Jarvis Chapter 22 Review, EXAM 3 FINALE
patellar ligament
connects patella to tibia
When assessing a client s lungs, the nurse recalls that the left lung
consists of two lobes
A client has a normal pupillary light reflex. The nurse recognizes that this indicates that:
constriction of both pupils occurs in response to bright light
Where is the apical pulse?
fifth intercostal, left midclavicular line
rales (crackles)
fine crackling sounds heard on auscultation (during inhalation) when there is fluid in the alveoli
Which pulse site is typically used to obtain a pulse rate from a client?
radial
Bronchophony
the spoken voice sound heard through the stethoscope, which sounds soft, muffled, and indistinct over normal lung tissue
What would be the best approach for the nurse to use when performing a functional assessment of an older client?
Observe the client's ability to perform the tasks
What does PERRLA mean?
Pupils Equal, Round, Reactive to Light and Accommodation
What is the meaning of the term PERRLA?
Pupils equal, round, reaction to light and accommodation
What is the meaning of the term PERRLA?
Pupils, equal, round, reactive, light, accommodation
What would the nurse ask in order to gain insight into a disabled client's functional ability?
"How has your disability affected your daily life?"
During an interview, the client answers questions quietly and appears sad. While answering questions about her marriage, she begins to cry. Which is the nurse's appropriate response?
"I see that you are upset. Is there something you'd like to discuss?
In assessing a patient s major risk factors for heart disease, which would the nurse want to include when taking a history?"
"Smoking, hypertension, obesity, diabetes, high cholesterol"
A nurse is interviewing a client who was diagnosed with type 2 diabetes mellitus 6 months ago however the client has gained more weight and the blood glucose levels remain high. The nurse suspects that the client is non-compliant with their diet. Which response by the nurse would enhance data collection in this situation?
"Tell me, how have you managed with your diet for these past few months?"
abnormal respiratory patterns
- Tachypnea - Bradypnea - Hyperventilation - Hypoventilation - Cheyne-Stokes
Assessment of older adults
-Is more complex -Is more detailed -Is longer to perform, need more time they like touch no elderspeak face the hearing impaired
A nurse is interviewing a client who was diagnosed with type 2 diabetes mellitus 6 months ago however the client has gained more weight and the blood glucose levels remain high. The nurse suspects that the client is non-compliant with their diet. Which response by the nurse would enhance data collection in this situation?
24 hr recall
During an interview, the nurse is discussing dietary habits with a client. Which tool would be the best choice to use as a quick screening tool to assess dietary intake?
24 hr recall
ANS: acute gout. Acute gout occurs primarily in men over 40 years of age. Clinical findings consist of redness, swelling, heat, and extreme tenderness. Gout is a metabolic disorder of disturbed purine metabolism, associated with elevated serum uric acid. See Table 22-1 for descriptions of the other terms.
A 40-year-old man has come into the clinic with complaints of "extreme tenderness in my toes." The nurse notices that his toes are slightly swollen, reddened, and warm to the touch. His complaints would suggest: A) osteoporosis. B) acute gout. C) ankylosing spondylitis. D) degenerative joint disease.
A patient has been diagnosed with venous stasis. Which of the following would the nurse most likely observe?
A brownish discoloration to the skin of the lower leg
carotid sinus
A dilation of a common carotid artery; involved in regulation of systemic blood pressure. excessive vagal stimulation here could slow down the heart rate
Marasmus
A disease of severe protein-calorie malnutrition during early infancy, in which growth stops, body tissues waste away, and the infant eventually dies.
Risk factors that may lead to skin disease and breakdown include:
A lifetime of environmental trauma.
A nurse is conducting health screening for osteoporosis. Which of the following clients is at greatest risk for developing this disorder?
A sedentary 65 year old woman who smokes cigarettes.
A client reports the mole on his scalp has started itching and it bleeds when he scratches it. What other finding would be a danger sign for pigmented skin lesions?
ABCDE (Asymmetry, Border, Color, Diameter, Evolving size)
In which situation should the nurse screen for intimate partner violence (IPV)?
ALL OF THEM
Which term is used to denote the movement of a limb towards the body?
Adduction
How do we assess the ear, what techniques do we need to use for children vs adults?
Adults: Up and back; Children: down and back
What is the purpose of the side to side pattern used during respiratory assessment?
Allow comparison of like areas of the lungs
The nurse is performing an assessment on a preschool aged client. Which method will aid in the ability to gather needed data?
Allow the child to touch or try equipment before the exam
ANS: abduct her hip while she is lying on her back. Limitation of abduction of the hip while supine is the most common motion dysfunction found in hip disease. The other options are not correct.
An 80-year-old woman is visiting the clinic for a checkup. She states, "I can't walk as much as I used to." The nurse is observing for motor dysfunction in her hip and should have her: A) internally rotate her hip while she is sitting. B) abduct her hip while she is lying on her back. C) adduct her hip while she is lying on her back. D) externally rotate her hip while she is standing.
ANS: of the shortening of the vertebral column. Postural changes are evident with aging; decreased height is most noticeable and is due to shortening of the vertebral column. Long bones do not shorten with age. Intervertebral disks actually get thinner with age. Subcutaneous fat is not lost but is redistributed to the abdomen and hips.
An 85-year-old patient comments during his annual physical that he seems to be getting shorter as he ages. The nurse should explain that decreased height occurs with aging because:
The client has stiffness and fixation of a joint. Choose the correct term for this.
Ankylosis
Heart sound landmarks:
Aortic (2nd intercostal space, right sternal border), Pulmonic (2nd intercostal space, left sternal border), Erb's point (3rd intercostal space, left sternal border), mitral (5th intercostal space, left midclavicular line)
Where do you assess the S2 sound the best?
Aortic and Pulmonic
Diastolic murmurs
Aortic regurgitation Mitral stenosis always indicates heart disease.
In which situation should the nurse screen for intimate partner violence (IPV)?
As a routine part of each health care encounter
Medication administration or procedural errors can be prevented by completing which task?
Asking the client to give their name and date of birth
When assessing a 2-3 year old child, what is important to consider?
Assess least invasive to most invasive.
After inspecting the abdomen for skin color, surface characteristics, and surface movement, what would be the nurse's next assessment of the abdomen?
Auscultate
What is a common change seen in geriatric clients?
Blood pressure increases due to decreased vessel elasticity
The nurse notes fanning of the toes when the sole of the foot of an adult client is stimulated during assessment of the plantar reflex. How would the nurse chart this correctly?
Babinski response
The best way to assess the general temperature of the skin is for the nurse to use which part of the hand?
Back of the hand
What is a common symptom of cystitis?
Burning and pain
A client's respirations are 8. How could these respirations be documented?
Bradypneic
Which sounds are heard over the posterior thorax area?
Bronchovesicular sounds
The nurse auscultates a blowing, swooshing sound of an area of abnormal blood flow. Choose the best term.
Bruit
A nurse is assessing a client with an abdominal aortic aneurysm and expect which finding?
Bruit heard over the middle upper abdomen
What is a term for a nutritional abnormality represented by recurrent binge and purge eating cycle?
Bulimia
CAGE Questionnaire: referring to alcoholism
C=cutting down (have you felt the need to cut down?) A=Annoyed by others criticisms G=guilty feelings about drinking E=Eye openers-do you feel the need to drink in the morning? "yes" suspect alcohol abuse
Why would the nurse use the bell of the stethoscope when listening to the abdomen?
Children
The nurse is comparing the right and left legs of a client and notices that they are asymmetric in size. What additional data might the nurse collect at this time?
Check length, width, edema, pulses
What does thoracic expansion assess?
Chest movement
The nurse is performing the Romberg test. The nurse notes the findings are abnormal. Which client response occurred in this situation?
Client moved his feet apart to steady himself
What heart action creates the first heart sound, S1?
Closing of the mitral and tricuspid valves
A client with chronic hypoxia from pulmonary disease is noted to have enlargement of the ends of their fingers and angles of the nail base is greater than a straight line. What is this called?
Clubbing
A 46-year-old man requires assessment of his sigmoid colon. Which of the following is most appropriate for this examination?
Colonoscopy
The components of a nail examination include:
Contour, consistency, and color
Systole is:
Contraction
Systole
Contraction of the heart
The client has stiffness and fixation of a joint. Choose the correct term for this.
Contracture
What is the name for an abnormal respiratory sound characterized by discontinuous popping sounds caused by fluid in the small airways?
Crackles
The nurse notes an audible, crunching/grating sound on the client's knee while climbing the stairs. Choose the best term.
Crepitus
A nurse notes that a client has ascites. What does this indicate?
Decreased liver function
An 85-year-old man has been hospitalized after a fall at home, and his 86-year-old wife is his primary caregiver. The nurse should assess for signs of caregiver burnout. What is a sign of this burnout?
Depression
small intestine
Digestive organ where most chemical digestion and absorption of food takes place
Which of the following statements is most appropriate when the nurse is obtaining a genitourinary history from an elderly man?
Do you need to get up at night to urinate?
A nurse is inspecting the ear canal of a 2 year old child. How would the pinna be moved to achieve better visualization of the tympanic membrane?
Down and back
When taking the health history, the patient complains of pruritus. What is a common cause of this symptom?
Drug reactions
ANS: polydactyly. Polydactyly is the presence of extra fingers or toes. Syndactyly is webbing between adjacent fingers or toes. The other terms are not correct.
During a neonatal examination, the nurse notices that the newborn infant has six toes. This finding is documented as: A) unidactyly. B) syndactyly. C) polydactyly. D) multidactyly.
ANS: herniated nucleus pulposus. Lateral tilting and sciatic pain with straight leg raising are findings that occur with a herniated nucleus pulposus. The other options are not correct.
During an examination, the nurse asks a patient to bend forward from the waist and notices that the patient has lateral tilting. When his leg is raised straight up, he complains of a pain going down his buttock into his leg. The nurse suspects: A) scoliosis. B) meniscus tear. C) herniated nucleus pulposus. D) spasm of paravertebral muscles.
What area would the nurse expect to hear the S1 and S2 of the equal loudness?
Erb's point
Breast Examination: Expected findings
FEMALE: Breast should be firm, elastic, and without lesions or nodules. Breast tissue may feel granular or lumpy bilaterally in some women MALE: No edema, masses or tenderness should be present. Areolas are round and darker pigmented.
What would the nurse test to determine the coordinated functioning of cranial nerves III, IV and VI (oculomotor, trochlear, abducens)?
Whisker test
Breast Examination: Unexpected findings
FEMALE: Fibrocystic breast disease is characterized by tender cysts that are often more prominent during menstruation MALE: Unilateral or bilateral (but asymmetrical) gynecomastia in adolescent boys or bilateral gynecomastia in older adult males may be present.
kidney
Filters waste from the blood like urea, water, salt and proteins.
The nurse is assessing a client for breast cancer risk factors. What is a non-modifiable risk factor for breast cancer?
Family history, early onset of menses, genetics, dense breast tissue
During an assessment of a healthy adult, where would the nurse expect to palpate the apical impulse?
Fifth intercostal space, near left midclavicular line.
When assessing the range of motion of the client's knee, the nurse expects the client to be able to perform which movement?
Flexion and extension
ballottement of patella
Fluid Palpate infrapatellar fat pad and patella
Functional Assessment Interview Goals
Functional assessment measures a person's self-care ability in the areas of general physical health or absence of illness; ADLs such as bathing, dressing, toileting, eating, walking; instrumental ADLs (IADLs) or those needed for independent living such as housekeeping, shopping, cooking, doing laundry, using the telephone, managing finances; nutrition; social relationships and resources; self-concept and coping; and home environment. CAGE
The nurse needs to take a blood pressure on an obese client and the only cuff available is a standard size. What would the nurse correctly anticipate in this situation?
High BP reading
The nurse auscultates a blowing, swooshing sound of an area of abnormal blood flow. Choose the best term.
bruit
Teachback method
Having patient explain back to you how they take their pill, give insulin, etc.
Which assessments would be appropriate for evaluating cerebellar function? (Select all that apply)
Heel to shin test Rapid alternating fingers
Which assessments would be appropriate for evaluating cerebellar function? (Select all that apply)
Heel to shin, finger to finger, finger to nose, knee up.
The nurse is taking a history on a client presenting with jaundice. Which question is related to a symptom or risk factor for jaundice?
Hemolysis, individuals who consume alcohol heavily
The nurse has determined that the client's bowel sounds are normal. What sounds did the nurse hear?
High pitched, irregular gurgling sounds
Which is an expected finding of an abdominal exam on an adult?
High-pitched gurgles every 5-15 seconds on auscultation
The nurse is having difficulty assessing heart sounds of a client because lungs sounds are too loud. What action does the nurse take to hear heart sounds more clearly?
Hold their breath
During an interview, the client answers questions quietly and appears sad. While answering questions about her marriage, she begins to cry. Which is the nurse's appropriate response?
I see you're upset, is there is anything you'd like to discuss?
"During a breast health interview, a client states that she has noticed pain in her left breast. The nurse s most appropriate response to this would be:"
I would like some more information about the pain in your left breast.
What is dyspepsia?
Indigestion
The nurse assesses the posterior tibial pulse by lightly palpating in which region?
Inside of ankle
What do you assess in the mouth and nose?
Inspect teeth and gums, check tongue for color, surface characteristics, and moisture; Inspect nasal mucosa, color, surface
What is the correct sequence of techniques used during an examination of the abdomen?
Inspection, auscultation, percussion, palpation (IAPP)
The nurse should use which location for eliciting a deep tendon reflex?
Knee
Which of the following are examples of communication barriers? (Select all that apply.)
Language, posture, do not give advice, attention
When assessing a 2-3 year old child, what is important to consider?
Least invasive to most invasive, do not let mom hold child while doing invasive work
Left Upper Quadrant (LUQ)
Left lobe of liver, stomach, pancreas, left kidney, spleen, portions of large intestine
When inspecting a client's posterior wall of the pharynx and tonsils, the nurse notes which finding as abnormal?
Lingual tonsils touching each other
The nurse is auscultating a client's abdomen for bowel sounds, no sounds have been detected for 2 minutes. What should the nurse should do next in this situation?
Listen for 3 more minutes (for a total of five)
The nurse detects a possible irregularity in the rhythm of a client's radial pulse. What should be the nurse next step?
Listen to the apical pulse
Auscultation
Listening with a stethoscope
What does hepatic pertain to?
Liver
internal jugular pulse
Location Lower, more lateral, under or behind the sternomastoid muscle 2. Quality Undulant and diffuse; two visible waves per cycle 3. Respiration Varies with respiration; its level descends during inspiration when intrathoracic pressure is decreased 4. Palpable No 5. Pressure Light pressure at the base of the neck easily obliterate 6. Position of person Level of pulse drops and disappears as the person is brought to a sitting position
During an assessment of a dark-skinned client with hepatitis B, what the nurse be looking for if assessing for jaundice?
Look in the eyes, palms of hands and feet. PALE
What area would the nurse listen to if wishing to listen to the tricuspid valve area?
Lower left sternal border
Chose the best term for the sound will the nurse will hear at the left midclavicular, fifth intercostal space?
Lub dub
Which data do nurses document under the category of Family Health History?
Maternal diseases, past family disease or illness
The nurse is comparing the right and left legs of a client and notices that they are asymmetric in size. What additional data might the nurse collect at this time?
Measure the circumference of each leg and compare the findings
malignant melanoma
Most serious form of skin cancer; often characterized by black or dark brown patches on the skin that may appear uneven in texture, jagged, or raised.
The nurse is assessing the motor function of an unconscious client. The nurse would plan to use which of the following to test the clients peripheral response to pain?
Nail bed pressure
When auscultating the right carotid artery, the nurse hears a swishing sound (a bruit). What would this suggest?
Narrow vessel and arterial disease
How do you take a carotid pulse?
Neck
On auscultating lung sounds in the adult client, the nurse documents which finding as normal?
No crackles, bruis, gurgling, ronchi, wheezes noted
A client's respirations are 8. How could these respirations be documented?
Normal respirations 12 -16. BRADY = slow TACHY = fast
ANS: 5 lumbar. There are 7 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 3 to 4 coccygeal vertebrae.
Of the 33 vertebrae in the spinal column, there are: A) 5 lumbar. B) 5 thoracic. C) 7 sacral. D) 12 cervical.
How will the nurse accurately palpate the carotid pulse?
One side at a time, head tilted
The nurse is assessing an older adult's functional ability. What is the definition of functional ability?
One's ability to perform activities necessary to live in modern society
Which statement will elicit the most information?
Open ended question
How will the nurse accurately palpate the carotid pulse?
Palpate in the groove between the trachea and the right and left sternocleidomastoid muscles one at a time
If a nurse uses their hand to press down into the abdomen to assess for tenderness, the nurse is performing which technique?
Palpation, 1cm & 2cm (how hard you press down)
Left Lower Quadrant (LLQ)
Part of descending colon Sigmoid colon Left ovary and tube Left ureter Left spermatic cord
What is the correct term for when the client's muscle is relaxed and the nurse moves a body part?
Passive ROM
What is the correct term for when the client's muscle is relaxed and the nurse moves a body part?
Passive ROM (range of motion)
The nurse noted a protrusion of the sternum and adjacent costal cartilage. Choose the correct term.
Pectus carinatum
The sac that surrounds and protects the heart is called the:
Pericardium
During an abdominal exam, the nurse assesses the client for rebound tenderness (Blumberg's sign). What would this indicate?
Peritonitis
A patient states, "Whenever I open my mouth real wide, I feel this popping sensation in front of my ears." How would the nurse further examine this complaint?
Place a finger over each of the client's temporomandibular joints, and ask the client to open and close their mouth.
When the nurse asks a 68-year-old client to stand with feet together and arms at his side with his eyes closed, he starts to sway and moves his feet further apart. The nurse would document this finding as a:"
Positive Romberg's sign
What are the functions of the skin?
Protection, regulation and sensation
constitutive proteins
Proteins that an organism produces all the time, and at a relatively constant rate.
A flat macular hemorrhage is called a(n):
Purpura
A client presents with small, elevated superficial lesions with purulent fluid. How would the nurse record these lesions?
Pustules
Which pulse site is typically used to obtain a pulse rate from a client?
Radial
Name the pulses
Radial Artery (Wrist), Brachial Artery (Inner Elbow), Popliteal Artery (Behind Knee), Posterior Tibial Artery (Ankle), Dorsalis Pedis Artery (Foot), Femoral Artery (Groin), Carotid Artery (Neck), Facial Artery (Face), Temporal Artery (Side Forehead)
Abnormal lung sounds
Rales = fluid in the bases (LA) Wheezing = bronchial constriction (LA) Rhonchi = large amount of secretion (midlung) Stridor = obstruction in (UA)
Diastole
Relaxation of the heart tricuspid and mitral valves are open
Liver functions
Responsible for: The metabolism of fats, proteins, and carbohydrates. Excretion of bilirubin, cholesterol, hormones, and drugs. Enzyme activation. Storage of glycogen, vitamins, and minerals. Synthesis of plasma proteins, such as albumin, and clotting factors. Blood detoxification and purification. Bile production and secretion.
Diastole is:
Resting
Prior to meeting the client, the nurse prepares by performing which of these nursing actions? (Select all that apply)
Review records, Avoid judgements
What is an example of the technique of clarification?
Rewording the same question later in the interview
On auscultation of a client's lungs, the nurse hears a low-pitched, coarse, loud, and snoring sound. What term does the nurse use to document this finding?
Rhonchi (Wheezes)
The nurse, assessing by palpation and/or percussion expects to locate the lower edge of the liver in which location?
Right Upper Quadrant
Right Upper Quadrant (RUQ)
Right lobe of liver, gallbladder, right kidney, portions of stomach, small and large intestine
During an examination, a nurse notes that there is a lesion on the client's upper back. What is the best way to document the size of this lesion?
Ruler
S1 vs. S2 sounds
S1 is louder than S2 at the apex; S2 is louder than S1 at the base. • S1 coincides with the carotid artery pulse. Feel the carotid gently as you auscultate at the apex; the sound you hear as you feel each pulse is S1 (Fig. 19-23). • S1 coincides with the R wave (the upstroke of the QRS complex) if the person is on an ECG monitor.
Conduction through the heart
SA node, AV node, Bundle of His, Purkinje fibers
The clinic nurse assesses the skin of a white client with a diagnosis of psoriasis. The nurse understands that which characteristic is associated with this skin disorder?
Scaly, red, flaky skin, spotted
On inspection the nurse notes a client with an abdominal shape as noted in the picture. How would the nurse document this finding?
Scaphoid
On performing a spinal assessment on your client, it is noted that the left shoulder is higher than the right and the right hip is higher than the left. What might this be related to?
Scoliosis
anaphylactic shock
Severe shock caused by an allergic reaction.
obstructive shock
Shock that occurs when there is a block to blood flow in the heart or great vessels, causing an insufficient blood supply to the body's tissues.
The clinic nurse assesses the skin of a white client with a diagnosis of psoriasis. The nurse understands that which characteristic is associated with this skin disorder?
Silvery-white scaly patches on the scalp, elbows, knees, and sacral regions
What does thoracic expansion assess?
Size
A patient is admitted to a hospital with a Stage III pressure ulcer. Which findings are characteristic of a stage IIl ulcer? Select all that apply.
Sores extends into the tissue below the skin, Forms a small crater, Fat may show up in wound or sore
The nurse assesses an apical heart rate and notes bradycardia. What was the apical heart rate?
Slow heart rate
What risk factors for osteoporosis?
Smoking
infant assessment
Start with feet and legs and work up the extremities. babies love faces
What is the part of the cardiac cycle in which the ventricles are contracting and pushing blood out of the chambers?
Systolic
A client s respirations are 44. These respirations are considered to be which of the following?
Tachypneic
What would the nurse do if they detect a possible irregularity in the rhythm of the client's radial pulse?
Take apical pulse
The nurse is listening to the vocal sounds of a client with pneumonia. She asks the client to say "1,2,3" repeatedly. What test is the nurse performing?
Whispered Pectoriloquy
Functions of the skin include:
Temperature regulation
pulse points in the body
Temporal, Carotid, Apical, Brachial, Radial, Popliteal, Posterior Tibial, Dorsalis Pedis
Which of the following statements is true regarding the internal structures of the breast?
The breast is composed of fibrous, glandular, and adipose tissue.
Which is an example of objective data a nurse would collect during a physical examination?
The client s radial and pedal pulses
ANS: joints. Joints are the functional units of the musculoskeletal system because they permit the mobility needed for the activities of daily living. The skeleton (bones) is the framework of the body.
The functional units of the musculoskeletal system are the: A) joints. B) bones. C) muscles. D) tendons.
Contracture
The lack of joint mobility caused by abnormal shortening of a muscle
Anthropometrics
The measurement of the size, proportions, and range of motion of the human body.
ANS: glenohumeral joint. A rotator cuff injury involves the glenohumeral joint, which is enclosed by a group of four powerful muscles and tendons that support and stabilize it. The nucleus pulposus is located in the center of each intervertebral disk. The medial epicondyle is located at the elbow.
The nurse is providing patient education for a man who has been diagnosed with a rotator cuff injury. The nurse knows that a rotator cuff injury involves the: A) nucleus pulposus. B) articular process. C) medial epicondyle. D) glenohumeral joint.
Wheezing
The production of whistling sounds during expiration such as occurs in asthma and bronchiolitis.
What is an example of objective data?
The skin of a client who has liver failure has a yellowish tint.
The client complains of ringing, crackling or buzzing in the ear. Choose the best term.
Tinnitus
What is the purpose of the side to side pattern used during the respiratory assessment?
To make sure sounds are symmetrical
ANS: anterior to the tragus The temporomandibular joint can be felt in the depression anterior to the tragus of the ear. The other locations are not correct.
To palpate the temporomandibular joint, the nurse's fingers should be placed in the depression _____ of the ear. A) distal to the helix B) proximal to the helix C) anterior to the tragus D) posterior to the tragus
What does thoracic expansion assess?
To test if lung expansion is EQUAL
Where do you assess the S1 sound the best?
Tricuspid and Mitral
The nurse is performing the Romberg test. The nurse notes the findings are abnormal. Which client response occurred in this situation?
Unstable, PT cannot properly balance with eyes closed
The nurse asks the client to puff out their cheeks and lift their eyebrows. Which cranial nerve is the nurse assessing?
VII (7) facial nerve
What is cheilosis?
Vertical cracks in lips
The client complains of a sense that the room is spinning around. Choose the best term.
Virtigo
What is being tested when the client is being assessed utilizing a Snellen chart?
Vision
What is a common change seen in geriatric clients?
Vital signs (BP increase and blood vesicles get harder) and skin
A 4-year-old client is brought to the emergency department a parent. The parent states that the child points to their stomach and says "It hurts so bad". Which pain assessment tool would be the best choice when assessing this child's pain?
WONG Baker test = FACES
What are considered to be modifiable risk factors for colon cancer?
Weight, physical activity, smoking, alcohol, diet,
What is an example of objective data?
What the NURSE observes
ANS: 5 Complete range of motion against gravity is normal muscle strength and is recorded as Grade 5 muscle strength.
When assessing muscle strength, the nurse observes that a patient has complete range of motion against gravity with full resistance. What Grade should the nurse record using a 0 to 5 point scale? A) 2 B) 3 C) 4 D) 5
ANS: proximal to distal. The musculoskeletal assessment should be done in an orderly approach, head to toe, proximal to distal, from the midline outward. The other options are not correct.
When performing a musculoskeletal assessment, the nurse knows that the correct approach for the examination should be: A) proximal to distal. B) distal to proximal. C) posterior to anterior. D) anterior to posterior.
ANS: bone marrow. The musculoskeletal system functions to encase and protect inner vital organs, support the body, produce red blood cells in the bone marrow, and store minerals.
When reviewing the musculoskeletal system, the nurse recalls that hematopoiesis takes place in the: A) liver. B) spleen. C) kidneys. D) bone marrow.
The nurse watches the uvula rise when the client says "ah". Which cranial nerve is being tested?
X (10) vagus nerve
To assess for jaundice, what would the nurse inspect for?
Yellowing of skin/eyes
What term refers to a linear skin lesion that runs along a nerve route?
Zosteriform
pectus excavatum
a chest that is hollowed out
family health history includes
a record of any illnesses or medical conditions that have afflicted members of a person's family
Bulla
a large blister that is usually more than 1 cm in diameter
Achilles tendon
a large tendon that runs from the heel to the calf
septic shock
a serious condition that occurs when an overwhelming bacterial infection affects the body
neurogenic shock
a state of shock (hypoperfusion) caused by nerve paralysis that sometimes develops from spinal cord injuries
lordosis
abnormal anterior curvature of the lumbar spine (sway-back condition)
Palpation
an examination technique in which the examiner's hands are used to feel the texture, size, consistency, and location of certain body parts
lower right quadrant
appendix, ureter, bladder, colon, gonads
posterior tibial pulse
artery supplying the foot, behind the medial ankle
dorsalis pedis artery
artery supplying the foot, lateral to the large tendon of the big toe
systolic murmur
between S1 and S2 may occur with a healthy heart or with heart disease
unilateral distention of external jugular veins
caused by local cause (kinking or aneurysm)
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 would the nurse be concerned about with these findings?
cerebellum
S2?
closure of the aortic and pulmonic valves
Hemoptysis is defined as:
coughing up blood
The nurse is aware that a change that may occur in the gastrointestinal system of an aging adult is:
decreased gastric acid secretion
lower left quadrant (LLQ)
descending and sigmoid portions of the colon
Dyspnea
difficult or labored breathing shortness of breath
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.
The nurse asks the client to bend the ankle so the toes aim towards the nose. The nurse is assessing the client's ability to perform what action?
dorsiflexion
A client being assessed has been diagnosed with pneumonia. The nurse assesses for abnormal voice sounds and can clearly hear an "a" sound over the left lower lobe of the lung when the client says "e, e, e". This is an example of an abnormal finding for which test??
egophony
"During report, the student nurse hears that a patient has hepatomegaly and recognizes that this term refers to a/an:"
enlarged liver
nocturia
excessive urination at night
Tail of Spence
extension of breast tissue into the axilla
full distended external jugular veins
external jugular veins above 45 degrees signify increased CVP as with heart failure.
The Glasgow Coma Scale is used to grade neurological responses to which three parameters?
eye opening, verbal response, motor response
A 4-year-old client is brought to the emergency department a parent. The parent states that the child points to their stomach and says "It hurts so bad". Which pain assessment tool would be the best choice when assessing this child's pain?
face scale
When assessing the range of motion of the client's knee, the nurse expects the client to be able to perform which movement?
flexion and extension
Acities
fluid accumulation in the abdomen
pectus carinatum (pigeon chest)
forward protrusion of the sternum
The nurse notes that a client has had a black, tarry stool and recalls that a possible cause would be:"
gastrointestinal bleeding
inspection
general observation of the patient as a whole, progressing to specific body areas
heart murmur
gentle, blowing, swooshing sound that can be heard on the chest wall. an abnormal sound from the heart produced by defects in the chambers or valves
venous hum
heard in children 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.
Ronchi (gurgles)
heard primarily during expiration, may clear with cough.
Paget's disease
intraductal carcinoma in the breast
Arrythmia
irregular heart beat
bruit in carotid artery
is abnormal indicated cvd
stomach
large muscular sac that continues the mechanical and chemical digestion of food
carotid artery
located in the groove between the trachea and the sternomastoid muscle, medial to and alongside that muscle artery on each side of the neck that supplies blood to the head
bronchial breath sounds
loud, high-pitched, hollow sounds normally heard over the trachea and the large bronchi
gynomastia
male breast development
"During an annual physical exam, a 43-year-old client states that she doesnt perform monthly breast self-examinations. 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:"
mammography may not detect all palpable lumps.
pituitary
master endocrine gland
Bronchiovesicular breath sounds
medium-pitched, moderately loud sounds heard over the mainstem bronchi; inspiration = expiration
supernumerary nipple
minute extra nipple along the embryonic milk line
heart failure symptoms
mostly due to pulmonary congestion like Dyspnea, Orthopnea, Paroxysmal nocturnal dyspnea (sudden onset of dyspnea usually occurring about 2 to 3 hours after lying down) Cough, Wheezing. some due to systemic flui overload (peripheral edema, weight gain], long- standing low cardiac output (fatigue) acites
Split S2 heart sound
normal phenomenon that occurs toward the end of inspiration in some people; due to the effects of respiration on the heart--inspiration separates the timing of the two valves' closure, and the aortic valve closes 0.06 second before the pulmonic valve producing split sound (t-dup); only heard in pulmonic valve area at 2nd intercostal space
S4 heart sound
occurs at the end of diastole coincides with atrial contraction in late diastole and "a" wave in jugular venous pressure curve; due to increased resistance to ventricular filling following vigorous atrial contraction
An 85-year-old patient comments during his annual physical that he seems to be getting shorter as he ages. The nurse should explain that decreased height occurs with aging because:
of the shortening of the vertebral column.
Peau d'orange
orange peel appearance of breast due to edema
A client tells the nurse, "I have to sleep propped up with 3 pillows so I can breathe at night." How would the nurse document this?
orthopena
If a nurse uses their hand to press down into the abdomen to assess for tenderness, the nurse is performing which technique?
palpation
sublaxation
partial or incomplete dislocation two bones in a joint stay in contact, but their alignment is off
General Survey
physical appearance, body structure, mobility, behavior first impression of the person
review of systems
physical examination of all body systems in a systematic manner as part of the nursing assessment
diaphoresis
profuse sweating
Kwashiorkor
protein deficiency111111111111114-.b.42 n c c/jjjjjjjjjj---09876543222222aQAzZzaabacaaaaaaaaaaaaaaaaaacdbafeeeeeffffffffffgfffhhjhh
A nurse is inspecting the ear canal of an adult client. Which is the best method to move the pinna in order to straighten the ear canal to better visualize the area?
pull pinna up and back
Left Upper Quadrant (LUQ)
refers to the area encompassing the left lobe of the liver, the stomach, the spleen, lateral portion of the pancreas, and portions of the small and large intestines
Right Upper Quadrant (RUQ)
refers to the area encompassing the right lobe of the liver, the gallbladder, medial portion of the pancreas, and portions of the small and large intestines
"While obtaining a history of a 3-month old infant from the mother, the nurse asks about the baby s ability to suck and grasp the mother s finger. What is the nurse assessing?"
reflex
parathyroid
regulates calcium levels in the blood
Thyroid
regulates metabolism
Hypolvolemic Shock
results from lack of blood volume circulating blood volume is inadequate to deliver sufficient oxygen and nutrients to the body
intervertebral discs
shock absorbers fibrocartilage pads that separate and cushion the vertebrae
orthopena
shortness of breath while lying flat; classic sign of heart failure
The most important technique when progressing from one auscultatory site on the thorax to another is:
side to side comparison
Bradycardia
slow heart rate
vesicular breath sounds
soft, fine, breezy, low-pitched sounds heard over peripheral lung tissue
S2
the second heart sound, heard when the semilunar (aortic and pulmonic) valves close heard best at the base all over the pericardium
Gallbladder function
stores and concentrates bile
stridor
strained, high-pitched sound heard on inspiration caused by obstruction in the pharynx or larynx
Tail of Spence
superior lateral corner of breast tissue, projects up and laterally into axilla
percussion
tapping on a surface to determine the difference in the density of the underlying structure
What area would the nurse listen to if wishing to listen to the tricuspid valve area?
the 4th area a,p,e,t,m
A pulse deficit is the difference between:
the apical pulse and the radial pulse rate Explanation: When a pulse deficit is present, the radial pulse is always lower than the apical pulse rate.
caregiver burnout
the depletion of physical, mental, and emotional energy causes anxiety and depression
S1
the first heart sound, heard when the atrioventricular (mitral and tricuspid) valves close heard best at the apex all over the pericardium
crepitation
the grating sound heard when the ends of a broken bone move together
galactorrhea
the production of breast milk in a women who is not breastfeeding
carotid pulse
the pulse felt along the large carotid artery on either side of the neck location Higher and medial to this muscle 2. Quality one wave per cycle 3. Respiration Does not vary 4. Palpable Yes 5. Pressure No change 6. Position of person Unaffected
Egophony
the voice sound of "eeeeee" heard through the stethoscope
S3
third heart sound immediately after s2 av valves open Left-to-right shunt (VSD, PDA, ASD), mitral regurgitation, LV failure (CHF) is abnormal in ppl over 35 yrs
The client complains of ringing, crackling or buzzing in the ear. Choose the best term.
tinnitis
telegraphic speech
toddler early speech stage in which a child speaks like a telegram—"go car"—using mostly nouns and verbs. dont stare at toddlers
Normal breath sounds
vesicular, bronchovesicular, bronchial
objective data
what the health professional observes by inspecting, palpating, percussing, and auscultating during the physical examination
subjective data
what the person says about himself or herself during history taking
Apical impulse location
• Location—The apical impulse should occupy only one interspace, the 4th or 5th, and be at or medial to the midclavicular line • Size—Normally 1 × 2 cm • Amplitude—Normally a short, gentle tap • Duration—Short; normally occupies only first half of systole lateral side of chest
ANS: "Your disease is due to repeated stress on the patellar tendon. It is usually self-limited, and your symptoms should resolve with rest." Osgood-Schlatter disease is painful swelling of the tibial tubercle just below the knee. It is most likely due to repeated stress on the patellar tendon. It is usually self-limited, occurring during rapid growth and most often in males. The symptoms resolve with rest. The other responses are not appropriate.
A 14-year-old boy who has been diagnosed with Osgood-Schlatter disease reports painful swelling just below the knee for the past 5 months. Which response by the nurse is appropriate? A) "If these symptoms persist, you may need arthroscopic surgery." B) "You are experiencing degeneration of your knee, which may not resolve." C) "Your disease is due to repeated stress on the patellar tendon. It is usually self-limited, and your symptoms should resolve with rest." D) "Increasing your activity and performing knee-strengthening exercises will help to decrease the inflammation and maintain mobility in the knee."
NS: olecranon bursitis. Subcutaneous nodules are raised, firm, and nontender and occur with rheumatoid arthritis in the olecranon bursa and along the extensor surface of the ulna. See Table 22-3 for a description of the other conditions.
A 68-year-old woman has come in for an assessment of her rheumatoid arthritis, and the nurse notices raised, firm, nontender nodules at the olecranon bursa and along the ulna. These nodules are most commonly diagnosed as: A) epicondylitis. B) gouty arthritis. C) olecranon bursitis. D) subcutaneous nodules.
ANS: tophi. Tophi are collections of sodium urate crystals resulting from chronic gout in and around the joint that cause extreme swelling and joint deformity. They appear as hard, painless nodules (tophi) over the metatarsophalangeal joint of the first toe and they sometimes burst with a chalky discharge (See Table 22-6). See Table 22-6 for descriptions of the other conditions.
A man who has had gout for several years comes to the clinic with a problem with his toe. On examination, the nurse notices the presence of hard, painless nodules over the great toe; one has burst open with a chalky discharge. This finding is known as: A) a callus. B) a plantar wart. C) a bunion. D) tophi.
ANS: limited range of motion during the Moro's reflex. For a fractured clavicle, the nurse should observe for limited arm range of motion and unilateral response to the Moro's reflex. The other tests are not appropriate for this problem.
A mother brings her newborn baby boy in for a checkup; she tells the nurse that he doesn't seem to be moving his right arm as much as his left and that he seems to have pain when she lifts him up under the arms. The nurse suspects a fractured clavicle and would observe for: A) a negative Allis test. B) a positive Ortolani's sign. C) limited range of motion during the Moro's reflex. D) limited range of motion during Lasègue's test
Esophagus
A muscular tube that connects the mouth to the stomach.
ANS: a common benign tumor." A ganglionic cyst is a common benign tumor; it does not become malignant, and it does not need to be drained. It is not caused by chronic repetitive motion injury
A patient has been diagnosed with a ganglion cyst over the dorsum of his left wrist. He asks the nurse, "What is this thing?" The nurse's best answer would be, "It is: A) a common benign tumor." B) a tumor that will have to be watched because it may turn malignant." C) caused by chronic repetitive motion injury." D) a skin infection that will need to be drained."
ANS: loss of bone density. After age 40, loss of bone matrix (resorption) occurs more rapidly than new bone formation. The net effect is a gradual loss of bone density, or osteoporosis. The other options are not correct.
A patient has been diagnosed with osteoporosis and asks the nurse, "What is osteoporosis?" The nurse explains to the patient that osteoporosis is defined as:
ANS: rotator cuff lesions. Rotator cuff lesions may cause limited range of motion and pain and muscle spasm during abduction, whereas forward flexion stays fairly normal. The other options are not correct.
A patient is able to flex his right arm forward without difficulty or pain but is unable to abduct his arm because of pain and muscle spasms; the nurse should suspect: A) crepitation. B) rotator cuff lesions. C) dislocated shoulder. D) rheumatoid arthritis.
ANS: adduction. Moving a limb toward the midline of the body is called adduction; abduction is moving a limb away from the midline of the body. Flexion is bending a limb at a joint; extension is straightening a limb at a joint.
A patient is being assessed for range of joint movement. The nurse asks him to move his arm in toward the center of his body. This movement is called: A) flexion. B) abduction. C) adduction. D) extension.
ANS: Rheumatoid arthritis Rheumatoid arthritis is worse in the morning when arising. Movement increases most joint pain, except in rheumatoid arthritis, in which movement decreases pain. The other options are not correct.
A patient is complaining of pain in his joints that is worse in the morning, is better after he has moved around for awhile, and then gets worse again if he sits for long periods of time. The nurse should assess for other signs of what problem? A) Tendinitis B) Osteoarthritis C) Rheumatoid arthritis D) Intermittent claudication
ANS: metacarpophalangeal The joint located just above the ring on the finger is the metacarpophalangeal joint. The interphalangeal joint is located distal to the metacarpophalangeal joint. The tarsometatarsal and tibiotalar joints are found in the foot and ankle. See Figure 22-10 for a diagram of the bones and joints of the hand and fingers.
A patient is visiting the clinic for an evaluation of a swollen, painful knuckle. The nurse notices that the knuckle above his ring on the left hand is swollen and that he is unable to remove his wedding ring. This joint is called the _____ joint. A) interphalangeal B) tarsometatarsal C) metacarpophalangeal D) tibiotalar
ANS: Crepitation Crepitation is an audible and palpable crunching or grating that accompanies movement and occurs when articular surfaces in the joints are roughened, as with rheumatoid arthritis. The other options are not correct.
A patient states, "I can hear a crunching or grating sound when I kneel." She also states that "it is very difficult to get out of bed in the morning because of stiffness and pain in my joints." The nurse should assess for signs of what problem? A) Crepitation B) A bone spur C) A loose tendon D) Fluid in the knee joint
ANS: genu valgum. Genu valgum is also known as "knock knees" and is present when there is more than 2.5 cm between the medial malleoli when the knees are together.
A patient tells the nurse that "all my life I've been called 'knock knees.'" The nurse knows that another term for "knock knees" is: A) genu varum. B) genu valgum. C) pes planus. D) metatarsus adductus.
ANS: flexion. Flexion, or bending a limb at a joint, would be required to move the hand to the mouth. Extension is straightening a limb at a joint. Moving a limb toward the midline of the body is called adduction; abduction is moving a limb away from the midline of the body.
A patient tells the nurse that she is having a hard time bringing her hand to her mouth when she eats or tries to brush her teeth. The nurse knows that for her to move her hand to her mouth, she must perform which movement? A) flexion. B) abduction. C) adduction. D) extension.
ANS: Swan neck deformities Changes in the fingers caused by chronic rheumatoid arthritis include swan neck and boutonniere deformities. Heberden's nodes and Bouchard's nodules are associated with osteoarthritis. Dupuytren's contractures occur because of chronic hyperplasia of the palmar fascia and causes contractures of the digits (see Table 22-4).
A patient who has had rheumatoid arthritis for years comes to the clinic to ask about changes in her fingers. The nurse will assess for signs of what problems? A) Heberden's nodes B) Bouchard's nodules C) Swan neck deformities D) Dupuytren's contractures
ANS: functional scoliosis. Functional scoliosis is flexible; it is apparent with standing and disappears with forward bending. Structural scoliosis is fixed; the curvature shows both when standing and when bending forward. See Table 22-7 for description of herniated nucleus pulposus. These findings are not indicative of a dislocated hip.
A patient's annual physical examination reveals a lateral curvature of the thoracic and lumbar segments of his spine; however, this curvature disappears with forward bending. The nurse knows that this abnormality of the spine is called: A) structural scoliosis. B) functional scoliosis. C) herniated nucleus pulposus. D) dislocated hip.
ANS: medial and lateral epicondyle. The epicondyles, the head of radius, and tendons are common sites of inflammation and local tenderness, or "tennis elbow." The other locations are not affected.
A professional tennis player comes into the clinic complaining of a sore elbow. The nurse will assess for tenderness at the: A) olecranon bursa. B) annular ligament. C) base of the radius. D) medial and lateral epicondyle.
cardiogenic shock
A state in which not enough oxygen is delivered to the tissues of the body, caused by low output of blood from the heart. It can be a severe complication of a large acute myocardial infarction, as well as other conditions.
ANS: of sharp pain that increases with movement A fracture causes sharp pain that increases with movement. The other pains do not occur with a fracture.
A teenage girl has arrived complaining of pain in her left wrist. She was playing basketball when she fell and landed on her left hand. The nurse examines her hand and would expect a fracture if the girl complains: A) of a dull ache. B) that the pain in her wrist is deep. C) of sharp pain that increases with movement. D) of dull throbbing pain that increases with rest.
ANS: ulnar deviation. Fingers drift to the ulnar side because of stretching of the articular capsule and muscle imbalance caused by chronic rheumatoid arthritis. Radial drift is not seen. See Table 22-4 for descriptions of swan neck deformity and Dupuytren's contracture.
A woman who has had rheumatoid arthritis for years is starting to notice that her fingers are drifting to the side. The nurse knows that this condition is commonly referred to as: A) radial drift. B) ulnar deviation. C) swan neck deformity. D) Dupuytren's contracture.
ANS: lordosis. Lordosis compensates for the enlarging fetus, which would shift the center of balance forward. This shift in balance in turn creates strain on the low back muscles, felt as low back pain during late pregnancy by some women. Scoliosis is lateral curvature of portions of the spine; ankylosis is extreme flexion of the wrist, as seen with severe rheumatoid arthritis; and kyphosis is an enhanced thoracic curvature of the spine.
A woman who is 8 months pregnant comments that she has noticed a change in posture and is having lower back pain. The nurse tells her that during pregnancy women have a posture shift to compensate for the enlarging fetus. This shift in posture is known as: A) lordosis. B) scoliosis. C) ankylosis. D) kyphosis.
ANS: dislocated shoulder. Dislocated shoulder occurs with trauma involving abduction, extension, and external rotation (e.g., falling on an outstretched arm or diving into a pool). See Table 22-2 for a description of the other conditions.
A young swimmer comes to the sports clinic complaining of a very sore shoulder. He was running at the pool, slipped on some wet concrete, and tried to catch himself with his outstretched hand. He landed on his outstretched hand and has not been able to move his shoulder since then. The nurse suspects: A) joint effusion. B) tear of rotator cuff. C) adhesive capsulitis. D) dislocated shoulder.
ANS: fourth lumbar An imaginary line connecting the highest point on each iliac crest crosses the fourth lumbar vertebra.
An imaginary line connecting the highest point on each iliac crest would cross the _____ vertebra. A) first sacral B) fourth lumbar C) seventh cervical D) twelfth thoracic
Pancreas
An organs in the abdominal cavity with two roles. The first is an exocrine role: to produce digestive enzymes and bicarbonate, which are delivered to the small intestine via the pancreatic duct. The second is an endocrine role: to secrete insulin and glucagon into the bloodstream to help regulate blood glucose levels.
The nurse is assessing capillary refill on a client and notes a color return that takes 5 seconds on each hand. How would the nurse correctly document this finding?
Sluggish
ANS: Flexion and extension The knee is a hinge joint, permitting flexion and extension of the lower leg on a single plane. The knee is not capable of the other movements listed.
The nurse is checking the range of motion in a patient's knee and knows that the knee is capable of which movement(s)? A) Flexion and extension B) Supination and pronation C) Circumduction D) Inversion and eversion
ANS: your acromion process." The bump of the scapula's acromion process is felt at the very top of the shoulder. The other options are not correct.
During an interview the patient states, "I can feel this bump on the top of both of my shoulders—it doesn't hurt but I am curious about what it might be." The nurse should tell the patient, "That is: A) your subacromial bursa." B) your acromion process." C) your glenohumeral joint." D) the greater tubercle of your humerus."
ANS: ligaments. Fibrous bands running directly from one bone to another that strengthen the joint and help prevent movement in undesirable directions are called ligaments.
Fibrous bands running directly from one bone to another that strengthen the joint and help prevent movement in undesirable directions are called: A) bursa. B) tendons. C) cartilage. D) ligaments.
The nurse palpates the abdomen with the knowledge that which organs are located in the RUQ?
Gallbladder, liver, head of pancreas
A dark-skinned client is admitted for pneumonia. What is the most accurate method to assess for cyanosis in this client? (Knowing they're blue isn't enough)
Gray or whitish skin around the mouth, and the conjunctivae may appear gray or bluish.
What would the nurse document if she observed overgrowth of scar tissue?
Keloid
A nurse inspects a client's hands and notices bilateral clubbing of the fingers. What condition correlates with this finding?
Lack of oxygen
A nurse is listening to the client's heart at the left sternal border, second intercostal space. Which area is being auscultated?
Pulmonic
What would be important to compare when assessing the musculoskeletal system?
Symmetry
ANS: talus
The ankle joint is the articulation of the tibia, the fibula, and the: A) talus. B) cuboid. C) calcaneus. D) cuneiform bones.
ANS: temporomandibular joint. The articulation of the mandible and the temporal bone is the temporomandibular joint. The other responses are not correct.
The articulation of the mandible and the temporal bone is known as the: A) intervertebral foramen. B) condyle of the mandible. C) temporomandibular joint. D) zygomatic arch of the temporal bone.
ANS: Hip dislocation Unequal gluteal folds may accompany hip dislocation after 2 to 3 months of age, but some asymmetry may occur in healthy children. Further assessment is needed. The other responses are not correct.
The nurse is examining a 2-month-old infant and notices asymmetry of the infant's gluteal folds. The nurse should assess for other signs of what disorder? A) Fractured clavicle B) Down syndrome C) Spina bifida D) Hip dislocation
large intestine
The last section of the digestive system, where water is absorbed from food and the remaining material is eliminated from the body
ANS: swelling from fluid in the suprapatellar pouch. For swelling in the suprapatellar pouch, the bulge sign confirms the presence of fluid. The other options are not correct.
The nurse has completed the musculoskeletal examination of a patient's knee and has found a positive bulge sign. The nurse interprets this finding to indicate: A) irregular bony margins. B) soft tissue swelling in the joint. C) swelling from fluid in the epicondyle. D) swelling from fluid in the suprapatellar pouch.
ANS: suspect that the infant may have weakness of the shoulder muscles. An infant who starts to "slip" between the nurse's hands shows weakness of the shoulder muscles. An infant with normal muscle strength wedges securely between the nurse's hands. The other responses are not correct.
The nurse is assessing a 1-week-old infant and is testing his muscle strength. The nurse lifts the infant with hands under the axillae and notices that the infant starts to "slip" between the hands. The nurse should: A) suspect a fractured clavicle. B) suspect that the infant may have a deformity of the spine. C) suspect that the infant may have weakness of the shoulder muscles. D) consider this a normal finding because the musculature of an infant this age is undeveloped.
ANS: flex the hip. The ischial tuberosity lies under the gluteus maximus muscle and is palpable when the hip is flexed.
The nurse is assessing a patient's ischial tuberosity. To palpate the ischial tuberosity, the nurse knows that it is best to have the patient:
ANS: Asymmetric joint involvement Pain with motion of affected joints Affected joints are swollen with hard, bony protuberances In osteoarthritis, asymmetric joint involvement commonly affects hands, knees, hips, and lumbar and cervical segments of the spine. Affected joints have stiffness, swelling with hard bony protuberances, pain with motion, and limitation of motion. The other options reflect signs of rheumatoid arthritis.
The nurse is assessing the joints of a woman who has stated, "I have a long family history of arthritis, and my joints hurt." The nurse suspects that she has osteoarthritis. Which of these are symptoms of osteoarthritis? Select all that apply.
ANS: negative Ortolani's sign. Normally this maneuver feels smooth and has no sound. With a positive Ortolani's sign, the nurse will feel and hear a "clunk" as the head of the femur pops back into place. A positive Ortolani's sign reflects hip instability. The Allis test also tests for hip dislocation, but is done by comparing leg lengths.
The nurse is examining a 3-month-old infant. While holding the thumbs on the infant's inner mid thighs and the fingers outside on the hips, touching the greater trochanter, the nurse adducts the legs until the nurse's thumbs touch and then abducts the legs until the infant's knees touch the table. The nurse does not notice any "clunking" sounds and is confident to record a: A) positive Allis test. B) negative Allis test. C) positive Ortolani's sign. D) negative Ortolani's sign.
ANS: This is a positive Allis sign and suggests hip dislocation. Finding one knee significantly lower than the other is a positive Allis sign and suggests hip dislocation. Normally the tops of the knees are at the same elevation. The other statements are not correct.
The nurse is examining a 6-month-old infant and places the infant's feet flat on the table and flexes his knees up. The nurse notes that the right knee is significantly lower than the left. Which of these statements is true of this finding? A) This is a positive Allis sign and suggests hip dislocation. B) The infant probably has a dislocated patella on the right. C) This is a normal finding for the Allis test for an infant of this age. D) The infant should return to the clinic in 2 weeks to see if this has changed.
ANS: greater trochanter.
The nurse is examining the hip area of a patient and palpates a flat depression on the upper, lateral side of the thigh when the patient is standing. The nurse interprets this finding as the: A) ischial tuberosity. B) greater trochanter. C) iliac crest. D) gluteus maximus muscle.
ANS: Epiphyses Lengthening occurs at the epiphyses, or growth plates. The other options are not correct.
The nurse is explaining the mechanism of the growth of long bones to a mother of a toddler. Where does lengthening of the bones occur? A) Bursa B) Calcaneus C) Epiphyses D) Tuberosities
ANS: intervertebral disks. Intervertebral disks are elastic fibrocartilaginous plates that cushion the spine like shock absorbers and help it move. The vertebral column is the spinal column itself. The nucleus pulposus is located in the center of each disk. The vertebral foramen is the channel, or opening, for the spinal cord in the vertebrae.
The nurse is explaining to a patient that there are "shock absorbers" in his back to cushion the spine and to help it move. The nurse is referring to his: A) vertebral column. B) nucleus pulposus. C) vertebral foramen. D) intervertebral disks.
ANS: start swimming to increase my weight-bearing exercise." Weight-bearing exercises include walking, low-impact aerobics, dancing, or stationary cycling. Swimming is not considered a weight-bearing exercise. The other responses are correct.
The nurse is teaching a class on osteoporosis prevention to a group of postmenopausal woman. A participant shows that she needs more instruction when she states, "I will: A) start swimming to increase my weight-bearing exercise." B) try to stop smoking as soon as possible." C) check with my doctor about taking calcium supplements." D) get a bone-density test soon."
ANS: circumduction. Circumduction is defined as moving the arm in a circle around the shoulder.
The nurse notices that a woman in an exercise class is unable to jump rope. The nurse knows that to jump rope, one's shoulder has to be capable of: A) inversion. B) supination. C) protraction. D) circumduction.
ANS: ballottement
The nurse should use which test to check for large amounts of fluid around the patella? A) Ballottement B) Tinel sign C) Phalen's test D) McMurray's test
ANS: hold both hands back to back while flexing the wrists 90 degrees for 60 seconds. For the Phalen's test, the nurse should ask the person to hold both hands back to back while flexing the wrists 90 degrees. Acute flexion of the wrist for 60 seconds produces no symptoms in the normal hand. The Phalen's test reproduces numbness and burning in a person with carpal tunnel syndrome. The other actions are not correct for testing for carpal tunnel syndrome.
The nurse suspects that a patient has carpal tunnel syndrome and wants to perform the Phalen's test. To perform this test, the nurse should instruct the patient to: A) dorsiflex the foot. B) plantarflex the foot. C) hold both hands back to back while flexing the wrists 90 degrees for 60 seconds. D) hyperextend the wrists with the palmar surface of both hands touching and wait for 60 seconds.
What would the nurse do in order to accurately assess the carotid pulse?
Touch the neck
Right Lower Quadrant (RLQ)
contains parts of the small and large intestines, right ovary, right fallopian tube, appendix, right ureter
