N 3320: Test #3 Exam Review, N3320: Test #2 Review, N3320 Test #1 Review

What are the areas of auscultation for the heart?

"A PET Monkey" Aortic - 2nd ICS, RSB Pulmonic - 2nd ICS, LSB Erbs Point - 3rd ICS, LSB Tricuspid - 4th ICS, LSB Mitral - 5th ICS, MCL

**What are the basic parts/steps of nursing process?

"ADPIE" Assessment Diagnosis Planning Implementation Evaluation

Describe appropriate assessment techniques for suspected alcohol or substance abuse

"CAGE" C -- cut back -- have you ever tried to cut back on your use? A -- annoyed/angered -- have you ever been annoyed/angered when questioned about use? G -- guilt -- have you ever felt guilt about your use? E -- eye opener -- have you ever had an eye-opener to get started in the morning? Risk factors for substance abuse: history of early aggressive behaviour lack of parental supervision history of substance abuse drug availability

What is amblyopia?

"Lazy eye" nerve pathways between brain and eye are not stimulated properly, so the brain favors the other eye Can be treated with eye drops, corrective lenses, or surgery

**Identify the domains that make up mental status and recognize examples of each.

(1) General Appearance - general description of the patient's appearance(2) Emotions - mood (feeling tone that prevails over time for a patient) and affect (behavioral/observable manifestation of mood), (3) Thoughts - description of a patient's thoughts during the interview, (4) Cognition - ability to use the higher cortical functions: thinking, logic, reasoning, and to communicate these thoughts to others. , (5) Judgment and Insight.

Describe normal findings of the RED REFLEX in an opthalmoscope examination

**Shine light beam towards the client's pupil** Should be easily visible through opthalmoscope Round, with regular border

Explain PHORIA

**Phoria is noticeable only with the cover test** When the stronger eye is covered, the weaker eyes moves to refocus When the weaker eye is covered, it will drift to a relaxed position Once the weaker eye is uncovered, it will quickly move back to reestablish fixation

Describe technique and the significance of ROMBERG TEST

**tests equilibrium** ask patient to stand with feet together, arms at sides (eyes open & eyes closed) Normal: patient can maintain position for 20 seconds without swaying or with minimal swaying

Describe normal findings of the OPTIC DISC in an opthalmoscope examination

**view client's eye from 3-5cm, bring retinal structures into sharp focus** round to oval with sharp defined border nasal edge may be slightly blurred creamy, yellow-orange to pink and 1.5mm wide Physiologic cup (where nerve enters eyball) should appear slightly depressed and lighter color Discs border may be surrounded by rings and crescents, consisting of white sclera or black retinal pigment

**Grading system for peripheral pulses

0 = absent 1+ = diminished, weak (easy to obliterate) 2+ = normal (obliterate with normal pressure) 3+ = bounding (unable to obliterate or requires firm pressure)

Describe grading system for documenting muscle strength

5 - active motion against full resistance - normal 4 - active motion against some resistance - slight weakness 3 - active motion against gravity - average weakness 2 - Passive ROM - poor ROM 1 - slight flicker of contraction - Severe weakness 0 - no muscular contraction - paralysis

Describe the grading system for reflexes

4+ - hyperactive, very brisk, rhythmic oscillations (clonus) 3+ - more brisk or active than normal, but not indicative of disorder 2+ - normal, usual response 1+ - decreased, less active than normal 0 - no response

**Correct technique for obtaining blood pressure

1. assemble equipment 2. client should be in a restful position for 5-10 minutes 3. Remove clothing from arm, palpate pulses of brachial art. 4. Place cuff so midline of bladder is over arterial pulses 5. support arm slightly flexed at heart level 6. Take blood pressure (inflate, deflate, listen for Korotkoff's Cuff guidelines: Length 80% Width 40% of arm circumference length to width ration of 2:1

Describe electrical conduction of the heart

1. conduction starts with impulses generated by the SA node 2. Both atria contract simultaneously and send blood to the ventricles 3. Current is conducted across the atria by the AV node 4. Impulse is then relayed to the AV bundle (Bundle of his) in upper inter ventricular septum 5. Impulse then travels down the right & left bundle branches and the Purkinje fibers in both ventricles, causing them to contract simultaneously

**What are the 7 steps involved in the analysis phase of nursing assessment

1. identify abnormal data and strengths 2. cluster data 3. draw inferences 4. propose possible nursing diagnoses 5. check for defining characteristics 6. confirm or rule out diagnoses 7. document conclusions "Izzy can't doodle pink cheetahs & colored dinosaurs."

Recognize appropriate questions in a nutrition assessment scenario

24 hr diet recall (efficient and easy if patient has good memory) Height & weight Recent weight loss or gain any recent diets Daily fluid intake any changes to appetite , taste or smell food allergies chronic illnesses, trauma or surgery Concomitant (occurring with something else) meds or herbs Lifestyle & health practices

The nurse is preparing to conduct a physical assessment of a client's chest and will be utilizing all of the following examination techniques. Place the techniques in the correct order for use. All options must be used. a. Percussion b. Auscultation c. Inspection d. Palpation

3-4-1-2 IPPA Inspection Palpation Percussion Auscultation Rationale: The nurse uses inspection first when assessing the client because this is the least invasive. This helps to promote trust and relaxation in the client for the parts of the examination to follow. Palpation is done next except in an abdominal assessment, in which a nurse would use auscultation prior to palpation to prevent stimulation of bowel sounds. Percussion is usually the third step of the examination process and auscultation is last.

Describe normal findings of the RETINAL VESSELS in an opthalmoscope examination.

4 sets of arterioles and venules Arterioles are bright red and narrow; have a light reflex that appears as a thin, center white line Venules are darker red and larger; narrow as they move away from Optic Disc AV ratio should be 2:3 or 4:5 Veins pass underneath the arteriole (arteriole wall is transparent)

States of obesity when given client weight and height: BMI

<18.5 = underweight 18.5-24.9 = normal 25.0-29.9 = overweight >30.0 = obese

States of obesity when given client weight and IDEAL BODY WEIGHT for height

>120% of IBW= obesity 110-120% of IBW = overweight 80-90% of IBW = lean client, possible malnutrition 70-80% of IBW = moderate malnutrition <70% of IBW = severe malnutrition

How do you identify lesions suspicious for melanoma?

ABCDE A - asymmetry B - borders C - color D - diameter E - elevation

What is Cranial Nerve VI?

Abducens Controls lateral eye movements

Assessment findings related to cranial nerve VI

Abducens Lazy eye

Assessment findings related to cranial nerve VIII

Acoustic-Vestibulocochlear Weber (vibration) & Rinne test (hearing)

**Describe skin assessment in older adults

Actinic keratoses waxy or raised skin lesions irregular shaped lesions scaly elevate lesions herpes zoster pinpoint sized red round nonblanching petechiae large bruises extremely thin fragile skin with excessive purpura Signs of dehydration

What are the various classifications of pain?

Acute -- usually associated with recent injury Chronic nonmalignant pain - persists for longer than 6 months Cancer pain - due to compression of peripheral nerves or meninges due to damage following surgery, chemo, radiation, tumor growth & infiltration

What are non-modifiable risk factors for stroke?

Age - increases with age Gender - males at more risk Genes or Race - family history, AA, MA, AI, HI, AsAm Diseases such as cancer, CKD, arthritis , carotid artery stenosis, sickle cell disease Weak areas in artery wall or abnormal arteries Pregnancy - during and in the weeks following Man-man or infected heart valves, certain heart defects, a very weak heart, abnormal heartbeats

**When given choices, choose the highest priority items for assessment.

Airway Breathing Circulation Anything abnormal vs normal is a higher priority

What are modifiable risks for osteoporosis?

Alcohol smoking low body mass <20kg/m2 poor nutrition (low calcium and protein intake) vitamin D deficiency Eating disorder insufficient exercise

**Discuss the analysis phase of the nursing assessment

Analyze and form connections between subjective and objective data; use diagnostic reasoning skills to interpret data accurately, requires RN to think critically and rationally Occurs in 7 steps.

**Recognize examples of appropriate documentation.

Appropriate Documentation: -Keep confidential, print neatly in nonerasable ink, use correct grammar/spelling/medical Abbreviations -Document to the point in least words possible - "Bowel sounds present in all quadrants at 36/min" -Use phrases/not sentences - "Bilateral lung sounds clear." - Record data finding to the point - "Has 3 year history of hypertension treated with medication. BP sitting right arm 140/86, left arm 136/86" - Write entries objectively - Record client's understanding & perception - "Client expresses concern regarding being discharged soon after gallbladder surgery because of inability to rest at home with six children." -Record complete information/details for all patient symptoms -Include additional assessment content when applicable - Support objective data with specific observations - "Appears depressed as demonstrated by wearing dirty clothes, avoids eye contact, and unkempt appearance."

What are abnormal findings associated with the cornea and lens?

Areas of roughness or dryness Opacities

Explain process of obtaining and documenting telephone orders

Ask receiver to read back Document phone call with time, receiver, sender, and information shared SBAR

Best language to use when charting

Avoid wordiness Use phrases not sentences Record Data findings, NOT how they are obtained Use objective entries Record clients understanding and perception of problems Avoid the word "normal" Complete info and details for S&S Support objective data with observations

What are 3 types of skin cancer?

Basal cell carcinoma melanoma squamous cell carcinoma

Describe normal visual acuity in infants and children

Birth - 20/100 to 20/400 1 year - 20/200 2 years - 20/70 5 years - 20/30 6+ years - 20/20

What are normal findings when inspecting iris and pupils of infants and children?

Blue iris in light-skinned infants brown in dark-skinned infants

What are the different test that indicate appendicitis?

Blumberg's (rebound tenderness; referred rebound) Rosving's sign Psoas Sign Obturator Hypersensitivity "Blue rhinos party obnoxiously hard"

Identify anatomical location of the various peripheral pulses

Brachial - med. to biceps tendon in & above bend of elbow Radial - lateral aspect of the wrist Ulnar - medial aspect of the wrist Femoral - under the inguinal ligament Popliteal - behind the knee Dorsalis Pedis - great toe side of the top of the foot Posterior Tibial - behind medial malleolus of the ankle

What are normal breath sounds?

Bronchial -- High pitched, harsh or hollow Bronchovesicular -- medium pitched, mixed quality Vesicular - low pitched, breezy

What are abnormal findings when inspecting iris and pupils of infants and children?

Brushfield's spots - indicates down syndrome sluggish pupils - neurological problems Miosis - iritis or narcotic abuse/use Mydriasis - emotional factors (fear), trauma, certain drug use

What tests are used to assess knee swelling?

Bulge Test - detects small amounts of fluid in the knee - stroke knee; press laterally and observe for bulge Ballottement Test - Detects large amounts of fluid in the knee - Press thumb and index finger of nondominant had on each side of patella - push patella down on femur with dominant hand Abnormal: fluid wave or click palpated may indicate meniscal tear

Identify parts of the COLDSPA acronym

C -- character -- describe problem O -- onset -- when did it start? L -- location -- where does it hurt? D -- duration -- how long as it being going on? S -- severity -- rate your pain P -- Pattern -- what makes it better or worse? A -- associated factors -- able to perform ADLs?

Process of calculating fluid balance including the amount to allow for insensible fluid loss

Calculate I&O for 72 hours Insensible loss = 800-1000mL per day (add to total output)

Describe the mechanisms involved in pain for the cancer patient

Can be acute or chronic 3 types: somatic, visceral, neuropathic Experience breakthrough pain May be triggered by a blocked vessel or a tumor pressing on a nerve Can be side effect of cancer treatment 90% experience severe pain which is often undertreated

Proper technique for assessing the carotid & temporal pulses

Carotid: don't palpate bilaterally because that can reduce blood supply to the brain Temporal: palpate between top of ear and eye (diminishes with age)

Discuss the anatomy of the external ear

Consists of Auricle (Pinna) and External Auditory Canal External Auditory Canal is an "S" shaped structure with modified sweat glands that secrete cerumen (wax) to keep tympanic membrane (eardrum) soft and defend against foreign bodies

Discuss possible significance of neck pain.

Cervical strain - most common cause of neck pain characterized by impaired ROM and abnormalities of soft tissue Causes: sleep in wrong position, carrying a heavy suitcase, or being in a car accident Cervical disc degenerative disease and spinal cord tumors - pain radiates to the back, shoulder, and arms Neck pain with loss of sensation in legs may occur with spinal cord compression

Describe and discuss checklists.

Checklists - lists information for quick alert & personalizes with comment sections, promotes easy/rapid documentation, risk might miss information if not included in check-list

What are modifiable risk factors for stroke?

Cigarette smoking High Cholesterol High blood pressure Sedentary lifestyle Excessive weight Diabetes Mellitus Poor diet and physical inactivity Overweight and obesity High c-reactive protein levels High blood sugar Peripheral artery disease

What are some findings that are significant for CATARACTS?

Clouding of the usually clear lens of the eye Causes an abnormal red reflex -- black spots against the background of a red light reflex

Describe the technique for the RINNE TEST

Compares air and bone conduction sounds Strike a tuning fork and place the base of the fork on the patients mastoid process Ask the patient to tell you when the sound is no longer heard Move the tuning fork to the front of the ear and ask the patient to tell you if the sound is audible after the fork has been moved Normal: AC > BC

**List the four different types of assessments

Comprehensive Ongoing Focused Emergency "COF-E"

What is an abnormal finding of the Weber test?

Conductive Hearing loss -- patient will hear the sound in the poor ear (good ear is distracted by other noises); bad ear receives the sound conducted by bone vibration Sensorineural hearing loss -- patient will hear the sound better in good ear (nerve damage in bad ear make sound seem louder in unaffected ear)

What is an abnormal finding of the Rinne Test?

Conductive hearing loss: BC>AC Sensorineural hearing loss: AC>BC **Test is used to determine CAUSE of hearing loss once it is determined that there is hearing loss**

Describe anatomy of the lungs

Cone shaped structures that extend from the clavicle to the diaphragm Inspiration -- extend to 8th ICS and 12th posteriors Expiration -- rise to 5th or 6th ICS and 10th posteriorly Right (3 lobes) and Left (2 lobes) are separated by fissures that run obliquely

How do you assess for gross peripheral vision?

Confrontation Test Have patient cover one eye and stand 2 feet away HCP covers opposite eye and extends same arm as the eyes that is covered by the patient Patient should see the examiner's finger at the same time the examiner sees it

Differentiate between consensual response, the light reflex, and accommodation.

Consensual response -- constriction of pupil in opposite eye as the one exposed to light Direct -- constriction occurs in the eye exposed to light Accommodation -- ability of eyes to focus on near objects All of these responses are controlled by CRANIAL NERVE III (Oculomotor nerve)

Discuss the A&P of the FIBROUS tissue of the breast

Cooper's ligaments provide support for glandular tissue Run from skin through the breast and attach to the deep fascia of the muscles

**Describe critical thinking and discuss its importance in the nursing process.

Critical thinking is the way in which the nurse processes information using knowledge, past experiences, intuition, & cognitive abilities to formulate conclusions. Nurse must use an open mind to explore alternatives when making plans. Must reflect on thoughts & gather more information when necessary. Use experiences to add to their personal knowledge base. An awareness of human interactions & the environment, to provide cues that influence decisions.

**Describe 2 types of posturing

De-CORE-ticate -- arms are flexed toward the core; abnormal flexor posture Decerebrate -- arms and legs extended and rotate hands and arm internally; abnormal extensor posture

Describe correct assessment technique for musculoskeletal system

Demonstrate movement for pt and provide clear directions Observe gait and posture Inspect joints, muscles, and extremities for size, symmetry, and color Palpate joints, muscles, and extremities for tenderness, edema, heat, nodules, or crepitus Test muscle strength and ROM ofjoints Compare bilateral findings of joints and muscles Perform special tests for carpal tunnel syndrome Perform "bulge," "ballottement," and McMurray's knee tests

What are physical findings suspicious for breast cancer?

Dimpling or retraction of nipple or fibrous tissue Breast pain Discharge from one breast irregularly shaped, hard nodules

What is the function of the FRONTAL lobe?

Directs voluntary skeletal actions Communication Emotions Intellect Reasoning ability Judgement Behavior Broca's area - responsible for speech

Example of actual diagnosis for nutrition

Disturbed body image related to recent weight loss AEB....

What are examples of secondary skin lesions?

Erosion Scar ulcer Fissure

**Describe skin assessment in children

Everything with newborns PLUS: body piercings & tattoos more than 6 Cafe au Lait spots excessive dryness flaking or scaling poor turgor edema periorbital edema Russell's sign Bite marks grayish/brown oval bodies

Identify basic concepts of Health Belief Model

Existence of sufficient motivation Belief that one is susceptible to a serious problem Belief that change following a health recommendation would be beneficial at a level of acceptable costs

**Explain how to respond to patients who refuse to cooperate with examination procedures.

Explain the importance of the examination procedure and the risk of missing important information from any part of the exam. The client's right to choose. Some practices have patient sign a refusal to treat document. Don't be judgemental, avoid conflict, be open-minded, "check yourself before you wreck yourself"

What is Cranial Nerve VII?

Facial contains sensory fibers for taste on anterior 2/3 of tongue stimulates secretions from salivary glands and tears from lacrimal glands

**Examples of communication facilitators and communication blockers

Facilitators: - Professional Appearance, Professional demeanor, Neutral Facial Expression, Nonjudgmental Attitude, Reflective Silence, Effective listening, Open & Closed ended questions, Laundry list for pt to choose from, rephrase information, Well-placed phrases (um-hm, go on, yes), Inferring, Provide information/answer questions as they arise Communication Blockers: Excessive or insufficient eye contact, appearing distracted or distant, standing while patient is seated, using biased or leading questions, rushing through the interview, reading the questions

Describe an abnormal finding associated with the eyelashes

Failure of lids to close Entropion - inverted lower lid Ectropion -- everted lower lid

What is an abnormal finding associated with the positions test?

Failure of the eyes to move in all directions indicates a muscle weakness or cranial nerve dysfunction Nystagmus -- associated with an inner ear disorder, MS, brain lesions or narcotic use

Discuss the anatomy of the inner ear

Fluid-filled Consists of Bony Labyrinth and Inner membrane Labyrinth Bony labyrinth: Cochlea -- contains sensory organ for hearing Vestibule -- where vestibular nerve connects with cochlear nerve to form Vestibulochochlear Nerve (CN VIII) Semicircular canals - sense position and head movement to help body maintain static and dynamic equilibrium

Discuss abnormal findings associated with the EXTERNAL AUDITORY CANAL

Foul-smelling, sticky, yellow discharge - otitis externa or impacted foreign body Blood, purulent discharge -- otitis media with ruptured eardrum Blood or water discharge -- skull trauma Impacted earwax -- conductive hearing loss Refer to client with foreign bodies to HCP for prompt removal If object is a button-like battery, medical attention is urgent

Discuss the A&P of the GLANDULAR tissue of the breast

Functional tissue (milk production) 15-20 lobes that radiate in a circular fashion from the nipple Each lobe contains several lobules in which secreting alveoli are embedded in grapelike clusters Mammary ducts -- alveoli converge in single lactiferous duct that leaves each lobe and conveys milks to the nipple

What are Non-modifiable risk factors for breast cancer?

Gender - females are 100x at risk (estrogen & progesterone are implicated) Age - risk increases with age, especially for invasive breast cancers Genetics Race/Ethnicity Family History Personal History Breast Consistency Early Menstruation Previous chest radiation Diethylstilbestrol exposure (1940s, 1950s)

What is an abnormal finding of the bulbar conjunctiva and sclera?

Generalized redness -- conjunctivitis Areas of dryness -- allergies or trauma Episcleritis -- noninfectious inflammation; nodular in appearance OR redness and dilated vessels

What are 3 variations in communication?

Gerontological Cultural Emotional

What is Cranial Nerve IX?

Glossopharyngeal contains sensory fibers for tase on posterior third of tongue and sensory fibers of the pharynx Results in the gag reflex when stimulated

What are some findings that are significant for GLAUCOMA?

Group of eye conditions resulting in optic nerve damage caused by abnormally high Intraocular pressure pressure inteferes with the blood supply to the optic structures Scotoma -- blind spot with normal or diminished peripheral vision Seeing halos around lights (narrow-angle) Night blindness

What are the tests used to identify carpal tunnel syndrome?

Phalen's Test Tinel's Sign Flick Signal Thumb Weakness

Identify abdominal changes in liver disease

Hard, firm liver may indicate cancer Modularity may occur with tumors, metastatic cancer, late cirrhosis, syphillis Tenderness from vascular engorgement considered enlarged if 1-3cm below costal margin Enlargement due to hepatitis, liver tumors, cirrhosis, vascular engorgement

How do you assess near visual acuity?

Have patient hold vision chart 14" from eyes and cover one eye with an opaque card before reading top to bottom

What is brachophony?

Have patient say "99" and it should not be understandable over areas of healthy lung tissue. If 99 is understandable, there is consolidation occurring, such as penumonia

What is egophony?

Have patient say the letter "E" and the sound should sound the same over healthy tissue; like "beeeeet" or a goat bleating

How do you assess distant visual acuity?

Have patient stand 20 ft away from Snellen or E chart and ask to read each line aloud

Explain how to inspect the bulbar conjunctiva and sclera

Have the patient look in all directions and observe for CLARITY, COLOR, & TEXTURE Should be clear, moist, and smooth Underlying structures are visible; sclera is white.

Describe assessment of upper respiratory system complaints

Have you experience change in ability to smell or taste? (URI = decreased ability to smell or taste) Hoarseness? Inspect nasal mucuosa (URI = red & swollen nasal mucosa)

What are modifiable risk factors for breast cancer?

Having no children after age of 30 Recent oral contraceptive use Hormone replacement therapy No history of breast feeding Alcohol consumption Excess weight or obesity Weight gain as adult female Limited physical activity

Explain SENSORINEURAL hearing loss

Hearing taking place when sound waves are channeled through the auditory canal tympanic membrane vibrates vibrations transmitted through middle ear by auditory ossicles to the inner ear nerve impulses travel to brain for interpretation Caused by damage to inner ear and the impaired ear cannot make the conversion into nerve impulses result of prolonged exposure to loud noises or ototoxic meds

Describe SIBILANT wheeze

High pitched Air passes through constricted passages Acute asthma; chronic emphysema

What is a normal finding in infants and children when performing an extraocular muscle test?

Hirschberg Test -- light reflects symmetrically in the center of both pupils Light causes pupils to vasoconstrict bilaterally and blink reflex occurs Blink reflex also occurs as an object is brought towards the eyes By 10 days of age, when turning the head, the infant's eyes should follow the movement of the head

Identify risk factors for osteoporosis

History of fractures Dowager's Hump Height Reduction

What are possible causes of gynecomastia?

Hormone Imbalances Drug Abuse Cirrhosis Leukemia Thyrotoxicosis

Assessment findings related to cranial nerve XII

Hypoglossal Decreased tongue strength

What is Cranial Nerve XII?

Hypoglossal innervates tongue muscles that promote movement of food and talking

What are abnormal findings associated with the light reflexes?

If light is shone into a blind eye, no response is either pupil If light is shone into an unaffected eye, both pupils will constrict No reaction at all (direct or consensual)

Advantages and Disadvantages of electronic charting

Improves quality, safety, and efficiency of client Reduces medication errors Allows patients and families to engage in care & treatment Allows patient data to be accessed for research purposes

**Recognize examples of inappropriate documentation.

Inappropriate Documentation - Never white out or ink out mistakes, no slang/jargon/labels, try not to write the word normal, incorrect

Physiological findings associated with pain

Increased heart rate, blood pressure Increased peripheral, systemic, coronary artery vascular resistance decrease in cognitive function, mental confusion, altered temperament, high somatization, dilated pupils Increased ADH, epinephrine, norepinephrine, aldosterone, glucagons increased respiratory rate and sputum retention Decreased urinary output: fluid overload, depression of immune response, urinary retention decreased gastric and intestinal motility Hyperglycemia, glucose intolerance, insulin resistance, protein catabolism Muscle spasm; perspiration

Common symptoms associated with HYPOthyroidism

Increased sensitivity to cold constipation diarrhea fatigue heavier menstrual periods Pale, dry skin thin, brittle hair or nails weakness unintentional weight gain If left untreated: decrease taste and smell, hoarseness, puffy face, hands, feet, slow speech

What is the function of the OCCIPITAL lobe?

Influences the ability to read and understand Primary visual receptor center

What is a normal finding when inspecting the external eye of an infant?

Inner canthus distance is approximately 2.5cm Horizontal Slant No epicanthal folds Outer canthus aligns with tips of the pinnas (ear)

What is the proper sequence for assessing the abdomen

Inspect Auscultate Percuss Palpate

Describe the assessment for the knees

Inspect for size, shape, symmetry, swelling, deformities, and alignment Palpate for tenderness, warmth, consistency, and nodules - begin 10cm above patella, use fingers/thumbs to move toward the knee Test for Swelling Palpate the tibiofemoral space Test ROM Test for Pain or injury

How do you assess the lacrimal apparatus?

Inspect for swelling or redness Palpate for a blockage

**What are 4 techniques for obtaining data during a physical exam?

Inspection Palpation Percussion Auscultation "IPPA"

Describe the proper examination technique for the cardiovascular system

Inspection: Jugular venous pulse Jugular venous distention Palpate: apical impulse (mitral area) Auscultation: listen and feel for carotid arteries if you suspect CV disease ask client to hold their breath Position on the client's ride size; supine; 30 degrees elevate

Describe proper technique for peripheral vascular assessment

Inspection: arms size and venous pattern Observe color distribution of hair lesions or ulcers on legs looks for varicosities and thrombophlebitis Palpation: Temperature Cap refill Pulses on the extremities epitrochlear and superficial inguinal lymph nodes Allen test -- patency of radial or ulnar arteries Edema

Describe physical examination of the thorax

Inspection: signs of labored breathing, patient's position, configuration Palpation: tenderness or sensations, crepitus, remits, lesions Percussion: Tone (hyperresonance = trapped air), diaphragmatic excursion Auscultation: breath sounds (crackles/wheezing), voice sounds

**Describe and discuss integrated cued checklists

Integrated Cued Checklist - combines assessment data with nursing diagnoses, helps combine & validate data into one form, easy to use by all levels of healthcare provider so it increases communication within providers

Describe proper descriptive terms for various levels of consciousness

Lethargy -- opens eyes, answers questions, go back to sleep Obtunded -- opens eyes to LOUD voice, responds slowly with confusion, unaware of environment Stupor -- client awakens to vigorous shake or painful stimuli, returns to unresponsive sleep Coma -- client remains unresponsive to all stimuli and eyes stay closed

Describe the configurations of skin lesions (shapes)

Linear Annular (circular) Clustered Discrete (distinct lesion) Nummular (coin shaped; grouped) Confluent (small lesions that run together to form larger)

What are some common nail disorders?

Longitudinal ridging --aging Half-and-half nails -- white proximally, pink distally--renal Pitting -- psoriasis Koilonychia -- concave nails -- trauma, iron def., endocrine/cardiac disease Yellow nail syndrome -- yellow, grow slow, curved -- AIDS, respiratory syndrome Paronychia -- local infection --infected hang nail

Describe normal findings in the FOVEA and MACULA in an opthalmoscope examination

Macula is darker area, one-disc diameter in size, located to the temporal side of optic disc Fovea - star-like light relex within macula

Types of Primary skin lesions

Macule & Patch Papule & Plaque Nodule & Tumor Vesicle & Bulla Wheal Pustule Cyst

Discuss abnormal findings associated with the AURICLE, TRAGUS, & LOBULE

Malaligned or low set ears seen with GU disorder or chromosomal defects enlarge post- & pre-auricular lymph nodes -- infection Tophi (uric acid nodules) -- gout Blocked sebaceous glands --postauricular cysts Ulcerated, crusted nodules that bleed -- skin cancer Redness, swelling, scaling, or itching -- otitis externa Pale blue color -- frostbite

Explain how to inspect the iris and pupil

Measure pupils against a gauge (normal 3-5mm) Iris is typically round, flat, and even colors Pupil is round with regular borders & centered in the iris

**Explain the introductory phase of the nursing interview

Meets client and explains what to expect during process; maintains confidentiality; HIPAA

**Describe and discuss the minimum data set.

Minimum Data Set - commonly used in long-term care facilities, prompts nurse for specific criteria, includes specialized information, meets the needs of multiple data users

Common symptoms associated with CUSHING's syndrome

Moon-shaped face reddened cheeks increased facial hair Striae Thin, Fragile Skin

What is the proper procedure for a neurological examination?

Move from a level of higher cerebral integration to a lower level of reflex activity Complete exam includes: Mental Status Cranial Nerves Motor and Cerebellar systems Sensory system Reflexes

What is an abnormal finding associated with visual acuity?

Myopia -- impaired far vision 2nd number will be higher 20/200 indicates legally blind

Malnutrition: Pre-albumin levels

Normal: 15-30mg/dl Mild Depletion: 10-15 Moderate Depletion: 5-10 Severe Depletion: <5mg/dl

Malnutrition: Transferrin (iron binding molecule)

Normal: 200-400mg/dl Mild Depletion: 150-199 Moderate Depletion: 100-149 Severe Depletion: <100 Higher # of transferrin = iron deficiency Lower # of transferrin = liver disease

Malnutrition: Serum Albumin levels

Normal: 3.5-5.5g/dl Mild Depletion: 2.8-3.5 Moderate Depletion: 2.1-2.7 Severe Depletion: <2.1

Malnutrition: HbA1C

Normal: 4-6% Diabetic: <7%

Malnutrition: Total Protein levels

Normal: 6-8g/dl Abnormal: <5.0g/dl

Malnutrition: Hemoglobin lab value

Normal: Males - 13-18mg/dl Females - 13-16mg/dl Abnormal: males < 13mg/dl Females <11mg/dl

Malnutrition: Hematocrit (% of RBCs in the blood) Lab value

Normal: Males - 40-52% Females: 36-48% Abnormal: Males <39% Females: <35%

Describe the difference between Nuclear cataracts and Peripheral cataracts.

Nuclear cataracts -- appear grey when seen with a flashlight Peripheral cataracts -- look like gray spokes that point inward when seen with a flashlight

What is Cranial Nerve III?

Oculomotor Controls eye movements, constrict pupils, and elevates eylids

Assessment findings related to cranial nerve III

Oculomotor Drooping eyelids

What is Cranial Nerve I?

Olfactory carries smell impulses from nose to brain

What is an acronym to remember cranial nerves?

Ooh, Ooh, Ooh, to touch and feel very good velvet. Such Heaven!

**Describe and discuss open ended forms.

Open-Ended Forms - Traditional form requires narrative description of problem & lists topics, takes a lot of time, provides a total picture to include complaints in patient's own words, increased risk of not asking a pertinent question

**State the advantages and disadvantages of open ended and closed ended questions

Open-Ended: can elicit significant information pt would not have otherwise given. "How have you been feeling lately? However, it leaves room for the patient to deter from the assessment Closed-Ended: help focus on specific information, clarify answers & keep the interview on track. "When did the pain start?" Closed-ended questions are bad in that they do not pull information unless you specify a question.

What is Cranial Nerve II?

Optic carries visual impulses from eye to brain

What is Obturator sign?

Pain in the RLQ Flex knee and hip, internally and externally rotate the leg Irritation of the obturator muscle in the hips

What is Rosving's Sign?

Pain in the RLQ during pressure in the LLQ

What is an expected finding with a rotator cuff tear?

Painful and limited ABDUCTION accompanied by muscle weakness and atrophy

**What is a risk diagnosis?

Patient doesn't currently have the problem, but are at a high risk for developing; vulnerability example: Poor nutrition and incontinence "Risk for..."

How to palpate lymph nodes

Patient seated upright Palpate lymph nodes with figerpads in a slow, walking, gentle, circular motion Patient should bend head slightly toward the side being palpated to relax muscles in that areas Compare bilaterally

What is the PR interval on an EKG?

Period of time for the impulse to reach the ventricles time from beginning of atrial depolarization to the beginning of ventricular contraction

What are examples of vascular skin lesions?

Petechiae Ecchymosis hematoma cherry angioma spider angioma telangiectasis

What are abnormal findings associated with Cover test?

Phoria - mild weakness; Esophoria (inward drift) or Exophoria (outward drift) Strabismus -- constant malalignment of eyes Tropia - specific type of malalignment; Esotropia (inward turn) or Exotropia (outward turn) "Tropia Turns"

What are the dimensions of pain?

Physical - perception of pain and body's reaction to it Sensory - quality & severity of pain Behavioral - verbal & nonverbal behavior in response to it Sociocultural - influences of social context and background Cognitive - "beliefs, attitudes, intentions and motivations" related to pain management Affective - feelings related to pain experience Spiritual - meaning and purpose that the person "attributes to pain, self, others, the divine"

**Explain the differences between a physician assessment and a nursing assessment

Physician assessment -- focused primarily on patient's physiological status Nursing assessment-Holistic data collection

Describe assessment for venous and arterial insufficiency

Position Change Test (arterial) -- how long does it take color to return to tips of toes after arterial blood is occluded to legs Ankle-brachial index -- ratio of ankle systolic BP to the arm systolic BP (same in healthy person) Manual Compression Test -- assess competence of venous valves in clients with varicose veins Trendelenburg Test -- trendelenburg position & a tourniquet applied to upper thigh (no pulsation = normal)

**What is a collaborative problem?

Potential complications of a client's condition that a nurse cannot treat independently. They will probably occur with a specific disease, injury or treatment.

Where in the head and neck are lymph nodes located?

Pre auricular Post auricular Occipital Tonsillar Submandibular Submental Superficial cervical Posterior cervical Deep cervical Supraclavicular

**What are the 4 stages of the assessment nursing interview?

Pre-introductory phase Introductory phase Working phase Summary & Closing

What is an abnormal finding associated with near visual acuity?

Presbyopia (impaired near vision) patient has to move chart away form eyes to focus on the print Normal vision is 14/14

**Discuss the process of documentation phase of the nursing assessment.

Promotes effective communication among health care team to facilitate safe & efficient patient care. Proper documentation improves quality, safety & efficiency of care; reduces disparities; coordination of patient care improves; health data of populations being accessed for research will improve patient care for all.

Describe an abnormal finding with the position of the eyeball.

Protrusion -- indication of Grave's Disease Sunken appearance -- indication of severe dehydration or wasting illnesses

What is an abnormal finding associated with the eyelids?

Ptosis (drooping eyelid) Myasthenia gravis Weakened muscles or tissue Congenital disorder Retracted lid margins

**State how pulse pressure is calculated and discuss its physiological significance.

Pulse pressure is the difference between the systolic and diastolic pressure readings. It is measured in millimeters of mercury (mmHg). It represents the force that the heart generates each time it contracts. If resting blood pressure is (systolic-diastolic) 120-80 millimeters of mercury (mmHg), pulse pressure is 40. Produced when ventricles contract and send blood from aorta to rest of body; pulse is blood moving through the arteries Obtained from arterial pulse sites: radial, antecubital, carotid, femoral

What is an abnormal finding associated with accommodation of pupils?

Pupils do not constrict, and eyes do not converge

**Explain the Working phase of the nursing interview

RN gains info FROM client regarding reasons for seeking care, health hx, family hx, lifestyle, etc...

**Explain the pre-introductory phase of the nursing interview

RN review's client chart BEFORE meeting client; may assist nurse during the interview process

Example of health promotion diagnosis for nutrition

Readiness for enhanced fluid balance related to a desire for information pertaining to a need for increased fluids

Discuss abnormal findings associated with the TYMPANIC MEMBRANE

Red, bulging eardrum and distorted, diminished, or absent light reflex -- acute otitis media Yellowish, bulging membrane with bubbles behind -- serous otitis media Bluish or dark red color -- blood behind eardrum from skull trauma White spots -- scarring from infection Perforations -- trauma from infection Prominent landmarks -- eardrum retraction from negative ear pressure resulting form blocked Eustachian tube Obscured or absent landmarks -- eardrum thickening from chronic otitis media

What is the function of the HYPOTHALAMUS?

Regulates body functions: water balance appetite vital signs sleep cycles pain perception emotional status

3 techniques for assessing memory

Remote memory -- asking client about something related to past (first job, first house, etc...) Recent memory -- asking client about something that occurred recently (breakfast or lunch that day, what the weather is like) Learn new information -- ask client to repeat unrelated words and then repeat those words in 5 min increments

Explain the differences between REMOTE and RECENT memory

Remote memory is the ability to recall information in the past (long-term memory) Recent memory is the ability to recall recent events without difficulty (short-term memory)

Describe PLEURAL FRICTION rub

Results of rubbing two inflamed pleural surfaces together Pleuritis

Example of risk diagnosis for nutrition

Risk for imbalanced nutrition: more than body requirements related to increased sedentary lifestyle and decreasing metabolic demands

What is the S2 sound?

closure of semilunar valves (aortic & pulmonic) Beginning of diastole (relaxation) "Dub" Heard at base (top) of the heart

Explain how to inspect the cornea and lens

Shine a light from the side of the eye for an OBLIQUE view Look through the pupil to inspect the lens

When palpating lymph nodes, what should you assess?

Size & Shape - <1cm (if larger, lymphadenopathy) Delimitation - discrete or confluent Mobility -- mobile or metastatic (fixed) Consistency - soft or hard Tenderness - not sore or tender (enlarged & tender=acute infection)

Discuss the anatomy of the middle ear

Small, air-filled chamber in the temporal bone Includes 3 bones that are responsible for transmitting sound waves: Malleus (hammer) Incus (anvil) Stapes (stirrup)

What is an abnormal finding associated with the lacrimal apparatus?

Swelling caused by infection, blockage, or inflammatory condition Excessive tearing may be caused by an obstruction Drainage upon palpation

Discuss physiology of hearing

Sound vibrations travel through inner ear causing eardrum to vibrate Sound waves are then transmitted to the ossicles as the vibration of eardrum causes these ossicles to vibrate Sound waves are passed to the fluid of the inner ear Movement stimulates hair cells of organ of Conti and initiates nerve impulses that travel to the brain by way of CN8

**Recognize appropriate equipment for specific examinations as described in the text.

Sphygmomanometer- Blood Pressure & auscultate lung, GI, Heart - Stethoscope - auscultate blood pressure, pulses, breath sounds, heart sounds, thyroid, bowel sounds - Thermometer - to take temperature - Watch - time used to assess pulse & respiratory rate - Pain scale - Patient can identify their level of pain - Calipers - measurement to determine body fat - Tape measure - body and wound measurements, extremities for edema - Skin Pen - to mark areas on the body in order to track change - Scale - weight - Pen light - Pupillary constriction, view mouth & nose, - Ruler - used to measure wounds, markings, lesions, etc. - Magnifying glass - view skin & lesions - Wood's light - test for fungus - Eye Chart - visual acuity - Ophthalmoscope - Examine retina of eye and red reflex - Tuning forks - test for bone & air conduction of sound, vibratory sensation - Otoscope - Examine ear canal & tympanic membrane, view inside of nose - tongue depressor - view throat, mouth & check strength in tongue - Doppler Ultrasound - weak pulses - Goniometer - measure degree of flexion & extension in joints - Cotton Applicator - "Q-tip" used for packing, cleaning, etc. - Reflex hammer - test deep tendon reflexes - Cotton ball & paper clip - test light, sharp and dull touch - Occult Test - Rectal blood test card - Vaginal Speculum - inspect cervix and vaginal canal - Bifid spatula - swab - pH paper - used to gauge the acidity or alkalinity of a solution

What is Cranial Nerve XI?

Spinal Accessory Innervates neck muscles and promotes movement of shoulders and head rotation promotes some movement of larynx

What are the 5 stages of pressure ulcers? Define each stage.

Stage I -- redness, skin intact, nonblanchable Stage II -- partial dermis thickness loss, shallow open ulcer, with a red/pink wound bed without slough Stage III -- full thickness dermis loss, subcutaneous fat visible Stage IV -- full thickness tissue loss with exposed bone, muscle, tendon; slough or eschar may be present Unstageable -- full thickness tissue loss in which base of ulcer is covered by a slough (yellow, tan, gray, green, or brown) and eschar (tan, brown, black)

Discuss the A&P of the FATTY tissue of the breast

Substance of the breast glandular tissue is embedded in the adipose tissue

How do you perform the POSITIONS TEST?

Tests muscle strength & cranial nerve function Hold an object 12 in from patient's face Move the object through all 6 cardinal positions in a clockwise direction observe eye movement -- should be smooth and symmetric in all directions

What is the S1 sound?

closure of the AV valves beginning of systole (contraction) "Lub" Heard at apex (bottom) of the heart

**Describe assessment stage of the nursing process

collecting subjective and objective data

The clinic nurse is conducting a health history. Place in proper sequence the questions the nurse would ask using the standard format for collecting health history information. All options must be used. a. "Does anyone in your family have diabetes mellitus?" b. "For what reason did you come to the clinic today?" c. "What is your date of birth?" d. "Can you tell me about your support systems?" e. "Have you ever been hospitalized?"

The clinic nurse is conducting a health history. Place in proper sequence the questions the nurse would ask using the standard format for collecting health history information. All options must be used. 3) "What is your date of birth?" 2) "For what reason did you come to the clinic today?" 5) "Have you ever been hospitalized?" 1) "Does anyone in your family have diabetes mellitus?"4) "Can you tell me about your support systems?" Rationale: Date of birth is an item in the category of biographical data, which is gathered first. Why the client came to the clinic is the chief complaint or reason for seeking care and is included in the category of present health or illness, which is gathered second. Assessment of prior hospitalizations is part of the past history, which is gathered third. Family history of disorders is the fourth category of assessment. Inquiring about support systems is part of the psychosocial history, which is assessed fifth. The sixth category, review of systems, is not assessed in this question.

**Describe the process of identifying an appropriate nursing diagnosis.

The nursing diagnosis process includes: 1. data clustering, 2. identifying patient needs or problems, and 3. formulating the nursing diagnosis or collaborative problem.

What is a normal finding when inspecting the eyelids of an infant?

Transient edema, absence of tears

What is Cranial Nerve V?

Trigeminal Carries sensory impulses of pain, touch, and temperature from face to brain Influences clenching and lateral jaw movements

What is Cranial Nerve IV?

Trochlear contracts one eye muscle to control inferomedial eye movement

What is an abnormal finding when inspecting the external eye of an infant?

Wide-set position upward slant thick epicanthal folds sun-setting appearance

**5 ways to take temperature and expected variations in readings

Tympanic: ear, 98.0 -100.9 oral: mouth, 96.6-99.5 Axillary: armpit, 95.6-98.5 Temporal Arterial: forehead/temple, 97.4-100.3 Rectal: bottom, 97.4-100.3

**Correct technique for obtaining temperature

Tympanic: place probe a to opening of ear canal for 2-3s Oral: place thermometer under client's tongue, close mouth, hold until you hear a beep Axillary: place thermometer in armpit and ask client to arm down and across the chest Temporal: stroke thermometer across client's forehead over the temporal artery Rectal: insert into rectum and hold glass thermometer in place for 3 minutes......use this route as a last resort!!!

Describe relationship between assessment and the rest of the nursing process

collection of subjective and objective data basis of nursing process; without proper gathering of information, remaining steps will be hindered

**Describe appropriate steps to take in assessing a client where there are cultural barriers between the client and the nurse.

Use a culture broker or interpreter. Can try communicating with pictures.

Describe the technique for McMurray Test.

Used when a patient complains of giving in or locking knees Pt flexes one knee or hip Hold heel of foot Rotate lower leg and foot laterally Slowly extend the knee, noting pain and clicking Rotate lower leg and foot medially

What is Cranial Nerve X?

Vagus Carries sensations from the throat, larynx, heart, lungs, bronchi, GI tract, and abdominal viscera promotes swallowing, talking, and production of digestive juices

Explain the QRS complex on an EKG.

Ventricle contract (depolarize) and atria relax (repolarize) S1 heard

Give an example of verbal and non-verbal communication

Verbal : open- or closed- ended questions, laundry lists, rephrasing, well place phrases, inferring, and providing information Nonverbal: appearance, demeanor, facial expression, attitude, silence, listening

**Discuss the process of validating data phase of the nursing assessment.

Verifying accuracy & reliability of the data collected by repeating assessment, clarify with patient through questions, verify data with another healthcare professional, or compare objective to subjective. failure to validate results in premature closing of assessment and results in incomplete data collection, which could lead to diagnostic errors during remainder of nursing process Information requiring validations: discrepancies/gaps between subj. and obj. dtat discrepancies between what client says at different times findings that are highly abnormal or inconsistent with each other

What is Cranial Nerve VIII?

Vestibulocochlear Contains sensory fibers for hearing and balance

What are the types of pain?

Visceral - abdominal organs become distended or contract forcefully Parietal -- parietal peritoneum becomes inflamed Referred --occurs at distant sites that are innervated at approximately the same levels as the disrupted abdominal organ; travels form primary site and localizes at distant site

Different types of pain scales

Visual Analog Scale (VAS) Numeric Rating Scale (NRS) - popular - patients with NO cognitive impairment Numeric Pain Intensity Scale (NPI) Verbal descriptor scale - popular Simple descriptive pain intensity scale Graphic rating scale Verbal rating scale Faces pain scale (FPS) - Popular -- cognitively impaired N-PASS -- assess neonates and infant behaviors FLACC -- Peds Memorial Pain assessment - 4 part cancer assessment

Precautions for avoiding a head injury

wear seatbelt Don't drink and drive Wear Helmet Remove tripping hazards for seniors Maintain regular physical activity (improve balance) Make living areas safe for children

Discuss assessment for possible hearing loss

Whisper Test Weber Test Rinne Test Romberg Test **all used for screening purposes**

**Identify risk factors for osteoporosis.

Women over 65 or who have a fracture risk equal to a woman over 65. History of fractures, dowager's hump, height reduction, age, female, family history, previous fracture, race/ethnicity, menopause/hysterectomy, long-term glucocorticoid therapy, Rheumatoid arthritis, hypogonadism in men. Modifiable- alcohol, smoking, Low BMI, poor nutrition, vitamin D deficiency, eating disorders, insufficient exercise.

Formula for calculating Ideal Body Weight (IBW)

Women: 100lbs for 5ft + 5lb for each inch over 5ft Men: 106lbs for 5ft + 5lbs for each inch over 5ft (actual weight/IBW) x 100 = %IBW

What are abnormal findings when inspecting the sclera and conjunctiva in infants and children?

Yellow = jaundice Blue = osteogenesis imperfecta Redness = conjunctivitis

**Describe preparations/equipment for objective physical exams

comfortable, warm room temperature private area free of interruptions from others quiet area free from distractions adequate lighting firm exam table or bed at height that prevents stooping bedside table or tray to hold equipment needed for exam

The nurse demonstrates the purpose of a health history by documenting which information about a client's respiratory system? a. Perception of his or her respiratory health status b. Tactile fremitus and breath sounds c. Vital signs including respiratory rate and oxygen saturation d. Respiratory excursion and respiratory effort

a Rationale: The purpose of the health history is to document the client's perceptions of his or her health, which is subjective data. Tactile fremitus and breath sounds, vital signs, and respiratory excursion and effort are objective data. They are part of the physical assessment, which is the head-to-toe examination of the client.

After the nurse gathers health assessment data on a client admitted with pneumonia, the nurse would take which action? a. Review the information gathered to analyze the data b. Report all findings to the healthcare provider c. Schedule an interdisciplinary planning meeting d. Develop appropriate client goals for identified problems

a Rationale: After completing a health assessment the nurse systematically analyzes the data and then plans care for the client. Only abnormal findings are reported to the healthcare provider. Interdisciplinary care planning meetings are a team approach to developing a plan to resolve problems. Goals are developed to address health problems found on assessment once the nurse has completed the analysis phase of the nursing process, which leads to nursing diagnoses.

In an effort to provide a comfortable environment for a client during a physical assessment, the nurse would take which action? a. Drape the client prior to beginning the examination b. Urge the client to have all abnormal findings treated promptly c. Avoid wearing gloves so the client won't feel as though the nurse does not wish to touch the skin d. Obtain a signed consent to perform a physical assessment

a Rationale: Properly draping a client will provide warmth during the exam and help to avoid client embarrassment. While clients should seek treatment for abnormal findings, this is not part of promoting a comfortable environment. When coming in contact with body fluid during the exam, the nurse must follow standard precautions, so gloves may be worn during part of the exam. There is no need for a specific signed consent for physical assessment.

Prior to obtaining data for a health history the nurse should take which action? a. Introduce self to client and position client comfortably in a chair b. Bring in a family member to verify all data c. Review medical record to validate client information d. Tape record client information to avoid omissions

a Rationale: Taking a health history takes time so it is important to place the client at ease by introducing oneself and making the client comfortable. To maintain confidentiality the nurse should not invite anyone into the examination room unless requested by the client. While the nurse may review information in the medical record, the nurse gathers data from the client during a health history. No information should be tape recorded to maintain confidentiality and also because it may make the client uncomfortable. The nurse may document the history as the client is revealing it.

The nurse needs to remember that when assessing pain: a. The lack of expression of pain does not always equate with the pain being experienced. b. Pain medication can significantly increase a patient's pain tolerance. c. The majority of cultures value the concept of suffering in silence. d. Most people experience approximately the same pain tolerance.

a Rationale: An obvious response to pain is not always apparent because psychosociocultural factors may dictate behavior. Fear of the treatment for pain, lack of validation, acceptance of pain as punishment for previous behavior, and the need to be strong, courageous, or uncomplaining are factors that influence behavioral responses to pain. The opposite may be true for the 2nd option. Many ethnic groups are able to express their pain making the 3rd option untrue. The 4th option is not accurate because pain tolerance varies widely among people and is influenced by experiences, psychological issues, and sociocultural factors.

**Describe standard precautions of infection control and explain how they relate to the assessment process.

a) Hand Hygiene - upon entering and leaving pt room b) PPE - wear if potential to come into contact with blood or body fluids c) Patient Placement - Place infectious person in single occupancy room d) Equipment - establish procedures to ensure clean equipment for each patient e) Care of Environment - routine cleaning of surfaces (beds, counters, etc) f) Laundry - clean gown and bedding g) Injectable - new needles, syringes, cannulas, etc. Dispose of properly

When obtaining information about a child's health history, the nurse would include which data? Select all that apply: a. Past medical history b. Present medical complaint c. Review of systems d. General survey e. Vital signs

a,b,c Rationale: The components of a health history include past and present medical history as well as a review of systems (subjective data). General survey and vital signs are components of the objective data assessment.

The nurse assesses the range of motion of an ankle by moving the ankle through which types of movements? Select all that apply. a. Plantar flexion b. Dorsiflexion c. Inversion d. Eversion e. Rotation

a,b,c,d Rationale: Plantar flexion (option 1) is the ability to flex the ankle by pointing the toes downward. Dorsiflexion (option 2) is the ability to flex the ankle by pointing the toes upward. Inversion (option 3) is the ability of the client to point the foot inward, while eversion (option 4) is the ability to move the foot outward. Rotation (option 5) is movement of a bone on an axis.

What is the P wave on an EKG?

atrial depolarization, which results in atrial contraction

Prior to beginning a physical examination of a client, the nurse would carry out which activities? Select all that apply. a. Wash hands b. Provide for privacy of the client c. Obtain a healthcare provider's order d. Explain the procedure to the client e. Position the client comfortably

a,b,d,e Rationale: Prior to performing any assessment or procedure the nurse should wash hands or use another method of hand hygiene, such as an alcohol rub, to prevent infection. The nurse should also ensure client privacy and make the client as comfortable as possible. The nurse should explain the procedure to the client so the client can anticipate what is to follow, which may help the client to be more relaxed. The nurse would not need a healthcare provider's order to carry out the assessment because physical assessment is within the scope of nursing practice.

During physical assessment, the nurse would palpate the skin for which characteristics? Select all that apply. a. Temperature b. Texture c. Pigmentation d. Moisture e. Elasticity

a,b,d,e Rationale: The nurse would palpate the skin for temperature, which should be warm. Texture should be smooth, firm, and even. Palpation is also used to evaluate the skin for moisture and the skin should be dry. Palpating for elasticity is done by assessing for mobility and turgor. The skin should immediately return to the normal position and not tent. Pigmentation is assessed through the use of inspection rather than palpation.

The nurse is obtaining a health assessment on a client who reports leg pain and inability to perform activities of daily living (ADLs). The nurse would ask which questions to obtain information about the client's ability to carry out ADLs? Select all that apply. a. "Can you tell me how the pain is affecting your life?" b. "Do you know what is causing the problem?" c. "Does anyone in your family have any musculoskeletal problems?" d. "Can you describe how your activity level has changed?" e. "Can you tell me about your hobbies?"

a,d Rationale: During musculoskeletal assessment, it is important to determine how problems interfere with ADLs, because pain may limit movement and activity the nurse would ask open-ended questions, such as how the pain is affecting the client's life (option 1). Asking how the client's activity level has changed (option 4) will also yield data about limitations that affect ADLs. Although it is helpful to ask the client if he or she knows the cause of the problem as part of the interview (option 2), this will not provide information about reduced ability to perform ADLs. Inquiring about family history is an important part of the interview (option 3); however, this also will not provide information about ADLs. Hobbies (option 5) are useful as recreational activities and could possibly yield data about injury; however, hobbies are not part of the ADLs, so it is not needed when determining ADL status.

**Define the differences between acute and chronic pain.

a. Acute- usually associated with a recent injury. b. Chronic- usually associated with a specific cause or injury and described as a constant pain that persist for more than 6 months.

**Describe ways of assessing pain in the alert and oriented patient as well as in the patient who is unable to communicate.

a. Alert and oriented- Use coldspa (character, onset, location, duration, severity, pattern, associated factors), you can use the numeric rating scale. b. Unable to communicate- use the hierarchy of pain assessment techniques. And use the Faces scale. i. Self-Repot ii. Search for potential causes iii. Observe patient behavior iv. Surrogate reporting v. Attempt an analgesic trial

**Describe the grading system for muscle strength.

a. Ask the client to move each extremity through its full ROM with resistance, if not then gravity and then with assistance. i. 5- Active motion against full resistance, Normal ii. 4- Active motion against some resistance, slight weakness iii. 3- Active motion against gravity, Average weakness iv. 2- Passive ROM (gravity removed and assisted by examiner), Poor ROM v. 1- Slight flicker of contraction, severe weakness vi. 0- no muscular contraction, paralysis

**Identify the purposes and method of the general survey.

a. It provides the nurse with an overall impression of the clients whole being.

**Describe assessment for carpal tunnel syndrome.

a. Phalen's Test- rest elbows on a table, place backs of both hands together while flexing the wrist at a 90 degree angle with fingers pointed downward andwrist dangling. Hold for 60seconds. No tingling, numbness or pain then no carpal tunnel. If symptoms develop may have carpal tunnel. b. Tinel's- use your finger to percuss lightly over the median nerve. No tingle or shock sensation no carpal. Shock or tingling, carpal tunnel.

**Discuss the physiological and psychological aspects of pain.

a. Physiological- Nociceptors detect signals from damaged tissue and chemicals released from damaged tissues and transmit the sensations to the CNS. Transduction is the release of chemical by damaged tissue that affect the nociceptors and send the message up the sensory neuron. Transmission, pain impulse from the nociceptor relays the pain from the spinal cord to the brain. Perception, the pain is perceived in the brain. Modulation, pain message is inhibited. a. Psychological- developmental level, age and culture can affect pain perception and assessment.

**Explain expected findings of vital signs in the normal client and describe the expected relationships between variations when vital signs are out of normal limits.

a. Temp- Between 98-100.9 if tympanic. Lower is hypothermia could be caused by long exposure to the cold, hypoglycemia, hypothyroidism, starvation, neurologic dysfunction, or shock. Higher is hyperthermia could be caused by Infections, inflammation, malignancies, trauma, or various blood endocrine and immune disorders. b. Pulse Rate- 60-100 is normal for adults. Tachycardia greater than 100, May occur with fever, certain meds, stress, and other abnormal states such as cardiac dysrhythmias. Bradycardia anything lower than 60- sitting or standing for long periods of time, heart block or dropped beats. c. Respiratory rate- breaths between 12-20 per minute. Observe rhythm and depth. If irregular rhythm count for a full minute. d. Blood pressure- Normal 120/80 or less, Prehypertension 120-139/80-89, Hypertension stage 1 140-159/90-99, stage 2 Greater than 160/100. A pressure difference of 10 or lower between arms is normal. e. Pulse pressure- Normal between 30 to 50. Anything lower or higher could mean cardiovascular disease.

Symptoms of Venous insufficiency

aching, cramping pain pulses are present but difficult to palpate b/c of edema pigmentation in gaiter area, thickened and tough, reddish-blue, associated with dermatitis Ulcers along medial malleolus/anterior tib area; irregular border; granulation base; moderate to severe leg edema

Example of actual diagnosis for pain

acute pain related to injury agents AEB...

What are non-modifiable risks for osteoporosis?

age female gender family history previous fracture race/ethnicity menopause/hysterectomy long-term glucocorticoid therapy Rheumatoid Arthritis Primary/secondary hypogonadism in men

**Explain gerontological consideration in communication.

aging process; do not assume someone has a health problem because of their age assess hearing acuity and work to develop a relationship of trust, privacy, and partnership avoid medical jargon and slang; be straightforward and simple

Describe changes in skin due to environmental stimuli

allergic reactions such as rash or hives premature aging if unprotected during exposure temperature extremes affect blood supply and can damage layers

Explan how to assess consensual response to light

also called "indirect response" Shining the light into one eye and observing the opposite eye for a response

**Describe Diagnosis stage of the nursing process

analyzing data collected to make a professional nursing judgement (diagnosis, collaborative problem, referral)

What is a scar?

another name: cicatrix skin mark left after healing of wound, replacement is by a connective tissue

Describe normal findings of the ANTERIOR CHAMBER in an opthalmoscope examination

anterior chamber is transparent

What is a spider angioma?

appears on face/neck/arms/trunk associated with liver disease, pregnancy, vit B deficiency red arteriole

What is Flick Signal?

ask "what do you do when your symptoms are worse?" If patient responds with a motion that resembles shaking a thermometer, carpal tunnel may be suspected

What is Thumb weakness?

ask patient to raise thumb up from plan of palm; ask patient to stretch thumb so the pad rests on the pad of the little finger pad abnormal: patient cannot raise thumb from plane and stretch thumb

What is whispered pectoriloquy?

ask patient to whisper "1-2-3". It should not be distinguishable over normal healthy tissue. Over abnormalities, the whisper will be clear & distinct

Describe the COVER TEST

assesses extraocular muscle function detects deviation in alignment or strength and slight deviations in eye movement by interrupting the fusion reflex that normally keeps the eyes parallel

**Describe Evaluation stage of nursing process

assessing whether outcome criteria has been met and revising the plan as necessary

Discuss safety teaching for hearing health

avoid sound exposure louder than a washing machine avoid recreational risks that involve loud sounds or risks of head/ear injury avoid listening to extremely loud music for long periods of time Have hearing checked periodically, especially after age 50 If hearing loss is detected, obtain and use devices to improve hearing Immunize children against childhood diseases (MMR, meningitis) Screen for STIs if pregnant Avoid use of ototoxic drugs avoid feeding newborn while lying on back have newborn infant screened for hearing treatment for ear infections treatment for tonsil and adenoid infections teach child to avoid putting foreign bodies in ear avoid use of instruments to remove wax from ears due to change of impacting it further (see profession for wax control)

The nurse is gathering a health history on an adult female seeking healthcare because of recent onset of leg pain when walking for two blocks. When gathering data on the family history the nurse should include which item? a. History of gallbladder surgery b. Maternal history of diabetes c. History of two pregnancies d. History of performing self-breast examination monthly

b Rationale: Family history is information about diseases that family members have experienced. The nurse should gather information about a family history of heart disease, hypertension, stroke, cancers, autoimmune diseases, mental health disorders, and diabetes. History of gallbladder surgery, two pregnancies, and performing self-breast examinations are part of the client history.

A patient's weekly blood pressure readings for 2 months have ranged between 124/84 and 136/88 mm Hg, with an average reading of 126/86 mm Hg. The nurse knows that this blood pressure falls within which blood pressure category? a. Normal blood pressure b. Prehypertension c. Stage 1 hypertension d. Stage 2 hypertension

b Rationale: TABLE 8-2 Categories for Blood Pressure Levels in Adults (Ages 18 and Older) Blood Pressure Level (mmHg) Category Systolic Diastolic Normal <120 <80 Prehypertension 120-139 80-89 Stage 1 hypertension 140-159 90-99 Stage 2 hypertension ≥160 ≥100

When assessing an older adult, the nurse keeps in mind that which vital sign changes occur with aging? a. Increase in pulse rate b. Widened pulse pressure c. Increase in body temperature d. Decrease in diastolic blood pressure

b Rationale: Widening of the pulse pressure is seen with aging due to less elastic peripheral arteries (option 2). There is no difference in the normal pulse rate range for older adults (option 1). Research has shown that for older adults, normal body temperature values for all routes are consistently lower than values reported in younger populations (option 3). Older adults may have more rigid, arteriosclerotic arteries that may increase their blood pressure.

Pain is a protective mechanism warning of tissue injury and is largely a(n): a. Objective experience b. Subjective experience c. Acute symptom of short duration d. Symptom of a severe illness or disease

b Rationale: Only the patient knows whether pain is present and what the experience is like. Seldom can it be an objective experience. Many patients have chronic pain that lasts a long time. It is not always a symptom of a severe illness or disease.

To determine the quality and intensity of a cardiac murmur, the nurse would take which action? a. Use a Doppler ultrasound device b. Use the bell of the stethoscope c. Percuss the thorax cavity e. Palpate the chest wall to feel the intensity of the murmur

b Rationale: To listen to low frequency sounds, the nurse would use the bell of the stethoscope by placing it lightly on the skin. Murmurs are most often low-pitched sounds. In contrast, the diaphragm of the stethoscope is used to elicit high-pitched sounds, which may characterize some murmurs. A Doppler is used to auscultate for peripheral pulses that are not palpable. Percussion will not provide information on low- or high-pitched sounds. Palpation will not provide information on sounds.

**Describe implementation stage of the nursing process

carrying out the plan

When completing the review of systems the nurse would ask which questions to gather information about past medical history? Select all that apply. a. "Are you having any difficulty breathing?" b. "Have you had any throat problems?" c. "Tell me more about your eye surgery two years ago." d. "Do you have productive cough?" e. "Can you please describe the pain in your neck?"

b,c Rationale: A review of systems is a method to gather information about past and present health of the medical history. This question SPECIFICALLY asked about review of systems relating to past history. Asking about throat problems or talking about eye surgery from two years ago provides past medical history data. Asking about difficulty breathing assesses the current health problem. Asking about a productive cough or pain in the neck assesses a current illness.

**Explain cultural consideration in communication

be aware of cultural variation when communication such as: reluctance to reveal personal information to strangers reluctance to openly express emotional distress or pain Variation in meanings of terms used across cultures variation in use/meaning of nonverbal communication disease/illness perception; "susto" = latin america disease caused by shock or fright family roles in decision making process Variation in time (US = future orientated, others = past oriented)

What is the proper way to auscultate the abdomen?

begin in RLQ and proceed clockwise to all 4 quadrants Listen for at least 1 min (5min for all 4 quadrants) Normal sounds are heard at a rate of 5-30/min

What is health promotion diagnosis?

behavior motivated by the desire to increase well-being and actualize human potetial example: Readiness for enhanced sleep "Readiness for enhanced...." or "Stated as a problem such as: diversional activity deficit, sedentary lifestyle"

What is the function of the BRAIN STEM?

between cerebral cortex and spinal cord and consists of mostly nerve fibers Midbrain - relay center for ear and eye reflexes Pons - links cerebellum to the cerebrum and midbrain to the medulla Medulla Oblongata - controls and regulates respiratory function, HR and force, and BP "Beauty Shops Make Pretty Men"

What are Argyll Robertson's Pupils

bilaterally small pupils that constrict when focusing on a near object, but DO NOT constrict when exposed to bright light

What is telangiectasis?

bluish or red lesion with varying shape found ont he legs and anterior chest ex: varicose veins

Explain CONDUCTION hearing loss

bone conduction occurs when the temporal bone vibrates with sound waves and the vibrations are picked up by the tympanic membrane and/or the auditory ossicles Perception of sound----not interpretations of sound caused by something blocking the passage of vibrations from getting to the inner ear such as wax buildup or fluid in the middle ear

What is ecchymosis?

bruising

The client is experiencing a headache that has lasted for 24 hours. Which of the following statements would be the most appropriate way for the nurse to document this complaint? a. Client states, "I have a headache." b. Client experiencing headache; states that it "has lasted 24 hours." c. Client states, "I have had a headache for the last 24 hours." d. Headache present without evidence of concurrent nausea.

c Rationale: If a client presents with a headache, the nurse documents it as a subjective complaint because the nurse cannot observe a headache, #1 does not include the timeframe. #2 is incorrect because only the length of time is in quotations but the headache complaint should also be in quotations. #4 is incorrect because it does not include all the information the client has provided.

Describe changes in skin due to common medications

cause photosensitivity can elicit an allergic reaction

A client is admitted for evaluation of upper gastrointestinal symptoms. The nurse would document which statement as objective data in the client's medical record? a. Client states, "I have a headache." b. Client states, "I had chicken pox as a child." c. Client has distended abdomen and active bowel sounds. d. Client states, "I feel nauseated after eating."

c Rationale: Objective data is information the nurse can directly obtain and verify. The nurse can observe distention (using inspection) and active bowel sounds (using auscultation). The nurse cannot observe a headache, nausea, or a history of chicken pox. Subjective data is obtained during the review of systems, the aspect of the health history in which the nurse verbally gathers data from the client.

When documenting subjective data for the cardiovascular system the nurse would include which of the following? a. Vital signs b. Peripheral pulses c. Chest pain d. Heart sounds

c Rationale: Subjective data includes any information that the client experiences, such as perceptions of pain and other sensations within the body. Subjective data is that which can only be relayed to the nurse by the client. Vital signs, peripheral pulses, and heart sounds are part of the objective data that the nurse identifies.

The nurse is gathering information about the health promotion activities of an adult female client. The nurse should ask the client about which items related to health promotion? a. Number of viable pregnancies and deliveries and number of pregnancies not resulting in a live birth b. Allergies to medications c. Performance of self-breast examination d. Results of the last Papanicolaou (Pap) test

c Rationale: The health promotion activity that a female would practice would be the performance of monthly self-breast exam. Data about previous pregnancies, allergies, and the results of the last Pap smear are part of the previous medical history, not current health practices.

The nurse should measure rectal temperatures in which of these patients? a. School-age child b. Elderly adult c. Comatose client d. Patient receiving oxygen by nasal cannula

c Rationale: Use this route only if other routes are not practical (e.g., client cannot cooperate, is comatose, cannot close mouth, or tympanic thermometer is unavailable. Never force the thermometer into the rectum and never use a rectal thermometer for clients with severe coagulation disorders, recent rectal, anal, vaginal or prostate surgeries, diarrhea, hemorrhoids, colitis, or fecal impaction.

The nurse is examining the spine of a client who is experiencing an extreme curvature of the lumbar area. How should the nurse document this finding? a. Kyphosis b. Scoliosis c. Lordosis d. Osteoporosis

c Rationale: Lordosis is an exaggerated curvature of the spine. Kyphosis (option 1) is an extreme curvature of the thoracic curvature. Scoliosis (option 2) is a lateral curvature of the spine. Osteoporosis (Option 4) is a decrease in skeletal mass. Older adults with osteoporosis may also get kyphosis. As a test-taking strategy, if two answers are related (kyphosis and osteoporosis), then neither can be the correct choice.

What question should the nurse include in the assessment of a 50-year old postmenopausal woman's musculoskeletal system? a. "How many times have you fallen?" b. "Do you use any walking aids?" c. "Do you take calcium supplements?" d. "Do you play sports?"

c Rationale: Postmenopausal women should be asked about whether they take calcium supplements to reduce the risk of osteoporosis. A 50-year-old should not be at risk for falls since falls occur most often in older adulthood (option 1). Most 50-year-olds do not walk with canes or walkers (option 2). Asking about playing sports (option 4) is usually a question asked of children.

The nurse is performing a mental status examination. Which statement is true regarding the assessment of mental status? a. Mental status assessment diagnoses specific psychiatric disorders b. Mental disorders occur in response to everyday life stressors c. Mental status functioning is inferred through assessment of an individual's behaviors d. Mental status can be assessed directly, just like other systems of the body (e.g., cardiac and breath sounds)

c Rationale: A healthy mental status is needed to think clearly and respond appropriately to function effectively in all activities of daily living (ADLs). It is reflected in one's appearance, behaviors, speech, thought patterns, and decisions and in one's ability to function in an effective manner in relationships in home, work, social, and recreational settings. One's mental health may vary from day to day depending on a variety of factors. Assessment of mental health is inferred from the answers the client gives to your interview questions and from your observations of the client's behaviors. Be alert for all verbal and behavioral clues that reflect the client's mental status from the very first interaction you have with the client.

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

c Rationale: Motion increases pain associated with many joint problems but decreases pain associated with rheumatoid arthritis. Swelling is seen with rheumatoid arthritis. Tenderness and nodules may also be seen with rheumatoid arthritis

What are normal findings when inspecting the sclera and conjunctiva of infants and children?

clear, free of discharge, lesions, redness, or lacerations Small subconjunctival hemorrhages may be seen in newborms

How to African americans view pain?

challenge to be fought inevitable and to be endured stigmatized punishment from God god and prayer are more powerful than medicine

Describe changes in skin due to diabetes, obesity

changes in sensation or temperature Obese patients experience dry, itchy skin, rashes and drainage

What is pain modulation?

changes or inhibits pain message relay in the spinal cord Endogenous NTs modulate pain; endogenous opioids, such as endorphins, enkephalins; serotonin, norepinephrine, GABA, ACh, oxytocin

What is a vesicle or bulla?

circumscribed, elevated, palpable mass containing serous fluid ex: herpes, poison ivy, 2nd degree burn

Symptoms of arterial insufficiency

claudication pulses are diminished or absent skin is pale, dry, shiny, cool; hair loss, thick and rigid nails Ulcers occur at tips of toes, webs, heels; painful; deep; circular; pale black to dry and gangrene; minimal leg edema

Describe normal findings in the RETINAL BACKGROUND in an opthalmoscope examination

consistent in texture Red-orange color of background is lighter than optic disc

What are the different locations of pain?

cutaneous - skin visceral - abdominal cavity Deep somatic - ligaments, tendons phantom - perceived in nerves left by missing/paralyzed body part Neuropathic - abnormal processing of pain messages and results from past damage to peripheral or CNS nerves due to sustained neurochemical levels Intractable pain - high resistance to pain relief

The nurse is assessing orientation in a 79-year-old patient. Which of these responses would be the best for the nurse to conclude that this patient is oriented? a. "I know that my name is John. I couldn't tell you where I am. I think it is 2017, though." b. "I know that my name is John, but to tell you the truth, I get kind of confused about the date." c. "I know that my name is John; I guess I'm at the hospital in Arlington. No, I don't know the date." d. "I know that my name is John. I am at the hospital in Arlington. I couldn't tell you what date it is, but I know that it is February 2017."

d Rationale: Many aging persons experience social isolation, loss of structure without a job, a change in residence, or some short-term memory loss. These factors affect orientation, and the person may not provide the precise date or complete name of the agency. You may consider aging persons oriented if they know generally where they are and the present period. That is, consider them oriented to time if the year and month are correctly stated. Orientation to place is accepted with the correct identification of the type of setting (e.g., the hospital) and the name of the town. The item "D" would be best as it provides the most complete information.

The nurse is reviewing principles of pain. Which type of pain is due to an abnormal processing of the pain impulse through the peripheral or central nervous system? a. Visceral b. Referred c. Cutaneous d. Neuropathic

d Rationale: Neuropathic pain causes an abnormal processing of pain messages and results from past damage to peripheral or central nerves due to sustained neurochemical levels, but exact mechanisms for the perception of neuropathic pain are unclear. Visceral pain (option 1) is in the abdominal cavity, thorax, or cranium. Referred pain (option 2) is pain that is perceived in body areas away from the pain source. Cutaneous pain (option 3) is in the skin or subcutaneous tissue.

**What is objective data? Examples?

data collected from a physical assessment; the facts example: Physical characteristics, heart rate, BP, Lab results (think facts only)

**Describe an ongoing assessment

data collection that occurs after the comprehensive database is established; consists of mini overview as a follow-up on health status; looking for deterioration or improvement

**What is subjective data? Examples?

data obtained from the client regarding their current problem/health history; patient's perception example: feelings, desire, belief, ideas, values, personal info Biographical Data, Symptoms, personal/family history (think "Sub" is opinion that can only come from subject)

**Describe planning stage of the nursing process

determining outcome criteria and developing a plan

What is transmission?

direct excitation of the primary afferent fibers stimulation leads to activation of the fiber terminals, which results in neurotransmitters to be released out of the dorsal horn of the spinal cord

Discuss the function of the CEREBRUM

divided into right and left hemisphere each hemisphere sends and receives impulse from opposite sites of the body Each hemisphere consists of frontal, parietal, temporal, and occipital lobes

Describe assessment for DysphaGia

do you have difficulty swallowing? Observe for: coughing, drooling, pocketing, or spitting out food; drooping mouth, chronic congestion, weak or hoarse voice

What is a wheal?

elevated mass with transient borders that are irregular ex: uticaria (hives)

What is a papule & plaque?

elevated, palpable, solid mass ex: mole, warts, psoriasis (plaque0

What is a nodule or tumor?

elevated, solid, palpable mass that extends deeper into the dermis ex: lipoma

What is pain perception?

emotional status that affects the level of pain perceived Frontal cortex is responsible for rational interpretation

What is a cyst?

encapsulated fluid filled/semi-solid mass that is located in the subcutaneous tissue of dermis

How do Native americans view pain?

endured may not ask for medication Metaphors and imaged from nature are used to describe pain

How do Hindu's view pain?

endured as a part of preparing for cycle of reincarnation remain conscious when nearing death to experience events of dying and perhaps rebirth

What is anisocoria?

equality in pupil size of <.5mm; considered normal

What is Kernig's sign?

flex the patient's leg at both the hip and knee, then straighten the knee Pain and increased resistance to extending the knee are positive Kernig's sign Bilateral sign indicates meningitis

**Explain emotional variations in communication

experience different emotions when seeking healthcare such as anxiety, panic, anger, etc...

How do the Jewish view pain?

expressed with much complaining shared, recognized and validated by others (affirmation)

What are C-fibers?

fibers responsible for burning, throbbing, or aching pain transmit signals to spinal cord with 1 second (SLOW) Polymodal

What are A-delta fibers?

fibers responsible for pricking, sharp pain transmit signals to spinal cord within .1 second (FAST) temperature and mechanical sensitive -- INTENSE

What is Brudzinski's sign?

flex the neck and watch the hips and knees in reaction Pain and flexion of the hips and knees are a positive sign

**What are appropriate ways to prevent the spread of infection?

hand hygiene PPE clean and disinfect surfaces use aseptic technique for sterile equipment use single-dose vials sterile technique for invasive procedures

**Describe typical age-related changes in mental status

making a bad decision once in a while missing a monthly payment forgetting which day it is and remembering later forgetting which words to use losing things from time to time

**What is an actual nursing diagnosis?

indicates the client is currently experiencing the state problem or has a dysfunctional pattern Example: impaired skin integrity related to immobility Nursing diagnosis + "related to..."

What is an abnormal finding when inspecting the eyelids of infants & children?

inflammation, swelling, purulent discharge (infection, blocked tear duct, STD) Children: Inflammation from: Blepharitis - eyelid inflammation Hordeolum - infection of glands of eyelid Dacryocystitis - infection of lacrimal duct Ptosis (nerve palsy) Stye (red, painful) Chalazion (non-tender nodule) sunken eyelids (dehydration) Periorbital edema (fluid retention)

Describe COARSE crackles

inhaled air comes int contact with secretions in large bronchi and trachea Pneumonia, pulmonary edema, pulmonary fibrosis

Describe FINE crackles

inhaled air suddenly opens the small deflated air passage that are coated and sticky Early: bronchitis, asthma, emphysema Late: Pneumonia, CHF

Describe examination techniques for mouth and throat

inspect lips, teeth, and gums Inspect buccal mucosa (penlight & tongue depressor) Inspect and palpate tongue Inspect for Wharton's duct Observe sides of tongue inspect hard & soft palates and uvula Note any odor Assess uvula Inspect tonsils and posterior pharyngeal wall

What is the function of the PARIETAL lobe?

interprets tactile sensations: touch, pain, temperature, shapes, two-point discrimination

What is an abnormal finding associated with the iris and pupil?

irregularly shaped iris Miosis Mydriasis Anisocoria (normal in 20% of population)

What does 20/20 vision mean?

it means that a client can distinguish what a person with normal vision can distinguish from 20 ft away

**Discuss the processes of data collection phase of the nursing assessment.

must be systematic & continuous to prevent excluded significant data refer to client's changing health status client data should include past history as well as current problems to collect data accurately, client & nurse must actively participate

**Describe pulse pressure and how it is obtained

produced when ventricles contract and send blood from aorta to rest of body; pulse is blood moving through the arteries obtained from arterial pulse sites: radial, antecubital, carotid, femoral

Explain the function of the DIENCEPHALON

lies beneath the cerebral hemisphere Consists of the Thalamus, Hypothalamus, and Brain stem "Dirty Toothpaste Hurts Bad"

What is a fissure?

linear crack in the skin that may extend to the dermis ex: chapped lips

What is hematoma?

localized collection of blood creating an elevated bruise

What is an erosion?

loss of superficial epidermis that does not extend to the dermis; depressed, moist area ex: canker sore

Describe SONOROUS wheeze

low pitched Air passes through constricted passages Bronchitis, single obstructions

What is the U wave on an EKG?

may or may not be present; represents final phase of ventricular repolarization

Compare and contrast memory, judgement, abstract reasoning, and orientation

memory -- ability to recall past and recent events Judgement -- ability to rationalize Abstract reasoning -- explains similarities and differences between objects and proverbs correctly; can joke and use puns correctly Orientation -- aware of self, others, time, home address, current location

Malnutrition: Fasting blood glucose (FBS)

normal: 65-99mg/dL Pre diabetes: 100-135mg/dl Critical: <40mg/dl or >400mg/dl

What is a cherry angioma?

papular or round, red/purple lesion found on the body

**Correct technique for obtaining respiration

observe rise and fall of the chest with each breath count for 30 seconds and multiply by 2 Normal 12-20 breaths per minute observe rhythm and depth

Describe how to test for accommodation of pupils

occurs when a client moves focus from a distant point to a near point hold pencil about 12" away from client and ask client to focus on object as you move inward toward the eyes

Risk factors for thrombophlebitis

oral contraceptives impaired circulation sedentary lifestyle smoking cardiovascular disease

What is transduction?

pain begins when there is tissue injury or damage stimulating the nociceptors (afferent receptors that RECEIVE pain) inflammatory process signals the release of cytokines, neuropeptides, and substance P (vasodilation)

What is Psoas Sign?

pain in the RLQ dur to the irritation of the iliopsoas muscle Ask client to lie on the left side and hyperextend the right leg of the client at the hip

What are the signs and symptoms of meningitis?

pain in the neck and resistance to flexion Brudzinski's sign Kernigs Sign Assess pupillary response to light - Argyll Robertson's pupils indicate meningitis

How do Asians and Asian Americans view pain?

pain is natural mind over body; positive thinking honorable

Discuss abnormal findings associated with the AURICLE & MASTOID PROCESS

painful auricle or tragus -- otitis externa or postauricular cyst Tenderness over mastoid process -- mastoiditis Tenderness behind the hear -- Otitis media

Describe how nursing assessment has changed over time

passive/patient support (altruism)--> active role observations --> diagnoses, interventions, measuring outcomes modern nurses play a role in community health

What is an abnormal findings associated with the Romberg Test?

patient moves feet apart to prevent falls or starts to fall from loss of balance Indicates a vestibular disorder (CN8)

Describe the technique for the WEBER TEST

performed if a patient reports diminished or loss of hearing in one ear Strike a tuning fork and place it on the center of the pt's head. Ask whether the pt hears the sound better in one ear or the same in both ears. Normal: vibrations heard equally well

**Describe a focused assessment

performed when a comprehensive database exists for a client who seeks care regarding a SPECIFIC health concern

What is the ST segment on an EKG?

period between ventricular depolarization and the beginning of ventricular repolarization; very short time between the end of a contraction and beginning of relaxation

Describe Alzheimer's changes in mental status

poor judgement and decision making inability to manage a budget losing track of the date or the season difficulty having a conversation misplacing things and being unable to retrace steps to find them

What is Grey-Turner sign?

purple discoloration of the flanks indicated bleeding within abdominal wall, possibly from trauma to the kidneys, pancreas, or the abdominal wall, or from pancreatitis

What is a pustule?

pus filled vesicle ex: acne

**Describe an emergency assessment

rapid assessment performed in life threatening situations (airway, breathing, circulation...)

Example of a health promotion diagnosis for pain

readiness for enhanced comfort

What is the function of the TEMPORAL lobe?

receives and interprets impulses from the ear Contains Wernicke's area - interprets auditory stimuli

Discuss abnormal findings associated with the color and consistency of ear canal walls

reddened, swollen canals - otitis externa exostoses (nonmalignant, nodular swellings) Polyps that may block the view of the eardrum

**Describe auscultation technique

requires use of stethoscope to listen to heart/lung sounds sounds are classified based on: Intensity -- loud/soft Pitch -- high/low Duration -- length Quality -- musical, crackling, raspy

How do Hispanics view pain?

response is expressive and endured to perform gender role duties natural, but may be result of sinful or immoral behavior

What is the Phalen's test?

rest elbows on table, place backs of both hands against each other Flex wrists 90 degrees w/fingers pointed downward and wrists dangling hold for 60 seconds Abnormal: tingling, numbness, pain

What is paralytic strabismus?

result of weakness or paralysis of one or more extraocular muscles Nerve affected with be on the same side as they eye affected 6th nerve paralysis (Abducens): eye cannot look to outer side 4th nerve paralysis (Trochlear): eyes cannot look down when turned inward 3rd nerve paralysis (Oculomotor): looks straight ahead

Example of risk diagnosis for pain

risk for activity intolerance related to chronic pain and immobility

what is petechiae?

round, red/purple macule that is 1-2 mm in size ex: emboli to the skin

What is the function of the THALAMUS?W

screens and directs impulses to specific areas of the cerebral cortex

What is Blumberg's sign?

sharp stabbing pain felt as examiner releases pressure from abdomen

Explain how to test pupillary reaction to light

shine a light obliquely into one eye and observe for reaction Asking to look at a distant object ensures that the reaction is to the light and not to a near reaction

What is an ulcer?

skin loss extending pas epidermis with necrotic tissue loss ex: venous stasis ulcer

What is a macule or patch?

small, flat, nonpalpable skin color change Ex: rash

Define gynecomastia

smooth, firm, movable disc of glandular tissues

Describe technique for assessing suspected bladder distention

smooth, round, somewhat firm mass validated by dull percussion tone

**Describe a comprehensive assessment

subjective data about the client's perception about his/her health (includes history of current or family) and objective data collected during the physical exam

Common symptoms associated with HYPERthyroidism

sudden weight loss, without changes in appetite or diet Increased appetite Rapid heartbeat (>100bpm), irregular, or palpitations Nervousness, anxiety, irritability Tremor in hands and fingers sweating changes in menstrual patterns Increased sensitivity to heat Changes in bowel patterns; more frequent Enlarged thyroid (goiter) Fatigue, insomnia Muscle weakness

**Explain the summary & closing phase of the nursing interview

summarizes info and validates concern; plans goals & resolutions with client; answers any other concerns or questions the patient may have

What are appropriate patient positions for assessing the abdomen?

supine with arms at side supine with arms folded over chest legs slightly flexed to relax abdominal muscles Deep breaths

What is considered a normal position and alignment for the eyeball in the eye socket?

symmetrically aligned without protruding or sinking

**Describe Percussion technique

technique used by tapping parts of the body to produce sound waves elicits pain and tenderness helps RN to determine location, size, shape or changes in borders of organ or neighboring organ Detects abnormal masses (superficial abnormal structures)

What is Murphy's sign?

test for cholecystitis accentuated sharp pain that causes the client to hold his or her breath (inspiratory arrest)

What is the QT interval on an EKG?

total time of ventricular depolarization and depolarization; beginning of Q wave to the end of the T wave

What is abnormal in infants and children when performing an extraocular muscle test?

unequal alignment of light on the pupils = strabismus Doll's eye reflex occurs when the eyes do not follow or adjust to movement of the head (stay stationary)

What are some risk factors for skin cancer?

unprotected sun exposure medication that causes hypersensitivity certain chemical exposure atypical moles severe sunburns as a child genetics/family history

What is Tinel's Sign?

use finger to percuss lightly over median nerve abnormal: tingling or shocking sensation

What are risk factors for mouth and throat cancer?

use of tobacco products Heavy alcohol use Chewing Betel nuts exposure to sunlight (lip cancer only) Male Fair Skin Poor oral hygiene Poor diet/nutrition: low in fruits & veggies, Vit A deficiency, betel nuts Weakened immune system

**Correct technique for obtaining pulse

use pads of two middle fingers and light palpate the radial artery count the number of beats for 30 seconds if the pulse is regular and multiply by 2 If irregular, count for a full minute. Then, verify by taking apical pulse as well Normal 60-100bpm tachycardia = >100 Bradycardia = <60 evaluate rhythm, amplitude, contour, elasticity

**Describe the use of referrals

used when a patient is at risk for complications parameters are set as to what to monitor and when to call provider document suspected problem, need for referral and to whom client is being referred

**Describe Palpation technique

uses parts of hand to touch and feel for various characteristics Light palpation -- little to no depression Moderate palpation -- 1-2 cm Deep palpation -- 2.5-5 cm

**Describe inspection technique

uses senses to observe and detect any normal/abnormal findings; used from the moment you meet the client and continues throughout examinations

What are normal variations in breast size and conformation?

variety of sizes; round and pendulous; one breast may be larger than the other Linear stretch marks may be seen during and after pregnancy OR with significant weight gain or loss Areolas vary from dark pink to dark brown; round & vary in size; Montgomery Tubercles are present Nipples are nearly equal bilaterally in size and are in the same location on each breast Nipples are usually everted, but they may be inverted or flat Supernumerary nipples may appear along the embryonic "milk line"

What is the T wave on an EKG?

ventricular relaxation; return to a resting state S2 heard

**Describe skin assessment in newborns

yellow skin blue skin pallor anemia redness ecchymosis (or circular burn) petechiae/lesions/rashion any abnormal skin lesions