Health Assessment #4: HEENT & GI
Fissured tongue
Fissures appear with increasing age, sometimes termed furrowed tongue. Food debris may accumulate in the crevices and become irritating, but a fissured tongue is benign.
order of GI assessment
Inspect AUSCULTATE percuss palpate
Where would you expect to find tenderness upon palpation in a patient with acute diverticulitis?
LLQ
Psoas muscle test
Pt lays supine and examiner pushes down on pt's R thigh and asks pt to raise R leg. Pt has pain in RLQ (appendicitis)
PERRLA
Pupils Equal Round Reactive to Light and Accommodation (DID YOU ACTUALLY TEST ACCOMMODATION?!)
Candidiasis
Thick white coating from Candida infection. Raw red surface is where the coat was scraped off. Infection may also occur without the white coating. Seen in immunosuppressant from chemo or prednisone therapy.
True or false: Macrocephally is an anomaly characterized by a larger head in proportion to the body
True
true or false the Rinne test results may be normal in a patient with sensorineural hearing loss
True
Name that disease location - poorly localized periumbilical pain that usually migrates to the RLQ quality - mild but increasing, possibly cramping, then steady and more severe aggravation - movement or cough timing - lasts roughly 4-6 hrs depending on intervention relieving - n/a associated - anorexia, nausea, possibly vomiting, low fever
acute appendicitis
what should you do before testing a patient's olfactory abilities?
ask about allergies
the frontal sinuses are the only ones readily accessible to clinical examination a) true b) false
b) false
you need to further localize abdominal pain. you have the patient ________
breathe in deep and contract abdomen (coughing motion) — let patient point to most tender spot
a smooth large liver with a firm, non-tender edge is suggestive of _________________
cirrhosis
scaphoid abdomen
concave emaciated patients
The nurse performs the Rinne test on a patient and concludes that BC > AC. what kind of hearing loss is present?
conductive
what lines the cheeks? a) lingual mucosa b) labial mucosa c) alveolar mucosa d) buccal mucosa
d) buccal mucosa
Presbyopia
decreased accommodation with aging (loss of accommodation / need reading glasses) normal after 40 y.o.
what are the three patterns of IBS?
diarrhea- predominant constipation-predominant mixed
diplopia
double vision
What structures may normally be tender to deep palpation?
enlarged liver (URQ), normal cecum (LRQ), normal aorta (epigastric), normal or spastic sigmoid colon (LLQ)
confrontation
evaluates peripheral vision instruct patient to look at your eyes and maintain eye contact Wiggle two fingers in each outer quadrant at edge of visual field work from behind patient forward have patient tell you when they see your fingers test all 6 fields
EOMs
extraocular muscles/movements looking for nystagmus
An enlarged liver that is firm or hard with an irregular edge or surface that may or may not be tender suggests ______
hepatocellular carcinoma.
Ataxia
inability to walk
Conjuctiva
inner lining of lids
which kidney is HARDER To palpate?
left kidney
corneal light reflex
light should reflect at the same point in each eye
Myopia
nearsighted can't see things far away
name four causes of hearing loss involving the inner ear
presbycusis ototoxicity Meniere's Disease noise exposure
Nystagmus
rapid shaking of eyes from left to right normal at extremes of gaze may be present in labyrinth disorders like vertigo
The nurse performs the Webber test on a patient with hearing loss in the left ear. The patient reports that the sound is louder in the right ear. the nurse conclude that the hearing loss is ______.
sensorineural
name that headache: location: bilateral. may be generalized or localized to the back of the head and upper neck or to the frontotemporal area quality: steady, pressing or tightening. nonthrobbng pain. mild to moderate intensity timing: gradual onset, lasts 30 minutes to 7 days, episodic / chronic associated: photophobia, phonophobia, scalp tenderness, nausea absent triggers: sustained muscle tension, as in driving or typing, stress, sleep disturbances relieving: possibly massage, relaxation
tension headache
Sclera
white outer layer of eyeball
rebound tenderness
"does it hurt more when I press down or when I let go?" caused by vibrations generated along the peritoneum by quick release of pressure. Tells you about peritoneal dysfunction
what are some red flag characteristics and associated symptoms of a headache?
"worst headache of my life", "like a thunderbolt", over 50 y.o., vomiting, trauma, pregnancy, elevated BP, rashes
what are risk factors for hepatitis C?
-Repeated percutaneous exposure to blood -IV drug users -Transfusion with clotting factors before 1987 -Hemodialysis -Sex partners using IV drugs -Blood transfusion or organ transplant before 1992 -Occupational exposure -Multiple or infected sex partner
Who does the CDC recommend receive the hepatitis B vaccine?
1) All adults in high-risk settings 2) In primary care or specialty settings 3) Adults in occupations involving exposure to blood or other potentially infectious body fluids 4) High risk pregnant women with no titers
how far in front of the patient should you stand for the confrontation test?
12"
how far do you hold the hand-held snellen chart from the patient's nose?
14"
How long is the external auditory canal in adults?
2.5 cm long (adults)
normal # of bowel sounds per minute
5-34
what its the range of human speech?
500 Hz to 3000 Hz
when assessing for an appendicitis, what signs might the nurse look for? (select all that apply) a) cutaneous hyperesthesia b) rovsing sign c) obfuscation sign d) psoas sign e) murphy sign
A, B & D cutaneous hyperesthesia, roving sign and psoas sign
Smooth tongue
Also known as atrophic glossitis. Smooth and often sore tongue that has lost its papillae. Sometimes it is just in patches. Suggests a deficiency in riboflavin, niacin, folic acid, vitamin B12, pyridoxine or iron or treatment with chemo.
what does the Rinne test evaluate?
Compares AC to BC AC > BC = normal
differentiate between conductive and sensorineural hearing loss
Conductive loss -mechanical dysfunction in external or middle ear foreign object in canal, perforated TM, otosclerosis Sensorineural loss -cochlear, auditory nerve damage or auditory area of cerebral cortex damaged -Presbycusis (loss of high frequency sound due to aging) -Inner ear disease, ototoxic drugs
Functions of middle ear
Conducts sound, equalizes air pressure and reduces loudness
How do you assess for strabismus?
Cover/Uncover test
What are the three risk categories for hepatitis B?
1) Sexual contacts 2) People with percutaneous or mucosal exposure to blood 3) Others: travelers, patients with chronic liver disease or HIV infection, people seeking protection for hepatitis B
Vaccines are available for which strains of hepatitis?
A & B
the nurse is admitting a client who is in hypertensive crisis. the doctor's notes indicate that bruits that are both systolic and diastolic have been noted and renal artery stenosis is suspected as the cause of the hypertension. Where would the nurse auscultate the patient's abdomen to hear these bruits? (select all that apply) a) costovertebral angles b) epigastrium c) iliac arteries d) femoral arteries e) right upper quadrant
A, B & E right upper quadrant epigastrium costovertebral angles
the nurse notes guarding while palpating the abdomen of a newly admitted patient despite asking the patient to try to relax. the nurse should (select all that apply) a) distract the patient with conversation b) tell the patient to take a deep breath and hold it c) assess relaxation of abdominal muscle after the patient exhales d) have the patient mouth breathe with the jaw dropped open e) have the patient stand during the examination
A, C & D
what are associated manifestations of a headache caused by a traumatic brain injury? (select all that apply) a) seizures b) changes in appetite c) attention span deficit d) apathy e) gait changes
A, C & E associated manifestations of headache associated with TBI include vision changes, nausea and vomiting, attention span deficits, drainage from the ears, eyes or mouth, tremors, seizures or gait changes
What are the bordering landmarks of the anterior triangle of the neck? (select all that apply) a) the mandible b) the omohyoid muscle c) the midline of the neck d) the clavicle e) the sternomastoid
A, C & E the anterior triangle is bordered by the mandible above, the sternomastoid laterally and the midline of the neck medially
Which strains of hepatitis are incurable?
B & C
what activities are known to aggravate a tension headache? (select all that apply) a) listening to music b) driving c) exercise d) typing e) prolonged sleep
B & D driving and typing
when performing a Rinne test, the nurse would perform the steps in which order? a) place tuning fork in front of the ear and ask the patient if she can hear the sound b) place the base of a vibrating tuning fork on the pasted bone until the patient says she cannot hear the sound
B then A
What structure is located in the LLQ of the abdomen A) Liver B) sigmoid colon C) Duodenum D) Gallbladder
B) sigmoid colon
the nursing instructor is discussing assessment of the head and neck with the class. what identifying characteristic would the instructor use for the thyroid cartilage? a) the curve on its inferior edge b) its relation to the cricoid cartilage c) the notch on its superior edge d) its position just below the mandible
C the thyroid cartilage is readily identified by the notch on its superior edge
what are some examples of introductory questions for GI history assessment?
Change of appetite, diet Food intolerances versus food allergies 24 hour dietary recall Weight changes Difficulty swallowing (dysphagia) Exposures Travel to and from U.S. Stressors Medications N/V elimination Visceral dysfunction Surgery Tests and results GI cancer Substance abuse - Alcohol, opiates, tobacco Family history of GI Cancer, colitis, IBS
Name that disease quality - small, soft to loose or watery with possible bleeding. possible obstructive symptoms. timing - ? associated - cramping periumbilical or RLQ or diffuse pain with weight loss. perianal or perirectal abscesses and fistulas. may cause small or large bowel obstruction risk factors - often teens and young adults. More common in Ashkenazi Jewish descendants. Increases risk of colon cancer.
Crohn Disease
rounded "moon face" with red cheeks and possible excessive hair growth in the mustache and sideburn areas is indicative of _____________________
Cushing Syndrome
differentiate between vertigo and dizziness
Dizziness is a nonspecific term used by patients encompassing several disorders that clincians must carefully sort out. Vertigo is an intense spinning sensation accompanied by nystagmus and ataxia
protuberant abdomen
Fat Fluid (acites) flatus fetus feces fatal growths
Name that disease location - chest or epigastric quality - heartburn, regurgitation timing- after meals, spicy foods aggravation - lying down, bending over, physical activity relieving - antacids; avoiding alcohol/smoking,fatty meals, chocolate, certain drugs and calcium channel blockers associated - wheezing, chronic cough, SOB, dysphasia, regurgitation, halitosis, sore throat
GERD
classic findings for alcoholism
Hepatosplenomegaly (HSM) Ascites Caput medusa (Belly looks medusa like - distended veins on belly) Spider angiomas Peripheral edema Palmar erythema Erythematic or bulbous nose
Angioedema
Localized subcutaneous or submucosal swelling caused by leakage of intravascular fluid into the interstitial space. Two types are common. When vascular permeability is triggered by mast cells in allergic and NSAID reactions, look for associated urticaria and pruritis. These are uncommon in angioedema from bradykinin and complement-derived mediators, the mechanism in ACE inhibitor reactions. Angioedema is usually benign and resolves within 24-48 h. it can be life-threatening when it involves the larynx, tongue or upper airway or develops into anaphylaxis.
Presbycusis
Loss of hearing with age - specifically high pitched sounds
Name the auditory ossicles. Where are they located? what do they do?
Malleus, Incus, Stapes located in the middle ear transmits vibration from TM to inner ear
normal liver span
Normal span 6 - 12 cm
Large normal tonsils
Normal tonsils may be enlarged without being infected, especially in children. The difference is that normal tonsils are pink and do not have exudate.
Flat expressions, mask-like expression, oily skin and eyebrows that are constantly elevated are classic signs of
Parkinsons
Exudative Tonsilitis
Red throat has white exudate on the tonsils. This, together with fever and enlarged cervical nodes increases the probability of Group A strep or infectious mononucleosis. Anterior cervical lymph nodes are usually enlarged in the former, posterior in the later.
Murphy's sign
Sharp pain upon inspiration when examiner's hand is palpating the liver (cholecystitis)
Pharyngitis
These two photos show reddened throats without exudate. In A, redness and vascularity of the pillars and uvula are mild to moderate In B, redness is diffuse and intense. Probable causes include several kinds of viruses and bacteria. If the patient has no fever, exudate or enlargement of cervical lymph nodes, chances of infection by either group A strep or Epstein-Barr virus are reduced.
Thrush on the palate (Candidiasis)
Thrush is a yeast infection due to Candida. Shown here on the palate, it may appear elsewhere in the mouth. Thick white plaques are somewhat adherent to the underlying mucosa. Predisposing factors are prolonged treatment with antibiotics or corticosteroids and AIDs.
Name that disease quality - frequent watery stools often containing blood timing - typically abrupt, often recurrent, persisting and may awaken at night associated - cramping, tenses, urgency, fever, fatigue, weakness, abdominal pain if complicated by toxic megacolon. risk factors - often young adults, Ashkenazi Jewish descendants. Linked to altered CD4+ T-cell Th2 response. Increases risk of colon cancer.
Ulcerative colitis
Dysequilibrium
Unsteadiness or imbalance when walking, especially in older patients. Causes include fear of walking, visual loss, weakness from musculoskeletal problems and peripheral neuropathy
Hairy leukoplakia
Whitish raised asymptomatic plaques with a feathery or corrugated pattern commonly occur on the sides of the tongue. Unlike candidiasis, these areas cannot be scraped off. Condition is caused by Epstein-barr virus infection and seen with HIV and AIDs
presyncope
a near faint from "feeling faint or lightheaded. can be caused by orthostatic hypotension, especially from medication, arrhythmias and vasovagal attacks
a patient in the clinic where you work is considered legally blind. the nurse knows that this means the vision in his better eye, corrected by glasses, is what? a) 20/200 or less b) 20/100 or less c) 20/300 or less d) 20/400 or less
a) 20/200 or less
Pt. complains of dysuria and pain upon direct palpation of the suprapubic region. What else should the nurse assess? a) Costovertebral angle tenderness b) Percuss epigastric area c) Establish liver borders d) Auscultate over suprapubic region
a) Costovertebral angle tenderness
Potential cause of hypoactive bowel sounds a) Peritonitis b) Diarrhea c) Laxative use d) gastroenteritis
a) Peritonitis
an alternate pathway that bypasses the external and middle ear is called what? a) bone conduction b) sensory conduction c) neuro conduction d) air conduction
a) bone conduction
What are you testing when you ask the patient to follow your finger or pencil as you move it in toward the bridge of the nose? a) convergence b) EOM c) accommodation d) visual fields
a) convergence
the nurse observes an inward turning of the lower lid in a 77 year old patient. the nurse documents a) entropion b) ectropion c) exophthalmos d) ptosis
a) entropion
a nurse notes thrush on the palate of a patient. the most appropriate question the nurse should ask is: a) have you been on antibiotics recently b) do you smoke c) have you traveled out of the country in the last month d) have you been tested for HIV
a) have you been on antibiotics recently
What is vital in maintaining vision and a healthy outlook for clients? a) health education b) emotional support c) physical exercise d) monthly eye exams
a) health education
a patient presents to the clinic with sores around the mouth. the nurse notes vesicular lesions on the upper lip and right corner of the lips. the patient describes these as painful. the nurse suspects: a) herpes simplex b) angioedema c) actinic cheilitis d) syphilis
a) herpes simplex
the nurse does a health history. the patient states that he has lost 30lb in the last couple months without really trying. the patient also states he feels warm all the time and sometimes feels like he has heart palpitations. the nurse would anticipate orders to evaluate the patient for: a) hyperthyroidism b) hyperproteinemia c) hypernatremia d) hyperbilirubinemia
a) hyperthyroidism
your patient describes her stool as soft, light yellow to gray, mushy, greasy, foul smelling and usually floats in the toilet. what would you suspect is wrong with your patient? a) malabsorption syndrome b) ulcerative colitis c) crohn disease d) lactose intolerance
a) malabsorption syndrome
the nurse is assessing a client with a bladder disorder. Where would the nurse expect the pain to be? a) suprapubic b) back c) perineal d) upper abdomen
a) suprapubic
Rosing's sign is a test of referred rebound tenderness in appendicitis. a) true b) false
a) true
The nurse tests the six cardinal directions to test for extra ocular movement of the eye. a) true b) false
a) true
When the spleen enlarges, the nurse would not be surprised to percuss dullness over the stomach. a) true b) false
a) true
a parent is very upset because she is told her child has a refractive error. the nurse reassures the parent that refractive errors are the most common visual change in children. a) true b) false
a) true
the thyroid gland is usually larger in women than in men a) true b) false
a) true
What can cause bladder distention? (mark all that apply) a) multiple sclerosis b) medications c) perineal fissure d) rectal abscess e) stroke
a, b, & e multiple sclerosis, medications & stroke bladder distention results from outlet obstruction due to urethral stricture or prostatic hyperplasia, and also from medications and neurologic disorders such as stroke or multiple sclerosis
the nurse should ask about or assess which associated factors when a patient complains of cluster headaches? select all that apply a) miosis b) ptosis c) rhinorrhea d) lacrimation e) photophobia
a, b, c & d rhinorrhea, ptosis (drooping eyelid), miosis (excessive pupil constriction) and lacrimation
a patient with hypothyroidism is admitted to the medical unit. the nurse would expect to assess which signs/symptoms? select all that apply. a) lethargy b) lower systolic blood pressure c) weight loss d) cool skin e) constipation
a, b, d & e
your patient is complaining of nasal stuffiness. what drugs should you ask if she is taking? mark all that apply a) guanethidine d) nicotine c) alcohol d) oral contraceptives e) guaifenesin
a, c & d oral contraceptives alcohol guanethidine
when providing client education on hearing, the nurse should remind clients to utilize ear plugs when they are what? (select all that apply) a) at train stations b) cleaning their homes c) working with children d) at concerts e) using lawnmowers
a, d & e train stations, concerts and lawn mowers
Name that disease location - periumbilical / upper abdominal OR lower abdominal / generalized quality - cramping aggravation - ingestion of food or liquids timing - paroxysmal relieving - n/a associated - vomiting of bile and mucus or fecal matter. obstipation develops. vomiting late if at all. prior symptoms of underlying cause
acute bowel obstruction
Name that disease location - RUQ or epigastrum; may radiate or with scapula or shoulder quality - steady, aching aggravation - jarring, deep breathing timing - gradual onset relieving - n/a associated - anorexia, N/V, fever, no jaundice
acute cholecystitis
Name that disease quality - loose to watery stools, often with blood, pus or mucus timing - varying duration associated - lower abdominal cramping and often rectal urgency, tenesmus, fever risk factors - travel, contaminated food or water, frequent anal intercourse
acute diarrhea (inflammatory)
Name that disease quality - watery stools without blood, pus or mucus timing - duration of a few days, possibly longer. associated - N/V, periumbilical cramping pain. risk factors - travel, exposure to epidemic or food source
acute diarrhea (noninflammatory)
Name that disease location - LLQ quality - may be cramping at first, then becomes steady aggravation - n/a timing - often gradual onset relieving - n/a associated - fever, constipation, N/V, abdominal mass with rebound tenderness
acute diverticulitis
Name that disease location - epigastric (may radiate to the back or abdomen, 20% with severe sequelae of organ failure) quality - usually steady aggravation - lying supine, dyspnea if pleural effusions from capillary leak syndrome. selected medications, high triglycerides timing - acute onset, persistent pain relieving - leaning forward with trunk flexed associated - N/V, abdominal distention, fever, often recurrent; 80% with history of previous attacks and alcohol abuse or gallstones
acute pancreatitis
bilateral suprapubic tenderness just above the inguinal ligaments suggests_________
acute salpingitis
percussion sounds for: all 4 quadrants: liver: bladder: stomach: kidneys:
all 4 quadrants: mostly tympanic liver: dull bladder: tympanic if full stomach: tympanic (meals can lead to dullness esp. @ base of stomach) kidneys: dull (but watch for painful reaction)
which arteries do you auscultate for bruits? where?
aorta, renal arteries, iliac, and femoral arteries (with bell) aorta: xiphoid process is your landmark renal: xiphoid process and midclavicular line iliac: umbilicus and midclavicular line femoral: palpate with legs flat and then auscultate
hairy tongue
associated with Candida, bacterial overgrowth, antibiotic therapy and poor dental hygiene. may occur spontaneously. may occur after taking too many TUMS.
What does it mean if a patient has 20/100 vision?
at 20 feet they can see what normal people can see at 100 feet
What structure is located in the RUQ of the abdomen? (select all that apply) a) spleen b) gallbladder c) ascending colon d) bladder
b & c
Which structure is located in the LUQ of the abdomen? (select all that apply) a) liver b) stomach c) badder d) spleen e) descending colon
b & d
Mobile & tender lymph nodes suggest _____ while fixed firm nodes suggest ___________ a) infection; HIV b) Inflammation; cancer c) Malignancy; infection d) Pharyngitis; enlarged thyroid
b) Inflammation; cancer
you are assessing visual fields on a patient newly admitted for eye surgery. the patient's left eye repeatedly does not see your fingers until they have crossed the line of gaze. you would document that the patient has what? a) a bitemporal hemianopsia b) a left temporal hemianopsia c) a quadrantic defect d) a homonymous hemianopsia
b) a left temporal hemianopsia
the client has epigastric pain that is poorly localized and radiates to the back. what would be an important diagnosis to assess for? a) acute cholecystitis b) acute pancreatitis c) acute diverticulitis d) biliary colic
b) acute pancreatitis
a client presents at the clinic with a chief complaint of indigestion. the patient tells the nurse, "it usually happens after I do things like mowing the lawn or doing other yard work." what should the nurse suspect? a) aortic aneurysm b) angina c) ulcer disease d) gallbladder disease
b) angina
the client presents a the clinic with a chief complaint of pain in her upper abdomen. on assessment the nurse notes that the client has recurrent pain, more than two times weekly, in her upper abdomen, and that this recurrent pain started 2 months ago. what term should the nurse use for this type of pain? a) discomfort b) dyspepsia c) dysphagia d) odynohagia
b) dyspepsia
primary headaches are more worrisome than secondary headaches a) true b) false
b) false
a patient has conjunctivitis. the nurse understand that conjunctivitis differs from conjunctival hemorrhage in that conjunctivitis a) is not painful b) has a watery, mucoid discharge c) usually follows trauma d) can result from a cough
b) has a watery, mucoid discharge
examine painful areas: a) first b) last c) skip painful areas
b) last
when palpating the abdomen, the nurse may be able to feel the lower edge of the liver in which quadrant? a) left upper b) right upper c) right lower d) left lower
b) right upper
the nurse notes that the ophthalmologist suspects death of the optic nerve. when looking into the eye, the nurse would expect to see what color if the disk is dead? a) yellow b) white c) red d) black
b) white
when palpating the thyroid, stand ______ the patient and have the patient swallow while your right hand ______ and your left hand _______
behind / palpates / displaces
geographic tongue
benign - can change over time
hematemesis
blood in vomit can look like coffee grounds with upper GI bleed, frank blood higher up (i.e. esophagus)
what does the webber test evaluate?
bone conduction (should be equal bilaterally)
hematochezia
bright red stools causes: colon cancer, hyperplasia or adenomatous polyps, diverticula of the colon, inflammatory conditions of the colon and rectum, ischemic colitis, hemorrhoids, anal fissure
What structure is located in the RLQ of abdomen a) Stomach b) Descending colon c) Appendix d) liver
c) Appendix
upon examination of the ear with an otoscope, the nurse documents the skin of the ear canal as thickened, red and itchy. the nurse would expect this finding with a diagnosis of a) otitis media with serous effusion b) purulent ottis media c) chronic otitis media d) acute otitis media
c) chronic otitis media
a client presents at the clinic with a chief complaint of right ear pain. the nurse notes a rash in the right ear canal. what should the nurse know is a possible cause of these symptoms? a) acute mastoiditis b) acute ossiculo-mastitis c) chronic otitis media d) chronic otosclerosis
c) chronic otitis media unusually soft wax, debris from inflammation or rash in the ear canal or discharge through a perforated eardrum may be secondary to acute or chronic otitis media.
the nurse is using the ophthalmoscope to examine the patient's eyes. the nurse holds the scope a) in the left hand for the right eye and in the right hand for the left eye b) in the right hand for both eyes c) in the right hand for the right eye and in the left hand for the left eye d) in the left hand for both eyes
c) in the right hand for the right eye and in the left hand for the left eye
A patient has COPD. On examination, the nurse would expect a) difficulty in percussing liver dullness b) the liver to be enlarged c) liver dullness to be displaced downward d) the liver span to be decreased
c) liver dullness to be displaced downward
during your physical examination of a patient you note an enlarged tender tonsillar lymph node. what do you do next? a) assess for meningitis b) assess for dietary changes c) look for a source such as infection in the area that it drains d) look for involvement of other regions of the body
c) look for a source such as infection in the area that it drains
When examining the eye with an ophthalmoscope, where would the nurse look to visualize the optic disc? a) laterally toward the ear b) downward toward the chin c) medially toward the nose d) upward toward the forehead
c) medially toward the nose follow the blood vessels as they get wider. follow the vessels medially toward the nose and look for the round yellowish orange structure which is the optic disk.
while examining a patient, the nurse observes abdominal pulsations between xiphoid and umbilicus. the nurse would decide that these are: a) pulsations of renal arteries b) pulsations of the inferior vena cava c) normal abdominal aortic pulsations d) increased peristalsis from a bowel obstruction
c) normal abdominal aortic pulsations
A female patient presents with right lower quadrant pain that radiates from the periumbilical area. the abdomen is rigid on palpation. the nurse would prepare for physician follow-up for possible a) diverticulitis b) small bowel obstruction c) pelvic inflammatory disease d) peptic ulcer disease
c) pelvic inflammatory disease
a 16 year old white female is brought to the clinic by her mother with a chief complaint of severe headache lasting more than 24 hours. the mother states "Just before the headache started my daughter was craving food. I couldn't feed her enough." what is this called? a) aura b) neurologic onset c) prodrome d) aberrant sign
c) prodrome a prodrome is an unusual feeling such as euphoria, craving food, fatigue or dizziness. auras are more neurological, such as a change in vision or numbness or weakness in an arm or leg
when assessing a patient with graves disease, how would you expect the thyroid glands to be? a) firm b) tender c) soft d) nodular
c) soft
the nurse would expect to assess which symptoms in a patient complaining of migraine headaches? select all that apply. a) continuous b) muscle tension c) recurrent d) throbbing e) photophobia
c, d & e recurrent, throbbing and photophobia
Name that disease location - epigastric radiating though back quality - severe, persistent, deep aggravation - alcohol, heavy or fatty meals timing - chronic or recurrent course relieving - possibly leaning forward with trunk flexed, often intractable associated - diarrhea with fatty stools and DM
chronic pancreatitis
The nurse performs the Webber test on a patient with hearing loss in the left ear. The patient reports that the sound is louder in the left ear. the nurse conclude that the hearing loss is ______.
conductive (less room noise=vibrations better heard)
when assessing the patient the nurse notes that the tonsils are touching the uvula. how would the nurse document the tonsils? a) T4 b) T2 c) T1 d) T3
d) T3
the nurse is performing a physical examination and notes an enlarged left supraclavicular lymph node. the nurse understands that this could be indicative of: a) tonsillitis b) a goiter c) nasopharyngitis d) a metastasis
d) a metastasis
Which is a characteristic symptom of Graves hyperthyroidism? a) episcleritis b) pinguecula c) pterygium d) exophthalmos
d) exophthalmos bilateral exophthalmos (protrusion of eyeballs) suggests the infiltrative opthalmopathy of Graves hyperthyroidism.
a patient complains of feeling like he is slowly losing his central vision. the nurse knows this symptom could represent a) open-angle glaucoma b) retinal detachment c) hemianopsia d) macular degeneration
d) macular degeneration
you are assessing a patient for acute cholecystitis. what sign would you assess for? a) psoas sign b) obstipation sign c) cutaneous hyperesthesia d) murphy sign
d) murphy sign a sharp increase in tenderness with a sudden stop in inspiratory effort constitutes a positive Murphy sign of acute cholecystitis. Hepatic tenderness may also increase with this maneuver but is usually less well localized.
which type of incontinence occurs when excessive bladder volume exceeds urethral pressure. a) urge incontinence b) stress incontinence c) functional incontinence d) overflow incontinence
d) overflow incontinence
you note anterior bulging of the physiologic cup when performing a funduscopic examination of your patient's eyes. what would you document? a) hyperopia b) positive axoplasmic sign c) arteriovenous crossings d) papilledema
d) papilledema describes swelling of the optic disc and anterior bulging of the physiologic cup
a client arrives in the ER by ambulance after falling down his front steps. The nurse notes two soft lumps, approximately 3 cm in diameter, on the side of his head. what would the nurse identify these as? a) edema from fall b) signs of abuse c) pigmented nevi d) pilar cysts
d) pilar cysts
a patient tells the nurse that he is constantly congested in spite of using a decongestant at least twice daily. the nurse understand the patient may be experiencing a) rhinorrhea b) vasomotor rhinitis c) allergic rhinitis d) rhinitis medicamentosa
d) rhinitis medicamentosa
during an assessment, the patient describes vomiting moderate amounts that "smell like poop." the nurse might suspect a) hypercalcemia b) gastric varices c) irritable bowel syndrome d) small bowel obstruction
d) small bowel obstruction
What structure in the inner ear senses the position and movements of the head and helps to maintain balance? a) the jumbo b) the ossicle c) the cochlea d) the labyrinth
d) the labyrinth the labyrinth within the inner ear senses the position and movements of the head and help to maintain balance
Visceral pain is associated with a hollow abdominal organ such as the intestine. Visceral pain is a) right or left sided b) more severe than parietal pain c) also called referred pain d) usually difficult to localize
d) usually difficult to localize
when visualizing the structures of the nose, the nurse recalls that air travels from the anterior nares to the trachea through the: a) ala nasi, vestibule and ethmoid sinuses b) ala nasi, turbinates and nasopharynx c) turbinates, ethmoid sinuses and nasal passages d) vestibule, nasal passages and nasopharynx
d) vestibule, nasal passages and nasopharynx
conjunctivitis (symptoms)
diffuse dilation of conjunctival vessels with redness that tends to be maximal peripherally mild discomfort rather than pain, vision unaffected except for temporary mild blurring due to discharge (watery, mucoid or mucopurulent). pupil unaffected, cornea clear. Caused by bacterial, viral and other infections or allergy, irritation
For children, which way do you pull the pinna prior to inspection of the auditory canal?
down and back
what is the difference between dysphasia and dysphagia?
dysphasia: difficulty speaking dysphagia: difficulty swallowing
Strabismus
eye drifts and wanders while other eye is normal (weaker eye wanders)
Exophthalmos
eyeball protrudes forward. when bilateral, it suggests the infiltrative ophthalmopathy of Graves hyperthyroidism. edema of the eyelids and conjunctival injection may be associated. unilateral exophthalmos is seen in Graves disease or a tumor or inflammation in the orbit.
Convergence
eyes inward
Hyperopia
farsighted can't see things that are close
Hepatitis A is transmitted __________. After infection, it takes approx. _____________ months for the liver to recover.
fecal oral route 6 months
Name three causes of hearing loss involving the external ear
foreign body obstruction cerumen impaction external otitis
Otoliths
hang out on cilliary hairs in your semicircular canals and tell you your body position / orientation. When they get dislodged, you end up with vertigo.
name that headache: location: frontal sinus or maxillary sinus quality: aching, throbbing, variable timing: onset variable, duration is a few hours each day in a repetitive pattern until treatment associated: local tenderness, nasal congestion, discharge, fever triggers: coughing, sneezing, jarring of head relieving: nasal decongestants, antibiotics
headache from sinusitis
name that headache: location: generalized quality: steady or throbbing, very severe timing: may be sudden onset, fairly rapid usually less than 24 hr and lasts a variable amount of time (usually days) associated: stiff neck, fever, photophobia, change in mental status triggers: n/a relieving: immediate treatment with antibiotics until diagnosis of if bacterial or viral
headache indicative of meningitis
what does the whisper test evaluate?
high frequency loss and gross hearing
hyperactive (increased motility) bowel sounds
high pitched, loud
Name that disease: signs: warm, smooth, moist skin, increased systolic and decreased diastolic BP, tachycardia or atrial fibrillation, hyper dynamic cardiac pulsations with an accentuated S1, tremor and proximal muscle weakness symptoms: nervousness, weight loss despite increased appetite, excessive sweating and heat intolerance, palpitations, frequent bowel movements, muscular weakness of the proximal type and tremor possible lid lag, stare, or exophthalmos
hyperthyroidism
Name that disease signs: dry, course, cool skin sometimes yellowish from carotene, nonpitting edema and loss of hair, periorbital puffiness, decreased systolic and increased diastolic BP, bradycardia and, in late stages, hypothermia, intensity of heart sounds sometimes decreased, impaired memory, mixed hearing loss, somnolence, peripheral neuropathy and carpal tunnel syndrome symptoms: fatigue, lethargy, modest weight gain with anorexia, dry course skin with cold intolerance, swelling of face, hands and legs, constipation, weakness, muscle cramps, arthralgias, paresthesias, impaired memory and hearing
hypothyroidism
assessing for ascities
if you lay patient on back, tympanic at most protuberant point, dull at sides. If you lie patient on side, dull at portion of belly closest to table, tympanic on portion of stomach closest to ceiling. think of a water bottle and where the water and air settle as you tip it on its side or stand it up straight.
a smooth large liver with a smooth tender edge suggests _______________
inflammation (as in hepatitis) or venous congestion (as in right sided HF)
black stools are a side effect of which medications?
iron tablets *note, black stool is used to describe dark stools that are caused by things other than fecal blood. Melena is the term used to refer to the passage of black stools that are positive for fecal blood
Riedel lobe
is a normal elongation of the right lobe, making it easily palpable is it projects downward toward the iliac crest. This is a normal variation in shape, and not an increase in liver volume or size.
absent (obstruction) bowel sounds
listen to that quadrant for full 5 minutes NEVER SIMPLY DOCUMENT ABSENT BOWEL SOUNDS...FOLLOW UP WITH PROVIDER
where is the eustachian tube located and what is its function? how does it change over the lifespan?
located in the middle ear and equalizes air pressure from middle ear to nasopharynx. it is more horizontal in child; more angled in adult
hypoactive (decreased motility) bowel sounds
low gurgling <4 in1min
headache that presents with stiff neck pain and/or rash is concern for ________________
meningitis
name that headache: location: unilateral in 70%, bifrontal or global in 30% quality: throbbing, aching, pain, moderate to severe in intensity, preceded by an aura in up to 30% timing: fairly rapid onset (peak in 1-2 hrs), lasts 4 -72 hrs, recurrent - usually monthly , but weekly in about 10%. Peak occurrence early to mid-adolescence associated: prodrome (NV, photophobia, phonophobia), aura (flickering, zig-zagging lines, paresthesias of hand, arm or face or language dysfunction) triggers: alcohol, certain foods, stress, menses, high altitude, aggravated by noise and bright lights relieving: quiet, dark room, sleep, transient relief from pressure on the involved artery
migraine headache
coordination between these two structures control facial expression
muscles and the facial nerve (CN VII)
a dull, puffy face (pronounced edema around the eyes that does not pit with pressure) accompanied by course , dry and thin hair and a dry scalp is indicative of _______
myxedema (severe hypothyroidism)
edematous and pale face with swelling starting around the eyes and in the morning (may appear slit like) is indicative of ___________________
nephrotic syndrome
name three cause of hearing loss involving the middle ear
otitis media serous otitis otosclerosis
Name that disease location - epigastric (may radiate straight to the back) quality - variable (epigastric gnawing, burning, boring, aching or hunger-like. asymptomatic 20% of the time) aggravation - variable timing - intermittent relieving - food & antacids associated - N/V, belching, bloating, heartburn, weight loss
peptic ulcer / dyspepsia
the nurse notes that one eye cannot open as wide as the other. the nurse documents this as _____
ptosis causes include: myasthenia graves, damage to oculomotor nerve, damage to the sympathetic nerve supply (Horner syndrome), weakened muscle, relaxed tissues or congenital
Accommodation
pupillary constriction when focusing on a near object after looking far away Far vision, pupils dilate Near vision, pupils constrict
Rovsing sign
push on LLQ then quickly remove hand Rebound tenderness in RLQ or pain in RLQ during LLQ pressure (appendicitis)
diastasis recti
separation of the two rectus abdomens muscles, through which abdominal contents form a midline ridge typically extending from the xiphoid to the umbilicus and seen only when the patient raises the head and shoulders. risk factors: repeated pregnancies, obesity and chronic lung disease clinically benign
Borborygmi
stomach growl
You feel a mass in the patient's upper left quadrant upon light palpation. you ______
stop palpation immediately and notify provider ASAP
you feel a thrill over the aorta. your next action is to _____________________
stop palpation immediately and notify provider ASAP
how should the patient be positioned for the GI assessment?
supine, knees flexed
What are the criteria for diagnosing IBS?
symptoms present >6 months and abdominal pain for >3 months plus at least two of three features: 1) improvement with defecation 2) onset with change in stool frequency 3) onset with change in stool form and appearance
melena
tarry stools (result of blood in stool) causes: GERD, gastritis, peptic ulcer, gastritis or stress ulcers, esophageal or gastric varices, a mucosal tear in the esophagus due to retching or vomiting.
What is the cochlea?
the cochlea is part of the labyrinth of the inner ear and converts vibrations and sends them via the cochlear nerve to the brain.
What is the labyrinth and where is it located? What is its function?
the labyrinth is a structure in the inner ear that consists of the semicircular canals, vestibule, and cochlea. it is responsible for balance and the transmission of sound
For adults, which way do you pull the pinna prior to inspection of the auditory canal?
up and back
causes of gastroenteritis
viruses, bacteria, parasite, medications, food intolerances
A patient with chronic COPD. The nurse can expect the liver edge to be palpable _____________ the costal margin. Percussion reveals the upper edge is ______________, making the vertical span of the liver _______________.
well below / also low / is normal because the diaphragm is flattened and low in COPD, the liver id displaced downward, but the overall size of the liver is the same.