abdominal pain signs and symptoms

ACUTE: appendicitis, cholecystitis, bowel obstruction, or perforated organ CHRONIC: gastric ulcers,

During the ear examination of an 80-year-old patient, which of the following would be a normal finding? 1. A high-tone frequency loss 2. Increased elasticity of the pinna 3. A thin, translucent membrane 4. A shiny, pink tympanic membrane

ANS: 1 A high-tone frequency hearing loss is apparent for those affected with presbycusis, the hearing loss that occurs with aging.

The nurse is assessing a patient with a history of intravenous drug abuse. In assessing his mouth, the nurse notices a dark red confluent macule on the hard palate. This could be an early sign of: 1. AIDS. 2. measles. 3. leukemia. 4. carcinoma.

ANS: 1 Oral Kaposi's sarcoma is a bruise-like, dark red or violet, confluent macule that usually occurs on the hard palate. It may appear on the soft palate or gingival margin. Oral lesions may be among the earliest lesions to develop with acquired immunodeficiency syndrome.

A patient is unable to differentiate between sharp and dull stimulation to both sides of her face. The nurse suspects: 1. Bell's palsy. 2. damage to the trigeminal nerve. 3. frostbite with resultant paresthesia to the cheeks. 4. scleroderma with a pronounced proliferation of connective tissue in the face and cheeks.

ANS: 2 Facial sensations of pain or touch are mediated by CN V, the trigeminal nerve.

While auscultating heart sounds on a 7-year-old for a "routine physical," the nurse hears the following: an S3, a soft murmur at left midsternal border, and a venous hum when the child is standing. Which of the following would be true regarding the findings? 1. S3 is indicative of heart disease in children. 2. These can all be normal findings in a child. 3. These are indicative of congenital problems. 4. The venous hum most likely indicates an aneurysm.

ANS: 2 Physiologic S3 is common in children. A venous hum, caused by turbulence of blood flow in the jugular venous system, is common in healthy children and has no pathologic significance. Heart murmurs that are innocent (or functional) in origin are very common through childhood.

A male patient with a history of AIDS has come in for an examination and he states, "I think that I have the mumps." The nurse would begin by examining the: 1. thyroid gland. 2. parotid gland. 3. cervical lymph nodes. 4. mouth and skin for lesions.

ANS: 2 The parotid gland may become swollen with the onset of mumps, and parotid enlargement has been found with HIV.

A woman comes to the clinic and states, "My eyes have gotten so puffy, and my eyebrows and hair have become coarse and dry." The nurse suspects: 1. cachexia. 2. cretinism. 3. myxedema. 4. scleroderma.

ANS: 3 Myxedema (hypothyroidism) is a deficiency of thyroid hormone that, when severe, causes a nonpitting edema or myxedema. The patient will have a puffy edematous face especially around eyes (periorbital edema), coarse facial features, dry skin, and dry, coarse hair and eyebrows

Which of the following cranial nerves is responsible for conducting nerve impulses to the brain from the organ of Corti? 1. CN I 2. CN III 3. CN VIII 4. CN XI

ANS: 3 The nerve impulses are conducted by the auditory portion of CN VIII to the brain.

A 10-year-old is at the clinic for "a sore throat lasting 6 days." The nurse is aware that which of the following would be consistent with an acute infection? 1. Tonsils 1+/1-4+ and pink 2. Tonsils 2+/1-4+ with small plugs of white debris 3. Tonsils 3+/1-4+ with large white spots 4. Tonsils 3+/1-4+ with yellowish exudate

ANS: 3 With an acute infection, tonsils are bright red and swollen and may have exudate or large white spots. Tonsils are enlarged to 2+, 3+, or 4+ with an acute infection.

During an assessment of a healthy adult, where would the nurse expect to palpate the apical impulse? 1. Third left intercostal space at the midclavicular line 2. Fourth left intercostal space at the sternal border 3. Fourth left intercostal space at the anterior axillary line 4. Fifth left intercostal space at the midclavicular line

ANS: 4 Location—the apical impulse should occupy only one interspace, the fourth or fifth, and be at or medial to the midclavicular line.

The nurse notices that a patient's submental lymph nodes are enlarged. In an effort to identify the cause of the node enlargement, the nurse would assess the: 1. infraclavicular area. 2. supraclavicular area. 3. area distal to the enlarged node. 4. area proximal to the enlarged node.

ANS: 4 When nodes are abnormal, check the area they drain for the source of the problem. Explore the area proximal (upstream) to the location of the abnormal node.

Catabolism

Breaking down of more complex molecules into simpler molecules

Benefits of breastfeeding

Breastfeeding is recommended for full-term infants for the first year of life because breast milk is ideally formulated to promote normal infant growth and development and natural immunity. Other advantages of breastfeeding are (1) fewer food allergies and intolerances, (2) reduced likelihood of overfeeding, (3) less cost than commercial infant formulas, and (4) increased mother-infant interaction time.

23. During an examination of a woman, the nurse notices that her left breast is slightly larger than her right breast. Which of these statements is true about this finding? A) Breasts should always be symmetric. B) This finding is probably due to breastfeeding and is nothing to worry about. C) This finding is not unusual, but the nurse should verify that this change is not new. D) This finding is very unusual and means she may have an inflammation or growth.

C) This finding is not unusual, but the nurse should verify that this change is not new.

Aging female breast

Decreased breast size and elasticity

How to assess trigeminal nerve damage

Decreased strength in one or both sides of jaw Asymmetry in jaw movement Pain with teeth clenching Decreased or unequal touch sensation

Vesicle

Elevated cavity containing free fluid, up to 1 cm. "blister" - Chicken pox, herpes zosterum.

Sternomastoid

Enables head rotation and flexion and divides each side of neck into two triangles: anterior and posterior triangles

Signs of acromegaly

Enlarged skull and thickened cranial bones Elongated head Massive face Overgrowth of nose and jaw Heavy eyebrow ridge Coarse facial features Large hands and feet

Best indicator of pain

Facial grimace, holding body part

Ambiguous Genitalia

Female pseudohermaphroditism is a congenital anomaly resulting from hyperplasia of the adrenal glands, which exposes female fetus to androgens. Causes masculinized external genitalia. Enlarged clitoris and fused labia (ambiguous means clitoris looks like small penis)

Pressure

Force exerted by a substance in contact with another substance

Phases of the interview

Introduction Working phase Open-ended questions Closed questions Closing

Macrocephaic

Larger than average head size

Paranasal Sinuses

Made up of the Frontal, Ethmoid, Maxillary, and sphenoid sinuses.

Positive feedback

Mechanism that intensifies a change in the body's physiological condition in response to a stimulus

Testing stool for occult blood

Negative response = normal He attest positive = occult blood

Epulis (E-poo-lis)

Non-tender, fibrous nodule of the gum

Cyanosis, Pallor

OCCURS: with MI or low cardiac output - decreased tissue perfusion

Decrease in cerebral blood flow

Occurs with aging Can cause dizziness and loss of balance with position change. These people need to be taught to get up slowly to prevent falls.

Slow Conduction

Occurs with aging Decreases between 5 and 10% with aging This delay at the synapse causes the impulse to take longer to travel resulting in diminished touch and pain sensation and sense of smell.

Visceral pain

Originates from the larger internal organs (i.e., stomach, intestine, gallbladder, pancreas). It often is described as dull, deep, squeezing, or cramping. The pain can stem from direct injury to the organ or stretching of the organ from tumor, ischemia, distention, or severe contraction. Examples of visceral pain include ureteral colic, acute appendicitis, ulcer pain, and cholecystitis. The pain impulse is transmitted by ascending nerve fibers along with nerve fibers of the autonomic nervous system (ANS). That is why visceral pain often presents along with autonomic responses such as vomiting, nausea, pallor, and diaphoresis.

Plaque

Papules coalesce to form surface elevation >1cm - plateau like - psoriasis.

External male genitalia

Penis & scrotum

Parietal Lobe

Postcentral gyrus: Primary center for sensation

Where are most breast tumors located?

Tail of spence (axillary)

Types of headaches

Tension, Migraine & Cluster

Naturalization

The conferring, by any means, of citizenship upon a person after birth

Why you would have a false high or false low when taking a blood pressure

The cuff size is important; using a cuff that is too narrow yields a falsely high BP because it takes extra pressure to compress the artery, and having a cuff that is too big will yield a false low BP.

Systole

The heart's pumping phase

sinus arrhythmia

The rate usually increases with inspiration and decreases with expiration (towards normal). , irregular heartbeat originating in the sinoatrial node

Preload

The venous return that builds during diastole.

Appropriate BP cuff size

The width of the rubber bladder should equal 40% of the circumference of the person's arm. The length of the bladder should equal 80% of this circumference.

PQRS(T)U

Timing- Onset, exactly when did it first occur? Duration, How long did it last? Frequency, How often does it occur?

Apex of the Heart

Tip of the heart pointing down toward the 5th left intercostal space.

Aphasia

True language disturbance; defect in word choice and grammar or defect in comprehension; defect is in higher integrative language processing.

During infancy, _________ predominates so that head size changes in proportion to body height

Trunk growth

Appearance of basal cell carcinoma

Usually starts as a skin-colored papule (may be deeply pigmented) with a pearly translucent top and overlying telangiectasia (broken blood vessel). Then develops rounded, pearly borders with central red ulcer or looks like large open pore with central yellowing.

"Prolonged use of a bottle can increase the risk for tooth decay and ear infections."

While obtaining a history from the mother of a 1 year old, the nurse notices that the baby has had a bottle in his mouth the entire time. The mother states, "It makes a great pacifier." The best response by the nurse would be:

Korotkoff's sounds

a series of five sounds produced by blood within the artery with each ventricular contraction

Rebound tenderness

a sign of inflammation of the peritoneum in which increased pain is elicited by the sudden release of the fingertips pressing on the abdomen.

Tic

a spasmodic contraction of the face, head, or neck

While performing an assessment of a 65-year-old man with a history of hypertension and coronary artery disease, the nurse notices the presence of bilateral pitting edema in the lower legs. The skin is puffy and tight but normal in color. No increased redness or tenderness is observed over his lower legs, and the peripheral pulses are equal and strong. In this situation, the nurse suspects that the likely cause of the edema is which condition? a. Heart failure b. Venous thrombosis c.. Local inflammation d. Blockage of lymphatic drainage

a. Heart failure

Prevention

any action directed toward promoting health and preventing the occurrence of disease

A semiconscious woman is brought to the emergency department after she was found on the floor in her kitchen. Her face, nail beds, lips, and oral mucosa are a bright cherry-red color. The nurse suspects that this coloring is due to: a. Polycythemia. b. Carbon monoxide poisoning. c. Carotenemia. d. Uremia.

b. Carbon monoxide poisoning.

A few days after a summer hiking trip, a 25-year-old man comes to the clinic with a rash. On examination, the nurse notes that the rash is red, macular, with a bull's eye pattern across his midriff and behind his knees. The nurse suspects: a. Rubeola. b. Lyme disease. c. Allergy to mosquito bites. d. Rocky Mountain spotted fever.

b. Lyme disease.

Pulmonic Regurgitation

back flow of blood through incompetent pulmonic valve into the right ventricle

What happens to facial bones as one ages?

become more prominent

Bruit

blowing, swooshing sound heard through a stethoscope when an artery is partially occluded

Murmurs

blowing, swooshing sound that occurs with turbulent blood flow in heart or great vessels OCCURS: with congenital and acquired valvular defects

Bruit

blowing, swooshing sound, artery partially occluded

normal breath sounds

bronchial, bronchovesicular,vesicular

Clubbing

bulbous enlargement of distal phalanges of fingers and toes that occurs with chronic cyanotic heart and lung conditions

The nurse suspects that a patient has a distended bladder. How should the nurse assess for this condition? a. Percuss and palpate in the lumbar region. b. Inspect and palpate in the epigastric region. c. Auscultate and percuss in the inguinal region. d. Percuss and palpate the midline area above the suprapubic bone.

d. Percuss and palpate the midline area above the suprapubic bone.

Orthopnea

difficulty breathing when supine

orthopnea

difficulty breathing when supine; two-pillow comfort

Inverted

nipples that are depressed or invaginated

2+

normal

Whispered pectoriloquy

patient whispers "1,2,3" normal = muffled. AB: consolidation= clear.

Priapism

persistent abnormal erection of the penis accompanied by pain and tenderness

Hernias

protrusion of abdominal organs through the muscle wall - Umbilical - Epigastric - Incisional - Inguinal

Plantar

surface of the sole of the foot

Hemoptysis

the coughing up blood

pulse rate

the number of heartbeats or pulses felt in 1 minute

If muscle weakness is present, the cover-uncover test will show

the uncovered eye will JUMP positions to re-establish vision

What is it called when the upper eyelid DOES NOT overlap the superior portion of the iris?

"Lid lag"

Tinnitus: definition/causes

"Phantom sound"

Sensor

(Also a receptor) reports and monitored physiological value to the control center

Discuss special considerations when interviewing an older adult.

- address by surname - avoid honey, sweetie, awesome slang-- elderspeak - adjust pace of interview - avoid shortened sentences, slowed speech, and simple vocab that sounds like baby talk - don't shout - touch is a nonverbal skill thats very impt w/ older adults

Diminished breath sounds indicate?

- bronchial tree is obstruted - emphysema - anything obstructs transmission of sound

Heart and Neck Vessels: The aging adult

- gradual rise in SBP - orthostatic hypotension - increase in AP diameter - systolic murmurs common - carotid artery (narrowed by artherosclerosis)

Conductive hearing loss: cause

- impacted cerumen - foreign bodies - perforated tympanic membrane - pus/serum in the middle ear - otosclerosis (decrease in mobility of the ossicles)

Breast Cancer Risk Factors

- inherited mutation from one/both parents - white women (@ 45 yo and older) - A-A women (before 45 yo) - more likely to die

Superficial Reflexes

- initiated by gentle cutaneous stimulation Ex) plantar reflex is initiated by stimulating the lateral aspect of the sole of the foot - response is downward flexion of toes - indirectly test for proper corticospinal tract functioning - Babinski's sign: abnormal plantar reflex indicates corticospinal damage where the great toe dorsiflexes and the small toes fan laterally

Signs and Symptoms of breast cancer

- new lumps, massess - retraction of nipple - tenderness - discharge - irregular axillary nodes - elevation

NMT: The aging adult

- nose appears more prominent (sub-q fat loss) - nasal hairs coarser, stiffer - sense of smell decreases - loss of taste buds wiht 80% reduction of taste functioning - increase in oral candidiasis - gums recede - teeth erode - teeth hypersensitivity - natural tooth loss

Risk factors for CAD

- nutrition - smoking - alcohol - exercise - drugs

Percussion of abdomen

- percuss lightly on all 4 quadrants - tympany should dominate b/c air rises to GI surface when pt is supine *dullness occurs over a distended bladder, adipose tissue, fluid, or a mass *hyperresonance is present with gaseous distention

Tracheal Shift: Reasons for shifting to each side

- pushed to unaffected/healthy side with aortic aneurysm, tumor, unilateral thyroid lobe enlargement, and pneumothroax - pulled toward affected/diseased side with large atelectasis, pleural adhesions, and fibrosis - tracheal tug (rhythmic downward pull) with systole and aortic arch aneurysm

Anatomy and PhysiologyThe Head

-Cranium -Face -Neck -Thyroid gland -Lymph nodes

Why use percussion?

1) Map organ location 2) Density (air, fluid, or solid) 3) Detect superficial abnormal mass 4) Elicit pain if structure is inflamed 5) Elicit deep tendon reflex

BSE and mammogram recommendations

1. In shower/lying down 2. Vertical strip pattern 3. Monthly

objective data of physical exam for head

1. Inspect & Palpate: temporal area & Skull for size and shape 2. Inspect the Face & facial structures 3. Palpate temporal artery & temporomandibular joint (TMJ) 4. Inspect neck and palpate 5. Look for symmetry 6. Check range of motion (ROM) 7. Inspect & Palpate: Lymph nodes, Trachea Thyroid gland (posterior approach & anterior approach- auscultate if enlarged) 8. Inspect: (neck, movement of neck structures, cervical vertebrae, neck range of motion) 9. Palpate: trachea, thyroid gland, thyroid cartilage)

REMEMBER - having a concussion raises the risk of having another, especially within ________ after following the initial concussion

10 days

PNS

12 Pairs of Cranial Nerves 31 Pairs of the spinal nerves Carries sensory afferent messages to the CNS from sensory receptors.

Average BP

120/80

glasgow coma scale

15 = no coma, 7 coma, 3 profound coma. Eye opening, verbal response, motor response

Grading of pulses

3+ Increased, full, bounding 2+ Normal 1+ Weak 0 Absent

Tonsils 3+/1-4+ with large white spots.

A 10-year-old is at the clinic for "a sore throat lasting 6 days." The nurse is aware that which of these findings would be consistent with an acute infection?

Keloid

A hypertrophic scar, skin is elevated by excess scar tissue.

Glaucoma

A mid-dilated pupil can be a sign of glaucoma.

What is a bruit?

A soft, pulsatile, whooshing, blowing sound heard best with the bell of the stethoscope Indicates blood flow turbulence

Tongue size

AB: enlarged tongue with mental retardation, hypothyroidism, acromegal AB: sm tongue with malnutrition

During the history, a patient tells the nurse that he has frequent nosebleeds and asks the best way to get them to stop. What would be the nurse's best response? 1. "While sitting up, place a cold compress over your nose." 2. "Sit up with your head tilted forward and pinch your nose." 3. "Just let the bleeding stop on its own, but don't blow your nose." 4. "Lie on your back with your head tilted back and pinch your nose."

ANS: 2 With a nosebleed, the person should sit up with the head tilted forward and pinch the nose between the thumb and forefinger for 5 to 15 minutes.

The nurse is performing an otoscopic examination on an adult. Which of the following is true? 1. Tilt the person's head forward during the exam. 2. Once the speculum is in the ear, release the traction. 3. Pull the pinna up and back before inserting the speculum. 4. Use the smallest speculum to decrease the amount of discomfort.

ANS: 3 Pull the pinna up and back on an adult or older child. This helps straighten the S- shape of the canal.

Dehydration - S&S

Adult - Mucous membranes are dry, and lips look parched, cracked and sometimes fissured. Infant - Poor turgor

Unauthorized Residents

All foreign born noncitizens who are not legal residents

Permanent Resident Alien

An alien admitted to the United States as a lawful permanent resident

Thyroid gland

An important endocrine gland straddles trachea in middle of the neck secretes thyroxine (T4) and triiodothyronine (T3),which are hormones that stimulate rate of cellular metabolism

Where are the breasts located?

Anterior to pectoralis major and serratus anterior muscles, between 2nd and 6th ribs.

Prostate placement in body

Anterior wall of rectum Size: 2.5 long by 4 cm wide, not protrude more than 1 cm into rectum Shape: Heart shape, with palpable central groove Surface: Smooth Consistency: Elastic, rubbery Mobility: Slightly moveable Sensitivity: Nontender to palpation

32. The nurse is preparing to teach a woman about breast self-examination (BSE). Which statement by the nurse is correct? A) "BSE is more important than ever for you because you have never had any children." B) "BSE is so important because one out of nine women will develop breast cancer in her lifetime." C) "BSE on a monthly basis will help you feel familiar with your own breasts and their normal variations." D) "BSE will save your life because you are likely to find a cancerous lump between mammograms."

C) "BSE on a monthly basis will help you feel familiar with your own breasts and their normal variations."

3. In performing an assessment of a woman's axillary lymph system, the nurse should assess which of these nodes? A) Central, axillary, lateral, and sternal nodes B) Pectoral, lateral, anterior, and sternal nodes C) Central, lateral, pectoral, and subscapular nodes D) Lateral, pectoral, axillary, and suprascapular nodes

C. Central, lateral, pectoral, and subscapular nodes

12. In examining a 70-year-old male patient, the nurse notices that he has bilateral gynecomastia. Which of the following describes the nurse's best course of action? A) Recommend that he make an appointment with his physician for a mammogram. B) Ignore it; it is not unusual for men to have benign breast enlargement. C) Explain that this condition may be the result of hormonal changes and recommend that he see his physician. D) Tell him that gynecomastia in men is usually associated with prostate enlargement and recommend that he be screened thoroughly.

C. Explain that this condition may be the result of hormonal changes and recommend that he see's his physcian

Neurologic System:

CNS: Brain and Spinal Cord PNS: 12 Pairs of Cranial Nerves 31 Pairs of the spinal nerves Carries sensory afferent messages to the CNS from sensory receptors.

Aortic stenosis

Calcification of aortic valve cusps that restrict forward flow of blood during systole

Aortic Stenosis

Calcification of aortic valve cusps that restricts forward flow of blood during systole

Pulmonic Stenosis

Calcification of pulmonic valve that restricts forward flow of blood during systole

Pulmonic stenosis

Calcification of pulmonic valve that restricts forward flow of blood during systole.

Mitral Stenosis

Calcified mitral valve impedes forward flow of blood into left ventricle during diastole.

Pain rating scales

Can indicate a baseline intensity, track changes, and give some degree of evaluation to a treatment modality.

Breast cancer risk factors

Certain tumor genes, genetic mutation, white women, Hx

Where are the 4 lymph node areas?

Cervical nodes (located throughout the head and neck and drain in head and neck) Axillary nodes (in the axillary/breast area and drain in breast and upper arm) Epitrochlear node (in the antecubital fossa and drains the hand and lower arm) Inguinal nodes (in the groin and drains the lower extremities, external genetalia, and the anterior abdominal wall)

Dementia

Chronic progressive loss of cognitive and intellectual functions, although perception and consciousness are intact. Characterized by disorientation, impaired judgment, memory loss.

Annular

Circular

Sources of Data

Client* Family Healthcare Providers Chart/Medical Records

Diamond-shaped anterior fontanel

Closes between 9 months and 2 years

Cerebellar System Location

Coiled structure under the occipital lobe. Receives information about what kind of motor messages are being sent from the cortex to the muscles.

Hot/cold illness

Cold - earache, chest cramps, paralysis, gastrointestinal discomfort, rheumatism, and tuberculosis. Hot - abscessed teeth, sore throats, rashes, and kidney disorders.

The dermis layer contains:

Collagen (connective tissue), nerves, sensory receptors, blood vessels, and lymphatics.

What do fungal infections of the ear look like?

Colony of black or white dots on drum or canal wall (otomycosis)

Macule

Color change, flat and circumscribed <1cm *EX: Freckles*

Macule

Color change, flat and circumscribed <1cm - freckles

Deep somatic pain

Comes from sources such as the blood vessels, joints, tendons, muscles, and bone. Pain may result from pressure, trauma, or ischemia. Often is described as aching or throbbing.

Control center

Compares values to their normal range, deviations cause the activation of an effector

Cerebellar System

Complex motor system coordinates movement, maintains equilibrium and helps maintain posture and maintains muscle tone.

Cerebellum

Complex motor system coordinates movement, maintains equilibrium and helps maintain posture and maintains muscle tone.

Cleft lip

Congenital deformities

What if no reflex, what are other options? Do I just chart, no response.

Continue with assessment and return to retest

X-ray

Form of high energy electromagnetic radiation with the short wavelength capable penetrating solids and Ionizing gases, used in medicine as a diagnostic aid to visualize body structures such as bones

4 bones (these are the main ones)

Houses and protects 1.Frontal 2.Parietal 3.Temporal 4.Occipital

When auscultating the heart, your first step is to

Identify S1 and S2

Dyspnea

Labored, or difficult breathing

Lacrimal apparatus consists of:

Lacrimal gland Puncta Nasolacrimal gland

8 Critical characteristics of a symptom

Location, Quality, Severity, Timing, Setting, Relieving Factors, Associated Factors, Patients Perception

Glascow coma Scale

NORMAL: 15 COMA: >7 Eye: 4 Motor: 6 Verbal: 5

Cluster headaches

Nasal congestion or runny nose Watery or reddened eye Eyelid drooping Feelings of agitation Always one-sided Pain is often behind or around the eye, temple, forehead, cheek

The jaeger card is used to test what?

Near vision in patients over the age of 40.

Anatomy and PhysiologyThe Neck

Neck Composed of: Muscles Ligaments Cervical vertebra

Epistaxis (Ep-i-stacks-is)

Nosebleed, usually from the anterior septum

Increased breath sounds indicate?

OCCUR: when consolidation (pneumonia) or compression (fluid in intrapleural space) - dense lung area

Edema

OCCURS: lymphatic drainage is obstructed after breast surgery or radiation; systemic illness; DVT; heart failure

Sinus arrhythmia

Occurs NORMALLY in young adults and children

Loss of vibration sense

Occurs with peripheral neuropathy like Diabetes, and alcoholism *Often first sensation lost

First heart sound (S1)

Occurs with the closure of the atrioventricular (AV) valve signaling the beginning of systole.

Second Heart Sound (S2)

Occurs with the closure of the semilunar valves, aortic and pulmonic; signals the end of systole.

Bulge sign

Occurs with very small amounts of effusion, 4-8 ml, from fluid flowing across the joint within the suprapatellar pouch. Assessed by firmly stroking up the medial aspect of the knee 2-3 times to displace any fluid, tapping the lateral aspect, and watching the medial side in the hollow for a distinct bulge from a fluid wave

Cranial Nerve III

Oculomotor Function: Motor Function of extraoccular movement, opening of eyelids Parasympathetic functions of pupil constriction and lens shape.

What do CN III, CN IV, and CN VI assess?

Oculomotor, Trochlear, and Abducens nerves (Eyes)

Renal responses to pain

Oliguria, urinary retention

Breast symmetry comparison

One larger/smaller is usual unless recent change

Turbinate

One of 3 bony projections into nasal cavity.

Dyspareunia

Painful intercourse

Posterior cavity

Posterior body cavity that houses the brain and spinal cord also referred to as the dorsal cavity

Temporal Lobe

Primary auditory receptor

Reproduction

Process but which new organisms are generated

Pulmonic valve

Right semilunar valve separating the right ventricle and the pulmonary artery.

Pacemaker of the heart

SA node

What does the lacrimal gland do?

Secrete tears

acute pain

Short term pain. Self limiting. Predictable trajectory, dissipates after injury heals.

Emergency database

This is an urgent, rapid collection of crucial information and often is compiled concurrently with lifesaving measures. Diagnosis must be swift and sure. For example, a person is brought into a hospital ED with suspected substance overdose. The first history questions are, "What did you take?" "How much did you take?" and "When?" The person is questioned simultaneously while his or her airway, breathing, circulation, level of consciousness, and disability are being assessed.

Intention Tremor

Tremor that appears within intentional movement; No tremor at rest

Opening of adult's parotid gland is opposite what?

Upper 2nd molar

1+Reflex

Weak Response

Complete Database

a complete health history and full physical examination

The nurse is reviewing statistics for lactose intolerance. In the United States, the incidence of lactose intolerance is higher in adults of which ethnic group? a. Blacks b. Hispanics c. Whites d. Asians

a. Blacks

The nurse just noted from the medical record that the patient has a lesion that is confluent in nature. On examination, the nurse expects to find: a. Lesions that run together. b. Annular lesions that have grown together. c. Lesions arranged in a line along a nerve route. d. Lesions that are grouped or clustered together.

a. Lesions that run together.

During an assessment of a newborn infant, the nurse recalls that pyloric stenosis would be exhibited by: a. Projectile vomiting. b. Hypoactive bowel activity. c. Palpable olive-sized mass in the right lower quadrant. d. Pronounced peristaltic waves crossing from right to left.

a. Projectile vomiting.

When palpating the abdomen of a 20-year-old patient, the nurse notices the presence of tenderness in the left upper quadrant with deep palpation. Which of these structures is most likely to be involved? a. Spleen b. Sigmoid colon c. Appendix d. Gallbladder

a. Spleen

Orthopnea

ability to breathe only in an upright position

Edema

accumulation of fluid in extracellular spaces; swelling

Hydrocephalus

accumulation of fluid in the spaces of the brain

The nurse knows that during an abdominal assessment, deep palpation is used to determine: a. Bowel motility. b. Enlarged organs. c. Superficial tenderness. d. Overall impression of skin surface and superficial musculature.

b. Enlarged organs.

The nurse is preparing to examine a patient who has been complaining of right lower quadrant pain. Which technique is correct during the assessment? The nurse should: a. Examine the tender area first. b. Examine the tender area last. c. Avoid palpating the tender area. d. Palpate the tender area first, and then auscultate for bowel sounds.

b. Examine the tender area last.

Which of the following assessments should be performed last on a 4-week-old infant? a. Auscultate breath sounds b. Otoscopic examination of the tympanic membrane c. Weight, length, and head circumference d. Palpate fontanels and suture lines

b. Otoscopic examination of the tympanic membrane Invasive procedures such as an otoscopic examination should be performed at the end of the examination of an infant.

A patient has hypoactive bowel sounds. The nurse knows that a potential cause of hypoactive bowel sounds is: a. Diarrhea. b. Peritonitis. c. Laxative use. d. Gastroenteritis.

b. Peritonitis.

A patient is suspected of having inflammation of the gallbladder, or cholecystitis. The nurse should conduct which of these techniques to assess for this condition? a. Obturator test b.. Test for Murphy sign c. Assess for rebound tenderness d. Iliopsoas muscle test

b.. Test for Murphy sign

A 35-year-old pregnant woman comes to the clinic for a monthly appointment. During the assessment, the nurse notices that she has a brown patch of hyperpigmentation on her face. The nurse continues the skin assessment aware that another finding may be: a. Keratoses. b. Xerosis. c. Chloasma. d. Acrochordons.

c. Chloasma.

The nurse notices that a patient has had a black, tarry stool and recalls that a possible cause would be: a. Gallbladder disease. b. Overuse of laxatives. c. Gastrointestinal bleeding. d. Localized bleeding around the anus.

c. Gastrointestinal bleeding.

The nurse has discovered decreased skin turgor in a patient and knows that this finding is expected in which condition? a. Severe obesity b. Childhood growth spurts c. Severe dehydration d. Connective tissue disorders such as scleroderma

c. Severe dehydration

A newborn infant is in the clinic for a well-baby checkup. The nurse observes the infant for the possibility of fluid loss because of which of these factors? a. Subcutaneous fat deposits are high in the newborn. b. Sebaceous glands are overproductive in the newborn. c. The newborn's skin is more permeable than that of the adult. d. The amount of vernix caseosa dramatically rises in the newborn.

c. The newborn's skin is more permeable than that of the adult.

Risk factors that may lead to skin disease and breakdown include: a. loss of protective cushioning of the dermal skin layer. b. decreased vascular fragility. c. a lifetime of environmental trauma. d. increased thickness of the skin.

c. a lifetime of environmental trauma. Accumulating factors that place an aging person at risk for skin disease and breakdown include thinning of the skin, decrease in vascularity and nutrients, loss of protective cushioning of the subcutaneous layer, a lifetime of environmental trauma to skin, social changes of aging, an increasingly sedentary lifestyle, and the chance of immobility. Aging results in the loss of protective cushioning of the subcutaneous layer of the skin. Aging results in decreased vascularity of the skin. Aging results in thinning of the skin.

During assessment of extraocular movements, two back-and-forth oscillations of the eyes in the extreme lateral gaze occurs. This response indicates: a. that the patient needs to be referred for a more complete eye examination. b. a disease of the vestibular system, further evaluation is needed. c. an expected movement of the eyes during this procedure. d. this assessment should be repeated in 15 minutes to allow the eyes to rest.

c. an expected movement of the eyes during this procedure. Nystagmus is a back-and-forth oscillation of the eyes. End-point nystagmus, a few beats of horizontal nystagmus at extreme lateral gaze, occurs normally.

The extrapyramidal system is located in the: a. hypothalamus. b. cerebellum. c. basal ganglia. d. medulla.

c. basal ganglia. The basal ganglia are large bands of gray matter buried deep within the two cerebral hemispheres that form the subcortical associated motor system (the extrapyramidal system).

An example of a primary lesion is a(n): a. erosion. b. ulcer. c. urticaria. d. port-wine stain.

c. urticaria. Urticaria is a primary lesion; a primary lesion is one that develops on previously unaltered skin. Erosions are secondary lesions; a secondary lesion is one that changes over time or changes because of a factor such as scratching or infection. Ulcers are secondary lesions; a secondary lesion is one that changes over time or changes because of a factor such as scratching or infection. A port-wine stain is a vascular lesion.

Homans sign

calf pain occuring when foot is sharply dorsiflexed

prenatal exposure to smoke causes

chronic hypoxia, premature delivery, low birth weight

Grouped

clusters of lesions

crepitus

coarse crackling sensation palpable over the skin surface; occurs in subcutaneous emphysema when air escapes from the lung and enters subcutaneous tissue

Atelectasis

collapsed lung; incomplete expansion of alveoli

Fibromyalgia

condition with widespread aching and pain in the muscles and soft tissue

A 65-year-old man with emphysema and bronchitis has come to the clinic for a follow-up appointment. On assessment, the nurse might expect to see which finding? a. Anasarca b. Scleroderma c. Pedal erythema d. Clubbing of the nails

d. Clubbing of the nails Clubbing of the nails occurs with congenital cyanotic heart disease and neoplastic and pulmonary diseases. The other responses are assessment findings not associated with pulmonary diseases.

A 45-year-old man is in the clinic for a physical examination. During the abdominal assessment, the nurse percusses the abdomen and notices an area of dullness above the right costal margin of approximately 11 cm. The nurse should: a. Document the presence of hepatomegaly. b. Ask additional health history questions regarding his alcohol intake. c. Describe this dullness as indicative of an enlarged liver, and refer him to a physician. d. Consider this finding as normal, and proceed with the examination.

d. Consider this finding as normal, and proceed with the examination.

The nurse is documenting the assessment of an infant. During the abdominal assessment, the nurse noticed a very loud splash auscultated over the upper abdomen when the nurse rocked her from side to side. This finding would indicate: a. Epigastric hernia. b. Pyloric obstruction. c. Hypoactive bowel sounds. d. Hyperactive bowel sounds.

d. Hyperactive bowel sounds. A succussion splash, which is unrelated to peristalsis, is a very loud splash auscultated over the upper abdomen when the infant is rocked side to side. It indicates increased air and fluid in the stomach as observed with pyloric obstruction or large hiatus hernia (see Chapter 21).

Which physical method techniques would the nurse use to determine if a newborn had an inguinal hernia? a. Inspection and percussion b. Percussion and auscultation c. Auscultation and inspection d. Inspection and palpation

d. Inspection and palpation The nurse would use both inspection and palpation to confirm the presence of a hernia. Inspection would be used to determine the presence of a hernia, but not percussion or auscultation.

A patient has had a "terrible itch" for several months that he has been continuously scratching. On examination, the nurse might expect to find: a. A keloid. b. A fissure. c. Keratosis. d. Lichenification.

d. Lichenification.

The nurse notices that a patient has a solid, elevated, circumscribed lesion that is less than 1 cm in diameter. When documenting this finding, the nurse reports this as a: a. Bulla. b. Wheal. c. Nodule. d. Papule.

d. Papule.

A mother brings her child into the clinic for an examination of the scalp and hair. She states that the child has developed irregularly shaped patches with broken-off, stublike hair in some places; she is worried that this condition could be some form of premature baldness. The nurse tells her that it is: a. Folliculitis that can be treated with an antibiotic. b... Traumatic alopecia that can be treated with antifungal medications. c. Tinea capitis that is highly contagious and needs immediate attention. d. Trichotillomania; her child probably has a habit of absentmindedly twirling her hair.

d. Trichotillomania; her child probably has a habit of absentmindedly twirling her hair.

Discrete

distinct, individual lesions

Dorsalis Pedis

dorsum of the foot

Cyanosis

dusky blue mottling of the skin and mucous membranes due to excessive amount of reduced hemoglobin in blood

Premature Thelarche

early breast developement with no other hormone- dependent signs (pubis hair, menses).

acute pain behaviors

guarding, grimacing, vocalizations, agitation, restlessness, stillness, diaphoresis. or change in vital signs.

pleural friction rub

has a grating quality as if 2 pieces of leather are being rubbed together; pleurae become inflamed and lose normal lubricating fluid

Biomedical/Scientific (Causes of Illness)

illness causation is based on the assumption that all events in life have a cause and effect

Cranium bone is joined by

immovable Sutures *Sagittal *coronal *lambdoid

crypts

indentations on surface of tonsils

Referred pain examples

inflammated appendix-->pain in periumbilical area. This is due to both sites being innervated by the same spinal nerve

Peritonitis

inflammation of peritoneum

Culture

it is the thoughts, communications, actions, beliefs, values, and institutions of racial, ethnic, religious, or social groups

Cricoid cartilage or upper tracheal ring

just above the thyroid isthmus, within about 1cm

Femoral Artery

major artery in the leg, passes under inguinal ligamen, travels down the thigh

systolic pressure

maximum pressure felt on artery during left ventricle contraction, or systole (top number)

Homan sign

pain on flexion of foot (causing calf pain) = positive sign; possible DVT

Rebound tenderness

pain that increases when pressure (as from a hand) is removed

Dysuria

painful urination

Paresthesia

partial numbness or the loss of feeling

Clinical Portrait of Heart Failure

pathological condition in which the heart loses its ability to pump blood efficiently

Emergency Database

rapid collection of crucial information; medications and allergies

Tachycardia

rapid heart rate, >90 beats per minute in the adult

cheilitis

red, scaling painful fissures at the corner of the mouth

Deep veins

run along the deep arteries and conduct most of the venous return from the legs

Ulnar radial arteries

run distally and form two arches supplying the hand

What is a bruit?

rushing sound that can be heard with a stethoscope

Tanner staging

sexual maturity rating (5 stages) 1. Preadolescent (only elevated nipple) 2. Breast Bud-stage (small mound of breast and nipple, areola widens 3. Breast and areola enlarge; nipple flish w/breast surface. 4. Areola and nipple form a secondary mound over breast 5. Mature breast: only nipple protrudes, areola is flush with breast contour.

What can pupil size reveal?

small changes may indicate increasing intracranial pressure

Circumcision

surgical removal of the foreskin

Acculturation

the process of adapting to and acquiring another culture

Holistic Health

the view that the mind, body and spirit are interdependent and function as a whole within the environment.

Gyrate

twisted, coiled, spiral

Testicular Torsion

twisting of the spermatic cord causing decreased blood flow to the testis

Palpitation

uncomfortable awareness of rapid or irregular heart rate

Deviation

underlying cancer causes fibrosis in the mammaryducts, which pulls the nipple angle toward it. Swelling behind the nipple will tilt the nipple laterally.

Medical Diagnosis

used to evaluate the cause and ethnology of disease; focus is on the function or malfunction of a specific organ system

Nursing Diagnosis

used to evaluate the response of the whole person to actual or potential health problems

Incompetent valve

valve does not close properly

Profile sign

viewing the finger from side to detect early clubbing

1+

weak, thready pulse, shock, peripheral arterial disease

Candidiasis

yeast infection (white, cheesy, curdlike patch) on tongue

Aging Adult

~Pain is NOT A NORMAL PROCESS during this developmental stage

Arteries

carry blood away from the heart

Kyphosis

(hunch back) posterior thoracic curvature

Apical Impulse

(point of maximal impulse, PMI) pulsation created as the left ventricle rotates against the chest wall during systole, normally at the 5th left intercostal space in the midclavicular line

Ear: drainage can indicate?

- OM if drum has ruptured

20/20 vs. 20/100

20/20: normal acuity 20/100: "You can read at 20 feets what the normal eye can see from 100 feet away"

"These bumps are Fordyce's granules, which are sebaceous cysts and are not a serious condition."

A 32-year-old woman is at the clinic for "little white bumps in my mouth." During the assessment, the nurse notes that she has a 0.5 cm white, nontender papule under her tongue and one on the mucosa of her right cheek. What would the nurse tell the patient?

Dysphagia

A 92-year-old patient has had a stroke. The right side of his face is drooping. The nurse might also suspect which of these assessment findings?

What is ptosis?

A drooping of the upper eyelid

Highest risk of hypertension

A higher percentage of men than women have hypertension until age 45. From age 45 to 64, the percentages are similar; after age 64, women have a much higher percentage of hypertension than men do Among racial groups the prevalence of hypertension in Blacks is among the highest in the world, and it is rising 2 to 3 times more common among women taking oral contraceptives (especially among obese and older women) than in women who do not take them

Mental status assessment

A mental status assessment documents a dysfunction and determines how that dysfunction affects self-care in everyday life. Mental status cannot be scrutinized directly like the characteristics of skin or heart sounds. Its functioning is inferred through assessment of an individual's behaviors. Usually you can assess mental status through the context of the health history interview. During that time keep in mind the four main headings of mental status assessment: (A,B,C,T) Appearance Behavior Cognition Thought processes

Individuals at high risk for suicide

A precise suicide plan to take place in the next 24 to 48 hours using a lethal method constitutes high risk. Important clues and warning signs of suicide: Prior suicide attempts Depression, hopelessness Firearms in the home Family history of suicide Incarceration Family violence, including physical or sexual abuse Self-mutilation Anorexia Verbal suicide messages (defeat, failure, worthlessness, loss, giving up, desire to kill self) Death themes in art, jokes, writing, behaviors Saying goodbye (giving away prized possessions)

Hypothesis

A tentative explanation for a cue or a set of cues that can be a basis for further investigation.

Trousseau sign

A test for latent tetany in which carpal spasms are induced by inflating sphygmomanometer cuff on the upper arm to a pressure exceeding systolic blood pressure for three minutes; used in hypocalcemia and hypomagnesemia.

Cryptorchidism

A testicle that hasn't moved into the bag of skin below the penis before birth.

hyporeflexia

Absence of reflex, lower motor neuron problem (spinal cord injury)

Inappropriate affect

Affect clearly discordant with content of person's speech. ex: laughs while discussing admission for liver biopsy.

Scar

After a skin lesion is repaired normal tissue is lost and replaced with connective tissue.

Cause of decreased smell

Aging

numeric rating scales

Ask the patient to choose a number that rates the level of pain, with 0 being no pain and 10 being the worst.

Reason for seeking care

Brief, spontaneous statement in the person's own words that describes the reason for the visit

Leukoplakia

Chalky white, thick, raised patch on the sides of the tongue. Precancerous

Nutrient

Chemical obtain from foods and beverages that is critical to human survival

Triangle-shaped posterior fontanel

Closes by 1 to 2 months

deep somatic pain

Comes from blood vessels, joints, tendons, muscles, and bone.

What causes gray hair?

Decrease in melanocyte function

Vesicle

Elevated cavity containing free fluid, up to 1 cm. "blister" - *EX: Chicken pox, herpes zosterum*

The general background of the eye is generally what color?

Light red to dark brown-red Generally, it corresponds with skin color

Organ

Functionally distinct structure composed of two or more types of tissues

Black Hairy Tongue

Fungus infection overgrowth

Pericardial Friction Rub

High pitched, scratchy extra cardiac sound heard when the precordium is inflamed

4+ Reflex

Hyperreflexia with clonus

Crypts

Indentation on the surface of the tonsils

Pharyngitis

Inflammation of the throat

Pinworms - S&S

Intense itching and irritated anal skin in children

Elation

Joy & optimism, overconfidence, increased motor activity; not necessarily pathologic. ex: "I'm feeling very happy."

Anterior cavity

Larger body cavity located anterior to the Prosterior (dorsal) body cavity, includes the serious membrane lined pleural cavities for the lungs, pericardial cavity for the heart, pericardial cavity for the heart, peritoneal cavity for the Abdominal and pelvic organs, also referred to as the ventral cavity

Confluent

Lesions run together

Psychological Factors

Men are more STOIC about pain, but will whine, Women will cry

Intermittent claudication is:

Muscular pain brought on by exercise

Pain assessment

PQRST method

Breast feeding advantages

Passive Immunity

Dorsal cavity

Posterior body cavity that houses the brain and spinal cord, also referred to the Prosterior body cavity

Differentiation

Process by which unspecialized cells become specialized in structure and function

Pleura

Serous membrane that lines the pleural cavity and covers the lungs

Tachycardia

Rapid heart rate, greater than 95 beats per minute

diaphoresis

SOB episodes associated with night sweats

Age of children possessing modesty

School-age (5-10)

Bradycardia

Slow heart rate, less than 50 beats per minute.

Fordyce Granules

Small isolated, white or yellow papules on the oral mucosa

Cranial Nerve XI

Spinal Motor Function: Movement of the trapezius and sternomastoid muscles

Muscles involved with CN XI

Sternomastoid & Trapezius

Systemic anatomy

Studies of structures that contribute tips Pacific by systems

Microscopic anatomy

Study a very small structures of the body using magnification

A murmur heard after S1 and before S2 is classified as:

Systolic ( possible benign)

pulse rhythm

THAT REGULARITY OF THE TIME BETWEEN EACH HEART BEAT

Circumstantiality

Talks with excessive and unnecessary detail, delays reaching point

Inching

Technique of moving the stethoscope incrementally across the precordium through the auscultatory areas while listening to the heart sounds.

Vital signs

Temp Pulse Respirations Blood pressure

Know where pulses are found and describe where they are palpated

Temporal Carotid Brachial Radial Ulnar Femoral Political Dorsalis pedis Posterior tibial

Gynecomastia

Temporary enlargement of breast tissue in men, may reapear in aging male because of testosterone deficiency.

Global aphasia

The most common and severe form. Spontaneous speech is absent or reduced to a few stereotyped words or sounds. Comprehension is absent or reduced to only the person's own name and a few select words. Repetition, reading, and writing are severely impaired. Prognosis for language recovery is poor. Caused by a large lesion that damages most of combined anterior and posterior language areas.

Prostate cancer

The most frequently diagnosed cancer in men. Detected by prostate-specific antigen (PSA) blood test or digital rectal exam (DRE)

What is the pupillary light reflex?

The normal constriction of the pupils when bright light shines on the pupil

Firm pressure

The nurse is palpating the sinus areas. If the findings are normal, then the patient should report which sensation?

Rectal temperature in an adult

The rectal temperature is the preferred route when the other routes are not practical (e.g., for the comatose or confused person; people in shock; or those who cannot close the mouth because of breathing or oxygen tubes, wired mandible, or other facial dysfunction). Wear gloves and insert a lubricated rectal probe cover on an electronic thermometer only 1 inch into the adult rectum, directed toward the umbilicus. (For a glass thermometer, leave in place for image minutes.) Do not let go of the temperature probe while it is inserted into the rectum. Disadvantages to the rectal route are patient discomfort and the invasive nature of the procedure.

Sagittal plane

Two dimensional, vertical plane that divides the body or Organ into right and left sides

Malocclusion (Malo-clue-sion)

Upper or lower dental arches out of alignment.

Leukorrhea

Whitish or yellowish discharge from vagina

The best method for listening to pericardial friction rub is:

With the diaphragm, patient sitting up and leaning forward, breath held in expiration.

Scoliosis

a lateral or side-to-side curvature of the spine

Stethoscope

a medical instrument for listening to the sounds generated inside the body

Evidence based practice

a systematic approach emphasizing the best research evidence, the clinicians experience, patient preferences and values, physical examination, and assessment.

Resting tremor

a tremor that is apparent when the client is at rest and diminishes with activity

Exophthalmos

abnormal protrusion of the eyeball

stroke volume

amount of blood pumped out of the heart with each beat

Epitrochlear node

antecubital fossa and drains the hand and lower arm

lay term for aphthous ulcers

canker sores

Nullipara

condition of first pregnancy

Pregnant women's breasts?

delicate blue vascular pattern is visible over the breasts. breasts increase in size, also nipple. stretch marks, nipple become darker and more erecticle. areola widens, darker, montgomery glands.

Atherosclerosis

deposition of fatty plaques on the intima of the arteries

Umbilicus

depression on the abdomen marking site of entry of umbilical cord

Axillary nodes

drain the breast and upper arm

normal adult thorax configuration

elliptical shape with ateroposterior-to-transverse diameter as 1:2

Angina

episodes of severe chest pain due to inadequate blood flow to the myocardium

Pyrosis

heartburn; burning sensation in upper abdomen due to reflux of gastric acid

Full bounding pulse (3+)

hyperkenetic states, anemia, hyperthryroidism

Venous ulcer development

obesity

Sign

objective abnormality that you as an examiiner could detect on physical examination or in laboratory reports

Kyphosis

outward or convex curvature of the thoracic spine; hunchback

Illiopsoas muscle test

straight leg raise - sign of appendicitis - push down on their leg - if positive they will have right lower pain

Colostrum

yellow fluid that is a precursor for milk in pregnant woman and may be expressed after the 4th month of pregnancy. Rich w/antibodies and protect newborn against infection before milk comes in.

Review ROM grading

5: (normal) full ROM against gravity; full resistance 4: (good) full ROM against gravity; some resistance 3: (fair) full ROM with gravity 2: (poor) full ROM with gravity eliminated (passive motion) 1: (trace) slight contraction 0: (zero) no contraction

Average age of breast development

8-9 y/o for African-American girls, 10 y/o for White girls.

Bradycardia rate

<90 beats/min in newborns <60 beats/min in older infants or children <50 beats/min in adults

Bulla

>1cm superficial in epidermis. *EX: Friction blister, burns, contact dermatitis*

Bulla

>1cm superficial in epidermis. friction blister.

Tumor

>few cm's. firm or soft. deeper into dermis. *EX: Lipoma "oma"*

Tumor

>few cm's. firm or soft. deeper into dermis. lipoma "oma"

"Have you noticed any dryness in your mouth?"

A 72-year-odl patient has a history of hypertension and chronic lung disease. An important question for the nurse to include in the history would be:

Endometriosis

A condition in which the tissue that lines the uterus grows somewhere else

PARKINSON'S SYNDROME

A deficiency of the neurotransmitter dopamine and degeneration of the basal ganglia in the brain. The immobility of features produces a face that is flat and expressionless, "mask-like," with elevated eyebrows, staring gaze, oily skin, and drooling.

Subculture

A group that may have a loose group identity with few or no cultural traditions in common with a shared language, sometimes personality traits and body of tradition of its own.

Signs of alcoholism

A problematic pattern of alcohol use leading to clinically significant impairment or distress, as manifested by at least two of the following occurring within a 12-month period: 1. Alcohol is often taken in larger amounts or over a longer period than was intended. 2. There is a persistent desire or unsuccessful efforts to cut down or control alcohol use. 3. A great deal of time is spent in activities necessary to obtain alcohol, use it, or recover from its effects. 4. Craving or a strong desire or urge to use alcohol. 5. Recurrent alcohol use results in a failure to fulfill major role obligations at work, school, or home. 6. Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol. 7. Important social, occupational, or recreational activities are given up or reduced because of alcohol use. 8. Recurrent alcohol use in situations in which it is physically hazardous. 9. Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol. 10. Tolerance, as defined by either of the following: a. A need for markedly increased amounts of alcohol to achieve intoxication or desired effect b. A markedly diminished effect with continued use of the same amount of alcohol 11. Withdrawal, as manifested by either of the following: a. The characteristic withdrawal syndrome for alcohol b. Alcohol (or a closely related substance such as a benzodiazepine) taken to relieve or avoid withdrawal symptoms.

BRUIT

A soft, pulsatile, whooshing, blowing sound heard best with the bell of the stethoscope. The bruit is not present normally. It may indicate hyperthyroidism

38. During an examination, the nurse notes a supernumerary nipple just under the patient's left breast. The patient tells the nurse that she always thought it was a mole. Which statement about this finding is correct? A) It is a normal variation and not a significant finding. B) It is a significant finding and needs further investigation. C) It also contains glandular tissue and may leak milk during pregnancy and lactation. D) The patient is correct—it is actually a mole that happens to be located under the breast.

A) It is a normal variation and not a significant finding.

9. A woman has just learned that she is pregnant. What are some things the nurse should teach her about her breasts? A) She can expect her areolae to become larger and darker in color. B) Breasts may begin secreting milk after the fourth month of pregnancy. C) She should inspect her breasts for visible veins and report this immediately. D) During pregnancy, breast changes are fairly uncommon; most of the changes occur after the birth.

A) She can expect her areolae to become larger and darker in color.

2. The nurse is examining a 62-year-old man and notes that he has gynecomastia bilaterally. The nurse should explore his history for which related conditions? Select all that apply. A) Obesity B) Malnutrition C) Hyperthyroidism D) Type 2 diabetes mellitus E) Liver disease F) History of alcohol abuse

A,C,E,F

1. The nurse is assessing the breasts of a 68-year-old woman and discovers a mass in the upper outer quadrant of the left breast. When assessing this mass, the nurse keeps in mind that characteristics of a cancerous mass include which of the following? Select all that apply. A) Nontender mass B) Dull, heavy pain on palpation C) Rubbery texture and mobile D) Hard, dense, and immobile E) Regular border F) Irregular, poorly delineated border

A,D,F

Skin: Danger Signs of skin for cancer

A- asymmetry (not regularly rounded, or oval) B- border irregularity (notching, scalloping, ragged edges, or poorly defined margins) C- color variation (areas of brown, black, blue, red, white, or combination) D- diameter (greater than 6 mm = pencil eraser) E- elevation, evolution (rapid changes, new lesions, itching, bruising, burning, bleeding)

24. The nurse is assisting with a self-breast examination clinic. Which of these women reflect abnormal findings during the inspection phase of breast examination? A) Woman whose nipples are in different planes (deviated) B) Woman whose left breast is slightly larger than her right C) Nonpregnant woman whose skin is marked with linear striae D) Pregnant woman whose breasts have a fine blue network of veins visible under the skin

A) Woman whose nipples are in different planes (deviated)

Formulate a response you would make to a client who has spoken in a sexually aggressive way.

"I am uncomfortable when you talk to me that way; please don't."

State a useful phrase to use as a closing when ending the interview.

"Is there anything else you would like to mention?"

Aortic regurgitation

(Aortic insufficiency) incompetent aortic valve that allows backward flow of blood into left ventricle during diastole.

Herpes Simplex Virus - Type 2

(Genital) S: episodes of local pain, dysuria, fever O: clusters of small, shallow vesicles with surrounding, erythema; erupt on genital areas and inner thigh. Also, inguinal adenopathy, edema. Vesicles on labia rupture in 1 to 3 days, leaving painful ulcers. Initial infection last 7 to 10 days. Virus remains dormant indefinitely; recurrent infection last 3 to 10 days

Fibroid

(Myoma) hard, painless nodules in uterine wall that cause uterine enlargement

Supernumerary nipple

(extra nipple),

HEADACHES

*Cluster *Tension *Tumor related *Migraine

Lymphatic System: The aging adult

- DP, PT pulses may be difficult to find - Trophic changes - arterial insufficiency (thin, shiny skin, thick-ridged nails, loss of hair on lower legs)

Lymphadenopathy: clues

- acute infection - nodes are warm, tender, and firm but freely moveable - chronic inflammation (EX: TB) - cancerous nodes are hard, > 3 cm, unilateral, nontender, matted, fixed, - HIV: enlarged, non-tneder, mobile (ESP: occipital) - single enlarged non-tender, hard left supraclavicular node - neoplasm in throx/abdomen - "Virchow node" - painless, rubbery, discrete node that gradually appear (Hodgkin lymphome, ESP: cervical region)

Thorax and Lungs: Aging adult

- chest cage shows increase AP diameter (round barrel shape) - kyphosis (outward curvature of thoracic cage) - chest expansion somewhat decreased - costal cartliages calcified - less mobile thorax - may tire easily - mouth breathing may be required

Stridor occurs with?

- croup - acute epiglottis (in children) - foreign inhalation - obstructed airway

Nutritional Assessment: Aging Adult

- diet changes from when you weer in your 40s, 50s? (why; which factors affect the way you eat; adequate vitamin D and calcium intake)

Why do the nodes enlarge in the breast?

- enlarge with local infection of breast, arm, or hand - with breast cancer metaseses

Nutritional Assessment: Infants and Children

- gestational nutrition of Mom (drug use, diet-complications, birth weigth, evidence of delayed physical or mental growth) - breastfed or bottlefe (type, frequency, duration of feeding; difficulties; timing and method of weening) - child's willingness to ear what you prepare (special likes/dislikes, how much, control of non-nutritious snacks, how to avoid food aspiration) - overweight and obesity risk factors (overweight parent; low-income; maternal smoking; large birth weight; rapid weight gain from birth to 5 months)

Heart and Neck Vessels: The Pregnant woman

- increase in resting P (10-15 more bpm) - drop in BP - gestational hypertension - palpation of apical impulse - increased blood volume - workload - slight left axis deviation of heart

NMT: Pregnant woman

- nasal stuffiness - epitaxis - gums hyperemic and softened

Contour of Abdomen

- scaphoid (caves in) - flat - rounded - protuberant

Skin and the aging adult, hair, nails, turgor, thickening, moisture

- senile lentigines ("liver spots") - keratoses (raised thick areas of pigmentation - scaly, crusted, warty) - dry skin (xerosis) - acrohordons ("skin tags") - sebaceous hyperplasia (raised yellow paupiles with central depression - thining skin (= parchment paper, fat diminishes) - hair growth decreases (alopecia) - nail growth rate decreases - skin turgor decreases (recedes slowly, tents)

Artery sites

- temporal - carotid - brachial - radial - ulnar - femoral - popliteal - dorsalis pedis - posterior tibial

Murphy sign

- tests for cholecystitis - positive test is inspiratory arrest with deep palpation under liver

Thorax and Lungs: Pregnant woman

- thoracic cage appears wider - costal angle widens (by 50%) - respirations are deeper (40% increase in tidal volume

Health Disparity

-The Unusual and Disproportionate frequency of a given health problem (diabetes, hypertension, cancers) within a Population when compared with other populations. - Occurs in a broader social and economic context

Musculoskeletal changes with age

-decrease in height, kyphosis, lose fat in periphery and deposit it centrally -ROM should not decrease unless they have an underlying disease process like arthritis

TMJ

-temporal mandibular joint. Open mouth wide, move side to side, palpate TMJ. Is there crepitus or tenderness?

Documentation of Pulses

0+ Absent or not discernible 1+ Thready, weak, difficult to feel 2+ Normal, detected readily, obliterated by strong pressure 3+ Bounding, difficult to obliterate

Standard Precautions to use with all patients

1) Wash hands 2) Wear clean gloves 3) Wear mask and eye protection 4) Wear a gown 5) Be careful with used patient care equipment 6) Design/follow adequate hospital procedure 7) Be careful with used linen 8) Place infectious in private room

Grading tonsils

1+ visibl E2+ halfway between tonsillitis pillars and uvula 3+ touching the uvula 4+ touching one another

Weak, Thready pulse (1+)

1+: A pulse with a decreased volume that feels weak and thin

Direction of blood flow

1. Blood (deoxygenated) enters the heart via the superior and inferior vena cava and goes into the RT atrium 2. Blood (deoxygenated) leaves the RT atrium and goes through the tricuspid valve to the RT ventricle 3. Blood (deoxygenated) leaves the RT ventricle and goes through the pulmonic valve to the pulmonary artery 4. Deoxygenated blood flows through the pulmonary artery to the lungs to receive oxygen, where it becomes oxygenated blood 5. Oxygenated blood returns to the heart via the pulmonary veins and enters the heart via the LT atrium 6. Oxygenated blood leaves the LT atrium and goes through the mitral valve to the LT ventricle 7. LT ventricle ejects the oxygenated blood through the aortic valve into the aorta 8. The aorta delivers oxygenated blood to the body Rinse...and repeat!

Describe the points to consider in preparing the physical setting for the interview

1. Comfortable room temperature 2. Sufficient lighting 3. Quiet environment- reduce noise 4. Remove distractions 5. Place distant between you and the client (4 to 5 ft.) 6. Equal status seating 7. Face to Face Contact 8. Reduce Note Taking

Four Types of Assessment

1. Complete or Comprehensive: establish baseline 2. Focused: targeted to specific health needs/risks 3. Ongoing: systematic follow-up 4. Emergency: rapid, urgent

Middle ear functions

1. Conducts sound vibrations from the outer ear to central hearing apparatus 2. Protects inner ear by reducing amplitude of loud sounds

Lymphatic System

1. Conserve fluid/plasma proteins that leak our of capillaries 2. Form part of immune system 3. Absorb lipids from small intestine

list the 9 types of examiner responses that could be used during the interview, and give a short example of each

1. Facilitation - Nodding yes 2. Silence - Waiting for response without interruption 3. Reflection - Pt: "It's so hard staying in bed during my pregnancy. I have kids at home I'm worried about." Response: "You feel worried and anxious about your children?" 4. Empathy - Pt: "This is just great! I own a business, direct my employees and now I can't even go to the bathroom without help." Response: "It must be hard, one day having so much control and now feeling dependent on someone else." 5. Clarification - Response: "The heaviness in your chest occurs with walking up a flight of stairs or more than one block, but stops when you rest, Is that correct?" Pt: "Yes, that's it." 6. Confrontation - You look sad, or You sound angry 7. Interpretation - It seems that every time you feel the stomach pain, you have some type of stress in your life. 8. Explanation - You order your dinner from the menu provided, and it takes approximately 30 minutes to arrive. 9. Summary - Review pertinent facts, allow client time to make corrections

During assessment of infants and children, the nurse measures the head circumference and compares the measure to the chest circumference. For each finding listed below, match to the appropriate age. 1. Newborn infant 2. Toddler, age 2 years 3. Child, age 4 years

1. Head circumference equal to chest circumference. 2. Head circumference greater than chest circumference. 3. Head circumference less than chest circumference. ANS:2,1,3

State at least 7 types of nonverbal behaviors that an interviewer could make.

1. Physical Appearance 2. Posture 3. Gestures 4. Facial Expressions 5. Eye Contact 6. Voice (tone) 7. Touch

Review lymph nodes abnormal finding and criteria

1. Preauricuar 2. Posterior Auricular 3. Occipital 4. Submental 5. Submandibular 6. Juglodigastic 7. Superficial Cervical 8. Deep Cervical 9. Posterior Cervical 10. Supraclavicular

Order of Palpation of Lymph Nodes

1. Preauricular, in front of ear 2. Posterior auricular (mastoid), superficial to mastoid process 3. Occipital, at base of skull 4. Submental, midline, behind tip of mandible 5. Submandibular, halfway between angle and tip of mandible 6. Jugulodigastric, under angle of mandible 7.Superficial cervical, overlying sternomastoid muscle 8.Deep cervical, deep under sternomastoid muscle 9.Posterior cervical, in posterior triangle along edge of trapezius muscle 10.Supraclavicular, just above and behind clavicle, at sternomastoid muscle.

list the 10 traps of interviewing, and give a short example of each

1. Providing false reassurance-Now don't worry, I'm sure you and the baby will be alright 2. Giving unwanted advice-If I were you, than I would... 3. Using authority-Your doctor/nurse knows best 4. Using avoidance language-saying passed on instead of death 5. Distancing-using impersonal speech to put space between a threat and the self (using the left breast instead of my left breast) 6. Using professional jargon-Adjust vocabulary for patient - hypertension instead of high blood pressure 7. Using leading or biased questions- you don't smoke do you? 8. Talking too much - talking instead of listening 9. Interrupting - speaking before patient is finished 10. Using why too much - Why did you wait so long before coming to the hospital?

1. List 8 items of information that should be communicated to the client concerning the terms or expectations of the interview

1. Time and place of interview 2. Introductions of yourself and brief explanation of your role 3. Purpose of the interview 4. Duration of the interview 5. Expectations of participation for each person 6. Presence of other people 7. Confidentiality 8. Any costs to the client

4 groups of axillary nodes?

1. central axillary- high up in middle of axilla(receive lymph from 3 other nodes) 2. Pectoral- anterior, just inside anterior axillary fold 3. Subscapular-posterior, deep in posterior axillary fold 4. Lateral- along the humerus inside upper arm

To assess for arterial deficiency, raise legs 12 inches off exam table and then have the person sit up and dangle the leg. The color should return to the legs in :

10 seconds or less

Bounding pulse 3+

3+: A pulse with an increased volume that feels very strong and full

34. A 43-year-old woman is at the clinic for a routine examination. She reports that she has had a breast lump in her right breast for years. Recently, it has begun to change in consistency and is becoming harder. She reports that 5 years ago her physician evaluated the lump and determined that it "was nothing to worry about." The examination validates the presence of a mass in the right upper outer quadrant at 1 o'clock, approximately 5 cm from the nipple. It is firm, mobile, nontender, with borders that are not well defined. The nurse's recommendation to her is: A) "Because of the change in consistency of the lump, it should be further evaluated by a physician." B) "The changes could be related to your menstrual cycles. Keep track of changes in the mass each month." C) "This is probably nothing to worry about because it has been present for years and was determined to be noncancerous at that time." D) "Because you are experiencing no pain and the size has not changed, continue to monitor the lump and return to the clinic in 3 months."

A. "Because of the change in consistency of the lump, it should be further evaluated by a physician."

14. The nurse is reviewing statistics regarding breast cancer. Which woman, aged 40 years in the United States, has the highest risk for development of breast cancer? A) African-American B) White C) Asian D) American Indian

A. African American

20. During an annual physical exam, a 43-year-old patient states that she doesn't perform monthly breast self-examinations (BSE). She tells the nurse that she believes that mammograms "do a much better job than I ever could to find a lump." The nurse should explain to her that: A) BSEs may detect lumps that appear between mammograms. B) breast self-examination is unnecessary until the age of 50 years. C) she is correct, mammography is a good replacement for breast self-examination. D) she doesn't need to perform breast self-examination as long as a physician checks her breasts yearly.

A. BSE's may detect lumps that appear between mammograms

The nurse suspects that a patient has hyperthyroidism. Which of the following findings would the nurse most likely find on examination? Increased heart rate, weight loss Decreased heart rate, weight gain Increased heart rate, weight gain Decreased heart rate, weight loss

A. Increased heart rate, weight loss

27. The nurse is palpating a female patient's breasts during an examination. Which of these positions is most likely to make significant lumps more distinct during breast palpation? A) Supine with arms raised over her head B) Sitting with arms relaxed at the sides C) Supine with arms relaxed at the sides D) Sitting with arms flexed and fingertips touching shoulders

A. Supine with arms raised over her head

19. A patient is newly diagnosed with benign breast disease. The nurse recognizes that which statement about benign breast disease is true? The presence of benign breast disease: A) makes it harder to examine the breasts. B) frequently turns into cancer in a woman's later years. C) is easily reduced with hormone replacement therapy. D) is usually diagnosed before a woman reaches childbearing age.

A. makes it harder to examine the breast

36. The nurse is discussing breast self-examination with a postmenopausal woman. The best time for postmenopausal women to perform breast self-examination is: A) the same day every month. B) daily, during the shower or bath. C) 1 week after her menstrual period. D) every year with her annual gynecologic examination.

A. the same day every month

During a cardiovascular assessment, the nurse knows that a "thrill" is: 1. a vibration that is palpable. 2. palpated in the right epigastric area. 3. associated with ventricular hypertrophy. 4. a murmur auscultated at the third intercostal space.

ANS: 1 A thrill is a palpable vibration. It signifies turbulent blood flow and accompanies loud murmurs. The absence of a thrill does not rule out the presence of a murmur.

Which racial group has the highest prevalence of heart disease and stroke in the United States? 1. Blacks 2. Whites 3. American Indians 4. Mexican-Americans

ANS: 1 According to the American Heart Association, the prevalence of heart disease and stroke is higher among black adults than in other racial groups.

When performing an otoscopic examination of a 5-year-old child with a history of chronic ear infections, the nurse sees that his right tympanic membrane is amber- yellow in color and there are air bubbles behind the tympanic membrane. The child reports occasional hearing loss and a popping sound with swallowing. The preliminary analysis based on this information is that: 1. this is most likely a serous otitis media. 2. the child has an acute purulent otitis media. 3. there is evidence of a resolving cholesteatoma. 4. the child is experiencing the early stages of perforation.

ANS: 1 An amber-yellow color to the tympanic membrane suggests serum in the middle ear. Often an air/fluid level or bubbles behind the tympanic membrane are visible. The patient may have feelings of fullness, transient hearing loss, and a popping sound with swallowing.

During an examination of a 3-year-old child, the nurse notes a bruit over the left temporal area. What should the nurse do? 1. Continue the examination because this is a normal finding for this age. 2. Check for the bruit again in 1 hour. 3. Notify the parents that a bruit has been detected in their child. 4. Stop the examination and notify the physician.

ANS: 1 Bruits are common in the skull in children under 4 or 5 years of age or in children with anemia. They are systolic or continuous and are heard over the temporal area.

While discussing the history of a 6-month-old infant, the mother tells the nurse that she took a great deal of aspirin while she was pregnant. What question would the nurse want to include in the history? 1. "Does your baby seem to startle with loud noise?" 2. "Has the baby had any surgeries on the ears?" 3. "Have you noticed any drainage from her ears?" 4. "How many ear infections has your baby had since birth?"

ANS: 1 Children at risk for hearing deficit include those exposed in utero to a variety of conditions, such as maternal rubella, or to maternal ototoxic drugs.

The nurse is performing an assessment on a 7-year-old child who has symptoms of chronic watery eyes, sneezing, and clear nasal drainage. The nurse notes the presence of a transverse line across the bridge of the nose, dark blue shadows below the eyes, and a double crease on the lower eyelids. These findings are characteristic of: 1. allergies. 2. a sinus infection. 3. nasal congestion. 4. an upper respiratory infection.

ANS: 1 Chronic allergies often develop chronic facial characteristics. These include blue shadows below the eyes, a double or single crease on the lower eyelids, open-mouth breathing, and a transverse line on the nose.

A 25-year-old woman in her fifth month of pregnancy has a blood pressure of 100/70 mm Hg. In reviewing her previous exam, the nurse notes that her blood pressure in her second month was 124/80 mm Hg. In evaluating this change, what does the nurse know to be true? 1. This is the result of peripheral vasodilatation and is an expected change. 2. Because of increased cardiac output, the blood pressure should be higher this time. 3. This is not an expected finding because it would mean a decreased cardiac output. 4. This would mean a decrease in circulating blood volume, which is dangerous for the fetus.

ANS: 1 Despite the increased cardiac output, arterial blood pressure decreases in pregnancy because of peripheral vasodilatation. The blood pressure drops to its lowest point during the second trimester and then rises after that.

During an assessment of a 20-year-old patient with a 3-day history of nausea and vomiting, the nurse notes the following: dry mucosa and deep fissures in the tongue. This finding is reflective of: 1. dehydration. 2. irritation by gastric juices. 3. a normal oral assessment. 4. side effects from nausea medication.

ANS: 1 Dry mouth occurs with dehydration or fever. The tongue has deep vertical fissures.

During a well-baby checkup, a mother is concerned because her 2-month- old infant cannot hold her head up when she is pulled to a sitting position. Which response by the nurse is appropriate? 1. "Head control is usually achieved by 4 months of age." 2. "You shouldn't be trying to pull your baby up like that until she is older." 3. "This is a concern because head control should be achieved by this time." 4. "This is a concern because it indicates possible nerve damage to the neck muscles."

ANS: 1 Head control is achieved by 4 months, when the baby can hold the head erect and steady when pulled to a vertical position.

The nurse is doing an oral assessment on a 40-year-old black patient and notes the presence of a 1-cm, nontender, grayish-white lesion on the left buccal mucosa. Which of the following is true concerning this lesion? 1. This lesion is leukoedema and is common in blacks. 2. This is the result of hyperpigmentation and is normal. 3. This is torus palatinus and would normally only be found in smokers. 4. This type of lesion is indicative of cancer and should be tested immediately.

ANS: 1 Leukoedema, a grayish-white benign lesion occurring on the buccal mucosa, is present more often in blacks than in whites.

In percussing the left cardiac border, the nurse would expect to hear dullness at the 1. third left intercostal space midclavicular line and fifth left intercostal space left sternal border. 2. fourth left intercostal space medial to midclavicular line and second left intercostal space midclavicular line. 3. fifth left intercostal space midclavicular line and second left intercostal space sternal border. 4. fifth left intercostal space sternal border and second right intercostal space midclavicular line.

ANS: 1 Normally, the left border of cardiac dullness is at the midclavicular line in the fifth interspace and slopes in toward the sternum as you progress upward so that by the second interspace the border of dullness coincides with the left sternal border.

A 31-year-old patient tells the nurse that he has noticed a progressive loss in his hearing. He says that it does seem to help when people speak louder or if he turns up the volume. The most likely cause of his hearing loss is: 1. otosclerosis. 2. presbycusis. 3. trauma to the bones. 4. frequent ear infections.

ANS: 1 Otosclerosis is a common cause of conductive hearing loss in young adults between the ages of 20 and 40 years.

The nurse is preparing to do an otoscopic examination on a 2-year-old child. Which of the following reflects correct procedure? 1. Pull the pinna down. 2. Pull the pinna up and back. 3. Tilt the child's head slightly toward the examiner. 4. Have the child touch his chin to his chest.

ANS: 1 Pull the pinna down on an infant and a child under 3 years of age.

In performing auscultation of heart sounds, which sequence would the nurse use 1. Aortic area—pulmonic area—Erb's point—tricuspid area—mitral area 2. Pulmonic area—aortic area—Erb's point—tricuspid area—mitral area 3. Aortic area—tricuspid area—Erb's point—mitral area—pulmonic area 4. Pulmonic area—Erb's point—tricuspid area—pulmonic area—mitral area

ANS: 1 Sounds produced by the valves may be heard all over the precordium. Therefore, learn to inch your stethoscope in a Z pattern, from the base of the heart across and down, and then over to the apex. Or start at the apex and work your way up.

The mother of a 10-month-old tells the nurse that she has noticed that her son becomes blue when he is crying and that the frequency of this is increasing. He is also not crawling yet. During the examination the nurse palpates a thrill at the left lower sternal border and auscultates a loud systolic murmur in the same area. What would be the most likely cause of these findings? 1. Tetralogy of Fallot 2. Atrial septal defect 3. Patent ductus arteriosus 4. Ventricular septal defect

ANS: 1 Tetralogy of Fallot subjective findings include (1) severe cyanosis, not in the first months of life but developing as the infant grows, and right ventricle outflow (i.e., pulmonic) stenosis gets worse; (2) cyanosis with crying and exertion at first, then at rest; (3) slowed development. Objective findings include (1) thrill palpable at left lower sternal border; (2) S1 normal, S2 has A2 loud and P2 diminished or absent; (3) murmur is systolic, loud, crescendo-decrescendo.

When assessing the tongue of an adult, the nurse knows that an abnormal finding would be: 1. a smooth glossy dorsal surface. 2. a thin white coating over the tongue. 3. raised papillae on the dorsal surface. 4. visible venous patterns on the ventral surface.

ANS: 1 The dorsal surface of the tongue is normally roughened from papillae. A thin white coating may be present.

A colleague is assessing an 80-year-old patient who has ear pain and asks him to hold his nose and swallow. The nurse knows that which of the following is true concerning this technique? 1. This should not be used in an 80-year-old patient. 2. This technique is helpful in assessing for otitis media. 3. This is especially useful in assessing a patient with an upper respiratory infection. 4. This will cause the eardrum to bulge slightly and make landmarks more visible.

ANS: 1 The eardrum is flat, slightly pulled in at the center, and flutters when the person performs the Valsalva maneuver or holds the nose and swallows (insufflation). One may elicit these maneuvers to assess drum mobility. Avoid these with an aging person because they may disrupt equilibrium.

The portion of the ear that consists of movable cartilage and skin is called the: 1. auricle. 2. concha. 3. outer meatus. 4. mastoid process.

ANS: 1 The external ear is called the auricle or pinna and consists of movable cartilage and skin.

The nurse is assessing the apical pulse of a 3-month-old infant and finds the rate to be 135 beats per minute. The nurse interprets this result as: 1. normal for this age. 2. lower than expected. 3. higher than expected, probably as a result of crying. 4. higher than expected, reflecting persistent tachycardia.

ANS: 1 The heart rate may range from 100 to 180 beats per minute immediately after birth and then stabilize to an average of 120 to 140 beats per minute. Infants normally have wide fluctuations with activity, from 170 beats per minute or more with crying or being active to 70 to 90 beats per minute with sleeping. Persistent tachycardia is greater than 200 beats per minute in newborns or greater than 150 beats per minute in infants.

The muscles in the neck that are innervated by CN XI are the: 1. sternomastoid and trapezius. 2. spinal accessory and omohyoid. 3. trapezius and sternomandibular. 4. sternomandibular and spinal accessory.

ANS: 1 The major neck muscles are the sternomastoid and the trapezius. They are innervated by CN XI, the spinal accessory.

The salivary gland that is located in the cheek in front of the ear is the: 1. parotid gland. 2. Stenson's gland. 3. sublingual gland. 4. submandibular gland.

ANS: 1 The mouth contains three pairs of salivary glands. The largest, the parotid gland, lies within the cheeks in front of the ear extending from the zygomatic arch down to the angle of the jaw.

Which of the following statements is true concerning air conduction? 1. It is the most efficient pathway for hearing. 2. It is caused by the vibrations of bones in the skull. 3. The amplitude of sound determines the pitch that is heard. 4. A loss of air conduction is called a conductive hearing loss.

ANS: 1 The normal pathway of hearing is air conduction, and it is the most efficient.

The sac that surrounds and protects the heart is called the: 1. pericardium. 2. myocardium. 3. endocardium. 4. pleural space.

ANS: 1 The pericardium is a tough fibrous double-walled sac that surrounds and protects the heart. It has two layers that contain a few milliliters of serous pericardial fluid.

A patient's laboratory data reveal an elevated thyroxine level. The nurse would proceed with an examination of the: 1. thyroid gland. 2. parotid gland. 3. adrenal gland. 4. thyroxine gland.

ANS: 1 The thyroid gland is a highly vascular endocrine gland that secretes thyroxine (T4) and tri-iodothyronine (T3).

The nurse suspects that a patient has hyperthyroidism and laboratory data indicate that the patient's thyroxine and tri-iodothyronine hormone levels are elevated. Which of the following findings would the nurse most likely find on examination? 1. Tachycardia 2. Constipation 3. Rapid dyspnea 4. Atrophied nodular thyroid

ANS: 1 Thyroxine and tri-iodothyronine are thyroid hormones that stimulate the rate of cellular metabolism, thus resulting in tachycardia. With an enlarged thyroid as in hyperthyroidism, you might expect to find diffuse enlargement (goiter) or a nodular lump.

During an examination, the nurse knows that the best way to palpate the lymph nodes in the neck is described by which statement? 1. Using gentle pressure, palpate with both hands to compare the two sides. 2. Using strong pressure, palpate with both hands to compare the two sides. 3. Gently pinch each node between one's thumb and forefinger and move down the neck muscle. 4. Using the index and middle fingers, gently palpate by applying pressure in a rotating pattern.

ANS: 1 Use gentle pressure because strong pressure could push the nodes into the neck muscles. It is usually most efficient to palpate with both hands, comparing the two sides symmetrically.

The nurse assesses the hearing of a 7-month-old by clapping hands. What is the expected response? 1. The infant turns the head to localize sound. 2. No obvious response to noise 3. A startle and acoustic blink reflex 4. The infant stops movement and appears to listen.

ANS: 1 With a loud sudden noise, you should note these responses: 6 to 8 months—infant turns head to localize sound, responds to own name.

The nurse is doing an assessment on a 21-year-old patient and notes that his nasal mucosa appears pale, gray, and swollen. What would be the most appropriate question to ask the patient? 1. "Are you aware of having any allergies?" 2. "Do you have an elevated temperature?" 3. "Have you had any symptoms of a cold?" 4. "Have you been having frequent nosebleeds?"

ANS: 1 With chronic allergy, mucosa looks swollen, boggy, pale, and gray.

A patient states that she is unable to hear well with her left ear. The Weber test shows lateralization to the right ear. Rinne has AC>BC with ratio of 2:1 in both ears, left-AC 10 sec and BC 5 sec, right-AC 30 sec and BC 15 sec. What would be the interpretation of these results? 1. The patient may have sensorineural loss. 2. The test results are reflective of normal hearing. 3. Conduction of sound through bones is impaired. 4. These results make no sense, so further tests should be done.

ANS: 1 With sensorineural loss, sound lateralizes to "better" ear or unaffected ear. Normal ratio of AC>BC is intact but is reduced overall. That is, the person hears poorly both ways.

When examining children affected with Down syndrome (trisomy 21), the nurse looks for the possible presence of: 1. ear dysplasia. 2. a long, thin neck. 3. a protruding thin tongue. 4. a narrow and raised nasal bridge.

ANS: 1 With the chromosomal aberration trisomy 21, also known as Down syndrome, head and face characteristics may include upslanting eyes with inner epicanthal folds, a flat nasal bridge, a small broad flat nose, a protruding thick tongue, ear dysplasia, a short broad neck with webbing, and small hands with a single palmar crease.

During an assessment of a 68-year-old man with a recent onset of right- sided weakness, the nurse hears a blowing, swishing sound with the bell of the stethoscope over the left carotid artery. This finding would indicate: 1. a valvular disorder. 2. blood flow turbulence. 3. fluid volume overload. 4. ventricular hypertrophy.

ANS: 2 A bruit is a blowing, swishing sound indicating blood flow turbulence; normally none is present

The vital signs of a 70-year-old patient with a history of hypertension are BP 180/100 and HR 90. The nurse hears an extra heart sound at the apex immediately before S1. The sound is heard only with the bell while patient is in left lateral position. With these findings and the patient's history, the nurse knows that this extra heart sound is most likely: 1. split S1. 2. atrial gallop. 3. diastolic murmur. 4. summation sound.

ANS: 2 A pathologic S4 is termed an atrial gallop or an S4 gallop. It occurs with decreased compliance of the ventricle and with systolic overload (afterload), including outflow obstruction to the ventricle (aortic stenosis) and systemic hypertension. A left-sided S4 occurs with these conditions. It is heard best at the apex with the patient in the left lateral position.

While performing the otoscopic exam of a 3-year-old boy who has been pulling on his left ear, the nurse finds that his left tympanic membrane is bright red and the light reflex is not visible. The most likely cause is: 1. fungal infection. 2. acute otitis media. 3. rupture of the drum. 4. blood behind the drum.

ANS: 2 Absent or distorted light reflex and a bright red color of the eardrum are indicative of acute otitis media.

The nurse suspects that a patient has otitis media. Early signs of otitis media include which of the following findings of the tympanic membrane? 1. Red and bulging 2. Hypomobility 3. Retraction with landmarks clearly visible 4. Flat, slightly pulled in at the center, and moves with insufflation

ANS: 2 An early sign of otitis media is hypomobility of the tympanic membrane.

During an oral examination of a 4-year-old American Indian child, the nurse notices that her uvula is partially split. Which of the following statements is accurate? 1. This is a cleft palate and is common in American Indians. 2. This is a bifid uvula, which occurs in some American Indian groups. 3. This is due to an injury and should be reported to the authorities. 4. This is torus palatinus, which occurs frequently in American Indians.

ANS: 2 Bifid uvula, a condition in which the uvula is split either completely or partially, occurs in some American Indian groups.

A 40-year-old patient who has just finished chemotherapy for breast cancer tells the nurse that she is concerned about her mouth. During the assessment the nurse finds the following: areas of buccal mucosa that are raw and red with some bleeding as well as other areas that have a white, cheesy coating. The nurse recognizes that this abnormality is: 1. carcinoma. 2. candidiasis. 3. leukoplakia. 4. Koplik's spots.

ANS: 2 Candidiasis is a white, cheesy, curd-like patch on the buccal mucosa and tongue. It scrapes off, leaving raw, red surface that bleeds easily. It also occurs after the use of antibiotics or corticosteroids and in immunosuppressed persons.

A patient presents with excruciating headache pain on one side of his head, especially around his eye, forehead, and cheek that lasts about 1/2 to 2 hours, occurring once or twice each day. The nurse suspects: 1. hypertension. 2. cluster headaches. 3. tension headaches. 4. migraine headaches.

ANS: 2 Cluster headaches produce pain around the eye, temple, forehead, and cheek and are unilateral and always on the same side of the head. They are excruciating and occur once or twice per day and last 1/2 to 2 hours each.

The nurse is performing a middle ear assessment on a 15-year-old patient who has a history of chronic ear infections. When examining the right tympanic membrane, the nurse sees the presence of dense white patches. The tympanic membrane is otherwise unremarkable. It is pearly, with the light reflex at 5 o'clock and landmarks visible. The nurse should: 1. refer the patient for the possibility of a fungal infection. 2. know that these are scars caused from frequent ear infections. 3. consider that these findings may represent the presence of blood in the middle ear. 4. be concerned about the ability to hear because of this abnormality on the tympanic membrane.

ANS: 2 Dense white patches on the tympanic membrane are sequelae of repeated ear infections. They do not necessarily affect hearing.

During an assessment of an infant, the nurse notes that the fontanels are depressed and sunken. The nurse suspects which condition? 1. Rickets 2. Dehydration 3. Mental retardation 4. Increased intracranial pressure

ANS: 2 Depressed and sunken fontanels occur with dehydration or malnutrition.

A mother brings her newborn in for an assessment and asks, "Is there something wrong with my baby? His head seems so big." The nurse knows the following about relative proportions of the head and trunk of the newborn: 1. At birth, the head is one fifth the total length. 2. Head circumference should be greater than chest circumference at birth. 3. The head size reaches 90% of its final size when the child is 3 years old. 4. When the anterior fontanel closes at 2 months, the head will be more proportioned to the body.

ANS: 2 During the fetal period, head growth predominates. Head size is greater than chest circumference at birth, and the head size grows during childhood, reaching 90% of its final size when the child is age 6 years.

The nurse is assessing a 16-year-old patient with head injuries from a recent motor vehicle accident. Which of the following statements indicates the most important reason for assessing for any drainage from the canal? 1. If the drum has ruptured, there will be purulent drainage. 2. Bloody or clear watery drainage can indicate a basal skull fracture. 3. The auditory canal many be occluded from increased cerumen. 4. There may be occlusion of the canal caused by foreign bodies from the accident.

ANS: 2 Frank blood or clear watery drainage (cerebrospinal leak) after trauma suggests a basal skull fracture and warrants immediate referral.

In assessing a 70-year-old man, the nurse finds the following: BP 140/100 mm Hg; HR 104 and slightly irregular; split S2. Which of these findings can be explained by expected hemodynamic changes related to age? 1. Increase in resting heart rate 2. Increase in systolic blood pressure 3. Decrease in diastolic blood pressure 4. Increase in diastolic blood pressure

ANS: 2 From ages 20 to 80 years, systolic blood pressure tends to increase within the normal range by 25% to 30%. No significant change in diastolic pressure occurs with age. No change in resting heart rate occurs with aging. Cardiac output at rest is not changed with aging.

In assessing the carotid arteries of an older patient with cardiovascular disease, the nurse would: 1. palpate the artery in the upper one third of the neck. 2. listen with the bell of the stethoscope to assess for bruits. 3. palpate both arteries simultaneously to compare amplitude. 4. instruct patient to take slow deep breaths during auscultation.

ANS: 2 If cardiovascular disease is suspected, auscultate each carotid artery for the presence of a bruit. Avoid compressing the artery because this could create an artificial bruit and it could compromise circulation if the carotid artery is already narrowed by atherosclerosis.

A patient in her first trimester of pregnancy is diagnosed with rubella. The nurse recognizes that the significance of this in relation to the infant's hearing is which of the following? 1. Rubella may affect the mother's hearing but not the infant's. 2. Rubella can damage the infant's organ of Corti, which will impair hearing. 3. Rubella is only dangerous to the infant in the second trimester of pregnancy. 4. Rubella can impair the development of CN VIII and thus affect hearing.

ANS: 2 If maternal rubella infection occurs during the first trimester, it can damage the organ of Corti and impair hearing.

When examining an elderly patient, the nurse recognizes that which finding is due to the aging process? 1. Teeth that appear shorter 2. A tongue that looks smoother in appearance 3. Buccal mucosa that is beefy red in appearance 4. A small, painless lump on the dorsum of the tongue

ANS: 2 In the aging adult, the tongue looks smoother because of papillary atrophy. The teeth are slightly yellowed and appear longer because of recession of gingival margins.

When using an otoscope to assess the nasal cavity, which of the following would the nurse need to do? 1. Insert the speculum at least 3 cm into the vestibule. 2. Avoid touching the nasal septum with the speculum. 3. Gently displace the nose to the side that is being examined. 4. Keep the speculum tip medial to avoid touching the floor of the nares.

ANS: 2 Insert the apparatus into the nasal vestibule, again avoiding pressure on the sensitive nasal septum.

When examining the ear with an otoscope, the nurse remembers that the tympanic membrane should appear: 1. light pink with a slight bulge. 2. pearly gray and slightly concave. 3. pulled in at the base of the cone of light. 4. whitish with a small fleck of light in the superior portion.

ANS: 2 It is a translucent membrane with a pearly gray color and a prominent cone of light in the anteroinferior quadrant, which is the reflection of the otoscope light. The drum is oval and slightly concave, pulled in at its center by one of the middle ear ossicles, the malleus.

The nurse has just completed a lymph assessment on a 60-year-old healthy female patient. The nurse knows that most lymph nodes in healthy adults are normally: 1. shotty. 2. not palpable. 3. large, firm, and fixed to the tissue. 4. rubbery, discrete, and mobile.

ANS: 2 Most lymph nodes are not palpable in adults. The palpability of lymph nodes decreases with age.

A woman who is in the second trimester of pregnancy mentions that she has had "more nosebleeds than ever" since she became pregnant. The nurse recognizes that this is due to: 1. a problem with the patient's coagulation system. 2. increased vascularity in the upper respiratory tract as a result of the pregnancy. 3. increased susceptibility to colds and nasal irritation. 4. inappropriate use of nasal sprays.

ANS: 2 Nasal stuffiness and epistaxis may occur during pregnancy as a result of increased vascularity in the upper respiratory tract.

The nurse knows that normal splitting of the second heart sound is associated with: 1. expiration. 2. inspiration. 3. exercise state. 4. low resting heart rate.

ANS: 2 Normal or physiologic splitting of the second heart sound is associated with inspira- tion because of the increased blood return to the right side of the heart, delaying closure of the pulmonic valve.

A 31-year-old patient tells the nurse that he has noticed pain in his left ear when people speak loudly to him. The nurse knows that this finding: 1. is normal for people of that age. 2. is a characteristic of recruitment. 3. may indicate a middle ear infection. 4. indicates that the patient has a cerumen impaction.

ANS: 2 Recruitment is a marked loss occurring when sound is at low intensity; sound actually may become painful when repeated at a louder volume.

The direction of blood flow through the heart is best described by which of the following? 1. Vena cava—right atrium—right ventricle—lungs—pulmonary artery—left atrium —left ventricle 2. Right atrium—right ventricle—pulmonary artery—lungs—pulmonary vein—left atrium—left ventricle 3. Aorta—right atrium—right ventricle—lungs—pulmonary vein—left atrium—left ventricle—vena cava 4. Right atrium—right ventricle—pulmonary vein—lungs—pulmonary artery—left atrium—left ventricle

ANS: 2 Returning blood from the body empties into the right atrium and flows into the right ventricle and then goes to the lungs through the pulmonary artery. The lungs oxygenate the blood and it is then returned to the left atrium by the pulmonary vein. It goes from there to the left ventricle and then out to the body through the aorta.

A heart sound heard during the interval between the second heart sound (S2) and the next first sound (S1) is a(n): 1. systolic sound. 2. diastolic sound. 3. atrial filling sound. 4. ventricular contraction sound.

ANS: 2 S2 signifies the onset of diastole. Any sound heard between S2 and the next first heart sound (S1) is a diastolic sound. A sound heard between S1 and S2 is a systolic sound.

The component of the conduction system referred to as the pacemaker of the heart is the: 1. atrioventricular (AV) node. 2. sinoatrial (SA) node. 3. bundle of His. 4. bundle branches.

ANS: 2 Specialized cells in the SA node near the superior vena cava initiate an electrical impulse. (Because the SA node has an intrinsic rhythm, it is the "pacemaker.")

A patient says that she has recently noticed a lump in the front of her neck below her "Adam's apple" that seems to be getting bigger. During the assessment, the finding that reassures the nurse that this may not be a cancerous thyroid nodule is that the lump (nodule): 1. is tender. 2. is mobile and not hard. 3. disappears when the patient smiles. 4. is hard and fixed to the surrounding structures.

ANS: 2 Suspect any painless, rapidly growing nodule, especially the appearance of a single nodule in a young person. Cancerous nodules tend to be hard and are fixed to surrounding structures.

A patient has come in for an examination and states, "I have this spot in front of my ear lobe here on my cheek that seems to be getting bigger and is real tender. What do you think it is?" The nurse notes swelling below the angle of the jaw and suspects that it could be an inflammation of his: 1. thyroid gland. 2. parotid gland. 3. occipital lymph node. 4. submental lymph node.

ANS: 2 Swelling with the parotid gland occurs below the angle of the jaw and is most visible when the head is extended. Painful inflammation occurs with mumps, and swelling also occurs with abscesses or tumors. Swelling occurs anterior to the lower ear lobe.

In assessing for an S4 with a stethoscope, the nurse would listen with the: 1. bell at the base with the patient leaning forward. 2. bell at the apex with the patient in the left lateral position. 3. diaphragm in the aortic area with the patient sitting. 4. diaphragm in the pulmonic area with the patient supine.

ANS: 2 The S4 is a ventricular filling sound. It occurs when atria contract late in diastole. It is heard immediately before S1. This is a very soft sound, of very low pitch. You need a good bell, and you must listen for it. It is heard best at the apex, with the person in the left lateral position.

A patient comes to the clinic complaining of neck and shoulder pain and is unable to turn her head. The nurse suspects damage to CN _____ and proceeds with the examination by: 1. XI; palpating the anterior and posterior triangles. 2. XI; asking the patient to shrug her shoulders against resistance. 3. XII; percussing the sternomastoid and submandibular neck muscles. 4. XII; assessing for a positive Romberg's sign.

ANS: 2 The major neck muscles are the sternomastoid and the trapezius. They are innervated by CN XI, the spinal accessory. The innervated muscles assist with head rotation and head flexion, movement of the shoulders, and extension and turning of the head.

The primary purpose of the ciliated mucous membrane in the nose is to: 1. warm the inhaled air. 2. filter out dust and bacteria. 3. filter coarse particles from inhaled air. 4. facilitate movement of air through the nares.

ANS: 2 The nasal hairs filter the coarsest matter from inhaled air, whereas the mucous blanket filters out dust and bacteria.

The nurse is palpating the sinus areas. If the findings are normal, the patient would report which sensation? 1. No sensation 2. Firm pressure 3. Pain during palpation 4. Pain sensation behind eyes

ANS: 2 The person should feel firm pressure but no pain.

In assessing the tonsils of a 30-year-old, the nurse notes that they are involuted, granular in appearance, and appear to have deep crypts. What is correct response to these findings? 1. Refer the patient to a throat specialist. 2. Nothing, this is the appearance of normal tonsils. 3. Continue with assessment looking for any other abnormal findings. 4. Obtain a throat culture on the patient for possible strep infection.

ANS: 2 The tonsils are the same color as the surrounding mucous membrane, although they look more granular and their surface shows deep crypts. Tonsillar tissue enlarges during childhood until puberty and then involutes.

The physician reports that a patient has a tracheal shift. The nurse is aware that this means that the patient's trachea is: 1. pulled to the affected side with systole. 2. pushed to the unaffected side with a tumor. 3. pulled to the unaffected side with plural adhesions. 4. pushed to the affected side with thyroid enlargement.

ANS: 2 The trachea is pushed to the unaffected side with an aortic aneurysm, a tumor, unilateral thyroid lobe enlargement, and pneumothorax.

The nurse is assessing a patient with possible cardiomyopathy and assesses the hepatojugular reflux. If heart failure is present, the nurse would see which finding while pushing on the right upper quadrant of the patient's abdomen, just below the rib cage? 1. The jugular veins will rise for a few seconds and then recede back to the previous level if the heart is working properly. 2. The jugular veins will remain elevated as long as pressure on the abdomen is maintained. 3. An impulse will be visible at the fourth or fifth intercostal space, at or inside the midclavicular line. 4. The jugular veins will not be detected during this maneuver.

ANS: 2 When performing hepatojugular reflux, the jugular veins will rise for a few seconds and then recede back to the previous level if the heart is able to pump the additional volume created by the pushing; however, with heart failure, the jugular veins remain elevated as long as pressure on the abdomen is maintained.

While performing an assessment of the mouth, the nurse notices that the patient has a 1-cm ulceration that is crusted with an elevated border. It is located on the outer third of the lower lip. What other information would be most important for the nurse to assess? 1. Nutritional status 2. When the patient first noticed the lesion 3. Whether the patient has had a recent cold 4. Whether the patient has had any recent exposure to sick animals

ANS: 2 With carcinoma, the initial lesion is round and indurated, and then it becomes crusted and ulcerated with an elevated border. Most cancers occur between the outer and middle thirds of the lip. Any lesion that is still unhealed after 2 weeks should be referred.

A 17-year-old student is a swimmer on her high school's swim team. She has had three bouts of otitis externa so far this season and wants to know what to do to prevent it. The nurse instructs her to: 1. use a cotton-tipped swab to dry the ear canals thoroughly after each swim. 2. use rubbing alcohol or 2% acetic acid eardrops after every swim. 3. irrigate the ears with warm water and a bulb syringe after each swim. 4. rinse the ears with a warmed solution of mineral oil and hydrogen peroxide.

ANS: 2 With otitis externa (swimmer's ear), swimming causes the external canal to become waterlogged and swell; skinfolds are set up for infection. Prevent by using rubbing alcohol or 2% acetic acid ear drops after every swim.

In performing a voice test to assess hearing, which of the following would the nurse do? 1. Shield the lips so that the sound is muffled. 2. Whisper two-syllable words and ask the patient to repeat them. 3. Ask the patient to place his finger in his ear to occlude outside noise. 4. Stand about 4 feet away to ensure that the patient can really hear at this distance.

ANS: 2 With your head 30 to 60 cm (1 to 2 ft) from the person's ear, exhale and whisper slowly some two-syllable words such as Tuesday, armchair, baseball, or fourteen. Normally, the person repeats each word correctly after you say it.

1. The nurse is teaching a health class to high-school-age boys. When discussing the topic of the use of smokeless tobacco (SLT), which of the following statements are accurate? (Select all that apply. 1. One pinch of SLT in the mouth for 30 minutes delivers the equivalent of one cigarette. 2. The use of SLT has been associated with a greater risk of oral cancer than smoking has. 3. Pain is an early sign of oral cancer. 4. Pain is rarely an early sign of oral cancer. 5. Tooth decay is another risk of SLT because of the use of sugar as a sweetener. 6. SLT is considered a healthy alternative to smoking.

ANS: 2, 4, 5 One pinch of SLT in the mouth for 30 minutes delivers the equivalent of three cigarettes; pain is rarely an early sign of oral cancer. Many brands of SLT are sweetened with sugars, promoting tooth decay. SLT is not considered a healthy alternative to smoking, and the use of SLT has been associated with a greater risk of oral cancer than smoking has.

The nurse is testing the hearing of a 78-year-old man and keeps in mind the changes in hearing that occur with aging, such as: (Select all that apply.) 1. Hearing loss related to aging begins in the mid 40s. 2. The progression is slow. 3. The aging person has low-frequency tone loss. 4. The aging person may find it harder to hear consonants than vowels. 5. Sounds may be garbled and difficult to localize. 6. Hearing loss reflects nerve degeneration of the middle ear.

ANS: 2, 4, 5 Presbycusis is a type of hearing loss that occurs with aging; it is a gradual sorineural loss caused by nerve degeneration in the inner ear or auditory nerve. Its onset usually occurs in the fifth decade, and then it slowly progresses. The person first notices a high-frequency tone loss; it is harder to hear consonants (high-pitched components of speech) than vowels. This makes words sound garbled. The ability to localize sound is impaired also.

The nurse is assessing a patient in the hospital who has received numerous antibiotics and notes that his tongue appears to be black and hairy. In response to his concern, what would the nurse say? 1. "We need to get a biopsy and see what the cause is." 2. "This is an overgrowth of hair and will go away in a few days." 3. "This is a fungal infection caused by all the antibiotics you've received." 4. "This is probably caused by the same bacteria you had in your lungs."

ANS: 3 A black, hairy tongue is not really hair but the elongation of filiform papillae and painless overgrowth of mycelial threads of fungus infection on the tongue. It occurs after the use of antibiotics, which inhibit normal bacteria and allow proliferation of fungus.

The nurse notices that an infant has a large, soft lump on the side of his head and that his mother is very concerned. She tells the nurse that she noticed the lump about 8 hours after her baby's birth, and that it seems to be getting bigger. One possible explanation for this is: 1. hydrocephalus. 2. craniosynostosis. 3. cephalhematoma. 4. caput succedaneum.

ANS: 3 A cephalhematoma is a subperiosteal hemorrhage that is the result of birth trauma. It is soft, fluctuant, and well defined over one cranial bone. It appears several hours after birth and gradually increases in size.

A patient has been shown to have a sensorineural hearing loss. During the assessment, it would be important for the nurse to: 1. speak loudly so he can hear the questions. 2. assess for middle ear infection as a possible cause. 3. ask the patient what medications he is currently taking. 4. look for the source of the obstruction in the external ear.

ANS: 3 A simple increase in amplitude may not enable the person to understand words. Sensorineural hearing loss may be caused by presbycusis, a gradual nerve degenera- tion that occurs with aging and by ototoxic drugs, which affect the hair cells in the cochlea.

During an admission assessment, the nurse notices that a male patient has an enlarged and rather thick skull. The nurse suspects acromegaly and would further assess for: 1. exophthalmos. 2. bowed long bones. 3. coarse facial features. 4. an acorn-shaped cranium.

ANS: 3 Acromegaly is excessive secretion of growth hormone that creates an enlarged skull and thickened cranial bones. Patients will have elongated heads, massive faces, prominent noses and lower jaws, heavy eyebrow ridges, and coarse facial features.

During an examination of a female patient, the nurse notes lymphadenopathy and suspects an acute infection. Acutely infected lymph nodes would be: 1. clumped. 2. unilateral. 3. firm but freely movable. 4. hard and nontender.

ANS: 3 Acutely infected lymph nodes are bilateral, enlarged, warm, tender, and firm but freely movable.

A patient with a middle ear infection asks the nurse, "What does the middle ear do?" The nurse responds by telling the patient that the middle ear functions to: 1. maintain balance. 2. interpret sounds as they enter the ear. 3. conduct vibrations of sounds to the inner ear. 4. increase amplitude of sound for the inner ear to function.

ANS: 3 Among its other functions, the middle ear conducts sound vibrations from the outer ear to the central hearing apparatus in the inner ear.

During a cardiovascular assessment, the nurse knows that an S4 heart sound is: 1. heard at the onset of atrial diastole. 2. usually a normal finding in the elderly. 3. heard at the end of ventricular diastole. 4. heard best over the second left intercostal space with the individual sitting upright.

ANS: 3 An S4 heart sound is heard at the end of diastole when the atria contract (atrial systole) and when the ventricle is resistant to filling. The S4 occurs just before the S1.

The nurse is performing an assessment on a 65-year-old male. He reports a crusty nodule behind the pinna. It bleeds intermittently and has not healed over the past 6 months. On physical assessment, the nurse finds an ulcerated crusted nodule with an indurated base. The preliminary analysis in this situation is that this: 1. is most likely a benign sebaceous cyst. 2. is most likely a Darwin's tubercle and is not significant. 3. could be a potential carcinoma and should be referred. 4. is a tophus, which is common in the elderly and is a sign of gout.

ANS: 3 An ulcerated crusted nodule with an indurated base that fails to heal is characteristic of a carcinoma. These lesions fail to heal and bleed intermittently. Individuals with such symptoms should be referred for a biopsy.

During an assessment of a 20-year-old Asian patient, the nurse notices that he has dry, flaky cerumen in his canal. What is the significance of this finding? 1. This is probably the result of lesions from eczema in his ear. 2. This represents poor hygiene. 3. This is a normal finding and no further follow-up is necessary. 4. This could be indicative of change in cilia; the nurse should assess for conductive hearing loss.

ANS: 3 Asians and American Indians are more likely to have dry cerumen, whereas blacks and whites usually have wet cerumen.

During an oral assessment of a 30-year-old black patient, the nurse notes bluish lips and a dark line along the gingival margin. What would the nurse do in response to this finding? 1. Check the patient's hemoglobin for anemia. 2. Assess for other signs of insufficient oxygen supply. 3. Proceed with assessment, knowing that this is a normal finding. 4. Ask if he has been exposed to an excessive amount of carbon monoxide.

ANS: 3 Black persons normally may have bluish lips.

A mother brings in her newborn infant for an assessment and tells the nurse that she has noticed that whenever her newborn's head is turned to the right side, she straightens out the arm and leg on the same side and flexes the opposite arm and leg. After finding this on examination, the nurse would tell her that this is: 1. abnormal and is called the atonic neck reflex. 2. normal and should disappear by the first year of life. 3. normal and should disappear between 3 and 4 months of age. 4. abnormal. The baby should be flexing the arm and leg on the right side of his body when the head is turned to the right.

ANS: 3 By 2 weeks the infant shows the tonic neck reflex when supine and the head is turned to one side (extension of same arm and leg, flexion of opposite arm and leg). The tonic neck reflex disappears between 3 and 4 months of age.

The nurse is assessing a 3-year-old who is here for "drainage from the nose." On assessment, it is found that there is a purulent drainage from the left nares that has a very foul odor and no drainage from the right nares. The child is afebrile with no other symptoms. What should the nurse do next? 1. Refer to the physician for an antibiotic order. 2. Have the mother bring the child back in 1 week. 3. Perform an otoscopic examination of the left nares. 4. Tell the mother that this is normal for children of this age.

ANS: 3 Children are apt to put an object up the nose, producing unilateral purulent drainage and foul odor. Because some risk for aspiration exists, removal should be prompt.

Which of the following would be true regarding otoscopic examination of a newborn? 1. Immobility of the drum is a normal finding. 2. An injected membrane would indicate infection. 3. The normal membrane may appear thick and opaque. 4. The appearance of the membrane is identical to that of an adult.

ANS: 3 During the first few days, the tympanic membrane often looks thickened and opaque. It may look "injected" and have a mild redness from increased vascularity.

A 92-year-old patient has had a stroke. The right side of his face is drooping. The nurse might also suspect which of the following? 1. Epistaxis 2. Agenesis 3. Dysphagia 4. Xerostomia

ANS: 3 Dysphagia is difficulty with swallowing and may occur with a variety of disorders, including stroke and other neurologic diseases.

Which of the following describes the closure of the valves in a normal cardiac cycle? 1. The aortic valve closes slightly before the tricuspid valve. 2. The pulmonic valve closes slightly before the aortic valve. 3. The tricuspid valve closes slightly later than the mitral valve. 4. Both the tricuspid and pulmonic valves close at the same time.

ANS: 3 Events occur just slightly later in the right side of the heart because of the route of myocardial depolarization. As a result, two distinct components to each of the heart sounds exist, and sometimes you can hear them separately. In the first heart sound, the mitral component (M1) closes just before the tricuspid component (T1).

A visitor from Poland who does not speak English seems to be somewhat apprehensive about the nurse examining his neck. He would probably be most comfortable with the nurse examining his thyroid: 1. from behind with the nurse's hands placed firmly around his neck. 2. from the side with the nurse's eyes averted toward the ceiling and thumbs on his neck. 3. from the front with the nurse's thumbs placed on either side of his trachea and his head tilted forward. 4. from the front with the nurse's thumbs placed on either side of his trachea and his head tilted backward.

ANS: 3 Examining this patient's thyroid from the back may be unsettling for him. It would be best to examine his thyroid using the anterior approach, asking him to tip his head forward and to the right and then the left.

The nurse notices that a patient's palpebral fissures are not symmetrical. On examination, the nurse may find that there has been damage to:1. 1.CN III. 2.CN V. 3.CN VII. 4.CN VIII.

ANS: 3 Facial muscles are mediated by CN VII; asymmetry of palpebral fissures may be due to CN VII damage.

When assessing a newborn infant who is just 5 minutes old, the nurse knows that which of the following would be true? 1. The left ventricle is larger and weighs more than the right. 2. The circulation of a newborn is identical to that of an adult. 3. There is an opening in the atrial septum where blood can flow into the left side of the heart. 4. The foramen ovale closes just minutes before birth and the ductus arteriosus closes immediately after.

ANS: 3 First, about two thirds of the blood is shunted through an opening in the atrial septum, the foramen ovale into the left side of the heart, where it is pumped out through the aorta. The foramen ovale closes within the first hour because the pressure in the right side of the heart is now lower than in the left side.

In assessing a patient's major risk factors for heart disease, which would the nurse want to include when taking a history? 1. Family history, hypertension, stress, age 2. Personality type, high cholesterol, diabetes, smoking 3. Smoking, hypertension, obesity, diabetes, high cholesterol 4. Alcohol consumption, obesity, diabetes, stress, high cholesterol

ANS: 3 For major risk factors for coronary artery disease, collect data regarding elevated serum cholesterol, elevated blood pressure, blood glucose levels above 130 mg/dl or known diabetes mellitus, obesity, cigarette smoking, low activity level.

During a well-baby check, the nurse notices that a 1-week-old infant's face looks small compared with his cranium, which seems enlarged. On further examination, the nurse also notes dilated scalp veins and downcast, or "setting sun," eyes. The nurse suspects which condition? 1. Craniotabes 2. Microcephaly 3. Hydrocephalus 4. Caput succedaneum

ANS: 3 Hydrocephalus occurs with obstruction of drainage of cerebrospinal fluid that results in excessive accumulation, increasing intracranial pressure, and enlargement of the head. The face looks small compared with the enlarged cranium, and dilated scalp veins and downcast, or "setting sun," eyes are noted.

A patient's thyroid is enlarged, and the nurse is preparing to auscultate the thyroid for the presence of a bruit. A bruit is a: 1. low gurgling sound best heard with the diaphragm of the stethoscope. 2. loud, whooshing, blowing sound best heard with the bell of the stethoscope. 3. soft, whooshing, pulsatile sound best heard with the bell of the stethoscope. 4. high-pitched tinkling sound best heard with the diaphragm of the stethoscope.

ANS: 3 If the thyroid gland is enlarged, auscultate it for the presence of a bruit, which is a soft, pulsatile, whooshing, blowing sound heard best with the bell of the stethoscope.

The nurse is performing a cardiac assessment on a 65-year-old patient 3 days after her myocardial infarction. Heart sounds are normal when she is supine, but with the patient sitting and leaning forward, the nurse hears a high-pitched, scratchy sound at the apex with the diaphragm. It disappears on inspiration. The nurse suspects: 1. increased cardiac output. 2. another myocardial infarction. 3. inflammation of the precordium. 4. ventricular hypertrophy resulting from muscle damage.

ANS: 3 Inflammation of the precordium gives rise to a friction rub. The sound is high pitched and scratchy, like sandpaper being rubbed: It is best heard with the diaphragm, with the person sitting up and leaning forward, and with the breath held in expiration. A friction rub can be heard any place on the precordium but usually is best heard at the apex and left lower sternal border, places where the pericardium comes in close contact with the chest wall.

Immediately after birth, the nurse is unable to suction the nares of a newborn. An attempt is made to pass a catheter through both nasal cavities with no success. What would be the nurse's best response? 1. Attempt to suction again with a bulb syringe. 2. Wait a few minutes and try again once the infant stops crying. 3. Recognize this is a situation that requires immediate intervention. 4. Contact the physician and request assistance when he gets a chance.

ANS: 3 It is essential to determine patency of the nares in the immediate newborn period because most newborns are obligate nose breathers. Nares blocked with amniotic fluid are suctioned gently with a bulb syringe. If obstruction is suspected, a small lumen (5F to 10F) catheter is passed down each naris to confirm patency. The inability to pass a catheter through the nasal cavity indicates choanal atresia, which needs immediate intervention.

29. During a hearing assessment the nurse finds that sound lateralizes to the patient's left ear with the Weber test. What can the nurse conclude from this? 1. The patient has a conductive hearing loss in the right ear. 2. Lateralization is a normal finding with the Weber test. 3. The patient could have either a sensorineural or a conductive loss. 4. A mistake has occurred; the test must be repeated.

ANS: 3 It is necessary to perform the Weber and Rinne tests to determine the type of loss. With conductive loss, sound lateralizes to the "poorer" ear owing to background room noise. With sensorineural loss, sound lateralizes to the "better" ear or unaffected ear.

When the nurse is auscultating the carotid artery for bruits, which of the following reflects correct technique? 1. While listening with the bell of the stethoscope, have the patient take a deep breath and hold it. 2. While auscultating one side with the bell of the stethoscope, palpate the carotid artery on the other side to check pulsations. 3. Lightly apply the bell of the stethoscope over the carotid artery; have the patient take a breath, exhale, and hold it briefly while the nurse listens. 4. Firmly place the bell of the stethoscope over the carotid artery, have the patient take a breath, exhale, and hold it briefly while the nurse listens.

ANS: 3 Lightly apply the bell of the stethoscope over the carotid artery at three levels; have the patient take a breath, exhale, and hold it briefly while you listen. Holding the breath on inhalation will also tense the levator scapulae muscles, which makes it hard to hear the carotids. Examine only one carotid artery at a time to avoid compromising arterial blood flow to the brain. Avoid pressure over the carotid sinus, which may lead to decreased heart rate, decreased blood pressure, and cerebral ischemia with syncope.

The nurse notices that the mother of a 2-year-old boy brings him into the clinic quite frequently for various injuries and suspects there may be some child abuse involved. In doing the inspection of his mouth, the nurse should inspect for: 1. swollen, red tonsils. 2. ulcerations on the hard palate. 3. bruising on the buccal mucosa or gums. 4. small yellow papules along the hard palate.

ANS: 3 Note any bruising or laceration on the buccal mucosa or gums of an infant or young child. Trauma may indicate child abuse from a forced feeding of a bottle or spoon.

During an examination, the nurse knows that Paget's disease would be indicated by which of the following findings? 1. Positive Macewen's sign 2. Premature closure of the sagittal suture 3. Headache, vertigo, tinnitus, and deafness 4. Elongated head with heavy eyebrow ridge

ANS: 3 Paget's disease occurs more often in males and is characterized by bowed, long bones, sudden fractures, and enlarging skull bones that press on cranial nerves causing symptoms of headache, vertigo, tinnitus, and progressive deafness.

While performing a well-child assessment on a 5-year-old, the nurse notes the presence of palpable, bilateral, cervical, and inguinal lymph nodes. They are approxi- mately 0.5 cm in size, round, mobile, and nontender. The nurse suspects that this: 1. child has chronic allergies. 2. child may have an infection. 3. is a normal finding for a well child of this age. 4. child should be referred for additional evaluation.

ANS: 3 Palpable lymph nodes are normal in children until puberty when the lymphoid tissue begins to atrophy. Lymph nodes may be up to 1 cm in size in the cervical and inguinal areas, but are discrete, movable, and nontender.

26. During the precordial assessment on an 8-month pregnant patient, the nurse palpates the apical impulse at the fourth left intercostal space lateral to the midclavicular line. This would indicate 1. right ventricular hypertrophy. 2. increased volume and size of the heart as a result of pregnancy. 3. displacement of the heart from elevation of the diaphragm. 4. increased blood flow through the internal mammary artery.

ANS: 3 Palpation of the apical impulse is higher and lateral compared with the normal position because the enlarging uterus elevates the diaphragm and displaces the heart up and to the left and rotates it on its long axis.

A 45-year-old man is in the clinic for "a routine physical." During the history the patient states he's been having difficulty sleeping. "I'll be sleeping great and then I wake up and feel like I can't get my breath." The nurse's best response to this would be: 1. "When was your last electrocardiogram?" 2. "It's probably because it's been so hot at night." 3. "Do you have any history of problems with your heart?" 4. "Have you had a recent sinus infection or upper respiratory infection?"

ANS: 3 Paroxysmal nocturnal dyspnea occurs with heart failure. Lying down increases volume of intrathoracic blood, and the weakened heart cannot accommodate the increased load. Classically, the person awakens after 2 hours of sleep, arises, and flings open a window with the perception of needing fresh air.

A 70-year-old patient tells the nurse that he has noticed that he is having trouble hearing, especially in large groups. He says he "can't always tell where the sound is coming from" and the words often sound "mixed up." What might the nurse suspect as the cause for this change? 1. Atrophy of the apocrine glands 2. Cilia becoming coarse and stiff 3. Nerve degeneration in the inner ear 4. Scarring of the tympanic membrane

ANS: 3 Presbycusis is a type of hearing loss that occurs with aging, even in people living in a quiet environment. It is a gradual sensorineural loss caused by nerve degeneration in the inner ear or auditory nerve. This makes words sound garbled. The ability to localize sound is impaired also. This communication dysfunction is accentuated when background noise is present.

When listening to heart sounds, the nurse knows that which of the following statements concerning S1 is true? 1. S1 is louder than S2 at the base. 2. S1 indicates the beginning of diastole. 3. S1 coincides with the carotid artery pulse. 4. S1 is caused by closure of the semilunar valves.

ANS: 3 S1 is the start of systole, and is louder than S2 at the apex; S2 is louder than S1 at the base. S1 coincides with carotid artery pulse. Feel the carotid gently as you auscultate at the apex; the sound you hear as you feel each pulse is S1.

A patient comes into the clinic complaining of facial pain, fever, and malaise. On examination, the nurse notes swollen turbinates and purulent discharge from the nose. The patient also complains of a dull, throbbing pain in his cheeks and teeth on the right side and pain when the nurse palpates the areas. The nurse recognizes that this patient has: 1. posterior epistaxis. 2. frontal sinusitis. 3. maxillary sinusitis. 4. nasal polyps.

ANS: 3 Signs include facial pain, after upper respiratory infection, red swollen nasal mucosa, swollen turbinates, and purulent discharge. Person also has fever, chills, and malaise. With maxillary sinusitis, dull throbbing pain occurs in cheeks and teeth on the same side, and pain with palpation is present. With frontal sinusitis, pain is above the supraorbital ridge

Which of the following would the nurse expect to find during a cardiac assessment on a 4-year-old child? 1. S3 when sitting up 2. Persistent tachycardia above 150 3. Murmur at second left intercostal space when supine 4. Palpable apical impulse in fifth left intercostal space lateral to midclavicular line

ANS: 3 Some murmurs are common in healthy children or adolescents and are termed innocent or functional. The contractile force of the heart is greater in children. This increases blood flow velocity. The increased velocity plus a smaller chest measure- ment makes an audible murmur. The innocent murmur is heard at the second or third left intercostal space and disappears with sitting, and the young person has no associated signs of cardiac dysfunction.

The electrical stimulus of the cardiac cycle follows which sequence? 1. AV node—SA node—bundle of His 2. Bundle of His—AV node—SA node 3. SA node—AV node—bundle of His—bundle branches 4. AV node—SA node—bundle of His—bundle branches

ANS: 3 Specialized cells in the SA node near the superior vena cava initiate an electrical impulse. The current flows in an orderly sequence, first across the atria to the AV node low in the atrial septum. There it is delayed slightly so that the atria have time to contract before the ventricles are stimulated. Then the impulse travels to the bundle of His, the right and left bundle branches, and then through the ventricles.

A physician tells the nurse that a patient's vertebra prominens is tender and asks the nurse to re-evaluate the area in 1 hour. The area of the body the nurse will assess is the area: 1.just above the diaphragm. 2.just lateral to the knee cap. 3.at the level of the C7 vertebra. 4.at the level of the T11 vertebra.

ANS: 3 The C7 vertebra has a long spinous process, called the vertebra prominens, that is palpable when the head is flexed.

Which of the following statements is true regarding the apical impulse? 1. It is palpable in all adults. 2. It occurs with the onset of diastole. 3. Its location may be indicative of heart size. 4. It should normally be palpable in the anterior axillary line.

ANS: 3 The apical impulse is palpable in about 50% of adults. It is located in the fifth left intercostal space in the midclavicular line. Horizontal or downward displacement of the apical impulse may indicate an enlargement of the left ventricle.

During an examination, the nurse finds that a patient's left temporal artery is more tortuous and feels hardened and tender compared with the right temporal artery. The nurse suspects which condition? 1. Crepitation 2. Mastoiditis 3. Temporal arteritis 4. Bell's palsy

ANS: 3 The artery looks more tortuous and feels hardened and tender with temporal arteritis.

During an assessment of a 26-year-old at the clinic for "a spot on my lip I think is cancer" the nurse notes the following findings: a group of clear vesicles with an erythematous base around them located at the lip-skin border. The patient mentions that she just returned from Hawaii. What would be the most appropriate response by the nurse? 1. Tell the patient she will need to see a skin specialist. 2. Discuss the benefits of having a biopsy done of any unusual lesion. 3. Tell the patient this is herpes simplex I and will heal in 4 to 10 days. 4. Tell the patient that this is most likely the result of a riboflavin deficiency and discuss nutrition.

ANS: 3 The cold sores are groups of clear vesicles with a surrounding erythematous base. These evolve into pustules or crusts and heal in 4 to 10 days. The most likely site is the lip-skin junction. Infection often recurs in the same site. It may be precipitated by sunlight, fever, colds, or allergy.

The nurse is examining a patient's ears and notices cerumen in the external canal. Which of the following statements about cerumen is correct? 1. Sticky honey-colored cerumen is a sign of infection. 2. The presence of cerumen is indicative of poor hygiene. 3. The purpose of cerumen is to protect and lubricate the ear. 4. Cerumen is necessary for transmitting sound through the auditory canal.

ANS: 3 The ear is lined with glands that secrete cerumen, a yellow waxy material that lubricates and protects the ear.

A patient, an 85-year-old woman, is complaining about the fact that the bones in her face have become more noticeable. What explanation should the nurse give to her? 1. Diets low in protein and high in carbohydrates may cause enhanced facial bones. 2. It is probably because she doesn't use a dermatologically approved moisturizer. 3. It is probably due to a combination of factors such as decreased elasticity, subcutaneous fat, and moisture in her skin. 4. Facial skin becomes more elastic with age. This increased elasticity causes the skin to be more taught, drawing attention to the facial bones.

ANS: 3 The facial bones and orbits appear more prominent in the aging adult, and the facial skin sags owing to decreased elasticity, decreased subcutaneous fat, and decreased moisture in the skin.

A mother is concerned that her 18-month-old has 12 teeth. She is wondering if this is normal for a child of this age. The nurse's best response would be: 1. "How many teeth did you have at this age?" 2. "All 20 deciduous teeth are expected to erupt by age 4 years." 3. "This is a normal number of teeth for an 18-month-old." 4. "Normally, by age 2 1/2, 16 deciduous teeth are expected."

ANS: 3 The guidelines for the number of teeth for children under 2 years old are as follows: the child's age in months minus the number 6 should be equal to the expected number of deciduous teeth. Normally, all 20 teeth are in by 21/2 years old. In this instance, the child is 18 months old, minus 6, equals 12 deciduous teeth expected.

The projections in the nasal cavity that increase the surface area are called the: 1. meatus. 2. septum. 3. turbinates. 4. Kiesselbach's plexus.

ANS: 3 The lateral walls of each nasal cavity contain three parallel bony projections: the superior, middle, and inferior turbinates. They increase the surface area so that more blood vessels and mucous membrane are available to warm, humidify, and filter the inhaled air.

While counting the apical pulse on a 16-year-old patient, the nurse notes an irregular rhythm. His rate speeds up on inspiration and slows on expiration. What would be the nurse's response? 1. Talk with the patient about his intake of caffeine. 2. Do an electrocardiogram after the exam. 3. No further response is needed because this is normal. 4. Refer the patient to a cardiologist for further testing.

ANS: 3 The rhythm should be regular, although sinus arrhythmia occurs normally in young adults and children. With sinus arrhythmia, the rhythm varies with the person's breathing, increasing at the peak of inspiration, and slowing with expiration.

When listening to heart sounds, the nurse knows that the valve closures that can be heard best at the base of the heart are: 1. mitral, tricuspid. 2. tricuspid, aortic. 3. aortic, pulmonic. 4. mitral, pulmonic.

ANS: 3 The second heart sound (S2) occurs with closure of the semilunar valves and signals the end of systole. Although it is heard over all the precordium, S2 is loudest at the base.

During an assessment of an 80-year-old patient, the nurse would expect to find: 1. hypertrophy of the gums. 2. an increased production of saliva. 3. a decreased ability to identify odors. 4. finer and less prominent nasal hair.

ANS: 3 The sense of smell may be reduced because of a decrease in the number of olfactory nerve fibers.

The temporomandibular joint is just below the temporal artery and anterior to the:1. hyoid. 2. vagus. 3. tragus. 4. mandible.

ANS: 3 The temporomandibular joint is just below the temporal artery and anterior to the tragus.

During an examination of a patient in her third trimester of pregnancy, the nurse notices that the patient's thyroid gland is slightly enlarged. No enlargement had been noted previously. The nurse suspects that: 1. she has an iodine deficiency. 2. she is exhibiting early signs of goiter. 3. this is a normal finding during pregnancy. 4. further tests are needed for possible thyroid cancer.

ANS: 3 The thyroid gland enlarges slightly during pregnancy owing to hyperplasia of the tissue and increased vascularity.

During an examination, the patient states he is hearing a buzzing sound and says that it is "driving me crazy!" The nurse recognizes that this symptom is: 1. vertigo. 2. pruritus. 3. tinnitus. 4. cholesteatoma.

ANS: 3 Tinnitus is a sound that comes from within a person; it can be a ringing, crackling, or buzzing sound. It accompanies some hearing or ear disorders.

When examining the face, the nurse is aware that the two pairs of salivary glands that are accessible to examination are the _____ glands. 1. occipital and submental 2. parotid and jugulodigastric 3. parotid and submandibular 4. submandibular and occipital

ANS: 3 Two pairs of salivary glands accessible to examination on the face are the parotid glands in the cheeks over the mandible, anterior to and below the ear, and the submandibular glands, beneath the mandible at the angle of the jaw. The parotid glands are not normally palpable.

A patient has been diagnosed with strep throat. The nurse is aware that without treatment which complication may occur? 1. Rubella 2. Leukoplakia 3. Rheumatic fever 4. Scarlet fever

ANS: 3 Untreated strep throat may lead to rheumatic fever. When performing a health history, ask whether the patient's sore throats were documented as streptococcal.

When examining the nares of a 45-year-old patient who has complaints of rhinorrhea, itching of the nose and eyes, and sneezing, the nurse notes the following: pale turbinates, swelling of the turbinates, and clear rhinorrhea. Which of the following is most likely the cause? 1. Nasal polyps 2. Acute sinusitis 3. Allergic rhinitis 4. Nasal carcinoma

ANS: 3 With allergic rhinitis, rhinorrhea, itching of the nose and eyes, and sneezing are present. On physical examination, there is serous edema, and the turbinates usually appear pale with a smooth, glistening surface.

During an otoscopic examination, the nurse notes an area of black and white dots on the tympanic membrane and ear canal wall. What does this finding suggest? 1. Malignancy 2. Viral infection 3. Blood in the middle ear 4. Yeast or fungal infection

ANS: 4 A colony of black or white dots on the drum or canal wall suggests a yeast or fungal infection (otomycosis).

During inspection of the precordium of an adult patient, the nurse notices the chest moving in a forceful manner along the fourth-fifth left intercostal space at the midclavicular line. This finding most likely suggests: 1. a normal heart. 2. a systolic murmur. 3. enlargement of the left ventricle. 4. enlargement of the right ventricle.

ANS: 4 A heave or lift is a sustained forceful thrusting of the ventricle during systole. It occurs with ventricular hypertrophy as a result of increased workload. A right ventricular heave is seen at the sternal border; a left ventricular heave is seen at the apex.

A mother brings her 4-month-old to the clinic with concerns regarding a small pad in the middle of the upper lip that has been there since 1 month of age. The infant has no health problems. On physical examination, the nurse notes a 0.5-cm, fleshy, elevated area in the middle of the upper lip. There is no evidence of inflammation or drainage. What would the nurse tell this mother? 1. "This is an area of irritation caused from teething and is nothing to worry about." 2. "This is an abnormal finding and should be evaluated by another health care provider." 3. "This is the result of chronic drooling and should resolve within the next month or two." 4. "This is a sucking tubercle caused from the friction of breast- or bottle-feeding and is normal."

ANS: 4 A normal finding in infants is the sucking tubercle, a small pad in the middle of the upper lip from the friction of breast- or bottle-feeding.

During the cardiac auscultation the nurse hears a sound occurring immediately after S2 at the second left intercostal space. To further assess this sound, what would the nurse do? 1. Have patient turn to the left side and listen with the bell. 2. Ask patient to hold his breath while the nurse listens again. 3. No further assessment is needed because the nurse knows it is an S3. 4. Watch patient's respirations while listening for effect on the sound.

ANS: 4 A split S2 is a normal phenomenon that occurs toward the end of inspiration in some people. A split S2 is heard only in the pulmonic valve area, the second left interspace. When you first hear the split S2, do not be tempted to ask the person to hold his or her breath so that you can concentrate on the sounds. Breath holding will only equalize ejection times in the right and left sides of the heart and cause the split to go away. Instead, concentrate on the split as you watch the person's chest rise up and down with breathing.

When assessing the tongue of an adult, the nurse knows that an abnormal finding would be: 1. A painful vesicle inside the cheek for 2 days 2. The presence of moist, nontender Stenson's ducts 3. Stippled gingival margins that adhere snugly to the teeth 4. An ulceration on the side of the tongue with rolled edges.

ANS: 4 An ulceration on the side, base, or under the tongue raises the suspicion of cancer and must be investigated. Risk of early metastasis is present because of rich lymphatic drainage.

Which of the following best describes the test the nurse should use to assess the function of cranial nerve X? 1. Observe the patient's ability to articulate specific words. 2. Assess movement of the hard palate and uvula with the gag reflex. 3. Have the patient stick out the tongue and observe for tremors or pulling to one side. 4. Ask the patient to say "ahhh" and watch for movement of the soft palate and uvula.

ANS: 4 Ask the person to say "ahhh" and note that the soft palate and uvula rise in the midline. This tests one function of CN X, the vagus nerve.

The findings from an assessment of a 70-year-old patient with swelling in his ankles include jugular venous pulsations 5 cm above the sternal angle when the head of his bed is elevated 45 degrees. The nurse knows that this finding indicates: 1. decreased fluid volume. 2. increased cardiac output. 3. narrowing of jugular veins. 4. increased pressure in the right side of his heart.

ANS: 4 Because no cardiac valve exists to separate the superior vena cava from the right atrium, the jugular veins give information about activity on the right side of the heart. They reflect filling pressures and volume changes. Normal jugular venous pulsation is 2 cm or less above the sternal angle. Elevated pressure is more than 3 cm above the sternal angle at 45 degrees and occurs with right-sided heart failure.

During an assessment, the nurse notes that the apical impulse is displaced laterally, and it is palpable over a wide area. This indicates: 1. systemic hypertension. 2. pulmonic hypertension. 3. pressure overload, as in aortic stenosis. 4. volume overload, as in mitral regurgitation.

ANS: 4 Cardiac enlargement displaces the apical impulse laterally and over a wider area when left ventricular hypertrophy and dilatation are present. This is volume overload, as in mitral regurgitation, aortic regurgitation, or left-to-right shunts.

A 32-year-old woman is at the clinic for "little white bumps in my mouth." During the assessment, the nurse notes that she has a 0.5 cm white, nontender papule under her tongue and one on the mucosa of her right cheek. What would the nurse tell the patient? 1. "These spots are seen with infections such as strep throat." 2. "These could be indicative of a serious lesion, so I will refer you to a specialist." 3. "This is called leukoplakia and can be caused by chronic irritation such as smoking." 4. "These bumps are Fordyce's granules, which are sebaceous cysts and not a serious condition."

ANS: 4 Fordyce's granules are small, isolated white or yellow papules on the mucosa of the cheek, tongue, and lips. These little sebaceous cysts are painless and not significant.

An assessment of a 23-year-old patient reveals the following: an auricle that is tender and reddish-blue in color with small vesicles. Additional information the nurse would need to know includes which of the following? 1. Any change in the ability to hear 2. Any recent drainage from the ear 3. Recent history of trauma to the ear 4. Any prolonged exposure to extreme cold

ANS: 4 Frostbite causes reddish-blue discoloration and swelling of the auricle after exposure to extreme cold. Vesicles or bullae may develop, and the person feels pain and tenderness.

A pregnant woman states that she is concerned about her gums because she has noticed they are swollen and have started bleeding. What would be an appropriate response by the nurse? 1. "This is probably due to a vitamin C deficiency." 2. "I'm not sure what causes it but let me know if it's not better in a few weeks." 3. "You need to make an appointment with your dentist as soon as possible to have this checked." 4. "This can be caused by the change in hormone balance in your system when you're pregnant."

ANS: 4 Gingivitis is when gum margins are red and swollen and bleed easily. The condition may occur in pregnancy and puberty because of a changing hormonal balance.

During a cardiac assessment on an adult patient in the hospital for "chest pain," the nurse finds the following: jugular vein pulsations 4 cm above sternal angle when he is elevated at 45 degrees, BP 98/60, HR 130; ankle edema; difficulty in breathing when supine; and an S3 on auscultation. Which of the following best explains the cause of these findings? 1. Fluid overload 2. Atrial septal defect 3. Myocardial infarction 4. Heart failure

ANS: 4 Heart failure causes decreased cardiac output when the heart fails as a pump and the circulation becomes backed up and congested. Signs and symptoms: dyspnea, orthopnea, paroxysmal nocturnal dyspnea, decreased blood pressure, dependent, pitting edema; anxiety; confusion; jugular vein distention; fatigue. The S3 may be the earliest sign of heart failure.

During an interview, the patient states he has the sensation that "everything around him is spinning." The nurse recognizes that the portion of the ear responsible for this sensation is: 1. the cochlea. 2. cranial nerve VIII. 3. the organ of Corti. 4. the bony labyrinth.

ANS: 4 If the labyrinth ever becomes inflamed, it feeds the wrong information to the brain, creating a staggering gait and a strong, spinning, whirling sensation called vertigo.

In performing an examination of a 3-year-old with a suspected ear infection, the nurse would: 1. omit the otoscopic exam if the child has a fever. 2. pull the ear up and back before inserting the speculum. 3. ask the mother to leave the room while examining the child. 4. perform the otoscopic examination at the end of the assessment.

ANS: 4 In addition to its place in the complete examination, eardrum assessment is manda- tory for any infant or child requiring care for illness or fever. For the infant or young child, the timing of the otoscopic examination is best toward the end of the complete examination.

The nurse is obtaining a history on a 3-month-old infant. During the interview, the mom states, "I think she is getting her first tooth because she has started drooling a lot." The nurse's best response would be 1. "You're right, drooling is usually a sign of the first tooth." 2. "It would be unusual for a 3-month-old to be getting her first tooth." 3. "This could be the sign of a problem with the salivary glands." 4. "She is just starting to salivate and hasn't learned to swallow the saliva."

ANS: 4 In the infant, salivation starts at 3 months. The baby will drool periodically for a few months before learning to swallow the saliva. This drooling does not herald the eruption of the first tooth, although many parents think it does.

A mother brings her 2-month-old daughter in for an examination and says, "My daughter rolled over against the wall and now I have noticed that she has this spot that is soft on the top of her head. Is there something terribly wrong?" The nurse's response would be: 1."Perhaps that could be a result of your dietary intake during pregnancy." 2."Your baby may have craniosynostosis, a disease of the sutures of the brain." 3."That 'soft spot' you are referring to may be an indication of cretinism or congeni- tal hypothyroidism." 4."That 'soft spot' is normal, and actually allows for growth of the brain during the first year of your baby's life."

ANS: 4 Membrane-covered "soft spots" allow for growth of the brain during the first year. They gradually ossify; the triangular-shaped posterior fontanel is closed by 1 to 2 months, and the diamond-shaped anterior fontanel closes between 9 months and 2 years.

A patient complains that while studying for an examination he began to notice a severe headache in the frontotemporal area of his head that is throbbing and is somewhat relieved when he lies down. He tells the nurse that his mother also had these headaches. The nurse suspects that he may be suffering from: 1. hypertension. 2. cluster headaches. 3. tension headaches. 4. migraine headaches.

ANS: 4 Migraine headaches tend to be supraorbital, retro-orbital, or frontotemporal with a throbbing quality. They are of a severe quality and are relieved by lying down. Migraines are associated with family history of migraine.

During a check-up, a 22-year-old woman tells the nurse that she uses an over-the-counter nasal spray because of her allergies. She also notes that it does not work as well as it used to when she started using it. The best response by the nurse would be: 1. "You should never use over-the-counter nasal sprays because of the risk of addiction." 2. "You should try switching to another brand of medication to prevent this problem." 3. "It is important to keep using this spray to keep your allergies under control." 4. "Using these nasal medications irritates the lining of the nose and may cause rebound swelling."

ANS: 4 Misuse of over-the-counter nasal medications irritates the mucosa, causing rebound swelling, a common problem.

A 30-year-old woman with a history of mitral valve problems states that she has been "very tired." She has started waking up at night and feels like her "heart is pounding." During the assessment, the nurse palpates a thrill and lift at the fifth left intercostal space midclavicular line. In the same area the nurse also auscultates a blowing, swishing sound right after S1. These findings would be most consistent with: 1. heart failure. 2. aortic stenosis. 3. pulmonary edema. 4. mitral regurgitation.

ANS: 4 Mitral regurgitation subjective findings include fatigue, palpitation, and orthopnea. Objective findings are (1) a thrill in systole at apex, (2) lift at apex, (3) apical impulse displaced down and to the left, (4) S1 diminished, S2 accentuated, S3 at apex often present, and (5) murmur: pansystolic, often loud, blowing, best heard at apex, radiating well to the left axilla.

The nurse is aware that the four areas in the body where lymph nodes are accessible are the: 1. head, breasts, groin, and abdomen. 2. arms, breasts, inguinal area, and legs. 3. head and neck, arms, breasts, and axillae. 4. head and neck, arms, inguinal area, and axillae.

ANS: 4 Nodes are located throughout the body, but are accessible to examination only in four areas: head and neck, arms, axillae, and inguinal region.

Which of the following is true in relation to a newborn infant? 1. The sphenoid sinuses are full size at birth. 2. The maxillary sinuses reach full size after puberty. 3. The frontal sinuses are fairly well developed at birth. 4. The maxillary and ethmoid sinuses are the only ones present at birth.

ANS: 4 Only the maxillary and ethmoid sinuses are present at birth.

Which of the following is a risk factor for ear infections in young children? 1. Family history 2. Air conditioning 3. Excessive cerumen 4. Secondhand cigarette smoke

ANS: 4 Passive or second hand smoke is a risk factor for ear infections.

The mother of a 2-year-old is concerned about the upcoming placement of tympanostomy tubes in her son's ears. The nurse would include which of the following in the teaching plan? 1. The tubes are placed in the inner ear. 2. The tubes are used in children with sensorineural loss. 3. The tubes are permanently inserted during a surgical procedure. 4. The purpose of the tubes is to decrease the pressure and allow for drainage.

ANS: 4 Polyethylene tubes are inserted surgically into the eardrum to relieve middle ear pressure and promote drainage of chronic or recurrent middle ear infections. Tubes extrude spontaneously in 6 months to 1 year.

While obtaining a history from the mother of a 1-year-old, the nurse notices that the baby has had a bottle in his mouth the entire time. The mother states, "it makes a great pacifier." The best response by the nurse would be: 1. "You're right, bottles make very good pacifiers." 2. "Use of a bottle is better for the teeth than thumb sucking." 3. "It's okay to do this as long as the bottle contains milk and not juice." 4. "Prolonged use of a bottle can increase the risk for tooth decay and ear infections."

ANS: 4 Prolonged use of a bottle during the day or when going to sleep places the infant at risk for tooth decay and middle ear infections.

Which of the following statements concerning the eustachian tube is true? 1. It is responsible for the production of cerumen. 2. It remains open except when swallowing or yawning. 3. It allows passage of air between the middle and outer ear. 4. It helps equalize air pressure on both sides of the tympanic membrane.

ANS: 4 The eustachian tube allows equalization of air pressure on each side of the tympanic membrane so that the membrane does not rupture (e.g., during altitude changes in an airplane). The tube is normally closed, but it opens with swallowing or yawning.

The tissue that connects the tongue to the floor of the mouth is the: 1. uvula. 2. palate. 3. papillae. 4. frenulum.

ANS: 4 The frenulum is a midline fold of tissue that connects the tongue to the floor of the mouth.

The mother of a 2-year-old is concerned because her son has had three ear infections in the past year. What would be an appropriate response by the nurse? 1. "It is unusual for a small child to have frequent ear infections unless there is something else wrong." 2. "We need to check the immune system of your son to see why he is having so many ear infections." 3. "Ear infections are not uncommon in infants and toddlers because they tend to have more cerumen in the external ear." 4. "Your son's eustachian tube is shorter and wider than yours because of his age, which allows for infections to develop more easily."

ANS: 4 The infant's eustachian tube is relatively shorter and wider, and its position is more horizontal than the adult's, so it is easier for pathogens from the nasopharynx to migrate through to the middle ear.

In an individual with otitis externa, which of the following signs would the nurse expect to find on assessment? 1. Rhinorrhea 2. Periorbital edema 3. Pain over the maxillary sinuses 4. Enlarged superficial cervical nodes

ANS: 4 The lymphatic drainage of the external ear flows to the parotid, mastoid, and superficial cervical nodes. The signs are severe swelling of the canal, inflammation, and tenderness.

The mother of a 3-month-old states that her daughter has not been gaining weight. With further questioning, the nurse finds that the infant falls asleep after nursing and wakes up after a short amount of time, hungry again. What other information would the nurse want to have? 1. The position that baby sleeps in 2. Sibling history of eating disorders 3. Amount of background noise when eating 4. Presence of dyspnea or diaphoresis when sucking

ANS: 4 To screen for heart disease in an infant, focus on feeding. Note fatigue during feeding. Infant with heart failure takes fewer ounces each feeding, becomes dyspneic with sucking, may be diaphoretic and then falls into exhausted sleep and awakens after a short time hungry again.

Which of the following best describes what is meant by atrial kick? 1. The atria contract during systole and attempt to push against closed valves. 2. The contraction of the atria at the beginning of diastole can be felt as a palpitation. 3. This is the pressure exerted against the atria as the ventricles contract during systole. 4. The atria contract toward the end of diastole and push the remaining blood into the ventricles.

ANS: 4 Toward the end of diastole, the atria contract and push the last amount of blood (about 25% of stroke volume) into the ventricles. This active filling phase is called presystole, or atrial systole, or sometimes the "atrial kick."

The nurse is taking the history of a patient who may have a perforated eardrum. What would be an important question in this situation? 1. "Do you ever notice ringing or crackling in your ears?" 2. "When was the last time you had your hearing checked?" 3. "Have you ever been told you have any type of hearing loss?" 4. "Was there any relationship between the ear pain and the discharge you mentioned?"

ANS: 4 Typically with perforation, ear pain occurs first, stopping with a popping sensation, and then drainage occurs.

A patient visits the clinic because he has recently noticed that the left side of his mouth is paralyzed. He states that he cannot raise his eyebrow or whistle. The nurse suspects that he has: 1. Cushing's syndrome. 2. Parkinson's syndrome. 3. Bell's palsy. 4. had a cerebrovascular accident (stroke).

ANS: 4 With an upper motor neuron lesion (as with CVA) the patient will have paralysis of lower facial muscles, but the upper half of the face is not affected owing to the intact nerve from the unaffected hemisphere. The person is still able to wrinkle the forehead and close the eyes.

A 72-year-old patient has a history of hypertension and chronic lung disease. An important question for the nurse to include in the history would be: 1. "Do you use a fluoride supplement?" 2. "Have you had tonsillitis in the last year?" 3. "At what age did you get your first tooth?" 4. "Have you noticed any dryness in your mouth?"

ANS: 4 Xerostomia (dry mouth) is a side effect of many drugs used by older people: antidepressants, anticholinergics, antispasmodics, antihypertensives, antipsychotics, bronchodilators.

The nurse is preparing for a certification course in skin care and needs to be familiar with the various lesions that may be identified on assessment of the skin.. Which of the following definitions are correct? Select all that apply. a. Petechiae: Tiny punctate hemorrhages, 1 to 3 mm, round and discrete, dark red, purple, or brown in color b. Bulla: Elevated, circumscribed lesion filled with turbid fluid (pus) c. Papule: Hypertrophic scar d. Vesicle: Known as a friction blister e. Nodule: Solid, elevated, and hard or soft growth that is larger than 1 cm

ANS: A, D, E A pustule is an elevated, circumscribed lesion filled with turbid fluid (pus). A hypertrophic scar is a keloid. A bulla is larger than 1 cm and contains clear fluid. A papule is solid and elevated but measures less than 1 cm.

The nurse suspects that a patient has appendicitis. Which of these procedures are appropriate for use when assessing for appendicitis or a perforated appendix? Select all that apply. a. Test for the Murphy sign b. Test for the Blumberg sign c. Test for shifting dullness d.. Perform the iliopsoas muscle test e. Test for fluid wave

ANS: B, D Testing for the Blumberg sign (rebound tenderness) and performing the iliopsoas muscle test should be used when assessing for appendicitis. The Murphy sign is used when assessing for an inflamed gallbladder or cholecystitis. Testing for a fluid wave and shifting dullness is performed when assessing for ascites.

A patient has been admitted to a hospital after the staff in the nursing home noticed a pressure ulcer in his sacral area. The nurse examines the pressure ulcer and determines that it is a stage II ulcer. Which of these findings are characteristic of a stage II pressure ulcer? Select all that apply. a. Intact skin appears red but is not broken. b.. Partial thickness skin erosion is observed with a loss of epidermis or dermis. c. Ulcer extends into the subcutaneous tissue. d. Localized redness in light skin will blanch with fingertip pressure. e. Open blister areas have a red-pink wound bed. f. Patches of eschar cover parts of the wound.

ANS: B, E Stage I pressure ulcers have intact skin that appears red but is not broken, and localized redness in intact skin will blanche with fingertip pressure. Stage II pressure ulcers have partial thickness skin erosion with a loss of epidermis or also the dermis; open blisters have a red-pink wound bed. Stage III pressure ulcers are full thickness, extending into the subcutaneous tissue; subcutaneous fat may be seen but not muscle, bone, or tendon. Stage IV pressure ulcers involve all skin layers and extend into supporting tissue, exposing muscle, bone, and tendon. Slough (stringy matter attached to the wound bed) or eschar (black or brown necrotic tissue) may be present.

The nurse is assessing a patient's pulses and notices a difference between the patient's apical pulse and radial pulse. The apical pulse was 118 beats per minute; the radial pulse was 105 beats per minute. Calculate the pulse deficit. Pulse deficit equals: _________

ANS: The pulse deficit equals 13 beats per minute.

A 19-year-old college student is brought to the emergency department with a severe headache he describes as "Like nothing I've ever had before." His temperature is 104° F, and he has a stiff neck. What do these signs and symptoms suggest? 1. Head injury 2. Cluster headache 3. Migraine headache 4. Meningeal inflammation

ANS:4 Acute onset of neck stiffness and pain along with headache and fever occurs with meningeal inflammation. A severe headache in an adult or child who has never had it before is a red flag.

COPD - S&S

AP = transverse diameter or "barrel chest" Sit in a tripod position (leaning forward with arms braced on knees or chair) Neck muscles are hypertrophied Paradoxical pulse Clubbing of distal phalanx Decreased breath sounds & expiratory wheeze Accessory muscle use

Dysmenorrhea

Abdominal cramping and pain associated with menstruation

Cranial Nerve VI

Abducens Motor Function: Lateral movement of the eye

How does cranial nerve VI regulate eye movement?

Abducts the eye. (The ABDUCens nerve ABDUCts the eye.)

Endometriosis

Aberrant growths of endometrial tissue scattered throughout pelvis

Peripheral Neuropathy

Abnormal Finding for Vibration Test Is worse at the feet and gradually improves as you move up the leg.

Peripheral neuropathy

Abnormal Finding for Vibration Test Is worse at the feet and gradually improves as you move up the leg.

Gynecomastia

Abnormal development of breast tissue in males

Summation Gallop

Abnormal mid-diastolic heart sound heard when both the pathologic S3 and S4 sounds are present.

Exophthalmos

Abnormal protrusion of eye

hyperreflexia

Abnormally increased reflexes resulting from nervous system damage (stroke)

When does milk come in?

About 1 to 3 days after baby is born.

The normal size of apical impulse

About 2 cm

Flight of ideas

Abrupt change, rapid skipping from topic to topic, practically continuous flow of accelerated speech; topics usually have recognizable associations or are plays on words. ex: take this pill? this pill is blue. i feel blue. She wore blue velvet.

Amenorrhea

Absence of menstruation; termed secondary amenorrhea when menstration has begun and then cease; most common cause is pregnancy

Paralysis

Absence of strength secondary to nervous impairment

Adnexa

Accessory organ of the uterus (i.e.; ovaries and fallopian tubes)

VIsceral Pain

Aching, Poorly localized, Often accompanied by autonomic responses (vomiting, nausea, pallor, diaphoresis)

Cranial Nerve VIII

Acoustic Sensory Function: Hearing and equilibrium

Angina Pectoris

Acute chest pain that occurs when myocardial demand exceeds its oxygen supply

Angina pectoris

Acute chest pain that occurs when myocardial demand exceeds the oxygen supply

Delirium

Acute confusional state. Characterized by disorientation, disordered thinking and perceptions, defective memory, agitation and inattention.

Effects of prolonged bottle and pacifier use

Acute otitis media (ear infections)

When evaluating a patient's pain, the nurse knows that an example of acute pain would be: A) arthritic pain. B) fibromyalgia. C) kidney stones. D) low back pain.

Acute pain is short-term and dissipates after an injury heals, such as with kidney stones. The other conditions are examples of chronic pain where the pain continues for 6 months or longer and does not stop when the injury heals. Points Earned: 1.0/1.0 Correct Answer(s): C

Accommodation

Adaptation of eye for near vision; observed by convergence (motion toward) of axes and pupillary constriction

Proper diets for teenagers

Adolescence presents rapid physical growth and endocrine and hormonal changes. Caloric and protein requirements increase to meet this demand, and because of bone growth and increasing muscle mass (and in girls the onset of menarche), calcium and iron requirements also increase.

Know how to position otoscope for examining ear with adult and child

Adult: Up and Back Child: Down and Back

How to examine the ears

Adults or older child: pull the pinna up and back Infants and child < 3: pull the pinna straight down

Normal factors varying BP

Age- rise thru childhood into adulthood Gender- after puberty females lower Race-black adults higher than whites Diurnal rhythm-daily cycle- BP climbs to high in afternoon and low in morning Weight-higher in obese Exercise-increased activity yields higher BP Emotions- momentarily rises w/ fear, anger, pain Stress-elevated w/ continual tension

Physical Appearances

Age-appears his/her stated age Sex- sex development appropriate for gender/age Level of Conscience-alert & oriented Skin color-tone even,pigmentation, on lesions Facial Features-symmetric w/movement No signs of acute distress present

Other factors that may contribute to Breast Cancer

Alcohol intake, being overweight, and weight gain.

Legal Resident

All persons who were granted lawful permanent residence

What if woman mentions breast lump?

Always check normal breast first to find a baseline of normal consistency

Palpation production of sound

Amplitude (intensity) loud or soft Pitch ( vibrations) high (more) or low (less) pitch Quality (timbre) diff. due to distinct overtones Duration length of time the note lingers

Dehydration

An abnormally low amount of water in the body SKIN: dry, flaky, cracked, parched (esp lips)

Non-Immigrant

An alien who seeks temporary entry to the United States for a specific purpose

Parolee

An alien, appearing to be inadmissible to the inspecting officer, allowed into the United States for urgent humanitarian reasons or when that alien's entry is determined to be for significant public benefit

Aneurysm

An aneurysm that pushes on certain blood vessels in the brain can cause a dilated pupil as well as other symptoms.

Lymphatic System

An extensive vessel system, is major part of immune system, which detects and eliminates foreign substances from body

Hemorrhoids - S&S

An external hemorrhoid starts below the anorectal junction and is covered by anal skin. When thrombosed, it contains clotted blood and becomes a painful, swollen, shiny blue mass that itches and bleeds with defecation. When it resolves, it leaves a painless, flabby skin sac around the anal orifice An internal hemorrhoid starts above the anorectal junction and is covered by mucous membrane. When the person performs a Valsalva maneuver (bearing down), it may appear as a red mucosal mass All hemorrhoids result from increased portal venous pressure: as occurs with straining at stool, chronic constipation, pregnancy, obesity, chronic liver disease, or the low-fiber diet common in Western society

Homan's sign

An indication of incipient or established thrombosis in the leg veins in which slight pain occurs at the back of the knee or calf when, with the knee bent, the ankle is slowly and gently dorsiflexed

Physical communication cues

An open position with extension of large muscle groups shows relaxation, physical comfort, and a willingness to share information. A closed position with arms and legs crossed looks defensive and anxious. Changes in posture during the interview can also suggest a different comfort level with new topics. For example, if your client began the interview in an open posture but immediately assumes a closed posture when asked about his or her sexuality, he or she may be uncomfortable with the new topic.

Weight loss related to illness

An unexplained weight loss may be a sign of a short-term illness (e.g., fever, infection, disease of the mouth or throat) or a chronic illness (e.g., endocrine disease, malignancy, depression, anorexia nervosa, bulimia).

When your doctor examines your pupils, he or she will first look for anisocoria. What is anisocoria?

Anisocoria is a condition in which your pupil sizes are unequal. Twenty percent of the general population has normal anisocoria and does not signal anything abnormal. In some cases, however, unequal pupil sizes can be a symptom of disease

Irritability

Annoying, easily provoked, impatient.

Polycyclyic

Annular lesions grow together

Epitrochlear nodes location and why assess

Anticubital fossa and drains to hand/lower arm WHY? Indicates infection of hands/forearm -- generalized lymphadenopathy

Refugee

Any person who is outside his or her country of nationality who is unable or unwilling to return to that country because of persecution or a well-founded fear of persecution

Questions to ask about headaches

Any unusually frequent or severe headaches? When did they start? How often do they occur? Where in your head do you feel the headaches? Do they seem to be associated with anything?

Midline Contains

Aorta-Uterus (female(If enlarged))-Bladder (if distended)

Aortic Regurgitation

Aortic Insufficiency. Incompetent aortic valve that allows backward flow of blood into the left ventricle during diastole.

Symptoms of cocaine use

Appearance: Pupillary dilation, tachycardia or bradycardia, elevated or lowered blood pressure, sweating, chills, nausea, vomiting, weight loss Behavior: Euphoria, talkativeness, hypervigilance, pacing, psychomotor agitation, impaired social or occupational functioning, fighting, grandiosity, visual or tactile hallucinations.

How to assess anxious patients

Appearing unhurried and taking the time to listen to all of the client's concerns can help diffuse some anxiety. Avoiding the traps to interviews and using therapeutic responses are other ways to help diffuse anxiety.

Ultrasonography

Application of ultrasonic waves to visualize subcutaneous body structure such as tendons and organs

What is palpation?

Applies your sense of touch to assess these factors: texture; temperature; moisture; organ location and size; and any swelling, vibration or pulsation, rigidity or spasticity, crepitation, presence of lumps or masses, and presence of tenderness or pain.

Bones of neonatal skull are separated by sutures and fontanels

Are separated by sutures and fontanels, spaces where the sutures intersect

Precordium

Area of the chest wall overlaying the heart and great vessels.

Precordium

Area of the chest wall overlying the heart and great vessels

Frontal Lobe

Areas Concerned with personality, behavior, emotions, and intellectual function. PRECENTRAL GYRUS: Initiates voluntary movement.

Different ways to determine height

Arm span (fingertip to fingertip) = height Body length from crown to pubis is roughly = to that of pubis to sole

Symptoms of cocaine overdose

Arrhythmias. Severe tachycardia. Very high blood pressure. Dangerously high body temperature. Sweating. Nausea. Confusion. Severe anxiety or agitation. Psychosis. Tremors. Seizures. Stroke.

Dysarthria

Articulation disorder. Distorted speech sounds; speech may sound unintelligible; basic language intact.

How to talk to patients about quitting smoking

Ask patients if they smoke, and if they do how much do they smoke. Then ask "have you ever tried to quit?" and "how did it go?" to introduce plans about smoking cessation.

Finger to nose test

Ask the person to close their eyes and to stretch out the arms. Then ask person to touch the tip of their nose with each index finger, alternating hands and increasing speed.

Romberg Test

Ask the person to stand up with feet together and arms at the sides. Once in a stable position, wait 20 seconds. Normal Finding: a person can maintain posture and balance even with visual orienting information blocked, although slight swaying may occur.

Romberg test

Ask the person to stand up with feet together and arms at the sides. Once in a stable position, wait 20 seconds. Normal Finding: a person can maintain posture and balance even with visual orienting information blocked, although slight swaying may occur. AB: (Positive): Loss of balance that occurs when closing the eyes. Occurs with cerebellar ataxia (multiple sclerosis, alcohol intoxication) loss of proprioception and vestibular function

Brief Form McGill Pain Questionnaire

Asks patient to rank a list of DESCRIPTORS in terms of their intensity and to give an OVERALL intensity rating to his or her pain

The Short-Form McGill Pain Questionnaire

Asks the patient to rank a list of descriptors in terms of their intensity and to give an overall intensity rating to his or her pain.

Brief Pain Inventory

Asks the patient to rate the pain within the PAST 24 hours using graduated scales (0-10) with respect to its impact on areas such as mood, walking ability and sleep

Brief Pain Inventory

Asks the patient to rate the pain within the past 24 hours using graduated scales (0-10) with respect to its impact on areas such as mood, walking ability, and sleep.

Tandem walking

Assess balance by asking person to walk a straight line in a heel-to-toe fashion. This decreases the base of support and will accentuate any problem with coordination. Normal Finding: The person can walk straight and stay balanced.

Rapid Alternating Movements

Assess coordination by asking person to pat the knees with both hands, lift up, turn hands over and pat knees with the backs of the hands. Then ask them to do it faster. Normal Finding: Done with a equal turning and quick rhythmic pace

How to assess CN V

Assess the muscles of mastication by palpating the temporal and masseter muscles as the person clenches the teeth. Muscles should feel equally strong on both sides. Next try to separate the jaws by pushing down on the chin; normally you can't.

Location of the Tragus nerve

At the temporal mandibular joint

How long does breast development take?

Average 3 years, but range is from 1.5 to 6 years, pubic hair develops and axillary hair appears 2 years after onset of pubic hair.

Timing of menses?

Average of 12 years for African American, average of 13 years for White girls.

Prostate gland age to assess, PSA

Average risk: 50 yo Higher risk (A/A, Hx): 45 yo

Tail of Spence

Axillary breast tissue (most common site of breast cancer)

Other breast changes in aging women?

Axillary hair decreases. Lactiferous ducts are more palpable and feel firm because of fibrosis and calcification.

37. While inspecting a patient's breasts, the nurse finds that the left breast is slightly larger than the right with the presence of Montgomery's glands bilaterally. The nurse should: A) palpate over the Montgomery's glands, checking for drainage. B) consider these normal findings and proceed with the examination. C) ask extensive history questions regarding the woman's breast asymmetry. D) continue with examination and then refer the patient for further evaluation of the Montgomery's glands.

B) consider these normal findings and proceed with the examination.

42. During a breast examination on a female patient, the nurse notices that the nipple is flat, broad, and fixed. The patient states it "started doing that a few months ago." This finding suggests: A) dimpling. B) a retracted nipple. C) nipple inversion. D) deviation in nipple pointing.

B. A retracted nipple

Prevention is the best policy for treating traumatic brain injuries (TBI). The age group with the highest incidents of hospitalization and death from TBI are: A. Children, age 0 to 4 B. Adolescents, age 15 to 19 C. Adults, age 65 and older D. Older adults, age 75 and older

B. Adolescents, age 15 to 19

13. During an examination of a 7-year-old girl, the nurse notices that the girl is showing breast budding. What should the nurse do next? A) Ask her if her periods have started. B) Assess the girl's weight and body mass index (BMI). C) Ask the girl's mother at what age she started to develop breasts. D) Nothing; this is a normal finding.

B. Assess the girls weight and body mass index

21. During an interview, a patient reveals that she is pregnant. She states that she is not sure whether she will breastfeed her baby and asks for some information about this. Which of these statements by the nurse is accurate with regard to breastfeeding? A) "Breastfed babies tend to be more colicky." B) "Breastfeeding provides the perfect food and antibodies for your baby." C) "Breastfed babies eat more often than infants on formula." D) "Breastfeeding is second nature and every woman can do it."

B. Breastfeeding provides the perfect food and anitbodies for your baby.

1. Which of the following statements is true regarding the internal structures of the breast? The breast is: A) mainly muscle, with very little fibrous tissue. B) composed of fibrous, glandular, and adipose tissue. C) composed mostly of milk ducts, known as lactiferous ducts. D) composed of glandular tissue, which supports the breast by attaching to the chest wall.

B. Combosed of fibrous, glandular and adipose tissue

The nurse is assessing a patient's face and neck bilaterally for nerve damage. The patient is unable to differentiate between dull and sharp sensation. The nurse suspects damage to which nerve? Cranial nerve IV: trochlear nerve Cranial nerve V: trigeminal nerve Cranial nerve VII: facial nerve Cranial nerve XI: spinal accessory nerve

B. Cranial nerve V: trigeminal nerve

16. During a breast health interview, a patient states that she has noticed pain in her left breast. The nurse's most appropriate response to this would be: A) "Don't worry about the pain; breast cancer is not painful." B) "I would like some more information about the pain in your left breast." C) "Oh, I had pain like that after my son was born; it turned out to be a blocked milk duct." D) "Breast pain is almost always the result of benign breast disease."

B. I would like some more information about the pain in your left breast.

2. In performing a breast examination, the nurse knows that it is especially important to examine the upper outer quadrant of the breast. The reason for this is that the upper outer quadrant is: A) the largest quadrant of the breast. B) the location of most breast tumors. C) where most of the suspensory ligaments attach. D) more prone to injury and calcifications than other locations in the breast.

B. The location of most breast tumors

4. If a patient reports a recent breast infection, then the nurse should expect to find _____ node enlargement. A) nonspecific B) ipsilateral axillary C) contralateral axillary D) inguinal and cervical

B. ipsilateral axillary

How to determine total body fat

BMI BMI classifications for adults: Underweight < 18.5 kg/m2 Normal weight 18.5 to 24.9 kg/m2 Overweight 25 to 29.9 kg/m2 Obesity (class 1) 30 to 34.9 kg/m2 Obesity (class 2) 35 to 39.9 kg/m2 Extreme obesity (class 3) ≥ 40

Pupil size is determined by.....

Balance between parasympathetic and sympathetic chain of ANS

List at least 5 points to consider when using an interpreter during an interview.

Be aware of differences from patient and interpreter Plan your words Be patient Longer than expected Avoid using family (children)

Allow patients time to answer questions

Be silent and wait for them to reply

Why do you do an abuse assessment screen?

Because domestic abuse is so common

Review abnormal finding with tongue

Beefy red tongue, smooth glossy area, enlargement, dry mouth, deep vertical fissures, saliva excess (drooling)/decreased, lesions, ulcers

Gynecomastia

Benign enlargement of male breast that occurs when peripheral tissues convert androgen hormones to estrogens. Occurs with obesity, cushing syndrom, liver cirrhosis, adreanal disease, hyperthyroidism, and numerous ddrugs.

Fibroadenoma

Benign tumors. Solitary nontender mass that is solid, firm, rubbery, elastic. Round, oval, or lobulated; 1-5 cm. freely movable, slippery, fingers slide easily through tissue.

Responsiveness

Billy of an organism or a system to adjust to changes in conditions

Components of Health History

Biographic data, reason for seeking care, present health or history of present illness, past history, family history, review of systems, functional assessment or activities of daily living

Stool colors

Black: tarry due to ocult blood (melena) from GI bleeding OR non-tarry from iron meds Gray: hepatitis Red: GI bleeding or localized bleeding around anus

Population prone to hypertension

Blacks Dyslipidemia Diabetes mellitus Smokers Gender (men and postmenopausal women) Family history of cardiovascular disease: women < 65 yr or men < 55 yr

Cultural groups that are administered least pain med

Blacks and Hispanics

Epistaxis

Bleeding from nose

Chadwick sign

Bluish discoloration of cervix that occurs normally in pregnancy at 6 to 8 weeks gestation

Base of the heart

Boarder area of the hearts outline located at the 3rd right and left intercostal spaces.

Venous stasis - S&S

Brown discoloration of the skin with irregular borders. Caused by hemosiderin deposits from red blood cell degradation

Clubbing

Bulbous enlargement of distal phalanges of the fingers and toes that occurs with chronic cyanotic heart and lung conditions

What changes are expected to be seen in an aging adult's vital signs

By the 80's and 90's weight and height decreases. Temp: Changes in the body's temperature regulatory mechanism leave the aging person less likely to have fever but at a greater risk for hypothermia. Thus the temperature is a less reliable index of the older person's true health state. Sweat gland activity is also diminished. Pulse: The normal range of heart rate is 50 to 95 beats/min, but the rhythm may be slightly irregular. The radial artery may feel stiff, rigid, and tortuous in an older person, although this condition does not necessarily imply vascular disease in the heart or brain. The increasingly rigid arterial wall needs a faster upstroke of blood, so the pulse is actually easier to palpate. Respiration: Aging causes a decrease in vital capacity and a decreased inspiratory reserve volume. You may note a shallower inspiratory phase and an increased respiratory rate. BP: The aorta and major arteries tend to harden with age. As the heart pumps against a stiffer aorta, the systolic pressure increases, leading to a widened pulse pressure. With many older people, both the systolic and diastolic pressures increase, making it difficult to distinguish expected aging values from abnormal hypertension.

33. A 55-year-old postmenopausal woman is being seen in the clinic for a yearly examination. She is concerned about changes in her breasts that she has noticed over the past 5 years. She states that her breasts have decreased in size and that the elasticity has changed so that her breasts seem "flat and flabby." The nurse's best reply would be: A) "This change occurs most often because of long-term use of bras that do not provide enough support to the breast tissues." B) "This is a normal change that occurs as women get older. It is due to the increased levels of progesterone during the aging process." C) "Decreases in hormones after menopause causes atrophy of the glandular tissue in the breast. This is a normal process of aging." D) "Postural changes in the spine make it appear that your breasts have changed in shape. Exercises to strengthen the muscles of the upper back and chest wall will help to prevent the changes in elasticity and size."

C) "Decreases in hormones after menopause causes atrophy of the glandular tissue in the breast. This is a normal process of aging."

35. During a discussion about breast self-examination with a 30-year-old woman, which of these statements by the nurse is most appropriate? A) "The best time to examine your breasts is during ovulation." B) "Examine your breasts every month on the same day of the month." C) "Examine your breasts shortly after your menstrual period each month." D) "The best time to examine your breasts is immediately before menstruation."

C) "Examine your breasts shortly after your menstrual period each month."

25. During the physical examination, the nurse notices that a female patient has an inverted left nipple. Which statement regarding this is most accurate? A) Normal nipple inversion is usually bilateral. B) A unilateral inversion of a nipple is always a serious sign. C) It should be determined whether the inversion is a recent change. D) Nipple inversion is not significant unless accompanied by an underlying palpable mass.

C) It should be determined whether the inversion is a recent change.

43. A 54-year-old man comes to the clinic with a "horrible problem." He tells the nurse that he has just discovered a lump on his breast and is fearful of cancer. The nurse knows that which statement about breast cancer in males is true? A) Breast masses in men are difficult to detect because of minimal breast tissue. B) Breast cancer in men rarely spreads to the lymph nodes. C) One percent of all breast cancer occurs in men. D) Most breast masses in men are diagnosed as gynecomastia.

C) One percent of all breast cancer occurs in men.

6. A patient contacts the office and tells the nurse that she is worried about her 10-year-old daughter having breast cancer. She describes a unilateral enlargement of the right breast with associated tenderness. She is worried because the left breast is not enlarged. What would be the nurse's best response? A) Tell the mother that breast development is usually fairly symmetric and she should be examined right away. B) Tell the mother that she should bring her daughter in right away because breast cancer is fairly common in preadolescent girls. C) Tell the mother that, although an examination of her daughter would rule out a problem, it is most likely normal breast development. D) Tell the mother that it is unusual for breasts that are first developing to feel tender because they haven't developed much fibrous tissue.

C) Tell the mother that, although an examination of her daughter would rule out a problem, it is most likely normal breast development.

39. While examining a 75-year-old woman, the nurse notices that the skin over her right breast is thickened and the hair follicles are exaggerated. This condition is known as: A) dimpling. B) retraction. C) peau d'orange. D) benign breast disease.

C) peau d'orange.

40. When a breastfeeding mother is diagnosed with a breast abscess, which of these instructions from the nurse is correct? The mother needs to: A) continue to nurse on both sides to encourage milk flow. B) discontinue nursing immediately to allow for healing. C) temporarily discontinue nursing on affected breast and manually express milk and discard it. D) temporarily discontinue nursing on affected breast but can manually express milk and give it to the baby.

C) temporarily discontinue nursing on affected breast and manually express milk and discard it.

15. The nurse is preparing for a class in early detection of breast cancer. Which statement is true with regard to breast cancer in African-American women in the United States? A) Breast cancer is not a threat to African-American women. B) African-American women have a lower incidence of regional or distant breast cancer than white women. C) African-American women are more likely to die of breast cancer at any age. D) Breast cancer incidence in African-American women is higher than that of white women after age 45.

C. African American women are more likely to die of breast cancer at any age

17. During a history interview, a female patient states that she has noticed a few drops of clear discharge from her right nipple. What should the nurse do next? A) Contact the physician immediately to report the discharge. B) Ask her if she is possibly pregnant. C) Ask her some additional questions about the medications she is taking. D) Immediately obtain a sample for culture and sensitivity testing.

C. Ask her some additional questions about the medications she is taking

29. A patient states during the interview that she noticed a new lump in the shower a few days ago. It was on her left breast near her axilla. The nurse should plan to: A) palpate the lump first. B) palpate the unaffected breast first. C) avoid palpating the lump because it could be a cyst, which might rupture. D) palpate the breast with the lump first but plan to palpate the axilla last.

C. Avoid palpating the lump because it could be a cyst, which might rupture

8. A woman is in the family planning clinic seeking birth control information. She states that her breasts "change all month long" and that she is worried that this is unusual. What is the nurse's best response? A) Tell her that it is unusual. The breasts of nonpregnant females usually stay pretty much the same all month long. B) Tell her that it is very common for breasts to change in response to stress and that she should assess her life for stressful events. C) Tell her that, because of the changing hormones during the monthly menstrual cycle, cyclic breast changes are common. D) Tell her that breast changes normally occur only during pregnancy and that a pregnancy test is needed at this time.

C. Tell her that, because of changing hormones during the monthly menstrual cycle, cyclic breast changes are common

30. The nurse has palpated a lump in a female patient's right breast. The nurse documents this as a small, round, firm, distinct, lump located at 2 o'clock, 2 cm from the nipple. It is nontender and fixed. There is no associated retraction of skin or nipple, no erythema, and no axillary lymphadenopathy. Which of these statements reveals the information that is missing from the documentation? It is missing information about: A) the shape of the lump. B) the lump's consistency. C) the size of the lump. D) whether the lump is solitary or multiple.

C. The size of the lump

18. During a physical examination, a 45-year-old woman states that she has had a crusty, itchy rash on her breast for about 2 weeks. In trying to find the cause of the rash, which of these would be important for the nurse to determine? A) Is the rash raised and red? B) Does it appear to be cyclic? C) Where did it first appear—on the nipple, the areola, or the surrounding skin? D) What was she doing when she first noticed the rash, and do her actions make it worse?

C. Where did it first appear-on the nipple, the areola, or the surrounding skin?

31. The nurse is conducting a class about breast self-examination (BSE). Which of these statements indicates proper BSE technique? A) The best time to perform BSE is in the middle of the menstrual cycle. B) The woman needs to do BSE only bimonthly unless she has fibrocystic breast tissue. C) The best time to perform BSE is 4 to 7 days after the first day of the menstrual period. D) If she suspects that she is pregnant, the woman should not perform a BSE until her baby is born.

C. the best time to perform BSE is 4 to 7 days after the first day of the menstrual period

Cranial nerve 7 assessing and abnormal findings

CN 7: Facial (expression, taste)

What conditions can affect pupil size?

CNS disease

Pupil size abnormalities can sometimes signal disease. The following diseases can affect pupil size:

CNS diseases

Right Lower Quadrant Contains

Cecum-Appendix-Right ovary and tube (female)-Right ureter-Right spermatic cord (male)

GETTING STARTED - SUBJECTIVE INFO

Change in texture of skin, hair or nails? Change in energy level, sleep habits, or emotional? Experience palpitations, blurred vision, or change in bowel habits? Past medical history: Previous head or neck problems (trauma, etc) Undergone radiation therapy for a problem in neck region?

Development

Changes an organism goes through during its life

Nurse intuition

Characterized by immediate recognition of patterns; expert practitioners learn to attend to a pattern of assessment data and act without consciously labeling it.

Cushings syndrome

Characterized by weight gain and edema with central trunk and cervical obesity (buffalo hump) and round, plethoric face (moon face).

Initial Pain Assessment

Clinician asks the patient to answer eight questions concerning location, duration, quality, intensity, and aggravating/relieving factors.

The second heart sound is the result of:

Closing of the aortic and pulmonic valves

Choanal Atresia (Co-anal: a-Tray-she-a)

Closure of nasal cavity due to congenital septum between nasal cavity and the pharynx

Clustering data

Cluster or group together the assessment data that appear to be causal or associated. For example, with a person in acute pain, associated data are rapid heart rate, increased BP, and anxiety. Organizing the data into meaningful clusters is slow at first; experienced examiners cluster data more rapidly because they recall proven results of earlier patient situations and recognize the same patterns in the new clinical situation.

Neologism

Coining a new word; invented word has no real meaning except for the person; may condense several words. ex: "I have to turn on my thinkilator."

Scale

Compact, desiccated flaked of skin, dry or greasy. Psoriasis.

Vertigo

Condition of dizziness, "room spinning"

What is conductive hearing loss: examples (permanent or temporary)?

Conductive: mechanical dysfunction (impacted wax, foreign bodies, perforated, pus, serum, otosclerious, etc) Sensorineural: loss pathology of inner ear

Posterior Column Tract

Conducts the sensations of position.

Functions of the Eustachian tube

Connects the middle ear with the nasopharynx and allows passage of air. The tube is normally closed, but it opens with swallowing or yawning. Allows equalization of air pressure on each side of the tympanic membrane so the membrane does not rupture (e.g., during altitude changes in an airplane).

Lacrimal apparatus

Constant irrigation to keep conjunctiva/cornea moist and lubricated; secretes tears

The muscles of the eyes are innervated by three cranial nerves. Name the three nerves.

Cranial nerve VI: Abducens nerve Cranial nerve IV: Trochlear nerve Cranial nerve III: Oculomotor nerve

When observing the optic disc, what are normal findings?

Creamy yellow-orange to pink in color Shape: round or oval Position: NASAL side of the background Edges: distinct

Coronal Sutures

Crowns the head from ear to ear at the union of the frontal and parietal bones. suture between the frontal and parietal bones

5. A 9-year-old girl is in the clinic for a sports physical. After some initial shyness she finally asks, "Am I normal? I don't seem to need a bra yet, but I have some friends who do. What if I never get breasts?" The nurse's best response would be: A) "Don't worry, you still have plenty of time to develop." B) "I know just how you feel, I was a late bloomer myself. Just be patient and they will grow." C) "You will probably get your periods before you notice any significant growth in your breasts." D) "I understand that it is hard to feel different from your friends. Breasts usually develop between 8 and 10 years of age."

D) "I understand that it is hard to feel different from your friends. Breasts usually develop between 8 and 10 years of age."

10. The nurse is teaching a pregnant woman about breast milk. Which statement by the nurse is correct? A) "Your breast milk is present immediately after delivery of the baby." B) "Breast milk is rich in protein and sugars (lactose) but has very little fat." C) "The colostrum, which is present right after birth, does not contain the same nutrition as breast milk does." D) "You may notice a thick, yellow fluid expressed from your breasts as early as the fourth month of pregnancy."

D) "You may notice a thick, yellow fluid expressed from your breasts as early as the fourth month of pregnancy."

28. Which of these clinical situations would the nurse consider to be outside normal limits? A) A patient has had one pregnancy. She states that she believes she may be entering menopause. Her breast examination reveals breasts that are soft and sag slightly. B) A patient has never been pregnant. Her breast examination reveals large pendulous breasts that have a firm, transverse ridge along the lower quadrant in both breasts. C) A patient has never been pregnant. She reports that she should begin her period tomorrow. Her breast examination reveals breast tissue that is nodular and somewhat engorged. She states that the examination was slightly painful. D) A patient has had two pregnancies and she breastfed both of her children. Her youngest child is now 10 years old. Her breast examination reveals breast tissue that is somewhat soft and she has a small amount of thick yellow discharge from both nipples.

D) A patient has had two pregnancies and she breastfed both of her children. Her youngest child is now 10 years old. Her breast examination reveals breast tissue that is somewhat soft and she has a small amount of thick yellow discharge from both nipples.

11. A 65-year-old patient remarks that she just can't believe that her breasts sag so much. She states it must be from lack of exercise. What explanation should the nurse offer her? A) After menopause, only women with large breasts experience sagging. B) After menopause, sagging is usually due to decreased muscle mass within the breast. C) After menopause, a diet that is high in protein will help maintain muscle mass, which keeps the breasts from sagging. D) After menopause, the glandular and fat tissue atrophies, causing breast size and elasticity to diminish, resulting in breasts that sag.

D) After menopause, the glandular and fat tissue atrophies, causing breast size and elasticity to diminish, resulting in breasts that sag.

22. The nurse is reviewing risk factors for breast cancer. Which of these women have risk factors that place them at a higher risk for breast cancer? A) 37 year old who is slightly overweight B) 42 year old who has had ovarian cancer C) 45 year old who has never been pregnant D) 65 year old whose mother had breast cancer

D. 65 year old whose mother had breast cancer

When recording the findings of the lymph glands, a nurse should note all except: A. Size B. Shape C. Consistency D. Color

D. Color

26. The nurse is performing a breast examination. Which of these statements best describes the correct procedure to use when screening for nipple and skin retraction during a breast examination? Have the woman: A) bend over and touch her toes. B) lie down on her left side and notice any retraction. C) shift from a supine position to a standing position; notice any lag or retraction. D) slowly lift her arms above her head and note any retraction or lag in movement.

D. Slowly lift her arms above her head and note any retraction or lag in movement

decorticate rigidity

Decorticate rigidity occurs when there are lesions of the cerebral hemispheres. Damage to the brain occurs above the brainstem and cerebellum (i.e., above the tentorium). There is upper extremity flexion (arms in fetal position) and lower extremity extension.

Eye changes with aging adult: presbyopia

Decrease in ability for lens to change shape to accommodate for near vision

DVT

Deep Vein Thrombosis: formation of a blood clot in a vein CAUSES: inflammation, blocked venous return, cyanosis, edema

Stethoscope bell

Deep hallow cup like shape For soft, low pitched sounds (extra heart sounds or murmurs) Hold lightly against skin

Ulcer

Deeper depression extending into dermis

Hypopituitary dwarfism

Deficiency in growth hormone in childhood results in retardation of growth below the 3rd percentile, delayed puberty, hypothyroidism, and adrenal insufficiency.

Tumor Related Headaches

Definition- Location- Character- Duration- Quantity and severity- Timing- Triggers- Symptoms Treatments

Migraine Headaches

Definition- (HA) of genetically transmitted vascular origin; headache plus prodrome, aura Location-Mainly one-sided but may occur on both sides, behind eyes, temples and forehead. Character- throbbing, pulsating Duration- rapid onset, peaks 1-2 hr, lasts 4-72 hr, maybe longer Quantity and severity- moderate-to-severe pain Timing- 2 per month, last 1-3 days, approx 1in 10 pts have weekly headaches Triggers- hormonal changes, foods, alcohol, caffeine, MSG, nitrates, chocolate, cheese, hunger, letdown after stress, lack of sleep, fragrances, flashing light, exercise, change in weather. Symptoms- blind spots, flashes of lights, vertigo Treatments-lie down, darken room, eyeshade, sleep, avoid opioid

Tension Headaches

Definition- (HA) of musculoskeletal origin, less disabling form of headache Location- usually both sides, across frontal, temporal, and/or occipital region of head: forehead, sides, and back of head Character- band like tightness, viselike nonthrobbing, nonpulsatile Duration- gradual onset, last 30 mins to days Quantity and severity- diffuse, dull aching pain, mild to moderate pain Timing- situational, in response to overwork, posture Triggers- stress, anxiety, depression, poor posture, not worsened by physical activities symptoms- Fatigue, anxiety, stress sensation of band tightness around head, of being gripped like a vice, photophobia or phonophobia Treatments- may include medication (aspirin), heat on tense muscles, or massage and rest

Cluster Headaches

Definition- Intermittent, excruciating, unilateral with autonomic signs. Location- Always one-sided, often behind or around eye, temple, forehead and cheek. Character- continuous, burning, piercing, excruciating Duration- Abrupt onset, peaks in minutes lasts 45-90 minutes Quantity and severity- can occur multiply times a day in clusters lasting weeks, severe stabbing pain Timing-1-2/day, each lasting 1/2 to 2 hrs for 1to 2 months; then remission for months or years. Triggers- alcohol, stress, day time napping, wind or heat exposure. Symptoms- runny nose, nasal congestion, red watery eyes, drooping eye lid Treatment- need to move, pace floors

Knee Bend/Hop in Place

Demonstrates normal position sense, muscle strength and cerebellar function.

Capillary refill

Depress the nail edge to blanch and then release, noting the return of color. This indicates the status of the peripheral circulation. Normally color return is instant or at least within a few seconds in a cold environment. A sluggish color return takes longer than 1 or 2 seconds.

Cutaneous pain

Derived from skin surface and subcutaneous tissues. Cutaneous pain is superficial, sharp, or burning.

cutaneous pain

Derived from the skin surface and subcutaneous tissues.

Superior

Describe the position above or higher than another part of the body proper, also referred as the cranial

Inferior

Describe the position below or lowers then another body part of the body proper, near or toward the tail ( in humans, the coccyx or lowest part of the spinal column ) also referred to as Caudal

Deep

Describes A position farther from the surface of the body

Cranial

Describes a position above or higher then another part of the body proper, also referred to as superior

Distal

Describes a position further from the point of attachment or the trunk of the body

Proximal

Describes a position nearer to the point of attachment or trunk of the body

Dorsal

Describes the back or direction toward the back of the body also referred to as posterior

Posterior

Describes the back or direction toward the back of the body, also referred to as dorsal

Ventral

Describes the front direction toward the front of the body, also referred to as anterior

Anterior

Describes the front or direction toward the front of the body, also referred to as ventral

Medial

Describes the middle or direction toward the middle of the body

Caudal

Describes the position below or lower then another body part proper, near or toward the tail(in humans,the coccyx,or lowest part of the spinal column); also referred to as inferior

Lateral

Describes the side or direction toward the side of the body

Muscles of respiration

Diaphragm Intercostal muscles Forced inspiration/expiration also include the accessory neck muscles and the abdominal muscles.

Parts of a stethoscope and what they do?

Diaphragm - best for high-pitched sounds such as breath, bowel, and normal heart sounds Bell - best for soft, low-pitched sounds such as extra heart sounds or murmurs

Additional history for infants -SUBJECTIVE

Did mother use any alcohol, street drugs? How often Was delivery vaginal, cesarean? any difficulty? Use of forceps? What was told about baby's growth? was everything on schedule?

Dysphagia

Difficulty/Painful swallowing

Most characteristic sign of varicose veins:

Dilated, tortuous superficial bluish vessels

Review abnormal breast findings: Dimpling, fixation, retraction, Peau d'orange and cancer

Dimpling Peau d'orange "pigskin" or orange-peel look Fixation to chest wall/Skin retraction

What are the two types of pupillary light reflexes?

Direct light reflex--the eye is exposed to bright light constricts Consensual light reflex--the opposite eye from the one exposed to the light still constricts

Septum

Divides the airway in the nasal cavity

Cranial cavity

Division of the prostate your year(dorsal) cavity that houses the brain

Thoracic cavity

Divisions of an anterior (ventral)cavity that houses the heart, lungs, esophagus, and trachea

What is Xerosis?

Dry skin

Arterial Ulcers

Due to poor arterial flow, usually on TOES

Atrial Systole Occurs

During Ventricular Diastole

dehydration

During an assessment of a 20-year-old patient with a 3-day history of nausea and vomiting, the nurse notices dry mucosa and deep vertical fissures in the tongue. These findings are reflective of:

Tell the patient this is herpes simplex 1 and will heal in 4-10 days.

During an assessment of a 26 year old at the clinic for "a spot on my lip I think is cancer," the nurse notices a group of clear vesicles with an erythematous base around them located at the lip-skin border. The patient mentions that she just returned from Hawaii. What would be the most appropriate response by the nurse?

Assess for other signs of insufficient oxygen supply.

During an oral assessment of a 30-year-old African-American patient, the nurse notices bluish lips and a dark line along the gingival margin. What would the nurse do in response to this finding?

"Sit up with your head tilted forward and pinch your nose."

During the history, a patient tells the nurse that he has frequent nosebleeds and asks the best way to get them to stop. What would be the nurse's best response?

Cyanosis

Dusky blue mottling of the skin and mucous membrane due to a large decrease of hemoglobin in the blood.

Female internal and external genitalia

EXTERNAL: vulva (pudendum), labia majors (outer lips), labia minora (inner lips), frenulum ("fourchette"- transverse fold), clitoris (erectile body), vestibule (boat-shaped cleft), urethral meatus, Skene (paraurethral) glands, vaginal orifice, hymen, vestibular (Bartholin) glands INTERNAL: vagina, rugae, cervix, squamocolumnar junction, anterior/posterior fornix, rectouterine pouch/cul-de-sac of Douglas, uterus, Fallopian tubes, ovaries

Pagets Disease

Early lesion has unilateral, clear, yellow discharge and dry, scaling crusts, friable at nipple apex. Spreads outward to areola with red halo on areola and crusted retracted nippl.e Red plaque surrounding nipple with bloody discharge when surface is eroded. Symptoms include tingling, burning, itching

Obesity effects

Early onset of breast budding can occur in those with a higher BMI (and early menarche).

Pica

Eating and licking abnormal substances or a depraved appetite craving and eating substances not normally considered nutrients

Ectropion vs. Entropion

Ectropion--loose, lower lid that rolls OUTWARD and does not completely close with the upper eyelid Entropion--a loose, lower lid that rolls INWARD and irritates the eye (the eyelashes consistently rub on the cornea)

The nurse palpates a thrill on the right 2nd/3rd ICS. This may indicate

Either aortic stenosis or systemic hypertension.

What is Raynaud's?

Episodes of abrupt, progressive tricolor change of the fingers in response to cold, vibration, or stress: (1) white (pallor) in top figure from arteriospasm and resulting deficit in supply (2) blue (cyanosis) in lower figure from slight relaxation of the spasm that allows a slow trickle of blood through the capillaries and increased oxygen extraction of hemoglobin (3) finally red (rubor) in heel of hand caused by return of blood into the dilated capillary bed or reactive hyperemia.

What happens to breasts of aging women?

Estrogen and progesterone secretion decreases, which causes breast glandular tissue to atrophy. that is replaced with fibrous connective tissue. decrease breast size, droop and sag. Drooping is accentuated by kyphosis

When to do a mammogram?

Every year at 40 and clinical breast exam, done after menstrual cycle b/c will be softer and less tender, older people breast exam on certain day of each month

Visceral Reflex

Example: Pupillary response to light and accommodation

Euphoria

Excessive well-being; unusually cheerful or elated, which is inappropriate considering physical and mental condition; implies a pathologic mood. ex: "im high" "i feel like im flying." "i feel like im on top of the world."

Broca aphasia

Expressive aphasia. Can understand language but can not express self using language. Characterized by nonfluent, dysarthic, & effortfull speech. Speech is mostly nouns & verbs (agrammatic or telegraphic) Auditory and reading comprehension in tact.

Broca aphasia

Expressive aphasia. The person can understand language but cannot express himself or herself using language. This is characterized by nonfluent, dysarthric, and effortful speech. The speech is mostly nouns and verbs (high-content words) with few grammatic fillers, termed agrammatic or telegraphic speech. Repetition and reading aloud are severely impaired. Auditory and reading comprehensions are surprisingly intact. Lesion is in anterior language area called the motor speech cortex or Broca area.

When the nurse is testing the triceps reflex, what is the expected response?

Extension of the arm

Meth mouth

Extensive dental caries, gingivitis, tooth cracking, and edentulism due to meth abuse

Pallor

Extreme or unnatural paleness

GETTING STARTED - SUBJECTIVE INFO

FHX - Head or neck cancer in family? History of migranes in family? Lifestyle & health practices - Smoke or chew tobacco? Use helmet when riding, etc? Typical posture when relaxing, sleep, work? Recreational activity type Problems with head & neck interfere with ADLs?

Confabulation

Fabricates events to fill in memory gaps.

Prone

Face down

Supine

Face up

Cranial Nerve VII

Facial Motor Function: facial muscles, close eye, labial speech, close mouth Sensory Function: Taste (sweet, salty, sour, bitter) on the anterior 2/3 of the tongue Parasympathetic function-saliva and tear secretion

Behavior

Facial expression-appropriate to situation Mood & affect-comfortable, cooperative,interacts pleasantly Speech-clear & understandable Dress- appropriate to weather, clean, fits, etc... Personal hygiene-clean & groomed appropriately for age, culture, occupation, etc...

Tension headache signs and symptoms

Fatigue Anxiety Stress Sensation of head being squeezed Sometimes photophobia or phonophobia Usually both sides, across frontal, temporal, and/or occipital region of head (forehead, sides, and back of head)

The nurse is assessing a patient in the hospital who has received numerous antibiotics and notices that his tongue appears to be black and hairy. In response to his concern, what would the nurse say? A) "We will need to get a biopsy and see what the cause is." B) "This is an overgrowth of hair and will go away in a few days." C) "This is a fungal infection caused by all the antibiotics you've received." D) "This is probably caused by the same bacteria you had in your lungs."

Feedback: A black, hairy tongue is not really hair but the elongation of filiform papillae and painless overgrowth of mycelial threads of fungus infection on the tongue. It occurs after the use of antibiotics, which inhibit normal bacteria and allow proliferation of fungus. Points Earned: 1.0/1.0 Correct Answer(s): C

A patient tells the nurse that he has noticed that one of his moles has started to burn and bleed. When assessing his skin, the nurse would pay special attention to the danger signs for pigmented lesions and would be concerned with which additional finding? A) Color variation B) Border regularity C) Symmetry of lesions D) Diameter less than 6 mm

Feedback: Abnormal characteristics of pigmented lesions are summarized in the mnemonic ABCD: asymmetry of pigmented lesion, border irregularity, color variation, and diameter greater than 6 mm. Points Earned: 1.0/1.0 Correct Answer(s): A

During an admission assessment, the nurse notices that a male patient has an enlarged and rather thick skull. The nurse suspects acromegaly and would further assess for: A) exophthalmos. B) bowed long bones. C) coarse facial features. D) an acorn-shaped cranium.

Feedback: Acromegaly is excessive secretion of growth hormone that creates an enlarged skull and thickened cranial bones. Patients will have elongated heads, massive faces, prominent noses and lower jaws, heavy eyebrow ridges, and coarse facial features. Exophthalmos is associated with hyperthyroidism. Bowed long bones and an acorn-shaped cranium result from Paget's disease. Points Earned: 1.0/1.0 Correct Answer(s): C

A mother and her 13-year-old daughter express their concern related to the daughter's recent weight gain and increase in appetite. Which of these statements represents information the nurse should discuss with them? A) It is necessary to diet and exercise at this age. B) Snacks should be high in protein, iron, and calcium. C) Teenagers who have a weight problem should not be allowed to snack. D) A low-calorie diet is important to prevent the accumulation of fat.

Feedback: After a period of slow growth in late childhood, adolescence is characterized by rapid physical growth and endocrine and hormonal changes. Caloric and protein requirements increase to meet this demand. Because of bone growth and increasing muscle mass (and, in girls, the onset of menarche), calcium and iron requirements also increase. Points Earned: 1.0/1.0 Correct Answer(s): B

The nurse is providing nutrition information to the mother of a 1-year-old child. Which of these statements represents accurate information for this age group? A) It is important to maintain adequate fat and caloric intake. B) The recommended dietary allowances for an infant are the same as for an adolescent. C) At this age the baby's growth is minimal so caloric requirements are decreased. D) The baby should be placed on skim milk to decrease the risk of coronary artery disease when older.

Feedback: Because of rapid growth, especially of the brain, infants and children younger than 2 years should not drink skim or low-fat milk or be placed on low-fat diets—fat (calories and essential fatty acids) is required for proper growth and central nervous system development. Points Earned: 1.0/1.0 Correct Answer(s): A

19. The nurse is performing a middle ear assessment on a 15-year-old patient who has a history of chronic ear infections. When examining the right tympanic membrane, the nurse sees the presence of dense white patches. The tympanic membrane is otherwise unremarkable. It is pearly, with the light reflex at 5 o'clock and landmarks visible. The nurse should: A) refer the patient for the possibility of a fungal infection. B) know that these are scars caused from frequent ear infections. C) consider that these findings may represent the presence of blood in the middle ear. D) be concerned about the ability to hear because of this abnormality on the tympanic membrane

Feedback: Dense white patches on the tympanic membrane are sequelae of repeated ear infections. They do not necessarily affect hearing. Points Earned: 1.0/1.0 Correct Answer(s): B

A patient is unable to differentiate between sharp and dull stimulation to both sides of her face. The nurse suspects: A) Bell's palsy. B) damage to the trigeminal nerve. C) frostbite with resultant paresthesia to the cheeks. D) scleroderma.

Feedback: Facial sensations of pain or touch are mediated by cranial nerve (CN) V, which is the trigeminal nerve. Bell's palsy is associated with CN VII damage. Frostbite and scleroderma are not associated this problem. Points Earned: 1.0/1.0 Correct Answer(s): B

During an assessment of the sclera of an African-American patient, the nurse would consider which of these an expected finding? A) Yellow fatty deposits over the cornea B) Pallor near the outer canthus of the lower lid C) Yellow color of the sclera that extends up to the iris D) The presence of small brown macules on the sclera

Feedback: In dark-skinned people, one normally may see small brown macules in the sclera. Points Earned: 0.0/1.0 Correct Answer(s): D

An Inuit visiting Nevada from Anchorage has come to the clinic in July during the hottest part of the day. It so happens that the clinic's air conditioning is broken and the temperature is very hot. The nurse knows that which of these statements is true about the Inuit sweating tendencies? A) They will sweat profusely all over their bodies because they are not used to the hot temperatures. B) They don't sweat because their apocrine glands are less efficient in hot climates. C) They will sweat more on their faces and less on their trunks and extremities. D) There is no difference in their sweating tendencies when compared to other ethnic groups.

Feedback: Inuits have made an interesting environmental adaptation whereby they sweat less than whites on their trunks and extremities but more on their faces. Points Earned: 1.0/1.0 Correct Answer(s): C

The nurse is assessing an obese patient for signs of metabolic syndrome. This condition is diagnosed when three or more certain risk factors are present. Which of these assessment findings are risk factors for metabolic syndrome? Select all that apply. A) Fasting plasma glucose level less than 100 mg/dL B) Fasting plasma glucose level greater than or equal to 110 mg/dL C) Blood pressure reading of 140/90 mm Hg D) Blood pressure reading of 110/80 mm Hg E) Triglyceride level of 120 mg/dL

Feedback: Metabolic syndrome is diagnosed when three or more of the following risk factors are present: (1) fasting plasma glucose level greater than or equal to 100 mg/dL; (2) blood pressure greater than or equal to 130/85 mm Hg; (3) waist circumference greater than or equal to 40 inches for men and 35 inches for women; (4) high-density lipoprotein cholesterol less than 40 in men and less than 50 in women; and (5) triglyceride levels greater than or equal to 150 mg/dL (ATP III, 2001). Points Earned: 1.0/1.0 Correct Answer(s): B, C

12. A patient complains that while studying for an examination he began to notice a severe headache in the frontotemporal area of his head that is throbbing and is somewhat relieved when he lies down. He tells the nurse that his mother also had these headaches. The nurse suspects that he may be suffering from: A) hypertension. B) cluster headaches. C) tension headaches. D) migraine headaches.

Feedback: Migraine headaches tend to be supraorbital, retro-orbital, or frontotemporal with a throbbing quality. They are of a severe quality and are relieved by lying down. Migraines are associated with family history of migraines. Points Earned: 0.0/1.0 Correct Answer(s): D

The nurse has just completed a lymph node assessment on a 60-year-old healthy female patient. The nurse knows that most lymph nodes in healthy adults are normally: A) shotty. B) not palpable. C) large, firm, and fixed to the tissue. D) rubbery, discrete, and mobile.

Feedback: Most lymph nodes are not palpable in adults. The palpability of lymph nodes decreases with age. Normal nodes feel movable, discrete, soft, and nontender. Points Earned: 1.0/1.0 Correct Answer(s): B

A 31-year-old patient tells the nurse that he has noticed a progressive loss in his hearing. He says that it does seem to help when people speak louder or if he turns up the volume. The most likely cause of his hearing loss is: A) otosclerosis. B) presbycusis. C) trauma to the bones. D) frequent ear infections.

Feedback: Otosclerosis is a common cause of conductive hearing loss in young adults between the ages of 20 and 40 years. Presbycusis is a type of hearing loss that occurs with aging. Trauma and frequent ear infections are not a likely cause of his hearing loss. Points Earned: 0.0/1.0 Correct Answer(s): A

During an admission assessment of a patient with dementia, the nurse assesses for pain because the patient has recently had several falls. Which of these are appropriate for the nurse to assess in a patient with dementia? Select all that apply. A) Ask the patient, "Do you have pain?" B) Assess the patient's breathing independent of vocalization. C) Note whether the patient is calling out, groaning, or crying. D) Have the patient rate pain on a 1 to 10 scale. E) Observe the patient's body language for pacing and agitation.

Feedback: Patients with dementia may say "no" when, in reality, they are very uncomfortable because words have lost their meaning. Patients with dementia become less able to identify and describe pain over time, even though pain is still present. People with dementia communicate pain through their behaviors. Agitation, pacing, and repetitive yelling may indicate pain and not a worsening of the dementia. See Figure 10-10 for the Pain Assessment in Advanced Dementia (PAINAD) Scale, which may also be used to assess pain in persons with dementia. Points Earned: 1.0/1.0 Correct Answer(s): B, C, E

While obtaining a history from the mother of a 1 year old, the nurse notices that the baby has had a bottle in his mouth the entire time. The mother states, "It makes a great pacifier." The best response by the nurse would be: A) "You're right, bottles make very good pacifiers." B) "Use of a bottle is better for the teeth than thumb sucking." C) "It's okay to do this as long as the bottle contains milk and not juice." D) "Prolonged use of a bottle can increase the risk for tooth decay and ear infections."

Feedback: Prolonged bottle use during the day or when going to sleep places the infant at risk for tooth decay and middle ear infections. Points Earned: 1.0/1.0 Correct Answer(s): D

A patient states that the pain medication is "not working" and rates his postoperative pain at a 10 on a 1 to 10 scale. Which of these assessment findings indicates an acute pain response to poorly controlled pain? A) Confusion B) Hyperventilation C) Increased blood pressure and pulse D) Depression

Feedback: Responses to poorly controlled acute pain include tachycardia, elevated blood pressure, and hypoventilation. Confusion and depression are associated with poorly controlled chronic pain. See Table 10-1. Points Earned: 1.0/1.0 Correct Answer(s): C

A patient comes into the clinic complaining of facial pain, fever, and malaise. On examination, the nurse notes swollen turbinates and purulent discharge from the nose. The patient also complains of a dull, throbbing pain in his cheeks and teeth on the right side and pain when the nurse palpates the areas. The nurse recognizes that this patient has: A) posterior epistaxis. B) frontal sinusitis. C) maxillary sinusitis. D) nasal polyps.

Feedback: Signs of maxillary sinusitis include facial pain, after upper respiratory infection, red swollen nasal mucosa, swollen turbinates, and purulent discharge. The person also has fever, chills, and malaise. With maxillary sinusitis, dull throbbing pain occurs in cheeks and teeth on the same side, and pain with palpation is present. With frontal sinusitis, pain is above the supraorbital ridge. Points Earned: 1.0/1.0 Correct Answer(s): C

A 40-year-old woman reports a change in mole size, accompanied by color changes, itching, burning, and bleeding over the past month. She has a dark complexion and has no family history of skin cancer, but she has had many blistering sunburns in the past. The nurse would: A) tell the patient to watch the lesion and report back in 2 months. B) refer the patient because of the suspicion of melanoma on the basis of her symptoms. C) ask additional questions regarding environmental irritants that may have caused this condition. D) suspect that this is a compound nevus, which is very common in young to middle-aged adults.

Feedback: The ABCD danger signs of melanoma are asymmetry, border irregularity, color variation, and diameter. In addition, individuals may report a change in size, development of itching, burning, bleeding, or a new-pigmented lesion. Any of these signs raise suspicion of malignant melanoma and warrant immediate referral. Points Earned: 1.0/1.0 Correct Answer(s): B

A colleague is assessing an 80-year-old patient who has ear pain and asks him to hold his nose and swallow. The nurse knows that which of the following is true concerning this technique? A) This should not be used in an 80-year-old patient. B) This technique is helpful in assessing for otitis media. C) This is especially useful in assessing a patient with an upper respiratory infection. D) This will cause the eardrum to bulge slightly and make landmarks more visible.

Feedback: The eardrum is flat, slightly pulled in at the center, and flutters when the person performs the Valsalva maneuver or holds the nose and swallows (insufflation). One may elicit these maneuvers to assess drum mobility. However, these maneuvers should be avoided with an aging person because they may disrupt equilibrium. Points Earned: 1.0/1.0 Correct Answer(s): A

The primary purpose of the ciliated mucous membrane in the nose is to: A) warm the inhaled air. B) filter out dust and bacteria. C) filter coarse particles from inhaled air. D) facilitate movement of air through the nares.

Feedback: The nasal hairs filter the coarsest matter from inhaled air, whereas the mucous blanket filters out dust and bacteria. The rich blood supply of the nasal mucosa warms the inhaled air. Points Earned: 1.0/1.0 Correct Answer(s): B

A newborn infant is in the clinic for a well-baby check. The nurse observes the infant for the possibility of fluid loss because of which of these factors? A) Subcutaneous fat deposits are high in the newborn. B) Sebaceous glands are overproductive in the newborn. C) The newborn's skin is more permeable than that of the adult. D) The amount of vernix caseosa rises dramatically in the newborn

Feedback: The newborn's skin is thin, smooth, and elastic and is relatively more permeable than that of the adult, so the infant is at greater risk for fluid loss. The subcutaneous layer in the infant is inefficient, not thick, and the sebaceous glands are present but decrease in size and production. Vernix caseosa is not produced after birth. Points Earned: 1.0/1.0 Correct Answer(s): C

When examining the nares of a 45-year-old patient who has complaints of rhinorrhea, itching of the nose and eyes, and sneezing, the nurse notices the following: pale turbinates, swelling of the turbinates, and clear rhinorrhea. Which of these conditions is most likely the cause? A) Nasal polyps B) Acute sinusitis C) Allergic rhinitis D) Acute rhinitis

Feedback: With allergic rhinitis, rhinorrhea, itching of the nose and eyes, and sneezing are present. On physical examination, there is serous edema, and the turbinates usually appear pale with a smooth, glistening surface. See Table 16-1 for descriptions of the other conditions. Points Earned: 1.0/1.0 Correct Answer(s): C

During an examination, the nurse notices that the patient stumbles a bit while walking, and, when she sits down, she holds on to the sides of the chair. The patient states, "It feels like the room is spinning!" The nurse notices that the patient is experiencing: A) objective vertigo. B) subjective vertigo. C) tinnitus. D) dizziness.

Feedback: With objective vertigo, the patient feels like the room spins; with subjective vertigo, the person feels like he or she is spinning. Tinnitus is a sound that comes from within a person; it can be a ringing, crackling, or buzzing sound. It accompanies some hearing or ear disorders. Dizziness is not the same as true vertigo; the person who is dizzy may feel unsteady and lightheaded. Points Earned: 1.0/1.0 Correct Answer(s): A

pulse force

Force shows the strength of the heart's stroke volume. "weak thready" pulse reflects a decreased SV (i.e. occurs with hemorrhagic shock) "full, bounding" pulse denotes increased SV: anxiety, exercise, and some abnormal conditions. Recorded using a three-point scale: 3+ full, bounding 2+ normal 1+ weak, thready 0 absent Scale is somewhat subjective

Uvula

Free projection hanging down from the middle of the soft palate

How to assess a heart murmur

Frequency or pitch: described as high pitched or low pitched Intensity or loudness: loud or soft Location: describe the area of maximum intensity of the murmur by noting the valve area or intercostal spaces. Duration: very short for heart sounds; silent periods are longer Timing: systole or diastole and whether it obscures or muffles the heart sounds

How do you palpate the sinus areas? •

Frontal and Maxillary Sinuses- • Using your thumbs, press the frontal sinuses by pressing up and under the eyebrows and over the MAXILLARY sinuses below the cheekbones. Take care not to press directly on the eyeballs. Normally, the person should feel firm pressure but no pain. . • Sinus areas are tender to palpation in persons with chronic allergies and acute infection (sinusitis).

Fourth heart sound (S4)

Gallop, atrial gallop, very soft, low pitched ventricular filling sound that occurs in late diastole.

Review of Systems

General overall health state, Skin, Hair, Head, Eyes, Ears, Nose and Sinuses, Mouth and throat, Neck, Breast, Axilla, Respiratory system, Cardiovascular, Peripheral vascular, Gastrointestinal, Urinary System, Male genitals, Female genitals, Sexual Health, Musculoskeletal system, Neurologic system, Hematologic system, Endocrine system

What to do with abnormal breath sounds

Get verification of what you're hearing and have an expert listen.

What are breasts composed of?

Glandular tissue(15-20 lobes that contain alveoli which produce milk), fibrous tissue connecting ligaments, and adipose tissue.

Medications affect on pupils

Glaucoma and antihistamines can sometimes cause *dilated pupils*

Cranial Nerve IX

Glossopharyngeal Motor Function-pharynx including swallowing and phonation Sensory Function- taste on posterior one-third of the tongue, pharynx (gag reflex)

Nursing Model

Gordon's Functional Health Patterns

Organ system

Group of organs that work together to carry out a particular function

Tissue

Group of similar are closely related cells that act together there to perform at Specific function

Infants and children facial bones

Grow at varying rate, esp nasal and jaw. In toddler the mandible and maxilla are small and the nasal bridge is low thus the whole face seems small compared to the skull

Developmental History for children

Growth, Milestones, Current development (children 1-preschool)

Acute Pain Behaviors

Guarding, grimacing, moaning, agitation, stillness, diaphoresis, change in vital signs

Sport Concussion-Signs and Symptoms

HA/pressure nausea/vomiting Sensitivity to light and/or coordination Changes in memory, judgment, and/or speech Sleep pattern changes Can arise quickly or be delayed - appearing days later Most people sx disappear in about 10 days but for some the effects can linger.

Constipation in the elderly

Happens often because they don't absorb nutrients

Spinothalmic tract

Has sensory fibers that transmit the sensations of pain, temperature, and light touch

During fetal period, head growth predominates;

Head size is greater than chest circumference at birth and reaches 90% of final size at 6 years old

Assessment sequence

Head to toe

Bradycardia

Heart rate less than 50 beats per minute in the adult

Diastole

Heart's filling phase

Negative feedback

Hello static mechanism that tends to stabilize and upset in the bodies phychological condition by preventing and excessive response to a stimulus, typically as the stimulus is removed

Subjective Data

How do you behave when you are in pain?

Subjective Data

How much pain do you have?

S = Severity scale

How severe is the pain on a scale of 0 to 10, with zero being no pain and 10 being the worst pain ever? Does it interfere with activities? How bad is it at its worst? Does it force you to sit down, lie down, slow down? How long does an episode last?

Naturalistic theory

Human life is only one aspect of nature and a part of the general order of the cosmos. These people believe that the forces of nature must be kept in natural balance or harmony.

The neck is contained within are the:

Hyoid bone Major blood Vessels Larynx Trachea Thyroid gland

Cranial Nerve XII

Hypoglossal Motor Function: Movement of the tongue

5 phases of Korotkoff's sounds

I - Tapping- soft clear increasing intensity II - Swooshing - soft murmur follows tapping III - Knocking - crisp high pitched sound IV - Abrupt muffling- mutes to low-pitched cushioned murmur; blowing quality V- Silence

Set point

I deal value for physiological parameter, the level or small range within which of physiological perimeter such as blood pressure is stable and optimally helpful, that is, with in its parameters of homeostasis

Can you palpate the thyroid in the normal adult? •

If the person has a long, thin neck, you sometimes will feel the isthmus over the tracheal rings. The lateral lobes usually are not palpable; check them for enlargement, consistency, symmetry, and the presence of nodules.

Test for scoliosis

If you suspect a spinal curvature during inspection, this may be more clearly seen when the person touches the toes. While the person is bending over, mark a dot on each spinous process. When the person resumes standing, the dots should form a straight vertical line. If the dots for a slight S-shape when the person stands, a spinal curve is present.

Plane

Imaginary two dimensional surface that passes through the body

Midclavicular Line (MCL)

Imaginary vertical line bisecting the middle of the clavicle in each hemithorax.

Echolalia

Imitation, repeats others words or phrases, often with mumbling, mocking, or mechanical tone.

Recognize this is a situation that requires immediate intervention.

Immediately after birth, the nurse is unable to suction the nares of a newborn. An attempt is made to pass a catheter through both nasal cavities with no success. What should the nurse do next?

Aging adult hearing changes and causes

Impacted wax

Impaired judgement

Impaired judgment (unrealistic or impulsive decisions, wish fulfillment) occurs with mental retardation, emotional dysfunction, schizophrenia, and organic brain disease.

neuropathic pain

Implies an abnormal processing of the pain message. The most difficult to asses and treat.

Wernicke's area

In Temporal lobe Associated with language comprehension. When damaged, receptive aphasia results meaning the person hears sound, but it has no meaning (Like hearing a foreign language)

Section

In anatomy, a single flat surface of a three-dimensional structure that has been cut through

Nothing, because this is the appearance of normal tonsils

In assessing the tonsils of a 30 year old, the nurse notices that they are involuted, granular in appearance, and appear to have deep crypts. What is the correct response to these findings?

When does menarche occur?

In breast stage 3 or 4 just after about 12 y/o.

Broca's area

In frontal lobe, mediates motor speech. When injured, expressive aphasia results meaning the person cannot talk. (Can understand language and know what he or she wants to say but can produce it)

Location of the parotid glands

In the cheeks over the mandible, anterior to and below the ear.

Word salad

Incoherent mixture of words, phrases, and sentences; illogical, disconnected, includes neologisms.

LVH, Left Ventricular Hypertrophy

Increase in thickness of myocardial wall that occurs when the heart pumps against chronic outflow obstruction. Aortic Stenosis

Left ventricular hypertrophy (LVH)

Increase in thickness of myocardial wall that occurs when the heart pumps against the chronic outflow obstruction (aortic stenosis)

A pulse with amplitude of 3+ is:

Increased and full

GRAVES DISEASE

Increased production of thyroid hormones causes an increased metabolic rate, just like ramping up the furnace. this is manifested by goiter exophthalmos (bulging eye balls). Symptoms include nervousness, fatigue, weight loss, muscle cramps and heat intolerance. Signs include forceful tachycardia; shortness of breath; excessive sweating; fine muscle tremor; thin silky hair; warm, moist skin; infrequent blinking and a staring appearance.

Causes of ear infections

Infant's eustachian tube is relatively shorter and wider and more horizontal than adult's, so it is easier for pathogens from nasopharynx to migrate through to middle ear Lumen surrounded by lymphoid tissue, which increases during childhood and is easily occluded Prolonged bottle use Most important cause is environmental: children in high-risk groups have multiple pathogens and total bacterial load is high (daycare) Passive or gestational smoking

At risk for undernutrition

Infants, children, pregnant women, recent immigrants, people with low incomes, hospitalized people, and aging adults.

Vulvovaginitis in Children

Infection caused by candida albicans in a diabetic child. symptoms=pruritus, burning w/ urine, red, shiny, edematous vulva, discharge. also with infection from respiratory or bowel pathogen, sexually transmitted infection, or foreign body

Causes of hypoactive bowel sounds

Inflammation of the peritoneum (peritonitis) From paralytic ileus as following abdominal surgery Late bowel obstruction Constipation Occurs also with pneumonia

Timing of puberty?

Influenced by genetic and environmental factors. genetics determing 50-80% of variation.

OBJECTIVE INFO-Face

Inspect and Palpate the Face- Facial Structures-expression approp to behavior, symmetric-eyebrows, palpebral fissures, nasolabial folds, and sides of mouth Frontal and Maxillary Sinuses-

OBJECTIVE INFO-Physical exam

Inspect and Palpate the Skull- Size and Shape-round symmetric (normocephalic), shape symmetric and smooth Temporal Area- palpate temporal artery above the Zygomatic (cheek) bone between the eye and top of the ear. TMJ- is just below the temporal artery and anterior to the tragus. palpate as mouth is open, note smooth movement w/ no limitations or tenderness.

Assessment of the sclera and conjunctiva

Inspect for color change, swelling, lesions, or foreign body Should appear moist and glossy Conjunctiva is clear; Sclera is white

Raynaud's Phenomenon

Intermittent attaches of vasoconstriction of the arterioles, pallor cyanosis and redness

Where does 75% of lymphatic drainage go?

Ipsilateral(same side) axillary nodes.

Thyroid cartilage

Is above the cricoid cartilage, with a small palpable notch in its upper edge. "Adams apple" in male

Graphesthesia

Is the ability to "read" a number by having it traced on the skin. With the person's eyes closed, use a blunt instrument to trace a single digit number or a letter on the palm. Ask the person to tell you what it is. This is a Good measure of sensory loss if the person cannot make the hand movements needed for stereognosis.

Cerebral Cortex Function

Is the center for humans highest functions governing thought, memory, reasoning, sensation and voluntary movement.

Cerebral Cortex

Is the cerebrum's outer layer of nerve cell bodies which look like "gray matter" because it lacks myelin

Cerebral Cortex

Is the cerebrum's outer layer of nerve cell bodies which look like "gray matter" because it lacks myelin - center for humans highest functions governing thought, memory, reasoning, sensation and voluntary movement.

Mandible articulate where?

It moves up, down, and sideways from the temporomandibular joint, which is anterior to each ear.

Fissure

LInear crack with abrupt edges extends into denis, dry or moist

Flat affect

Lack of emotional response; no expression of feelings; voice monotonous & face immobile. ex: topic varies, expression does not.

Aphasia

Language comprehension & production secondary to brain damage disorder. True language disturbance; defect in word choice & grammar or defect in comprehension; defect is in higher integrative language processing.

Ventral cavity

Larger body cavity located anterior to the Prost your dorsal body cavity, includes the serious membrane lined plural cavities for the lungs, pericardial cavity for the heart, and Pertioneal cavity for the abdominal and pelvic organs come also referred to as the anterior body cavity

Four characteristics of culture?

Learned Shared Adapted Dynamic

Mitral Valve

Left AV valve separating the left atria and ventricle

Mitral Valve

Left Atrioventricular (AV) valve separating the left atrium and ventricle.

Assessing symmetry of testes

Left lower than right

Capillary refill timing

Less than 3 seconds

Breast exam positioning

Lie down

Third pair of salivary glands sublingual glands

Lie in the floor of the mouth.

How to assess bowel sounds

Listen over the RUQ, RLQ, LLQ, and LUQ with your stethoscope. Just note if they are present, hyperactive, or hypoactive. If you don't hear anything, listen for a full 5 minutes.

Auscultating the lungs

Listen to one full respiration with the diaphragm of the stethoscope in each of the lung fields moving from side to side (RU, RM, RL, LU, LL).

Female inspection position

Lithomy, Standing

Right Upper Quadrant

Liver-Gallbladder-Duodenum-Head of Pancreas-Right Kidney and adrenal-Hepatic flexure of colon-Part of Ascending and transverse colon

Right Upper Quadrant Contains

Liver-Gallbladder-Duodenum-Head of Pancreas-Right Kidney and adrenal-Hepatic flexure of colon-Part of Ascending and transverse colon

Organism

Living being that has a cellular structure and that can independently perform all physiologic functions necessary for life

Lifestyle modifications for high BP

Lose weight Limit alcohol Regular exercise Cut sodium Recommended daily potassium, Ca, magnesium Stop smoking Reduce saturated fat and cholesterol

Positive Romberg Sign

Loss of balance that occurs when closing the eyes. Occurs with cerebellar ataxia (multiple sclerosis, alcohol intoxication) loss of proprioception and vestibular function

Depersonalization

Loss of identity;feels estranged, perplexed about own identity and meaning of existence. ex: "I don't feel real." "I feel like I'm not really here."

Paralysis

Loss of motor function due to a lesion in the neurologic or muscular system or loss of sensory innervation

Lung Cancer

Lung cancer that affects the top part of the lung can impact the pupillary nerve fibers.

What do bull's eye pattern wounds mean?

Lyme disease

Lymphatics

Lymph nodes of the head & neck -Size and shape: -< 1cm ,Round -Usually non-palpable -Infectious - enlarged, painful -Cancer - enlarged >3cms, non-painful

Edema (Peau d-Orange)

Lymphatic obstructin produces edema. Thickens the skin and exaggerates hair follices giving a pigskin or orange-peel loo. suggests cancer. Usually begins in the skin around and beneath the areola.No discharge unless lactating or pregnant

Patch

Macules >1cm - *EX: Mongolian spot, Vitiligo, Cafe au lait spot, etc*

Patch

Macules >1cm - mongolian spot, vitiligo, ect.

Liver span

Measure height of liver in the R midclavicular line. Begin at area of lung resonance & percuss down the interspaces until sound changes to dull. Mark spot. Find abdominal tympany and percuss up midclavicular line. Mark where sound changes from tympany to dull- normally at right costal margin. Measure distance between two. Normal- 6-12 cm. Taller ppl have longer livers. Males have larger liver span. Mean 10.5 cm- male, 7 cm- female.

To screen for deep vein thrombosis

Measure the widest point of extremity with a tape measure

Vital signs in infants

Measure vital signs with the same purpose and frequency as you would in an adult. With an infant, reverse the order of vital sign measurement to respiration, pulse, and temperature. Taking a rectal temperature may cause the infant to cry, which will increase the respiratory and pulse rate, thus masking the normal resting values. Temp: Use a rectal temperature, may be supine of side-laying with the examiner's hand flexing the knees up onto the abdomen. An infant also may lie prone across the adult's lap. Separate the buttocks with one hand, and insert the lubricated electronic rectal probe no farther than 1 inch into the rectum. Pulse: Palpate or auscultate an apical rate with infants and toddlers. Count the pulse for a full minute to take into account normal irregularities such as sinus arrhythmia. The heart rate normally fluctuates more with infants and children than with adults in response to exercise, emotion, and illness. Respiration: Watch the infant's abdomen for movement because an infant's respirations are normally more diaphragmatic than thoracic. The sleeping respiratory rate is the most accurate. Count a full minute because the pattern varies significantly from rapid breaths to short periods of apnea. BP: Children younger than 3 years have such small arm vessels that it is difficult to hear Korotkoff sounds with a stethoscope. Instead use an electronic BP device that uses oscillometry, such as Dinamap, and gives a digital readout for systolic, diastolic, and MAP and pulse. Or use a Doppler ultrasound device to amplify the sounds. This instrument is easy to use and can be used by one examiner.

Computed tomography (CT)

Medical imaging technique in which a computer enhance cross-section x-ray image is obtained

Magnetic resonance imaging (MRI)

Medical imaging technique in which a device generates a magnetic field to obtain detailed sectional images of the internal structures of the body

Positron emission tomography (PET)

Medical imaging technique in which radiopharmaceuticals are trace to reveal metabolic and physiological functions in the tissue

Galactorrhea

Medications that my cause clear nipple discharge(oral contraceptives, phenothiazines, diuretics, digitalis, steroids, calcium channel blockers)

Serous membrane

Membrane that covers organs and reduces friction come also referred to as serosa

Serosa

Membrane that covers organs and reduces friction, also referred to as serous membrane

Signs and symptoms of Alzheimer's disease

Memory loss Losing track Forgetting words Getting lost Poor judgement Abstract failing Losing things Mood swings Personality change Growing passive

Aging female reproductive changes

Menopause, vaginal itching/discharge/pain, pressure, loss of urine

Mexican-American illness patterns

Mexican men think that having diarrhea is completely normal.

Mitral regurgitation

Mitral insufficiency. Incompetent mitral valve allows regurgitation of blood back into the left atrium during systole

Mitral Regurgitation

Mitral insufficiency; incompetent mitral valve allows regurgitation of blood back into left atrium during systole.

Social and Environmental Factors

More emotional support → pain is more tolerable

Heave, Lift

More prominent thrust of the heart against the chest wall during systole OCCURS: with ventricular hypertrophy - increased workload SEEN: sternal border, apex

Global aphasia

Most common & sever form. Spontaneous speech is absent or reduced to a few stereotyped words or sounds. Comprehension is absent or reduced to only the person's own name & in a few words. Repetition, reading, writing severely impaired. Poor prognosis for language recovery.

During an assessment of the cranial nerves, the nurse finds the following; lack of blinking in the right eye with corneal reflex, intact ability to sense light touch on face, loss of movement with facial features on the right side. This would indicate dysfunction of which cranial nerves?

Motor component of VII

Two trapezius muscles

Move shoulders and extend and turn head

Signs and symptoms of dehydration

Mucous membranes are dry, and lips look parched and cracked Poor turgor Depressed and sunken fontanels in infants Blank sunken eyes With extreme dryness the skin is fissured

Benign Breast Disease

Multiple tender masses. Swelling and tenderness, mastalgia(severe pain), nodularity, dominant lumps, nipple discharge, infections and inflammations.

Parotid gland responsible for...

Mumps

Stages of hypertension

Normal BP: <120 systolic/<80 diastolic Pre HTN: systolic 120-139/80-89 diastolic Stage 1 HTN: systolic 140-159/ 90-99 diastolic Stage 2 HTN: systolic >160/ >100 diastolic

What you will hear with auscultation of anterior chest?

Normal, abnormal or adventitious breath sounds Bronchial, bronchovesicular and vesicular are normal Crackles (rales) or wheezes (ronchi) are adventitious

To assess judgement in the context of the interview

Note what the person says about job plans, social or family obligations, and plans for the future. Job and future plans should be realistic, considering the person's health situation. In addition, ask the person to describe the rationale for personal health care and how he or she decided whether or not to comply with prescribed health regimens. The person's actions and decisions should be realistic.

Syphilitic Chancre

O: Begins as a small, solitary silvery papule that erodes to a red, round or oval, superficial ulcer with a yellowish serous discharge. Palpation-nontender indurated base; can be lifted like a button between thumb and finger. Nontender inguinal lymphadenopathy

Erosion

O: cervical lips inflamed and eroded. Reddened granular surface is superficial inflammation, with no ulceration (loss of tissue). Usually secondary to purulent or muco-purulent cervical discharge. Biopsy needed to distinguish erosion from carcinoma; cannot rely on inspection

Unequal chest expansion occurs with?

OCCURS: with marked atelectasis, lobar pneumonia, pleural effusion, thoracic trauma (fractured ribs, pneumothorax)

Glaucoma

OPtic nerve neuropathy caused by increased intraocular pressure and includes loss of peripheral vision

A known risk factor for venous ulcer development is:

Obesity

abdominal distention

Obesity - uniform roundness Air or Gas - single round curve, tympany over large area Ascites - single curve, everted umbilicus, taut, glistening skin, tympany over top but dull over fluid, no aortic pulsation Ovarian cyst - curve in lower half of abdomen, midline. everted umbilicus; fluid wave and shifting dullness, aortic pulsation Pregnancy Feces - mass palpated in intestines Tumor - localized distention; dull over mass; palpate to define borders

Testing persons gait/balance

Observe persons gait as they walk 10 to 20 feet, turns and returns to the starting point Normal Finding:The person moves with a sense of freedom; The gait is smooth, rhythmic and effortless, the opposing arm swing is coordinated and the turns are smooth. Step Length about 15inches from heel to heel.

First Heart Sound

Occurs with closure of the atrioventricular AV valves signaling the beginning of systole

Second Heart Sound

Occurs with closure of the semilunar valves, aortic, and pulmonic and signals the end of systole

Nutrition problems in the elderly

Older adults have increased risk for undernutrition or overnutrition. Poor physical or mental health, social isolation, alcoholism, limited functional ability, poverty, and polypharmacy are the major risk factors for malnutrition in older adults. Normal physiologic changes in aging adults that directly affect nutritional status include poor dentition, decreased visual acuity, decreased saliva production, slowed GI motility, decreased GI absorption, and diminished olfactory and taste sensitivity.

What breast structures are present at birth?

Only lactiferous ducts within the nipple, NO alveoli have developed.

Contrast open-ended versus closed questions, and explain the purpose of each during the interview

Open-ended-asks for narrative information. It states topic to be discussed but only in general terms. Use it to begin the interview, introduce a new section of questions and whenever the person introduces a new topic (Tell me how I can help you?) This question encourages the person to respond in paragraphs and give a spontaneous account in any order. It lets the person express themselves fully. Closed questions-ask for specific information. Use the direct questions after the person's opening narrative to fill in any details they left out. Also use when you need specific fact. (Are your headaches on one side or both?) Useful when you need specific facts, or to fill in any details that where initially left out.

To inspect the ocular fundus you use:

Ophthalmoscope

Paradoxical Splitting

Opposite of normal split S2 so that the split is heard in expiration, and in inspiration the sounds fuse to one sound.

Cranial Nerve II

Optic Function: Vision

Thrush

Oral candidiasis in a new born

Effector

Organ that can cause a change in a value

visceral pain

Originates from larger interior organs.

What to look for in the pupil?

PERRLA Your doctor is also looking at the size and shape of the pupil in both bright light and dim light. The speed and quality of pupillary response to stimuli will also be noted. Your doctor may also test your pupillary reaction to near stimuli such as small print. Any differences between your pupils is also noted.

How to assess CN III

PERRLA- Note the size, shape, and symmetry of both pupils. Shine a light into each pupil, and note the direct and consensual light reflex. Both pupils should constrict briskly.

Apical Impulse

PMI. Pulsation created as the left ventricle rotates against the chest wall during systole, normally at the 5th left inter coastal space in the midclavicular line.

Initial Pain Assessment Tool

PQRSTU assessment (8 critical char.)

apical pulse

PULSE LOCATED AT THE FIFTH INTERCOSTAL SPACE, TO THE LEFT OF THE STERNUM, AT THE APEX (TIP) OF THE HEART

radial pulse

PULSE LOCATED AT THE INNER ASPECT OF THE WRIST (THUMB SIDE)

Foot care related to peripheral vascular disease

PVD causes thickening of the toenails

referred pain

Pain felt at a particular site but originating from another location.

Referred abdominal pain

Pain location not over the involved organ. Pain is referred to a site where the organ was during fetal development: the organ migrates during fetal development but its nerves persist in referring sensations from the former location

Anterolateral spinolathamic tract

Pain signals ascend to the brain by this tract

chronic pain

Pain that continues for 6 months or longer. It does not stop when an injury heals.

Referred pain

Pain that is felt at a particular site but originates from another location. Both sites are innervated by the same spinal nerve, and it is difficult for the brain to differentiate the point of origin. Referred pain may originate from visceral or somatic structures.

Claudication

Pain with walking

Hemorrhoids/varicose vein

Painless, flabby Papuans cause by varicose veins EXTERNAL: below anorectal junction & covered by anal skin INTERNAL: above anorectal junction & covered by mucous membranr

Parotid Glands (Pa-rot-id)

Pair of Salivary glands in the cheeks in front of the ears. Largest Salivary gland. Opens in Stensen's duct

Thrill

Palpable Vibration on the chest wall accompanying severe heart murmur

Thrill

Palpable vibration on the chest wall accompanying severe heart murmur.

How to assess inflammation in a dark skinned person

Palpate the skin for increased warmth or taut or tightly pulled surfaces that may indicate edema and hardening of deep tissues or blood vessels.

OBJECTIVE INFO -Neck

Palpate with patient relaxed, neck flexed. Follow sequence: Inspect and Palpate the Neck- Symmetry-head position is centered in the midline, held erect and still,accessory muscles symmetric ROM-any limitation? chin to chest, head to the right and left, ear to shoulders without elevating shoulders, extend head backwards Cervical vertebrae- test strength and status of cranial nerve XI by trying to resist the persons movement with hands as the person shrugs the shoulders and turns the head to each side. Lymph Nodes- gentle circular motion of the finger pads. ( normally the salivary glands are non palpable) If symptoms arise check parotid tenderness by palpating in line from the out corner to the lobule of the ear) use both hands comparing both sides symmetrically but submental is easier with one hand. For deep cervical chain, tip head towards side being examined to relax ipsilateral muscle then you can press your fingers under the muscle. Supraclavicular hunch shoulders and elbows forward; this relaxes the skin. If nodes are palpable note size, location, shape, delimitation (discrete/matted together., mobility, consistency and tenderness. Trachea- should be midline; palpate for tracheal shift. place your index finger on the trachea in the sternal notch and slip it off to each side Thyroid Gland- See below When to auscultate- if thyroid gland is enlarged auscultate for the presence of BRUIT. Auscultate the Carotids (done with assessment of heart)

Plaque

Papules coalesce to form surface elevation >1cm - plateau like - *EX: Psoriasis*

Two pairs of salivary glands are accessible to examination on the face

Parotid glands are in cheeks over mandible, anterior to and below ear; the largest of salivary glands they are not normally palpable. Submandibular glands beneath mandible at angle of jaw.

Left Lower Quadrant

Part of descending colon-Sigmoid colon-Left ovary and tube (female)-Left ureter-Left spermatic cord (male)

Bell

Part of stethoscope that you use to listen to low pitched sounds...Used to listen to low pitched heart sounds.

Diaphragm

Part of stethoscope used to listen high pitched heart sounds.

Mammary Duct Ectasia

Pastelike matter in subareolar ducts produce sticky, purulent discharge that may be white, gray , brown, green or bloody. Itching, burning, drawing pain occurs around nipple. May have redness and swelling. ducts are palpable and rubbery. NOT malignant

Babinskis sign

Pathologic Reflex Abnormal response is dorsiflexion of the big toge and fanning of all toes. "Upgoing toes" Occurs with upper motor neuron disease of the corticospinal tract.

Additional history for the aging adults- SUBJECTIVE

Patient-centered care. If dizziness is a problem are you able to drive safely? how does it affect daily activities? If neck pain is a problem, affect daily activities? drive, perform at work, housework?

auscultatory gap

Period during which sound disappears then reappears when taking a blood pressure measurement ( temporary disappearance of sound when taking a patient's BP)

Buccal (Buckle)

Pertaining to the cheek

General Survey

Physical Appearance Body Structure Mobility Behavior

Best indicator of a child's general health

Physical growth

The best index for a child's health

Physical growth

How to use a Snellen eye chart

Place the Snellen alphabet chart in a well-lit spot at eye level Position the person on a mark exactly 20 feet from the chart Use an opaque card to shield one eye at a time during the test If the person wears glasses or contact lenses, leave them on. Remove only reading glasses because they blur distance vision Ask the person to read through the chart to the smallest line of letters possible and encourage trying the next smallest line also Record the result using the numeric fraction at the end of the last successful line read. Indicate whether the person missed any letters or if corrective lenses were worn

How to use a Snellen chart

Place the Snellen alphabet chart in a well-lit spot at eye level. Position the person on a mark exactly 20 feet from the chart. Use an opaque card to shield one eye at a time during the test. If the person wears glasses or contact lenses, leave them on. Remove only reading glasses because they blur distance vision. Ask the person to read through the chart to the smallest line of letters possible.

Apical Impulse

Point of maximal impulse (PMI); pulsation created as the left ventricle rotates against the chest wall during systole, normally at the 5th left intercostal space in the midclavicular line.

Superficial

Position near to the surface of the body

Plantar Reflex

Position the thigh in a slight external rotation. With the reflex hammer, draw a light stroke up the lateral side of the sole of the food AND inward across the ball of the foot like in an upside down J shape. Normal Response: Plantar flexion of the toes (toes curl) and inversion and flexion of the forefoot.

Breast normal inspection for pregnant female, lactating female and aging female

Pregnant: delicate blue vascular pattern, increase in size, striae (stretch marks), darker areola, feel modular Lactating: Colostrum changes to milk production, enlarged, reddened, shiny, warm, hard

Past Health for children (extra)

Prenatal status, Labor and delivery, Postnatal status, are to be asked of the mother

OBJECTIVE INFO

Prepare client Upright position Remember cultural differences Gather equipment Gloves Small cup of water stethoscope

Occipital Lobe

Primary visual receptor.

List the pros and cons of note-taking during the interview

Pro -A complete history -not relying on memory Con -Breaks eye contact -Shifts attention from the person -Interrupts patient's narrative flow -Impedes observation of patient's non-verbal behavior -Threatening to the patient when discussing sensitive issues

Renewal

Process by which work out cells are replaced

Growth

Process of increasing in size

Aspects of cultural care

Professional health care that is culturally sensitive, culturally appropriate, and culturally competent.

Cystocele

Prolapse of urinary bladder and its vaginal mucosa into the vagina with straining or standing

Lichenification

Prolonged intense scratching eventually thickens the skin and produces tightly packed sets of papules

Capillary refill indicates

Proper perfusion

Function of the eyelids:

Protect the eyes from injury, strong light, and dust.

What is the lacrimal apparatus?

Provides constant irrigation to keep the conjunctiva and cornea moist and lubricated.

(P)QRSTU

Provocative or palliative- what brings it on? what were you doing when you first noticed it? what makes it better or worse?

Pulmonic regurgitation

Pulmonic insufficiency; back flow of blood through incompetent pulmonic valve into the right ventricle.

The nurse palpates a thrill on the left 2nd/3rd ICS. This may indicate

Pulmonic stenosis or pulmonic hypertension

Expected findings in the eyes of the elderly

Pupil size decreases The lens loses elasticity, becoming hard and glasslike, which decreases ability to change shape to accommodate for near vision; this condition is termed presbyopia By age 70, normally transparent fibers of lens begin to thicken and yellow, the beginning of cataracts Visual acuity may diminish gradually after age 50, and more so after age 70 As a result of atrophy of elastic tissues, the skin around the eyes may show wrinkles or crow's feet The upper lid may be so elongated as to rest on the lashes, resulting in a pseudoptosis The eyes may appear sunken from atrophy of the orbital fat

Define PERRLA

Pupils Equal, Round, Reactive to Light and Accomodating. This means that the pupils are the same size, round, constrict to light and constrict to near vision.

GETTING STARTED - SUBJECTIVE INFO

Questions to ask: Headache-unusually frequent or severe? Head injury? Dizziness? Neck pain? Lumps or swelling? Common or concerning symptoms Head or neck surgery Traumatic brain injury

Normal range

Range of values around the set point that do not cause a reaction by the control center

Lability

Rapid shift of emotions. ex: person expresses euphoric, tearful, angry feeling in rapid succession.

Breast Abscess

Rare complication of generalized infection if untreated. Pocket of pus accumulates in one local area. Continue to nurse on unaffected side, treat with antibiotics, surgical incision, and drainage.

Right Cerebral Cortex

Receives sensory information from and controls motor function on the left side of the body.

Left Cerebral Cortex

Receives sensory information from and controls motor function to the right side of the body

Wernicke aphasia

Receptive aphasia. Opposite of broca. Can hear sounds and words but can not relate them to previous experiences. speech is fluent, effortless, and articulated but has many paraphasias & neologisms. Repetition, reading, writing impaired.

Wernicke aphasia

Receptive aphasia. The linguistic opposite of Broca aphasia. The person can hear sounds and words but cannot relate them to previous experiences. Speech is fluent, effortless, and well articulated but has many paraphasias (word substitutions that are malformed or wrong) and neologisms (made-up words) and often lacks substantive words. Speech can be totally incomprehensible. Often there is a great urge to speak. Repetition, reading, and writing also are impaired. Lesion is in posterior language area called the association auditory cortex or Wernicke area.

Source of History

Record who furnishes the information, judge how reliable the informant seems and how willing, note any special circumstances

Chancre

Red, round superficial ulcer with a yellowish serous discharge that is a sign of syphilis

Cheilitis (Ky-Lie-tis)

Red, scaling, shallow, painful fissures at corner of the mouth.

Gingivitis

Red, swollen gun margins that bleed easily

Rhinitis (Rye-nI-tis)

Red, swollen inflammation of the nasal mucosa

Facial expressions

Reflect Mood. Expressions are formed by the facial muscle, which are mediated by cranial nerve VII (facial nerve).

Numeric Rating Scales

Reflects only pain intensity, tracts changes in pain, rates pain on a scale of 0-10

PQ(R)STU

Region or radiation- Where is it? Does it spread anywhere?

Tolerance to substances

Requires increased amount of substance to produce same effect. Diminished effect from same amount of substance.

Name the 5 components of the inner eye.

Retina Optic disc Retinal vessels General background Macula

Deep tendon reflexes: indicate what when performed correctly?

Reveals the intactness of the reflex arc at specific spinal levels as well as the normal override on the reflex of the higher cortical levels. Consists of: Biceps, Triceps, Brachioradialis, Quadriceps, Achilles Reflexe

Deep tendon reflex

Reveals the intactness of the reflex arc at specific spinal levels as well as the normal override on the reflex of the higher cortical levels. Consists of: Biceps, Triceps, Brachioradialis, Quadriceps, Achilles Reflexes

deep tendon reflex

Reveals the intactness of the reflex arc at specific spinal levels as well as the normal override on the reflex of the higher cortical levels. Consists of: Patella, Biceps, Triceps, Brachioradialis, Quadriceps, Achilles Reflexes

Allergies - S&S

Rhinorrhea Altered smell Sinuses tender to palpation Inflammed, watery eyes

Signs and symptoms of allergies (related to the nose)

Rhinorrhea (nasal discharge) Rhinitis (inflamation) Altered smell Sinuses tender to palpation

Tricuspid Valve

Right AV valve separating the right atria and ventricle.

Teach breast timing

Right after menstrual period

Tricuspid Valve

Right atrioventricular valve separating the right atrium and ventricle.

Pulmonic Valve

Right semilunar valve separating the right ventricle and pulmonary artery

Cor Pulmonale

Right ventricular hypertrophy and heart failure due to pulmonary hypertension.

Papillae (Pa-pil-E)

Rough, bumpy elevations on the dorsal surface of the tongue.

Scoliosis

S-shaped curvature of the thoracic spine

Normal heart sounds and where are they heard

S1: "lubb": apex S2: "dubb": base

Third Heart Sound

S3. Soft, low-pitched ventricular filling sound that occurs in the early diastole and may be an early sign of heart failure

Pathologic S3 and S4 are indications of?

S3: heart failure, volume overload S4: CAD

Fourth Heart Sound

S4. Very soft, low pitched ventricular filling sound that occurs in the late diastole. Gallop, atrial gallop

endometriosis

S: Cyclic or chronic pelvic pain, low back pain O:masses are aberrant growths of endometrial tissue scattered throughout pelvis, small firm nodules, tender to palpation on posterior aspect of funds, uterosacral ligaments, ovaries, ovaries are enlarged. May cause infertility

Red Rash- contact dermatitis

S: History of skin contact with allergenic substance in environment, intense pruritus O: Primary lesion-red swollen vesicles. Then may have weeping of lesions, crusts, scales, thickening of skin, excoriations from scratching. May result from reaction to feminine hygiene spray or synthetic underclothing

Candidasis (moniliasis)

S: Intense pruritus, thick with discharge O: Vulva and vagina are erythematous and edematous. Discharge is usually thick white cruddy. Diagnose by microscopic examination of discharge Predisposing cause- use of oral contraceptives or antibiotics, more alkaline vaginal pH, also pregnancy from increased glycogen and diabetes

Solid ovarian Mass (ovarian cancer)

S: May have abdominal pain, increased abdominal size, bloating, GI symptoms, may be asymptomatic O: ovarian mass but may palpate solid tumor on ovary. Heavy solid fixed poorly defined, benign mass may feel mobile and solid Biopsy needed to distinguish the two types of masses. Pap smear doesn't detect. Screening with serum CA 125 test.

Human Papillomavirus (HPV) Genital Warts

S: Painless warty growths, may be unnoticed by women. O: Pink or fleshy soft pointed moist warty papules. Single or multiple in a cauliflower-like patch. Occur around vulva, intuits, anus, vagina, cervix HOV infection is common among sexually active women, especially adolescents

Diethylstilbestrol (DES) Syndrome

S: Prenatal exposure to DES causes cervical and vaginal abnormalities not apparent until adolescence. O: Red, granular patches. Cervical abnormalities: circular groove, transverse ridge, protuberant anterior lip

Pediculosis Pubis (crab lice)

S: Severe perineal itching O: Excoriations and erythematous areas. May see little dark spots (lice are small), nits (eggs) adherent to pubic hair near root. Usually localized in pubic hair, occasionally in eyebrows and eyelashes

Ectopic pregnancy

S: amenorrhea or irregular vaginal bleeding, pelvic pain O: softening of cervix and funds , movemnt of cervix and uterus =pain, palpable tender pelvic max, solid, mobile, unilateral. This has potential for serious sequelae, seek gynecologic consultation bf it ruptures or shows signs of acute peritonitis

Bacterial Vaginosis (Gardnerella vaginalis, Haemophilus, or Nonspecific vaginitis)

S: discharge, "constant wetness" with fishy smell O: no inflammation, pH >4.5, wet mount shows "clue cells: epithelial cells with stippled borders

Abscess of Bartholin's Gland

S: local pain can be severe O: Overlying skin red, shiny, and hot. Posterior part of labia swollen; palpable fluctuant mass and tenderness. Mucosa shows red spot at site of duct opening. Requires incision and drainage, antibiotic therapy

Chlamydia

S: minimal or no symptoms. May have urinary frequency , vaginal discharge, postcoital bleeding, cervical tenderness easily mistaken for gonorrhea. Can cause pelvic inflammatory disease (PID) and cause infertility. Most common STI. Can be detected in urine sample

Myomas (uterine Fibroids)

S: often no symptoms, Sometimes vaginal discomfort, bloating, heaviness, pelvic pressure, frequent urination, backache O: uterus irregularly enlarged, firm mobile nodular with hard painless nodules in uterine wall. Heavy bleeding produces anemia They are usually benign, Estrogen dependent; after menopause, the lesions usually regress but don't disappear. Surgery may be needed

Atrophic Vaginitis

S: postmenopausal itching, dryness, burning, dyspareunia, mucoid discharge O: Pale mucosa with abraded areas that bleed easily may have bloody discharge Infection related to chronic estrogen deficiency

Fallopian tube mass - PID

S: sudden fever (100.4), suprapubic pain, tenderness O: acute-ridgid, some discharge, movement of cervix and uterus = pain, chronic bilateral tenderness w/ fixed masses complications= ectopic pregnancy, infertility, and reinfection

Urethral Caruncle

S: tender, painful with urination, frequency, hematuria, dyspareunia, or asymptomatic O: small, deep red mass protruding from meatus, usually secondary to urethritis or skenitis; lesion may bleed on contact

Trichomoniasis

S: watery and often malodorous vaginal discharge, frequent urination, terminal dysuria, itching. Symptoms worsen during menstruation when pH becomes optimal for growth O: Vulva may be erythematous. Vagina red, granular, sometimes red raised papules and petechiae. Frothy yellow-green, foul smell

prenatal/postnatal exposure to second hand smoke causes

SIDS, decreased respiratory illnesses, acute/chronic otitis media, asthma, ADHD/depression

Objective Data

SIGNS: What the health professional observes by inspecting, palpating, percussing and osculating during the physical examination.

Subjective Data

SYMPTOMS: What the person says about him or herself during history taking.

Pericardium

Sac that encloses the heart

Depression

Sad, gloomy, dejected; symptoms may occur with rainy weather, after a holiday, or with an illness; if the situation is temporary, symptoms fade quickly. ex: "I've got the blues."

Submandibular Gland

Salivary gland that lies beneath the mandible at an angle of the jaws. Opens into Wharton's duct. Walnut shape

Sublingual Gland

Salivary gland that lies within the floor of the mouth under the tongue. Almond shape

When to weigh patients

Same time every day

Visibility of Tonsils

Scale for Tonsils 1+.......Visible 2+.......Halfway between tonsillar pillars and uvula 3+.......Touching the Uvula 4+.......Touching one another

Physiology

Science that studies the chemistry, biochemistry, and physics of the bodies functions

Erosion

Scooped out but shallow depression

Appearance of scrotum

Scrotal wall consists of thin skin lying in folds, or rugae, and underlying cremaster muscle Cremaster muscle controls size of scrotum by responding to ambient temperature LT testicle is lower because LT spermatic cord is longer

The best area to listen to the pulmonic valve

Second left interspace

Transmission-Based Precautions

Second tier of CDC guidelines that applies to specific categories of patients and that include air, contact, and droplet precautions. Used in addition to Standard Precautions.

Functional Assessment

Self esteem, Self concept, Activity/exercise, Sleep/rest, Nutrition/elimination, Interpersonal relationships/resources, Spiritual resources, Coping and stress management, Personal Habits, Alcohol, Illicit or street drugs, Environment/hazards, Intimate partner violence, Occupational health

Excoriation

Self inflicted abrasion; superficial; sometimes crusted scratches from intense itching.

What are senile tremors?

Senile tremors are benign and include head nodding (as if saying yes or no) and tongue protrusion. If some teeth have been lost, the lower face looks unusually small, with the mouth sunken in.

Tympanic membrane thermometer (TNT)

Senses infrared emissions of the tympanic membrane (eardrum). The tympanic membrane shares the same vascular supply that perfuses the hypothalamus (the internal carotid artery); thus it is an accurate measurement of core temperature. The TMT is a noninvasive, nontraumatic device that is extremely quick and efficient.

Photophobia

Sensitivity to light

Presbycusis: high or low pitch sound loss?

Sensorineural loss: 1st high frequency loss

Sagittal Sutures

Separates the head lengthwise between the two parietal bones. along the sagittal plane; separates the two parietal bones

Lambdoid Sutures

Separates the parietal bones crosswise from the occipital bone. separate occipital bone from parietal

Signs and symptoms of otitis externa (swimmers ear)

Severe painful movement of the pinna and tragus Redness and swelling of pinna and canal Scanty purulent discharge Fever Scaling and itching Enlarged tender regional lymph nodes Hearing normal or slightly diminished

PQR(S)TU

Severity scale- How bad is it (on a scale of 1 to 10)? Is it getting better, worse, or staying the same?

Gonorrhea

Sexually transmitted infection Characterized by purulent vaginal discharge or may have no symptoms

Fingernail patters for patients with psoroasis

Sharply defined pitting and crumbling of nails with distal detachment.

What do atelectatic crackles sound like?

Short, popping, crackling sounds that last only a few breaths Are heard only in the periphery, usually in dependent portions of the lungs, and disappear after the first few breaths or after a cough

Causes of unexplained weight loss

Short-term illness (e.g., fever, infection, disease of the mouth or throat) or a chronic illness (e.g., endocrine disease, malignancy, depression, anorexia nervosa, bulimia).

Cranium (Skull)

Skull is rigid box that protects brain and is supported by cervical vertebra

Koplik spots (Ca-plick)

Small, blue-white spots with a red halo over the mucosa. Early sign of measles

Caruncle

Small, deep red mass protruding from urethral meatus, usually die to urethritis

Cell

Smallest independently functioning unit of all organisms, and animals,a cell contains cytoplasm, composed of fluid and organelles

Polyp

Smooth, pale gray nodules in the nasal cavity due to chronic allergic rhinitis

Vision tests include:

Snellen eye chart Jaeger card Confrontation test

Third Heart Sound (S3)

Soft, low pitched ventricular filling sound that occurs in early diastole (S3 gallop) and may be an early sign of heart failure.

Hyperthyroidism - S&S

Soft, warm, moist skin Excessive sweating Presence of bruit upon thyroid auscultation Nervousness Fatigue Weight loss Muscle cramps Heat intolerance Forceful tachycardia Shortness of breath Fine tremor of the tongue

Plaque

Soft, whitish debris on teeth

Hegar sign

Softening of cervix that is a sign of pregnancy, occurring at 10 to 12 weeks gestation

Nodule

Solid, elevated, hard, or soft. >1cm. *EX: Fibroma*

Nodule

Solid, elevated, hard, or soft. >1cm. fibroma

Cancer

Solitary, unilateral, nontender mass. Single focus in one area but can be interspersed w/other nodules. Solid, hard, dense, irregular borders, poorly delineated. MOST COMMON in upper outer quadrant.

Cultural and Lifestyle Factors

Some CULTURAL groups are more demonstrative, others more reserved about pain

Metabolism

Some of all the bodies chemical reactions

Fixation

Something pathologically wrong with smaller breast. As cancer becomes invasive, fibrosis fixes the breast to the underlying pectoral muscles.

Papule

Something you can feel <1cm - superficial hardening of epidermis - elevated nevus *EX: Mole, Wart*

Papule

Something you can feel <1cm - superficial hardening of epidermis - elevated nevus (mole)

Inflammation in dark skinned patients

Sometimes has a purplish tinge but can't really see inflammation in dark skinned patients, you must palpate the skin for increased warmth or taut or tightly pulled surfaces that may indicate edema and hardening of deep tissues or blood vessels.

Percussion of spleen

Spleen is usually obscured by stomach contents. Percuss for a dull note from the 9th to 11th intercostal space just behind the left midaxillary line. Usually not wider than 7 cm in the adult

The organs that aid in the lymphatic system are:

Spleen, Tonsils, Thymus

How to do a whispered voice test

Stand arm's length (2 feet) behind the person. Test one ear at a time while masking hearing in the other ear to prevent sound transmission around the head. Move your head to 1 to 2 feet from the person's ear. Exhale fully and whisper slowly a set of 3 random numbers and letters, such as "5, B, 6." Normally the person repeats each number/letter correctly after you say it. If the response is not correct, repeat the whispered test using a different combination of 3 numbers and letters. A passing score is correct repetition of at least 3 of a possible 6 numbers/letters. Assess the other ear using yet another set of whispered items "4, K, 2."

Positions for exam of prostate

Standing, Left Lateral Decubitus

Body Structure

Stature- height normal for age & genetics Nutrition-weight appears normal range for height & fat evenly distributed Symmetry-body parts equal & proportioned Posture-stands comfortably erect for age Position- sits comfortably arms relaxed, head turned to examiner Body build,contour-arm span=height,crown to pubis roughly= pubis to sole

Homeostasis

Steady state of body systems that living organisms maintain

Major neck muscles _______ and _______ are innervated by cranial nerve XI

Sternomastoid and trapezius

Balance Test Abnormal Findings

Stiff, immobile posture. Staggering or reeling. Wide base of support. Lack of arm swing or rigid arms. Unequal rhythm of steps Slapping of foot. Scraping of toe of shoe.

What does the autonomic nervous system (sympathetic/parasympathetic) do for the eye?

Stimulation of the parasympathetic branch, through CN III, causes constriction of the pupil. Stimulation of the sympathetic branch dilates the pupil and elevates the eyelid.

Left Upper Quadrant

Stomach-Spleen-Left lobe of liver-Body of pancreas-Left kidney and adrenal-Splenic flexure of colon-Part of transverse and descending colon

Left Upper Quadrant Contains

Stomach-Spleen-Left lobe of liver-Body of pancreas-Left kidney and adrenal-Splenic flexure of colon-Part of transverse and descending colon

Gross anatomy

Study of the larger structures of the body, typically with the unaided eye, also referred to macroscopic anatomy

Regional anatomy

Study of the structures that contribute to specific body regions

Vertigo: subjective and objective

Sub: Feels like room is spinning Obj: Person feels as if they spin

Parts of a database

Subjective data (what the person says about himself or herself during history taking) Objective data (what you as the health professional observe by inspecting, percussing, palpating, and auscultating during the physical examination)

Blocking

Sudden interruption in train of thought, unable to complete sentence, seems related to wrong strong emotion.

Cachectic appearance

Sunken eyes, hollow cheeks, and exhausted defeated expression OCCURS: chronic wasting diseases (cancer, dehydration, starvation)

What to avoid with hypoglycemic medications

Sunlight (they increase sunlight sensitivity)

Wheal

Superficial, raised, transient, slightly irregular due to edema - *EX: Mosquito bite, Allergic rxn*

Wheal

Superficial, raised, transient, slightly irregular due to edema - mosquito bite

Tail of Spence

Superior lateral corner of breast tissue.

Edema

Swelling of legs or dependent body part due to increased interstitial fluid

Edema

Swelling of the legs or dependent body part due to increased interstitial fluid.

Bruit

Swooshing sound over carotid artery

Most reliable indicator of pain

THE PATIENT

Syncope

Temporary loss of consciousness due to decreased cerebral blood flow (fainting); caused by ventricular asystole, pronounced bradycardia, or ventricular fibrillation.

Syncope

Temporary loss of consciousness due to decreased cerebral blood flow, caused by ventricular systole, pronounced bradycardia, or ventricular fibrillation. Fainting

Deciduous

Temporary/Baby teeth

Kinesthesia

Test the persons ability to perceive passive movements of the extremities. (Positions) Move a finger on the big toe up and won and ask the person to tell you which way it moved. Make sure the persons's eyes are closed and that they understand the test.

Stereognosis

Test the persons ability to recognize objects by feeling their forms, sizes and weights. Example: With person's eyes closed place a familiar object like a paper clip, key, coin, cottonball or pencil in their hands and ask them to identify it. Normal Finding: Person will explore it with fingers and correctly name it. Assess with a different object in each hand.

What is considered the pacemaker of the heart?

The SA node

Gallop Rhythm

The addition of the 3rd or a 4th heart sounds; makes a rhythm sound like the cadence of a galloping horse.

Signs & symptoms of aging on the skin

The aging skin loses its elasticity; it folds and sags. By the 70s to 80s, it looks parchment thin, lax, dry, and wrinkled.

Body temperature

The body maintains a steady temperature through a thermostat, or feedback mechanism, regulated in the hypothalamus of the brain. The thermostat balances heat production (from metabolism, exercise, food digestion, external factors) with heat loss (through radiation, evaporation of sweat, convection, conduction).

Atherosclerosis

The build-up of fats, cholesterol, and other substances in and on the artery walls.

lithotomy

The client is lying on back, w/ knees bent, thighs apart, and feet resting in stirrups. The position is used for pelvic exams in females,rectal exams& some operations.

During an assessment the nurse notices that an elderly patient has tears rolling down his face from his left eye. Closer examination shows that the lower lid is loose and rolling outward. The patient complains of his eye feeling "dry and itchy." Which action by the nurse is correct? A) Assess the eye for a possible foreign body. B) Document the finding as ptosis. C) Assess for other signs of ectropion. D) Contact the prescriber because these are signs of basal cell carcinoma.

The condition described is known as ectropion, and it occurs in aging due to atrophy of elastic and fibrous tissues. The lower lid does not approximate to the eyeball, and, as a result, the puncta cannot siphon tears effectively, and excessive tearing results. Ptosis is drooping of the upper eyelid. These are not signs of a foreign body in the eye or basal cell carcinoma. Points Earned: 1.0/1.0 Correct Answer(s): C

Properties of the Dermis

The dermis is the inner supportive layer consisting mostly of connective tissue or collagen and elastic tissue. The nerves, sensory receptors, blood vessels, and lymphatics lie in the dermis. In addition, appendages from the epidermis such as the hair follicles, sebaceous glands, and sweat glands are embedded in the dermis.

Diastole

The hearts filling phase.

Crossed Representation

The left cerebral cortex receives sensory information from and controls motor functions to the right side of the body, while the right cerebral cortex receives sensory information from the left side of the body.

Aortic Valve

The left semilunar valve separating the left ventricle and the aorta.

Testing the Deep tendon reflex

The limb should be relaxed and the muscle partially stretched. Stimulate the reflex by directing a short, snappy blow of the hammer onto the muscles insertion tendon. Example: Knee Jerk or Patellar Area

What the numbers mean in the results of the Snellen chart exam (i.e. 20/20):

The numerator indicates the distance the person is standing from the chart, and the denominator gives the distance at which a normal eye could have read that particular line. Therefore "20/30" means you can read at 20 feet what the normal eye can see from 30 feet away. (The larger the denominator, the poorer the vision)

Perform an otoscopic examination of the left nares

The nurse is assessing a 3 year old for "drainage from the nose." On assessment, it is found that there is a purulent drainage from the left nares that has a very foul odor and no drainage from the right nares. The child is afebrile with no other symptoms. What should the nurse do next?

A decreased ability to identify odors

The nurse is assessing an 80-year-old patient. Which of these findings would be expected for this patient?

"Are you aware of having any allergies?"

The nurse is doing an assessment on a 21-year-old patient and notices that his nasal mucosa appears pale, gray, and swollen. What would be the most appropriate question to ask the patient?

This lesion is leukoedema and is common in darkly pigmented persons.

The nurse is doing an oral assessment on a 40-year-old African-American patient and notices the presence of a 1-cm, nontender, grayish-white lesion on the left buccal mucosa. Which of these statements is true concerning this lesion?

"She is just starting to salivate and hasn't learned to swallow the saliva."

The nurse is obtaining a history on a 3-month-old infant. During the interview, the mother states, "I think she is getting her first tooth because she has started drooling a lot." the nurse's best response would be:

Avoid touching the nasal septum with the speculum.

The nurse is using an otoscope to assess the nasal cavity. Which of these techniques is correct?

bruising on the buccal mucosa or gums

The nurse notices that the mother of a 2-year-old boy brings him into the clinic quite frequently for various injuries and suspects there may be some child abuse involved. In doing the inspection of his mouth, the nurse should inspect for:

How does cranial nerve III regulate eye movement?

The oculomotor nerve allows the eye to look up and out, up and in, down and out, and toward the nose.

Stensons Duct

The opening of the parotid salivary gland. It looks like a small dimple opposite the upper second molar.

Afterload

The opposing pressure the ventricle must generate to open the aortic valve against the higher aortic pressure.

What does the review of systems provide?

The past and present health state of each body system

Explain the findings of 20/30 vision.

The patient can see at 20 feet what a "normal" person sees at 30 feet.

the confrontation test determines:

The patient's peripheral vision capabilities by comparing it to the testers peripheral vision.

Mean Arterial Pressure (MAP)

The pressure forcing blood into the tissues averaged over the cardiac cycle. This is not an arithmetic average of systolic and diastolic pressures because diastole lasts longer. Rather it is a value closer to diastolic pressure plus one third the pulse pressure.

Filter out dust and bacteria

The primary purpose of the ciliated mucous membrane in the nose is to:

Health promotion

The process of enabling people to increase control over, and to improve, their health. It moves beyond a focus on individual behavior towards a wide range of social and environmental interventions. The purpose of health promotion is to positively influence the health behavior of individuals and communities as well as the living and working conditions that influence their health.

Turbinates

The projections in the nasal cavity that increase the surface area are called the:

Pupil control

The pupil is controlled by a very long nerve pathway in the body. The nerve that controls the pupil starts in the brain, then travels down the spinal cord, up over the top of the lung, under the subclavian artery, up the neck and through extensions of the brain, and finally travels close to the optic nerve and then to the pupil. Any interruption along this pathway could possibly affect this nerve and cause changes in pupillary reaction.

Who gets rectal temperatures done?

The rectal temperature is the preferred route when the other routes are not practical. (e.g., for the comatose or confused person; people in shock; or those who cannot close the mouth because of breathing or oxygen tubes, wired mandible, or other facial dysfunction).

parotid

The salivary gland that is the largest and located in the cheek in front of the ear is the

How to stop the spread of infection

The single most important step to decrease risk of microorganism transmission is to wash your hands promptly and thoroughly: (1) before and after every physical patient encounter (2) after contact with blood, body fluids, secretions, and excretions (3) after contact with any equipment contaminated with body fluids (4) after removing gloves Clean your stethoscope endpiece with an alcohol wipe before and after every patient contact. The best routine is to combine stethoscope rubbing with every episode of hand hygiene.

• Are senile tremors normal or abnormal in elderly? •

The temporal arteries may look twisted and prominent. In some aging adults, a mild rhythmic tremor of the head may be normal.

What happens to the thyroid during pregnancy?

The thyroid gland enlarges slightly during pregnancy as a result of hyperplasia of the tissue and increased vascularity.

frenulum

The tissue that connects the tongue to the floor of the mouth is the:

How does cranial nerve IV regulate eye movement?

The trochlear nerve allows the eye to look downward and inward

Myelin

The white insulation on the axon that increases the conduction velocity of nerve impulses

BP cuff guideline

The width of the rubber bladder should equal 40% of the circumference of the person's arm. The length of the bladder should equal 80% of this circumference.

Yin/yang theory

Theory in which health exists when all aspects of the person are in perfect balance. States that all organisms and objects in the universe consist of yin and yang energy forces. The seat of the energy forces is within the autonomic nervous system, where balance between the opposing forces is maintained during health. Yin energy represents the female and negative forces such as emptiness, darkness, and cold, whereas yang forces are male and positive, emitting warmth and fullness. Foods are classified as hot and cold in this theory and are transformed into yin and yang energy when metabolized by the body. Yin foods are cold, and yang foods are hot. Cold foods are eaten with a hot illness, and hot foods are eaten with a cold illness.

Infant "Soft Spot"

These membrane-covered, allow growth of brain during 1st year; gradually ossify

Why interviewing the elderly takes longer

They have a longer story to tell and more background material to sort through

Atrophic Skin changes that occur with peripheral arterial insufficiency include:

Thin, shiny skin with loss of hair

Petechiae

Tiny purpuric lesions; punctate hemorrhages, round and discrete; dark red, purple, or brown in color. Caused by bleeding from superficial capillaries; will not blanch. May indicate abnormal clotting factors. In dark-skinned people petechiae are best visualized in the areas of lighter melanization (e.g., the abdomen, buttocks, and volar surface of the forearm). When the skin is black or very dark brown, petechiae cannot be seen in the skin.

Purpose of functional assessment

To determine if patient is able to carry out ADLs (Activities of daily living) -dress, bathe, toilet, and feed self? -can they use the phone, see tv? -drive a car? -write a check?

A function of the venous system

To hold more blood when blood volume increases

Erbs Point

Traditional auscultatory area in the 3rd left intercostal space.

Cranial Nerve V

Trigeminal Motor Function: Muscles of mastication (chewing) Sensory Function:sensation of face and scalp, cornea, mucous membranes of mouth and nose

Cranial Nerve IV

Trochelear Motor Function: Down and inward movement of the eye

Rinne test

Tuning fork on mastoid

Weber test

Tuning fork on skill

Pustule

Turbid fluid (pus) in the cavity *EX: Impetigo and acne*

Pustule

Turbid fluid in the cavity. impetigo and acne.

Frontal plane

Two dimensional, vertical plane that divides the body or organ into anterior and posterior portions

Normal cerumen

Two major types: (1) dry cerumen, which is gray and flaky and frequently forms a thin mass in the ear canal; and (2) wet cerumen, which is honey brown to dark brown and moist.

Transverse plane

Two-dimensional, horizontal plane that divides the body or organ into superior and inferior portions

Palpitation

Uncomfortable awareness of rapid or irregular heart rate.

Mastitis

Uncommon, inflammatory mass before abscess formation. usually in single quadrant. Area is red, swollen, tender, very hot, and hard forming outward from areola upper edge. Woman has a headache, malaise, fever, chills, and sweating, increased pulse and flu-like symptoms. may occur during first 4 months of lactation or from stasis of a plugged duct. Treat w/rest, local heat, antibiotics, and frequent nursing.

Ataxia

Uncoordinated or unsteady gait

PQRST(U)

Understanding Patient's Perception of the problem- What do you think it means?

decerebrate rigidity

Upper extremities- stiffly extended, adducted, internal rotation,palms pronated. Lower extremities-stiffly extended, plantar flexion; teeth clenched;hyperextended back;indicates lesion in the brain stem at midbrain or upper pons

When to use a Doppler for pulses and what you will hear

Use this device to detect a weak peripheral pulse, to monitor blood pressure in infants or children, or to measure a low blood pressure or blood pressure in a lower extremity. You will hear a swishing, whooshing sound.

Stethoscope diaphragm

Used most often For high pitched sounds (breath, bowel, and normal heart sounds) Hold firmly against patient's skin

descriptor scale

Useful for older adults, this scale lists words to indicate pain intensity, such as no pain, mild pain, moderate pain, and severe pain.

Why use a tempanic membrane temperature (TMT) for a temp?

Useful with toddlers who squirm at the restraint needed for the rectal route and with preschoolers who are not yet able to cooperate for an oral temperature yet fear the disrobing and invasion of a rectal temperature. The TMT is a noninvasive, nontraumatic device that is extremely quick and efficient.

Descriptor Scales

Uses words to DESCRIBE pain intensity

How to palpate the sinuses

Using your thumbs, press the frontal sinuses by pressing firmly up and under the eyebrows and over the maxillary sinuses below the cheekbones.

How do you test cranial nerve function of the eyes?

Utilize the six cardinal positions of gaze

Cranial Nerve X

Vagus Motor Function: Pharynx and Larynx (talking and swallowing) Sensory Function: General sensation from carotid body, carotid sinus, pharynx , viscera Parasympathetic function: carotid reflex

Most appropriate palpation technique for breast exam by clinician

Vertical strip pattern

Edema graded as 4+ is considered:

Very deep pitting, indentation lasts a long time

Think of neck as conduit of many structures

Vessels, muscles, nerves, lymphatics, and viscera of respiratory and digestive systems o Internal carotid branches off common carotid and runs inward and upward to supply brain o External carotid supplies face, salivary glands, and superficial temporal area. * The carotid artery and internal jugular vein lie beneath the sternomastoid muscle. The external jugular vein runs diagonally across the sternomastoid muscle.

HPV Condylomata

Virus = various forms. Warty growth appears as abnormal thickened with epithelium. Visibility of lesion is enhanced by acetic acid wash

Spinal cavity

Visions of the dorsal cavity that houses the spinal cord also referred to as the vertebral cavity

Migraine headache signs and symptoms

Visual changes i.e. blind spots or flashes of light Tingling in an arm or leg Vertigo Change in mood or behavior Hunger cravings Nausea Vomiting Photophobia or phonophobia Abdominal pain Person looks sick Commonly one-sided but may occur on both sides Pain is often behind the eyes, the temples, or forehead

What you see with CN II damage

Visual field loss Papilledema with increased intracranial pressure Optic atrophy

Waist to hip ratio

Waist circumference ---------------------------- Hip circumference

Paresis

Weakness

When to wear gloves

Wear gloves when you anticipate that contact with blood or other potentially infectious materials, mucous membranes, non intact skin, or potentially contaminated intact skin (e.g., patient incontinent of stool or urine) could occur.

body mass index

Weight ( in Kilograms) ------------------------------ Height ( in meters)squared or Weight (in lbs) ------------------- x 703 Height (in inches) squared

The maxillary and ethmoid sinuses are the only sinuses present at birth

What are the only sinuses present at birth

Q = Quality/Quantity

What does it feel like? Use words to describe the pain such as sharp, dull, stabbing, burning, crushing, throbbing, nauseating, shooting, twisting, or stretching.

P = Provocation/Palliation

What were you doing when the pain started? What caused it? What makes it better? Worse? What seems to trigger it? Stress? Position? Certain activities? What relieves it? Medications, massage, heat/cold, changing position, being active, resting? What aggravates it? Movement, bending, lying down, walking, standing?

Uticaria

Wheal's coalesce to form extensive reaction *EX: Hives*

Screening for suicidal thoughts

When a person expresses feelings of sadness, hopelessness, despair, or grief, it is important to assess for any possible risk of physical harm to himself or herself. Begin with more general questions. If you hear affirmative answers, continue with more specific questions: • Have you ever felt that life is not worth living? • Have you ever felt so blue that you thought of hurting yourself? • Do you feel like hurting yourself now? • Do you have a plan to hurt yourself? • How would you do it? • What would happen if you were dead? • How would other people react if you were dead? • Whom could you tell if you felt like killing yourself?

What is a tracheal shift?

When the trachea shifts to one side (either the healthy side or the diseased side) secondary to a disease or abnormality. Examples: The trachea is PUSHED TO THE UNAFFECTED SIDE with an aortic aneurysm, a tumor, unilateral thyroid lobe enlargement, and pneumothorax. The trachea is PULLED TOWARD THE AFFECTED SIDE with large atelectasis, pleural adhesions, or fibrosis. Tracheal tug is a rhythmic downward pull that is synchronous with systole and occurs with aortic arch aneurysm.

T = Timing

When/at what time did the pain start? How long did it last? How often does it occur: hourly? daily? weekly? monthly? Is it sudden or gradual? What were you doing when you first experienced it? When do you usually experience it: daytime? night? early morning? Are you ever awakened by it? Does it lead to anything else? Is it accompanied by other signs and symptoms? Does it ever occur before, during, or after meals? Does it occur seasonally?

Questions to ask patient about their pain

Where does it hurt? Rate the pain on a scale from 1-10? How would you describe it (dull, ache, sharp, throbbing, pulling)? When did it start? What were you doing when it started? Does anything make the pain better? Does anything make it worse? Is the pain affecting your daily life in any way?

R = Region/Radiation

Where is the pain located? Does it radiate? Where? Does it feel as if it travels/moves around? Did it start elsewhere and is now localized to one spot?

Ask the patient to say "ahhh" and watch for movement of the soft palate and uvula.

Which of these techniques best describes the test the nurse should use to assess the function of cranial nerve X?

Breast Cancer Statistics

White women have higher incidence of breast cancer BUT African American women have higher incidence of DEATH because of breast cancer. (could be because of insufficient use of screening measures and lack of access to health care).

Candidiasis (Can-D-D-A-sis)

White, cheesy, curdle patch on buccal mucosa due to superficial fungal infection

How to close an interview

With a summary. The summary is a final statement of what you and the client agree the health state to be. It should include positive health aspects, any health problems that have been identified, any plans for action, and an explanation of the following physical examination. As you part from clients, thank them for the time spent and for their cooperation.

Parts of a pulse

With every beat the heart pumps an amount of blood—the stroke volume—into the aorta. This is about 70 mL in the adult. The force flares the arterial walls and generates a pressure wave, which is felt in the periphery as the pulse. Palpating the peripheral pulse gives the rate and rhythm of the heartbeat and local data on the condition of the artery. Assess the pulse, including (1) rate, (2) rhythm, and (3) force.

Finger to finger test

With person's eyes open, ask that he or she use the index finger to touch your finger, then his or her own nose. After a few times move your finger to a different spot. Normal Finding: Persons movement smooth and accurate

Food frequency questionnaire

With this tool information is collected on how many times per day, week, or month the individual eats particular foods, providing an estimate of usual intake. Drawbacks to the use of the food frequency questionnaire are: (1) it does not always quantify amount of intake, and (2) like the 24-hour recall, it relies on the individual's or family member's memory for how often a food was eaten.

Proprioception

Without looking you know where your body parts are in relation to space and each other, vibration and finely localized touch.

Anxiety

Worried, uneasy, apprehensive from the anticipation of a danger whose source is unknown. ex: I feel nervous and high strung. I worry all the time. I cant make up my mind.

Fear

Worried, uneasy, external danger is known and identified. ex: fear of flying in airplanes.

Jaundice - S&S

Yellowing of the skin, sclera & mucous membranes Light or clay colored stools Dark golden urine Sometimes pruritis

Types of Naturalistic (Cause of Illness)

Yin/Yang Theory Hot/Cold Theory

Know what 20/20 means or 20/60 and so forth

You can read from 20 feet away what the normal eye can see from 30 feet away

subjective vertigo

____ is present when the patient experiences the sensation of turning or moving around in space. Objective vertigo is the sensation of objects moving around the patient.

orthostatic vital signs

a comparison of blood pressure and heart rate readings while a patient is supine and while the patient is sitting upright or standing, an increase in heart rate of more than 20 bpm and decrease in blood pressure of more than 20 mmHg when the patient becomes upright is considered a positive orthostatic test.

Crepitus

a crackling or grating sound usually of bones

hypoxemia

a decrease of oxygen in the blood; also increases respiration but is less effective than hypercapnia.

Wellness

a dynamic process and view of health; a move toward optimal functioning

abnormal forced expiratory time

a forced expiration of 6 seconds or more occurs with obstructive lung disease.

acinus

a functional respiratory unit that consists of bronchioles, alveolar ducts, alveolar sacs, and the alveoli.

Genital herpes

a viral STD that produces painful blisters on the genital area

Just before going home, a new mother asks the nurse about the infant's umbilical cord. Which of these statements is correct? a. "It should fall off in 10 to 14 days." b.. "It will soften before it falls off." c. "It contains two veins and one artery." d. "Skin will cover the area within 1 week."

a. "It should fall off in 10 to 14 days."

The nurse is reviewing a patients medical record and notes that he is in a coma. Using the Glasgow Coma Scale, which number indicates that the patient is in a coma? a. 6 b. 12 c. 15 d. 24

a. 6 A fully alert, normal person has a score of 15, whereas a score of 7 or less reflects coma on the Glasgow Coma Scale (see Figure 23-59).

The nurse is testing the deep tendon reflexes of a 30-year-old woman who is in the clinic for an annual physical examination. When striking the Achilles heel and quadriceps muscle, the nurse is unable to elicit a reflex. The nurses next response should be to: a. Ask the patient to lock her fingers and pull. b. Complete the examination, and then test these reflexes again. c. Refer the patient to a specialist for further testing. d. Document these reflexes as 0 on a scale of 0 to 4+.

a. Ask the patient to lock her fingers and pull. Sometimes the reflex response fails to appear. Documenting the reflexes as absent is inappropriate this soon in the examination. The nurse should try to further encourage relaxation, varying the persons position or increasing the strength of the blow. Reinforcement is another technique to relax the muscles and enhance the response. The person should be asked to perform an isometric exercise in a muscle group somewhat away from the one being tested. For example, to enhance a patellar reflex, the person should be asked to lock the fingers together and pull.

The nurse knows that determining whether a person is oriented to his or her surroundings will test the functioning of which structure(s)? a. Cerebrum b. Cerebellum c. CNs d. Medulla oblongata

a. Cerebrum The cerebral cortex is responsible for thought, memory, reasoning, sensation, and voluntary movement. The other structures are not responsible for a persons level of consciousness.

A patient tells the nurse that he has noticed that one of his moles has started to burn and bleed. When assessing his skin, the nurse pays special attention to the danger signs for pigmented lesions and is concerned with which additional finding? a. Color variation b. Border regularity c. Symmetry of lesions d. Diameter of less than 6 mm

a. Color variation

A patient tells the nurse that he has noticed that one of his moles has started to burn and bleed. When assessing his skin, the nurse pays special attention to the danger signs for pigmented lesions and is concerned with which additional finding? a. Color variation b. Border regularity c. Symmetry of lesions d. Diameter of less than 6 mm

a. Color variation Abnormal characteristics of pigmented lesions are summarized in the mnemonic ABCD: asymmetry of pigmented lesion, border irregularity, color variation, and diameter greater than 6 mm.

Which of these tests would the nurse use to check the motor coordination of an 11-month-old infant? a. Denver II b. Stereognosis c. Deep tendon reflexes d. Rapid alternating movements

a. Denver II To screen gross and fine motor coordination, the nurse should use the Denver II with its age-specific developmental milestones. Stereognosis tests a persons ability to recognize objects by feeling them and is not appropriate for an 11-month-old infant. Testing the deep tendon reflexes is not appropriate for checking motor coordination. Testing rapid alternating movements is appropriate for testing coordination in adults.

Which of the following assessments would be used to screen a young child for developmental delays? a. Denver II test b. Snellen chart c. Cerebellar function test d. Ortolani sign

a. Denver II test The Denver II screening test is used to screen infants and young children for developmental delays. The Snellen eye chart is used to determine visual acuity. Cerebellar function is a test of motor coordination; rapid alternating movements test cerebellar function. Ortolani sign assesses for hip stability in an infant.

The nurse is percussing the seventh right intercostal space at the midclavicular line over the liver. Which sound should the nurse expect to hear? a. Dullness b. Tympany c. Resonance d. Hyperresonance

a. Dullness

Which of these percussion findings would the nurse expect to find in a patient with a large amount of ascites? a. Dullness across the abdomen b. Flatness in the right upper quadrant c. Hyperresonance in the left upper quadrant d.. Tympany in the right and left lower quadrants

a. Dullness across the abdomen

The nurse is examining a patient who tells the nurse, "I sure sweat a lot, especially on my face and feet but it doesn't have an odor." The nurse knows that this condition could be related to: a. Eccrine glands. b.. Apocrine glands. c. Disorder of the stratum corneum. d. Disorder of the stratum germinativum.

a. Eccrine glands.

The nurse is examining a patient who tells the nurse, I sure sweat a lot, especially on my face and feet but it doesnt have an odor. The nurse knows that this condition could be related to: a. Eccrine glands. b. Apocrine glands. c. Disorder of the stratum corneum. d. Disorder of the stratum germinativum.

a. Eccrine glands. The eccrine glands are coiled tubules that directly open onto the skin surface and produce a dilute saline solution called sweat. Apocrine glands are primarily located in the axillae, anogenital area, nipples, and naval area and mix with bacterial flora to produce the characteristic musky body odor. The patients statement is not related to disorders of the stratum corneum or the stratum germinativum.

During reporting, the student nurse hears that a patient has hepatomegaly and recognizes that this term refers to: a. Enlarged liver. b. Enlarged spleen. c. Distended bowel. d. Excessive diarrhea.

a. Enlarged liver.

The wife of a 65-year-old man tells the nurse that she is concerned because she has noticed a change in her husbands personality and ability to understand. He also cries very easily and becomes angry. The nurse recalls that the cerebral lobe responsible for these behaviors is the __________ lobe. a. Frontal b. Parietal c. Occipital d. Temporal

a. Frontal The frontal lobe has areas responsible for personality, behavior, emotions, and intellectual function. The parietal lobe has areas responsible for sensation; the occipital lobe is responsible for visual reception; and the temporal lobe is responsible for hearing, taste, and smell.

A female patient tells the nurse that she has four children and has had three pregnancies. How should the nurse document this? a. Gravida 3, para 4 b. Gravida 4, para 3 c. This information cannot be documented using the terms gravida and para. d. The patient seems to be confused about how many times she has been pregnant.

a. Gravida 3, para 4 Gravida refers to the number of pregnancies, and para refers to the number of children. One pregnancy was with twins.

Which approach to a complete physical assessment should be used for an adolescent? a. Head-to-toe approach b. Focused approach c. Systems approach divided into two or three visits d. Problem-centered approach

a. Head-to-toe approach A head-to-toe approach is appropriate for an adolescent for a complete physical examination. A focused or problem-centered approach would be used for a follow-up visit, not an initial visit for a complete physical assessment. A physical assessment of an adolescent could be completed in one visit.

While performing an assessment of a 65-year-old man with a history of hypertension and coronary artery disease, the nurse notices the presence of bilateral pitting edema in the lower legs. The skin is puffy and tight but normal in color. No increased redness or tenderness is observed over his lower legs, and the peripheral pulses are equal and strong. In this situation, the nurse suspects that the likely cause of the edema is which condition? a. Heart failure b. Venous thrombosis c. Local inflammation d. Blockage of lymphatic drainage

a. Heart failure Bilateral edema or edema that is generalized over the entire body is caused by a central problem such as heart failure or kidney failure. Unilateral edema usually has a local or peripheral cause.

To test for gross motor skill and coordination of a 6-year-old child, which of these techniques would be appropriate? Ask the child to: a. Hop on one foot. b. Stand on his head. c. Touch his finger to his nose. d. Make funny faces at the nurse.

a. Hop on one foot. Normally, a child can hop on one foot and can balance on one foot for approximately 5 seconds by 4 years of age and can balance on one foot for 8 to 10 seconds at 5 years of age. Children enjoy performing these tests. Failure to hop after 5 years of age indicates incoordination of gross motor skills. Asking the child to touch his or her finger to the nose checks fine motor coordination; and asking the child to make funny faces tests CN VII. Asking a child to stand on his or her head is not appropriate.

In a person with an upper motor neuron lesion such as a cerebrovascular accident, which of these physical assessment findings should the nurse expect? a. Hyperreflexia b. Fasciculations c. Loss of muscle tone and flaccidity d. Atrophy and wasting of the muscles

a. Hyperreflexia Hyperreflexia, diminished or absent superficial reflexes, and increased muscle tone or spasticity can be expected with upper motor neuron lesions. The other options reflect a lesion of lower motor neurons (see Table 23-7).

A 59-year-old patient has a herniated intervertebral disk. Which of the following findings should the nurse expect to see on physical assessment of this individual? a. Hyporeflexia b. Increased muscle tone c. Positive Babinski sign d. Presence of pathologic reflexes

a. Hyporeflexia With a herniated intervertebral disk or lower motor neuron lesion, loss of tone, flaccidity, atrophy, fasciculations, and hyporeflexia or areflexia are demonstrated. No Babinski sign or pathologic reflexes would be observed (see Table 23-7). The other options reflect a lesion of upper motor neurons.

The nurse just noted from the medical record that the patient has a lesion that is confluent in nature. On examination, the nurse expects to find: a. Lesions that run together. b. Annular lesions that have grown together. c. Lesions arranged in a line along a nerve route. d. Lesions that are grouped or clustered together.

a. Lesions that run together. Confluent lesions (as with urticaria [hives]) run together. Grouped lesions are clustered together. Annular lesions are circular in nature. Zosteriform lesions are arranged along a nerve route.

During an assessment of a 62-year-old man, the nurse notices the patient has a stooped posture, shuffling walk with short steps, flat facial expression, and pill-rolling finger movements. These findings would be consistent with: a. Parkinsonism. b. Cerebral palsy. c. Cerebellar ataxia. d. Muscular dystrophy.

a. Parkinsonism. The stooped posture, shuffling walk, short steps, flat facial expression, and pill-rolling finger movements are all found in parkinsonism. (See Table 23-8 for more information and for the descriptions of the other options.)

Multiple Response The nurse is preparing for a certification course in skin care and needs to be familiar with the various lesions that may be identified on assessment of the skin. Which of the following definitions are correct? Select all that apply. a. Petechiae: Tiny punctate hemorrhages, 1 to 3 mm, round and discrete, dark red, purple, or brown in color b. Bulla: Elevated, circumscribed lesion filled with turbid fluid (pus) c. Papule: Hypertrophic scar d. Vesicle: Known as a friction blister e. Nodule: Solid, elevated, and hard or soft growth that is larger than 1 cm

a. Petechiae: Tiny punctate hemorrhages, 1 to 3 mm, round and discrete, dark red, purple, or brown in color d. Vesicle: Known as a friction blister e. Nodule: Solid, elevated, and hard or soft growth that is larger than 1 cm A pustule is an elevated, circumscribed lesion filled with turbid fluid (pus). A hypertrophic scar is a keloid. A bulla is larger than 1 cm and contains clear fluid. A papule is solid and elevated but measures less than 1 cm.

To assess the head control of a 4-month-old infant, the nurse lifts up the infant in a prone position while supporting his chest. The nurse looks for what normal response? The infant: a. Raises the head, and arches the back. b. Extends the arms, and drops down the head. c. Flexes the knees and elbows with the back straight. d. Holds the head at 45 degrees, and keeps the back straight.

a. Raises the head, and arches the back. At 3 months of age, the infant raises the head and arches the back as if in a swan dive. This response is the Landau reflex, which persists until 1 years of age (see Figure 23-43). The other responses are incorrect.

In the assessment of a 1-month-old infant, the nurse notices a lack of response to noise or stimulation. The mother reports that in the last week he has been sleeping all of the time, and when he is awake all he does is cry. The nurse hears that the infants cries are very high pitched and shrill. What should be the nurses appropriate response to these findings? a. Refer the infant for further testing. b. Talk with the mother about eating habits. c. Do nothing; these are expected findings for an infant this age. d. Tell the mother to bring the baby back in 1 week for a recheck.

a. Refer the infant for further testing. A high-pitched, shrill cry or cat-sounding screech occurs with central nervous system damage. Lethargy, hyporeactivity, and hyperirritability, as well as the parents report of significant changes in behavior all warrant referral. The other options are not correct responses.

While obtaining a health history of a 3-month-old infant from the mother, the nurse asks about the infants ability to suck and grasp the mothers finger. What is the nurse assessing? a. Reflexes b. Intelligence c. CNs d. Cerebral cortex function

a. Reflexes Questions regarding reflexes include such questions as, What have you noticed about the infants behavior, Are the infants sucking and swallowing seem coordinated, and Does the infant grasp your finger? The other responses are incorrect.

A 21-year-old patient has a head injury resulting from trauma and is unconscious. There are no other injuries. During the assessment what would the nurse expect to find when testing the patients deep tendon reflexes? a. Reflexes will be normal. b. Reflexes cannot be elicited. c. All reflexes will be diminished but present. d. Some reflexes will be present, depending on the area of injury.

a. Reflexes will be normal. A reflex is a defense mechanism of the nervous system. It operates below the level of conscious control and permits a quick reaction to potentially painful or damaging situations.

Which of these actions is most appropriate to perform on a 9-month-old infant at a well-child checkup? a. Testing for Ortolani sign b. Assessment for stereognosis c. Blood pressure measurement d. Assessment for the presence of the startle reflex

a. Testing for Ortolani sign Until the age of 12 months, the infant should be assessed for Ortolani sign. If Ortolani sign is present, then it could indicate the presence of a dislocated hip. The other tests are not appropriate for a 9-month-old child.

A 75-year-old woman who has a history of diabetes and peripheral vascular disease has been trying to remove a corn on the bottom of her foot with a pair of scissors. The nurse will encourage her to stop trying to remove the corn with scissors because: a. The woman could be at increased risk for infection and lesions because of her chronic disease. b. With her diabetes, she has increased circulation to her foot, and it could cause severe bleeding. c. She is 75 years old and is unable to see; consequently, she places herself at greater risk for self-injury with the scissors. d. With her peripheral vascular disease, her range of motion is limited and she may not be able to reach the corn safely.

a. The woman could be at increased risk for infection and lesions because of her chronic disease.

A 75-year-old woman who has a history of diabetes and peripheral vascular disease has been trying to remove a corn on the bottom of her foot with a pair of scissors. The nurse will encourage her to stop trying to remove the corn with scissors because: a. The woman could be at increased risk for infection and lesions because of her chronic disease. b. With her diabetes, she has increased circulation to her foot, and it could cause severe bleeding. c. She is 75 years old and is unable to see; consequently, she places herself at greater risk for self-injury with the scissors. d. With her peripheral vascular disease, her range of motion is limited and she may not be able to reach the corn safely.

a. The woman could be at increased risk for infection and lesions because of her chronic disease. A personal history of diabetes and peripheral vascular disease increases a persons risk for skin lesions in the feet or ankles. The patient needs to seek a professional for assistance with corn removal.

During the assessment of an 80-year-old patient, the nurse notices that his hands show tremors when he reaches for something and his head is always nodding. No associated rigidity is observed with movement. Which of these statements is most accurate? a. These findings are normal, resulting from aging. b. These findings could be related to hyperthyroidism. c. These findings are the result of Parkinson disease. d. This patient should be evaluated for a cerebellar lesion.

a. These findings are normal, resulting from aging. Senile tremors occasionally occur. These benign tremors include an intention tremor of the hands, head nodding (as if saying yes or no), and tongue protrusion. Tremors associated with Parkinson disease include rigidity, slowness, and a weakness of voluntary movement. The other responses are incorrect.

A 45-year-old farmer comes in for a skin evaluation and complains of hair loss on his head. His hair seems to be breaking off in patches, and he notices some scaling on his head. The nurse begins the examination suspecting: a. Tinea capitis. b. Folliculitis. c. Toxic alopecia. d. Seborrheic dermatitis.

a. Tinea capitis.

A 45-year-old farmer comes in for a skin evaluation and complains of hair loss on his head. His hair seems to be breaking off in patches, and he notices some scaling on his head. The nurse begins the examination suspecting: a. Tinea capitis. b. Folliculitis. c. Toxic alopecia. d. Seborrheic dermatitis.

a. Tinea capitis. Tinea capitis is rounded patchy hair loss on the scalp, leaving broken-off hairs, pustules, and scales on the skin, and is caused by a fungal infection. Lesions are fluorescent under a Wood light and are usually observed in children and farmers; tinea capitis is highly contagious. (See Table 12-12, Abnormal Conditions of Hair, for descriptions of the other terms.)

During the taking of the health history, a patient tells the nurse that it feels like the room is spinning around me. The nurse would document this finding as: a. Vertigo. b. Syncope. c. Dizziness. d. Seizure activity.

a. Vertigo. True vertigo is rotational spinning caused by a neurologic dysfunction or a problem in the vestibular apparatus or the vestibular nuclei in the brainstem. Syncope is a sudden loss of strength or a temporary loss of consciousness. Dizziness is a lightheaded, swimming sensation. Seizure activity is characterized by altered or loss of consciousness, involuntary muscle movements, and sensory disturbances.

During an examination, the nurse finds that a patient has excessive dryness of the skin. The best term to describe this condition is: a. Xerosis. b. Pruritus. c. Alopecia. d. Seborrhea.

a. Xerosis.

During an examination, the nurse finds that a patient has excessive dryness of the skin. The best term to describe this condition is: a. Xerosis. b. Pruritus. c. Alopecia. d. Seborrhea.

a. Xerosis. Xerosis is the term used to describe skin that is excessively dry. Pruritus refers to itching, alopecia refers to hair loss, and seborrhea refers to oily skin.

What term refers to a linear skin lesion that runs along a nerve route? a. Zosteriform b. Annular c. Dermatome d. Shingles

a. Zosteriform Zosteriform describes a lesion that has a linear arrangement along a nerve root. Annular describes a lesion that is circular and begins in the center and spreads to the periphery. A dermatome is an area of skin that is mainly supplied by a single spinal nerve. Shingles (herpes zoster) are small grouped vesicles that emerge along the route of a cutaneous sensory nerve, followed by pustules, and then crusts; shingles is caused by the herpes zoster virus.

To determine if a dark-skinned patient is pale, the nurse should assess the color of the: a. conjunctivae. b. earlobes. c. palms of the hands. d. skin in the antecubital space.

a. conjunctivae. To detect pallor in a dark-skinned patient, the nurse should assess an area with the least pigmentation, such as the conjunctivae or mucous membranes.

The components of a nail examination include: a. contour, consistency, and color. b. shape, surface, and circulation. c. clubbing, pitting, and grooving. d. texture, toughness, and translucency.

a. contour, consistency, and color. The nails should be assessed for shape and contour, consistency, and color.

An area of the body that is supplied mainly from one spinal segment through a particular spinal nerve is identified as a: a. dermatome. b. dermal segmentation. c. hemisphere. d. crossed representation.

a. dermatome. A dermatome is a circumscribed skin area that is supplied mainly from one spinal cord segment through a particular spinal nerve. Dermal segmentation is the cutaneous distribution of the various spinal nerves. Each half of the cerebrum is a hemisphere. Crossed representation is a feature of the nerve tracts; the left cerebral cortex receives sensory information from and controls motor function to the right side of body, whereas the right cerebral cortex likewise interacts with the left side of the body.

The presence of primitive reflexes in a newborn infant is indicative of: a. immaturity of the nervous system. b. prematurity of the infant. c. mental retardation. d. spinal cord alterations.

a. immaturity of the nervous system. The nervous system is not completely developed at birth, and motor activity in the newborn is under the control of the spinal cord and medulla. The neurons are not yet myelinated. Movements are directed primarily by primitive reflexes. As the cerebral cortex develops during the first year, it inhibits these reflexes, and they disappear at predictable times. Persistence of the primitive reflexes is an indication of central nervous system dysfunction.

A flat macular hemorrhage is called a(n): a. purpura. b. ecchymosis. c. petechiae. d. hemangioma.

a. purpura. Purpura is a flat, macular, red-to-purple hemorrhage that is a confluent and extensive patch of petechiae and ecchymoses greater than 3 mm. An ecchymosis is a hemorrhage that is greater than 3 mm. Petechiae are tiny punctate hemorrhages that are 1 to 3 mm; round and discrete; and dark red, purple, or brown caused by bleeding from superficial capillaries. Hemangiomas are vascular lesions caused by a benign proliferation of blood vessels in the dermis.

Automatic associated movements of the body are under the control and regulation of: a. the basal ganglia. b. the thalamus. c. the hypothalamus. d. Wernicke's area.

a. the basal ganglia. The basal ganglia controls automatic associated movements of the body. The thalamus is where sensory pathways of the spinal cord, cerebellum, and brainstem form synapses on their way to the cerebral cortex. The hypothalamus is a major respiratory center with basic vital functions: temperature, appetite, sex drive, heart rate, and blood pressure control; sleep center; anterior and posterior pituitary gland regulation; and coordination of autonomic nervous system activity and stress response. Wernicke's area in the temporal lobe is associated with language comprehension.

A nurse notices that a patient has ascites, which indicates the presence of: a.. Fluid. b. Feces. c. Flatus. d. Fibroid tumors.

a.. Fluid.

Ascites

abnormal accumulation of fluid in the abdomen

Ascites

abnormal accumulation of serous fluid within the peritoneal cavity, associated with congestive heart failure, cirrhosis, cancer, or portal hypertension

Lordosis

abnormal anterior curvature of the lumbar spine (sway-back condition)

Hypospadias

abnormal congenital opening of the male urethra on the undersurface of the penis

Clubbing

abnormal curving (early - straight @ 180, then convex) of the nails that is often accompanied by enlargement of the fingertips OCCURS with congenital cyanotic heart disease, lung cancer, and pulmonary diseases

dull note of lungs signals

abnormal density in lungs, as with pneumonia, pleural effusion, tumor or atelectasis

Bronchophony

abnormal increase in clarity of transmitted voice sounds heard when auscultating the lungs

adventitious sounds

abnormal lung sounds, caused by moving air colliding with secretions in tracheobronchial passageways or by popping open of previously deflated airways

Neuropathic Pain

abnormal processing of pain message; Burning, Shooting or Tingling

Hernia

abnormal protrusion of bowel through weakening in abdominal musculature

Paresthesia

abnormal sensation (such as burning, prickling, or tingling sensation, often in the extremities; may be caused by nerve damage or peripheral neuropathy

Egophony

abnormal voice sound that exists when the patient's "eee" sounds like a loud "aaa"

bradycardia

abnormally slow heartbeat ( in adult less than 60 bpm, and not an athelete.

Scaphoid

abnormally sunken abdominal wall as with malnutrition or underweight

Anuria

absence of urine

Edema

accumulation of fluid in interstitial spaces 1+: mild pitting, slight indentation, no perceptible swelling 2+: moderate pitting, indentation subsides rapidly 3+: deep pitting; indentation remains for a short time; leg looks swollen 4+: very deep pitting, indentation lasts a long time; leg very swollen

Adventitious lung sounds

added sounds superimposed on the basic breath sounds crackles, wheezes, rales

respirations

after taking pulse, commit that number to memory and calculate respiration rate for 30 seconds and multiply by two. Note the rhythm is regularly regular and the character is full and brisk

asthma

allergic to certain inhaled allergens, produces complex response characterized by bronchospasm and inflammation

pleural effusion

an abnormal amount of fluid around the lung. Pleural effusions can result from many medical conditions.

Hyperresonance

an abnormal booming sound produced during percussion of the lungs

Ischemia

an inadequate blood supply to an organ or part of the body, especially the heart muscles.

hypercapnia

an increase of CO2 in the blood; the normal stimulus to breathe.

Ophthalmoscope

an instrument for viewing the interior of the eye or examining the retina

Religion

an organized system of beliefs concerning the cause, nature, and purpose of the universe, especially belief in or the worship of God or gods. The third major component of a person's heritage gives a person a frame of reference and a perspective with which to organize information. plays a most significant role in the ways people practice their health care

S1 loudest?

apex

Nabothian Cysts

are benign growths that commonly appear on the cervix after childbirth. small smooth yellow nodules that may be single or many. odorless and nonirritating

Precrodium

area of chest wall overlying the heart and great vessels

axillary temp

armpit- safe & accurate for infants & young children when environment reasonably controlled

Most common pain conditions for aging adult

arthritis, osteoarthritis, osteoporosis, PVD, cancer, neuropathies, angina, and chronic constipation

bronchophony

ask person to repeat "99" while listen with stethoscope over chest wall. normal finding= voice is soft, muffled and indistinct. abnormal= you auscultate a clear "99"

whispered pectoriloquy

ask person to whisper a phrase as you auscultate. normal = faint, muffled and almost inaudible. abnormal= whispered voice is transmitted clearly, still faint, almost as if person whispering right into your stethoscope

anabolism

assembly of more complex molecules from simpler molecules

pulse oximeter

assess arterial oxygen saturation; normal 97%-99%

Striae

atrophic pink, purple, or white linear streaks on the breasts, associated with pregnancy, excessive weight gain, or rapid growth during adolescence

paroxysmal nocturnal dyspnea

awakening from sleep with SOB and needing to be upright to achieve comfort

A 40-year-old man states that his physician told him that he has a hernia. He asks the nurse to explain what a hernia is. Which response by the nurse is appropriate? a. "No need to worry. Most men your age develop hernias." b. "A hernia is a loop of bowel protruding through a weak spot in the abdominal muscles." c. "A hernia is the result of prenatal growth abnormalities that are just now causing problems." d.. "I'll have to have your physician explain this to you."

b. "A hernia is a loop of bowel protruding through a weak spot in the abdominal muscles."

The nurse is watching a new graduate nurse perform auscultation of a patient's abdomen. Which statement by the new graduate shows a correct understanding of the reason auscultation precedes percussion and palpation of the abdomen? a. "We need to determine the areas of tenderness before using percussion and palpation." b. "Auscultation prevents distortion of bowel sounds that might occur after percussion and palpation." c. "Auscultation allows the patient more time to relax and therefore be more comfortable with the physical examination." d. "Auscultation prevents distortion of vascular sounds, such as bruits and hums, that might occur after percussion and palpation."

b. "Auscultation prevents distortion of bowel sounds that might occur after percussion and palpation."

During an abdominal assessment, the nurse is unable to hear bowel sounds in a patient's abdomen. Before reporting this finding as silent bowel sounds, the nurse should listen for at least: a. 1 minute. b. 5 minutes. c. 10 minutes. d. 2 minutes in each quadrant.

b. 5 minutes.

The nurse is assessing the abdomen of an older adult. Which statement regarding the older adult and abdominal assessment is true? a. Abdominal tone is increased. b. Abdominal musculature is thinner. c. Abdominal rigidity with an acute abdominal condition is more common. d. The older adult with an acute abdominal condition complains more about pain than the younger person.

b. Abdominal musculature is thinner.

The nurse places a key in the hand of a patient and he identifies it as a penny. What term would the nurse use to describe this finding? a. Extinction b. Astereognosis c. Graphesthesia d. Tactile discrimination

b. Astereognosis Stereognosis is the persons ability to recognize objects by feeling their forms, sizes, and weights. Astereognosis is an inability to identify objects correctly, and it occurs in sensory cortex lesions. Tactile discrimination tests fine touch. Extinction tests the persons ability to feel sensations on both sides of the body at the same point.

A 52-year-old woman has a papule on her nose that has rounded, pearly borders and a central red ulcer. She said she first noticed it several months ago and that it has slowly grown larger. The nurse suspects which condition? a. Acne b. Basal cell carcinoma c. Melanoma d. Squamous cell carcinoma

b. Basal cell carcinoma Basal cell carcinoma usually starts as a skin-colored papule that develops rounded, pearly borders with a central red ulcer. It is the most common form of skin cancer and grows slowly. This description does not fit acne lesions. (See Table 12-11 for descriptions of melanoma and squamous cell carcinoma.)

A 5-year-old child is in the clinic for a checkup. The nurse would expect him to: a. Need to be held on his mothers lap. b. Be able to sit on the examination table. c. Be able to stand on the floor for the examination. d. Be able to remain alone in the examination room.

b. Be able to sit on the examination table. At 4 or 5 years old, a child usually feels comfortable on the examination table. Older infants and young children aged 6 months to 2 or 3 years should be positioned in the parents lap.

A semiconscious woman is brought to the emergency department after she was found on the floor in her kitchen. Her face, nail beds, lips, and oral mucosa are a bright cherry-red color. The nurse suspects that this coloring is due to: a. Polycythemia. b. Carbon monoxide poisoning. c. Carotenemia. d. Uremia.

b. Carbon monoxide poisoning. A bright cherry-red coloring in the face, upper torso, nail beds, lips, and oral mucosa appears in cases of carbon monoxide poisoning.

The two parts of the nervous system are the: a. Motor and sensory. b. Central and peripheral. c. Peripheral and autonomic. d. Hypothalamus and cerebral.

b. Central and peripheral. The nervous system can be divided into two partscentral and peripheral. The central nervous system includes the brain and spinal cord. The peripheral nervous system includes the 12 pairs of cranial nerves (CNs), the 31 pairs of spinal nerves, and all of their branches.

The nurse keeps in mind that a thorough skin assessment is extremely important because the skin holds information about a person's: a. Support systems. b. Circulatory status. c. Socioeconomic status. d. Psychological wellness.

b. Circulatory status.

The nurse keeps in mind that a thorough skin assessment is extremely important because the skin holds information about a persons: a. Support systems. b. Circulatory status. c. Socioeconomic status. d. Psychological wellness.

b. Circulatory status. The skin holds information about the bodys circulation, nutritional status, and signs of systemic diseases, as well as topical data on the integumentary system itself.

The ability that humans have to perform very skilled movements such as writing is controlled by the: a. Basal ganglia. b. Corticospinal tract. c. Spinothalamic tract. d. Extrapyramidal tract.

b. Corticospinal tract. Corticospinal fibers mediate voluntary movement, particularly very skilled, discrete, and purposeful movements, such as writing. The corticospinal tract, also known as the pyramidal tract, is a newer, higher motor system that humans have that permits very skilled and purposeful movements. The other responses are not related to skilled movements.

An older patient has been diagnosed with pernicious anemia. The nurse knows that this condition could be related to: a. Increased gastric acid secretion. b. Decreased gastric acid secretion. c. Delayed gastrointestinal emptying time. d. Increased gastrointestinal emptying time.

b. Decreased gastric acid secretion.

Multi-Response: A 69-year-old patient has been admitted to an adult psychiatric unit because his wife thinks he is getting more and more confused. He laughs when he is found to be forgetful, saying Im just getting old! After the nurse completes a thorough neurologic assessment, which findings would be indicative of Alzheimer disease? Select all that apply. a. Occasionally forgetting names or appointments b. Difficulty performing familiar tasks, such as placing a telephone call c. Misplacing items, such as putting dish soap in the refrigerator d. Sometimes having trouble finding the right word e. Rapid mood swings, from calm to tears, for no apparent reason f. Getting lost in ones own neighborhood

b. Difficulty performing familiar tasks, such as placing a telephone call c. Misplacing items, such as putting dish soap in the refrigerator e. Rapid mood swings, from calm to tears, for no apparent reason f. Getting lost in ones own neighborhood Difficulty performing familiar tasks, misplacing items, rapid mood swings, and getting lost in ones own neighborhood can be warning signs of Alzheimer disease. Occasionally forgetting names or appointments, and sometimes having trouble finding the right word are part of normal aging. (For other examples of Alzheimer disease, see Table 23-2.)

In obtaining a health history on a 74-year-old patient, the nurse notes that he drinks alcohol daily and that he has noticed a tremor in his hands that affects his ability to hold things. With this information, what response should the nurse make? a. Does your family know you are drinking every day? b. Does the tremor change when you drink alcohol? c. Well do some tests to see what is causing the tremor. d. You really shouldnt drink so much alcohol; it may be causing your tremor.

b. Does the tremor change when you drink alcohol? Senile tremor is relieved by alcohol, although not a recommended treatment. The nurse should assess whether the person is abusing alcohol in an effort to relieve the tremor.

An older adult woman is brought to the emergency department after being found lying on the kitchen floor for 2 days; she is extremely dehydrated. What would the nurse expect to see during the examination? a. Smooth mucous membranes and lips b. Dry mucous membranes and cracked lips c. Pale mucous membranes d. White patches on the mucous membranes

b. Dry mucous membranes and cracked lips

An older adult woman is brought to the emergency department after being found lying on the kitchen floor for 2 days; she is extremely dehydrated. What would the nurse expect to see during the examination? a. Smooth mucous membranes and lips b. Dry mucous membranes and cracked lips c. Pale mucous membranes d. White patches on the mucous membranes

b. Dry mucous membranes and cracked lips With dehydration, mucous membranes appear dry and the lips look parched and cracked. The other responses are not found in dehydration.

A mother has noticed that her son, who has been to a new babysitter, has some blisters and scabs on his face and buttocks. On examination, the nurse notices moist, thin-roofed vesicles with a thin erythematous base and suspects: a. Eczema. b. Impetigo. c. Herpes zoster. d. Diaper dermatitis.

b. Impetigo.

A mother has noticed that her son, who has been to a new babysitter, has some blisters and scabs on his face and buttocks. On examination, the nurse notices moist, thin-roofed vesicles with a thin erythematous base and suspects: a. Eczema. b. Impetigo. c. Herpes zoster. d. Diaper dermatitis.

b. Impetigo. Impetigo is moist, thin-roofed vesicles with a thin erythematous base and is a contagious bacterial infection of the skin and most common in infants and children. Eczema is characterized by erythematous papules and vesicles with weeping, oozing, and crusts. Herpes zoster (i.e., chickenpox or varicella) is characterized by small, tight vesicles that are shiny with an erythematous base. Diaper dermatitis is characterized by red, moist maculopapular patches with poorly defined borders.

During an assessment of a 22-year-old woman who sustained a head injury from an automobile accident 4 hours earlier, the nurse notices the following changes: pupils were equal, but now the right pupil is fully dilated and nonreactive, and the left pupil is 4 mm and reacts to light. What do these findings suggest? a. Injury to the right eye b. Increased intracranial pressure c. Test inaccurately performed d. Normal response after a head injury

b. Increased intracranial pressure In a person with a brain injury, a sudden, unilateral, dilated, and nonreactive pupil is ominous. CN III runs parallel to the brainstem. When increasing intracranial pressure pushes down the brainstem (uncal herniation), it puts pressure on CN III, causing pupil dilation. The other responses are incorrect.

During a skin assessment, the nurse notices that a Mexican-American patient has skin that is yellowish-brown; however, the skin on the hard and soft palate is pink and the patients scleras are not yellow. From this finding, the nurse could probably rule out: a. Pallor b. Jaundice c. Cyanosis d. Iron deficiency

b. Jaundice Jaundice is exhibited by a yellow color, which indicates rising levels of bilirubin in the blood. Jaundice is first noticed in the junction of the hard and soft palate in the mouth and in the scleras.

The nurse is assessing the skin of a patient who has acquired immunodeficiency syndrome (AIDS) and notices multiple patchlike lesions on the temple and beard area that are faint pink in color. The nurse recognizes these lesions as: a. Measles (rubeola). b. Kaposi's sarcoma. c... Angiomas. d. Herpes zoster.

b. Kaposi's sarcoma.

The nurse is assessing the skin of a patient who has acquired immunodeficiency syndrome (AIDS) and notices multiple patchlike lesions on the temple and beard area that are faint pink in color. The nurse recognizes these lesions as: a. Measles (rubeola). b. Kaposis sarcoma. c. Angiomas. d. Herpes zoster.

b. Kaposis sarcoma. Kaposis sarcoma is a vascular tumor that, in the early stages, appears as multiple, patchlike, faint pink lesions over the patients temple and beard areas. Measles is characterized by a red-purple maculopapular blotchy rash that appears on the third or fourth day of illness. The rash is first observed behind the ears, spreads over the face, and then spreads over the neck, trunk, arms, and legs. Cherry (senile) angiomas are small (1 to 5 mm), smooth, slightly raised bright red dots that commonly appear on the trunk in all adults over 30 years old. Herpes zoster causes vesicles up to 1 cm in size that are elevated with a cavity containing clear fluid.

A few days after a summer hiking trip, a 25-year-old man comes to the clinic with a rash. On examination, the nurse notes that the rash is red, macular, with a bulls eye pattern across his midriff and behind his knees. The nurse suspects: a. Rubeola. b. Lyme disease. c. Allergy to mosquito bites. d. Rocky Mountain spotted fever.

b. Lyme disease. Lyme disease occurs in people who spend time outdoors in May through September. The first disease state exhibits the distinctive bulls eye and a red macular or papular rash that radiates from the site of the tick bite with some central clearing. The rash spreads 5 cm or larger, and is usually in the axilla, midriff, inguinal, or behind the knee, with regional lymphadenopathy.

During an examination, the nurse notices severe nystagmus in both eyes of a patient. Which conclusion by the nurse is correct? Severe nystagmus in both eyes: a. Is a normal occurrence. b. May indicate disease of the cerebellum or brainstem. c. Is a sign that the patient is nervous about the examination. d. Indicates a visual problem, and a referral to an ophthalmologist is indicated.

b. May indicate disease of the cerebellum or brainstem. End-point nystagmus at an extreme lateral gaze normally occurs; however, the nurse should carefully assess any other nystagmuses. Severe nystagmus occurs with disease of the vestibular system, cerebellum, or brainstem.

During the neurologic assessment of a healthy 35-year-old patient, the nurse asks him to relax his muscles completely. The nurse then moves each extremity through full range of motion. Which of these results would the nurse expect to find? a. Firm, rigid resistance to movement b. Mild, even resistance to movement c. Hypotonic muscles as a result of total relaxation d. Slight pain with some directions of movement

b. Mild, even resistance to movement Tone is the normal degree of tension (contraction) in voluntarily relaxed muscles. It shows a mild resistance to passive stretching. Normally, the nurse will notice a mild, even resistance to movement. The other responses are not correct.

During an assessment of the CNs, the nurse finds the following: asymmetry when the patient smiles or frowns, uneven lifting of the eyebrows, sagging of the lower eyelids, and escape of air when the nurse presses against the right puffed cheek. This would indicate dysfunction of which of these CNs? a. Motor component of CN IV b. Motor component of CN VII c. Motor and sensory components of CN XI d. Motor component of CN X and sensory component of CN VII

b. Motor component of CN VII The findings listed reflect a dysfunction of the motor component of the facial nerve (CN VII).

A mother of a 1-month-old infant asks the nurse why it takes so long for infants to learn to roll over. The nurse knows that the reason for this is: a. A demyelinating process must be occurring with her infant. b. Myelin is needed to conduct the impulses, and the neurons of a newborn are not yet myelinated. c. The cerebral cortex is not fully developed; therefore, control over motor function gradually occurs. d. The spinal cord is controlling the movement because the cerebellum is not yet fully developed.

b. Myelin is needed to conduct the impulses, and the neurons of a newborn are not yet myelinated. The infants sensory and motor development proceeds along with the gradual acquisition of myelin, which is needed to conduct most impulses. Very little cortical control exists, and the neurons are not yet myelinated. The other responses are not correct.

Multiple Response A patient has been admitted to a hospital after the staff in the nursing home noticed a pressure ulcer in his sacral area. The nurse examines the pressure ulcer and determines that it is a stage II ulcer. Which of these findings are characteristic of a stage II pressure ulcer? Select all that apply. a. Intact skin appears red but is not broken. b. Partial thickness skin erosion is observed with a loss of epidermis or dermis. c. Ulcer extends into the subcutaneous tissue. d. Localized redness in light skin will blanch with fingertip pressure. e. Open blister areas have a red-pink wound bed. f. Patches of eschar cover parts of the wound.

b. Partial thickness skin erosion is observed with a loss of epidermis or dermis. e. Open blister areas have a red-pink wound bed. Stage I pressure ulcers have intact skin that appears red but is not broken, and localized redness in intact skin will blanche with fingertip pressure. Stage II pressure ulcers have partial thickness skin erosion with a loss of epidermis or also the dermis; open blisters have a red-pink wound bed. Stage III pressure ulcers are full thickness, extending into the subcutaneous tissue; subcutaneous fat may be seen but not muscle, bone, or tendon. Stage IV pressure ulcers involve all skin layers and extend into supporting tissue, exposing muscle, bone, and tendon. Slough (stringy matter attached to the wound bed) or eschar (black or brown necrotic tissue) may be present.

The nurse knows that testing kinesthesia is a test of a persons: a. Fine touch. b. Position sense. c. Motor coordination. d. Perception of vibration.

b. Position sense. Kinesthesia, or position sense, is the persons ability to perceive passive movements of the extremities. The other options are incorrect.

The nurse is assessing the neurologic status of a patient who has a late-stage brain tumor. With the reflex hammer, the nurse draws a light stroke up the lateral side of the sole of the foot and inward, across the ball of the foot. In response, the patients toes fan out, and the big toe shows dorsiflexion. The nurse interprets this result as: a. Negative Babinski sign, which is normal for adults. b. Positive Babinski sign, which is abnormal for adults. c. Clonus, which is a hyperactive response. d. Achilles reflex, which is an expected response.

b. Positive Babinski sign, which is abnormal for adults Dorsiflexion of the big toe and fanning of all toes is a positive Babinski sign, also called up-going toes. This response occurs with upper motor neuron disease of the corticospinal (or pyramidal) tract and is an abnormal finding for adults.

The nurse is assessing the abdomen of a pregnant woman who is complaining of having "acid indigestion" all the time. The nurse knows that esophageal reflux during pregnancy can cause: a. Diarrhea. b. Pyrosis. c... Dysphagia. d. Constipation.

b. Pyrosis.

Which statement is true regarding the recording of data from the history and physical examination? a. Use long, descriptive sentences to document findings. b. Record the data as soon as possible after the interview and physical examination. c. If the information is not documented, then it can be assumed that it was done as a standard of care. d. The examiner should avoid taking any notes during the history and examination because of the possibility of decreasing the rapport with the patient.

b. Record the data as soon as possible after the interview and physical examination. The data from the history and physical examination should be recorded as soon after the event as possible. From a legal perspective, if it is not documented, then it was not done. Brief notes should be taken during the examination. When documenting, the nurse should use short, clear phrases and avoid redundant phrases and descriptions.

A 40-year-old woman reports a change in mole size, accompanied by color changes, itching, burning, and bleeding over the past month. She has a dark complexion and has no family history of skin cancer, but she has had many blistering sunburns in the past. The nurse would: a. Tell the patient to watch the lesion and report back in 2 months. b. Refer the patient because of the suggestion of melanoma on the basis of her symptoms. c. Ask additional questions regarding environmental irritants that may have caused this condition. d. Tell the patient that these signs suggest a compound nevus, which is very common in young to middle-aged adults.

b. Refer the patient because of the suggestion of melanoma on the basis of her symptoms.

A 40-year-old woman reports a change in mole size, accompanied by color changes, itching, burning, and bleeding over the past month. She has a dark complexion and has no family history of skin cancer, but she has had many blistering sunburns in the past. The nurse would: a. Tell the patient to watch the lesion and report back in 2 months. b. Refer the patient because of the suggestion of melanoma on the basis of her symptoms. c. Ask additional questions regarding environmental irritants that may have caused this condition. d. Tell the patient that these signs suggest a compound nevus, which is very common in young to middle-aged adults.

b. Refer the patient because of the suggestion of melanoma on the basis of her symptoms. The ABCD danger signs of melanoma are asymmetry, border irregularity, color variation, and diameter. In addition, individuals may report a change in size, the development of itching, burning, and bleeding, or a new-pigmented lesion. Any one of these signs raises the suggestion of melanoma and warrants immediate referral.

A 22-year-old woman comes to the clinic because of severe sunburn and states, "I was out in the sun for just a couple of minutes." The nurse begins a medication review with her, paying special attention to which medication class? a. Nonsteroidal antiinflammatory drugs for pain b. Tetracyclines for acne c. Proton pump inhibitors for heartburn d. Thyroid replacement hormone for hypothyroidism

b. Tetracyclines for acne

A 22-year-old woman comes to the clinic because of severe sunburn and states, I was out in the sun for just a couple of minutes. The nurse begins a medication review with her, paying special attention to which medication class? a. Nonsteroidal antiinflammatory drugs for pain b. Tetracyclines for acne c. Proton pump inhibitors for heartburn d. Thyroid replacement hormone for hypothyroidism

b. Tetracyclines for acne Drugs that may increase sunlight sensitivity and give a burn response include sulfonamides, thiazide diuretics, oral hypoglycemic agents, and tetracycline.

Which statement concerning the areas of the brain is true? a. The cerebellum is the center for speech and emotions. b. The hypothalamus controls body temperature and regulates sleep. c. The basal ganglia are responsible for controlling voluntary movements. d. Motor pathways of the spinal cord and brainstem synapse in the thalamus.

b. The hypothalamus controls body temperature and regulates sleep. The hypothalamus is a vital area with many important functions: body temperature controller, sleep center, anterior and posterior pituitary gland regulator, and coordinator of autonomic nervous system activity and emotional status. The cerebellum controls motor coordination, equilibrium, and balance. The basal ganglia control autonomic movements of the body. The motor pathways of the spinal cord synapse in various areas of the spinal cord, not in the thalamus.

The assessment of a 60-year-old patient has taken longer than anticipated. In testing his pain perception, the nurse decides to complete the test as quickly as possible. When the nurse applies the sharp point of the pin on his arm several times, he is only able to identify these as one very sharp prick. What would be the most accurate explanation for this? a. The patient has hyperesthesia as a result of the aging process. b. This response is most likely the result of the summation effect. c. The nurse was probably not poking hard enough with the pin in the other areas. d. The patient most likely has analgesia in some areas of arm and hyperalgesia in others.

b. This response is most likely the result of the summation effect. At least 2 seconds should be allowed to elapse between each stimulus to avoid summation. With summation, frequent consecutive stimuli are perceived as one strong stimulus. The other responses are incorrect.

During an abdominal assessment, the nurse would consider which of these findings as normal? a. Presence of a bruit in the femoral area b. Tympanic percussion note in the umbilical region c. Palpable spleen between the ninth and eleventh ribs in the left midaxillary line d. Dull percussion note in the left upper quadrant at the midclavicular line

b. Tympanic percussion note in the umbilical region

The nurse is assessing a patient who has liver disease for jaundice. Which of these assessment findings is indicative of true jaundice? a. Yellow patches in the outer sclera b. Yellow color of the sclera that extends up to the iris c. Skin that appears yellow when examined under low light d. Yellow deposits on the palms and soles of the feet where jaundice first appears

b. Yellow color of the sclera that extends up to the iris

The nurse is assessing a patient who has liver disease for jaundice. Which of these assessment findings is indicative of true jaundice? a. Yellow patches in the outer sclera b. Yellow color of the sclera that extends up to the iris c. Skin that appears yellow when examined under low light d. Yellow deposits on the palms and soles of the feet where jaundice first appears

b. Yellow color of the sclera that extends up to the iris The yellow sclera of jaundice extends up to the edge of the iris. Calluses on the palms and soles of the feet often appear yellow but are not classified as jaundice. Scleral jaundice should not be confused with the normal yellow subconjunctival fatty deposits that are common in the outer sclera of dark-skinned persons.

The _____________ reflex is an example of a __________ reflex. a. plantar; deep tendon b. abdominal; superficial c. quadriceps; pathologic d. corneal light; visceral

b. abdominal; superficial Superficial reflexes test the sensory receptor in the skin; the motor response is a localized muscle contraction. Superficial reflexes include abdominal, cremasteric, and plantar (or Babinski) reflexes. Deep tendon reflexes test the reflex arc at the spinal level and include the biceps, triceps, brachioradialis, quadriceps, and Achilles. The quadriceps reflex is a deep tendon reflex and is normal. The corneal light reflex assesses the parallel alignment of the eye (cranial nerves III, IV, and VI).

The __ coordinates movement, maintains equilibrium, and helps maintain posture. a. extrapyramidal system b. cerebellum c. upper and lower motor neurons d. basal ganglia

b. cerebellum The cerebellum controls motor coordination of voluntary movements, equilibrium (i.e., posture balance of the body), and muscle tone. The extrapyramidal system maintains muscle tone and controls body movements, especially gross automatic movements such as walking. The upper motor neurons are located within the central nervous system; influence or modify the lower motor neurons; and include the corticospinal, corticobulbar, and extrapyramidal tracts. The lower motor neurons are located mostly in the peripheral nervous system and extend from the spinal cord to the muscles; examples include the cranial nerves and spinal nerves. The basal ganglia control automatic associated movements of the body.

Cerebellar function is tested by: a. muscle strength assessment. b. performance of rapid alternating movements. c. the Phalen maneuver. d. superficial pain and touch assessment.

b. performance of rapid alternating movements. The cerebellum controls motor coordination of voluntary movements, equilibrium, and muscle tone. Cerebellar function is tested by balance tests (e.g., gait, Romberg test) and coordination and skilled movements (e.g., rapid alternating movements, finger-to-finger test, finger-to-nose test, heel-to-shin test). Muscle strength assessment examines the intactness of the motor system. The Phalen maneuver reproduces numbness and burning in a patient with carpal tunnel syndrome. Superficial pain and touch assessment examines intactness of the spinothalamic tract.

Clonus that may be seen when testing deep tendon reflexes is characterized by a(n): a. additional contraction of the muscle that is of greater intensity than the first contraction. b. set of rapid, rhythmic contractions of the same muscle. c. parallel response in the opposite extremity. d. contraction of the muscle that appears after the tendon is hit the second time.

b. set of rapid, rhythmic contractions of the same muscle. Clonus is a set of rapid, rhythmic contractions of the same muscle.

Functions of the skin include: a. production of vitamin C. b. temperature regulation. c. production of new cells by melanocytes. d. secretion of a drying substance called sebum.

b. temperature regulation. Functions of the skin include protection, prevention of penetration, perception (of touch, pain, temperature, and pressure), temperature regulation, identification, communication, wound repair, absorption and excretion, and production of vitamin D. The skin produces vitamin D, not vitamin C. The basal cell layer of the epidermis forms new skin cells. Melanocytes produce melanin, which gives brown tones to the skin and hair. Sebum is produced by the sebaceous glands to lubricate the skin and hair.

A 52-year-old woman has a papule on her nose that has rounded, pearly borders and a central red ulcer. She said she first noticed it several months ago and that it has slowly grown larger. The nurse suspects which condition? a.. Acne b.. Basal cell carcinoma c. Melanoma d. Squamous cell carcinoma

b.. Basal cell carcinoma

The nurse is listening to bowel sounds. Which of these statements is true of bowel sounds? Bowel sounds: a. Are usually loud, high-pitched, rushing, and tinkling sounds. b... Are usually high-pitched, gurgling, and irregular sounds. c. Sound like two pieces of leather being rubbed together. d. Originate from the movement of air and fluid through the large intestine.

b... Are usually high-pitched, gurgling, and irregular sounds.

During a skin assessment, the nurse notices that a Mexican-American patient has skin that is yellowish-brown; however, the skin on the hard and soft palate is pink and the patient's scleras are not yellow. From this finding, the nurse could probably rule out: a. Pallor b... Jaundice c. Cyanosis d. Iron deficiency

b... Jaundice

nystagmus

back-and-forth oscillation of the eyes; occurs with disease of the vestibular system, cerebellum, or brainstem

abnormal AP-to-transverse chest diameter in children

barrel shape persisting after age 6 years, may develop with chronic asthma or cystic fibrosis

Popliteal artery

below the knee, divides

Flexion

bending a limb at a joint

BPH

benign prostatic hyperplasia

palpation techniques: dorsa of hands

best for determining temperature because the skin here is thinner than on the palms

Hematuria

blood in the urine

Deep somatic pain examples

blood vessels, joints, tendons, muscles and bone

Cyanotic nail beds

blue tint of fingernails

Bluish cervix- Cyanosis

bluish discoloration of mucosa occurs normally in pregnancy and with any other condition causing hypoxia or venous congestion (heart failure, pelvic tumor)

Cyanosis

bluish discoloration of the skin bluish coloration of the skin caused by a deficient amount of oxygen in the blood

torus palatinus

bony protusion on palate; begins after puberty; benign; more common in females than males

chronic pain behaviors

bracing, rubbing, diminished activity, sighing, change in appetite, being with other people, movement, exercise, prayer, sleeping, or inactivity.

Chronic pain behaviors

bracing, rubbing, diminished activity, sighing, change in appetite, being with other people, movement, prayer, sleeping

Base of the Heart

broader area of heart's outline located at the 3rd right and left intercostal space

A 70-year-old woman who loves to garden has small, flat, brown macules over her arms and hands. She asks, "What causes these liver spots?" The nurse tells her, "They are: a. "Signs of decreased hematocrit related to anemia." b. "Due to the destruction of melanin in your skin from exposure to the sun." c. "Clusters of melanocytes that appear after extensive sun exposure." d. "Areas of hyperpigmentation related to decreased perfusion and vasoconstriction."

c. "Clusters of melanocytes that appear after extensive sun exposure."

A physician has diagnosed a patient with purpura. After leaving the room, a nursing student asks the nurse what the physician saw that led to that diagnosis. The nurse should say, "The physician is referring to the: a. "Blue dilation of blood vessels in a star-shaped linear pattern on the legs." b. "Fiery red, star-shaped marking on the cheek that has a solid circular center." c. "Confluent and extensive patch of petechiae and ecchymoses on the feet." d. "Tiny areas of hemorrhage that are less than 2 mm, round, discrete, and dark red in color."

c. "Confluent and extensive patch of petechiae and ecchymoses on the feet."

The nurse is reviewing the assessment of an aortic aneurysm. Which of these statements is true regarding an aortic aneurysm? a. A bruit is absent. b.. Femoral pulses are increased. c. A pulsating mass is usually present. d.. Most are located below the umbilicus.

c. A pulsating mass is usually present.

A man who was found wandering in a park at 2 AM has been brought to the emergency department for an examination; he said he fell and hit his head. During the examination, the nurse asks him to use his index finger to touch the nurses finger, then his own nose, then the nurses finger again (which has been moved to a different location). The patient is clumsy, unable to follow the instructions, and overshoots the mark, missing the finger. The nurse should suspect which of the following? a. Cerebral injury b. Cerebrovascular accident c. Acute alcohol intoxication d. Peripheral neuropathy

c. Acute alcohol intoxication During the finger-to-finger test, if the person has clumsy movement with overshooting the mark, either a cerebellar disorder or acute alcohol intoxication should be suspected. The persons movements should be smooth and accurate. The other options are not correct.

During an abdominal assessment, the nurse elicits tenderness on light palpation in the right lower quadrant.. The nurse interprets that this finding could indicate a disorder of which of these structures? a. Spleen b. Sigmoid c. Appendix d.. Gallbladder

c. Appendix

A black patient is in the intensive care unit because of impending shock after an accident. The nurse expects to find what characteristics in this patient's skin? a. Ruddy blue. b. Generalized pallor. c. Ashen, gray, or dull. d... Patchy areas of pallor.

c. Ashen, gray, or dull.

A black patient is in the intensive care unit because of impending shock after an accident. The nurse expects to find what characteristics in this patients skin? a. Ruddy blue. b. Generalized pallor. c. Ashen, gray, or dull. d. Patchy areas of pallor.

c. Ashen, gray, or dull. Pallor attributable to shock, with decreased perfusion and vasoconstriction, in black-skinned people will cause the skin to appear ashen, gray, or dull (see Table 12-2).

What term is used to describe involuntary muscle movements? a. Ataxia b. Flaccid c. Athetosis d. Vestibular function

c. Athetosis Athetosis is slow, writhing, continuous, and involuntary movements of the extremities. Ataxia is an impaired ability to coordinate movement, often characterized by a staggering gait and postural imbalance. Flaccid is weak, soft, and flabby; lacking normal muscle tone. Vestibular function is the sense of balance.

A patient is especially worried about an area of skin on her feet that has turned white. The health care provider has told her that her condition is vitiligo. The nurse explains to her that vitiligo is: a. Caused by an excess of melanin pigment b. Caused by an excess of apocrine glands in her feet c. Caused by the complete absence of melanin pigment d. Related to impetigo and can be treated with an ointment

c. Caused by the complete absence of melanin pigment

A patient is especially worried about an area of skin on her feet that has turned white. The health care provider has told her that her condition is vitiligo. The nurse explains to her that vitiligo is: a. Caused by an excess of melanin pigment b. Caused by an excess of apocrine glands in her feet c. Caused by the complete absence of melanin pigment d. Related to impetigo and can be treated with an ointment

c. Caused by the complete absence of melanin pigment Vitiligo is the complete absence of melanin pigment in patchy areas of white or light skin on the face, neck, hands, feet, body folds, and around orificesotherwise, the depigmented skin is normal.

A 30-year-old woman tells the nurse that she has been very unsteady and has had difficulty in maintaining her balance. Which area of the brain that is related to these findings would concern the nurse? a. Thalamus b. Brainstem c. Cerebellum d. Extrapyramidal tract

c. Cerebellum The cerebellar system coordinates movement, maintains equilibrium, and helps maintain posture. The thalamus is the primary relay station where sensory pathways of the spinal cord, cerebellum, and brainstem form synapses on their way to the cerebral cortex. The brainstem consists of the midbrain, pons, and medulla and has various functions, especially concerning autonomic centers. The extrapyramidal tract maintains muscle tone for gross automatic movements, such as walking.

When assessing the neonate, the nurse should test for hip stability with which method? a. Eliciting the Moro reflex b. Performing the Romberg test c. Checking for the Ortolani sign d. Assessing the stepping reflex

c. Checking for the Ortolani sign The nurse should test for hip stability in the neonate by testing for the Ortolani sign. The other tests are not appropriate for testing hip stability.

A 35-year-old pregnant woman comes to the clinic for a monthly appointment. During the assessment, the nurse notices that she has a brown patch of hyperpigmentation on her face. The nurse continues the skin assessment aware that another finding may be: a. Keratoses. b. Xerosis. c. Chloasma. d. Acrochordons.

c. Chloasma. In pregnancy, skin changes can include striae, linea nigra (a brownish-black line down the midline), chloasma (brown patches of hyperpigmentation), and vascular spiders. Keratoses are raised, thickened areas of pigmentation that look crusted, scaly, and warty. Xerosis is dry skin. Acrochordons, or skin tags, occur more often in the aging adult.

A 70-year-old woman who loves to garden has small, flat, brown macules over her arms and hands. She asks, What causes these liver spots? The nurse tells her, They are: a. Signs of decreased hematocrit related to anemia. b. Due to the destruction of melanin in your skin from exposure to the sun. c. Clusters of melanocytes that appear after extensive sun exposure. d. Areas of hyperpigmentation related to decreased perfusion and vasoconstriction.

c. Clusters of melanocytes that appear after extensive sun exposure. Liver spots, or senile lentigines, are clusters of melanocytes that appear on the forearms and dorsa of the hands after extensive sun exposure. The other responses are not correct.

A physician has diagnosed a patient with purpura. After leaving the room, a nursing student asks the nurse what the physician saw that led to that diagnosis. The nurse should say, The physician is referring to the: a. Blue dilation of blood vessels in a star-shaped linear pattern on the legs. b. Fiery red, star-shaped marking on the cheek that has a solid circular center. c. Confluent and extensive patch of petechiae and ecchymoses on the feet. d. Tiny areas of hemorrhage that are less than 2 mm, round, discrete, and dark red in color.

c. Confluent and extensive patch of petechiae and ecchymoses on the feet. Purpura is a confluent and extensive patch of petechiae and ecchymoses and a flat macular hemorrhage observed in generalized disorders such as thrombocytopenia and scurvy. The blue dilation of blood vessels in a star-shaped linear pattern on the legs describes a venous lake. The fiery red, star-shaped marking on the cheek that has a solid circular center describes a spider or star angioma. The tiny areas of hemorrhage that are less than 2 mm, round, discrete, and dark red in color describes petechiae.

A patient comes to the clinic and tells the nurse that he has been confined to his recliner chair for approximately 3 days with his feet down and he asks the nurse to evaluate his feet. During the assessment, the nurse might expect to find: a. Pallor b. Coolness c. Distended veins d. Prolonged capillary filling time

c. Distended veins

A patient comes to the clinic and tells the nurse that he has been confined to his recliner chair for approximately 3 days with his feet down and he asks the nurse to evaluate his feet. During the assessment, the nurse might expect to find: a. Pallor b. Coolness c. Distended veins d. Prolonged capillary filling time

c. Distended veins Keeping the feet in a dependent position causes venous pooling, resulting in redness, warmth, and distended veins. Prolonged elevation would cause pallor and coolness. Immobilization or prolonged inactivity would cause prolonged capillary filling time (see Table 12-1).

When taking the health history on a patient with a seizure disorder, the nurse assesses whether the patient has an aura. Which of these would be the best question for obtaining this information? a. Does your muscle tone seem tense or limp? b. After the seizure, do you spend a lot of time sleeping? c. Do you have any warning sign before your seizure starts? d. Do you experience any color change or incontinence during the seizure?

c. Do you have any warning sign before your seizure starts? Aura is a subjective sensation that precedes a seizure; it could be auditory, visual, or motor. The other questions do not solicit information about an aura.

During a health history, the patient tells the nurse, "I have pain all the time in my stomach. It's worse 2 hours after I eat, but it gets better if I eat again!" Based on these symptoms, the nurse suspects that the patient has which condition? a. Appendicitis b. Gastric ulcer c. Duodenal ulcer d. Cholecystitis

c. Duodenal ulcer

The nurse is performing an assessment on a 29-year-old woman who visits the clinic complaining of always dropping things and falling down. While testing rapid alternating movements, the nurse notices that the woman is unable to pat both of her knees. Her response is extremely slow and she frequently misses. What should the nurse suspect? a. Vestibular disease b. Lesion of CN IX c. Dysfunction of the cerebellum d. Inability to understand directions

c. Dysfunction of the cerebellum When a person tries to perform rapid, alternating movements, responses that are slow, clumsy, and sloppy are indicative of cerebellar disease. The other responses are incorrect.

A patient is having difficulty swallowing medications and food. The nurse would document that this patient has: a. Aphasia. b. Dysphasia. c. Dysphagia. d. Anorexia.

c. Dysphagia.

When the nurse is testing the triceps reflex, what is the expected response? a. Flexion of the hand b. Pronation of the hand c. Extension of the forearm d. Flexion of the forearm

c. Extension of the forearm The normal response of the triceps reflex is extension of the forearm. The normal response of the biceps reflex causes flexion of the forearm. The other responses are incorrect.

A 13-year-old girl is interested in obtaining information about the cause of her acne. The nurse should share with her that acne: a. Is contagious. b. Has no known cause. c. Is caused by increased sebum production. d. Has been found to be related to poor hygiene.

c. Is caused by increased sebum production.

A 13-year-old girl is interested in obtaining information about the cause of her acne. The nurse should share with her that acne: a. Is contagious. b. Has no known cause. c. Is caused by increased sebum production. d. Has been found to be related to poor hygiene.

c. Is caused by increased sebum production. Approximately 90% of males and 80% of females will develop acne; causes are increased sebum production and epithelial cells that do not desquamate normally.

A patient is complaining of a sharp pain along the costovertebral angles. The nurse is aware that this symptom is most often indicative of: a. Ovary infection. b.. Liver enlargement. c. Kidney inflammation. d. Spleen enlargement.

c. Kidney inflammation.

While gathering equipment after an injection, a nurse accidentally received a prick from an improperly capped needle. To interpret this sensation, which of these areas must be intact? a. Corticospinal tract, medulla, and basal ganglia b. Pyramidal tract, hypothalamus, and sensory cortex c. Lateral spinothalamic tract, thalamus, and sensory cortex d. Anterior spinothalamic tract, basal ganglia, and sensory cortex

c. Lateral spinothalamic tract, thalamus, and sensory cortex The spinothalamic tract contains sensory fibers that transmit the sensations of pain, temperature, and crude or light touch. Fibers carrying pain and temperature sensations ascend the lateral spinothalamic tract, whereas the sensations of crude touch form the anterior spinothalamic tract. At the thalamus, the fibers synapse with another sensory neuron, which carries the message to the sensory cortex for full interpretation. The other options are not correct.

The nurse is caring for a patient who has just had neurosurgery. To assess for increased intracranial pressure, what would the nurse include in the assessment? a. CNs, motor function, and sensory function b. Deep tendon reflexes, vital signs, and coordinated movements c. Level of consciousness, motor function, pupillary response, and vital signs d. Mental status, deep tendon reflexes, sensory function, and pupillary response

c. Level of consciousness, motor function, pupillary response, and vital signs Some hospitalized persons have head trauma or a neurologic deficit from a systemic disease process. These people must be closely monitored for any improvement or deterioration in neurologic status and for any indication of increasing intracranial pressure. The nurse should use an abbreviation of the neurologic examination in the following sequence: level of consciousness, motor function, pupillary response, and vital signs.

A nurse is evaluating a newborn for passage of meconium. Which finding would be considered to be abnormal? a. Meconium was passed within 24 hours of birth. b. Meconium was passed within 48 hours of birth. c. Meconium had a distinct odor. d. Meconium had a dark color.

c. Meconium had a distinct odor. Meconium can be passed up to 48 hours after birth.Meconium should not have any odor associated with it. This represents an abnormal finding.Meconium is dark in color.

While examining a patient, the nurse observes abdominal pulsations between the xiphoid process and umbilicus. The nurse would suspect that these are: a. Pulsations of the renal arteries. b. Pulsations of the inferior vena cava. c. Normal abdominal aortic pulsations. d. Increased peristalsis from a bowel obstruction.

c. Normal abdominal aortic pulsations.

During an assessment of an 80-year-old patient, the nurse notices the following: an inability to identify vibrations at her ankle and to identify the position of her big toe, a slower and more deliberate gait, and a slightly impaired tactile sensation. All other neurologic findings are normal. The nurse should interpret that these findings indicate: a. CN dysfunction. b. Lesion in the cerebral cortex. c. Normal changes attributable to aging. d. Demyelination of nerves attributable to a lesion.

c. Normal changes attributable to aging. Some aging adults show a slower response to requests, especially for those calling for coordination of movements. The findings listed are normal in the absence of other significant abnormal findings. The other responses are incorrect.

The nurse is assessing for inflammation in a dark-skinned person. Which technique is the best? a. Assessing the skin for cyanosis and swelling b. Assessing the oral mucosa for generalized erythema c. Palpating the skin for edema and increased warmth d. Palpating for tenderness and local areas of ecchymosis

c. Palpating the skin for edema and increased warmth

The nurse is assessing for inflammation in a dark-skinned person. Which technique is the best? a. Assessing the skin for cyanosis and swelling b. Assessing the oral mucosa for generalized erythema c. Palpating the skin for edema and increased warmth d. Palpating for tenderness and local areas of ecchymosis

c. Palpating the skin for edema and increased warmth Because inflammation cannot be seen in dark-skinned persons, palpating the skin for increased warmth, for taut or tightly pulled surfaces that may be indicative of edema, and for a hardening of deep tissues or blood vessels is often necessary.

Which piece of equipment would the nurse use to elicit a pupillary reflex in a newborn? a. Flashlight b. Tape measure c. Penlight d. Reflex hammer

c. Penlight A penlight would be appropriate to use to elicit a pupillary reflex in a newborn.Although a flashlight is a light source, it would not be used to elicit a pupillary reflex in a newborn. A tape measure would be used for measurement of length and circumference during the newborn physical examination.A reflex hammer would be used to evaluate motor reflexes.

The nurse is performing a neurologic assessment on a 41-year-old woman with a history of diabetes. When testing her ability to feel the vibrations of a tuning fork, the nurse notices that the patient is unable to feel vibrations on the great toe or ankle bilaterally, but she is able to feel vibrations on both patellae. Given this information, what would the nurse suspect? a. Hyperalgesia b. Hyperesthesia c. Peripheral neuropathy d. Lesion of sensory cortex

c. Peripheral neuropathy Loss of vibration sense occurs with peripheral neuropathy (e.g., diabetes and alcoholism). Peripheral neuropathy is worse at the feet and gradually improves as the examiner moves up the leg, as opposed to a specific nerve lesion, which has a clear zone of deficit for its dermatome. The other responses are incorrect.

A patient comes in for a physical examination and complains of "freezing to death" while waiting for her examination. The nurse notes that her skin is pale and cool and attributes this finding to: a. Venous pooling. b. Peripheral vasodilation. c. Peripheral vasoconstriction. d. Decreased arterial perfusion.

c. Peripheral vasoconstriction.

A patient comes in for a physical examination and complains of freezing to death while waiting for her examination. The nurse notes that her skin is pale and cool and attributes this finding to: a. Venous pooling. b. Peripheral vasodilation. c. Peripheral vasoconstriction. d. Decreased arterial perfusion.

c. Peripheral vasoconstriction. A chilly or air-conditioned environment causes vasoconstriction, which results in false pallor and coolness (see Table 12-1).

A patient has been admitted for severe psoriasis. The nurse expects to see what finding in the patient's fingernails? a. Splinter hemorrhages b. Paronychia c. Pitting d. Beau lines

c. Pitting

A patient has been admitted for severe psoriasis. The nurse expects to see what finding in the patients fingernails? a. Splinter hemorrhages b. Paronychia c. Pitting d. Beau lines

c. Pitting Sharply defined pitting and crumbling of the nails, each with distal detachment characterize pitting nails and are associated with psoriasis. (See Table 12-13 for descriptions of the other terms.)

The nurse is testing superficial reflexes on an adult patient. When stroking up the lateral side of the sole and across the ball of the foot, the nurse notices the plantar flexion of the toes. How should the nurse document this finding? a. Positive Babinski sign b. Plantar reflex abnormal c. Plantar reflex present d. Plantar reflex 2+ on a scale from 0 to 4+

c. Plantar reflex present With the same instrument, the nurse should draw a light stroke up the lateral side of the sole of the foot and across the ball of the foot, similar to an upside-down J. The normal response is plantar flexion of the toes and sometimes of the entire foot. A positive Babinski sign is abnormal and occurs with the response of dorsiflexion of the big toe and fanning of all toes. The plantar reflex is not graded on a 0 to 4+ scale.

A patient is unable to perform rapid alternating movements such as rapidly patting her knees. The nurse should document this inability as: a. Ataxia. b. Astereognosis. c. Presence of dysdiadochokinesia. d. Loss of kinesthesia.

c. Presence of dysdiadochokinesia. Slow clumsy movements and the inability to perform rapid alternating movements occur with cerebellar disease. The condition is termed dysdiadochokinesia. Ataxia is an uncoordinated or unsteady gait. Astereognosis is the inability to identify an object by feeling it. Kinesthesia is the persons ability to perceive passive movement of the extremities or the loss of position sense.

A 42-year-old woman complains that she has noticed several small, slightly raised, bright red dots on her chest. On examination, the nurse expects that the spots are probably: a. Anasarca. b. Scleroderma. c. Senile angiomas. d. Latent myeloma.

c. Senile angiomas. Cherry (senile) angiomas are small, smooth, slightly raised bright red dots that commonly appear on the trunk of adults over 30 years old.

The nurse has discovered decreased skin turgor in a patient and knows that this finding is expected in which condition? a. Severe obesity b. Childhood growth spurts c. Severe dehydration d. Connective tissue disorders such as scleroderma

c. Severe dehydration Decreased skin turgor is associated with severe dehydration or extreme weight loss.

The area of the nervous system that is responsible for mediating reflexes is the: a. Medulla. b. Cerebellum. c. Spinal cord. d. Cerebral cortex.

c. Spinal cord. The spinal cord is the main highway for ascending and descending fiber tracts that connect the brain to the spinal nerves; it is responsible for mediating reflexes.

A patient has a severed spinal nerve as a result of trauma. Which statement is true in this situation? a. Because there are 31 pairs of spinal nerves, no effect results if only one nerve is severed. b. The dermatome served by this nerve will no longer experience any sensation. c. The adjacent spinal nerves will continue to carry sensations for the dermatome served by the severed nerve. d. A severed spinal nerve will only affect motor function of the patient because spinal nerves have no sensory component.

c. The adjacent spinal nerves will continue to carry sensations for the dermatome served by the severed nerve. A dermatome is a circumscribed skin area that is primarily supplied from one spinal cord segment through a particular spinal nerve. The dermatomes overlap, which is a form of biologic insurance; that is, if one nerve is severed, then most of the sensations can be transmitted by the spinal nerve above and the spinal nerve below the severed nerve.

A newborn infant is in the clinic for a well-baby checkup. The nurse observes the infant for the possibility of fluid loss because of which of these factors? a. Subcutaneous fat deposits are high in the newborn. b. Sebaceous glands are overproductive in the newborn. c. The newborns skin is more permeable than that of the adult. d. The amount of vernix caseosa dramatically rises in the newborn.

c. The newborns skin is more permeable than that of the adult. The newborns skin is thin, smooth, and elastic and is relatively more permeable than that of the adult; consequently, the infant is at greater risk for fluid loss. The subcutaneous layer in the infant is inefficient, not thick, and the sebaceous glands are present but decrease in size and production. Vernix caseosa is not produced after birth.

A patient with a lack of oxygen to his heart will have pain in his chest and possibly in the shoulder, arms, or jaw. The nurse knows that the best explanation why this occurs is which one of these statements? a. A problem exists with the sensory cortex and its ability to discriminate the location. b. The lack of oxygen in his heart has resulted in decreased amount of oxygen to the areas experiencing the pain. c. The sensory cortex does not have the ability to localize pain in the heart; consequently, the pain is felt elsewhere. d. A lesion has developed in the dorsal root, which is preventing the sensation from being transmitted normally.

c. The sensory cortex does not have the ability to localize pain in the heart; consequently, the pain is felt elsewhere. The sensory cortex is arranged in a specific pattern, forming a corresponding map of the body. Pain in the right hand is perceived at a specific spot on the map. Some organs, such as the heart, liver, and spleen, are absent from the brain map. Pain originating in these organs is referred because no felt image exists in which to have pain. Pain is felt by proxy, that is, by another body part that does have a felt image. The other responses are not correct explanations.

While assessing a 7-month-old infant, the nurse makes a loud noise and notices the following response: abduction and flexion of the arms and legs; fanning of the fingers, and curling of the index finger and thumb in a C position, followed by the infant bringing in the arms and legs to the body. What does the nurse know about this response? a. This response could indicate brachial nerve palsy. b. This reaction is an expected startle response at this age. c. This reflex should have disappeared between 1 and 4 months of age. d. This response is normal as long as the movements are bilaterally symmetric.

c. This reflex should have disappeared between 1 and 4 months of age. The Moro reflex is present at birth and usually disappears at 1 to 4 months. Absence of the Moro reflex in the newborn or its persistence after 5 months of age indicates severe central nervous system injury. The other responses are incorrect.

The nurse is performing percussion during an abdominal assessment. Percussion notes heard during the abdominal assessment may include: a. Flatness, resonance, and dullness. b. Resonance, dullness, and tympany. c. Tympany, hyperresonance, and dullness. d. Resonance, hyperresonance, and flatness.

c. Tympany, hyperresonance, and dullness.

During an assessment, the nurse notices that a patient's umbilicus is enlarged and everted. It is positioned midline with no change in skin color. The nurse recognizes that the patient may have which condition? a. Intra-abdominal bleeding b. Constipation c. Umbilical hernia d. Abdominal tumor

c. Umbilical hernia

To assess the rooting reflex in a newborn, the nurse would: a. observe the abdomen for movement. b. stroke the bottom of the foot to see if the toes curl. c. examine the face looking at mouth movement. d. flex the hips to determine if there is any abnormal movement or clicking sound.

c. examine the face looking at mouth movement. To assess the rooting reflex, the nurse would look at the face and movement of the mouth in response to stimuli.Stroking the bottom of the foot would elicit a Babinski reflex.Flexing the hips to determine abnormal movment or the presence of a clicking sound would be done to assess for hip dysplasia.

An abnormal sensation of burning or tingling is best described as: a. paralysis. b. paresis. c. paresthesia. d. paraphasia.

c. paresthesia. Paresthesia is an abnormal sensation such as burning or tingling. Paralysis is a loss of motor function as a result of a lesion in the neurologic or muscular system or loss of sensory innervation. Paresis is a partial or incomplete paralysis. Paraphasia is a condition in which a person hears and comprehends words but is unable to speak correctly; incoherent words are substituted for intended words.

The nurse is reviewing information relative to the newborn focusing on the Apgar score results. The nurse understands that the Apgar score: a. indicates the infant's ability to feed and sustain weight gain during the first year. b. provides an idea of motor function progression during the neonatal period. c. provides evidence of the neonate's transition to the external environment. d. gives an idea of the neonate's cognitive function during the neonate period.

c. provides evidence of the neonate's transition to the external environment. The Apgar score provides information relative to the newborn's ability to adapt immediately after birth to extrauterine life. Apgar scoring indicates the newborn's immediate response to extrauterine life.

Testing the deep tendon reflexes gives the examiner information regarding the intactness of the: a. corticospinal tract. b. medulla. c. reflex arc at specific levels in the spinal cord. d. upper motor and lower motor neuron synaptic junction.

c. reflex arc at specific levels in the spinal cord. Measurement of the deep tendon reflexes reveals the intactness of the reflex arc at specific spinal levels. The corticospinal tract is the higher motor system that permits very skilled and purposeful movements such as writing. The medulla contains all ascending and descending fiber tracts; it has vital autonomic centers for respiration, heart, and gastrointestinal function as well as nuclei for cranial nerves VIII through XII. The upper motor neurons are located within the central nervous system and influence or modify the lower motor neurons and include the corticospinal, corticobulbar, and extrapyramidal tracts. The lower motor neurons are located mostly in the peripheral nervous system and extend from the spinal cord to the muscles; examples include the cranial nerves and spinal nerves.

A 42-year-old woman complains that she has noticed several small, slightly raised, bright red dots on her chest. On examination, the nurse expects that the spots are probably: a. Anasarca. b. Scleroderma. c... Senile angiomas. d. Latent myeloma.

c... Senile angiomas.

syphillis

can cause an Argyll-Robertson pupil. Argyll-Robertson pupils are small, unequal, misshapen pupils that constrict with near focusing but do not react normally to light.

stroke

can cause changes in the size (decrease) of the pupil

Head Trauma, concussion, injury (pupils)

can cause unequal pupils

thrush

candiadis in the newborn

Culturally sensitive

caregivers POSSESS some basic knowledge of and constructive attitudes toward the diverse cultural populations found in the setting in which they are practicing

Veins

carry blood to the heart

Occlusions

cause by atherosclerosis

Wernicke's area

center for humans highest functions governing thought, memory, reasoning, sensation and voluntary movement.

Macular degeneration is a loss in---

central vision caused by yello wdeposits (drusen) and neovascularity in the macula CAUSES: inability to read books/papers, sew, or do fine work and recognize faces

The cranium (skull) is supported by

cervical vertebrae: C1("atlas"), C2 ("axis") and down to C7.

atelectasis

complete or partial collapse of a lung or lobe of a lung — develops when the tiny air sacs (alveoli) within the lung become deflated. It's a breathing (respiratory) complication after surgery.

increased fremitus occurs with

compression or consolidation of lung tissue i.e. lobar pneumonia

inspection

concentrated watching, first at person as a whole then each body system

Multipara

condition of having two or more pregnancies

Epispadias

congenital defect in which the urinary meatus is located on the upper surface of the penis

Perforators

connecting veins that join two sets, have one way valves

Functions of the lymphatic system

conserve fluid and plasma proteins that leak out of the capillaries, form a major part of the immune system that defends the body against disease, absorb lipids from the intestinal tract

thorax of aging adult

costal cartilages become calcified resulting in less mobile thorax

Hemoptysis

coughing up blood

heritage components

culture, ethnicity, religion, spirituality

A father brings in his 2-month-old infant to the clinic because the infant has had diarrhea for the last 24 hours. He says his baby has not been able to keep any formula down and that the diarrhea has been at least every 2 hours. The nurse suspects dehydration. The nurse should test skin mobility and turgor over the infant's: a. Sternum. b. Forehead. c. Forearms. d. Abdomen.

d. Abdomen.

A father brings in his 2-month-old infant to the clinic because the infant has had diarrhea for the last 24 hours. He says his baby has not been able to keep any formula down and that the diarrhea has been at least every 2 hours. The nurse suspects dehydration. The nurse should test skin mobility and turgor over the infants: a. Sternum. b. Forehead. c. Forearms. d. Abdomen.

d. Abdomen. Mobility and turgor are tested over the abdomen in an infant. Poor turgor, or tenting, indicates dehydration or malnutrition. The other sites are not appropriate for checking skin turgor in an infant.

A 22-year-old man comes to the clinic for an examination after falling off his motorcycle and landing on his left side on the handle bars. The nurse suspects that he may have injured his spleen. Which of these statements is true regarding assessment of the spleen in this situation? a. The spleen can be enlarged as a result of trauma. b. The spleen is normally felt on routine palpation. c. If an enlarged spleen is noted, then the nurse should thoroughly palpate to determine its size. d. An enlarged spleen should not be palpated because it can easily rupture.

d. An enlarged spleen should not be palpated because it can easily rupture.

The nurse is bathing an 80-year-old man and notices that his skin is wrinkled, thin, lax, and dry. This finding would be related to which factor in the older adult? a. Increased vascularity of the skin b. Increased numbers of sweat and sebaceous glands c. An increase in elastin and a decrease in subcutaneous fat d. An increased loss of elastin and a decrease in subcutaneous fat

d. An increased loss of elastin and a decrease in subcutaneous fat

The nurse is bathing an 80-year-old man and notices that his skin is wrinkled, thin, lax, and dry. This finding would be related to which factor in the older adult? a. Increased vascularity of the skin b. Increased numbers of sweat and sebaceous glands c. An increase in elastin and a decrease in subcutaneous fat d. An increased loss of elastin and a decrease in subcutaneous fat

d. An increased loss of elastin and a decrease in subcutaneous fat An accumulation of factors place the aging person at risk for skin disease and breakdown: the thinning of the skin, a decrease in vascularity and nutrients, the loss of protective cushioning of the subcutaneous layer, a lifetime of environmental trauma to skin, the social changes of aging, a increasingly sedentary lifestyle, and the chance of immobility.

During an abdominal assessment, the nurse tests for a fluid wave. A positive fluid wave test occurs with: a. Splenomegaly. b. Distended bladder. c. Constipation. d. Ascites.

d. Ascites.

During the taking of the health history of a 78-year-old man, his wife states that he occasionally has problems with short-term memory loss and confusion: He cant even remember how to button his shirt. When assessing his sensory system, which action by the nurse is most appropriate? a. The nurse would not test the sensory system as part of the examination because the results would not be valid. b. The nurse would perform the tests, knowing that mental status does not affect sensory ability. c. The nurse would proceed with an explanation of each test, making certain that the wife understands. d. Before testing, the nurse would assess the patients mental status and ability to follow directions.

d. Before testing, the nurse would assess the patients mental status and ability to follow directions. The nurse should ensure the validity of the sensory system testing by making certain that the patient is alert, cooperative, comfortable, and has an adequate attention span. Otherwise, the nurse may obtain misleading and invalid results.

A 32-year-old woman tells the nurse that she has noticed very sudden, jerky movements mainly in her hands and arms. She says, They seem to come and go, primarily when I am trying to do something. I havent noticed them when Im sleeping. This description suggests: a. Tics. b. Athetosis. c. Myoclonus. d. Chorea.

d. Chorea. Chorea is characterized by sudden, rapid, jerky, purposeless movements that involve the limbs, trunk, or face. Chorea occurs at irregular intervals, and the movements are all accentuated by voluntary actions. (See Table 23-5 for the descriptions of athetosis, myoclonus, and tics.)

A 65-year-old man with emphysema and bronchitis has come to the clinic for a follow-up appointment. On assessment, the nurse might expect to see which finding? a. Anasarca b. Scleroderma c. Pedal erythema d. Clubbing of the nails

d. Clubbing of the nails

A 50-year-old woman is in the clinic for weakness in her left arm and leg that she has noticed for the past week. The nurse should perform which type of neurologic examination? a. Glasgow Coma Scale b. Neurologic recheck examination c. Screening neurologic examination d. Complete neurologic examination

d. Complete neurologic examination The nurse should perform a complete neurologic examination on an individual who has neurologic concerns (e.g., headache, weakness, loss of coordination) or who is showing signs of neurologic dysfunction. The Glasgow Coma Scale is used to define a persons level of consciousness. The neurologic recheck examination is appropriate for those who are demonstrating neurologic deficits. The screening neurologic examination is performed on seemingly well individuals who have no significant subjective findings from the health history.

The nurse is describing a scaphoid abdomen. To the horizontal plane, a scaphoid contour of the abdomen depicts a ______ profile. a. Flat b. Convex c. Bulging d. Concave

d. Concave

The nurse educator is preparing an education module for the nursing staff on the dermis layer of skin. Which of these statements would be included in the module? The dermis: a. Contains mostly fat cells. b. Consists mostly of keratin. c. Is replaced every 4 weeks. d. Contains sensory receptors.

d. Contains sensory receptors.

The nurse educator is preparing an education module for the nursing staff on the dermis layer of skin. Which of these statements would be included in the module? The dermis: a. Contains mostly fat cells. b. Consists mostly of keratin. c. Is replaced every 4 weeks. d. Contains sensory receptors.

d. Contains sensory receptors. The dermis consists mostly of collagen, has resilient elastic tissue that allows the skin to stretch, and contains nerves, sensory receptors, blood vessels, and lymphatic vessels. It is not replaced every 4 weeks.

A newborn infant has Down syndrome. During the skin assessment, the nurse notices a transient mottling in the trunk and extremities in response to the cool temperature in the examination room. The infant's mother also notices the mottling and asks what it is. The nurse knows that this mottling is called: a. Café au lait. b. Carotenemia. c... Acrocyanosis. d. Cutis marmorata.

d. Cutis marmorata.

A newborn infant has Down syndrome. During the skin assessment, the nurse notices a transient mottling in the trunk and extremities in response to the cool temperature in the examination room. The infants mother also notices the mottling and asks what it is. The nurse knows that this mottling is called: a. Caf au lait. b. Carotenemia. c. Acrocyanosis. d. Cutis marmorata.

d. Cutis marmorata. Persistent or pronounced cutis marmorata occurs with infants born with Down syndrome or those born prematurely and is a transient mottling in the trunk and extremities in response to cool room temperatures. A caf au lait spot is a large round or oval patch of light-brown pigmentation. Carotenemia produces a yellow-orange color in light-skinned persons. Acrocyanosis is a bluish color around the lips, hands and fingernails, and feet and toenails.

The nurse is aware that one change that may occur in the gastrointestinal system of an aging adult is: a. Increased salivation. b. Increased liver size. c. Increased esophageal emptying. d. Decreased gastric acid secretion.

d. Decreased gastric acid secretion.

While the nurse is taking the history of a 68-year-old patient who sustained a head injury 3 days earlier, he tells the nurse that he is on a cruise ship and is 30 years old. The nurse knows that this finding is indicative of a(n): a. Great sense of humor. b. Uncooperative behavior. c. Inability to understand questions. d. Decreased level of consciousness.

d. Decreased level of consciousness. A change in consciousness may be subtle. The nurse should notice any decreasing level of consciousness, disorientation, memory loss, uncooperative behavior, or even complacency in a previously combative person. The other responses are incorrect.

When taking the health history, the patient complains of pruritus. What is a common cause of this symptom? a. Excessive bruising b. Hyperpigmentation c. Melasma d. Drug reactions

d. Drug reactions Drug reactions can lead to pruritus or itching.Excessive bruising can occur in response to a traumatic event or a coagulation abnormality. It is associated with erythema, not pruritus. Hyperpigmentation is related to color changes. Melasma (also known as chloasma or the mask of pregnancy) is a facial skin discoloration related to hormones of pregnancy.

A patient comes to the clinic and states that he has noticed that his skin is redder than normal. The nurse understands that this condition is due to hyperemia and knows that it can be caused by: a... Decreased amounts of bilirubin in the blood b. Excess blood in the underlying blood vessels c. Decreased perfusion to the surrounding tissues d. Excess blood in the dilated superficial capillaries

d. Excess blood in the dilated superficial capillaries

A patient comes to the clinic and states that he has noticed that his skin is redder than normal. The nurse understands that this condition is due to hyperemia and knows that it can be caused by: a. Decreased amounts of bilirubin in the blood b. Excess blood in the underlying blood vessels c. Decreased perfusion to the surrounding tissues d. Excess blood in the dilated superficial capillaries

d. Excess blood in the dilated superficial capillaries Erythema is an intense redness of the skin caused by excess blood (hyperemia) in the dilated superficial capillaries.

The nurse is assessing a patient for possible peptic ulcer disease. Which condition or history often causes this problem? a. Hypertension b. Streptococcal infections c. Recurrent constipation with frequent laxative use d. Frequent use of nonsteroidal antiinflammatory drugs

d. Frequent use of nonsteroidal antiinflammatory drugs

The physician comments that a patient has abdominal borborygmi. The nurse knows that this term refers to: a. Loud continual hum. b. Peritoneal friction rub. c. Hypoactive bowel sounds. d. Hyperactive bowel sounds.

d. Hyperactive bowel sounds.

In assessing a 70-year-old patient who has had a recent cerebrovascular accident, the nurse notices right-sided weakness. What might the nurse expect to find when testing his reflexes on the right side? a. Lack of reflexes b. Normal reflexes c. Diminished reflexes d. Hyperactive reflexes

d. Hyperactive reflexes Hyperreflexia is the exaggerated reflex observed when the monosynaptic reflex arc is released from the influence of higher cortical levels. This response occurs with upper motor neuron lesions (e.g., a cerebrovascular accident). The other responses are incorrect.

A woman is leaving on a trip to Hawaii and has come in for a checkup. During the examination the nurse learns that she has diabetes and takes oral hypoglycemic agents. The patient needs to be concerned about which possible effect of her medications? a. Increased possibility of bruising b. Skin sensitivity as a result of exposure to salt water c. Lack of availability of glucose-monitoring supplies d. Importance of sunscreen and avoiding direct sunlight

d. Importance of sunscreen and avoiding direct sunlight

A woman is leaving on a trip to Hawaii and has come in for a checkup. During the examination the nurse learns that she has diabetes and takes oral hypoglycemic agents. The patient needs to be concerned about which possible effect of her medications? a. Increased possibility of bruising b. Skin sensitivity as a result of exposure to salt water c. Lack of availability of glucose-monitoring supplies d. Importance of sunscreen and avoiding direct sunlight

d. Importance of sunscreen and avoiding direct sunlight Drugs that may increase sunlight sensitivity and give a burn response include sulfonamides, thiazide diuretics, oral hypoglycemic agents, and tetracycline.

During an assessment of a 32-year-old patient with a recent head injury, the nurse notices that the patient responds to pain by extending, adducting, and internally rotating his arms. His palms pronate, and his lower extremities extend with plantar flexion. Which statement concerning these findings is most accurate? This patients response: a. Indicates a lesion of the cerebral cortex. b. Indicates a completely nonfunctional brainstem. c. Is normal and will go away in 24 to 48 hours. d. Is a very ominous sign and may indicate brainstem injury.

d. Is a very ominous sign and may indicate brainstem injury. These findings are all indicative of decerebrate rigidity, which is a very ominous condition and may indicate a brainstem injury.

A patient has had a terrible itch for several months that he has been continuously scratching. On examination, the nurse might expect to find: a. A keloid. b. A fissure. c. Keratosis. d. Lichenification.

d. Lichenification. Lichenification results from prolonged, intense scratching that eventually thickens the skin and produces tightly packed sets of papules. A keloid is a hypertrophic scar. A fissure is a linear crack with abrupt edges, which extends into the dermis; it can be dry or moist. Keratoses are lesions that are raised, thickened areas of pigmentation that appear crusted, scaly, and warty.

During the aging process, the hair can look gray or white and begin to feel thin and fine. The nurse knows that this occurs because of a decrease in the number of functioning: a. Metrocytes. b. Fungacytes. c... Phagocytes. d. Melanocytes.

d. Melanocytes.

During the aging process, the hair can look gray or white and begin to feel thin and fine. The nurse knows that this occurs because of a decrease in the number of functioning: a. Metrocytes. b. Fungacytes. c. Phagocytes. d. Melanocytes.

d. Melanocytes. In the aging hair matrix, the number of functioning melanocytes decreases; as a result, the hair looks gray or white and feels thin and fine. The other options are not correct.

The nurse is testing the function of CN XI. Which statement best describes the response the nurse should expect if this nerve is intact? The patient: a. Demonstrates the ability to hear normal conversation. b. Sticks out the tongue midline without tremors or deviation. c. Follows an object with his or her eyes without nystagmus or strabismus. d. Moves the head and shoulders against resistance with equal strength.

d. Moves the head and shoulders against resistance with equal strength. The following normal findings are expected when testing the spinal accessory nerve (CN XI): The patients sternomastoid and trapezius muscles are equal in size; the person can forcibly rotate the head both ways against resistance applied to the side of the chin with equal strength; and the patient can shrug the shoulders against resistance with equal strength on both sides. Checking the patients ability to hear normal conversation checks the function of CN VIII. Having the patient stick out the tongue checks the function of CN XII. Testing the eyes for nystagmus or strabismus is performed to check CNs III, IV, and VI.

The nurse is assessing for clubbing of the fingernails and expects to find: a. Nail bases that are firm and slightly tender. b. Curved nails with a convex profile and ridges across the nails. c.. Nail bases that feel spongy with an angle of the nail base of 150 degrees. d. Nail bases with an angle of 180 degrees or greater and nail bases that feel spongy.

d. Nail bases with an angle of 180 degrees or greater and nail bases that feel spongy.

The nurse is assessing for clubbing of the fingernails and expects to find: a. Nail bases that are firm and slightly tender. b. Curved nails with a convex profile and ridges across the nails. c. Nail bases that feel spongy with an angle of the nail base of 150 degrees. d. Nail bases with an angle of 180 degrees or greater and nail bases that feel spongy.

d. Nail bases with an angle of 180 degrees or greater and nail bases that feel spongy. The normal nail is firm at its base and has an angle of 160 degrees. In clubbing, the angle straightens to 180 degrees or greater and the nail base feels spongy.

A student nurse has been assigned to teach fourth graders about hygiene. While preparing, the student nurse adds information about the sweat glands. Which of the following should be included while discussing this topic? a. There are two types of sweat glands: eccrine glands and sebaceous glands. b. The evaporation of sweat, a dilute saline solution, increases body temperature. c. Eccrine glands produce sweat and are mainly located in the axillae, anogenital area, and navel. d. Newborn infants do not sweat and use compensatory mechanisms to control body temperature.

d. Newborn infants do not sweat and use compensatory mechanisms to control body temperature. Newborn infants' eccrine glands do not secrete sweat in response to heat until the first few months of life; newborn temperature regulation is ineffective. There are two types of sweat glands: eccrine glands and apocrine glands. The evaporation of sweat reduces body temperature. The apocrine glands produce a thick, milky secretion and open into the hair follicles; they are located mainly in the axillae, anogenital area, nipples, and navel.

The nurse notices that a patient has a solid, elevated, circumscribed lesion that is less than 1 cm in diameter. When documenting this finding, the nurse reports this as a: a. Bulla. b. Wheal. c. Nodule. d. Papule.

d. Papule. A papule is something one can feel, is solid, elevated, circumscribed, less than 1 cm in diameter, and is due to superficial thickening in the epidermis. A bulla is larger than 1 cm, superficial, and thin walled. A wheal is superficial, raised, transient, erythematous, and irregular in shape attributable to edema. A nodule is solid, elevated, hard or soft, and larger than 1 cm.

When the nurse asks a 68-year-old patient to stand with his feet together and arms at his side with his eyes closed, he starts to sway and moves his feet farther apart. The nurse would document this finding as: a. Ataxia. b. Lack of coordination. c. Negative Homans sign. d. Positive Romberg sign.

d. Positive Romberg sign. Abnormal findings for the Romberg test include swaying, falling, and a widening base of the feet to avoid falling. A positive Romberg sign is a loss of balance that is increased by the closing of the eyes. Ataxia is an uncoordinated or unsteady gait. Homans sign is used to test the legs for deep-vein thrombosis

The nurse notices that a school-aged child has bluish-white, red-based spots in her mouth that are elevated approximately 1 to 3 mm. What other signs would the nurse expect to find in this patient? a. Pink, papular rash on the face and neck b. Pruritic vesicles over her trunk and neck c. Hyperpigmentation on the chest, abdomen, and back of the arms d. Red-purple, maculopapular, blotchy rash behind the ears and on the face

d. Red-purple, maculopapular, blotchy rash behind the ears and on the face With measles (rubeola), the examiner assesses a red-purple, blotchy rash on the third or fourth day of illness that appears first behind the ears, spreads over the face, and then over the neck, trunk, arms, and legs. The rash appears coppery and does not blanch. The bluish-white, red-based spots in the mouth are known as Koplik spots.

The nurse educator is preparing an education module for the nursing staff on the epidermal layer of skin. Which of these statements would be included in the module? The epidermis is: a. Highly vascular. b. Thick and tough. c... Thin and nonstratified. d. Replaced every 4 weeks.

d. Replaced every 4 weeks.

The nurse educator is preparing an education module for the nursing staff on the epidermal layer of skin. Which of these statements would be included in the module? The epidermis is: a. Highly vascular. b. Thick and tough. c. Thin and nonstratified. d. Replaced every 4 weeks.

d. Replaced every 4 weeks. The epidermis is thin yet tough, replaced every 4 weeks, avascular, and stratified into several zones.

A man has come in to the clinic for a skin assessment because he is worried he might have skin cancer. During the skin assessment the nurse notices several areas of pigmentation that look greasy, dark, and "stuck on" his skin. Which is the best prediction? a. Senile lentigines, which do not become cancerous b. Actinic keratoses, which are precursors to basal cell carcinoma c. Acrochordons, which are precursors to squamous cell carcinoma d. Seborrheic keratoses, which do not become cancerous

d. Seborrheic keratoses, which do not become cancerous

A man has come in to the clinic for a skin assessment because he is worried he might have skin cancer. During the skin assessment the nurse notices several areas of pigmentation that look greasy, dark, and stuck on his skin. Which is the best prediction? a. Senile lentigines, which do not become cancerous b. Actinic keratoses, which are precursors to basal cell carcinoma c. Acrochordons, which are precursors to squamous cell carcinoma d. Seborrheic keratoses, which do not become cancerous

d. Seborrheic keratoses, which do not become cancerous Seborrheic keratoses appear like dark, greasy, stuck-on lesions that primarily develop on the trunk. These lesions do not become cancerous. Senile lentigines are commonly called liver spots and are not precancerous. Actinic (senile or solar) keratoses are lesions that are red-tan scaly plaques that increase over the years to become raised and roughened. They may have a silvery-white scale adherent to the plaque. They occur on sun-exposed surfaces and are directly related to sun exposure. They are premalignant and may develop into squamous cell carcinoma. Acrochordons are skin tags and are not precancerous.

A 78-year-old man has a history of a cerebrovascular accident. The nurse notes that when he walks, his left arm is immobile against the body with flexion of the shoulder, elbow, wrist, and fingers and adduction of the shoulder. His left leg is stiff and extended and circumducts with each step. What type of gait disturbance is this individual experiencing? a. Scissors gait b. Cerebellar ataxia c. Parkinsonian gait d. Spastic hemiparesis

d. Spastic hemiparesis With spastic hemiparesis, the arm is immobile against the body. Flexion of the shoulder, elbow, wrist, and fingers occurs, and adduction of the shoulder, which does not swing freely, is observed. The leg is stiff and extended and circumducts with each step. Causes of this type of gait include cerebrovascular accident. (See Table 23-6 for more information and for the descriptions of the other abnormal gaits.)

A mother brings her child into the clinic for an examination of the scalp and hair. She states that the child has developed irregularly shaped patches with broken-off, stublike hair in some places; she is worried that this condition could be some form of premature baldness. The nurse tells her that it is: a. Folliculitis that can be treated with an antibiotic. b. Traumatic alopecia that can be treated with antifungal medications. c. Tinea capitis that is highly contagious and needs immediate attention. d. Trichotillomania; her child probably has a habit of absentmindedly twirling her hair.

d. Trichotillomania; her child probably has a habit of absentmindedly twirling her hair. Trichotillomania, self-induced hair loss, is usually due to habit. It forms irregularly shaped patches with broken-off, stublike hairs of varying lengths. A person is never completely bald. It occurs as a child absentmindedly rubs or twirls the area while falling asleep, reading, or watching television. (See Table 12-12, Abnormal Conditions of Hair, for descriptions of the other terms.)

A 70-year-old woman tells the nurse that every time she gets up in the morning or after shes been sitting, she gets really dizzy and feels like she is going to fall over. The nurses best response would be: a. Have you been extremely tired lately? b. You probably just need to drink more liquids. c. Ill refer you for a complete neurologic examination. d. You need to get up slowly when youve been lying down or sitting.

d. You need to get up slowly when youve been lying down or sitting. Aging is accompanied by a progressive decrease in cerebral blood flow. In some people, this decrease causes dizziness and a loss of balance with a position change. These individuals need to be taught to get up slowly. The other responses are incorrect.

A scooped-out, shallow depression in the skin is called a(n): a. ulcer. b. excoriation. c. fissure. d. erosion.

d. erosion. An ulcer is a deeper depression extending into the dermis. An excoriation is a self-inflicted abrasion that is superficial. A fissure is a narrow opening of tissue or skin. An erosion is a scooped-out, shallow depression in the skin.

Poorley controlled chronic pain responses

depression, isolation, limited mobility and function, confusion, family distress, diminished quality of life

Dyspnea

difficult, labored breathing

Dyspnea

difficulty breathing difficult or labored breathing

Dysphagia

difficulty swallowing

Hypoactive bowel sounds

diminished or absent bowel sounds signal decreased motility as a result of inflammation as seen with peritonitis; from paralytic ileus as following abdominal surgery; or from late bowel obstruction. Also occurs with pneumonia

Hypoactive bowel sounds

diminished or absent bowel sounds signal decreased motility as a result of inflammation as seen with peritonitis; from paralytic ileus as following abdominal surgery; or from late bowel obstruction. Also occurs with pneumonia.

Retraction

dimple or pucker on the skin

crackles

discontinuous popping sounds heard over inspiration

Cervial nodes

drain the head and neck

Crepitation

dry crackling sound or sensation due to grating of the ends of damaged bone

Biculturalism

dual pattern of identification and often of divided loyalty

Secondary Prevention

early identification: mammograms, colonoscopy, screenings

Hot/Cold Theory

embraced by Hispanics, Arabs, Blacks & Asians; Four humors of body: blood, phlegm, black bile, yellow bile—regulate basic body functions, temp, dryness, and moisture.Treatment consists of adding/subtracting cold/heat, dryness/wetness to restore balance of humors. Drinks,foods,herbs, medicines and diseases-classified as hot/cold according to effects on body. Cold illnesses: earache,chest cramps,paralysis,GI discomfort, rheumatism,TB. Overheating illnesses: abscessed teeth,sore throats,rashes,kidney disorders

kyphosis

exaggerated posterior curvature of the thoracic spine (humpback); severe deformities impair cardiopulmonary function, associated with aging

Gynecomastia

excessive breast development in the male

Syncope

fainting or sudden loss of consciousness caused by lack of blood supply to the cerebrum

Cooper's ligaments

fibrous bands extending vertically from surface to attach on chest wall muscles. support breast tissue. They become contracted in cancer of the breast and produce dimples of the skin

What do lymph nodes do?

filter lymph and trap bacteria and other disease causing organisms

adventitious sounds commonly heard in immediate newborn period

fine crackles

What symptoms are evident for chronic iron deficiency anemia

fingernails- anemia may show "spoon nails with a concave shape

Cecum

first or proximal part of large intestine

cultural assessment

first step in developing cultural competency is to know yourself

Dependent edema

fluid accumulation in the tissues influenced by gravity

when to use apical pulse

for patients with irregular heart rate patients with bradycardia or tachycardia patients with a faint radial pulse patients taking cardiac medications infants and young children

pulse

force of pumping heart flares the arterial walls, generating a pressure wave which is felt in periphery

C7 vertebra

has a long spinous process that is palpable when the head is flexed. You can feel the vertebra prominens, on your own neck.

Yin/Yang Theory

health is believed to exist when all aspects of the person are in perfect balance (Asians)

Gordon's Functional Health Patterns

health perception/ maintenance, nutrition (metabolic), elimination, exercise, rest, cognitive (perceptual), self perception/concept, relationship, reproduction, coping/stress tolerance, beliefs/values

fowler's

high - back is in high position low (semi) - back in lower position (sitting up), this sitting position raises the patient's head 80-90 degrees. Pillow may be used under the head or arms. this position improves cardiac output and promotes ventilation. it is contraindicicated after spinal or brain surgery.

Tympany

high-pitched, musical, drum like percussion note heard when percussing over the stomach and intestine

The aging adult: prebycusis

high-tone frequency loss

Pulmonary responses to pain

hypoventilation, hypoxia, decreased cough, atelectasis

Primary Prevention

immunizations, use of seat belts

Immune responses to pain

impaired cellular immunity and wound healing

Presbyopia

impaired vision as a result of aging difficulty in nearsighted vision occurring in middle and old age

dysphasia

impairment in speech consisting of lack of coordination and inability to arrange words in their proper order

Culturally appropriate

implies that the caregiver apply the underlying background knowledge that must be possessed to provide a given person with the best possible health

Culturally competent

implies that the caregivers understand and attend to the total context of the individual's situation

how to people with COPD often sit

in a tripod position, leaning forward with arms braced again knees, chair or bed.

Inguinal node

in the groin drain most of the lymph of lower extremity, external genitalia, anterior abdominal wall

Superficial veins

in the subcutaneous tissue and responsible for most of the venous return

hyperventilation

inc in both rate and depth

Mastitis

inflammation of the breast

Conjunctivitis

inflammation of the conjunctiva

Salpingitis

inflammation of the fallopian tubes

Gingivitis

inflammation of the gums

Stomatitis

inflammation of the mucosa of the mouth

DVT

inflammation, blocked venous return, cyanosis, edema

Otoscope

instrument used for visual examination of the ear

Standard Precautions

intended fpr use with all patients regardless of their risk or presumed infection status

hypo-ventilation

irregular shallow pattern caused by overdue of narcotics or anesthetics

Heritage consistency

is a concept that describes "the degree to which one's lifestyle reflects his or her respective American Indian tribal culture. A given person's heritage is predicated on the concept of heritage consistency.

Brain Tumor, mass

is close to the origin of the pupillary nerve fibers, it can cause problems within the pupil.

Caput Succedaneum

is edematous swelling and ecchymosis caused by birth trauma; feels soft and may extend across suture lines. resolves first few days of life.

Socialization

is the process of being raised within a culture and acquiring the characteristics of that group.

Patella

kneecap

normal chest cage abnormality seen in aging adult

kyphosis, outward curvature of the thoracic spine, person compensates by holding head extended and tilted back

Mitral valve

left AV valve separating the left atria and ventricle

First Level Priority Problems

life-threatening/immediate (A: airway, B: breathing, C: cardiac/circulation D: vitals)

Ascultation

listening to sounds of the body, such as heart, blood vessels, lungs, abdomen, etc...

Aneurysms

local dilation of an artery or heart chamber due to weakening of walls COMMON: abdominal aortic aneurysm (AAA)

Tonsils

located at entrance to respiratory and gastrointestinal tracts, respond to local inflammation

Third Level Priority Problems

long-term interventions (teaching)

Borborygmi

loud, gurgling bowel sounds signaling increased motility or hyper peristalsis, occurs with early bowel obstruction, gastroenteritis, diarrhea

vesicular breath sound

low pitch, soft amplitude, rustling like wind in trees, over peripheral lung field where air flows through smaller bronchioles and alveoli; prolonged inspiration phase

Costal Margin

lower border of rib margin formed by the medial edges of the 8th, 9th, and 10th ribs

hyperresonance

lower-pitches, booming sound found when too much air is present such as emphysema or pneumothorax, abnormal in adults, normal in infants

Brachial Artery

major artery supplying the arm, runs in the biceps- triceps furrow of the upper arm and surfaces at the antecubital fossa in the elbow medial to the biceps tendon

Malignant melanoma

may start from preexisting nervus or de novo - usually brown (tan, black, pink-red, purple, mixed) irregulare, notched borders OCCURS: trunk, back, legs (women), palms, soles of feet, nails (A-A) MOST common cancer in women (ages 25-29) 2nd (after breast cancer - ages 30-34)

spirometer

measures lung health in chronic conditions such as asthma; normal FEV1/FVC ration is 75% or greater

Screen for deep vein thrombosis

measuring the widest point with a tape measure

Facial sensations( pain, touch)

mediated by the 3 sensory branches of cranial nerve V (trigeminal nerve).

Hymen

membranous fold of tissue partly closing the vaginal orifice

Diastasis recti

midline longitudinal ridge in the abdomen, a separation of abdominal rectus muscles

bronchovesicular breath sound

moderate pitch moderate amplitude, over major bronchi where fewer alveoli are located (between scapulae, around upper sternum in 1st and 2nd intercostal spaces)

Abduction

moving a body part away from an axis or the median line

Retraction

moving a body part backward and parallel to the ground

Protraction

moving a body part forward and parallel to the ground

Adduction

moving a body part toward the center or toward the median line

Circumduction

moving the arm in a circle around the shoulder

Inversion

moving the sole of the foot inward at the ankle

Eversion

moving the sole of the foot outward at the ankle

Myalgia

muscle pain OCCURS: viral illness

Intermittent claudication

muscular pain brought on by exercise

Epigastrium

name of the abdominal region between the costal margins

Biographic data

name, address, phone number, age, birthdate, gender, marital status, race, ethic origin, occupation, primary language

Witch's Milk

neonate breasts may be enlarged and visible due to maternal estrogen crossing the placenta. resolve within a few days to a few weeks.

interneuron

nerve cell located entirely in the central nervous system that integrates sensory information and sends motor commands

Nipple retraction

nipple looks flatter and broader, like an underlying crater. suggests cancer. can also occur with benign lesions and ectasia of the ducts. don't confuse with nipple inversion which has no broadening

Brawny edema is:

non pitting

Brawny edema

nonpitting

Epulis

nontender nodules on gum

chronic obstructive breathing

normal inspiration and prolonged expiration to overcome inc airway resistance

Pupillary response

normal resting pupil: 3, 4, 5 mm rxn to light: contrict (decrease) equally: 1 mm

Epistaxis

nosebleed

Claudication distance

number of blocks walked or stairs climbed to produce pain

forced expiratory time

number of seconds it takes for the person to exhale from total lung capacity to residual volume; screens for airflow obstruction; normal = 4 seconds or less

Data Organization

nursing model non-nursing models

Lymphatic systems detects and eliminates foreign substances from body

o Vessels allow flow of clear, watery fluid from tissue spaces into circulation o Nodes are small, oval clusters of lymphatic tissue that filter lymph and engulf pathogens, preventing potentially harmful substances from entering the circulation o Greatest supply is in head and neck

crackles only in lower lung fields in children

occur with heart failure

hypertrophy (enlargement) of abdominal muscles

occurs in chronic emphysema

Venous hum

occurs rarely. Heard in periumbilical region. Originates from inferior vena cava. Medium pitch, continuous sound, pressure on bell may obliterate it. May have palpable thrill. Occurs with portal hypertension and cirrhotic liver.

decreased fremitus occurs with

occurs when anything obstructs transmission of vibrations. i.e. obstructed bronchus, plerural effusions or thickening, emphysema

diastolic pressure

occurs when the ventricles are relaxed; the lowest pressure against the walls of an artery (bottom number)

unequal chest expansion occurs with

occurs with atelectasis, lobar pneumonia, pleural effusion, thoracic trauma

Mastalgia

occurs with trauma, inflammation, infection, and benign breast disease.

dorsal recumbent

on back, knees bent, lying flat on back w/knees bent

Focused Database

one used for a limited or short term problem; what brought the patient there

Ulcer

open skin lesion extending into dermis with sloughing of necrotic inflammatory tissue

Peau d'orange

orange-peel appearance of the breast due to edema

Spirituality

orne out of each person's unique life experience and his or her personal effort to find purpose and meaning in life.

Peritoneal friction rub--SPLEEN

over lower left rib cage in left anterior axillary line, from abscess, infection, or tumor

Syhphilitic chancre

painless ulceration (sore) most commonly formed during the primary stage of syphilis.

tactile fremitus

palpable vibration generated from larynx transmitted through patent bronchi and the lung parenchyma to the chest wall; vibrations should feel same on each side

Thrill

palpable vibration on the chest wall accompanying severe heart murmur

rhonchal fremitus

palpable with thick bronchial secretions

Temporal Artery

palpated in front of the ear

Carotid Artery

palpated in the groove between the sternomastoid muscle and the trachea

Stroke/CVA appearance

paralysis of lower facial muscle * CAN wrinkle forehead and close eyes

Bell's Palsy

paralysis of the facial nerve, causing muscular weakness in one side of the face. produces rapid onset of CN VII paralysis *CANNOT wrinkle forehead, raise eyebrow, close eyelid, whistle, or show teeth on left side

Skene's gland

paraurethral gland

Perservation

persistent repeating of verbal or motor response, even with varied stimuli.

Doppler ultrasounic stethoscope technique

person supine, gel on end of handheld transducer, over pulse at 90 degree angle, light pressure

Ethnicity

pertains to a social group within the social system that claims to possess variable traits such as a common geographic origin, migratory status, religion, race, language, shared values, traditions, or symbols, and food preferences Cultural background is a fundamental component of your ethnic background

How to test costovertebral angle tenderness

place one hand @ 12th rib on costovertebral angle, thump hand w/ulnar edge of opposite fist -normal: thud but no pain -abnormal: pain via inflammation of kidney or paranepheric area

in infants, rapid respiratory rates accompany

pneumonia, fever, pain, heart disease and anemia

mean arterial pressure (map)

pressure that drives blood into the tissues averaged over the entire cardiac cycle

Nociception

process whereby noxious stimuli are perceived as pain; central and peripheral nervous systems are intact

Diaphoresis

profuse sweating

Rectocele

prolapse of rectum and its vaginal mucosa into vagina with straining or standing

Secondary Level Priority Problems

prompt/urgent interventions (mental status changes, acute pain, risk of infection, abnormal lab values)

Cystocele

protrusion of the bladder

Rectocele

protrusion of the rectum

heart failure

pump failure with increasing pressure of cardiac overload causes pulmonary congestion or an increase amount of blood present in pulmonary capillaries

Subcutaneous nodules

raised, firm, and nontended and overlying skin moves freely EX: olecranon bursa (elbow)

tachypnea

rapid shallow breathing, inc rate >24 per minute, normal response to fever, fear of exercise

Hematuria

red-tinged or bloody urine

If the reflex with the hammer fails to elicit a response, what can you do? Reinforcement

relax muscles and enhance the response

Tic

repetitive twitching of a muscle at inappropriate times

cheyne-stokes respiration

respiration gradually wax and wane in a regular pattern, inc in rate and depth and then decreasing (severe heart failure, meningitis, drug overdose, in intracranial pressure) occurs normally in infants and aging persons during sleep

breakthrough pain

restarts or escalates before next scheduled analgesic dose

barrel chest

ribs are horizontal instead of normal downward slope, associated with normal aging and with chronic emphysema and asthma as a result of hyperinfaltion of lungs

Tricuspid valve

right AV valve separating the right atria and ventricle

Pulmonic valve

right semilunar valve separating the right ventricle and pulmonary artery

Circumlocution

round-about expression, substituting a phrase when can not think of name of object. "the thing you open the door with" instead of "key"

scoliosis

s-shaped curvature of the thoracic and lumbar spine, note unequal shoulder and scapular heigh and unequal hip levels

Aneurysms

sac formed by dilation in artery wall

6-minute walk test

safer simple clinical measure of functional status in aging adults

What happens to skin as one ages?

sags with decreased subcutaneous fat and elasticity

Parotid gland

salivary gland within the cheek just anterior to the ear AB: swollen with mumps

Linear

scratch, streak, line

Montgomery's glands

sebaceous glands in the areolas. secrets a protective lipid material during lactation.

tympanic membrane thermometer

senses infrared emissions of the eardrum, which shares the vascular supply with the hypothalamus

Dimpling

shallow dimple that shows skin retraction (skin tether). Cancer causes fibrosis which contracts the suspensory ligaments. Dimple may be apparent at rest. Note distortion of areola.

Loosening associations

shifting from one topic to an unrelated topic; person seems unaware that topics are unrelated.

atelectatic crackles

short, popping crackling sounds that last only a few breaths, heard in axillae and bases of lungs not pathologic

Striae

silvery white or pink scar tissue formed by stretching of abdominal skin as with pregnancy or obesity

biot respiration

similar to cheyne-stokes except pattern is irregular, series of normal respirations is followed by a period of apnea (seen with head trauma, brain abscess, heat stroke, spinal meningitis, encephalitis)

Musculoskeletal responses to pain

spasm, joint stiffness

coma

state of profound unconsciousness from which person cannot be aroused

Extension

straightening a limb at a joint

Phobia

strong, persistent, irrational fear of an object or situation; feels driven to avoid it.

symptom

subjective sensation that the person feels from the disorder

What gland become easier to feel as one ages?

submandibular

cephalhematoma

subperiosteal hemorrhage which is also a result of birth trauma. It is soft, fluctuant an well defined over one cranial bone becz the periosteum holds in the bleeding in place. Resolves within a few weeks to 3months.

pectus excavatum

sunken sternum and adjacent cartilages, depression occurs at 2nd intercostal space, becoming depressed most at junction of xiphoid with body of sternum

Cutaneous pain examples

superficial pain with sharp, burning sensation

4 major functions of the respiratory system

supplying oxygen to the body for energy production removing carbon dioxide as a waste product of energy reactions maintains homeostasis (acid-base balance) of arterial blood maintaining heat exchange

Lymphedema

swelling due to an abnormal accumulation of lymph fluid within the tissues

Cardiac responses to pain

tachycardia, elevated bp, increased cardiac output, increased myocardial O2 demand

percussion

tapping skin w/ short, sharp strokes to assess structures, yield vibration to depict location,size, and density of organ

Syncope

temporary loss of consciousness due to decreased cerebral blood flow (fainting) caused by ventricular systole, pronounced bradycardia, or ventricular fibrillation

facial expression of pt with COPD

tense, strained, tired and purse-lipped breathing

Biomedical model

the Western European/North American tradition that views health as the absence of disease.

Crepitation

the grating sound heard when the ends of a broken bone move together The grating sound or feeling of broken bones rubbing together OCCURS: articular surfaces in the jts roughened (EX: RA)

Diastole

the heart's filling phase

Systole

the heart's pumping phase

Aortic Valve

the left semilunar valve separating the left ventricle and the aorta

Anorexia

the loss of appetite for food, especially when caused by disease

Aphasia

the loss of the ability to speak, write, and/or comprehend the written or spoken word; usually caused by damage to left hemisphere

Lymphatic System

the network of vessels through which lymph drains from the tissues into the blood.

Claudication distance

the number of blocks walked or stairs climbed to produce pain

Assimilation

the process by which a person develops a new cultural identity and becomes like the members of the dominant culture

Diagnostic Reasoning

the process of taking the information provided and drawing conclusions to identify diagnoses. (deductive reasoning and formation of hypothesis)

Babinski sign

the toes flex upward when sole of foot is stimulated, indicating motor nerve damage

Environment

the total of all the condition and elements that make up the surroundings and influence the development of a person.

Crust

thickened, dried out exudate left when vesicles/ pustules burst or dry out.

Arteriosclerosis

thickening, loss of elasticity, and calcification (hardening) of arterial walls

PVD

thin, shiny skin, loss of hair

Malnutrition

thin, shiny, atrophic skin

Pregnant woman

thyroid gland enlarges slightly as result of hyperplasia of the tissue and increased vascularity.

palpation techniques: base of fingers or ulnar surface

to detect vibration

Geniometer

tool used to measure joint angles

Herb's point

traditional osculatory area in the 3rd left intercostal space

Bednar aphthae

traumatic areas/ulcers on posterior hard palate on either side of midline

Tertiary Prevention

treatment, medications, follow-up studies

Raynauds

tricolor change of the fingers in response to cold, vibration, stress

COPD way of breathing

tripod bent over with hands over knees

Pronation

turning the forearm so that the palm is down

Supination

turning the forearm so that the palm is up

Venous Ulcers

ulcers resulting from chronic venous insufficiency due to a lack of venous flow Due to poor venous return, usually on MEDIAL ANKLE

Basal cell carcinoma

usually starts with skin-colored papule - develops rounds, pearly edges with central red ulcer MOST common form of skin cancer OCCURS: sun-exposed areas (face, ears, scalp, shoulders)

Valsalva maneuver

voluntary procedure to remove feces, increases intra-abdominal pressure

Measurement

weight height Body mass index Waist to hip ratio

rectal temp

when other routes are not practical, coma, shock, confused, etc...

Clanging

word choice based on sound, not meaning, includes nonsense rhymes and puns.

Phalen test

wrists are bent down with backs of each hand touching / carpal tunnel sufferers feel tingling or pain within 60 seconds

common errors in blood pressure measurement

wrong size cuff faulty arm position taking BP when active, anxious, or in pain reinflating cuff without waiting (wait 2 mins)

Downfalls of note taking

• It breaks eye contact too often. • It shifts your attention away from the person, diminishing his or her sense of importance. • Trying to record everything a person says may cause you to ask him or her to slow down, or the person may slow his or her tempo to allow for you to take notes. Either way, the client's natural mode of expression is lost. • It impedes your observation of the client's nonverbal behavior. • It is threatening to the client during the discussion of sensitive issues

Anterior approach to palpate the thyroid gland

• This is an alternate method of palpating the thyroid, but it is more awkward to perform, especially for a beginning examiner. Stand facing the person. Ask him or her to tip the head forward and to the right. Use your right thumb to displace the trachea slightly to the person's right. Hook your left thumb and fingers around the sternomastoid muscle. Feel for lobe enlargement as the person swallows. Rmr for anterior RIGHT THUMB DISPLACES, LEFT THUMB PALPATES.

• Posterior approach to palpate the thyroid gland: •

• To palpate, move behind the person. Ask the person to sit up very straight and then to bend the head slightly forward and to the right. This will relax the neck muscles on the right side. Use the fingers of your left hand to push the trachea slightly to the right. • Then curve your right fingers between the trachea and the sternomastoid muscle, retracting it slightly, and ask the person to take a sip of water. The thyroid moves up under your fingers with the trachea and larynx as the person swallows. Reverse the procedure for the left side. Rmr for posterior RIGHT HAND PALPATES, LEFT HAND DISPLACES.