Health Assessment II Final Review PP

Review Melanoma assessment: ABCDE

A- asymmetrical: benign is not asymmetrical, both sides match, if asym. warning sign. for melanoma B- border: benign have smooth, even border. early melanomas tend to be uneven, scalloped, or notched. C- color: benign are often one color, variety of colors is warning sign D- diameter: benign have smaller diameter, melanomas have larger E- Evolving/evolution/elevation: benign look the same over time, be alert to evolving/ changing in any way

A healthcare provider has diagnosed a client with purpura. The nurse knows this is: a. Blue dilation of blood vessels in a star-shaped linear pattern on the legs b. Fiery red star-shaped markings on the cheek with a solid center c. Confluent & extensive patches of petechiae d. Tiny little areas of hemorrhage less than 2 mm, round & discrete

C. - confluent & extensive patches of petechiae come together causes purpura Purpura- rash of purple spots due to small blood vessels leaking blood into skin, joints, intestines, or organs

Can crackles clear with coughing?

No bedside purpose- pt. with dysphagia or anyone- have secretions sitting at back of throat- listening to upper lobe- can sound like crackles- tell pt. to cough- if it clears it is not crackles

Where will the nurse place the stethoscope to auscultate the apices of the lungs?

apex- above clavicle anteriorly, above scapula posteriorly base of lungs- sits on the diaphragm

The Advanced Practice Nurse (APN) is performing a clinical breast exam (CBE) on a female client. Which of the following will the nurse include? a. Do not include palpation of the axilla in the exam b. Palpate the 4 quadrants in a systematic manner c. Palpate only if there is pain d. Educate the client to only perform breast-self exam after age 35

b. ANSWER-Palpate the 4 quadrants in a systematic manner a- you do want to palpate there c- no pain with breast cancer d- check before 35

The nurse is caring for a client s/p hip arthroplasty. Which of the following interventions should the nurse include in the client's plan of care (POC)? a. Flex the operative hip 90 degrees b. Abduct the operative hip c. Adduct the operative hip d. Turn 45 degrees to the operative side

b. Abduct the operative hip

Which of the following statements illustrates the use of open-ended questions? Select all that apply a. Elicits cold facts b. Builds & enhances rapport c. Leaves interactions neutral d. Calls for short one-to two-word answers e. Used when narrative information is needed

b. Builds & enhances rapport e. Used when narrative information is needed

When auscultating the heart over the 2nd intercostal space to the left of the sternal border, the nurse is listening to what area? a. Erbs b. Pulmonic c. Aortic d. Tricuspid

b. Pulmonic

The nurse is performing a skin assessment on a client & assesses the skin for turgor. The nurse grasps a fold of skin in which body area to best assess? a. Back of the hand b. Sternal area c. Top of foot d. Sacral area Note: May be assessed in the abdomen for infants, sometimes the forehead with adults. Assess turgor for elasticity of the skin. *Tenting indicates decreased elasticity*

b. Sternal area

Assessing a client for increased intracranial pressure would include which of the the following: Change in LOC Pupillary changes Headache Papilledema All of the above

d- ANSWER- all of the above papilledema- look at eye, see bulding of optic disc- pressure in brain

A nurse notes documentation in a client's record that the client is experiencing anuria. The nurse determines the client: a. Is unable to produce urine b. Has a diminished capacity to form urine c. Has microscopic red blood cells in the urine d. Has episodes of oliguria

a. Is unable to produce urine

The RN is performing a Romberg test to assess cerebellar function. A negative Romberg is: a. Maintaining balance with feet together & eyes closed for 20-30 seconds without support b. Maintaining balance when sitting with eyes closed c. Maintaining balance with feet separated & eyes closed while standing d. Maintaining balance if sitting with eyes open

a. Maintaining balance with feet together & eyes closed for 20-30 seconds without support

Name and describe adventitious lung sounds.

adventitious sounds- these are added sounds that are not normally heard in the lungs- crackles fine(rales)- wheeze low pitched (rhonchi)- discontinuous sounds- crackles- coarse (coarse rales)- pneumonia atelectatic crackles pleural friction rub- pleuritis continuous sounds wheeze (high pitched) stridor- crowing sound- croup- truly obstructing airway- choking

In assessing the carotid arteries of an older client with cardiovascular disease the nurse should: a. Palpate the artery in the upper neck at the angle of the jaw b. Palpate the arteries simultaneously c. Instruct the pt. to take slow deep breaths during auscultation d. Listen w/the bell of the stethoscope to assess for bruit

d. Listen w/the bell of the stethoscope to assess for bruit

A client is complaining of new-onset calf & foot pain. The nurse notes that the leg below the knee is cool & pale. The dorsalis pedis & posterior-tibial pulses are assessed as "0" w/ palpation and "0" following validation with a Doppler. The priority nursing intervention is: a. Place a cradle over the bed to prevent pressure from bedding b. Elevate the leg c. Massage the leg d. Notify the healthcare provider immediately

d. Notify the healthcare provider immediately medical emergency- 5 P's

A client is admitted following surgical repair of fracture of the tibia. Which assessment should the nurse report to the healthcare provider? a. Pain that is relieved with medication b. Warm toes c. Palpable pedal pulse d. Paresthesia of the toes Remember the 5 P's! Pain . . . Pulses . . . Pallor . . . Paresthesia . . . Paralysis..

d. Paresthesia of the toes

During assessment of the lower extremities of a male client the nurse is unable to palpate the dorsalis pedis pulse. What action should the nurse take first? a. Notify the Physician b. Return in a few hours and reassess c. Ask the client if this is "normal" for him d. Reposition the fingers and assess again

d. Reposition the fingers and assess again

Where on the abdomen should the nurse auscultate for an abdominal aortic bruit?

epigastric area slightly left of midline under xiphoid process

Vesicular

normal breath sound - low pitch - soft amplitude - inspiration > expiration - quality, rustling, like sound of wind in trees - location, over peripheral lung fields where air flows through smaller bronchioles and alveoli or lesion of vesicle

Conjunctiva

transparent protective covering- thin mucous membrane folded like an envelope between the eyelids and eyeball. pull eye down, pink and moist

During the history, a client tells the nurse that "I have the sensation of a ringing and buzzing in my ear that is driving me crazy". The nurse suspects: a. Vertigo b. Syncope c. Otitis media d. Tinnitus

vertigo- sense that inside the head or room is spinning- often triggered by change in head position syncope- loss of consciousness- fainting- not enough blood is getting to brain otitis media- infection of air filled space behind the eardrum - pain fever, inflammation ANSWER- tinnitus- ringing or buzzing noise in one or both ears that may be constant or come and go, often associated with hearing loss

Would an abdominal aortic aneurysm produce a bruit? Why?

yes it would-- and turbulence- out pouching

What are the specific categories contained in the health history?

- Biographical data(age gender culture, religion, demographic) - allergies - Reason for seeking care - Present health or history of present illness - Past history (including surgeries&vaccinations) -medication reconciliation(pt. tells you what they are taking, and you need to accurately report that) - Family history - Review of systems- head to toe, asking subjective data, what pt. is doing for health promotion- do with any pt. you see. - Functional assessment/ ADLs- able to care for self, feed yourself, afford nutritional food, 24 hour diet, transportation, exercising regularly (how much walking do you do?), stairs, safe in your home, anyone who cares for you, socially who are the people that care for you, do you smoke/vape, drink alcohol, drug use? social/psycho social history

what do i check to make sure arterial circulation is in tact?

- CMS checks (circulation, motion, sensation) -- 5 P's do this wherever i am concerned pallor paresthesia pain- move limb- see if more pain paralysis- can you freeling move limb poki - extremity that is pale, cold, decreased pulse

Review the 5 listening points of the heart

- aortic- rt. side of chest- 2nd intercostal - pulmonic - erb's point- 3rd intercostal L - tricuspid -4th intercostal L - mitral -5th intercostal listen for s1 and s2- don't want to hear any extra sounds irregular- listen 1 full minute

what to do to help venous circulation

-elevate legs - TED hose - encourage ambulation see- edema, skin changes

Name the four components of general survey.

1. Physical Appearance 2. Body Structure 3. Mobility 4. Behavior

Presbyopia

gradual, age- related, loss of the eyes' ability to focus actively on nearby objects

A nurse is performing a lung assessment on a client diagnosed w/ RLL pneumonia. The client is asked to say "eee" & through the stethoscope the nurse hears an "aaa" sound over the RLL. What term should be used to document the finding? a. Tactile fremitus b. Egophony c. Bronchophony d. Whispered pectoriloquy

ANSWER - egophony- auscultate the chest while the person phonates a long "eee sound. normal- hear eee abnormal- sound changes to a bleating long "aaaaa" sound- consolidation- pneumonia bronchophony- repeat "ninety-nine" or "blue-moon" while listening normal- voice is soft, muffled, and indistinct, can hear sound, but can't hear exactly what is being said abnormal- pathology increases lung density- enhance transmission of voice- can hear a clear "ninety-nine" -- something in there that is carrying the sound- consolidation- pneumonia whispered pectoriloguy- ask person to whisper phrase like "one-two-three" as you listen normal- faint, muffled, almost inaudible abnormal- transmitted very clearly and distinctly, still a little faint, whispered sound as if right into stethoscope listening over pneumonia- crackles or rales- right upper

The nurse performs the confrontation test, the nurse has assessed: a. EOM's b. PERRLA c. Near vision d. Peripheral vision

ANSWER- peripheral vision confrontation test- measure of peripheral vision- compares pt's peripheral vision with your own- position yourself eye level with pt. two feet away, tell pt. to cover one eye with opaque card, look straight at you with other eye, cover your own eye opposite to the person's covered one, testing uncovered eye, hold finger as a target midline between you and person, slowly advance it in from periphery in several directions, tell person to say now when target is first seen.

Tuning fork

Acustic resonator- two pronged fork with prongs vibration- peripheral nephropathy Weber and Rene

Review Level of Consciousness (LOC)

Alert -The person is awake, alert, aware of stimuli from the environment and within the self, and responds appropriately to stimuli, conducts meaningful interpersonal interactions. Lethargic- not fully alert, drifts off to sleep when not stimulated Stupor or semi-coma- spontaneously unconscious, responds only to persistent and vigorous shake or pain, has appropriate motor response (withdraws hand to avoid pain), can only groan, mumble, or move restlessly Coma- completely unconscious, no response to pain or to any external or internal stimuli.

General Survey: what data is included in physical appearance?

Age Sex LOC Skin color Facial features no signs of acute distress are present

General Survey: what data is included in physical appearance? (add normal findings)

Age- person appears stated age Sex- sexual development is appropriate for gender and age LOC- person is alert and oriented, attends to your questions and responds appropriately Skin color- color tone is even, pigmentation varying with genetic background, skin is intact with no obvious lesions Facial features- facial features are symmetric with movement

A nurse is assessing a client admitted with congestive heart failure (CHF) for edema. The nurse assesses the following in dependent parts of the body. - when applying pressure there is a dent in the skin that lasts a very long time. The nurse should document this as: a. 1+ - (2mm depth) b. 2+ - (4mm depth) c. 3+ - (6mm depth) d. 4+ - (8mm depth)

Answer--d. 4+ - (8mm depth) (very deep pitting, indentation lasts a long time, leg is very swollen) 3+ - (deep pitting, indentation remains for a short time, leg looks swollen) 2+ - (moderate pitting, indentation subsides rapidly) 1+ - (mild pitting, slight indentation, no perceptible swelling of the leg)

Rhonchi

Coarse rattling respiratory sounds, usually caused by secretions in bronchial airways large airway blocked - deep sound- chair being dragged- adventitious lung sound -copd, cystic fibrosis

Review Orientation X4

Can be done throughout course of interview, or asked directly. Person- own name, age, who examiner is, type of worker Place- where person lives, present location, type of building, name of city and state Time- day of week, date, year, season Event/situation- why are you here

What is the proper sequence of the abdominal assessment . . . and why??

inspection alscul percussion palpation least invasive to most

General Survey: what data is included in Behavior?

Facial expression Mood and affect Speech Dress Personal hygiene

General Survey: what data is included in Behavior? (add normal findings)

Facial expression- maintains eye contact (unless culture taboo), expressions are appropriate for situation -thoughtful, serious, smiling-(note when at rest, and while talking) Mood and affect- person is comfortable and cooperative with examiner and interacts pleasantly Speech- articulation is clear and understandable Dress- clothing is appropriate to the climate, looks clean and fits body Personal hygiene- person appears clean and groomed appropriately for age, occupation, and socioeconomic group, hair is groomed, brushed, make up is appropriate for age.

General Survey: what data is included in Mobility?

Gait ROM

General Survey: what data is included in Mobility? (add normal findings)

Gait- normally, the base is wide as shoulder width, foot placement is accurate, walk is smooth, even, and well- balanced, and associated movements - symmetric arm swing- is present ROM- note full mobility for each joint, and that movement is deliberate, accurate, smooth, and coordinated no involuntary movement

After completing an initial assessment on a client, the nurse has charted: Vital signs: t-100.1 oral, Apical HR 98 irregular, RR 24 shallow, B/P 128/90, Pulse ox 90% on RA What type of data is this? What are you worried about?

Objective data Worried about-priority oxygenation and then infection

Tiny punctuate hemorrhages

Petechia

Explain PERRLA

Pupils Equal Round React Light Accommodation tests pupillary light reflex- advance light from side to side normally you will see- constriction of the same- sided pupil (direct light reflex) and simultaneous constriction of other pupil (consensual light reflex) (direct and consensual restriction) note gauge of pupil size in mm, before and after light reflex accommodation- focus on distant object- dilates pupil- then shift to near object- normal- pupillary constriction- and convergence of axes of eyes

General Survey: what data is included in Body structure?

Stature Nutrition Symmetry Posture Position Body build, contour

General Survey: what data is included in Body structure? (add normal findings)

Stature- height appears within normal range for age, genetic heritage Nutrition- weight appears within normal range for height and body build, body fat distribution is even Symmetry- body parts look equal bilaterally and are in relative proportion to each other Posture- person stands comfortably erect as appropriate for age. Position- person sits comfortably in chair or bed or table, arms relaxed at sides, head turned to examiner Body build, contour- proportions are 1. arm span (fingertip to fingertip) equals height 2. body length from crown to pubis roughly equal to length from pubis to sole obvious physical deformities- note any congenital or acquired deficits

Is a client recovering from abdominal surgery who is "splinting" and "guarding" their abdomen at risk for respiratory problems?

The patient may be in pain, and in turn will not deep breathe causing respiratory problems put pillow by incision so that when you take a deep breath it is easier voluntary guarding- saying that they cannot do it involuntary guarding- peritonitis in abdomen- it gets rigid- happens by self

What is the purpose of the health history?

To collect Subjective data- what the person says about them self. Screening tool for abnormal symptoms, health problems, and concerns.

Hypothyroidism can have the following signs and symptoms: Select all that apply a. Dry skin b. Dry hair c. Tachycardia d. Exophthalmos- bulging eyes e. Bradycardia

a. Dry skin b. Dry hair e. Bradycardia

Impairment of cranial nerve VII results in: a. Facial asymmetry b. Absence of the ability to smell c. Absence of eye movement d. Inability to chew

a. Facial asymmetry

When considering a nutritional assessment, the nurse is aware that the most common anthropometric measurements include: a. Height & weight b. Leg circumference c. Biceps skinfold thickness d. Hip & waist measurement *Review BMI & calculation of value

a. Height & weight BMI- weight(lbs)/height(in)x703 <18.5 underweight 18.5-24.9 normal weight 25.0- 29.9 overweight 30.0-39.9 obesity >40 extreme obesity hip and waste measurement- look at metabolic syndrome- waist is larger than hips- increases coronary artery disease

During an exam the nurse notices the client has round, flat red lesions on the skin of the forearm. The nurse suspects: a. Petechiae b. Pruritis c. Herpes zoster d. Psoriasis

a. Petechiae (tiny pinpricks, not raised, discrete (by themselves), show type of blood problem, or liver problem, b. Pruritis-itching- wheel c. Herpes zoster-shingles- vesicle d. Psoriasis-dry patches of skin

When assessing tactile fremitus, the nurse recalls that it is normal to feel tactile fremitus most intensely over which location? a. Third intercostal space b. Over the lobes posterior c. Between the scapulae d. Fifth intercostal space

a. Third intercostal space- closer we are to source of voice- tactile fremitus will be stronger- how much is not important- it goes down as it goes away from sound important when it is asymmetrical

Which of the following may be auscultated during the abdominal assessment? Select all that apply a. Vascular Sounds b. Pulsations below the xiphoid c. Referred pain d. Bowel Sounds

a. Vascular Sounds d. Bowel Sounds

A client's reason for seeking care is "shortness of breath". When obtaining a health history, which of these questions, by the nurse, would obtain the most helpful information? a. Will you please describe the activities that cause you to be short of breath? b. Have you been short of breath for long? c. Hon, are you short of breath now? d. Do you have interstitial pneumonia?

a. Will you please describe the activities that cause you to be short of breath? -open ended question b- is a close ended question

What part of the neuro assessment includes the following? Explain each: Vibration

activate tuning fork- bony prom and when they cannot feel anymore

Give the definitions for the following speech disorders and patterns: Dysarthria

articulation of speech- slurred speech

A mother is at the clinic with her 2-year-old son and states "he won't go to sleep at night & during the day he has several fits. I get so upset when this happens." The nurse's best verbal response should be: a. "Go on, I'm listening b. "Tell me what you mean by fits." c. "Yes, it can be upsetting when a child has a fit." d. "Don't be upset when he has a fit, all 2-year-olds have fits

b. "Tell me what you mean by fits." - it is open ended- and encourages her to explain more- also clarification to describe what she means by fits -clarify before asking more about something

Which of the following is a normal finding in the abdominal assessment? a. The presence of a bruit b. A tympanic percussion tone c. A palpable spleen d. A resonant percussion tone

b. A tympanic percussion tone

During the initial interview a female client reports a lesion on the perineum. Inspection reveals a small painful blister. The RN is aware that the most likely source of the lesion is: a. Syphilis b. Herpes c. Gonorrhea d. HPV

b. Herpes

What should the nurse include when educating a male client about testicular self exam (TSE)? a. Perform TSE prior to taking a shower b. If you note an enlarged testicle or lump, notify your healthcare provider c. The testicle should feel lumpy d. Perform TSE weekly

b. If you note an enlarged testicle or lump, notify your healthcare provider

A mother presents with her son, who has been in a new day care facility. On examination the nurse assesses moist, thin vesicles with an erythematous base around the nose and mouth. The nurse suspects: a. Eczema b. Impetigo c. Herpes zoster d. Dermatitis

b. Impetigo- aka school sores, highly contagious skin infection that causes red sores on the face- vesicle that is common in children- vesicle with honey colored fluid- itchy- bacterial herpes zoster- vesicle- along nerve lines- unilateral- painful- vesicle with clear fluid- viral dermatitis- rash eczema- dry patches

During percussion, the nurse knows that a resonant percussion tone over a lung lobe most likely results from: a. Shallow breathing b. Normal lung tissue c. Decreased adipose tissue d. Increased density of lung tissue

b. Normal lung tissue

An example of objective data obtained during the physical assessment includes: Select all that apply a.Sore throat b.Audible wheeze c.Headache d.Tinnitus e.Pressure ulcer rt. ankle

b. audible wheeze e. Pressure ulcer rt. ankle

The nurse has just recorded, guarding of the abdomen, positive Blumberg & Psoas signs in a client. The nurse suspects: a. Perforated spleen b. Enlarged gallbladder c. Hepatitis d. Appendicitis

blumberg- rebound tenderness- away from painful area- pain is positive sign- reliable sign of peritoneal inflammation- appendicitis psoas- aka cope's psoas test or obraztsoca's sign. indicates irritation to the iliopsoas group of hip flexors in abdomen, indicates inflammed appendix Answer- d. Appendicitis

When assessing a female client's LOC & orientation, the RN notes that she is alert, knows her name, where she is and the time of day. The client is able to explain why she is in the hospital. How should the RN document these assessment findings? a. A&O X3 b. Altered LOC c. A&O X4 d. A&O X2

c. A&O X4

On inspection of a client's foot, the nurse notes a 3 cm round ulcer on the Lt. great toe with a pale base, well-defined edges and no drainage. The nurse knows this could be a/an : a. Varicosity b. Venous stasis ulcer c. Arterial ulcer d. Pitting edema

c. Arterial ulcer- try and distal- pale because they don't have blood supply- do not have drainage

The nurse assesses a positive Murphy's sign in the client brought to the unit from the ED. The nurse continues with the assessment and begins the POC, which would most likely include: a. A report to the healthcare provider regarding the diagnosis of appendicitis b. Expecting that this client will be placed on a general diet c. Expecting that this client will be NPO for upcoming surgery to remove the gallbladder (cholecystectomy) d. Measuring of the abdominal girth for ascites

c. Expecting that this client will be NPO for upcoming surgery to remove the gallbladder

A client with a long history of COPD is being assessed. The nurse would be likely to inspect (Select all that apply): a. Asymmetric respiratory expansion b. Decreased tactile fremitus c. Hypertrophied neck muscles d. Anterior/posterior-to transverse diameter of 1:1 e. Tripod positioning

c. Hypertrophied neck muscles d. Anterior/posterior-to transverse diameter of 1:1 e. Tripod positioning COPD- do have decreased tactile fremitus Asymmetric respiratory expansion - tumor- or tumor, would make expansion less on one side normal is 1:2 goes to 1:1

The nurse notes documentation that a client's peripheral pulses are 2+. The nurse determines that the pulses are: a. Bounding b. Absent c. Normal d. Weak

c. Normal 0, absent 1, weak 2, normal 3, increased, full, bounding

An adult client with a history of allergies comes to the clinic with c/o wheezing and dyspnea. The assessment reveals nasal flaring, use of accessory muscles and tachypnea. This description is consistent with? a. Atelectasis b. Lobar pneumonia c. Asthma d. CHF

c. correct- Asthma (person's airway becomes inflamed, narrow, and swell, produce extra mucous, difficult to breathe)- not pneumonia because key term is history of allergies- - atelectasis ( complete or partial collapse of a lung or a section (lobe) of a lung s/s- fever, low spo2, shallow breathing, SOB, coughing - lobar pneumonia ( s/s- high fever, SOB, increased breathing rate, worsening cough( discolored or bloody), sharp chest pains -CHF (s/s- SOB, fatigue, swollen legs, rapid heart rate)

Explain the Allen Test

check for collateral circulation in hand can get circulation from ular artery or radial arter pump hand- block both arteries- becomes pale- let go of one artery- pinks up- block both again- let go of other artery- pinks up

What part of the neuro assessment includes the following? Explain each: Position

close eyes- have their finger, move it up down, side to side, ask which body part you are holding and which direction you are moving it

how do you fix arterial blockage

cold, pale, blue, no pulse it is surgical- have to go in and remove it sometimes there is medication that could be used to increase circulation- but mostly surgical

A client recovering from an open reduction of the humerus states, "I haven't been able to extend the fingers on my hand since this morning." What action should the RN take next? a. Massage the fingers b. Administer prescribed analgesics c. Elevate the arm to prevent edema d. Assess CMS with the 5 P's

d. Assess CMS with the 5 P's pain pallor paresthesia paralysis p- cold

When auscultating bowel sounds, the nurse knows: a. It is normal to inspect pulsations in thin clients b. Palpation should precede auscultation c. The bell of the stethoscope should be used d. Bowel sounds are not constant & it may take several minutes

d. Bowel sounds are not constant & it may take several minutes a. is normal but not when auscultating b. palp does not preceed aulsc c. use diaphragm

A 65-year-old man with emphysema has come to the clinic for a follow-up appt. On assessment of his skin, the nurse might expect to assess the following: a. Jaundice b. Senile angiomas c. Herpes zoster d. Clubbing of the nails

d. Clubbing of the nails may also see barrel chest, tripod positioning, use of accessory muscles, hypertrophy neck muscles-- all normal for COPD pt.

The RN is conducting a cranial nerve assessment on a client. The patient is unable to feel the vibration of the tuning fork when the Weber test is performed. The nurse documents a deficit of which cranial nerve? a. II b. III c. VI d. VIII

d. VIII- vestibulercochlear II- optic III- ocularmotor VI- abducens look up cranial nerves

Give the definitions for the following speech disorders and patterns: Dysphonia

difficulty phonating- always hoarse

venous ulcer

drainage- most commonly found on ankle- blood cannot get back up

arterial ulcer

dry- on distal- furthest place- last place to get oxygen

Give the definitions for the following speech disorders and patterns: Broca

expressive aphasia- understand everything- when try to talk comes out wrong

Why is the Glasgow Coma Scale done? What are the areas covered on the Glasgow Coma Scale?

glasgow cola scale- how we get objective data for LOC - eye response - verbal response - motor response normal- best score- 15 abnormal- under 8 serial assessment- to see if pt. is getting better or worse

Which of the following are age-related changes found in the musculoskeletal system of the older adult: a. Decreased height b. Progressive decrease in reaction time c. Slight flexion of the hips and knees d. Decreased ROM and flexibility e. Kyphosis f. Altered gait g. Changes in the normal angle of the hip, decreased abduction h. All of the above

h. All of the above

During an exam, the nurse notes that a client's legs turn white when they are raised above the pts. head. The nurse should suspect: a. Lymphedema b. Raynaud's disease c. Chronic venous insufficiency d. Chronic arterial insufficiency

lymphedema- swelling in an arm or leg caused by a lymphatic system blockage raynaud's disease- some of the body feel numb and cool in certain circumstances.fingers, toes, ears, and top of nose commonly involved. changes in color of skin. chronic venous insufficiency- improper functioning of the vein valves in the leg, causing swelling and skin changes- pain in legs, darkening of skin, discolored thick skin, swollen blood vessels in the skin, varicose veins ANSWER- chronic arterial insufficiency- common in older patients- lower limbs- calf pain on walking, relieved by rest, change in the color of legs, shiny skin on legs

What is orthopnea? How is it measured?

orthopnea- difficulty breathing when supine. measured by- number of pillows need to achieve comfort CHF --lung failure

Give the definitions for the following speech disorders and patterns: Wernicke

receptive aphasia- cannot understand

A client states he is frequently constipated and when he has a bowel movement, he notes rectal bleeding and pain. The client asks the nurse, "Do I have hemorrhoids or is there something else wrong with me?" The nurse assesses the perianal area and suspects: a. A rectal prolapse b. A pilonidal cyst. c. Hemorrhoids. d. A rectal abscess.

rectal prolapse- rectal mucous membrane protrudes through the anus- appearing as a moist red doughnut with radiating lines. occurs following- valsalva maneuver (exhaling with nostrils and mouth, or glottis closed) , straining at stool, or exercise pilonidal cyst- hair containing cyst or sinus located at midline over coccyx or lower sacrum. opens as a dimple with hair, red halo, or palpable cyst. congenital disorder 15yo - 30yo ANSWER-hemorrhoids- painful, flabby papules due to varicose vein of hemorrhodial plexus- occurs due to- increased portal venous pressure- straining at stool, chronic constipation, pregnancy, obesity, chronic liver disease, low fiber diet rectal abscess- localized cavity of pus from infection in a pararectal space. persistent throbbing rectal pain

Accommodation

reflex action of the eye, in response to focusing on a near object, then looking at a distant object, compromising coordinated changes in vergence, lens shape, and pupil size. pupils dilate when look far, constrict object is close- will dilate and constrict based on distance

Crepitus

skeletal Crackling or grating sound caused by bones rubbing against each other lungs or resp system- subcutaneous air- leak from resp tract, air escapes into subcutaneous tissue- when you press it sounds like rice crispies

What part of the neuro assessment includes the following? Explain each: Stereognosis & graphesthesia

stereog- able to distingush object with eyes closed graph- what number is being drawn

During palpation of the anterior chest wall, the nurse palpates a coarse crackling sensation over the skin surface. The nurse suspects: a. Tactile fremitus b. Friction rub c. Crepitus d. Adventitious sounds

tactile (vocal) fremitus- palpable vibration, sound generates from larynx, can feel as vibrations. friction rub- inflammation of precordium- gives rise to a friction rub.- high pitched and scratchy- best heard at apex and left lower sternal border-- pt. with pleuritis ANSWER- crepitus- coarse crackling sensation palpable over the skin surface. occurs in subcutaneous emphysema when air escapes from the lung and enters subcu tissue adventitious sounds- these are added sounds that are not normally heard in the lungs- crackles (rales)- wheeze (rhonchi)

What part of the neuro assessment includes the following? Explain each Light touch, sharp and dull

testing sensation light touch - cotton sharp and dull- broken tongue depressor being able to distingush between pinprick

Why is it important for clients to use Incentive Spirometry?

to help get air to the base of lungs- which involves deep expansion- without deep breathing- at risk for atelectisis -- will cause pneumonia

A 67-year-old client states he recently began to have pain in his left calf when climbing 10 stairs to his apartment. The pain is relieved by sitting for about 2 minutes; then he is able to resume his activities. This client is most likely experiencing: a. Thrombophlebitis b. Arterial obstruction (claudication) c. Paresthesia d. Venous insufficiency

thrombophlebitis- blood clot in a vein causes inflammation and pain ANSWER- claudication- pain, common in legs, caused by too little blood flow usually during exercise- often indicates peripheral artery disease paresthesia- prickling/ tingling - pins and needles venous insufficiency- improper functioning of the vein valves in the leg, causing swelling and skin changes

What part of the neuro assessment includes the following? Explain each: 2 pt. discrimination

two points with paperclip most sensitive in fingertip and periphery- not as good as you move away air conduction is greater than bone conduction

On inspection of a client's leg the nurse notes an ulcer on the lateral ankle with drainage. The nurse knows this could be : a. A varicosity b. A venous stasis ulcer c. An arterial ulcer d. Pitting edema Connect the concept of immobility and venous stasis!

varicosity- varicose vein- enlarged vein, artery, or lymph vessel ANSWER- venous stasis ulcer- after acute DVT, or chronic incompetent valves in deep veins-- aching pain in calf or lower leg, worse at end of day, and prolonged standing or sitting- firm brawny edema, coarse thickened skin, brown pigment discoloration- has drainage because it is getting blood flow arterial ulcer- located on lateral surface of ankles or distal digits- open wound due to poor perfusion- failing to heal- punched out look usually round- well defined, even wound margins- between or on tips of toes, outer ankle- dry because not getting blood flow pitting edema- observable swelling of body tissues due to fluid accumulation- demonstrated by applying pressure to swollen area

A client in the ICU develops pre-renal failure following surgery. Which of the following causes should the RN suspect? a. Vascular Disease b. Urethral obstruction c. Hypovolemia d. Glomerulonephritis

vascular disease- heart condition that includes diseased vessels, structural problems, and blood clots urethral obstruction- blockage that inhibits flow of urine ANSWER- Hypovolemia- liquid portion of blood (plasma) is too low glomerulonephritis- inflammation of the tiny filters in the kidneys that remove waste from blood

Red Reflex

when using ophthalmoscope light in pt. eye (on retina), note red glow filling the person's pupil. keep sight of red reflex and move closer to eye. - refers to reddish orange reflection of light from back of the eye, observed when using ophhalmoscope