Jarvis Modules 4-6 Module 4: Abdomen, Female and Male GU & Rectum Module 5: Musculoskeletal and Neurologic and Mental Status Systems Module 6: Skin, Hair, Nails, Breasts, and Nutritional Assessment
Furuncle
"boil" - suppurative inflammatory skin lesion due to infected hair follicle
Seborrheic dermatitis
"cradle cap"
Ephelides
"freckles" - small, flat macules of brown melanin pigment that occur on sun-exposed skin
CN V = Trigeminal Abnormalities Possible Causes
*ABNORMALITIES* - Absence of touch + pain - Paresthesias - No blinking - Weakness of temporalis muscles *POSSIBLE CAUSES* - Trauma - Tumor - Pressure from aneurysm - Inflammation - Bilateral weakness from UMN + LMN disorders
Snout Reflex
*Method of Testing* - Gently percuss oral region *Abnormal* - Puckering of lips *Indications* - Frontal lobe disease - Cerebral degenerative disease (EX. Alzheimer's disease) - Amyotrophic sclerosis - Corticobulbar lesions
Babinski - Pathologic Reflexes
*Method of Testing* - Stroke bottom of foot *Abnormal* - Extension of big toe - Fanning of toes *Indicates ...* - Corticospinal tract disease (EX. stroke)
Muscles Inspect Palpate
*SIZE* - Symmetric bilaterally - Should be within the size limit per age group - Extremities looks asymmetric - Measure each side in centimeters (< 1 cm = normal) *STRENGTH* - Equal in power - Test: extremities, neck + trunk *TONE* - Normal degree of tension / contraction of voluntarily relaxed muscles *INVOLUNTARY MOVEMENTS* - Normal = NONE - If there is movement - note: location, frequency, rate + amplitude
Serum proteins
-albumin -prealbumin -transferrin -c reactive proteins
Aging adult special considerations
-changes since middle adult years -vitamind D and calcium
Pregnancy Subjective Data
-cravings -folic acid -fish
Afferent vs. Efferent Nerves: 1) _________: sensory messages to the CNS. 2) ________: Motor messages away from CNS
1) Afferent 2) Efferent
4 point grading scale for pitting edema:
1+ mild 2+ moderate 3+ deep pitting 4+ very deep pitting, very swollen
Brown-Tan
1. Addison disease- cortisol deficiency stimulates increased melanin production 2. Cafe' au lait spots- increased melanin pigment in basal cell layer
PALLOR: (etiology)
1. Anemia 2. Shock 3. Local arterial insufficiency (localized) 4. Albinism 5. Vilitigo
Shapes of Lesions: (9 total)
1. Annular 5. Grouped 9. Polycyclic 2. Confluent 6. Target 3. Discrete 7. Linear 4. Gyrate 8. Zosteriform
Primary Skin Lesions:
1. Develop on previously unaltered skin; immediate result of a causative factor
internal anatomy
1. glandular tissue, 2. fibrous tissue, including the suspensory ligaments. 3. adipose tissue
Cholesterol
120-200... Fat metabolism (cardiac risk)
ANS: rotator cuff lesions. Rotator cuff lesions may cause limited range of motion and pain and muscle spasm during abduction, whereas forward flexion stays fairly normal. The other options are not correct.
A patient is able to flex his right arm forward without difficulty or pain but is unable to abduct his arm because of pain and muscle spasms; the nurse should suspect: A) crepitation. B) rotator cuff lesions. C) dislocated shoulder. D) rheumatoid arthritis.
ANS: metacarpophalangeal The joint located just above the ring on the finger is the metacarpophalangeal joint. The interphalangeal joint is located distal to the metacarpophalangeal joint. The tarsometatarsal and tibiotalar joints are found in the foot and ankle. See Figure 22-10 for a diagram of the bones and joints of the hand and fingers.
A patient is visiting the clinic for an evaluation of a swollen, painful knuckle. The nurse notices that the knuckle above his ring on the left hand is swollen and that he is unable to remove his wedding ring. This joint is called the _____ joint. A) interphalangeal B) tarsometatarsal C) metacarpophalangeal D) tibiotalar
ANS: Crepitation Crepitation is an audible and palpable crunching or grating that accompanies movement and occurs when articular surfaces in the joints are roughened, as with rheumatoid arthritis. The other options are not correct.
A patient states, "I can hear a crunching or grating sound when I kneel." She also states that "it is very difficult to get out of bed in the morning because of stiffness and pain in my joints." The nurse should assess for signs of what problem? A) Crepitation B) A bone spur C) A loose tendon D) Fluid in the knee joint
ANS: genu valgum. Genu valgum is also known as "knock knees" and is present when there is more than 2.5 cm between the medial malleoli when the knees are together.
A patient tells the nurse that "all my life I've been called 'knock knees.'" The nurse knows that another term for "knock knees" is: A) genu varum. B) genu valgum. C) pes planus. D) metatarsus adductus.
ANS: functional scoliosis. Functional scoliosis is flexible; it is apparent with standing and disappears with forward bending. Structural scoliosis is fixed; the curvature shows both when standing and when bending forward. See Table 22-7 for description of herniated nucleus pulposus. These findings are not indicative of a dislocated hip.
A patient's annual physical examination reveals a lateral curvature of the thoracic and lumbar segments of his spine; however, this curvature disappears with forward bending. The nurse knows that this abnormality of the spine is called: A) structural scoliosis. B) functional scoliosis. C) herniated nucleus pulposus. D) dislocated hip.
To determine if a dark skinned person is pale, the nurse should assess the color of the: A. Conjunctivae B. Ear lobes C. Palms of the hands D. Skin in the antecubital space
A. Conjunctivae
The components of a nail examination include: A. Contour, consistency, and color B. Shape, surface, circulation C. Clubbing, pitting, and grooving D. Texture, toughness, and translucency
A. Contour, consistency, and color
Lyme disease is more prevalent from: A. from May through September B. along the West Coast C. in children younger than 3 years D. in those participating in water sports
A. May through September
To assess for early jaundice, you will assess: A. sclera and hard palate B. nail beds C. lips D. all visible skin surfaces
A. sclera and hard palate
Circumsision
AAP states that health benifits out weight risks, reduse risk of HIV through heterosexual contact female partners reduced risk of HPV, bacterial vaginosis, trichomoniasis, cervical cancer reduced incidence of infant uti, phimosis, paraphimosis, penile cancer adv: pain bleeding swelling need pain med
The nurse is examining a patient who tells the nurse, "I sure sweat a lot, especially on my face and feet but it doesn't have an odor." The nurse knows that this could be related to: a. the eccrine glands. b. the apocrine glands. c. a disorder of the stratum corneum. d. a disorder of the stratum germinativum.
ANS the eccrine glands. The eccrine glands are coiled tubules that open directly onto the skin surface and produce a dilute saline solution called sweat. Apocrine glands are located mainly in the axillae, anogenital area, nipples, and naval and mix with bacterial flora to produce a characteristic musky body odor. The patient's statement is not related to disorders of the stratum corneum or the stratum germinativum.
Of the 33 vertebrae in the spinal column, there are: a. 5 lumbar. b. 5 thoracic. c. 7 sacral. d. 12 cervical.
ANS: A There are 7 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 3 to 4 coccygeal vertebrae.
The nurse is assessing the abdomen of a pregnant woman who is complaining of having "acid indigestion" all the time. The nurse knows that esophageal reflux during pregnancy can cause: a. diarrhea. b. pyrosis. c. dysphagia. d. constipation.
ANS: B Pyrosis, or heartburn (not constipation), is caused by esophageal reflux during pregnancy. The other options are not correct.
carcinoma
Begins as red, raised, warty growth or as an ulcer with watery discharge. As it grows, it may necrose & slough. Usually painless. Usually on glans or inner lip of foreskin. Chronic inflammation. Enlarged lymph nodes.
Graphesthesia Test
Being able to read a number when physically traced over the hand
The capillary beds should refill after being depressed in: A. <1 second B. >2 seconds C. 1-2 seconds D. time is not significant as long as color returns
C. 1 - 2 seconds
You examine nail beds for clubbing. The normal angle between the nail base and the nails is: A. 60 degrees B. 100 degrees C. 160 degrees D. 180 degrees
C. 160 degrees
Risk factors that may lead to skin disease and breakdown include: A. Loss of protective cushioning of the dermal skin layer B. Decreased vascular fragility C. A lifetime of environmental trauma D. Increased thickness of the skin
C. A lifetime of environmental trauma
The configuration for individual lesions arranged in circles or arcs, as occurs with ringworm, is called: A. linear B. clustered C. annular D. gyrate
C. annular
The "A" in the ABCDE rule stands for: A. accuracy B. appearance C. asymmetry D. attenuated
C. asymmetry SKIN SELF EXAMINATION: A - asymmetry B - border C - color D - diameter E - elevation and enlargement
Red raised warty growth or ulceration with watery discharge. Usually painless almost on the glans or inner lip of the foreskin
Carcinoma
Neurologic Recheck in children
Changes that were made in the level of consciousness - EX. trauma 1. Level of consciousness 2. Motor function 3. Pupillary response 4. Vital signs *NOT FULLY ALERT* 1. Name called 2. Light touch on person's arm 3. Vigorous shake of shoulder 4. Pain applied (rubbing person's sternum with your knuckles)
Nail Anatomy
Cuticle Lunula Lateral nail fold Posterior nail fold Nail matrix Nail bed Nail Plate
When taking the health history, the pt. c/o pruritus. What is a common cause of this symptom? A. Excessive bruising B. Hyperpigmentation C. Melasma D. Drug reactions
D. Drug reactions
A scooped out, shallow depression in the skin is called a(n): A. Ulcer B. Excoriation C. Fissure D. Erosion
D. Erosion
Which should be included while teaching 4th graders about the sweat glands, during a hygiene lesson? A. There are two types of sweat glands: the eccrine and the sebaceous B. The evaporation of sweat, a dilute saline solution, increases body temperature. C. Eccrine glands produce sweat and are mainly located in the axillae, anogenital area, and naval D. Newborn infants do not sweat and use compensatory mechanisms to control body temperature
D. Newborn infants do not sweat and use compensatory mechanisms to control body temperature
Ulcer:
Deeper depression-> into the dermis
Male pt c/o: enlarging testis, when enlarged has feeling of increased weight
Diffuse Tumor
ANS: herniated nucleus pulposus. Lateral tilting and sciatic pain with straight leg raising are findings that occur with a herniated nucleus pulposus. The other options are not correct.
During an examination, the nurse asks a patient to bend forward from the waist and notices that the patient has lateral tilting. When his leg is raised straight up, he complains of a pain going down his buttock into his leg. The nurse suspects: A) scoliosis. B) meniscus tear. C) herniated nucleus pulposus. D) spasm of paravertebral muscles.
a painless firm nodule on an area of the testi which is found on exam
Early Testicular Tumor
Skin rashes of childhood diseases:
MEASLES (Rubeola): red / purple blotchy rash, coppery, does not blanch GERMAN MEASLES (Rubella): pink, papular rash, paler than measles CHICKEN POX (Varicella): small tight vesicles, become pustules and then crust
Common variations on infant's skin:
MONGOLIAN SPOT: blue--black to purple macular area at sacrum (sometimes: buttocks, thighs, abdomen, shoulders, arms) CAF'E AU LAIT SPOT: large round, oval, patch of light brown pigmentation ERYTHEMA TOXICUM: rash on 3-4 day old newborns. Cheeks, trunk, chest, back, butt CUTIS MARMORATA: transient mottling of skin in trunk & extremities PHYSIOLOGIC JAUNDICE: 1/2 of all newborns, yellowing of skin, sclera, mucous membranes MILIA: tiny white papules or cheeks, nose, forehead, chin, caused by sebum occluding hair follicles
________ is a bundle of fibers outside CNS
Nerve
NAVEL
Nerve Artery Vein Empty space lymphatics place right hand upright on the mans right upper thigh, locate femoral artery pulse with index finger. empty space uder fourth finger ask to bear down and palpate femoral area for a bulge, normally none
Scrotal Hernia
Nontender swelling of scrotum; pain with straining; does not transilluminate; on palpation, feels like soft, mushy mass; caused by indirect inguinal hernia; intestines protrude into scrotal sac
Hydrocele
Nontender, swelling of testis; Normal finding in boys 2 years & younger (after this age, it's abnormal); fluid in scrotum (tunica vaginalis of scrotum) appearing as large, nontender scrotum that transluminates as faint pink glow; disappears spontaneously
Seborrhea
OILY: an inflammatory skin disorder affecting the scalp, face, and torso. Typically, seborrheic dermatitis presents with scaly, flaky, itchy, and red skin. It particularly affects the sebaceous-gland-rich areas of skin. In adolescents and adults, seborrhoeic dermatitis usually presents as scalp scaling similar to dandruff or as mild to marked erythema of the nasolabial fold
Purpuric lesions
PETECHIAE: superficial capillaries, not caused by mechanical injury BRUISE: contusion, mechanical injury, hemorrhage to tissues HEMATOMA: bruise that can be felt, mechanical injury, raised, swollen
Distinguish skin lesion terms:
PRIMARY: lesion develops on previously unaltered skin SECONDARY: when a lesion changes over time, and changes because of a factor (scratching, infection)
Primary skin lesions:
PUSTULE: Circular, elevated cavity filled with fluid or pus. MACULE: color change, flat. "Freckle" PAPULE: solid, elevated. Circumscribed PLAQUE: elevated. Wider than 1cm. NODULE: solid, elevated. hard or soft. larger than 1cm. TUMOR: firm or soft. larger than a few cm. Benign or malignant. WHEAL: superficial, raised, slightly irregular due to edema. VESICLE: elevated, contains free fluid. "blister"
Plaque:
Papules coalese to form surface elevation wider than 1 cm plateau shape, disk-like Ex: psoriasis, lichen planus
Foreskin is retracted and fixed-- with tight or inflamed foreskin. ---what is the condition and do you do?
Paraphimosis
Vilitigo
Patchy depigmentation from destruction of melanocytes, which results in patchy white spots. It tends to affect darker people's confidence due to appearance.
Rapid Alternating Movements (RAM)
Patient able to rapidly alternate back of hands to palm of hands while patting the knee in between of each. Normal = equal turning + quick and rhythmic pace
Transillumination
Perform only if you note swelling or mass in scrotal sac. Darken room & shine light from behind scrotal contents. Normal contents do not transilluminate. Abnormal findings: serous fluid (e.g. hydrocele or spermatocele) does transilluminate & shows red glow. Solid tissue & blood do not illuminate (e.g. hernia, epididymitis, tumor)
The Romberg Test
Person standing at stable position - feet together Eyes closed + hold position for 20 secs Bend knee / hop in one place (each leg) Tests out the balance
Hard nontender, subcutaneous plaques which are associated with a painful bending of penis when erect.
Peyronie Disease
Five functions of the skin:
Protection Perception Identification Communication Temperature regulation Wound repair Absorption & excretion Production of Vit. D
Intense perianal itching caused by pinworm infection in children and institutionalized adults and by prolapsed hemorrhoids, anal fissures, dermatitis, chronic diarrhea, poor hygiene--etc.
Pruritus Ani
Lability
Rapid shift of emotions Ex. Person expresses euphoria, tearful, angry feelings in rapid succession
protruding growth from the rectal membrane
Rectal Polyp
Target (Iris)
Resembles iris of eye, concentric rings of color in lesions Ex: erythema muliforme
Secondary Skin Lesions (10 total)
Results from change in primary lesion or break in surface (Crust, Scale, Fissure, Erosion, Scar, Ulcer, Excoriation, scar, atrophic scar, keliod, lichenification)
Circumlocution
Round-about expression, substituting a phrase when cannot think of name of object
Difference between sebaceous, eccrine, and apocrine glands:
SEBACEOUS: Oil glands - secrete protective lipid substances. Located everywhere except palms and soles. Mostly in scalp, forehead, face & chin. ECCRINE: sweat glands - dilute saline solution. APOCRINE: sweat glands - thick, milky secretion, opens to hair follicles (axillae, anogenital area, nipple, nasal
Linear:
Scratch, steak, line, or stripe
Zosteriform:
Shingles/herpes zoster; linear arrangement along a unilateral nerve route
Not symptomatic-- only noted on inspection- testicles are small-- what is the condition and do you do?
Small Testies
Nodule:
Solid, elevated, hard or soft, larger than 1 cm.
Basal cell carcinoma
Starts as a skin-colored papule (may be deeply pigmented) with a pearly translucent top and overlying telangiectasia (broken blood vessel). Develops rounded, pearly borders with central red ulcer, or looks like a large open pore with central yellowing. This is the most common form of skin cancer. Occur on sun exposed areas of face, ears, scalp, shoulders. Grows slowly.
Scrotal Edema
Tender, enlarged, reddened taut (may be pitting) edema; unable to feel scrotal contents; accompanies edema of lower extremities that occurs with CHF, renal failure & portal vein obstruction
Male pt c/o: excruciating unilateral pain in testicle-- sudden onset, often during sleep or after trauma, may have lower abdominal pain, nausea and vomiting-- what is the condition and do you do?
Testicular torsion
ANS: talus
The ankle joint is the articulation of the tibia, the fibula, and the: A) talus. B) cuboid. C) calcaneus. D) cuneiform bones.
ANS: temporomandibular joint. The articulation of the mandible and the temporal bone is the temporomandibular joint. The other responses are not correct.
The articulation of the mandible and the temporal bone is known as the: A) intervertebral foramen. B) condyle of the mandible. C) temporomandibular joint. D) zygomatic arch of the temporal bone.
The Skin
The body's largest organ system. Acts as the sentry that protects the body from environmental stress and adapts to other environmental influences. THREE LAYERS: Epidermis - the thin, tough outer layer Dermis - the inner supportive layer Subcutaneous - the adipose tissue below the dermis
Ambivalence
The existence of opposing emotions toward an idea, object, person Ex. A person feels love and hate towards another at the same time
ANS: joints. Joints are the functional units of the musculoskeletal system because they permit the mobility needed for the activities of daily living. The skeleton (bones) is the framework of the body.
The functional units of the musculoskeletal system are the: A) joints. B) bones. C) muscles. D) tendons.
Normal Nipple
The nipples should be placed symmetrically on the same plane on the two breasts. Nipples usually protrude, although some are flat and some are inverted.
ANS: start swimming to increase my weight-bearing exercise." Weight-bearing exercises include walking, low-impact aerobics, dancing, or stationary cycling. Swimming is not considered a weight-bearing exercise. The other responses are correct.
The nurse is teaching a class on osteoporosis prevention to a group of postmenopausal woman. A participant shows that she needs more instruction when she states, "I will: A) start swimming to increase my weight-bearing exercise." B) try to stop smoking as soon as possible." C) check with my doctor about taking calcium supplements." D) get a bone-density test soon."
ANS: circumduction. Circumduction is defined as moving the arm in a circle around the shoulder.
The nurse notices that a woman in an exercise class is unable to jump rope. The nurse knows that to jump rope, one's shoulder has to be capable of: A) inversion. B) supination. C) protraction. D) circumduction.
Nipple Retraction
The retracted nipple looks flatter and broader, like an underlying crater. A recent retraction suggests cancer, which causes fibrosis of the whole duct system and pulls in the nipple. It also may occur with benign lesions such as ectasia of the ducts.
Senile purpura
The vascular fragility increases in the aging adult, where a minor trauma may produce dark red discolored areas on the skin
fungal infection of the crural fold not extending to the scrotum, pospunertal males (jock itch)
Tinea Cruris
ANS: anterior to the tragus The temporomandibular joint can be felt in the depression anterior to the tragus of the ear. The other locations are not correct.
To palpate the temporomandibular joint, the nurse's fingers should be placed in the depression _____ of the ear. A) distal to the helix B) proximal to the helix C) anterior to the tragus D) posterior to the tragus
Pustule:
Turbid fluid (pus) in the cavity; elevated and circumscribed Ex: impetigo, acne
Cranial Nerve II --> Optic Nerve (eyes) Normal Abnormal
Using the confrontation test (covering one eye with ophthalmoscope) *NORMAL* - Color - Size - Shape *ABNORMAL* - Visual field loss - Papilledema (w/ Increased ICP) - Optic atrophy
Mastication and sensation of face, scalp, and cornea
V: Trigeminal
Two types of human hair:
VELLUS HAIR: fine, faint, covers most of the body except - palms, soles, dorsa of distal parts of fingers, umbilicus, glans penis, inner labia. TERMINAL HAIR: darker, thicker hair on scalp, eyebrows, axillae, pubic area, and face and chest in a male
Facial expression, tasting anterior two thirds of tongue, closing eyes
VII: Facial
nerve for hearing and equilibrium
VIII: Acoustic
ANS: 5 Complete range of motion against gravity is normal muscle strength and is recorded as Grade 5 muscle strength.
When assessing muscle strength, the nurse observes that a patient has complete range of motion against gravity with full resistance. What Grade should the nurse record using a 0 to 5 point scale? A) 2 B) 3 C) 4 D) 5
ANS: proximal to distal. The musculoskeletal assessment should be done in an orderly approach, head to toe, proximal to distal, from the midline outward. The other options are not correct.
When performing a musculoskeletal assessment, the nurse knows that the correct approach for the examination should be: A) proximal to distal. B) distal to proximal. C) posterior to anterior. D) anterior to posterior.
ANS: bone marrow. The musculoskeletal system functions to encase and protect inner vital organs, support the body, produce red blood cells in the bone marrow, and store minerals.
When reviewing the musculoskeletal system, the nurse recalls that hematopoiesis takes place in the: A) liver. B) spleen. C) kidneys. D) bone marrow.
Cranial Nerve VIII --> Acoustic (Vestibulocochlear) Nerve Normal Abnormal
Whisper Voice Test *NORMAL* - Patient able to repeat it back - Symmetry *ABNORMAL* - Patient not able to repeat it back - Asymmetry
frenulum
a fold of the foreskin extending from the urethral meatus ventrally
inguinal canal
a narrow tunnel passing obliquely between layers of abdominal muscle its openings are an internal ring located 1-2cm above the midpoint of the inguinal ligament
Specific phobia
a pattern of debilitating fear when faced with a particular object or situation
breast abscess
a rare complication of generalized infection if untreated, a pocket of puss that feels hard, looks red, and is quite tender accumulates in one local area,
herpes genitalis
a sexually transmitted infection characterized by clusters of small painful vesicles, caused by a virus
breast bud stage
a small mound of breast and nipple develops; the areola widens
graphesthesia
ability to read a number by having it traced on skin
stergnosis
ability to recognize objects by touch
Spermatocele
abnormal, fluid-filled sac in the epididymis; painless, usually found on examination; does transilluminate higher in scrotum than hydrocele & sperm may fluoresce; on palpation, you feel round, freely moveable mass lying above & behind testis; if large, it feels like an extra testis; usually small (<1cm)
Excoriation:
abrasion, scratch,
Pallor
absence of red-pink tones from the oxygenated hemoglobin in blood, excessively pale, whitish pink color to lightly pigmented skin
Optimal nutrition status
achieved when sufficient nutrients are consumed to support day to day body needs and any increased metabolic demands due to growth, pregnancy, or illness
Femoral Hernia
acquired due to increased abdominal pressure, muscle weakness, frequent stooping; hernia protrudes through femoral ring & below inguinal ligament; more often on right side; pain may be severe & may become strangulated; least common; occurs in women
Direct Inguinal Hernia
acquired weakness brought on by heavy lifting, muscle atrophy, obesity, chronic cough, ascities; hernia protrudes through *external* inguinal ring above inguinal ligament & *rarely enters scrotum*; usually *painless*; round swelling; less common; but occurs in men > 40
Delirium
acute confusional state, potentially preventable in hospitalized persons
orchitis
acute inflammation of testis, usually associated with mumps
________ is the loss of ability to recognize importance of sensory impressions
agnosia
_______ is the loss of ability to express thoughts in writing
agraphia
Subcutaneous layer
aids protection by cushioning. Adipose tissue.
lateral axillary nodes
along the humerus, inside the upper arm
lactiferous sinus
ampullae, the ducts form behind the nipple, which are reservoirs for storing milk
Chloasma
an irregular brown patch of hyperpigmentation on the face that may occur with pregnancy
deviation in nipple pointing
an underlying cancer causes fibrosis in the mammary ducts, which pulls the nipple angle toward it
_______ is a loss of pain sensation
analgesia
pectoral nodes
anterior - along the lateral edge of the pectoralis major muscle, just inside the anterior axillary fold
_________ is a loss of power of expression by speech, writing, or signs or loss of comprehensions of spoken or written language
aphasia
_________ is a loss of ability to perform purposeful movements in the absence of sensory or motor damage (inability to use objects correctly)
apraxia
teaching BSE
assist patient to establish a schedule, regular monthly exams, majority of women never get breast cancer, majority of lumps are benign, early detection is important, in non-invasive cancer survival is close to 100%
Saturated and Unsaturated
associated with cancer
_________ is a bizarre, slow, twisting, writhing movement, resembling a snake or worm
athetosis
Eczema
atopic dermatitis
a reflex action in which the big toe remains extended or extends itself when the sole of the foot is stimulated, abnormal except in young infants
babinski reflex
Alopecia
baldness - hair loss
Epidermis layer
basal cell layer. Uniformly thin. Stratum corneum. The thin, tough, outer layer of the skin
menarche
beginning of menstruation, occurs in breast development stage 3 or 4 usually just after the peak of the adolescent growth spurt around 12 years of age
Syphilitic chancre
begins within 2-4 weeks of infection, as a small solitary, silvery papule that erodes to a red, round or oval, superficial ulcer with a yellowish serous discharge. palpation reveals a nontender, indurated base that can be lifted like a button. lymph nodes enlarge early but are nontender. this is an STI easily treated with penicillin G but untreated cases lead to cardiac and neurologic problems, blindness
fibroadenoma
benign breast mass, most commonly present as self-detected in late adolescence, solitary nontender mass that is solid, firm, rubbery, and elastic, round, oval, or lobulated. 1-5 cm, freely movable, slippery; fingers slide it easily through tissue, usually no axillary lymphadenopathy, diagnose by triple test (palpation, ultrasound, and needle biopsy)
Lipoma
benign fatty tumor
Anasarca
bilateral edema, or edema that is generalized over the whole body
Chronic kidney disease determined by
blood test urinalysis imaging studies show dec. kidney function lasting 3 months or longer
Red urine
blood, nephritis, cystitis, cancer, following prostate surgery
carcinoma
bloody nipple discharge that is unilateral and from a single duct, requires further investigation
Acrocyanosis
bluish color around the lips, hands, fingernails, feet, and toenails
Cyanosis
bluish, dusky blue, mottled color to skin or mucous membranes, that signifies decreased perfusion - increased amount of unoxygenated hemoglobin. Dark skinned normally have bluish lips.
Infants
breastfeeding 1st year unless HIV positive... whole milk till 2
inspect inguinal region for
bulge as person stands and strains down normally none
Infants double weight
by 4th month, triple by 1 year
Test nerve 1 how?
by occluding one nostril at a time and identity smell
How to assess extraocular eye movement?
cardinal fields of gaze
lymphatics
central axillary nodes, pectoral, subscapular, lateral
________ is the part of brain associated with coordination of voluntary movements, equilibrium, and muscle tone
cerebellum
_________ is a sudden rapid jerky purposeless movement involving limbs, trunk, or face
chorea
Dementia
chronic progressive loss of cognitive and intellectual functions, although perception and consciousness are still intact
Annular:
circular, begin in center and spreads to periphery (ring worm)
Mid upper arm
circumference
lobules
clusters of alveoli that produce milk empties into a lactiferous duct 15 to 20 lobes
Genital herpes (HSV-2 infection)
clusters of vesicles with erythema that are painful & erupt on glans, foreskin, anus --> superficial ulcers; may have mild tingling before outbreak or shooting pain to butt or legs; initial outbreak treated with acyclovir; virus remains dormant indefinitely with recurrent infections
Neologism
coining a new word, invented word has no real meaning except for the person; may condense several words
spermatic cord
colleciton of vas deferens, blood vessels, lymphatics, and nerves that ascends along the testis and through the inguinal canal into the abdomen
_________ is a state of profound unconsciousness from which person cannot be aroused
coma
plugged duct
common when milk is not remobed completely because of poor latching, ineffective suckling, infrequent nursing, or switching to second breast too soon, tender lump that may be reddedned and warm to touch, no infection, keep breast as empty as possible and milk flowing
Scale
compact desiccated flakes of skin from shedding of dead skin cells
penis
composed of three cylindric columns of erectile tissue, the two corpora cavernosa on the dorsal side and the corpus spongiosum ventrally
urethra
conduit for both the genital and the urinary systems, it transverses the corpus spongiosum, and its meatus forms a slit at the glans tip
epispadias
congenital defect in which the urethra opens on the dorsal (upper) side of penis instead of at the tip
hypospadias
congenital defect in which urethra opens on the ventral (under) side of penis rather than at the tip
Indirect Inguinal Hernia
congenital or acquired A hernia that protrudes into *internal* inguinal ring & *can remain in canal or pass into scrotum*. *Pain with straining*, soft swelling that increases with increased abdominal pressure. Most common hernia. This condition usually is due to a congenital defect in the abdominal wall.
Prostate
continues to grow whole life gradual enlargement expected BPH
cremaster muscle
controls the size of the scrotum by responding to ambient temperature the best temperature for producing sperm, when it is cold the muscle contracts raising the sac and bringing the testes closer to the body to absorb heat neccessary for sperm viability, scrotal skin looks corrugated, when it is warmer, the muscle relaxes the scrotum lowers and the skin looks smoother
lactiferous
conveying milk
Rapid alternating movements: pat knees with hand, turn over and do same. Touch thumb to each finger then reverse order: This tests what?
coordination and skilled movement, cerebellum function
hydrocele
cystic fluid in tunica vaginalis surrounding the testis
areola
darkened area surrounding nipple, 1-2cm radius
GFR dec by half, serum cr doubles
dec in kidney function
_________ includes arms adducted, flexed, wrists & fingers flexed, legs extended, internally rotated, plantar flexed (spinal injury?)
decorticate rigidity
The aging adult
decreasing energy requirements
Amber urine
dehydration, laxatives, B vitamins
Atrophic Scar
depressed, divet in the area
Antopometric measures
derived weight measures
Divisions of the body that each nerve from spinal cord works with
dermatomes
varicocele
dilated tortuous varicose veins in the spermatic cord
intraductal palilloma
discrete benign tumors that arise in a single or multiple papillary duct, may have serous or serosanguineous discharge, often there is a palapble nodule in underlying duct, most common in women ages 40-60 most are benign, although multiple papilomas have a higher risk of subsequent cancer than do solitary ones requires core needle biopsy and possible excision
lump nipple
displaced, retracted, dimpled
light headedness, faint
dizziness
vas deferens
duct carrying sperm from the epididymis through the abdomen and then into the urethra
_______ is imperfect articulation of speech due to problems of muscular control resulting from central or peripheral nervous system damage
dysarthria
premature thelarche
early breast development with no other hormone dependent signs (pubic hair, menses)
circumcision
elective surgical procedure to remove all or part of the prepuce from the penis, medical benifits: reduced risk of acquiring HIV infection through heterosexual contact
Bulla
elevated cavity containing free fluid larger than 1cm diameter
Pustule
elevated cavity containing thick, turbid fluid
glans
erectile tissue at the distal end of the shaft where the corpus spongiosum expands
male breast
examination can be abbreviated by not omitted, inspect the chest wall noting skin surface and any lumps or swelling, palpate nipple area for lumps or enlargement, normal male breast has a flat disc of undeveloped breast tissue beneath the nipple should be even with no nodules
pale yellow urine
excess fluids; hepatitis, cirrhosis
gynecomastia
excessive breast development in the male
Brocas aphasia
expressive aphasia
difficulty producing language
expressive aphasia
tail of Spence
extension of breast tissue into the axilla, cone shaped, close to the pectoral group of axillary lymph nodes, SITE OF MOST TUMORS
_________ is the disappearance of conditioned response
extinction
Confabulation
fabricated events to fill in memory gaps
_________ is a rapid continuous twitching of resting muscle without movement of limb
fasciculation
breast milk
fat calories and essential fatty acids are required for CNS development
A complete colon blockage which results from decreased bowel motility
fecal impaction
Delusions
firm, fixed, false beliefs; irrational; person clings to delusion despite objective evidence to contrary
puberty
first sign is enlargement of the testes, next pubic hair appears then penis size increases
________ is a loss of muscle tone, limp
flaccidity
Scale
flakes of skin, dry skin
Macule
flat skin lesion with only a color change - freckles
bimanual breast palpation
for pendulous breasts, patient sitting, leaning forward, support inferior part of breast with one hand, use other hand to palpate breast tissue against supporting hand
phimosis
foreskin is advanced and tightly fixed over the glans penis
Paraphimosis
foreskin is retracted and fixed, so it cannot be returned to original position --> constriction impedes circulation & glans swells; medical emergency
paraphimosis
foreskin retracted and fixed behind the glans penis
lactiferous ducts
form a collecting duct system converging toward the nipple
Obesity
greater than 120% ideal body weight
Peyronie Disease
hard, nontender, subcutaneous plaques palpated on dorsal or lateral surface of penis. Single or multiple & asymmetric. Associated with painful bending of penis during erection. Occurs after 45 years of age.
Each vitamin
has a special function
Pediculosis capitis
head lice
Total lymphocyte count
immune function 1800-3000
Epidermal appendages
include hair, sebaceous (oil) glands, sweat glands, and nails
Adolescence
increased need for calories and protein... need snacks due to rapid physical growth and endocrine changes
Linea nigra
increased pigment along the midline of the abdomen - seen with pregnant women.
cystitis
inflammation of the urinary bladder
objective data
inspection: patient sitting, disrobed to waist, note symmetry, size and shape, skin normally smooth and even in color, observe the axillary and supra clavicular areas for any bulging discoloration or edema, nipples symmetrical, flat, inverted, discharge, bleeding
Erythema
intense redness of the skin due to excess blood in the dilated superficial capillaries, as in fever or inflammation. Dark skinned can not see erythema, so must palpate skin for warmth, edema, hardening
Lichenifcation
intense scratching -> thickens the skin-> looks like lichen moss
paget disease
intraductal carcinoma in the breast, early lesion has unilateral, clear, yellow discharge and dry, scalling crusts, friable at nipple apex, spreads outward to areola with erythematous halo on areola and crusted eczematous, retracted nipple. later lesion shows nipple reddened, excoriated, and ulcerated with bloody discharge and an erythematous plaque surrounding the nipple symptoms include tingling, burning, itching, except for the redness and occasional crackling from initial breastfeeding and dermatitis of the nipple area must be explored carefully and referred immediately
__________ is the rapid sudden jerk of a muscle
myoclonus
True Cryptorchidism
never descended testis; congenital
inverted
nipples that are depressed or invaginated
Phimosis
nonretractable foreskin forming pointy tip with tiny hole. foreskin is advanced and too tight to retract. congenital or acquired from adhesions secondary to infeciton.
peyronie disease
nontender hard plaques on the surface of penis, associated with painful bending of penis during erection
__________ is the stiffness in cervical neck area
nuchal rigidity
__________ is back & forth oscillation of the eyes
nystagmus
17%
of children are over nutrition
shape
oval, round, lobulated or indistinct
lymph drainage flow
pectoral, subscapular, and lateral drain into central axillary nodes which drains into the infraclavicular and supraclavicular nodes
Body weight as
percent of ideal body weight
Social anxiety disorder (social phobia)
persistent and irrational fear of speaking or performing in public
subscapular nodes
posterior - along the lateral edge of the scapula, deep in the posterior axillary fold
inguinal ligament
poupart ligament,
testis
produce sperm, has a solid oval shape, which is compressed laterally and measures 4 - 5cm long, is suspended vertically by the spermatic cord, left testis is lower than the right because the left spermatic cord is longer, each testis is covered by a double-layered membrane, the tunica vaginalis, which separates it from the scrotal wall the two layers are lubricated by fluid so the testis can slide a little within the scrotum, this helps prevent injury
Fat has role in
production of hormones
Diaphoresis
profuse perspiration
Wernickes aphasia
receptive aphasia, can speak and hear but can't understand meaning of words
Montgomery glands
sebaceous glands in the areola that secrete protective lipid during lactation; also called tubercles of Montgomery
Prealbumin
shorter half life, measures more sudden loss of protein 15-20
Foreskin of uncircumcised infant
should not be retracted 1st 3 months as it's normally tight; retraction increases risk of tearing adhesions attaching foreskin to shaft; adhesions normally resolve by 3-4 months
corona
shoulder where the glans joins the shaft
Hemangioma
skin lesion due to benign proliferation of blood vessels in the dermis
Telangiectasia
skin lesion due to permanently enlarged and dilated blood vessels that are visible
Plaque
skin lesion in which papules coalesce or come together
Confluent
skin lesions that run together
Ulcer
sloughing of necrotic inflammatory tissue that causes a deep depression in skin, extending into dermis
small testis
small & soft (<3.5cm) indicates atrophy with cirrhosis or hypopituitarism or sequelae of orchitis
Papule
solid, elevated, circumscribed skin lesion, palpable, <1 cm diameter
Striae gravidarum
stretch marks. May develop in the skin of the abdomen, breasts, thighs, upper arms
Carotenemia
yellow-orange color in light-skinned persons from large amounts of foods containing carotene
A 43-year-old woman is at the clinic for a routine examination. She reports that she has had a breast lump in her right breast for years. Recently, it has begun to change in consistency and is becoming harder. She reports that 5 years ago her physician evaluated the lump and determined that it "was nothing to worry about." The examination validates the presence of a mass in the right upper outer quadrant at 1 o'clock, approximately 5 cm from the nipple. It is firm, mobile, nontender, with borders that are not well defined. The nurse's recommendation to her is: a. "Because of the change in consistency of the lump, it should be further evaluated by a physician." b. "The changes could be related to your menstrual cycles. Keep track of the changes in the mass each month." c. "The lump is probably nothing to worry about because it has been present for years and was determined to be noncancerous 5 years ago." d. "Because you are experiencing no pain and the size has not changed, you should continue to monitor the lump and return to the clinic in 3 months."
ANS: "Because of the change in consistency of the lump, it should be further evaluated by a physician." A lump that has been present for years and is not exhibiting changes may not be serious but still should be explored. Any recent change or new lump should be evaluated. The other responses are not correct.
During an interview, a patient reveals that she is pregnant. She states that she is not sure whether she will breastfeed her baby and asks for some information about this. Which of these statements by the nurse is accurate with regard to breastfeeding? a. "Breastfed babies tend to be more colicky." b. "Breastfeeding provides the perfect food and antibodies for your baby." c. "Breastfed babies eat more often than infants on formula." d. "Breastfeeding is second nature, and every woman can do it."
ANS: "Breastfeeding provides the perfect food and antibodies for your baby." Exclusively breastfeeding for 6 months provides the perfect food and antibodies for the baby, decreases the risk of ear infections, promotes bonding, and provides relaxation.
A 9-year-old girl is in the clinic for a sports physical. After some initial shyness she finally asks, "Am I normal? I don't seem to need a bra yet, but I have some friends who do. What if I never get breasts?" The nurse's best response would be: a. "Don't worry, you still have plenty of time to develop." b. "I know just how you feel, I was a late bloomer myself. Just be patient, and they will grow." c. "You will probably get your periods before you notice any significant growth in your breasts." d. "I understand that it is hard to feel different from your friends. Breasts usually develop between 8 and 10 years of age."
ANS: "I understand that it is hard to feel different from your friends. Breasts usually develop between 8 and 10 years of age." Adolescent breast development usually begins between 8 and 10 years of age. The nurse should not belittle the girl's feelings by using statements like "don't worry" or by sharing personal experiences. The beginning of breast development precedes menarche by about 2 years.
During a breast health interview, a patient states that she has noticed pain in her left breast. The nurse's most appropriate response to this would be: a. "Don't worry about the pain; breast cancer is not painful." b. "I would like some more information about the pain in your left breast." c. "Oh, I had pain like that after my son was born; it turned out to be a blocked milk duct." d. "Breast pain is almost always the result of benign breast disease."
ANS: "I would like some more information about the pain in your left breast." Breast pain occurs with trauma, inflammation, infection, or benign breast disease. The nurse will need to gather more information about the patient's pain rather than make statements that ignore the patient's concerns.
The nurse is teaching a pregnant woman about breast milk. Which statement by the nurse is correct? a. "Your breast milk is immediately present after the delivery of your baby." b. "Breast milk is rich in protein and sugars (lactose) but has very little fat." c. "The colostrum, which is present right after birth, does not contain the same nutrients as breast milk." d. "You may notice a thick, yellow fluid expressed from your breasts as early as the fourth month of pregnancy."
ANS: "You may notice a thick, yellow fluid expressed from your breasts as early as the fourth month of pregnancy." After the fourth month, colostrum may be expressed. This thick yellow fluid is the precursor of milk, and it contains the same amount of protein and lactose but practically no fat. The breasts produce colostrum for the first few days after delivery. It is rich with antibodies that protect the newborn against infection, so breastfeeding is important.
Which of these clinical situations would the nurse consider to be outside normal limits? a. A patient has had one pregnancy and states that she believes she may be entering menopause. Her breast examination reveals breasts that are soft and slightly sagging. b. A patient has never been pregnant. Her breast examination reveals large pendulous breasts that have a firm, transverse ridge along the lower quadrant in both breasts. c. A patient has never been pregnant and reports that she should begin her period tomorrow. Her breast examination reveals breast tissue that is nodular and somewhat engorged. She states that the examination was slightly painful. d. A patient has had two pregnancies, and she breastfed both of her children. Her youngest child is now 10 years old. Her breast examination reveals breast tissue that is somewhat soft, and she has a small amount of thick yellow discharge from both nipples.
ANS: A patient has had two pregnancies and she breastfed both of her children. Her youngest child is now 10 years old. Her breast examination reveals breast tissue that is somewhat soft and she has a small amount of thick yellow discharge from both nipples. In nulliparous women, normal breast tissue feels firm, smooth, and elastic; after pregnancy, the tissue feels softer and looser. If any discharge appears, the nurse should note its color and consistency. Except in pregnancy and lactation, discharge is abnormal. Premenstrual engorgement is normal, and consists of a slight enlargement, tenderness to palpation, and a generalized nodularity. A firm, transverse ridge of compressed tissue in the lower quadrants, known as the inframammary ridge, is especially noticeable in large breasts.
The nurse notices that a school-aged child has *bluish-white, red-based spots in her mouth that are elevated about 1 mm to 3 mm.* What other signs would the nurse expect to find in this patient? a. A pink, papular rash on the face and neck b. Pruritic vesicles over her trunk and neck c. Hyperpigmentation on the chest, abdomen, and the back of the arms d. A red-purple, maculopapular, blotchy rash behind the ears and on the face
ANS: A red-purple, maculopapular, blotchy rash behind the ears and on the face With measles (rubeola), the examiner would assess a red-purple, blotchy rash on the third or fourth day of illness that appears first behind the ears and spreads over the face and then over the neck, trunk, arms and legs. It looks coppery and does not blanch. The bluish-white, red-based spots in the mouth are known as Koplik's spots.
The nurse is preparing for a class in early detection of breast cancer. Which statement is true with regard to breast cancer in African-American women in the United States? a. Breast cancer is not a threat to black women. b. Black women have a lower incidence of regional or distant breast cancer than white women. c. Black women are more likely to die of breast cancer at any age. d. Breast cancer incidence in black women is higher than that of white women after age 45.
ANS: African-American women are more likely to die of breast cancer at any age. African-American women have a higher incidence of breast cancer before age 45 years than white women, and are more likely to die of their disease. In addition, African-American women are significantly more likely to be diagnosed with regional or distant breast cancer than are white women. This racial difference in mortality rates may be related to insufficient use of screening measures and lack of access to health care.
A 65-year-old patient remarks that she just can't believe that her breasts sag so much. She states it must be from lack of exercise. What explanation should the nurse offer her? a. Only women with large breasts experience sagging. b. Sagging is usually due to decreased muscle mass within the breast. c. A diet that is high in protein will help maintain muscle mass, which keeps the breasts from sagging. d. The glandular and fat tissue atrophies, causing breast size and elasticity to diminish, resulting in breasts that sag.
ANS: After menopause, the glandular and fat tissue atrophies, causing breast size and elasticity to diminish, resulting in breasts that sag. After menopause, the glandular tissue atrophies and is replaced with connective tissue. The fat envelope atrophies also, beginning in the middle years and becoming marked in the eighth and ninth decades. These changes decrease breast size and elasticity, so the breasts droop and sag, looking flattened and flabby.
The nurse is bathing an 80-year-old man and notices that his skin is wrinkled, thin, lax, and dry. This finding would be related to which factor? a. Increased vascularity of the skin in the elderly b. Increased numbers of sweat and sebaceous glands in the elderly c. An increase in elastin and a decrease in subcutaneous fat in the elderly d. An increased loss of elastin and a decrease in subcutaneous fat in the elderly
ANS: An increased loss of elastin and a decrease in subcutaneous fat in the elderly An accumulation of factors place the aging person at risk for skin disease and breakdown: the thinning of the skin, the decrease in vascularity and nutrients, the loss of protective cushioning of the subcutaneous layer, a lifetime of environmental trauma to skin, the social changes of aging, the increasingly sedentary lifestyle, and the chance of immobility.
A black patient is in the intensive care unit because of impending shock after an accident. The nurse would expect to find what characteristics in this patient's skin?
ANS: Ashen, gray, or dull Pallor due to shock (decreased perfusion and vasoconstriction) in black-skinned people will cause the skin to appear ashen, gray, or dull. See Table 12-2.
During a history interview, a female patient states that she has noticed a few drops of clear discharge from her right nipple. What should the nurse do next? a. Immediately contact the physician to report the discharge. b. Ask her if she is possibly pregnant. c. Ask the patient some additional questions about the medications she is taking. d. Immediately obtain a sample for culture and sensitivity testing.
ANS: Ask her some additional questions about the medications she is taking. The use of some medications, such as oral contraceptives, phenothiazines, diuretics, digitalis, steroids, methyldopa, and calcium channel blockers, may cause clear nipple discharge. Bloody or blood-tinged discharge from the nipple, not clear, is significant, especially if a lump is also present. In the pregnant female, colostrum would be a thick, yellowish liquid, and it would be expressed after the fourth month of pregnancy.
During an examination of a 7-year-old girl, the nurse notices that the girl is showing breast budding. What should the nurse do next? a. Ask the young girl if her periods have started. b. Assess the girl's weight and body mass index (BMI). c. Ask the girl's mother at what age she started to develop breasts. d. Nothing; breast budding is a normal finding.
ANS: Assess the girl's weight and body mass index (BMI). Research has shown that girls with overweight or obese BMI levels have a higher occurrence of early onset of breast budding (before age 8 years for African-American girls and age 10 years for white girls) and early menarche.
During an annual physical exam, a 43-year-old patient states that she doesn't perform monthly breast self-examinations (BSE). She tells the nurse that she believes that mammograms "do a much better job than I ever could to find a lump." The nurse should explain to her that: a. BSEs may detect lumps that appear between mammograms. b. BSEs are unnecessary until the age of 50 years. c. She is correct—mammography is a good replacement for BSE. d. She does not need to perform BSEs as long as a physician checks her breasts annually.
ANS: BSEs may detect lumps that appear between mammograms. The monthly practice of breast self-examination, along with clinical breast examination and mammograms are complementary screening measures. Mammography can reveal cancers too small to be detected by the woman or by the most experienced examiner. However, interval lumps may become palpable between mammograms.
A 52-year-old woman has a papule on her nose that has rounded, *pearly borders and a central red ulcer*. She said she first noticed it several months ago and that it has slowly grown larger. The nurse suspects which condition? a. Acne b. Basal cell carcinoma c. Malignant melanoma d. Squamous cell carcinoma
ANS: Basal cell carcinoma Basal cell carcinoma usually starts as a skin-colored papule that develops rounded, pearly borders with a central red ulcer. It is the most common form of skin cancer, and it grows slowly. This description does not fit acne lesions. See Table 12-11 for descriptions of malignant melanoma and squamous cell carcinoma.
In performing an assessment of a woman's axillary lymph system, the nurse should assess which of these nodes? a. Central, axillary, lateral, and sternal b. Pectoral, lateral, anterior, and sternal c. Central, lateral, pectoral, and subscapular d. Lateral, pectoral, axillary, and suprascapular
ANS: Central, lateral, pectoral, and subscapular nodes The breast has extensive lymphatic drainage. Four groups of axillary nodes are present: (1) central, (2) pectoral (anterior), (3) subscapular (posterior), and (4) lateral.
A 65-year-old man with *emphysema and bronchitis* has come to the clinic for a follow-up appointment. On assessment, the nurse might expect to see which assessment finding? a. Anasarca b. Scleroderma c. Pedal erythema d. Clubbing of the nails
ANS: Clubbing of the nails Clubbing of the nails occurs with congenital cyanotic heart disease, neoplastic, and pulmonary diseases. The other responses are assessment findings not associated with pulmonary diseases.
A patient tells the nurse that he has noticed that one of his moles has started to burn and bleed. When assessing his skin, the nurse would pay special attention to the danger signs for *pigmented lesions* and would be concerned with which additional finding?
ANS: Color variation Abnormal characteristics of pigmented lesions are summarized in the mnemonic ABCD: asymmetry of pigmented lesion, border irregularity, color variation, and diameter greater than 6 mm.
An elderly woman is brought to the emergency department after being found lying on the kitchen floor 2 days, and she is *extremely dehydrated*. What would the nurse expect to see upon examination? a. Smooth mucous membranes and lips b. Dry mucous membranes and cracked lips c. Pale mucous membranes d. White patches on the mucous membranes
ANS: Dry mucous membranes and cracked lips With dehydration, mucous membranes look dry and lips look parched and cracked. The other responses are not found in dehydration.
In examining a 70-year-old male patient, the nurse notices that he has bilateral gynecomastia. Which of the following describes the nurse's best course of action? a. Recommend that he make an appointment with his physician for a mammogram. b. Ignore it. Benign breast enlargement in men is not unusual. c. Explain that this condition may be the result of hormonal changes, and recommend that he see his physician. d. Explain that gynecomastia in men is usually associated with prostate enlargement and recommend that he be thoroughly screened.
ANS: Explain that this condition may be the result of hormonal changes and recommend that he see his physician. Gynecomastia may reappear in the aging male and may be due to testosterone deficiency.
During the physical examination, the nurse notices that a female patient has an inverted left nipple. Which statement regarding this is most accurate? a. Normal nipple inversion is usually bilateral. b. Unilateral inversion of a nipple is always a serious sign. c. Whether the inversion is a recent change should be determined. d. Nipple inversion is not significant unless accompanied by an underlying palpable mass.
ANS: It should be determined whether the inversion is a recent change. The nurse should distinguish a recently retracted nipple from one that has been inverted for many years or since puberty. Normal nipple inversion may be unilateral or bilateral and usually can be pulled out (i.e., it is not fixed). Recent nipple retraction signifies acquired disease. See Table 17-3.
The nurse is assessing the skin of a patient who has AIDS and notices *multiple patch-like lesions on the temple and beard area that are faint pink in color*. The nurse recognizes these lesions as: a. measles (rubeola). b. Kaposi's sarcoma. c. angiomas. d. herpes zoster.
ANS: Kaposi's sarcoma. Kaposi's sarcoma is a vascular tumor that, in early stages, appears as multiple, patch-like, faint pink lesions over the patient's temple and beard areas. Measles is characterized by a red-purple maculopapular blotchy rash which appears on third or fourth day of illness. Rash appears first behind ears and spreads over face, then over neck, trunk, arms, and legs. Cherry (senile) angiomas are small (1 to 5 mm), smooth, slightly raised bright red dots that commonly appear on the trunk in all adults over 30 years old. Herpes zoster causes vesicles that are elevated with a cavity containing clear fluid, up to 1 cm in size.
A few days after a summer hiking trip, a 25-year-old man comes to the clinic with a rash. On examination, the nurse notes that the rash is red, macular, with a *bull's eye pattern* across his midriff and behind his knees. The nurse suspects: a. rubeola. b. Lyme disease. c. allergy to mosquito bites. d. Rocky Mountain spotted fever.
ANS: Lyme disease. Lyme disease occurs in people who spend time outdoors in May through September. The first state has the distinctive bull's eye, a red macular or papular rash that radiates from the site of the tick bite with some central clearing, 5 cm or larger, usually in the axilla, midriff, inguina, or behind the knee, with regional lymphadenopathy.
A new mother calls the clinic to report that part of her left breast is red, swollen, tender, very hot, and hard. She has a fever of 101 F. She has also had symptoms of the flu, such as chills, sweating, and feeling tired. The nurse notices that she has been breastfeeding for 1 month. From her description, what condition does the nurse suspect? a. Mastitis b. Paget disease c. Plugged milk duct d. Mammary duct ectasia
ANS: Mastitis The symptoms describe mastitis, which stems from infection or stasis caused by a plugged duct. A plugged duct does not have infection present. (See Table 17-7.) Refer to Table 17-6 for descriptions of Paget's disease and mammary duct ectasia.
The nurse is assessing for *inflammation in a dark-skinned person*. Which is the best technique? a. Assess the skin for cyanosis and swelling. b. Assess the oral mucosa for generalized erythema. c. Palpate the skin for edema and increased warmth. d. Palpate for tenderness and local areas of ecchymosis.
ANS: Palpate the skin for edema and increased warmth. Because you cannot see inflammation in dark-skinned persons, it is often necessary to palpate the skin for increased warmth, taut or tightly pulled surfaces that may be indicative of edema, and hardening of deep tissues or blood vessels.
A patient has been admitted to a hospital after the staff in the nursing home noticed a pressure ulcer in his sacral area. The nurse examines the *pressure ulcer and determines that it is a stage II ulcer*. Which of these findings are characteristic of a stage II pressure ulcer? Select all that apply. a. Intact skin appears red but not broken. b. Partial thickness skin erosion with loss of epidermis or dermis. c. Ulcer extends into the subcutaneous tissue. d. Localized redness in light skin will blanch with fingertip pressure. e. Open blister areas have a red-pink wound bed. f. Patches of eschar cover parts of the wound.
ANS: Partial thickness skin erosion with loss of epidermis or dermis., Open blister areas have a red-pink wound bed. Stage I pressure ulcers have intact skin that appears red but not broken, and localized redness in intact skin will blanche with fingertip pressure. Stage II pressure ulcers have partial thickness skin erosion with loss of epidermis or also the dermis, and open blisters have a red-pink wound bed. Stage II pressure ulcers are full thickness, extending into the subcutaneous tissue; subcutaneous fat may be seen but not muscle, bone, or tendon. Stage IV pressure ulcers involve all skin layers and extend into supporting tissue, exposing muscle, bone, and tendon. Slough (stringy matter attached to the wound bed) or eschar (black or brown necrotic tissue) may be present.
The nurse is preparing for a certification course in skin care and needs to be familiar with the various lesions that may be identified on assessment of the skin. Which of the following definitions are correct? Select all that apply. a. Petechiae: Tiny punctate hemorrhages, 1 to 3 mm, round and discrete, dark red, purple, or brown in color b. Bulla: An elevated, circumscribed lesion filled with turbid fluid (pus) c. Papule: A hypertrophic scar d. Vesicle: Also known as a friction blister e. Nodule: Solid, elevated, hard or soft, larger than 1 cm
ANS: Petechiae: Tiny punctate hemorrhages, 1 to 3 mm, round and discrete, dark red, purple, or brown in color, Vesicle: Also known as a friction blister, Nodule: Solid, elevated, hard or soft, larger than 1 cm An elevated, circumscribed lesion filled with turbid fluid (pus) is a pustule. A hypertrophic scar is a keloid. A bulla is larger than 1 cm and contains clear fluid; a papule is solid, elevated, but less than 1 cm.
A patient has been admitted for *severe psoriasis*. The nurse can expect to see what finding in the patient's fingernails? a. Splinter hemorrhages b. Paronychia c. Pitting d. Beau lines
ANS: Pitting Pitting nails are characterized by sharply defined pitting and crumbling of the nails with distal detachment, and they are associated with psoriasis. See Table 12-13 for descriptions of the other terms.
A woman has just learned that she is pregnant. What are some things the nurse should teach her about her breasts? a. She can expect her areolae to become larger and darker in color. b. Breasts may begin secreting milk after the fourth month of pregnancy. c. She should inspect her breasts for visible veins and immediately report these. d. During pregnancy, breast changes are fairly uncommon; most of the changes occur after the birth.
ANS: She can expect her areolae to become larger and darker in color. The areolae become larger and grow a darker brown as pregnancy progresses, and the tubercles become more prominent. (The brown color fades after lactation, but the areolae never return to the original color). A venous pattern is prominent over the skin surface and does not need to be reported as it is an expected finding. After the fourth month, colostrum, a thick, yellow fluid (precursor to milk) may be expressed from the breasts.
The nurse is discussing *epidermal appendages* with a newly graduated nurse. Which of these would be included in the discussion? a. Skin b. Arms c. Sweat glands d. Parotid glands
ANS: Sweat glands Epidermal appendages include hair, sebaceous glands, sweat glands, and nails.
A woman is in the family planning clinic seeking birth control information. She states that her breasts "change all month long" and that she is worried that this is unusual. What is the nurse's best response? a. Continual changes in her breasts are unusual. The breasts of nonpregnant women usually stay pretty much the same all month long. b. Breast changes in response to stress are very common and that she should assess her life for stressful events. c. Because of the changing hormones during the monthly menstrual cycle, cyclic breast changes are common. d. Breast changes normally occur only during pregnancy and that a pregnancy test is needed at this time.
ANS: Tell her that, because of the changing hormones during the monthly menstrual cycle, cyclic breast changes are common. Breasts of the nonpregnant woman change with the ebb and flow of hormones during the monthly menstrual cycle. During the 3 to 4 days before menstruation, the breasts feel full, tight, heavy, and occasionally sore. The breast volume is smallest on days 4 to 7 of the menstrual cycle.
A patient contacts the office and tells the nurse that she is worried about her 10-year-old daughter having breast cancer. She describes a unilateral enlargement of the right breast with associated tenderness. She is worried because the left breast is not enlarged. What would be the nurse's best response? a. Breast development is usually fairly symmetric and that the daughter should be examined right away. b. She should bring in her daughter right away because breast cancer is fairly common in preadolescent girls. c. Although an examination of her daughter would rule out a problem, her breast development is most likely normal. d. It is unusual for breasts that are first developing to feel tender because they haven't developed much fibrous tissue.
ANS: Tell the mother that, although an examination of her daughter would rule out a problem, it is most likely normal breast development. Occasionally one breast may grow faster than the other, producing a temporary asymmetry. This may cause some distress; reassurance is necessary. Tenderness is common also.
The nurse is conducting a class about breast self-examination (BSE). Which of these statements indicates proper BSE technique? a. The best time to perform BSE is in the middle of the menstrual cycle. b. The woman needs to perform BSE only bimonthly unless she has fibrocystic breast tissue. c. The best time to perform a BSE is 4 to 7 days after the first day of the menstrual period. d. If she suspects that she is pregnant, then the woman should not perform a BSE until her baby is born.
ANS: The best time to perform BSE is 4 to 7 days after the first day of the menstrual period. The nurse should help each woman establish a regular schedule of self-care. The best time to conduct breast self-examination is right after the menstrual period, or the fourth through seventh day of the menstrual cycle, when the breasts are the smallest and least congested. Advise the pregnant or menopausal woman who is not having menstrual periods to select a familiar date to examine her breasts each month, for example, her birth date or the day the rent is due.
A woman is leaving on a trip to Hawaii and has come in for a checkup. During the examination the nurse notices that she is diabetic and takes oral hypoglycemic agents. The patient needs to be concerned about which possible effect of her medications? a. An increased possibility of bruising b. Skin sensitivity as a result of exposure to salt water c. Lack of availability of glucose monitoring supplies d. The importance of sunscreen and avoiding direct sunlight
ANS: The importance of sunscreen and avoiding direct sunlight Drugs that may increase sunlight sensitivity and give a burn response include sulfonamides, thiazide diuretics, oral hypoglycemic agents, and tetracycline.
A newborn infant is in the clinic for a well-baby check. The nurse observes the infant for the possibility of fluid loss because of which of these factors? a. Subcutaneous fat deposits are high in the newborn. b. Sebaceous glands are overproductive in the newborn. c. The newborn's skin is more permeable than that of the adult. d. The amount of vernix caseosa rises dramatically in the newborn.
ANS: The newborn's skin is more permeable than that of the adult. The newborn's skin is thin, smooth, and elastic and is relatively more permeable than that of the adult, so the infant is at greater risk for fluid loss. The subcutaneous layer in the infant is inefficient, not thick, and the sebaceous glands are present but decrease in size and production. Vernix caseosa is not produced after birth.
During an examination of a woman, the nurse notices that her left breast is slightly larger than her right breast. Which of these statements is true about this finding? a. Breasts should always be symmetric. b. Asymmetry of breast size and shape is probably due to breastfeeding and is nothing to worry about. c. Asymmetry is not unusual, but the nurse should verify that this change is not new. d. Asymmetry of breast size and shape is very unusual and means she may have an inflammation or growth.
ANS: This finding is not unusual, but the nurse should verify that this change is not new. The nurse should notice symmetry of size and shape. It is common to have a slight asymmetry in size; often the left breast is slightly larger than the right. A sudden increase in the size of one breast signifies inflammation or new growth.
During a physical examination, a 45-year-old woman states that she has had a crusty, itchy rash on her breast for about 2 weeks. In trying to find the cause of the rash, which of these would be important for the nurse to determine? a. "Is the rash raised and red?" b. "Does it appear to be cyclic?" c. "Where did the rash first appear—on the nipple, the areola, or the surrounding skin?" d. "What was she doing when she first noticed the rash, and do her actions make it worse?"
ANS: Where did it first appear—on the nipple, the areola, or the surrounding skin? It is important for the nurse to determine where the rash first appeared. Paget's disease starts with a small crust on the nipple apex and then spreads to the areola. Eczema or other dermatitis rarely starts at nipple unless it results from breastfeeding. It usually starts on the areola or surrounding skin and then spreads to the nipple. See Table 17-6.
The nurse is assisting with a self-breast examination clinic. Which of these women reflect abnormal findings during the inspection phase of breast examination? a. Woman whose nipples are in different planes (deviated). b. Woman whose left breast is slightly larger than her right. c. Nonpregnant woman whose skin is marked with linear striae. d. Pregnant woman whose breasts have a fine blue network of veins visible under the skin.
ANS: Woman whose nipples are in different planes (deviated) The nipples should be symmetrically placed on the same plane on the two breasts. With deviation in pointing, an underlying cancer causes fibrosis in the mammary ducts, which pulls the nipple angle toward it. The other examples are normal findings. See Table 17-3.
During a breast examination on a female patient, the nurse notices that the nipple is flat, broad, and fixed. The patient states it "started doing that a few months ago." This finding suggests: a. Dimpling. b. Retracted nipple. c. Nipple inversion. d. Deviation in nipple pointing.
ANS: a retracted nipple. The retracted nipple looks flatter and broader, like an underlying crater. A recent retraction suggests cancer, which causes fibrosis of the whole duct system and pulls in the nipple. It also may occur with benign lesions such as ectasia of the ducts. The nurse should not confuse retraction with the normal long-standing type of nipple inversion, which has no broadening and is not fixed.
A father brings in his 2-month-old infant to the clinic because the infant has had diarrhea for the last 24 hours. He says that his baby has not been able to keep any formula down and that the diarrhea has been at least every 2 hours. The nurse suspects dehydration. The nurse should test skin mobility and turgor in this infant over the: a. sternum. b. forehead. c. forearms. d. abdomen.
ANS: abdomen. Test mobility and turgor over the abdomen in an infant. Poor turgor, or "tenting," indicates dehydration or malnutrition. The other areas are not appropriate sites for checking skin turgor in an infant.
The nurse is assessing for *clubbing of the fingernails* and would expect to find:
ANS: an angle of the nail base of 180 degrees or greater with a nail base that feels spongy. The normal nail is firm at its base and has an angle of 160 degrees. In clubbing, the angle straightens to 180 degrees or greater and the nail base feels spongy.
A semiconscious woman is brought to the emergency department after she was found on the floor in her kitchen. Her face, nail beds, lips, and oral *mucosa are a bright cherry-red* color. The nurse suspects that this coloring is due to: a. polycythemia. b. carbon monoxide poisoning. c. carotenemia. d. uremia.
ANS: carbon monoxide poisoning. A bright cherry-red coloring in the face, upper torso, nail beds, lips, and oral mucosa appears in cases of carbon monoxide poisoning.
A patient is especially worried about an area of *skin on her feet that has turned white*. The health care provider has told her that her condition is vitiligo. The nurse explains to her that *vitiligo* is: a. caused by an excess of melanin pigment. b. caused by an excess of apocrine glands in her feet. c. caused by the complete absence of melanin pigment. d. related to impetigo and can be treated with an ointment.
ANS: caused by the complete absence of melanin pigment. Vitiligo is the complete absence of melanin pigment in patchy areas of white or light skin on the face, neck, hands, feet, body folds, and around orifices—otherwise the depigmented skin is normal.
The nurse keeps in mind that a thorough skin assessment is very important because the skin holds information about a person's: a. support systems. b. circulatory status. c. socioeconomic status. d. psychological wellness.
ANS: circulatory status. The skin holds information about the body's circulation, nutritional status, and signs of systemic diseases as well as topical data on the integument itself.
A 70-year-old woman who loves to garden has *small, flat, brown macules* over her arms and hands. She asks, "What causes these liver spots?" The nurse tells her, "They are: a. signs of decreased hematocrit related to anemia." b. due to destruction of melanin in your skin from exposure to the sun." c. clusters of melanocytes that appear after extensive sun exposure." d. areas of hyperpigmentation related to decreased perfusion and vasoconstriction."
ANS: clusters of melanocytes that appear after extensive sun exposure." Liver spots, or senile lentigines, are clusters of melanocytes that appear on the forearms and dorsa of the hands after extensive sun exposure. The other responses are not correct.
While inspecting a patient's breasts, the nurse finds that the left breast is slightly larger than the right with the presence of Montgomery's glands bilaterally. The nurse should: a. Palpate over the Montgomery glands, checking for drainage. b. Consider these findings as normal, and proceed with the examination. c. Ask extensive health history questions regarding the woman's breast asymmetry. d. Continue with the examination, and then refer the patient for further evaluation of the Montgomery glands.
ANS: consider these normal findings and proceed with the examination. Normal findings of the breast include one breast (most often the left) slightly larger than the other and the presence of Montgomery's glands across the areola.
The nurse educator is preparing an education module for the nursing staff on the *dermis* layer of skin. Which of these statements would be included in the module? The dermis: a. contains mostly fat cells. b. consists mostly of keratin. c. is replaced every 4 weeks. d. contains sensory receptors.
ANS: contains sensory receptors The dermis consists mostly of collagen, has resilient elastic tissue that allows the skin to stretch, and contains nerves, sensory receptors, blood vessels, and lymphatics. It is not replaced every 4 weeks.
A newborn infant has Down syndrome. During the skin assessment, the nurse notices a transient mottling in the trunk and extremities in response to the cooler examination room temperature. The infant's mother also notices the mottling and asks what it is. The nurse knows that this *mottling* is called: a. café au lait. b. carotenemia. c. acrocyanosis. d. cutis marmorata.
ANS: cutis marmorata. Persistent or pronounced cutis marmorata occurs with Down syndrome or prematurity and is a transient mottling in the trunk and extremities in response to cooler room temperatures. A café au lait spot is a large round or oval patch of light-brown pigmentation. Carotenemia produces a yellow-orange color in light-skinned persons. Acrocyanosis is a bluish color around the lips, hands and fingernails, and feet and toenails.
A patient comes to the clinic and tells the nurse that he has been confined to his recliner chair for about 3 days with his feet down and he wants the nurse to evaluate his feet. During the assessment, the nurse might expect to find: a. pallor. b. coolness. c. distended veins. d. prolonged capillary filling time.
ANS: distended veins. Keeping the feet in a dependent position causes venous pooling, resulting in redness, warmth, and distended veins. Prolonged elevation would cause pallor and coolness. Immobilization or prolonged inactivity would cause prolonged capillary filling time. See Table 12-1.
A patient comes to the clinic and states that he has noticed that his skin is redder than normal. The nurse understands that this condition is due to *hyperemia* and knows that it can be caused by: a. decreased amounts of bilirubin in the blood. b. excess blood in the underlying blood vessels. c. decreased perfusion to the surrounding tissues. d. excess blood in the dilated superficial capillaries.
ANS: excess blood in the dilated superficial capillaries. Erythema is an intense redness of the skin caused by excess blood (hyperemia) in the dilated superficial capillaries.
The nurse is caring for a black child who has been diagnosed with *marasmus*. The nurse would expect to find the: a. hair to be less kinky and to be a copper-red color. b. head to be larger than normal, with wide-set eyes. c. skin on the hands and feet to be scaly and tender. d. lymph nodes in the groin to be enlarged and tender.
ANS: hair to be less kinky and to be a copper-red color. The hair of black children with severe malnutrition (e.g., marasmus) frequently changes not only in texture but in color—the child's hair becomes less kinky and assumes a copper-red color. The other findings are not present with marasmus.
A 13-year old girl is interested in obtaining information about the *cause of her acne*. The nurse would share with her that acne: a. is contagious. b. is caused by a poor diet. c. has no known cause. d. has been found to be related to poor hygiene.
ANS: has no known cause. About 70% of teens will have acne, and, although the cause is unknown, it is not caused by poor diet, oily complexion, a contagion, or poor hygiene.
While performing an assessment of a 65-year-old man with a history of hypertension and coronary artery disease, the nurse notices the presence of pitting edema in the lower legs bilaterally. The skin is puffy and tight but of normal color. There is no increased redness or tenderness over his lower legs, and the peripheral pulses are equal and strong. In this situation, the nurse suspects that the likely cause of the edema would be: a. heart failure. b. venous thrombosis. c. a local inflammation. d. blockage of lymphatic drainage.
ANS: heart failure. Bilateral edema or edema that is generalized over the entire body is caused by a central problem such as heart failure or kidney failure. Unilateral edema usually has a local or peripheral cause.
A patient's mother has noticed that her son, who has been to a new babysitter, has some *blisters and scabs on his face and buttocks*. On examination, the nurse notices moist, thin-roofed vesicles with a thin erythematous base and suspects: a. eczema. b. impetigo. c. herpes zoster. d. diaper dermatitis.
ANS: impetigo. Impetigo is moist, thin-roofed vesicles with a thin erythematous base. This is a contagious bacterial infection of the skin and most common in infants and children. Eczema is characterized by erythematous papules and vesicles with weeping, oozing, and crusts. Herpes zoster (chicken pox or varicella) is characterized by small, tight vesicles that are shiny with an erythematous base. Diaper dermatitis is characterized by red, moist maculopapular patches with poorly defined borders.
During a skin assessment, the nurse notices that a Mexican-American patient has skin that is yellowish-brown; however, the skin on the hard and soft palate is pink and the patient's scleras are not yellow. From this finding, the nurse could probably *rule out*: a. pallor. b. jaundice. c. cyanosis. d. iron deficiency.
ANS: jaundice. Jaundice is exhibited by a yellow color, which indicates rising amounts of bilirubin in the blood. It is first noticed in the junction of the hard and soft palate in the mouth and in the scleras.
The nurse just noted from a patient's medical record that the patient has a lesion that is confluent in nature. On examination, the nurse would expect to find:
ANS: lesions that run together. Confluent lesions (as with urticaria [hives]) run together. Grouped lesions are clustered together. Annular lesions are circular in nature. Zosteriform lesions are arranged along a nerve route.
A patient has had a *"terrible itch"* for several months that he has been scratching continuously. On examination, the nurse might expect to find:
ANS: lichenification. Lichenification results from *prolonged, intense scratching that eventually thickens the skin and produces tightly packed sets of papules*. A keloid is a hypertrophic scar. A fissure is a linear crack with abrupt edges that extends into the dermis, and it can be dry or moist. Keratoses are lesions that are raised, thickened areas of pigmentation that look crusted, scaly, and warty.
A 35-year-old pregnant woman comes to the clinic for a monthly appointment. During the assessment, the nurse notices that she has a *brown patch of hyperpigmentation on her face*. The nurse continues the skin assessment aware that another finding may be: a. keratoses. b. xerosis. c. linea nigra. d. acrochordons.
ANS: linea nigra. In pregnancy, skin changes can include striae, linea nigra (a brownish black line down the midline), chloasma (brown patches of hyperpigmentation), and vascular spiders. Keratoses are raised, thickened areas of pigmentation that look crusted, scaly, and warty. Xerosis is dry skin. Acrochordons, or "skin tags" occur more often in the aging adult.
A patient is newly diagnosed with benign breast disease. The nurse recognizes that which statement about benign breast disease is true? The presence of benign breast disease: a. Makes it hard to examine the breasts. b. Frequently turns into cancer in a woman's later years. c. Is easily reduced with hormone replacement therapy. d. Is usually diagnosed before a woman reaches childbearing age.
ANS: makes it harder to examine the breasts. The presence of benign breast disease (formerly fibrocystic breast disease) makes it harder to examine the breasts; the general lumpiness of the breast conceals a new lump. The other statements are not true.
During the aging process, the hair can look gray or white and begin to feel thin and fine. The nurse knows that this occurs because of a decrease in the number of functioning: a. metrocytes. b. fungacytes. c. phagocytes. d. melanocytes.
ANS: melanocytes. In the aging hair matrix, the number of functioning melanocytes decreases so the hair looks gray or white and feels thin and fine. The other options are not correct.
The nurse notices that a patient has a *solid, elevated, circumscribed lesion that is less than 1 cm in diameter*. When documenting this finding, the nurse would report this as a:
ANS: papule. A papule is something one can feel, is solid, elevated, circumscribed, less than 1 cm in diameter, and is due to superficial thickening in the epidermis. A bulla is larger than 1 cm, superficial, and thin walled. A wheal is superficial, raised, transient, erythematous, and irregular in shape due to edema. A nodule is solid, elevated, hard or soft, and larger than 1 cm.
While examining a 75-year-old woman, the nurse notices that the skin over her right breast is thickened and the hair follicles are exaggerated. This condition is known as: a. Dimpling. b. Retraction. c. Peau d'orange. d. Benign breast disease.
ANS: peau d'orange. This condition is known as peau d'orange. Lymphatic obstruction produces edema, which thickens the skin and exaggerates the hair follicles. The skin has a pig-skin or orange-peel look, and this condition suggests cancer.
A patient comes in for a physical, and she complains of "freezing to death" while waiting for her examination. The nurse notes that her skin is pale and cool and attributes this finding to: a. venous pooling. b. peripheral vasodilation. c. peripheral vasoconstriction. d. decreased arterial perfusion.
ANS: peripheral vasoconstriction. A chilly or air-conditioned environment causes vasoconstriction, which results in false pallor and coolness. See Table 12-1.
A 40-year-old woman reports a change in mole size, accompanied by color changes, itching, burning, and bleeding over the past month. She has a dark complexion and has no family history of skin cancer, but she has had many blistering sunburns in the past. The nurse would:
ANS: refer the patient because of the suspicion of melanoma on the basis of her symptoms. The ABCD danger signs of melanoma are asymmetry, border irregularity, color variation, and diameter. In addition, individuals may report a change in size, development of itching, burning, bleeding, or a new-pigmented lesion. Any of these signs raise suspicion of malignant melanoma and warrant immediate referral.
A man has come in to the clinic for a skin assessment because he is afraid he might have skin cancer. During the skin assessment the nurse notices several areas of pigmentation that look *greasy, dark, and "stuck on" his skin*. Which is the best prediction? He probably has:
ANS: seborrheic keratoses, which do not become cancerous. Seborrheic keratoses look like dark, greasy, "stuck-on" lesions that develop mostly on the trunk. These lesions do not become cancerous. Senile lentigines are commonly called liver spots and are not precancerous. Actinic (senile or solar) keratoses are lesions that are red-tan scaly plaques that increase over the years to become raised and roughened. They may have a silvery-white scale adherent to the plaque. They occur on sun-exposed surfaces and are directly related to sun exposure. They are premalignant and may develop into squamous cell carcinoma. Acrochordons are "skin tags" and are not precancerous.
A 42-year-old female patient complains that she has noticed several *small, slightly raised, bright red dots* on her chest. On examination, the nurse expects that the spots are probably: a. anasarca. b. scleroderma. c. senile angiomas. d. latent myeloma.
ANS: senile angiomas. Cherry (senile) angiomas are small, smooth, slightly raised bright red dots that commonly appear on the trunk in adults over 30 years old.
A 14-year-old girl is anxious about not having reached menarche. When taking the history, the nurse should ascertain which of the following? The age: a. The girl began to develop breasts. b. Her mother developed breasts. c. She began to develop pubic hair. d. She began to develop axillary hair.
ANS: she began to develop breasts Full development from stage 2 to stage 5 takes an average of 3 years, although the range is 1.5 to 6 years. Pubic hair develops during this time, and axillary hair appears 2 years after the onset of pubic hair. The beginning of breast development precedes menarche by about 2 years. Menarche occurs in breast development stage 3 or 4, usually just after the peak of the adolescent growth spurt, which occurs around age 12 years. See Figure 17-6.
A physician has diagnosed a patient with *purpura*. After leaving the room, a nursing student asks the nurse what the physician saw that led to that diagnosis. The nurse should say, "The physician is referring to:
ANS: that confluent and extensive patch of petechiae and ecchymoses on the feet." Purpura is a confluent and extensive patch of petechiae and ecchymoses and a flat macular hemorrhage seen in generalized disorders such as thrombocytopenia and scurvy. The blue dilation of blood vessels in a star-shaped linear pattern on the legs describes a venous lake. The fiery red, star-shaped marking on the cheek that has a solid circular center describes a spider or star angioma. The tiny little areas of hemorrhage that are less than 2 mm, round, discrete, and dark red in color describes petechiae.
In performing a breast examination, the nurse knows that it is especially important to examine the upper outer quadrant of the breast. The reason for this is that the upper outer quadrant is: a. The largest quadrant of the breast. b. The location of most breast tumors. c. Where most of the suspensory ligaments attach. d. More prone to injury and calcifications than other locations in the breast.
ANS: the location of most breast tumors. The upper outer quadrant is the site of most breast tumors. In the upper outer quadrant, the nurse should notice the axillary tail of Spence, the cone-shaped breast tissue that projects up into the axilla, close to the pectoral group of axillary lymph nodes.
The nurse is discussing breast self-examination with a postmenopausal woman. The best time for postmenopausal women to perform breast self-examination is: a. On the same day every month. b. Daily, during the shower or bath. c. One week after her menstrual period. d. Every year with her annual gynecologic examination.
ANS: the same day every month. Postmenopausal women are no longer experiencing regular menstrual cycles but need to continue to perform breast self-examination on a monthly basis. Choosing the same day of the month is a helpful reminder to perform breast self-examination.
The nurse has palpated a lump in a female patient's right breast. The nurse documents this as a small, round, firm, distinct, lump located at 2 o'clock, 2 cm from the nipple. It is nontender and fixed. There is no associated retraction of skin or nipple, no erythema, and no axillary lymphadenopathy. Which of these statements reveals the information that is missing from the documentation? It is missing information about: a. Shape of the lump b. Consistency of the lump c. Size of the lump d. Whether the lump is solitary or multiple
ANS: the size of the lump. If the nurse feels a lump or mass, he or she should note these characteristics: (1) location, (2) size—judge in centimeters in three dimensions: width length thickness, (3) shape, (4) consistency, (5) motility, (6) distinctness, (7) nipple, (8) the skin over the lump, (9) tenderness, and (10) lymphadenopathy.
A 75-year-old woman who has a history of diabetes and peripheral vascular disease has been trying to remove a corn on the bottom of her foot with a pair of scissors. The nurse will encourage her to stop trying to remove the corn with scissors because:
ANS: the woman could be at increased risk for infection and lesions because of her chronic disease. A personal history of diabetes and peripheral vascular disease increases a person's risk for skin lesions in the feet or ankles. The patient needs to see a professional for assistance with corn removal.
A 45-year-old farmer comes in for a skin evaluation and complains of hair loss on his head. He has noticed that his *hair seems to be breaking off in patches and that he has some scaling on his head*. The nurse would begin the examination suspecting: a. tinea capitis. b. folliculitis c. toxic alopecia. d. seborrheic dermatitis.
ANS: tinea capitis. Tinea capitis is rounded patchy hair loss on the scalp, leaving broken-off hairs, pustules, and scales on the skin. It is caused by a fungal infection. Lesions are fluorescent under a Wood light. It is usually seen in children and farmers and is highly contagious. See Table 12-12, Abnormal Conditions of Hair, for descriptions of the other terms.
A mother brings her child in to the clinic for an examination of the scalp and hair. She states that the child has developed some places where there are *irregularly shaped patches with broken-off, stub-like hair* and she is worried that this could be some form of premature baldness. The nurse tells her that it is:
ANS: trichotillomania and that her child probably has a habit of twirling her hair absentmindedly. Trichotillomania, self-induced hair loss, is usually due to habit. It forms irregularly-shaped patches with broken-off, stub-like hairs of varying lengths. A person is never completely bald. It occurs as a child rubs or twirls the area absently while falling asleep, reading, or watching television. See Table 12-12, Abnormal Conditions of Hair, for descriptions of the other terms.
Because hair for humans is no longer needed for protection from cold or trauma, it is called:
ANS: vestigial Hair is vestigial for humans. It no longer is needed for protection from cold or trauma.
During an examination, the nurse finds that a patient has *excessive dryness of the skin*. The best term to describe this condition is: a. xerosis. b. pruritus. c. alopecia. d. seborrhea.
ANS: xerosis. Xerosis is the term used to describe skin that is excessively dry. Pruritus refers to itching, alopecia refers to hair loss, and seborrhea refers to oily skin.
HbA1c
5-7%
tanner staging
5 stages of sexual maturity rating,
CHARACTERISTICS OF BREAST LUMPS
location, size, shape, consistency, movable, tenderness, nipple
Albumin
long half life (2-3 weeks) malnutrition, altered hydration, decreased liver function 3.5-5.5
galactorrhea
persistent white discharge of milk between nursing sessions or after weaning
Nutrition balance is affected by
physiologic, psychosocial, developmental, cultural, and economic factors
Urethral stricture
pinpoint constricted opening at meatus or inside urethra; congenital or secondary to urethral injury; gradual decrease in force & caliber of urine stream; shaft feels indurated
__________ is sensory information concerning body movements & position of the body in space
proprioception
Carbs proteins and lipids
provide energy
Freckles
small, flat macules of brown melanin pigment that occur on sun-exposed skin
alveoli
smallest structures in the mammary gland
When you depress the tounge and they say ahhhh what should happen
soft palette should rise and tonsils move medially
condylomata acuminata
soft, pointed, fleshy papules that occur on the genitalita and are caused by the human papillomavirus (HPV)
Nodule
solid, elevated, hard or soft skin lesion, >1 cm diameter
Phobia
strong, persistent, irrational fear of an object or situation; feels driven to avoid it
epididymis
structures composed of coiled ducts located over the superior and posterior surface of the testes, which store sperm
PSA
substance made by normal prostate gland levels inc with prostate cancer, BPH and prostatis can also cause this
Blocking
sudden interruption in train of thought, unable to complete sentences, seems related to strong emotion
torsion
sudden twisting of spermati cord; a surgical emergency
WBC in urine
suggests UTI
RBC in urine
suggests UTI, glomerulonephritis, renal calculi, trauma, cancer
Glycosuria
suggests hyperglycemia occuring with DM
Sebaceous cysts on scrotum
Normal finding; yellowish, 1-cm nodules that are firm, nontender & often multiple
retraction
dimple or pucker on the skin, caused by fibrosis in the breast tissue usually caused by growing neoplasms
Discrete:
distinct, individual lesions that remain separate ex: skin tags, acne, acrochordon
________ is impairment in speech consisting of lack of coordination & inability to arrange words in their proper order
dysphasia
Vesicle
elevated cavity containing free fluid up to 1 cm diameter
Hirsutism
excess body hair
Echolalia
imitation, repeats others words or phrases, often with a mumbling, mocking, or mechanical tone
Dysphonia
-disorder of voice -difficulty or discomfort in talking, with abnormal pitch or volume, caused by laryngeal disease. Voice sounds hoarse or whispered, but articulation and language are intact
Subjective Data
-eating patterns -food allergies -alcohol -exercise
Subjective Health History Questions
-eating patterns -usual weight -changes in appetite -chronic illness -food allergies
Posttraumatic Stress Disorder (PTSD)
-follows a traumatic event outside the range of usual human experience involving actual or threatened death, plane or train accident, violence -person relives the trauma many times, intrusively and unwillingly
CYANOSIS: (etiology)
1. Increased amounts of unoxygenated Hgb 2. Central/chronic heart & lung disease cause arterial desaturation 3. Peripheral- exposure to cold, anxiety
Jaundice
1. Increased bilirubin, liver impairment - takes on the color yellow 2. Carotenemia- increased carotene ingestion 3. Uremia- renal failure
Explain types of reflex responses
0-4 scale 2 is normal average reflex
Objective assessment of hair
* Inspect and palpate the hair, noting the color, texture, distribution. * Inspect for scalp lesions * Inspect for infestations
ANS: tophi. Tophi are collections of sodium urate crystals resulting from chronic gout in and around the joint that cause extreme swelling and joint deformity. They appear as hard, painless nodules (tophi) over the metatarsophalangeal joint of the first toe and they sometimes burst with a chalky discharge (See Table 22-6). See Table 22-6 for descriptions of the other conditions.
A man who has had gout for several years comes to the clinic with a problem with his toe. On examination, the nurse notices the presence of hard, painless nodules over the great toe; one has burst open with a chalky discharge. This finding is known as: A) a callus. B) a plantar wart. C) a bunion. D) tophi.
The nurse has discovered *decreased skin turgor* in a patient and knows that this is an expected finding in which of these conditions? a. Severe obesity b. Childhood growth spurts c. Severe dehydration d. Connective tissue disorders such as scleroderma
ANS: Severe dehydration Decreased skin turgor is associated with severe dehydration or extreme weight loss.
TSE
T = timing, once a month S = shower, warm water relaxes scrotal sac E = examine, check for changes & report them immediately Hold scrotum in palm & gently feel each testicle using thumb & 1st 2 fingers; if it hurts, you're using too much pressure. Testicle should be egg shaped and moveable, feels rubbery with smooth surface, like a peeled hard boiled egg. The epididymis is on top & behind the testicle & feels a little softer. The spermatic cord feels thick, straight strands of string.
striae
atrophic pink, purple, or white linear steaks on the breasts, associated with pregnancy, excessive weight gain, or rapid growth during adolescence
femoral canal
inferior to the inguinal ligament it is a potential space located 3 cm medial to and parallel with the femoral artery, can use the artery as a landmark to find this space
nipple
just below the center of the breast, rough, round, and usually protuberant; looks wrinkled and indented with tiny milk duct openings
Epispadias
meatus opens on dorsal (upper) side of glans as broad, spade like penis congenital defect in which the urethra opens on the upper side of the penis near the glans penis instead of the tip rare, but worse than hypospadias because of associated incontinence & pubic bone separation
Hypochondriasis
morbid worrying about his or her own health; feels sick with no actual basis for that assumption
Overnutrition leads to
ovestity, stroke, sleep apnea, cancer,
Generalized anxiety disorder (GAD)
pattern of excessive worrying and morbid fear of anticipated "disasters" in the job, personal relationships, health, or finances
Obessive Compulsive disorder (OCD)
pattern of recurrent obsessions and compulsions done to decrease anxiety and prevent a catastrophe
examination of nipples
performed after breast palpation, palpate nipple, noting any indurations or mass, use thumb and forefinger to apply gentle pressure to note any discharge
__________ is the ability to recognize objects by feeling their forms, sizes & weights while eyes are closed
stereognosis
Infant subjective data
-breast vs bottle -child's willingness to eat -overweight/obesity risk
male breast cancer
1% of breast cancers occur in men, no standard screening, detected by clinical symptoms
Hemoglobin Males
14-18
The nurse is percussing the seventh right intercostal space at the midclavicular line over the liver. Which sound should the nurse expect to hear? a. Dullness b. Tympany c. Resonance d. Hyperresonance
ANS: A The liver is located in the right upper quadrant and would elicit a dull percussion note.
An imaginary line connecting the highest point on each iliac crest would cross the _____ ver-tebra. a. first sacral b. fourth lumbar c. seventh cervical d. twelfth thoracic
ANS: B An imaginary line connecting the highest point on each iliac crest crosses the fourth lumbar vertebra.
nerve for smell
I: Olfactory
Asymmetry of scrotum
Normal finding; Left scrotal half usually lower than the right
Dermis layer
collagen. elastic tissue
common scrotal finding in boy younger than 2
hydrocele or fluid in scrotum large scrotum and transilluminates as a faint pin glow
CKD two main causes
hypertension diabetes
Cafe' au lait
large round or oval patch of light brown usually present at birth
Diffuse tumor
maintains shape of testis; enlarged, nontender testis; Has the feel of increased weight; does not transilluminate; does not cause usual sickening discomfort as with normal testis
__________ is the ability of the person to discriminate exactly where on the body the skin has been touched
point localization
common finding under scrotum
sebaceous cyst yellow, 1 cm nodule, firm , nontender, multiple
preadolesent
there is only a small elevated nipple
Bright yellow urine
vitamin supplements
hernia
weak spot in abdominal muscle wall (usually in area of inguinal canal or femoral canal) through which a loop of bowel may protrude
Urticaria (hives):
wheals coalesce to form extensive reaction, intensely pruritic
Cr, BUN changes
when the GFR decreases by half, serum Cr doubles; BUN rises with decreased kidney function but is less specific
Test nerve 8 how?
whisper test
Global aphasia
-most common and severe form -can produce few recognizable words and understand little or no spoken language -can not read or write
Wernicke aphasia
-receptive aphasia -can hear sounds and phrases but can not relate them to previous experiences
Bulimia nervosa
-recurrent episodes of uncontrollable binging -inappropriate compensatory behaviors: vomiting, laxatives, diuretics, exercise -self-image largely influenced by body image
For adults BMI for overweight
25 or greater
ANS: adduction. Moving a limb toward the midline of the body is called adduction; abduction is moving a limb away from the midline of the body. Flexion is bending a limb at a joint; extension is straightening a limb at a joint.
A patient is being assessed for range of joint movement. The nurse asks him to move his arm in toward the center of his body. This movement is called: A) flexion. B) abduction. C) adduction. D) extension.
While gathering equipment after an injection, a nurse accidentally received a prick from an improperly capped needle. To interpret this sensation, which of these areas must be intact?
ANS: Lateral spinothalamic tract, thalamus, and sensory cortex The spinothalamic tract contains sensory fibers that transmit the sensations of pain, temperature, and crude or light touch. Fibers carrying pain and temperature sensations ascend the lateral spinothalamic tract, whereas those of crude touch form the anterior spinothalamic tract. At the thalamus, the fibers synapse with another sensory neuron, which carries the message to the sensory cortex for full interpretation. The other options are not correct.
A 32-year-old woman tells the nurse that she has noticed "very sudden, jerky movements" mainly in her hands and arms. She says, "They seem to come and go, primarily when I am trying to do something. I haven't noticed them when I'm sleeping." This description suggests:
ANS: chorea. Chorea is characterized by sudden, rapid, jerky, purposeless movements that involve the limbs, trunk, or face. Chorea occurs at irregular intervals, and the movements are all accentuated by voluntary actions. See Table 23-5 for descriptions of athetosis, myoclonus, and tics.
The wife of a 65-year-old man tells the nurse that she is concerned because she has noticed a change in her husband's personality and ability to understand. He also cries and becomes angry very easily. The nurse recalls that the cerebral lobe responsible for these behaviors is the _____ lobe.
ANS: frontal The frontal lobe has areas concerned with personality, behavior, emotions, and intellectual function. The parietal lobe has areas concerned with sensation; the occipital lobe is responsible for visual reception; and the temporal lobe is concerned with hearing, taste and smell.
When the nurse asks a 68-year-old patient to stand with feet together and arms at his side with his eyes closed, he starts to sway and moves his feet farther apart. The nurse would document this finding as a(n):
ANS: positive Romberg sign. Abnormal findings for Romberg test include swaying, falling, and widening base of feet to avoid falling. Positive Romberg sign is loss of balance that is increased by closing of the eyes. Ataxia is uncoordinated or unsteady gait. Homans' sign is used to test the legs for deep vein thrombosis.
For children BMI
BMI equal to or greater than 95th percentil e
Male Pt c/o: fever, chills, malaise, urinary frequency and urgency, dysuria, urethral discharge; dull, aching pain in perineal and rectal area
BPH-- Benign Prostatic Hypertrohy
An example of a primary lesion is a(n): A. Erosion B. Ulcer C. Urticaria D. Port-wine stain
C. Urticaria (hives)
Malignant neoplasm in the rectum which is asymtomatic
Carcinoma
Grouped:
Cluster of lesions ex: vesicle of contact dermatitis
Nevus is the medical term for: A. freckle B. a birthmark C. an infected hair follicle D. a mole
D. a mole
TSE Abnormals
Firm, painless lump Enlarged, hard testicle
responsible for transporting oxygen
Hemoglobin
Triceps reflex
Hold dead arm. Hit just above elbow. Arm should extend
Elation
Joy and optimism, overconfidence, increased motor activity, not necessarily pathologic Ex. "I'm feeling very happy."
a localized cavity of pus from infection in the pararectal space
Rectal Abscess
Lateral movement of the eye
VI: Abducen s
__________ is a loss of memory
amnesia
Grey urine
contains melanin
subjective data
history of breast disease and or surgery, lumps or thickening, discharge or rash, swelling or trauma, pain, self breast exam, axillary tenderness
Keloid
hypertrophic scar, elevated beyond site of original injury
________- is the major respiratory center with basic vital functions: temperature, HR, BP, sex drive, appetite
hypothalamus
lump consistency
soft firm or hard
sudden loss of strength
syncope
Crust
thick, dried-out exudate left on skin when vesicles / pustules burst or dry up
cryptorchidism
undescended testes
SKIN Anatomy
Hair shaft Horney cell layer Basal cell layer Melanocyte Sebaceous gland Eccrine sweat gland Appocrine sweat gland Blood vessels Nerve Adipose tissue Epidermis Dermis Subcutaneous tissue Connective tissue Arrector pili muscle Hair follicle
Malignant melanoma
Half rise from preexisting nevi. Usually brown, but can be tan, black, pink-red, purple, or of mixed pigmentation. Often have irregular or notched borders. May have scaling, flaking, oozing texture. Commonly located on trunk and back in males & females, legs in females, and on the palms, soles of feet and nails of blacks.
Normal urine
clear, pale yellow, slightly acidic with pH range 4.5 - 8.0 Specific gravity is 1.003 dilute to 1.030 concentrated No protein, no glucose, fewer than 5 RBCs or WBCs
_________ is rapidly alternating involuntary contraction & relaxation of a muscle in response to sudden stretch
clonus
CN XII = Hypoglossal Abnormalities Possible Causes
*ABNORMALITIES* - Tongue deviates to the side - Slowed rate of movement from tongue *POSSIBLE CAUSES* - LMN lesions (flaccid paralysis) - Bilateral UMN lesions (stroke)
Scleroderma
"hard skin". a chronic connective tissue disorder associated with decreased mobility
Nevus
"mole" - circumscribed skin lesion due to excess melanocytes
Urticaria
(hives). Wheals coalesce to from extensive reaction, intensely pruritic
CN X = Vagus Abnormalities Possible Causes
*ABNORMALITIES* - Uvula deviates to the side (not midline) - Hoarse / brassy voice - Nasal Twang voice - Husky voice - Dysphagia - Fluids regurgitate through nose *POSSIBLE CAUSES* - Brainstem tumor - Neck injury - Soft palate weakness
Rooting Reflex
*Appears at BIRTH - disappears at 3-4 MONTHS* Brush / tap infants cheek next to mouth NORMAL = head turns toward the simulation + opens mouth
Tonic Neck Reflex
*Present at 2-3 MONTHS - disappears at 4-6 MONTHS* "Fencing position" Infant = supine position, relaxed / sleeping + head turned to one side with chin over shoulder
Palmer Grasp Reflex
*Present at BIRTH (strongest at 1-2 months) - disappears at 3-4 MONTHS* Offer finger from ulnar / pinky side for infant to grab NORMAL = tight grasp (sometimes even able to pull baby into a sitting position)
Breast Development in Pregnancy
-Pregnancy breast changes start during the second month and are a common early sign of pregnancy. -The nipples grow larger, darker, and more erectile. -After the fourth month colostrum may be expressed. -The breasts produce colostrum for the first few days after delivery. It is rich with antibodies that protect the newborn against infection; thus breastfeeding is important. Milk production (lactation) begins 1 to 3 days after delivery.
What are the components of the PNS
-all nerve fibers outside of brain: -->12 pair of cranial nerves -->31 pair of spinal nerves
Urine abnormalities
-cloudiness-wbc, bacteria proteinuria-glomural disease glycosuria-hyperglycemia diabetes WBC inc-UTI RBC- uti, glomerulonephritis, renal calcuti, trauma cancer
Panic Attack
-defined period of intense fear, anxiety, and dread accompanied by signs of dyspnea, choking, chest pain, increased heart rate, palpitations, nausea, and sweating -also has fear of impending doom, going crazy, or dying -sudden onset, lasts about 10 minutes
Dysarthia
-disorder of articulation -distorted speech sounds, speech may sound unintelligible, basic language intact
Anorexia nervosa
-intense fear of weight gain -distorted body image -restricted calories with significant low BMI -Subtypes: restricting and binge eating/purging type
Agoraphobia
-irrational fear of being out in the open or in a place where escape is difficult -fear is so intense person is reluctant to leave home
Types of Deep Tendon Reflexes
1. Bicep reflex 2. Triceps reflex 3. Brachioradialis reflex 4. Quadriceps reflex (knee jerk) 5. Achilles reflex (ankle jerk) 6. Clonus - Rapid rhythmic contraction of calf muscles + movement of foot after dorsiflexing the foot + holding the stretch
ERYTHEMA: (etiology):
1. Hyperemia (increased blood flow) 2. Polycythemia (increased RBCs, capillary stasis) 3. Carbon Monoxide poisoning 4. Venous Stasis: decreased blood flow from area, engorged
Vascular Lesions (I DOUBT THIS WILL BE ON TEST)
1. hemangiomas 2. Port- wine Stain 3. Strawberry Mark 4. Cavernous Hamangioma 5. Telangiectases 6. Venous Lake 7. Spider or Star angioma
Hemoglobin females
12-16
Penis size in infants
2-3cm; note that rarely a small penis may be an enlarged clitoris in genetically female infant; newborns with ambiguous genitalia should be evaluated to determine genetic sex for rearing
Obestity for BMI
30
How many spinal nerves? Describe
31 pair: 8 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 1 coccygeal
Abnormal characteristics of pigmented lesions are summarized in the mnemonic A-B-C-D-E:
A - asymmetry (not regularly round or oval, two halves of lesion do not look the same) B - border irregularity (notching scalloping, ragged edges, poorly defined margins) C - color variation (areas of brown, tan black, blue, red, white, or combination) D - diameter greater than 6mm (the size of a pencil eraser) E - elevation or enlargement ADDITIONAL: lesion that is rapidly changing, new pigmented lesion, development of itching, burning, bleeding.
ANS: limited range of motion during the Moro's reflex. For a fractured clavicle, the nurse should observe for limited arm range of motion and unilateral response to the Moro's reflex. The other tests are not appropriate for this problem.
A mother brings her newborn baby boy in for a checkup; she tells the nurse that he doesn't seem to be moving his right arm as much as his left and that he seems to have pain when she lifts him up under the arms. The nurse suspects a fractured clavicle and would observe for: A) a negative Allis test. B) a positive Ortolani's sign. C) limited range of motion during the Moro's reflex. D) limited range of motion during Lasègue's test
ANS: loss of bone density. After age 40, loss of bone matrix (resorption) occurs more rapidly than new bone formation. The net effect is a gradual loss of bone density, or osteoporosis. The other options are not correct.
A patient has been diagnosed with osteoporosis and asks the nurse, "What is osteoporosis?" The nurse explains to the patient that osteoporosis is defined as:
ANS: flexion. Flexion, or bending a limb at a joint, would be required to move the hand to the mouth. Extension is straightening a limb at a joint. Moving a limb toward the midline of the body is called adduction; abduction is moving a limb away from the midline of the body.
A patient tells the nurse that she is having a hard time bringing her hand to her mouth when she eats or tries to brush her teeth. The nurse knows that for her to move her hand to her mouth, she must perform which movement? A) flexion. B) abduction. C) adduction. D) extension.
ANS: Swan neck deformities Changes in the fingers caused by chronic rheumatoid arthritis include swan neck and boutonniere deformities. Heberden's nodes and Bouchard's nodules are associated with osteoarthritis. Dupuytren's contractures occur because of chronic hyperplasia of the palmar fascia and causes contractures of the digits (see Table 22-4).
A patient who has had rheumatoid arthritis for years comes to the clinic to ask about changes in her fingers. The nurse will assess for signs of what problems? A) Heberden's nodes B) Bouchard's nodules C) Swan neck deformities D) Dupuytren's contractures
ANS: ulnar deviation. Fingers drift to the ulnar side because of stretching of the articular capsule and muscle imbalance caused by chronic rheumatoid arthritis. Radial drift is not seen. See Table 22-4 for descriptions of swan neck deformity and Dupuytren's contracture.
A woman who has had rheumatoid arthritis for years is starting to notice that her fingers are drifting to the side. The nurse knows that this condition is commonly referred to as: A) radial drift. B) ulnar deviation. C) swan neck deformity. D) Dupuytren's contracture.
When reviewing the musculoskeletal system, the nurse recalls that hematopoiesis takes place in the: a. liver. b. spleen. c. kidneys. d. bone marrow.
ANS: D The musculoskeletal system functions to encase and protect inner vital organs, support the body, produce red blood cells in the bone marrow, and store minerals.
ANS: lordosis. Lordosis compensates for the enlarging fetus, which would shift the center of balance forward. This shift in balance in turn creates strain on the low back muscles, felt as low back pain during late pregnancy by some women. Scoliosis is lateral curvature of portions of the spine; ankylosis is extreme flexion of the wrist, as seen with severe rheumatoid arthritis; and kyphosis is an enhanced thoracic curvature of the spine.
A woman who is 8 months pregnant comments that she has noticed a change in posture and is having lower back pain. The nurse tells her that during pregnancy women have a posture shift to compensate for the enlarging fetus. This shift in posture is known as: A) lordosis. B) scoliosis. C) ankylosis. D) kyphosis.
During a routine visit, M.B. age 78, asks about small, round, flat, brown macules on the hands. The best response is: A. "these are the result of sun exposure and do not require treatment" B. "these are related to exposure to the sun. they may become cancerous." C. "these are the skin tags that occur with aging. No treatment is required." D. "I'm glad you brought this to my attention. I will arrange for a biopsy."
A. "age spots" - the result of sun exposure and do no require treatment
In obtaining a history on a 74-year-old patient the nurse notes that he drinks alcohol daily and that he has noticed a tremor in his hands that affects his ability to hold things. With this information, what should the nurse's response be?
ANS: "Does the tremor change when you drink the alcohol?" Senile tremor is relieved by alcohol, although this is not a recommended treatment. The nurse should assess whether the person is abusing alcohol in an effort to relieve the tremor.
The articulation of the mandible and the temporal bone is known as the: a. intervertebral foramen. b. condyle of the mandible. c. temporomandibular joint. d. zygomatic arch of the temporal bone.
ANS: C The articulation of the mandible and the temporal bone is the temporomandibular joint. The other responses are not correct.
Which structure is located in the left lower quadrant of the abdomen? a. Liver b. Duodenum c. Gallbladder d. Sigmoid colon
ANS: D The sigmoid colon is located in the left lower quadrant of the abdomen.
The area of the nervous system that is responsible for mediating reflexes is the:
ANS: spinal cord. The spinal cord is the main highway for ascending and descending fiber tracts that connect the brain to the spinal nerves, and it mediates reflexes.
Hemorrhagic Stroke
Acute rupture + bleeding from weakened artery in brain - Accounts for 13% of strokes *INTRACEREBRAL HEMORRHAGES* (more common) *Caused by ...* - Ruptured aneurysm - Arteriovenous malformation (rupturing of the arteries + veins = bleeding in brain + spine) - Disturbed coagulation cascade - Tumor - Cocaine abuse *SUBARACHNOID HEMORRHAGE* (less common) *Caused by ...* - Aneurysm between base of cerebral cortex + arachnoid layer of meninges *Signs + Symptoms* - Severe headache - Nausea + vomiting - Sudden loss of consciousness - Focal seizures
Inappropriate affect
Affect clearly discordant with content of person's speech Ex. laughs while discussion admission for liver biopsy
Breast Lumps: Benign Breast Disease
Age Group: 30-55 years; decreases after menopause Shape: Round, lobular Consistency: Firm to soft, rubbery Demarcation: Well demarcated Number: Usually multiple; may be single Mobility: Mobile Tenderness: Tender; usually increases before menses; may be noncyclic Skin retraction: none Pattern of Growth: Size may increase or decrease rapidly; cyclic with menstrual periods *Benign, although general lumpiness may mask other cancerous lump.
Breast Lumps: Cancer
Age Group: 30-80 years, risk increases after 50 years Shape: Irregular, star-shaped Consistency: Firm to stony hard Demarcation: Poorly defined Number: single Mobility: Fixed Tenderness: None, but can be tender Skin retraction: usually Pattern of growth: grows constantly *Serious, needs early treatment
ANS: abduct her hip while she is lying on her back. Limitation of abduction of the hip while supine is the most common motion dysfunction found in hip disease. The other options are not correct.
An 80-year-old woman is visiting the clinic for a checkup. She states, "I can't walk as much as I used to." The nurse is observing for motor dysfunction in her hip and should have her: A) internally rotate her hip while she is sitting. B) abduct her hip while she is lying on her back. C) adduct her hip while she is lying on her back. D) externally rotate her hip while she is standing.
ANS: of the shortening of the vertebral column. Postural changes are evident with aging; decreased height is most noticeable and is due to shortening of the vertebral column. Long bones do not shorten with age. Intervertebral disks actually get thinner with age. Subcutaneous fat is not lost but is redistributed to the abdomen and hips.
An 85-year-old patient comments during his annual physical that he seems to be getting shorter as he ages. The nurse should explain that decreased height occurs with aging because:
ANS: fourth lumbar An imaginary line connecting the highest point on each iliac crest crosses the fourth lumbar vertebra.
An imaginary line connecting the highest point on each iliac crest would cross the _____ vertebra. A) first sacral B) fourth lumbar C) seventh cervical D) twelfth thoracic
Assess level of consciousness? Explain
Appearance, Behavior, cognition, thought process
Irritability
Annoyed, easily provoked, impatient Ex. person internalizes a feeling of tension, and a seemingly mild stimulus "sets him/her off"
Polycyclic:
Annular (circular) lesions grow together Ex: Lichen, planus, psoriasis
Squamous cell carcinoma
Arise from actinic keratosis or de novo. Erythematous scaly patch with sharp margins, >1cm. Develops central ulcer and surrounding erythema. Usually on hands or head, areas exposed to UV radiation. Grows rapidly.
Finger - to - Nose Test
Arms stretch out with eyes closed Touch finger to nose - alternating btw each finger Movements = smooth + accurate
Heel - to - Shin Test
Ask patient to lie down in supine position Place heel of one side of leg on top of the opposite leg - run heel along the shin of the opposite leg (REPEAT to other side) Person moves in a straight line down the shin
Finger - to - Finger Test
Ask patient to use its own finger to touch their nose + touch the providers finger laid out in different areas in front + away from patient's face Patient's movements should be smooth + accurate
Cranial Nerve V --> Trigeminal Nerve (Jaw) Normal Abnormal
Assess motor + sensory functions on face *NORMAL* - Jaw muscles = in strength - Jaws not separate when pushed down - Able to feel cotton on (1) Ophthalmic (2) Maxillary (3) Mandibular *ABNORMAL* - Decreased strength in 1+ side of face - Asymmetry in jaw movement - Pain with clenching teeth - Decreased + unequal sensation *POSSIBLE CAUSES ...* - Stroke (sensation to face + body = lost opposite side of lesion)
Spinothalamic Tract Test
Assessing pain through light pricking using a pinprick in random orders - patient states if it's a sharp or dull prick Using a cotton ball ask patient to answer "yes" / "now" when they feel the sensation running down their body area Can be assessed in the arms + forearms + hands + chest + legs + thighs
Testicular cancer
Associated with hx of cryptorchidism; teach TSE to males 13-14 yrs old; most often occurs between 15-35 years; no early symptoms; when detected early & treated before metastasis, cure is nearly 100%
Testes abnormalities
Atrophied--small & soft Fixed--not freely moveable Nodules (pt will need ultrasound) Marked tenderness
Herpes zoster: A. caused by bacteria B. lesion on only one side of body; does not cross midline C. has absence of pain or edema D. forms pustular, umbilicated lesions
B. "shingles". Is a lesion on only one side of the body - does not cross the midline
Skin turgor is assessed by picking up a large fold of skin on the anterior chest under the clavicle. This is done to determine the presence of: A. edema B. dehydration C. vitiligio D. scleroderma
B. dehydration
What are the components of the CNS
Brain and spinal cord
Clubbing can be assessed by: A. observing for transverse ridges in the nails B. the presence of pits in the nails C. noting a change in the angle of the nail base D. palpating a rigid nail base
C. noting a change in the angle of the nail base
A risk factor for melanoma is: A. brown eyes B. darkly pigmented skin C. skin that freckles or burns before tanning D. use of sunscreen products
C. skin that freckles or burns before tanning
Secondary skin lesions:
CRUST: thickened, dried out exudate left when vesicles or pustules burst or dry up SCALE: compact desiccated flakes of skin. dry or greasy, silvery or white, dead skin FISSURE: linear crack with abrupt edges, extends into dermis, dry or moist EROSION: scooped out, but shallow depression, superficial ULCER: deeper depression extending into dermis, irregular shape, may bleed
Percent usual body weight...
Current weight/usual weight x 100
You note a lesion during an examination. The most complete description: A. raised, irregular lesion the size of a quarter, located on dorsum of left hand B. open lesion with no drainage or odor, approximately 1/4 inch in diameter C. pedunculated lesion below left scapula with consistent red color, no drainage or odor D. dark brown, raised lesion, with irregular border, on dorsum of right foot, 3 cm in size with no drainage
D. dark brown, raised lesion, with irregular border, on dorsum of right foot, 3 cm in size with no drainage
Flattening of the angle between the nail and its base is: A. found in subacute bacterial endocarditis. B. a description of spoon-shaped nails. C. related to calcium deficiency D. described as clubbing
D. described as clubbing
Xerosis
DRY: excessive dryness. the skin loses moisture and it may crack and peel. Bathing or hand washing too frequently, especially if one is using harsh soaps, may also contribute to xeroderma. Xeroderma can also be caused by a deficiency of vitamin A, vitamin D, systemic illness, severe sunburn, or some medication
CYANOSIS: (in dark skin)
Dark but dull, only severe cyanosis in apparent in skin. Check nail beds, oral mucousa, conjuctivae
Crust
Dried out vesicles/pustules
ANS: polydactyly. Polydactyly is the presence of extra fingers or toes. Syndactyly is webbing between adjacent fingers or toes. The other terms are not correct.
During a neonatal examination, the nurse notices that the newborn infant has six toes. This finding is documented as: A) unidactyly. B) syndactyly. C) polydactyly. D) multidactyly.
External variables influencing skin color
Emotions: fear, anger embarrassment Environment: hot room, chilly room, cigarette smoking Physical: prolonged elevation, dependent position, immobilization, prolonged inactivity
Cyst:
Encapsulated fluid-filled cavity in dermis or subcutaneous layer, tensely elevated skin Ex: sebaceous cyst
ANS: your acromion process." The bump of the scapula's acromion process is felt at the very top of the shoulder. The other options are not correct.
During an interview the patient states, "I can feel this bump on the top of both of my shoulders—it doesn't hurt but I am curious about what it might be." The nurse should tell the patient, "That is: A) your subacromial bursa." B) your acromion process." C) your glenohumeral joint." D) the greater tubercle of your humerus."
Vesicle:
Elevated cavity containing free fluid; up to 1 cm Ex: blister, herpes, chicken pox, contact dermititis
Late clubbing
Elevated edge of nail, with an angle >180 degrees, because of chronic obstructive pulmonary disease
Variables that can influence skin color:
Emotional: fear, anger, embarrassment Environment: hot, cold, cigarette smoking Physical: prolonged elevation, dependent position, immobilization, prolonged inactivity
Male pt c/o: severe sudden onset of pain in scrotum, relieved by elevation, also rapid swelling and fever-- what is the condition and do you do?
Epididymitis
Euphoria
Excessive well-being, unusually cheerful or elated, which is inappropriate considering physical and mental condition; implies a pathologic mood Ex. "I'm high." "I feel like I'm flying." "I feel on top of the world."
Differentiate abscess & furuncle
FURUNCLE: infected hair follicles ABSCESS: traumatic introduction of bacteria. Abcesses are usually large and deeper than furuncles.
List the Cranial Nerves in order
I: Olfactory II: Optic III: Oculomoter IV: trochlear V: Trigeminal VI: Abducens VII: Facial VIII: Auditory IX: Glossopharyngeal X: Vagus XI: Spinal accessory XII: Hypoglossal
4 Stages of Pressure Ulcers:
I: red, unbroken skin, does not blanch II: partial thickness skin erosion, loss of dermis / epidermis III: full thickness skin erosion, extends into subcutaneous tissue, resembles crater IV: full thickness skin erosion involving all skin layers, exposes muscle, tendon, bone - eschar or sloughing may be present
Nerve for vision
II: Optic
Ptosis (dropping of eyelid) is caused by what nerve
III: Oculomotor
nerve for extraocular eye movement, pupil constriction, down and inward movements of the eye
III: Oculomotor
Down & inward movement of the eye (cardinal field of gaze)
IV: Trochlear
Patch:
Larger than 1 cm Ex: mongolian spot, chloasma, measles rash
Bulla:
Larger than 1 cm diameter, single chamber, superficial in epidermis Ex: friction blister, pemphigus, burns, contact dermitis
Varicocele
Soft mass on spermatic cord; dilated toruous varcose veins on spermatic cord caused by incompetent valves, which permit blood reflux; 90% left sided; dull pain, constant pulling or dragging feeling or asymptomatic; upon palpation, it feels like soft irregular mass posterior to & above testis that collapses when supine & refills when upright; "bag of worms"; testis may be smaller due to impaired circulation
Early testicular tumor
Solitary firm, harder-than-normal nodule; painless, found on examination, may have hx of undescended testicle or familial testicular cancer
Cloudy urine
Suggests presence of WBCs, bacteria (UTI), casts (kidney stones); some foods/drugs can change urine color
Wheal:
Superficial, raised, transient, and erythematus; slightly irregular shape from edema, Ex: mosquito bite, allergic reaction, dermographism
Male Pt c/o: frequnency, nocturia, hematuria, weak stream, hesitancy, pain of burning on urination, continuous pain in lower back, pelvis, thigh
Symptoms and observations of carcinoma of the prostate
ANS: Asymmetric joint involvement Pain with motion of affected joints Affected joints are swollen with hard, bony protuberances In osteoarthritis, asymmetric joint involvement commonly affects hands, knees, hips, and lumbar and cervical segments of the spine. Affected joints have stiffness, swelling with hard bony protuberances, pain with motion, and limitation of motion. The other options reflect signs of rheumatoid arthritis.
The nurse is assessing the joints of a woman who has stated, "I have a long family history of arthritis, and my joints hurt." The nurse suspects that she has osteoarthritis. Which of these are symptoms of osteoarthritis? Select all that apply.
ANS: ballottement
The nurse should use which test to check for large amounts of fluid around the patella? A) Ballottement B) Tinel sign C) Phalen's test D) McMurray's test
Movement of tongue
XII: Hypoglossal
Flight of ideas
abrupt change; rapid skipping form topic to topic, practically continuous flow of accelerated speech; topics usually have recognizable associations or are play on words
Acute urinary retention
abrupt inability to pass urine with bladder distension & lower abdominal pain; common in men due to bladder outlet obstruction such as BPH; must catheterize to relieve discomfort
Cryptorchidism
absent testis; may be temporary migration or true cryptorchidism; in infant, try to search for testis along inguinal canal & try to milk them down; or have toddler sit with legs crossed to relax this reflex; migratory cryptorchidism due to strength of cremasteric reflex in prepubertal testes.
fixation
asymmetry, distortion, or decreased mobility with the elevated arm maneuver, as cancer becomes invasive, the fibrosis fixes the breast to the underlying pectoral muscles
___________ is the inability to perform coordinated movements
ataxia
thelarche
beginning of prepubertal breast development
Annular
circular shape to skin lesion
prepuce
foreskin; the hood or flap of skin over the glans penis that often is surgically removed after birth by circumcision
lump movable
freely movable, fixed to chest wall
Tinea Cruris
fungal infection of crural fold in postpubertal males (jock itch) after sweating or wearing occlusive clothing; red-brown half-moon shape with well defined borders
Pregnancy and lactation
gain 25-35 lbs during pregnancy... during lactation the need to increase caloric intake to 300 calories a day to keep up with body needs
Pruritus
itching. The most common skin symptom. Occurs with dry skin, aging, drug reactions, allergy, obstructive jaundice, uremia, lice
Confluent:
lesions run together ex: hives
scrotum
loose protective sac, which is a continuation of the abdominal wall, after adolescence the scrotal skin is deeply pigmented and has large sebaceous follicles t
Positive Rhomberg test indicates?
loss of balance when closing eyes, cerebellum problems
back and forth movement of eyes. Occurs with disease
nystagmus
lymphatics
of the penis and scrotal surface drain into the inguinal lymph nodes where as those of the testes drain into the abdomen
mastalgia
pain in breast
Orchitis
painful swelling of one or both testes, commonly associated with mumps that develop after puberty; does not transilluminate
Inguinal hernia test
palpate inguinal canal & ask man to bear down. Normally you feel no change. Palpable herniating mass bumps your fingertip or pushes against side of your finger. You can also palpate femoral artery on surface of skin & ask man to bear down to feel for hernia/bulge.
_________ is decreased or loss of motor function due to problem with motor nerve or muscle fibers
paralysis
___________ is impairment of loss of motor function & or sensory function in the lower half of the body
paraplegia
___________ is an abnormal sensation (burning, numbness, tingling, prickling, crawling skin sensation)
parasthesia
Wheal
raised red skin lesion due to interstitial fluid
Triglycerides
ranges are age related
difficulty understanding language
receptive aphasia
Hallucination
sensory perceptions for which there are no external stimuli; may strike any sense: visual, auditory, tactile, olfactory, gustatory
breast palpation
supide position with small pad/pillow under side to be palpated, arm raised over head, use pads of fingers and make gentle rotary movements on breast, use a pattern of concentric circles or laterally, like spokes of a wheel, palpate all areas of breast, clockwise fashion, make sure to include tail of Spence
nipple retraction
the retracted nipple looks flatter and broader, like an underlying crater. a recent retraction suggests cancer, which causes fibrosis of the whole duct system and pulls in the nipple, it may occur with benign lesions such as ectasia of the ducts, do not confuse retraction with the normal long-standing type of nipple inversion, which has no broadening and is not fixed
testicular torsion
twisting of the spermatic cord, occurs in late childhood/early adolescence; usually on left side; faulty anchoring of testis; excruciating unilateral pain with sudden onset often during sleep or following trauma; may have lower abd. pain, n/v, no fever; on palpation
___________ is ability to distinguish the separation of 2 simultaneous pinpricks on the skin
two point discrimination
Compulsion
unwanted repetitive, purposeful act; driven to do it; behavior thought to neutralize or prevent discomfort or some dreaded event
C reactive protein
used to determine when to begin nutritional support in critically ill patients
Absence of a gag reflex indicates damage to what nerve?
vagus
Cranial nerves mainly work the head and neck except for which one?
vagus
rotating spinning caused by vestibular damage
vertigo
test nerve 2 how?
visual acuity and confrontation
hood or flap
where the skin folds in and back on itself over the glans
pink urine
with menses, beets/berries, laxatives, kidney stones, UTI
Binge eating
-recurrent episodes of uncontrollable binging without compensatory behaviors -bing episode induce guilt, depression, embarrassment, or disgust
SKinfold thickness
-repeat 3 times, take average
Describe the three components of the brainstem & their function
1) *Midbrain:* contains many motor neurons & tracts 2) *Pons:* enlarged area with ascending and descending motor tracts ---> Two respiratory centers: pneumotaxic & apneuistic that coordinate w/ main respiratory center in the medulla 3) *Medulla:* continuation of spinal cord in the brain that contains all ascending and descending fiber tracts ---> Has vital autonomic centers (respiration, heart, gastrointestinal function) & nuclei for cranial nerves VIII through XII --->Pyramidal decussation (crossing of motor fibers) occurs here
1) The brain has how many hemispheres? 2) Has how many lobes? 3) Name them
1) 2 2) 4 3) frontal, temporal, occipital, and parietal
Subjective Data
1. Headache 2. Head Injury 3. Dizziness 4. Seizures 5. Tremors 6. Weakness 7. Incoordination 8. Numbness / tingling 9. Difficulty swallowing 10. Difficulty speaking 11. Patient-centered care 12. Environmental / occupational hazards
Primary Skin Lesion Types: (12 types total)
1. Macule 6. Plaque 11. Cyst 2. Patch 7. Wheal 12. Pustule 3. Nodule 8. Urticaria (hives) 4. Tumor 9. Vesicle 5. Papule 10. Bulla
Lesions (caused by trauma abuse)
1. Pattern injury (ex: cigarette burn) 2. hematoma/bruise you can feel 3. Bite marks (animal or human) 4. Contusion (bruise)
Normal GFR
125 ml/min
ANS: "Your disease is due to repeated stress on the patellar tendon. It is usually self-limited, and your symptoms should resolve with rest." Osgood-Schlatter disease is painful swelling of the tibial tubercle just below the knee. It is most likely due to repeated stress on the patellar tendon. It is usually self-limited, occurring during rapid growth and most often in males. The symptoms resolve with rest. The other responses are not appropriate.
A 14-year-old boy who has been diagnosed with Osgood-Schlatter disease reports painful swelling just below the knee for the past 5 months. Which response by the nurse is appropriate? A) "If these symptoms persist, you may need arthroscopic surgery." B) "You are experiencing degeneration of your knee, which may not resolve." C) "Your disease is due to repeated stress on the patellar tendon. It is usually self-limited, and your symptoms should resolve with rest." D) "Increasing your activity and performing knee-strengthening exercises will help to decrease the inflammation and maintain mobility in the knee."
ANS: acute gout. Acute gout occurs primarily in men over 40 years of age. Clinical findings consist of redness, swelling, heat, and extreme tenderness. Gout is a metabolic disorder of disturbed purine metabolism, associated with elevated serum uric acid. See Table 22-1 for descriptions of the other terms.
A 40-year-old man has come into the clinic with complaints of "extreme tenderness in my toes." The nurse notices that his toes are slightly swollen, reddened, and warm to the touch. His complaints would suggest: A) osteoporosis. B) acute gout. C) ankylosing spondylitis. D) degenerative joint disease.
NS: olecranon bursitis. Subcutaneous nodules are raised, firm, and nontender and occur with rheumatoid arthritis in the olecranon bursa and along the extensor surface of the ulna. See Table 22-3 for a description of the other conditions.
A 68-year-old woman has come in for an assessment of her rheumatoid arthritis, and the nurse notices raised, firm, nontender nodules at the olecranon bursa and along the ulna. These nodules are most commonly diagnosed as: A) epicondylitis. B) gouty arthritis. C) olecranon bursitis. D) subcutaneous nodules.
ANS: medial and lateral epicondyle. The epicondyles, the head of radius, and tendons are common sites of inflammation and local tenderness, or "tennis elbow." The other locations are not affected.
A professional tennis player comes into the clinic complaining of a sore elbow. The nurse will assess for tenderness at the: A) olecranon bursa. B) annular ligament. C) base of the radius. D) medial and lateral epicondyle.
ANS: of sharp pain that increases with movement A fracture causes sharp pain that increases with movement. The other pains do not occur with a fracture.
A teenage girl has arrived complaining of pain in her left wrist. She was playing basketball when she fell and landed on her left hand. The nurse examines her hand and would expect a fracture if the girl complains: A) of a dull ache. B) that the pain in her wrist is deep. C) of sharp pain that increases with movement. D) of dull throbbing pain that increases with rest.
Milia occur because: A. sebum occludes skin follicles B. of a vascular occlusion in the skin C. excess carotene is ingested D. of a genetic variation in skin tone
A. sebum occludes skin follicles
A nurse notices that a patient has ascites, which indicates the presence of: a. fluid. b. feces. c. flatus. d. fibroid tumors.
ANS: A Ascites is free fluid in the peritoneal cavity, and occurs with heart failure, portal hypertension, cirrhosis, hepatitis, pancreatitis, and cancer.
Subjective assessment of skin, hair & nails:
ASK THE FOLLOWING: * Past history of skin disease (hives, allergies, psoriasis, eczema) * Change in pigmentation * Change in mole * Excessive dryness or moisture * Pruritus * Excessive bruising * Rash or lesion * Medications * Hair loss * Change in nails * Environmental or occupational hazards * Self-care behaviors * FOR INFANT OR CHILD: ask about birthmarks, changes in skin color, diaper rash
Male pt c/o 1/2 of scrotum is empty-- what is the condition and do you do?
Absent testis, cryptochidism
Breast Lumps: Fibroadenoma
Age group: 15-30 years Shape: Round, lobular Consistency: Usually firm, rubbery Demarcation: Well demarcated, clear margins Number: Usually single Mobility: Very mobile, slippery Tenderness: Usually none Skin retraction: None Pattern of growth: Grows quickly and constantly *Benign—Diagnose by ultrasound and biopsy; may spontaneously resolve in women <20 years. Should be resected in women >35 years as it carries a small risk of associated cancer.
PALLOR: (in dark skin)
Appears yellow-brown, dull; black skin-> ashen gray, dull
When the meatus opens on the dorsal (upper) side of the glans or shaft
Epispadias
Rage
Furious, loss of control Ex. person has expressed violent behavior towards self or others
soft, pointed, moist, fleshy, painless papules (cauliflower like) on the shaft of the penis
Genital Warts
Standardized objective assessment that defines the LOC by giving it a numerical value
Glasgow coma scale
Male pt c/o painless swelling, although might have a sensation of increased weight or bulk in scrotum
Hydrocele
Opening of the urethral meatus on the ventrical (under) side of the glans or shaft
Hypospadius
Depersonalization
Loss of identity, feels estranged, perplexed about own identity and meaning of existence Ex. "I don't feel real." "I feel like I'm not really here."
Common variations on aging adult's skin:
LENTIGINES: liver spots SEBORRHEIC KERATOSIS: dark, greasy, "stuck on" - trunk, face, hands ACTINIC KERATOSIS" scaly, silver-white plaques - pre-malignant ACROCHORDONS: Skin tags, over growth of normal skin SEBACEOUS HYPERPLASIA: raised yellow papules w/central depression (mostly men), over forehead, nose, cheeks, pebbly look
ANS: 5 lumbar. There are 7 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 3 to 4 coccygeal vertebrae.
Of the 33 vertebrae in the spinal column, there are: A) 5 lumbar. B) 5 thoracic. C) 7 sacral. D) 12 cervical.
male c/o: acute or moderate pain of sudden onset, swollen testis, feeling of weight and fever. Note redness, swelling and tenderness. Does not trans-illuminate. what is the condition and do you do?
Orchitis
Explain Glasgow coma scale
Scale is divided into three areas: 1) eye opening 2) motor response 3) verbal response. --> Each area is rated separately and a number is given for the persons best response. --> Numbers are added together. --> Total score reflects the brains functional level as a whole. --> A fully alert normal person has a score of 15. --> A score of 7 or less reflects coma.
Pressure Ulcer (STAGES)
Stage 1: skin is red, not broken Stage 2: partial-thickness skin erosion, superficial (epidermis and dermis) Stage 3: Full-thickness ulcer, into the subcutaneous layer Stage 4: Full- thickness- involves all supporting tissue, brown/black necrotic tissue
Cranial Nerve XI --> Spinal Accessory Nerve Normal Abnormal
Testing motor functions *NORMAL* - Sternomastoid + trapezius muscle = size - Head + chin against force = strength - Shrugging of shoulder against force = strength *ABNORMAL* - Atrophy - Muscle weakness - Paralysis *POSSIBLE CAUSES ...* - Stroke - Injury to the peripheral nerve (surgical removal of lymph nodes)
Cranial Nerve XII --> Hypoglossal Nerve Normal Abnormal
Testing motor functions *NORMAL* - Tongue = NO tremors + wasting - Tongue = midline - Lingual speech = clear + distinct *ABNORMAL* - Atrophy - Tongue = NOT midline - Deviate towards paralyzed side
Cranial Nerve IX and X --> Glossopharyngeal + Vagus Nerve Normal Abnormal
Testing motor functions *NORMAL* - Uvula + soft palate rise in the midline (saying "ahhhh") - Tonsillar pillars move medially - Voice = smooth - Gag reflex *ABNORMAL* - Absence / asymmetry soft palate movement + tonsillar pillars - Hoarse + brassy voice *POSSIBLE CAUSES ...* - Stroke - Vocal cord dysfunction - Nasal twang (exaggerated nasality in speech)
ANS: flex the hip. The ischial tuberosity lies under the gluteus maximus muscle and is palpable when the hip is flexed.
The nurse is assessing a patient's ischial tuberosity. To palpate the ischial tuberosity, the nurse knows that it is best to have the patient:
ANS: Flexion and extension The knee is a hinge joint, permitting flexion and extension of the lower leg on a single plane. The knee is not capable of the other movements listed.
The nurse is checking the range of motion in a patient's knee and knows that the knee is capable of which movement(s)? A) Flexion and extension B) Supination and pronation C) Circumduction D) Inversion and eversion
ANS: Hip dislocation Unequal gluteal folds may accompany hip dislocation after 2 to 3 months of age, but some asymmetry may occur in healthy children. Further assessment is needed. The other responses are not correct.
The nurse is examining a 2-month-old infant and notices asymmetry of the infant's gluteal folds. The nurse should assess for other signs of what disorder? A) Fractured clavicle B) Down syndrome C) Spina bifida D) Hip dislocation
ANS: negative Ortolani's sign. Normally this maneuver feels smooth and has no sound. With a positive Ortolani's sign, the nurse will feel and hear a "clunk" as the head of the femur pops back into place. A positive Ortolani's sign reflects hip instability. The Allis test also tests for hip dislocation, but is done by comparing leg lengths.
The nurse is examining a 3-month-old infant. While holding the thumbs on the infant's inner mid thighs and the fingers outside on the hips, touching the greater trochanter, the nurse adducts the legs until the nurse's thumbs touch and then abducts the legs until the infant's knees touch the table. The nurse does not notice any "clunking" sounds and is confident to record a: A) positive Allis test. B) negative Allis test. C) positive Ortolani's sign. D) negative Ortolani's sign.
ANS: This is a positive Allis sign and suggests hip dislocation. Finding one knee significantly lower than the other is a positive Allis sign and suggests hip dislocation. Normally the tops of the knees are at the same elevation. The other statements are not correct.
The nurse is examining a 6-month-old infant and places the infant's feet flat on the table and flexes his knees up. The nurse notes that the right knee is significantly lower than the left. Which of these statements is true of this finding? A) This is a positive Allis sign and suggests hip dislocation. B) The infant probably has a dislocated patella on the right. C) This is a normal finding for the Allis test for an infant of this age. D) The infant should return to the clinic in 2 weeks to see if this has changed.
ANS: glenohumeral joint. A rotator cuff injury involves the glenohumeral joint, which is enclosed by a group of four powerful muscles and tendons that support and stabilize it. The nucleus pulposus is located in the center of each intervertebral disk. The medial epicondyle is located at the elbow.
The nurse is providing patient education for a man who has been diagnosed with a rotator cuff injury. The nurse knows that a rotator cuff injury involves the: A) nucleus pulposus. B) articular process. C) medial epicondyle. D) glenohumeral joint.
ANS: hold both hands back to back while flexing the wrists 90 degrees for 60 seconds. For the Phalen's test, the nurse should ask the person to hold both hands back to back while flexing the wrists 90 degrees. Acute flexion of the wrist for 60 seconds produces no symptoms in the normal hand. The Phalen's test reproduces numbness and burning in a person with carpal tunnel syndrome. The other actions are not correct for testing for carpal tunnel syndrome.
The nurse suspects that a patient has carpal tunnel syndrome and wants to perform the Phalen's test. To perform this test, the nurse should instruct the patient to: A) dorsiflex the foot. B) plantarflex the foot. C) hold both hands back to back while flexing the wrists 90 degrees for 60 seconds. D) hyperextend the wrists with the palmar surface of both hands touching and wait for 60 seconds.
Anxiety
Worried, uneasy, apprehensive from the anticipation of a danger whose source is unknown Ex. "I feel nervous and high-strung." "I worry all the time." "I can't seem to make up my mind."
Fear
Worried, uneasy, apprehensive; external danger is known and identified Ex. Fear of flying in airplanes
Intention Tremor
Worse with voluntary movements - rate varies *OCCURS WITH ...* - Cerebellar disease - MS *ESSENTIAL TREMORS* - most common in elders - benign + causes emotional stress during business / social situations *IMPROVES WITH ...* - Sedatives (propranolol) - Alcohol (not recommended = addiction)
Talking, swallowing, and sensory information from pharynx and carotid sinus
X: Vagus
Movement of trapezius and sternomastoid muscles
XI: Spinal Accessory
Test the cerebellum for ______
balance
The corneal reflex may be absent in?
contact lens wearers, elderly
_________ is the loss of motor power/paralysis on one side of the body usually caused by CVA; paralysis occurs on side opposite the lesion
hemiplegia
mastitis
inflammation of the breast, uncommon, inflammatory mass before abscess formation, usually occurs in single quadrant, area is red, swollen, tender, very hot, and hard, headache, malaise, fever, chills, sweating, increased pulse, flulike symptoms, may occur during first 4 months of lactaion from infection, or from stasis from plugged duct. treat with rest local heat to area, antibiotics, and frequent nursin to keep breast as empty as possible, must not wean now or the breast will become engorged and pain will increase
Renal calculi
kidney stones (calcium oxalate or uric acid crystals) in kidney tubules & migrate & become urgent as they get lodged in ureter & obstruct urine flow --> abrupt severe flank pain with radiation to groin or abdomen, n/v, restlessness, hematuria
Flat affect
lack of emotional response, no expression of feelings, voice monotonous and face immobile
tea colored urine
liver disease, jaundice, myoglobinuria, medications, blood
DRE
locate prostate in rectum looking for bumps and hard areas
Depression
long term depressed mood, with lack of pleasure, disturbed sleep and appetite, feelings of hopelessness, guilt, worthlessness, sadness, loneliness and despar, suicide ideation
Time from 4 months of age
most rapid period of growth in life cycle... infants lose weight during first few days of life
Urethral Stricture
narrowed opening of penis, shown by pinpoint meatus & narrow urine stream that may be caused by ulceration & increases risk for urine obstruction; poor stream is the red flag here; it may also indicate neurogenic bladder (autonomic bladder dysfunction)
Growth and repair of tissues
need protein, lipids, minerals and water
when to preform transillumination
only if you note a swelling or mass shine strong flashlight behind scrotal contents, normally doesnt transilluminate serous fluid transilluminates and shows a red glow solid tissue and blood do not transilluminate
mature breast
only the nipple protrudes; the areola is flush with the breast contour (the areola may continue as a secondary mound in some normal women)
Perseveration
persistent repeating of verbal or motor response, even with varied stimuli
Tinea pedis
ringworm of the foot
Erosion
scooped out, shallow depression in skin
Erosion
shallow depression, superficial
_________ is repetitive twitching of muscle group @ inappropriate times (wink/grimace)
tic
Obsession
unwanted, persistent thoughts or impulses; logic will not purge them from consciousness; experienced as intrusive and senseless
Ranges of triglycerides
up to 19..... 10-100 less than 20... 40-200
___________ is a nerve located entirely within the central nervous system
upper motor neuron
Chorea
*Definition* = Sudden + rapid + jerky + purposeless movements - limbs, trunk / face Irregular intervals - NOT rhythmic / repetitive Happens with voluntary acts Disappears with sleep *Common with ....* - Sydenham chorea - Huntington's disease
Tumor:
larger than a few cm in diameter, firm or soft, deeper into dermis; may be benign or malignant Ex: lipoma, hemangioma
Fissure
linear crack in skin extending into dermis
Fissure
linear crack- think of a tear in the skin
Zosteriform
linear shape of skin lesion along a nerve route
Harlequin
lower half of body turns red, upper half blanches
the __________ in the peripheral nervous system with its nerve fiber extending out to the muscle and only its cell body in the CNS
lower motor neuron
The physician comments that a patient has abdominal borborygmi. The nurse knows that this term refers to: a. a loud continuous hum. b. a peritoneal friction rub. c. hypoactive bowel sounds. d. hyperactive bowel sounds.
ANS: D Borborygmi is the term used for hyperperistalsis when the person actually feels his or her stomach growling.
breasts
mammary glands, lie anterior to the pectoralis major and serratus anterior muscles, located between the second and sixth ribs, extending from the side of the sternum to the midaxillary line, are accessory reproductive organs, and function to produce milk for nourishing the newborn.
Scrotal swelling
may be taut & pitting; occurs with heart failure, renal failure & local inflammation
Serum transferrin
measures iron binding capacity 170-250
Blue urine
medication side effect; asparagus; dye after prostate surgery
During an interview the patient states, *"I can feel this bump on the top of both of my shoulders, it doesn't hurt but I am curious about what it might be."* The nurse should tell the patient, "That is: a. your subacromial bursa." b. your acromion process." c. your glenohumeral joint." d. the greater tubercle of your humerus."
ANS: B The bump of the scapula's acromion process is felt at the very top of the shoulder. The other options are not correct.
Orange urine
medication side effect; some foods, laxatives, dehydration, jaundice
HbA1c
minior component of hemoglobin to which gucose is bound
supernumerary nipple
minute extra nipple along the embryonic milk line (track of the mammary ridge)
Illusion
misperception of an actual existing stimulus, by any sense
adipose tissue
where the lobes are suspended, layers of subcutaneous and retromammary fat actually provide most of the bulk of the breast. relative proportion of glandular, fibrous, and fatty tissue varies, depending on age, cycle, pregnancy, lactation, and general nutritional state
During an examination, the nurse would expect the cervical os of a woman who has never had children to appear: a. stellate. b. small and round. c. as a horizontal irregular slit. d. everted.
ANS: B The cervical os in a nulliparous woman is small and round. In the parous woman, it is a horizontal, irregular slit that also may show healed lacerations on the sides. See Figure 26-13.
ejaculatory duct
where the vas diferens continues back and down behind the bladder and joins the duct of the seminal vesicle, empties into the urethra
inspect and palpate axilllae
while patient is sitting, lift and support the arm so patient's muscles are relaxed, use the right hand to palpate the left axillae, reach fingers high into axillae, move fingers firmly down in four directions: down the chest wall, along the anterior and posterior borders of axillae and around the inner aspect of the arm. move arm through ROM to have access to areas
Hair-line linear markings:
white linear markings that normally are visible through the and on the pink nail bed.
Peau d'orange
with edema, hair follicles are more prominent, giving a pigskin or orange-peel look
Changing
word choice based on sound, not meaning, includes nonsense rhymes and puns
Physiologic jaundice
yellowing of skin, sclera, and mucous membranes due to increased numbers of red blood cells hemolyzed following birth
A 70-year-old woman tells the nurse that every time she gets up in the morning or after she's been sitting she gets "really dizzy" and feels like she is going to fall over. The nurse's best response would be:
ANS: "You need to get up slowly when you've been lying or sitting." Aging is accompanied by a progressive decrease in cerebral blood flow. In some people this causes dizziness and a loss of balance with position change. These people need to be taught to get up slowly. The other responses are incorrect.
Objective assessment of nails
* Inspect and palpate the nails, evaluating the shape, contour, consistency, and color. * Assess capillary refill
Objective assessment of skin
* Observe color & general pigmentation. * Observe subtle skin tone changes: symmetrical skin tone * Observe for color changes that may not be visible: mucous membranes, lips, nail beds, sclera * Assess skin temperature, moisture, texture, thickness, edema, mobility, turgor, vascularity or bruising, and lesions. * If a lesion is observed, note: color, elevation, shape, size, location and distribution on the body, and any exudate
Key properties of skin
* Protects the body * Prevents penetration * Allows perception of touch, pain, temperature, and pressure * Regulates temperature * Allows identification of people * Allows communication of emotions * Repairs wounds * Absorbs and excretes substances * Produces vitamin D
10 Warning Signs of Alzheimer's Disease
*1. MEMORY LOSS* - Forgetting recently learned information - Unable to recall information *2. LOSING TRACK* - Hard time performing familiar / everyday tasks *3. FORGETTING WORDS* - Forgets simple words (EX. tooth brush = that thing for my mouth) *4. GETTING LOST* - Disoriented to time + place (even in their own neighborhood) *5. POOR JUDGEMENT* - May wear up to 7 layers of clothings in a warm weather *6. ABSTRACT FAILING* - Hard time performing complex mental tasks (EX. forgetting what numbers are used for + how should it be used) *7. LOSING THINGS* - Misplacing things (EX. Putting clothes in the refrigerator) *8. MOOD SWINGS* - Rapid mood swings = no particular reasons *9. PERSONALITY CHANGES* - Dramatic changes (EX. Calm - crying within seconds) *10. GROWING PASSIVE* - Sleeping more than usual - Sitting in front of t.v. for long periods of time - Not wanting to do usual / daily activities
Objective Data
*1.* Perform Screening Neurologic Examination - Cranial nerves (2,3,6,7,8) - Motor function (strength + gait) - Sensation - Reflexes *2.* Complete Neurologic Examination - On patients who have neurologic concerns *3.* Neurologic Recheck - On patients who have neurologic deficits + require periodic assessments
Stretch Reflexes / Deep Tendon Reflexes (DTRs) Grading Scale
*4+* = Very brisk + hyperactive w/ clonus (rapid rhythmic contractions of same muscle) + indicative of disease *3+* = Brisker than average - may indicate disease (probably normal) *2+* = Average + normal *1+* = Diminished + low normal (occurs only with reinforcements) *0* = No response
CN XI = Spinal Accessory Abnormalities Possible Causes
*ABNORMALITIES* - Absence of movement of sternomastoid / trapezius muscles ( cannot turn head / shrug shoulders) *POSSIBLE CAUSES* - Neck injury - Torticollis (genetic - chin pulls back into shoulders = limitied ROM)
CN VII = Facial Abnormalities Possible Causes
*ABNORMALITIES* - Absent / symmetric facial movement -Loss of taste *POSSIBLE CAUSES* - Bell Palsy (LMN lesion) - Stroke - Tumor - Paralysis
CN I = Olfactory Abnormalities Possible Causes
*ABNORMALITIES* - Anosmia *POSSIBLE CAUSES* - Upper respiratory infections - Tobacco / cocaine use - Fracture of ethmoid area - Frontal lobe lesion - Tumor in olfactory bulb / tract
CN VIII = Acoustic Abnormalities Possible Causes
*ABNORMALITIES* - Decrease / loss of hearing *POSSIBLE CAUSES* - Inflammation - Occluded ear canal - Otosclerosis - Prebycusis - Drug toxicity - Tumor
CN II = Optic Abnormalities Possible Causes
*ABNORMALITIES* - Defect / absence of central vision - Defect in peripheral vision - Hemianopsia ( decreased vision / blindness in half of the visual field per eye) - Absent light reflex - Papilledema - Optic atrophy - Retinal lesions *POSSIBLE CAUSES* - Congenital blindness - Diseases (EX. Stroke / diabetes) - Trauma to orbit area - Increased ICP - Glaucoma
CN III = Oculomotor Abnormalities Possible Causes
*ABNORMALITIES* - Dilated pupils - Ptosis - Eye turns out + slightly down - Fail to move eye up + in + down - Absent light reflex *POSSIBLE CAUSES* - Paralysis from internal carotid aneurysm - Tumor - Inflammatory lesions - Oculomotor nerve palsy - Blindness - Drug influence - CNS injury
CN VI = Abducens Abnormalities Possible Causes
*ABNORMALITIES* - Failure to move eyes laterally - Diplopia (double vision) on later gaze *POSSIBLE CAUSES* - Brain stem tumor - Trauma - Fracture of orbit
CN IV = Trochlear Abnormalities Possible Causes
*ABNORMALITIES* - Failure to turn eyes down / out *POSSIBLE CAUSES* - Fracture of orbit - Brainstem tumor
CN IX = Glossopharyngeal Abnormalities Possible Causes
*ABNORMALITIES* - No gag reflexes *POSSIBLE CAUSES* - Weakness in vocal cords
Cranial Nerve I --> Olfactory Nerve (nose) Normal Abnormal
*DO NOT TEST ROUTINELY* Only test if patient report of *head trauma* + *abnormal mental status* + *presence of intracranial lesion* suspected *CANNOT* be tested if patient's passage way is occluded by upper respiratory infection / sinusitis *NORMAL* - Patient able to identify odor on both sides - Decreased *BILATERALLY* with aging - Symmetry *ABNORMAL* - Asymmetrical - Loss of sense on one side *POSSIBLE CAUSES ...* - Tobacco smoking - Allergic rhinitis - Cocaine usage
Athetosis
*Definition* = Slow + twisting + writhing + continuous movement resembling a snake / worm Involves more distal parts of the limb than proximal *OCCURS WITH ...* - Cerebral palsy Disappears with sleep
Paralysis
*Definition* = decreased / loss of motor power caused by problem with motor nerve / muscle fibers *CAUSES ... ACUTE* - Trauma - Spinal cord injury - Stroke - Poliomyelitis - Poluneuritis - Bell palsy *CAUSES ... CHRONIC* - Muscular dystrophy - Diabetic neuropathy - MS - Myasthenia Gravis *PATTERNS* - *Hemiplegia* = spastic / flaccid on one side of body + extremities - *Paraplegia* = symmetric paralysis of both extremities - *Quadriplegia* = paralysis in all 4 extremities - *Paresis* = weakness of muscles rather than paralysis
Seizure Disorder
*Definition* = excessive hyper-synchronous discharge of neurons *POSSIBLE CAUSES ...* - Cerebral trauma - Tumor + blood clot + infection - Hyponatremia - Acute alcohol + withdrawal - Medication overdose - Epilepsy *GRAND MAL SEIZURE* 1. Loss of consciousness 2. Tonic phase - muscular rigidity + opening of mouth and eyes + tongue biting + high pitched cry 3. Clonic Phase - Violent muscle contractions - Facial grimacing - Increased hear rate 4. Deep sleep + disorientation + confusion
Tic
*Definition* = involuntary + compulsive + repetitive twitching of a muscle group Due to neurologic (Tourette syndrome) / psychogenic (habit) cause
Tremor
*Definition* = involuntary contractions of opposing muscle groups Rhythmic + back and forth movement of 1+ joints - May occur at rest / voluntary movement Disappears while sleeping Slow rate = 3-6/ sec Fast rate = 10-20/ sec
Rest Tremor
*Definition* = muscles are quiet + supported against gravity Coarse + slow (3-6/sec) Partly / completely disappears with voluntary movements (EX. "pill rolling")
Fasciculation
*Definition* = rapid + continuous twitching of resting muscle / part of muscle without movement / limb *TYPES* 1. Fine - associated with LMN disease + atrophy + weakness 2. Coarse - occurs with cold exposure / fatigue + not significant
Myclonus
*Definition* = rapid + sudden jerk / short series of jerks at fairly regular intervals EX. hiccup = myoclonus at diaphragm Single myoclonic arm / leg = normal when person is falling asleep *SEVERE* with grand mal seizures
Muscle Tone ABNORMALITIES
*FLACCIDITY* *Definition* = decreased muscle tone. Muscle = weak + easily fatigued *Associated with ...* - Lower motor neuron (LMN) injury (anywhere from anterior horn cell - spinal cord - peripheral nerves) - Early stroke - Spinal cord injury *SPASTICITY* *Definition* = increased muscle tone. (spasm) *Associated with ...* - Upper motor neuron (UMN) injury to corticospinal motor tract (EX. paralysis with stroke) *RIGIDITY* *Definition* = Constant state of resistance / resists passive movements in any direction *Associated with... * - Injury to extrapyramidal motor tracts *COGNWHEEL RIGIDITY* *Definition* = increased tone is released by degrees during passive range of motion / small + regular jerking motions *Associated with ...* - Parkinsonism
Decorticate Rigidity
*Indicates* = hemispheric lesion of cerebral cortex *UPPER EXTREMITIES* - Flexion of arm + wrist + fingers - Adduction of arm ( tight against thorax) *LOWER EXTREMITIES* - Extension - Internal rotation - Plantar flexion
Decerebrate Rigidity
*Indicates* = lesion in brainstem at midbrain / upper pons *UPPER EXTREMITIES* - Stiffly extended + adducted - Internal rotations - Palms pronated *LOWER EXTREMITIES* - Stiffly extended - Plantar flexion - Teeth clenched - Hyperextended back
Sucking Relfex
*Method of Testing* - Touch oral region *Abnormal* - Sucking movement of lips + tongue + jaw + swallowing *Indicates* - Frontal lobe disease - Cerebral degenerative disease (EX. Alzheimer's disease) - Amyotrophic sclerosis - Corticobulbar lesions
Grasp Reflex
*Method of Testing* - Touch palm with your finger *Abnormal* - Uncontrolled + forced grabbing (Usually last thing to appear - IF appears = severe disease) *Indicates* - Frontal lobe lesion on collateral side (UNILATERAL) - Diffuse bifrontal lobe disease (BILATERAL)
Nystagmus
*NORMAL* - Extreme lateral gaze from cardinal gaze " cat whiskers" *ASSESS + NOTING ...* *1.* Presence in 1+ eye *2.* Pendular movement (movement right + left at regular speed) / Jerk (quick phase in one direction - slow down in other phase) - Classify jerk in direction of quick phase *3.* Amplitude - Degree of movement = fine, medium, coarse *4.* Frequency - Constant? - Fade after every few beats? *5.* Plane of movement - Horizontal, Vertical, Rotary, or combination?
Cranial Nerve III, IV, VI --> Oculomotor, Trochlear, Abducens Nerves (eye movements) Normal Abnormal
*NORMAL* - Palpebral fissures = width - Pupil (PERRLA) - Cardinal Gaze / "Cat Whiskers" = NO NYSTAGMUS *ABNORMAL* - Ptosis - Unilateral + dilated + nonreactive pupil = increased ICP - Strabismus
Moro Reflex
*Present at BIRTH - disappears at 1-4 MONTHS* Startled infant by making loud noises - "hugging a tree" NORMAL = symmetric abduction of arms + legs
Sucking Reflex
*Present at BIRTH - disappears at 10-12 MONTHS* Light touch lip + offer gloved finger for infant to suck on NORMAL = strong sucking reflex
Babinski Reflex
*Present at BIRTH - disappears at 24 MONTHS* Stroke finger up lateral edge across the ball of the infants foot NORMAL = *NO* fanning of the toes
Plantar Grasp Reflex
*Present at BIRTH - disappears at 8-10 MONTHS* Touch thumb at ball fo baby's foot NORMAL = toes curls down tightly
Ischemic Stroke
*SUDDEN* interruption of blood flow to the brain + accounts for 87% of strokes! *THROMBOTIC STROKES* - Atherosclerotic plaque formation - Insufficient O2 + glucose not being supplied to brain tissues *EMBOLIC STROKES* - Caused by atrial fibrillation + flutter + recent heart attacks + growth around prosthetic heart valves + endocarditis *ACUTE ISCHEMIC STROKES* *Signs + Symptoms* - Unilateral facial drooping - Arm drift - Weakness / paralysis on one half of the body - Difficulty speaking / understanding speech - Confusion - Loss of balance - Clouding of vision
Posterior (Dorsal) Column Tract Test
*VIBRATIONS* - Using a tuning fork over bony prominences (big toe) - Tell patient to tell you to indicate when vibrations start / stop - Normal = buzzing / vibrations at the distal area *POSITIONS (KINESTHESIA)* - Patient has eyes closed - You (health care provider) move fingers / toe up and down - Patient tells you whether it's moving up or down
Breast Development in Adolescents
-The onset of breast development occurs at an average (mean) age between 8 and 9 years for African-American girls and by 10 years for White girls. -One breast may grow faster than the other, producing a temporary asymmetry. -Tenderness is common. -Mature breast: Only the nipple protrudes; the areola is flush with the breast contour (the areola may continue as a secondary mound in some normal women). -Adolescent growth spurt around 12 years of age. -During the 3 to 4 days before menstruation, the breasts feel full, tight, heavy, and occasionally sore.
Aphasia
-disorder of language comprehension and production secondary to brain damage -true language disturbance, defect in word choice and grammar or defect in comprehension; defect is in higher integrative language processing
What is delirium characterized by?
-disorientation -disorder thinking and perceptions -defective memory -agitation -inattention
What is dementia characterized by?
-disorientation -impaired judgement -memory loss
Signs of malnutrition
-dry skin -dry hair -foamy plaqes on eyes -cracked lips -bleeding gums -brittle nails -pain in calves/muscles -issues with neuro
Broca aphasia
-expressive aphasia -can understand language but is unable to express thoughts -speech is mostly nouns and verbs
What is GAD characterized by?
-restlessness -muscle tension -diarrhea -palpitations -tachypnea -hypervigilance -fatigue -sleep disturbance
Adolescent Subjective Data
-weight loss (weight loss attempts vs obese) -anabolic steroids
ANS: Rheumatoid arthritis Rheumatoid arthritis is worse in the morning when arising. Movement increases most joint pain, except in rheumatoid arthritis, in which movement decreases pain. The other options are not correct.
A patient is complaining of pain in his joints that is worse in the morning, is better after he has moved around for awhile, and then gets worse again if he sits for long periods of time. The nurse should assess for other signs of what problem? A) Tendinitis B) Osteoarthritis C) Rheumatoid arthritis D) Intermittent claudication
ANS: dislocated shoulder. Dislocated shoulder occurs with trauma involving abduction, extension, and external rotation (e.g., falling on an outstretched arm or diving into a pool). See Table 22-2 for a description of the other conditions.
A young swimmer comes to the sports clinic complaining of a very sore shoulder. He was running at the pool, slipped on some wet concrete, and tried to catch himself with his outstretched hand. He landed on his outstretched hand and has not been able to move his shoulder since then. The nurse suspects: A) joint effusion. B) tear of rotator cuff. C) adhesive capsulitis. D) dislocated shoulder.
What term refers to a linear skin lesion that runs along a nerve route? A. Zosteriform B. Annular C. Dermatome D. Shingles
A. Zosteriform
ANS: a common benign tumor." A ganglionic cyst is a common benign tumor; it does not become malignant, and it does not need to be drained. It is not caused by chronic repetitive motion injury
A patient has been diagnosed with a ganglion cyst over the dorsum of his left wrist. He asks the nurse, "What is this thing?" The nurse's best answer would be, "It is: A) a common benign tumor." B) a tumor that will have to be watched because it may turn malignant." C) caused by chronic repetitive motion injury." D) a skin infection that will need to be drained."
A flat macular hemorrhage is called a(n): A. Purpura B. Ecchymosis C. Petechiae D. Hemangioma
A. Purpura
The nurse is examining a 62-year-old man and notes that he has gynecomastia bilaterally. The nurse should explore his history for which related conditions? Select all that apply. a. Malnutrition b. Hyperthyroidism c. Type 2 diabetes mellitus d. Liver disease e. History of alcohol abuse
ANS: Hyperthyroidism Liver disease History of alcohol abuse Gynecomastia occurs with obesity, Cushing's syndrome, liver cirrhosis, adrenal disease, hyperthyroidism, and numerous drugs: alcohol and marijuana use, estrogen treatment for prostate cancer, antibiotics (metronidazole, isoniazid), digoxin, ACE inhibitors, diazepam, and tricyclic antidepressants.
The nurse is preparing to teach a woman about breast self-examination (BSE). Which statement by the nurse is correct? a. "BSE is more important than ever for you because you have never had any children." b. "BSE is so important because one out of nine women will develop breast cancer in her lifetime." c. "BSE on a monthly basis will help you become familiar with your own breasts and feel their normal variations." d. "BSE will save your life because you are likely to find a cancerous lump between mammograms."
ANS: "BSE on a monthly basis will help you feel familiar with your own breasts and their normal variations." The nurse should stress that a regular monthly self-examination will familiarize her with her own breasts and their normal variations. This is a positive step that will reassure her of her healthy state. While teaching, the nurse should focus on the positive aspects of breast self-examination and should avoid citing frightening mortality statistics about breast cancer. This may generate excessive fear and denial that actually obstructs a woman's self-care action.
A 55-year-old postmenopausal woman is being seen in the clinic for a yearly examination. She is concerned about changes in her breasts that she has noticed over the past 5 years. She states that her breasts have decreased in size and that the elasticity has changed so that her breasts seem "flat and flabby." The nurse's best reply would be: a. "This change occurs most often because of long-term use of bras that do not provide enough support to the breast tissues." b. "This is a normal change that occurs as women get older and is due to the increased levels of progesterone during the aging process." c. "Decreases in hormones after menopause causes atrophy of the glandular tissue in the breast and is a normal process of aging." d. "Postural changes in the spine make it appear that your breasts have changed in shape. Exercises to strengthen the muscles of the upper back and chest wall will help prevent the changes in elasticity and size."
ANS: "Decreases in hormones after menopause causes atrophy of the glandular tissue in the breast. This is a normal process of aging." The hormonal changes of menopause cause the breast glandular tissue to atrophy, making the breasts more pendulous, flattened, and sagging.
When taking the history on a patient with a seizure disorder, the nurse assesses whether the patient has an aura. Which of these would be the best question for obtaining this information?
ANS: "Do you have any warning sign before your seizure starts?" Aura is a subjective sensation that precedes a seizure; it could be auditory, visual, or motor. The other questions are not correct regarding asking about an aura.
During a discussion about breast self-examination with a 30-year-old woman, which of these statements by the nurse is most appropriate? a. "The best time to examine your breasts is during ovulation." b. "Examine your breasts every month on the same day of the month." c. "Examine your breasts shortly after your menstrual period each month." d. "The best time to examine your breasts is immediately before menstruation."
ANS: "Examine your breasts shortly after your menstrual period each month." The best time to conduct breast self-examination is shortly after the menstrual period when the breasts are the smallest and least congested.
The mother of a 5-year-old girl tells the nurse that she has noticed her daughter "scratching at her bottom a lot the last few days." During the assessment, the nurse finds redness and raised skin in the anal area. This most likely indicates: a. pinworms. b. chickenpox. c. constipation. d. bacterial infection.
ANS: A In children, pinworms are a common cause of intense itching and irritated anal skin. The other options are not correct.
During the assessment of deep tendon reflexes, the nurse finds that a patient's responses are normal bilaterally. What number is used to indicate "normal" deep tendon reflexes when the documenting this finding. _____+
ANS: 2 Responses to assessment of deep tendon reflexes are graded on a 4-point scale. A rating of 2+ indicates normal or average response. A rating of 0 indicates no response, and a rating of 4+ indicates very brisk, hyperactive response with clonus, which is indicative of disease.
The nurse is reviewing a patient's medical record and notes that he is in a coma. Using the Glasgow Coma Scale, which number indicates that the patient is in a coma?
ANS: 6 A fully alert, normal person has a score of 15, whereas a score of 7 or less reflects coma on the Glasgow Coma Scale. See Figure 23-59.
The nurse is reviewing risk factors for breast cancer. Which of these women have risk factors that place them at a higher risk for breast cancer? a. 37 year old who is slightly overweight b. 42 year old who has had ovarian cancer c. 45 year old who has never been pregnant d. 65 year old whose mother had breast cancer
ANS: 65 year old whose mother had breast cancer Risk factors for breast cancer include having a first-degree relative with breast cancer (mother, sister, or daughter) and being older than 50 years. Refer to Table 17- 2 for other risk factors.
A patient tells the nurse that she is having a *hard time bringing her hand to her mouth when she eats or tries to brush her teeth*. The nurse knows that for her to move her hand to her mouth, she must perform which movement? a. flexion. b. abduction. c. adduction. d. extension.
ANS: A *Flexion*, or bending a limb at a joint, would be required to move the hand to the mouth. Extension is straightening a limb at a joint. Moving a limb toward the midline of the body is called adduction; abduction is moving a limb away from the midline of the body.
The nurse is reviewing a patient's medical record and notes that he is in a coma. Using the Glasgow Coma Scale, which number indicates that the patient is in a coma? a. 6 b. 12 c. 15 d. 24
ANS: A A fully alert, normal person has a score of 15, whereas a score of 7 or less reflects coma on the Glasgow Coma Scale. See Figure 23-59.
A patient has been diagnosed with a ganglion cyst over the dorsum of his left wrist. He asks the nurse, "What is this thing?" The nurse's best answer would be, "It is: a. a common benign tumor." b. a tumor that will have to be watched because it may turn malignant." c. caused by chronic repetitive motion injury." d. a skin infection that will need to be drained."
ANS: A A ganglionic cyst is a common benign tumor; it does not become malignant, and it does not need to be drained. It is not caused by chronic repetitive motion injury.
In the assessment of a 1-month-old infant, the nurse notices a lack of response to noise or stimulation. The mother reports that in the last week he has been sleeping all the time, and when he is awake all he does is cry. The nurse hears that the infant's cries are very high pitched and shrill. What should be the nurse's appropriate response to these findings? a. Refer the infant for further testing. b. Talk with the mother about eating habits. c. Nothing; these are expected findings for an infant this age. d. Tell the mother to bring the baby back in a week for a recheck.
ANS: A A high-pitched, shrill cry or cat-sounding screech occurs with central nervous system damage. Lethargy, hyporeactivity, hyperirritability, and parent's report of significant change in behavior all warrant referral. The other options are not correct responses.
The nurse is reviewing statistics for lactose intolerance. In the United States, the incidence of lactose intolerance is higher in adults of which ethnic group? a. African-Americans b. Hispanics c. Whites d. Asians
ANS: A A recent study found lactose-intolerance prevalence estimates as follows: 19.5% for African-Americans, 10% for Hispanics, and 7.72% for whites.
A 21-year-old patient has a head injury resulting from trauma and is unconscious. There are no other injuries. During the assessment what would the nurse expect to find when testing the patient's deep tendon reflexes? a. Reflexes will be normal. b. Reflexes cannot be elicited. c. All reflexes would be diminished but present. d. Some would be present depending on the area of injury.
ANS: A A reflex is a defense mechanism of the nervous system. It operates below the level of conscious control and permits a quick reaction to potentially painful or damaging situations.
Just before going home, a new mother asks the nurse about the infant's umbilical cord. Which of these statements is correct? a. "It should fall off by 10 to 14 days." b. "It will soften before it falls off." c. "It contains two veins and one artery." d. "Skin will cover the area within 1 week."
ANS: A At birth, the umbilical cord is white and contains two umbilical arteries and one vein inside the Wharton jelly. The umbilical stump dries within a week, hardens, and falls off by 10 to 14 days. Skin will cover the area by 3 to 4 weeks.
The nurse should use which test to check for large amounts of fluid around the patella? a. Ballottement b. Tinel sign c. Phalen's test d. McMurray's test
ANS: A Ballottement of the patella is reliable when larger amounts of fluid are present. The Tinel's sign and the Phalen's test are used to check for carpal tunnel syndrome. The McMurray's test is used to test the knee for a torn meniscus.
A 59-year-old patient has been diagnosed with prostatitis and is being seen at the clinic for complaints of burning and pain during urination. He is experiencing: a. dysuria. b. nocturia. c. polyuria. d. hematuria.
ANS: A Dysuria or burning with urination is common with acute cystitis, prostatitis, and urethritis. Nocturia is voiding during the night. Polyuria is voiding in excessive quantities. Hematuria is voiding with blood in the urine.
During a health history of a patient who complains of chronic constipation, the patient asks the nurse about high-fiber foods. The nurse relates that an example of a high-fiber food would be: a. broccoli. b. hamburger. c. iceberg lettuce. d. yogurt.
ANS: A High-fiber foods are either soluble type (i.e., beans, prunes, barley, broccoli) and insoluble type (i.e., cereals, wheat germ). The other examples are not considered high-fiber foods.
In a person with an upper motor neuron lesion such as a cerebrovascular accident, which of these physical assessment findings should the nurse expect to see? a. Hyperreflexia b. Fasciculations c. Loss of muscle tone and flaccidity d. Atrophy and wasting of the muscles
ANS: A Hyperreflexia, diminished or absent superficial reflexes, and increased muscle tone or spasticity can be expected with upper motor neuron lesions. The other options reflect a lesion of lower motor neurons. See Table 23-7.
An older man is concerned about his sexual performance. The nurse knows that in the absence of disease, a withdrawal from sexual activity later in life may be due to: a. side effects of medications. b. decreased libido with aging. c. decreased sperm production. d. decreased pleasure from sexual intercourse.
ANS: A In the absence of disease, a withdrawal from sexual activity may be due to side effects of medications such as antihypertensives, antidepressants, or sedatives. The other options are not correct.
A newborn baby boy is about to have a circumcision. The nurse knows that indications for circumcision include: a. cultural and religious beliefs. b. prevention of testicular cancer. c. improving the sperm count later in life. d. preventing dysuria.
ANS: A Indications for circumcision include cultural and religious beliefs, prevention of phimosis and inflammation of the glans penis and foreskin, decreasing the incidence of cancer of the penis, and decreasing the incidence of urinary tract infections in infancy.
When assessing a newborn infant's genitalia, the nurse notices that the genitalia are somewhat engorged. The labia majora are swollen, the clitoris looks large, and the hymen is thick. The vaginal opening is difficult to visualize. The infant's mother states that she is worried about the labia being swollen. The nurse should reply: a. "This is a normal finding in newborns and should resolve within a few weeks." b. "This could indicate an abnormality and may need to be evaluated by a physician." c. "We will need to have estrogen levels evaluated to make sure that they are within normal limits." d. "We will need to keep close watch over the next few days to see if the genitalia decrease in size."
ANS: A It is normal for a newborn's genitalia to be somewhat engorged. A sanguineous vaginal discharge or leukorrhea is normal during the first few weeks because of the maternal estrogen effect. During the early weeks, the genital engorgement resolves, and the labia minora atrophy and remain small until puberty.
A woman who is 8 months pregnant comments that she has noticed a change in posture and is having lower back pain. The nurse tells her that during pregnancy women have a posture shift to compensate for the enlarging fetus. This shift in posture is known as: a. lordosis. b. scoliosis. c. ankylosis. d. kyphosis.
ANS: A Lordosis compensates for the enlarging fetus, which would shift the center of balance for-ward. This shift in balance in turn creates strain on the low back muscles, felt as low back pain during late pregnancy by some women. Scoliosis is lateral curvature of portions of the spine; ankylosis is extreme flexion of the wrist, as seen with severe rheumatoid arthritis; and kyphosis is an enhanced thoracic curvature of the spine.
During an assessment of a newborn infant, the nurse recalls that pyloric stenosis would be manifested by: a. projectile vomiting. b. hypoactive bowel activity. c. palpable olive-sized mass in right lower quadrant. d. pronounced peristaltic waves crossing from right to left.
ANS: A Marked peristalsis together with projectile vomiting in the newborn suggests pyloric stenosis. After feeding, pronounced peristaltic waves cross from left to right, leading to projectile vomiting. One can also palpate an olive-sized mass in the right upper quadrant.
A woman is in the clinic for an annual gynecologic examination. The nurse should plan to begin the interview with the: a. menstrual history because it is generally nonthreatening. b. obstetric history because it is the most important information. c. urinary system history because there may be problems in this area as well. d. sexual history because it will build rapport to discuss this first.
ANS: A Menstrual history is usually nonthreatening; thus it is a good place to start. Obstetric, urinary, and sexual histories are also part of the interview but not necessarily the best topics with which to start.
To test for gross motor skill and coordination of a 6-year-old child, which of these techniques would be appropriate? a. Ask child to hop on one foot. b. Have the child stand on his head. c. Have child touch his finger to his nose. d. Have the child make "funny" faces at the nurse.
ANS: A Normally a child can hop on one foot and can balance on one foot for about 5 seconds by 4 years of age, and can balance on one foot for 8 to 10 seconds at 5 years of age. Children enjoy performing these tests. Failure to hop after 5 years of age indicates incoordination of gross motor skill. Touching the finger to the nose checks fine motor coordination. Having the child make "funny" faces tests cranial nerve VII. It is not appropriate to ask a child to stand on his or her head.
When performing a genitourinary assessment, the nurse notices that the urethral meatus is positioned ventrally. This finding is: a. called hypospadias. b. the result of phimosis. c. probably due to a stricture. d. often associated with aging.
ANS: A Normally the urethral meatus is positioned just about centrally. Hypospadias is the ventral location of the urethral meatus. The position of the meatus does not change with aging. Phimosis is the inability to retract the foreskin. A stricture is a narrow opening of the meatus.
The nurse is preparing to interview a postmenopausal woman. Which of these statements is true with regard to the history of a postmenopausal woman? a. The nurse should ask a postmenopausal woman if she ever has vaginal bleeding. b. Once a woman reaches menopause, the nurse does not need to ask any further history questions. c. The nurse should screen for monthly breast tenderness. d. Postmenopausal women are not at risk for contracting sexually transmitted infections and thus these questions can be omitted.
ANS: A Postmenopausal bleeding warrants further workup and referral. The other statements are not true.
While obtaining a history of a 3-month-old infant from the mother, the nurse asks about the infant's ability to suck and grasp the mother's finger. What is the nurse assessing? a. Reflexes b. Intelligence c. Cranial nerves d. Cerebral cortex function
ANS: A Questions regarding reflexes include such questions as "What have you noticed about the infant's behavior," "Do the infant's sucking and swallowing seem coordinated," and "Does the infant grasp your finger?" The other responses are incorrect.
During the assessment of an 80-year-old patient, the nurse notices that his hands show tremors when he reaches for something and his head is always nodding. There is no associated rigidity with movement. Which of these statements is most accurate? a. These are normal findings resulting from aging. b. These could be related to hyperthyroidism. c. These are the result of Parkinson disease. d. This patient should be evaluated for a cerebellar lesion.
ANS: A Senile tremors occasionally occur. These benign tremors include an intention tremor of the hands, head nodding (as if saying yes or no), and tongue protrusion. Tremors associated with Parkinson disease include rigidity, slowness, and weakness of voluntary movement. The other responses are incorrect.
When performing an external genitalia examination of a 10-year-old girl, the nurse notices that there is no pubic hair, and the mons and the labia are covered with fine vellus hair. These findings are consistent with stage _____ of sexual maturity, according to the Sexual Maturity Rating scale. a. 1 b. 2 c. 3 d. 4
ANS: A Sexual Maturity Rating stage 1 is the preadolescent stage. There is no pubic hair. The mons and labia are covered with fine, vellus hair as on the abdomen. See Table 26-1.
A male patient with possible fertility problems asks the nurse where sperm is produced. The nurse knows that sperm production occurs in the: a. testes. b. prostate. c. epididymis. d. vas deferens.
ANS: A Sperm production occurs in the testes, not in the other structures listed.
A 70-year-old man is visiting the clinic for difficulty in passing urine. In the history he indicates he has to urinate frequently, especially at night. He has burning when he urinates and has noticed pain in his back. Given this history, what might the nurse expect to find during the physical assessment? a. Asymmetric, hard, fixed prostate gland b. Occult blood and perianal pain to palpation c. Symmetrically enlarged, soft prostate gland d. A soft nodule protruding from rectal mucosa
ANS: A Subjective symptoms of carcinoma of the prostate include frequency, nocturia, hematuria, weak stream, hesitancy, pain or burning on urination, and continuous pain in lower back, pelvis, and thighs. Objective symptoms of carcinoma of the prostate include a malignant neoplasm often starts as a single hard nodule on the posterior surface, producing asymmetry and a change in consistency. As it invades normal tissue, multiple hard nodules appear, or the entire gland feels stone hard and fixed.
An 11-year-old girl is in the clinic for a sports physical. The nurse notices that she has begun to develop breasts, and during the conversation the girl reveals that she is worried about her development. The nurse should use which of these techniques to best assist the young girl in understanding the expected sequence for development? The nurse should: a. use the Tanner's table on the five stages of sexual development. b. describe her development and compare it with that of other girls her age. c. use Jacobsen's table on expected development on the basis of height and weight data. d. reassure her that her development is within normal limits and should tell her not to worry about the next step.
ANS: A Tanner's table on the five stages of pubic hair development is helpful in teaching girls the expected sequence of sexual development (see Table 26-1). The other responses are not appropriate.
The ankle joint is the articulation of the tibia, the fibula, and the: a. talus. b. cuboid. c. calcaneus. d. cuneiform bones.
ANS: A The ankle or tibiotalar joint is the articulation of the tibia, fibula, and talus. The other bones listed are foot bones, but not part of the ankle joint.
The nurse knows that determining whether a person is oriented to his or her surroundings will test the functioning of which of these structures? a. Cerebrum b. Cerebellum c. Cranial nerves d. Medulla oblongata
ANS: A The cerebral cortex is responsible for thought, memory, reasoning, sensation, and voluntary movement. The other options structures are not responsible for a person's level of consciousness.
A 62-year-old man is experiencing fever, chills, malaise, urinary frequency, and urgency. He also reports urethral discharge and a dull aching pain in the perineal and rectal area. These symptoms are most consistent with which of the following? a. Prostatitis b. A polyp c. Carcinoma of the prostate d. Benign prostatic hypertrophy (BPH)
ANS: A The common presenting symptoms of prostatitis are fever, chills, malaise, and urinary frequency and urgency. The individual may also have dysuria, urethral discharge, and a dull aching pain in the perineal and rectal area. See Table 25-3 for descriptions of carcinoma of the prostate and BPH. These are not the symptoms of a polyp.
Which of these statements is most appropriate when the nurse is obtaining a genitourinary history from an elderly man? a. "Do you need to get up at night to urinate?" b. "Do you experience nocturnal emissions, or 'wet dreams'?" c. "Do you know how to perform a testicular self-examination?" d. "Has anyone ever touched your genitals when you did not want them to?"
ANS: A The elderly male patient should be asked about the presence of nocturia. This may be due to diuretic medication, fluid retention from mild heart failure or varicose veins, or fluid ingestion 3 hours before bedtime, especially coffee and alcohol. The other questions are more appropriate for younger males.
The wife of a 65-year-old man tells the nurse that she is concerned because she has noticed a change in her husband's personality and ability to understand. He also cries and becomes angry very easily. The nurse recalls that the cerebral lobe responsible for these behaviors is the _____ lobe. a. frontal b. parietal c. occipital d. temporal
ANS: A The frontal lobe has areas concerned with personality, behavior, emotions, and intellectual function. The parietal lobe has areas concerned with sensation; the occipital lobe is responsible for visual reception; and the temporal lobe is concerned with hearing, taste and smell.
The nurse is checking the range of motion in a patient's knee and knows that the knee is capable of which movement(s)? a. Flexion and extension b. Supination and pronation c. Circumduction d. Inversion and eversion
ANS: A The knee is a hinge joint, permitting flexion and extension of the lower leg on a single plane. The knee is not capable of the other movements listed.
During an examination the nurse observes a female patient's vestibule and expects to see the: a. urethral meatus and vaginal orifice. b. vaginal orifice and vestibular (Bartholin) glands. c. urethral meatus and paraurethral (Skene) glands. d. paraurethral (Skene) and vestibular (Bartholin) glands.
ANS: A The labial structures encircle a boat-shaped space, or cleft, termed the vestibule. Within it are numerous openings. The urethral meatus and vaginal orifice are visible. The ducts of the paraurethral (Skene) glands and the vestibular (Bartholin) glands are present but not visible
When performing a musculoskeletal assessment, the nurse knows that the correct approach for the examination should be: a. proximal to distal. b. distal to proximal. c. posterior to anterior. d. anterior to posterior.
ANS: A The musculoskeletal assessment should be done in an orderly approach, head to toe, proximal to distal, from the midline outward. The other options are not correct.
The nurse is preparing to palpate the rectum and should use which of these techniques? a. Flex the finger and insert slowly toward the umbilicus. b. Instruct the patient first that this will be a painful procedure. c. Insert an extended index finger at a right angle to the anus. d. Place the finger directly into the anus to overcome the tight sphincter.
ANS: A The nurse should place the pad of the index finger gently against the anal verge. The nurse will feel the sphincter tighten and then relax. As it relaxes, the nurse should flex the tip of the finger and slowly insert it into the anal canal in a direction toward the umbilicus. The nurse should never approach the anus at right angles with the index finger extended-this would cause pain. The nurse should instruct the patient that palpation is not painful but may feel like needing to move the bowels.
Which of these percussion findings would the nurse expect to find in a patient with a large amount of ascites? a. Dullness across the abdomen b. Flatness in the right upper quadrant c. Hyperresonance in the left upper quadrant d. Tympany in the right and left lower quadrants
ANS: A The presence of fluid causes a dull sound to percussion. A large amount of ascitic fluid would produce a dull sound to percussion.
When palpating the abdomen of a 20-year-old patient, the nurse notices the presence of tenderness in the left upper quadrant with deep palpation. Which of these structures is most likely to be involved? a. Spleen b. Sigmoid colon c. Appendix d. Gallbladder
ANS: A The spleen is located in the left upper quadrant of the abdomen. The gallbladder is in the right upper quadrant, the sigmoid colon is in the left lower quadrant, and the appendix is in the right lower quadrant.
During report, the student nurse hears that a patient has "hepatomegaly" and recognizes that this term refers to: a. an enlarged liver. b. an enlarged spleen. c. distended bowel. d. excessive diarrhea.
ANS: A The term hepatomegaly refers to an enlarged liver. The term splenomegaly refers to an enlarged spleen. The other responses are not correct.
An older patient has been diagnosed with pernicious anemia. The nurse knows that this condition could be related to: a. increased gastric acid secretion. b. decreased gastric acid secretion. c. delayed gastrointestinal emptying time. d. increased gastrointestinal emptying time.
ANS: B Gastric acid secretion decreases with aging, and this may cause pernicious anemia (because it interferes with vitamin B12 absorption), iron deficiency anemia, and malabsorption of calcium.
Which of these tests would the nurse use to check the motor coordination of an 11-month-old infant? a. Denver II b. Stereognosis c. Deep tendon reflexes d. Rapid alternating movements
ANS: A To screen gross and fine motor coordination, the nurse should use the Denver II with its age-specific developmental milestones. Stereognosis tests a person's ability to recognize objects by feeling them, and is not appropriate for an 11-month-old infant. Testing of the deep tendon reflexes is not appropriate for checking motor coordination. Testing rapid alternating movements is appropriate for testing coordination in adults
During the history, a patient tells the nurse that "it feels like the room is spinning around me." The nurse would document this as: a. vertigo. b. syncope. c. dizziness. d. seizure activity.
ANS: A True vertigo is rotational spinning caused by neurologic dysfunction or a problem in the vestibular apparatus or the vestibular nuclei in the brainstem. Dizziness is a lightheaded, swimming sensation. Syncope is a sudden loss of strength or a temporary loss of consciousness. Seizure activity is characterized by altered or loss of consciousness, involuntary muscle movements, and sensory disturbances.
The nurse is teaching a class on osteoporosis prevention to a group of postmenopausal woman. A participant shows that she needs more instruction when she states, "I will: a. start swimming to increase my weight-bearing exercise." b. try to stop smoking as soon as possible." c. check with my doctor about taking calcium supplements." d. get a bone-density test soon."
ANS: A Weight-bearing exercises include walking, low-impact aerobics, dancing, or stationary cycling. Swimming is not considered a weight-bearing exercise. The other responses are correct.
A 59-year-old patient has a herniated intervertebral disk. Which of the following findings should the nurse expect to see on physical assessment of this individual? a. Hyporeflexia b. Increased muscle tone c. A positive Babinski's sign d. The presence of pathologic reflexes
ANS: A With a herniated intervertebral disk or lower motor neuron lesion there is loss of tone, flaccidity, atrophy, fasciculations, and hyporeflexia or areflexia. No Babinski's sign or pathologic reflexes would be seen. The other options reflect a lesion of upper motor neurons. See Table 23-7.
During a physical examination, the nurse finds that a male patient's foreskin is fixed and tight and will not retract over the glans. The nurse recognizes that this condition is: a. phimosis. b. epispadias. c. urethral stricture. d. Peyronie's disease.
ANS: A With phimosis, the foreskin is nonretractable, forming a pointy tip of the penis with a tiny orifice at the end of the glans. The foreskin is advanced and so tight that it is impossible to retract over the glans. This may be congenital or acquired from adhesions related to infection. See Table 24-3 for information on urethral stricture. See Table 24-4 for information on epispadias and Peyronie's disease.
The nurse is performing a digital examination of a patient's prostate gland and notices that characteristics of a normal prostate gland include which of the following? *Select all that apply.* a. The gland protruding 1 cm into the rectum b. Heart-shaped with a palpable central groove c. Flat with no groove palpable d. Boggy and soft consistency e. Smooth surface, elastic, or rubbery consistency f. Fixed mobility
ANS: A, B, E The size should be 2.5 cm long by 4 cm wide, and it should not protrude more than 1 cm into the rectum. The prostate should be heart-shaped, with a palpable central groove, a smooth surface, and elastic, rubbery consistency. Abnormal findings include a flat shape with no palpable groove, boggy with a soft consistency, and fixed mobility.
A patient tells the nurse that "all my life I've been called 'knock knees.'" The nurse knows that another term for "knock knees" is: a. genu varum. b. genu valgum. c. pes planus. d. metatarsus adductus.
ANS: B Genu valgum is also known as "knock knees" and is present when there is more than 2.5 cm between the medial malleoli when the knees are together.
A 16-year-old boy is brought to the clinic for a problem that he refused to let his mother see. The nurse examines him, and finds that he has scrotal swelling on the left side. He had the mumps the previous week, and the nurse suspects that he has orchitis. Which of the assessment findings below support this diagnosis? *Select all that apply.* a. Swollen testis b. Mass does transilluminate c. Mass does not transilluminate d. Nontender upon palpation e. Tender upon palpation f. Scrotal skin is reddened
ANS: A, C, E, F With orchitis, the testis is swollen, with a feeling of weight, and is tender or painful. The mass does not transilluminate, and the scrotal skin is reddened. Transillumination of a mass occurs with a hydrocele, not orchitis.
A man who was found wandering in a park at 2 AM has been brought to the emergency department for an examination because he said he fell and hit his head. During the examination, the nurse asks him to use his index finger to touch the nurse's finger, then his own nose, then the nurse's finger again (which has been moved to a different location). The patient is clumsy, unable to follow the instructions, and overshoots the mark, missing the finger. The nurse should suspect which of the following?
ANS: Acute alcohol intoxication During the finger-to-finger test, if the person has clumsy movement with overshooting the mark, either a cerebellar disorder or acute alcohol intoxication should be suspected. The person's movements should be smooth and accurate. The other options are not correct.
The nurse is reviewing statistics regarding breast cancer. Which woman, aged 40 years in the United States, has the highest risk for development of breast cancer? a. Black b. White c. Asian d. American Indian
ANS: African-American The incidence of breast cancer varies with different cultural groups. White women have a higher incidence of breast cancer than African-American women starting at age 45 years; but African-American women have a higher incidence before age 45 years. Asian, Hispanic, and American Indian women have a lower risk for development of breast cancer (American Cancer Society, 2009-2010).
A 30-year-old woman is visiting the clinic because of *"pain in my bottom when I have a bowel movement."* The nurse should assess for which problem? a. Pinworms b. Hemorrhoids c. Colon cancer d. Fecal incontinence
ANS: B Having painful bowel movements, known as dyschezia, may be due to a local condition (hemorrhoid or fissure) or constipation. The other responses are not correct.
To test for gross motor skill and coordination of a 6-year-old child, which of these techniques would be appropriate?
ANS: Ask child to hop on one foot. Normally a child can hop on one foot and can balance on one foot for about 5 seconds by 4 years of age, and can balance on one foot for 8 to 10 seconds at 5 years of age. Children enjoy performing these tests. Failure to hop after 5 years of age indicates incoordination of gross motor skill. Touching the finger to the nose checks fine motor coordination. Having the child make "funny" faces tests cranial nerve VII. It is not appropriate to ask a child to stand on his or her head.
The nurse places a key in the hand of a patient and he identifies it as a penny. What term would the nurse use to describe this finding?
ANS: Astereognosis Stereognosis is the person's ability to recognize objects by feeling their forms, sizes, and weights. Astereognosis is an inability to identify objects correctly, and it occurs in sensory cortex lesions. Tactile discrimination tests fine touch. Extinction tests the person's ability to feel sensations on both sides of the body at the same point.
A woman who is 22 weeks pregnant has a vaginal infection. She tells the nurse that she is afraid that this infection will hurt the fetus. The nurse knows that which of these statements is true? a. If intercourse is avoided, then the risk for infection is minimal. b. A thick mucus plug forms that protects the fetus from infection. c. The acidic pH of vaginal secretions promotes the growth of pathogenic bacteria. d. The mucus plug that forms in the cervical canal is a good medium for bacterial growth.
ANS: B A clot of thick, tenacious mucus forms in the spaces of the cervical canal (the mucus plug), which protects the fetus from infection. Cervical and vaginal secretions increase during pregnancy and are thick, white, and more acidic. The acidic pH keeps pathogenic bacteria from multiplying in the vagina, but the increase in glycogen increases the risk of candidiasis (commonly called a yeast infection) during pregnancy.
During a digital examination of the rectum, the nurse notices that the patient has hard feces in the rectum. The patient complains of feeling "full," has a distended abdomen, and states that she has not had a bowel movement "for several days." The nurse suspects which condition? a. Rectal polyp b. Fecal impaction c. Rectal abscess d. Rectal prolapse
ANS: B A fecal impaction is a collection of hard, desiccated feces in the rectum. The obstruction often results from decreased bowel motility, in which more water is reabsorbed from the stool. See Table 25-2 for descriptions of rectal polyp and abscess; See Table 25-1 for description of rectal prolapse.
During an abdominal assessment, the nurse is unable to hear bowel sounds in a patient's abdomen. Before reporting this finding as "silent bowel sounds" the nurse should listen for at least: a. 1 minute. b. 5 minutes. c. 10 minutes. d. 2 minutes in each quadrant.
ANS: B Absent bowel sounds are rare. The nurse must listen for 5 minutes before deciding bowel sounds are completely absent.
During a discussion for a men's health group, the nurse relates that the group with the highest incidence of prostate cancer is: a. Asian Americans. b. African-Americans. c. American Indians. d. Hispanics.
ANS: B According to the American Cancer Society (2010), African-American men have a higher rate of prostate cancer than other racial groups.
A 40-year-old man has come into the clinic with complaints of "extreme tenderness in my toes." The nurse notices that his toes are slightly swollen, reddened, and warm to the touch. His complaints would suggest: a. osteoporosis. b. acute gout. c. ankylosing spondylitis. d. degenerative joint disease.
ANS: B Acute gout occurs primarily in men over 40 years of age. Clinical findings consist of redness, swelling, heat, and extreme tenderness. Gout is a metabolic disorder of disturbed purine me-tabolism, associated with elevated serum uric acid. See Table 22-1 for descriptions of the oth-er terms.
A patient has been diagnosed with osteoporosis and asks the nurse, "What is osteoporosis?" The nurse explains to the patient that osteoporosis is defined as: a. increased bone matrix. b. loss of bone density. c. new, weaker bone growth. d. increased phagocytic activity.
ANS: B After age 40, loss of bone matrix (resorption) occurs more rapidly than new bone formation. The net effect is a gradual loss of bone density, or osteoporosis. The other options are not correct.
The nurse is listening to bowel sounds. Which of these statements is true of bowel sounds? a. They are usually loud, high-pitched, rushing, tinkling sounds. b. They are usually high-pitched, gurgling, irregular sounds. c. They sound like two pieces of leather being rubbed together. d. They originate from the movement of air and fluid through the large intestine.
ANS: B Bowel sounds are high-pitched, gurgling, cascading sounds that occur irregularly from 5 to 30 times per minute. They originate from the movement of air and fluid through the small intestine.
The ability that humans have to perform very skilled movements such as writing is controlled by the: a. basal ganglia. b. corticospinal tract. c. spinothalamic tract. d. extrapyramidal tract.
ANS: B Corticospinal fibers mediate voluntary movement, particularly very skilled, discrete, purposeful movements, such as writing. The corticospinal tract (also known as the pyramidal tract) is a newer, "higher" motor system that humans have that permits very skilled and purposeful movements. The other responses are not related to skilled movements.
A patient has hypoactive bowel sounds. The nurse knows that a potential cause of hypoactive bowel sounds is: a. diarrhea. b. peritonitis. c. laxative use. d. gastroenteritis.
ANS: B Diminished or absent bowel sounds signal decreased motility from inflammation as seen with peritonitis, with paralytic ileus after abdominal surgery, or with late bowel obstruction.
The nurse is assessing the neurologic status of a patient who has a late-stage brain tumor. With the reflex hammer, the nurse draws a light stroke up the lateral side of the sole of the foot and inward, across the ball of the foot. In response, the patient's toes fan out, and the big toe shows dorsiflexion. The nurse interprets this result as: a. a negative Babinski's sign, which is normal for adults. b. a positive Babinski's sign, which is abnormal for adults. c. clonus, which is a hyperactive response. d. the Achilles reflex, which is an expected response.
ANS: B Dorsiflexion of the big toe and fanning of all toes is a positive Babinski's sign, also called "upgoing toes." This occurs with upper motor neuron disease of the corticospinal (or pyramidal) tract and is an abnormal finding for adults.
After completing an assessment of a 60-year-old man with a family history of colon cancer, the nurse discusses with him early detection measures for colon cancer. The nurse should mention the need for a(n): a. annual proctoscopy. b. colonoscopy every 10 years. c. fecal test for blood every 6 months. d. digital rectal examinations every 2 years.
ANS: B Early detection measures for colon cancer include a digital rectal examination performed annually after age 50 years, a fecal occult blood test annually after age 50 years, sigmoidoscopy every 5 years or colonoscopy every 10 years after age 50 years; and a PSA blood test annually for men over 50 years old, except black men beginning at age 45 years (American Cancer Society, 2006).
During an examination, the nurse notices severe nystagmus in both eyes of a patient. Which of these conclusions by the nurse is correct? a. This is a normal occurrence. b. This may indicate disease of the cerebellum or brainstem. c. This is a sign that the patient is nervous about the examination. d. This indicates a visual problem, and a referral to an ophthalmologist is indicated.
ANS: B End-point nystagmus at an extreme lateral gaze occurs normally. The nurse should assess any other nystagmus carefully. Severe nystagmus occurs with disease of the vestibular system, cerebellum, or brainstem.
A 55-year-old man is experiencing severe pain of sudden onset in the scrotal area. It is somewhat relieved by elevation. On examination the nurse notices an enlarged, red scrotum that is very tender to palpation. It is difficult to distinguish the epididymis from the testis, and the scrotal skin is thick and edematous. This description is consistent with which of these? a. Varicocele b. Epididymitis c. Spermatocele d. Testicular torsion
ANS: B Epididymitis presents as severe pain of sudden onset in the scrotum that is somewhat relieved by elevation. On examination, the scrotum is enlarged, reddened, and exquisitely tender. The epididymis is enlarged and indurated and may be hard to distinguish from the testis. The overlying scrotal skin may be thick and edematous. See Table 24-6 for more information and for descriptions of the other terms.
A woman who has had rheumatoid arthritis for years is starting to notice that her fingers are drifting to the side. The nurse knows that this condition is commonly referred to as: a. radial drift. b. ulnar deviation. c. swan neck deformity. d. Dupuytren's contracture.
ANS: B Fingers drift to the ulnar side because of stretching of the articular capsule and muscle imbal-ance caused by chronic rheumatoid arthritis. Radial drift is not seen. See Table 22-4 for de-scriptions of swan neck deformity and Dupuytren's contracture.
The nurse is preparing to examine the external genitalia of a school-age girl. Which of these positions would be most appropriate in this situation? a. In the parent's lap b. In a frog-leg position on the examining table c. In the lithotomy position with the feet in stirrups d. Lying flat on the examining table with legs extended
ANS: B For school-age children it is best to place them on the examining table in a frog-leg position. With toddlers and preschoolers, it is best to have the child on the parent's lap in a frog-leg position.
A patient's annual physical examination reveals a lateral curvature of the thoracic and lumbar segments of his spine; however, this curvature disappears with forward bending. The nurse knows that this abnormality of the spine is called: a. structural scoliosis. b. functional scoliosis. c. herniated nucleus pulposus. d. dislocated hip.
ANS: B Functional scoliosis is flexible; it is apparent with standing and disappears with forward bending. Structural scoliosis is fixed; the curvature shows both when standing and when bending forward. See Table 22-7 for description of herniated nucleus pulposus. These find-ings are not indicative of a dislocated hip.
The structure that secretes a thin, milky alkaline fluid to enhance the viability of sperm is the: a. Cowper's gland. b. prostate gland. c. median sulcus. d. bulbourethral gland.
ANS: B In men, the prostate gland secretes a thin milky alkaline fluid that enhances sperm viability. The Cowper's glands (also known as bulbourethral glands) secrete a clear, viscid mucus. The median sulcus is a groove dividing the lobes of the prostate gland and does not secrete fluid.
A nurse is assessing a patient's risk of contracting a sexually transmitted infection (STI). An appropriate question to ask would be: a. "You know that it's important to use condoms for protection, right?" b. "Do you use a condom with each episode of sexual intercourse?" c. "Do you have a sexually transmitted infection?" d. "You are aware of the dangers of unprotected sex, aren't you?"
ANS: B In reviewing a patient's risk for sexually transmitted infections, the nurse should ask, in a nonconfrontational manner, whether condoms are used at each episode of sexual intercourse. Asking a person whether he or she has an infection does not address the risk.
The nurse is assessing the abdomen of an aging adult. Which of these statements regarding the aging adult and abdominal assessment is true? a. The abdominal tone is increased. b. The abdominal musculature is thinner. c. Abdominal rigidity with acute abdominal conditions is more common. d. The aging person complains of more pain with an acute abdominal condition than a younger person would.
ANS: B In the aging person, the abdominal musculature is thinner and has less tone than that of the younger adult, and abdominal rigidity with acute abdominal conditions is less common in aging. The aging person often complains less of pain than a younger person would with an acute abdominal condition.
A married couple has come to the clinic seeking advice on pregnancy. They have been trying to conceive for 4 months and have not been successful. What should the nurse do first? a. Ascertain whether either of them has been using broad-spectrum antibiotics. b. Explain that couples are considered infertile after 1 year of unprotected intercourse. c. Immediately refer the woman to an expert in pelvic inflammatory disease-the most common cause of infertility. d. Explain that couples are considered infertile after 3 months of engaging in unprotected intercourse and that they will need a referral to a fertility expert.
ANS: B Infertility is considered after 1 year of engaging in unprotected sexual intercourse without conceiving. The other actions are not appropriate.
The nurse knows that testing kinesthesia is a test of a person's: a. fine touch. b. position sense. c. motor coordination. d. perception of vibration.
ANS: B Kinesthesia, or position sense, is the person's ability to perceive passive movements of the extremities. The other options are incorrect.
The assessment of a 60-year-old patient has taken longer than anticipated. In testing his pain perception the nurse decides to complete the test as quickly as possible. When the nurse applies the sharp point of the pin on his arm several times, he is only able to identify these as one "very sharp prick." What would be the most accurate explanation for this? a. Patient has hyperesthesia as a result of the aging process. b. This is most likely the result of the summation effect. c. The nurse was probably not poking hard enough with the pin in the other areas. d. The patient most likely has analgesia in some areas of arm and hyperalgesia in others.
ANS: B Let at least 2 seconds elapse between each stimulus to avoid summation. With summation, frequent consecutive stimuli are perceived as one strong stimulus. The other responses are incorrect.
An 80-year-old woman is visiting the clinic for a checkup. She states, "I can't walk as much as I used to." The nurse is observing for motor dysfunction in her hip and should have her: a. internally rotate her hip while she is sitting. b. abduct her hip while she is lying on her back. c. adduct her hip while she is lying on her back. d. externally rotate her hip while she is standing.
ANS: B Limitation of abduction of the hip while supine is the most common motion dysfunction found in hip disease. The other options are not correct.
When performing a scrotal assessment, the nurse notices that the scrotal contents transilluminate and show a red glow. On the basis of this finding the nurse would: a. assess the patient for the presence of a hernia. b. suspect the presence of serous fluid in the scrotum. c. consider this normal and proceed with the examination. d. refer the patient for evaluation of a mass in the scrotum.
ANS: B Normal scrotal contents do not transilluminate. Serous fluid does transilluminate and shows as a red glow. Neither a mass nor a hernia would transilluminate.
The nurse is palpating a female patient's adnexa. The findings include a firm, smooth uterine wall; the ovaries are palpable and feel smooth and firm. The fallopian tube is firm and pulsating. The nurse's most appropriate course of action would be to: a. tell the patient that her examination was normal. b. give her an immediate referral to a gynecologist. c. suggest that she return in a month for a recheck to verify the findings. d. tell the patient that she may have an ovarian cyst that should be evaluated further.
ANS: B Normally the uterine wall feels firm and smooth, with the contour of the fundus rounded. Ovaries are not often palpable, but when they are, they normally feel smooth, firm, and almond shaped and are highly movable, sliding through the fingers. The fallopian tube is not palpable normally. No other mass or pulsation should be felt. Pulsation or palpable fallopian tube suggests ectopic pregnancy, which warrants immediate referral.
A patient is suspected of having inflammation of the gallbladder, or cholecystitis. The nurse should conduct which of these techniques to assess for this condition? a. Obturator test b. Test for Murphy's sign c. Assess for rebound tenderness d. Iliopsoas muscle test
ANS: B Normally, palpating the liver causes no pain. In a person with inflammation of the gallbladder, or cholecystitis, pain occurs as the descending liver pushes the inflamed gallbladder onto the examining hand during inspiration (Murphy's test). The person feels sharp pain and abruptly stops inspiration midway.
An 85-year-old patient comments during his annual physical that he seems to be getting shorter as he ages. The nurse should explain that decreased height occurs with aging because: a. long bones tend to shorten with age. b. of the shortening of the vertebral column. c. there is a significant loss of subcutaneous fat. d. there is a thickening of the intervertebral disks.
ANS: B Postural changes are evident with aging; decreased height is most noticeable and is due to shortening of the vertebral column. Long bones do not shorten with age. Intervertebral disks actually get thinner with age. Subcutaneous fat is not lost but is redistributed to the abdomen and hips.
The mother of a 10-year-old boy asks the nurse to discuss the recognition of puberty. The nurse should reply by saying: a. "Puberty usually begins about age fifteen." b. "The first sign of puberty is enlargement of the testes." c. "Penis size does not increase until about the age of sixteen." d. "The development of pubic hair precedes testicular or penis enlargement."
ANS: B Puberty begins sometime between ages 9 1/2 and 13 1/2 years. The first sign is enlargement of the testes. Next, pubic hair appears and then penis size increases.
In obtaining a history on a 74-year-old patient the nurse notes that he drinks alcohol daily and that he has noticed a tremor in his hands that affects his ability to hold things. With this information, what should the nurse's response be? a. "Does your family know you are drinking every day?" b. "Does the tremor change when you drink the alcohol?" c. "We'll do some tests to see what is causing the tremor." d. "You really shouldn't drink so much alcohol; it may be causing your tremor."
ANS: B Senile tremor is relieved by alcohol, although this is not a recommended treatment. The nurse should assess whether the person is abusing alcohol in an effort to relieve the tremor.
A 50-year-old woman calls the clinic because she has noticed some changes in her body and breasts and wonders if they could be due to the hormone replacement therapy (HRT) she started 3 months ago. The nurse should tell her: a. "Hormone replacement therapy is at such a low dose that side effects are very unusual." b. "Hormone replacement therapy has several side effects, including fluid retention, breast tenderness, and vaginal bleeding." c. "It would be very unusual to have vaginal bleeding with hormone replacement therapy, and I suggest you come in to the clinic immediately to have this evaluated." d. "It sounds as if your dose of estrogen is too high; I think you may need to decrease the amount you are taking and then call back in a week."
ANS: B Side effects of hormone replacement therapy include fluid retention, breast pain, and vaginal bleeding. The other responses are not correct.
When the nurse is discussing sexuality and sexual issues with adolescents, a permission statement helps to convey that it is normal to think or feel a certain way. Which of these is the best example of a permission statement? a. "It is okay that you have become sexually active." b. "Often girls your age have questions about sexual activity. Have you any questions?" c. "If it is okay with you, I'd like to ask you some questions about your sexual history." d. "Often girls your age engage in sexual activity. It is okay to tell me if you have had intercourse."
ANS: B Start with a permission statement, "Often girls your age experience . . . ." This conveys that it is normal to think or feel a certain way, and it is important to relay that the topic is normal and unexceptional
A 52-year-old patient states that when she sneezes or coughs she "wets herself a little." She is very concerned that something may be wrong with her. The nurse suspects that the problem is: a. dysuria. b. stress incontinence. c. hematuria. d. urge incontinence.
ANS: B Stress incontinence is involuntary urine loss with physical strain, sneezing, or coughing. Dysuria is pain or burning with urination. Hematuria is bleeding with urination. Urge incontinence is involuntary urine loss but it occurs due to an overactive detrusor muscle in the bladder that contracts and causes an urgent need to void.
The nurse is performing an examination of the anus and rectum. Which of these statements is correct and important to remember during this examination? a. The rectum is about 8 cm long. b. The anorectal junction cannot be palpated. c. Above the anal canal, the rectum turns anteriorly. d. There are no sensory nerves in the anal canal or rectum.
ANS: B The anal columns are folds of mucosa that extend vertically down from the rectum and end in the anorectal junction. This junction is not palpable, but it is visible on proctoscopy. The rectum is 12 cm long, and just above the anal canal, the rectum dilates and turns posteriorly.
During an internal examination, the nurse notices that the cervix bulges outside the introitus when the patient is asked to strain. The nurse will document this as: a. uterine prolapse, graded first degree. b. uterine prolapse, graded second degree. c. uterine prolapse, graded third degree. d. a normal finding.
ANS: B The cervix should not be found to bulge into the vagina. Uterine prolapse is graded as follows: first degree-cervix appears at introitus with straining; second degree-cervix bulges outside introitus with straining; and third degree-whole uterus protrudes, even without straining (essentially, uterus is inside out).
The external male genital structures include the: a. testis. b. scrotum. c. epididymis. d. vas deferens.
ANS: B The external male genital structures include the penis and scrotum. The testis, epididymis, and vas deferens are internal structures.
Which of these statements about the sphincters is correct? a. The internal sphincter is under voluntary control. b. The external sphincter is under voluntary control. c. Both sphincters remain slightly relaxed at all times. d. The internal sphincter surrounds the external sphincter.
ANS: B The external sphincter surrounds the internal sphincter but also has a small section overriding the tip of the internal sphincter at the opening. The external sphincter is under voluntary control. Except for the passing of feces and gas, the sphincters keep the anal canal tightly closed.
During an assessment of the cranial nerves, the nurse finds the following: asymmetry when the patient smiles or frowns, uneven lifting of eyebrows, sagging of the lower eyelids, and escape of air when the nurse presses against the right puffed cheek. This would indicate dysfunction of which of these cranial nerves? a. Motor component of IV b. Motor component of VII c. Motor and sensory components of XI d. Motor component of X and sensory component of VII
ANS: B The findings listed reflect a dysfunction of the motor component of cranial nerve VII, the facial nerve.
The nurse is examining the hip area of a patient and palpates a flat depression on the upper, lateral side of the thigh when the patient is standing. The nurse interprets this finding as the: a. ischial tuberosity. b. greater trochanter. c. iliac crest. d. gluteus maximus muscle.
ANS: B The greater trochanter of the femur is palpated when the person is standing, and it appears as a flat depression on the upper lateral side of the thigh. The iliac crest is the upper part of the hip bone; the ischial tuberosity lies under the gluteus maximus muscle and is palpable when the hip is flexed. The gluteus muscle is part of the buttocks.
Which of these statements concerning areas of the brain is true? a. The cerebellum is the center for speech and emotions. b. The hypothalamus controls temperature and regulates sleep. c. The basal ganglia are responsible for controlling voluntary movements. d. Motor pathways of the spinal cord and brainstem synapse in the thalamus.
ANS: B The hypothalamus is a vital area with many important functions: temperature controller, sleep center, anterior and posterior pituitary gland regulator, and coordinator of autonomic nervous system activity and emotional status. The cerebellum controls motor coordination, equilibrium, and balance. The basal ganglia control autonomic movements of the body. The motor pathways of the spinal cord synapse in various areas of the spinal cord, not the thalamus.
The nurse is assessing a patient's ischial tuberosity. To palpate the ischial tuberosity, the nurse knows that it is best to have the patient: a. stand. b. flex the hip. c. flex the knee. d. in the supine position.
ANS: B The ischial tuberosity lies under the gluteus maximus muscle and is palpable when the hip is flexed.
The two parts of the nervous system are the: a. motor and sensory. b. central and peripheral. c. peripheral and autonomic. d. hypothalamus and cerebral.
ANS: B The nervous system can be divided into two parts-central and peripheral. The central nervous system includes the brain and spinal cord. The peripheral nervous system includes the 12 pairs of cranial nerves, the 31 pairs of spinal nerves, and all their branches.
The nurse is palpating the prostate gland through the rectum and notices an abnormal finding if which of these is present? a. Palpable central groove b. Tenderness to palpation c. Heart shape d. Elastic and rubbery consistency
ANS: B The normal prostate gland should feel smooth, elastic, and rubbery; should be slightly movable; should be heart-shaped with a palpable central groove; and should not be tender to palpation.
During the examination portion of a patient's visit, she will be in lithotomy position. Which statement below reflects some things that the nurse can do to make this more comfortable for her? a. Ask her to place her hands and arms behind her head. b. Elevate her head and shoulders to maintain eye contact. c. Allow her to choose to have her feet in the stirrups or have them resting side by side on the edge of the table. d. Allow her to keep her buttocks about 6 inches from the edge of the table to prevent her from feeling as if she will fall off.
ANS: B The nurse should elevate her head and shoulders to maintain eye contact. The patient's arms should be placed at her sides or across the chest, not behind the head, because this position only tightens the abdominal muscles. The feet should be placed into the stirrups, knees apart, and buttocks at the edge of the examining table. Place the stirrups so the legs are not abducted too far.
The nurse is preparing to examine a patient who has been complaining of right lower quadrant pain. Which technique is correct during the assessment? The nurse should: a. examine the tender area first. b. examine the tender area last. c. avoid palpating the tender area. d. palpate the tender area first and then auscultate for bowel sounds.
ANS: B The nurse should save the examination of any identified tender areas until last. This method avoids pain and the resulting muscle rigidity that would obscure deep palpation later in the examination. Auscultation is done before percussion and palpation because percussion and palpation can increase peristalsis, which would give a false interpretation of bowel sounds.
The nurse has just completed an inspection of a nulliparous woman's external genitalia. Which of these would be a description of a finding within normal limits? a. Redness of the labia majora b. Multiple nontender sebaceous cysts c. Discharge that is sticky and yellow-green d. Gaping and slightly shriveled labia majora
ANS: B There should be no lesions, except for occasional sebaceous cysts. These are yellowish 1-cm nodules that are firm, nontender, and often multiple. The labia majora are dark pink, moist, and symmetrical; redness indicates inflammation or lesions. Discharge that is sticky and yellow-green may indicate infection. In the nulliparous woman, the labia majora meet in the midline, are symmetric and plump.
During the neurologic assessment of a "healthy" 35-year-old patient, the nurse asks him to relax his muscles completely. The nurse then moves each extremity through full range of motion. Which of these results would the nurse expect to find? a. Firm, rigid resistance to movement b. Mild, even resistance to movement c. Hypotonic muscles as a result of total relaxation d. Slight pain with some directions of movement
ANS: B Tone is the normal degree of tension (contraction) in voluntarily relaxed muscles. It shows a mild resistance to passive stretch. Normally, the nurse will notice a mild, even resistance to movement. The other responses are not correct.
A patient calls the clinic for instructions before having a Papanicolaou (Pap) smear. The most appropriate instructions from the nurse are: a. "If you are menstruating, please use pads to avoid placing anything into the vagina." b. "Avoid intercourse, inserting anything into the vagina, or douching within 24 hours of your appointment." c. "If you suspect that you have a vaginal infection, please gather a sample of the discharge to bring with you." d. "We would like you to use a mild saline douche before your examination. You may pick this up in our office."
ANS: B When instructing a patient before a Papanicolaou (Pap) smear is obtained, the nurse should follow these guidelines: Do not obtain during the woman's menses or if a heavy infectious discharge is present. Instruct the woman not to douche, have intercourse, or put anything into the vagina within 24 hours before collecting the specimens. Any specimens will be obtained during the visit, not beforehand.
The nurse knows that during an abdominal assessment, deep palpation is used to determine: a. bowel motility. b. enlarged organs. c. superficial tenderness. d. overall impression of skin surface and superficial musculature.
ANS: B With deep palpation, the nurse should notice the location, size, consistency, and mobility of any palpable organs and the presence of any abnormal enlargement, tenderness, or masses.
The nurse is assessing the joints of a woman who has stated, "I have a long family history of arthritis, and my joints hurt." The nurse suspects that she has osteoarthritis. Which of these are symptoms of osteoarthritis? *Select all that apply.* a. Symmetric joint involvement b. Asymmetric joint involvement c. Pain with motion of affected joints d. Affected joints are swollen with hard, bony protuberances e. Affected joints may have heat, redness, and swelling
ANS: B, C, D In osteoarthritis, asymmetric joint involvement commonly affects hands, knees, hips, and lumbar and cervical segments of the spine. Affected joints have stiffness, swelling with hard bony protuberances, pain with motion, and limitation of motion. The other options reflect signs of rheumatoid arthritis.
A 69-year-old patient has been admitted to an adult psychiatric unit because his wife thinks he is getting more and more confused. He laughs when he is found to be forgetful, saying "I'm just getting old!" After the nurse completes a thorough neurologic assessment, which findings would be indicative of Alzheimer's disease? *Select all that apply.* a. Occasionally forgetting names or appointments b. Difficulty performing familiar tasks, such as placing a telephone call c. Misplacing items, such as putting dish soap in the refrigerator d. Sometimes having trouble finding the right word e. Rapid mood swings, from calm to tears, for no apparent reason f. Getting lost in one's own neighborhood
ANS: B, C, E, F Difficulty performing familiar tasks, misplacing items, rapid mood swings, and getting lost in one's own neighborhood can be warning signs of Alzheimer's disease. Occasionally forgetting names or appointments, and sometimes having trouble finding the right word are part of normal aging. For other examples see Table 23-2.
The nurse suspects that a patient has appendicitis. Which of these procedures are appropriate for use when assessing for appendicitis or a perforated appendix? *Select all that apply.* a. Test for Murphy's sign. b. Test for Blumberg's sign. c. Test for shifting dullness. d. Perform iliopsoas muscle test. e. Test for fluid wave.
ANS: B, D Testing for Blumberg's sign (rebound tenderness) and performing the iliopsoas muscle test should be used to assess for appendicitis. Murphy's sign is used to assess for an inflamed gallbladder or cholecystitis. Testing for a fluid wave and shifting dullness is done to assess for ascites.
The nurse is palpating an ovarian mass during an internal examination of a 63-year-old woman. Which findings of the mass's characteristics would suggest the presence of an ovarian cyst? *Select all that apply.* a. Heavy and solid b. Mobile and fluctuant c. Mobile and solid d. Fixed e. Smooth and round f. Poorly defined
ANS: B, E An ovarian cyst (fluctuant ovarian mass) is usually asymptomatic, and would feel like a smooth, round, fluctuant, mobile, nontender mass on the ovary. A mass that is heavy, solid, fixed, and poorly defined suggests malignancy. A benign mass may feel mobile and solid.
During the history of a 78-year-old man, his wife states that he occasionally has problems with short-term memory loss and confusion: "He can't even remember how to button his shirt." In doing the assessment of his sensory system, which action by the nurse is most appropriate?
ANS: Before testing, the nurse would assess the patient's mental status and ability to follow directions at this time. The nurse should ensure validity of the sensory system testing by making sure the patient is alert, cooperative, comfortable, and has an adequate attention span. Otherwise, the nurse may obtain misleading and invalid results.
A patient has a severed spinal nerve as a result of trauma. Which of these statements is true in this situation? a. Because there are 31 pairs of spinal nerves, there is no effect if only one is severed. b. The dermatome served by this nerve will no longer experience any sensation. c. The adjacent spinal nerves will continue to carry sensations for the dermatome served by the severed nerve. d. This will only affect motor function of the patient because spinal nerves have no sensory component.
ANS: C A dermatome is a circumscribed skin area that is supplied mainly from one spinal cord segment through a particular spinal nerve. The dermatomes overlap, which is a form of biologic insurance. That is, if one nerve is severed, most of the sensations can be transmitted by the spinal nerve above and spinal nerve below.
The nurse is assessing a 1-week-old infant and is testing his muscle strength. The nurse lifts the infant with hands under the axillae and notices that the infant starts to "slip" between the hands. The nurse should: a. suspect a fractured clavicle. b. suspect that the infant may have a deformity of the spine. c. suspect that the infant may have weakness of the shoulder muscles. d. consider this a normal finding because the musculature of an infant this age is unde-veloped.
ANS: C An infant who starts to "slip" between the nurse's hands shows weakness of the shoulder muscles. An infant with normal muscle strength wedges securely between the nurse's hands. The other responses are not correct.
During the interview a patient reveals that she has some vaginal discharge. She is worried that it may be a sexually transmitted infection. The nurse's most appropriate response to this would be: a. "Oh, don't worry. Some cyclic vaginal discharge is normal." b. "Have you been engaging in unprotected sexual intercourse?" c. "I'd like some information about the discharge. What color is it?" d. "Have you had any urinary incontinence associated with the discharge?"
ANS: C Ask questions that help the patient reveal more information about her symptoms in a nonthreatening manner. Assess vaginal discharge further by asking about the amount, color, and odor. Normal vaginal discharge is small, clear or cloudy, and always nonirritating.
When taking the history on a patient with a seizure disorder, the nurse assesses whether the patient has an aura. Which of these would be the best question for obtaining this information? a. "Does your muscle tone seem tense or limp?" b. "After the seizure, do you spend a lot of time sleeping?" c. "Do you have any warning sign before your seizure starts?" d. "Do you experience any color change or incontinence during the seizure?"
ANS: C Aura is a subjective sensation that precedes a seizure; it could be auditory, visual, or motor. The other questions are not correct regarding asking about an aura.
The changes normally associated with menopause occur generally because the cells in the reproductive tract are: a. aging. b. becoming fibrous. c. estrogen dependent. d. able to respond to estrogen.
ANS: C Because cells in the reproductive tract are estrogen dependent, decreased estrogen levels during menopause bring dramatic physical changes. The other options are not correct.
The nurse notices that a patient has had a black, tarry stool and recalls that a possible cause would be: a. gallbladder disease. b. overuse of laxatives. c. gastrointestinal bleeding. d. localized bleeding around the anus.
ANS: C Black stools may be tarry as a result of occult blood (melena) from gastrointestinal bleeding. Red blood in stools occurs with localized bleeding around the anus.
A patient who is visiting the clinic complains of having "stomach pains for 2 weeks" and describes his stools as being "soft and black" for about the last 10 days. He denies taking any medications. The nurse is aware that these symptoms are most indicative of: a. excessive fat caused by malabsorption. b. increased iron intake resulting from a change in diet. c. occult blood resulting from gastrointestinal bleeding. d. absent bile pigment from liver problems.
ANS: C Black stools may be tarry due to occult blood (melena) from gastrointestinal bleeding or nontarry from ingestion of iron medications (not diet). Excessive fat causes the stool to become frothy; absence of bile pigment causes clay-colored stools.
The nurse is performing percussion during an abdominal assessment. Percussion notes heard during the abdominal assessment may include: a. flatness, resonance, and dullness. b. resonance, dullness, and tympany. c. tympany, hyperresonance, and dullness. d. resonance, hyperresonance, and flatness.
ANS: C Percussion notes normally heard during the abdominal assessment may include tympany, which should predominate because air in the intestines rises to the surface when the person is supine; hyperresonance, which may be present with gaseous distention; and dullness, which may be found over a distended bladder, adipose tissue, fluid, or a mass.
A patient who has had rheumatoid arthritis for years comes to the clinic to ask about changes in her fingers. The nurse will assess for signs of what problems? a. Heberden's nodes b. Bouchard's nodules c. Swan neck deformities d. Dupuytren's contractures
ANS: C Changes in the fingers caused by chronic rheumatoid arthritis include swan neck and bouton-niere deformities. Heberden's nodes and Bouchard's nodules are associated with osteoarthri-tis. Dupuytren's contractures occur because of chronic hyperplasia of the palmar fascia and causes contractures of the digits (see Table 22-4).
The nurse is performing a genitourinary assessment on a 50-year-old obese male laborer. On examination the nurse notices a painless round swelling close to the pubis in the area of the internal inguinal ring that is easily reduced when the individual is supine. These findings are most consistent with a(n) _____ hernia. a. scrotal b. femoral c. direct inguinal d. indirect inguinal
ANS: C Direct inguinal hernias occur most often in men over the age of 40 years. It is an acquired weakness brought on by heavy lifting, obesity, chronic cough, or ascites. The direct inguinal hernia is usually a painless, round swelling close to the pubis in the area of the internal inguinal ring that is easily reduced when the individual is supine. See Table 24-6 for a description of scrotal hernia. See Table 24-7 for descriptions of femoral hernias and indirect inguinal hernias.
The nurse suspects that a patient has carpal tunnel syndrome and wants to perform the *Phalen's test.* To perform this test, the nurse should instruct the patient to: a. dorsiflex the foot. b. plantarflex the foot. c. hold both hands back to back while flexing the wrists 90 degrees for 60 seconds. d. hyperextend the wrists with the palmar surface of both hands touching and wait for 60 seconds.
ANS: C For the Phalen's test, the nurse should ask the person to hold both hands back to back while flexing the wrists 90 degrees. Acute flexion of the wrist for 60 seconds produces no symp-toms in the normal hand. The Phalen's test reproduces numbness and burning in a person with carpal tunnel syndrome. The other actions are not correct for testing for carpal tunnel syndrome.
During a genital examination, the nurse notices that a male patient has clusters of small vesicles on the glans, surrounded by erythema. The nurse recognizes that these lesions are: a. Peyronie disease. b. genital warts. c. genital herpes. d. syphilitic cancer.
ANS: C Genital herpes, or HSV-2, infections are indicated with clusters of small vesicles with surrounding erythema, which are often painful and erupt on the glans or foreskin. See Table 24-4 for descriptions of the other options.
An accessory glandular structure for the male genital organs is the: a. testis. b. penis. c. prostate. d. vas deferens.
ANS: C Glandular structures accessory to the male genital organs are the prostate, seminal vesicles, and bulbourethral glands.
A patient has had three pregnancies and two live births. The nurse would record this information as gravida _____, para _____, AB _____. a. 2; 2; 1 b. 3; 2; 0 c. 3; 2; 1 d. 3; 3; 1
ANS: C Gravida is number of pregnancies. Para is number of births. Abortions are interrupted pregnancies, including elective abortions and spontaneous miscarriages.
During the interview with a female patient, the nurse gathers data that indicate that the patient is perimenopausal. Which of these statements made by this patient leads to this conclusion? a. "I have noticed that my muscles ache at night when I go to bed." b. "I will be very happy when I can stop worrying about having a period." c. "I have been noticing that I sweat a lot more than I used to, especially at night." d. "I have only been pregnant twice, but both times I had breast tenderness as my first symptom."
ANS: C Hormone shifts occur during the perimenopausal period, and associated symptoms of menopause may occur, such as hot flashes, night sweats, numbness and tingling, headache, palpitations, drenching sweats, mood swings, vaginal dryness, and itching. The other responses are not correct.
A 46-year-old man requires assessment of his sigmoid colon. The nurse is aware that which of these is most appropriate for this examination? a. Proctoscope b. Ultrasound c. Colonoscope d. Rectal exam with an examining finger
ANS: C The sigmoid colon is 40 cm long and is accessible to examination only with the colonoscope. The other responses are not appropriate for examination of the entire sigmoid colon.
During an examination, the nurse asks a patient to bend forward from the waist and notices that the patient has lateral tilting. When his leg is raised straight up, he complains of a pain going down his buttock into his leg. The nurse suspects: a. scoliosis. b. meniscus tear. c. herniated nucleus pulposus. d. spasm of paravertebral muscles.
ANS: C Lateral tilting and sciatic pain with straight leg raising are findings that occur with a herniated nucleus pulposus. The other options are not correct.
The nurse is performing a neurologic assessment on a 41-year-old woman with a history of diabetes. When testing her ability to feel the vibrations of a tuning fork, the nurse notices that the patient is unable to feel vibrations on the great toe or ankle bilaterally, but she is able to feel vibrations on both patellae. Given this information, what would the nurse suspect? a. Hyperalgesia b. Hyperesthesia c. Peripheral neuropathy d. Lesion of sensory cortex
ANS: C Loss of vibration sense occurs with peripheral neuropathy (e.g., diabetes and alcoholism). Peripheral neuropathy is worse at the feet and gradually improves as the examiner moves up the leg, as opposed to a specific nerve lesion, which has a clear zone of deficit for its dermatome
The nurse is aware that which of these statements is true regarding the incidence of testicular cancer? a. Testicular cancer is the most common cancer in men aged 30 to 50 years. b. The early symptoms of testicular cancer are pain and induration. c. Men with a history of cryptorchidism are at greatest risk for development of testicular cancer. d. The cure rate for testicular cancer is low.
ANS: C Men with undescended testicles (cryptorchidism) are at greatest risk for development of testicular cancer. The overall incidence of testicular cancer is rare. Testicular cancer has no early symptoms. When detected early and treated before metastasis, the cure rate is almost 100%.
When performing the bimanual examination, the nurse notices that the cervix feels smooth and firm, is round, and is fixed in place (does not move). When cervical palpation is performed, the patient complains of some pain. The nurse's interpretation of these results should be which of these? a. These findings are all within normal limits. b. The cervical consistency should be soft and velvety-not firm. c. The cervix should move when palpated; an immobile cervix may indicate malignancy.
ANS: C Normally the cervix feels smooth and firm, as the consistency of the tip of the nose. It softens and feels velvety at 5 to 6 weeks of pregnancy (Goodell's sign). The cervix should be evenly rounded. With a finger on either side, the examiner should be able to move the cervix gently from side to side, and doing so should produce no pain for the patient. Hardness of the cervix may occur with malignancy. Immobility may occur with malignancy, and pain may occur with inflammation or ectopic pregnancy.
While examining a patient, the nurse observes abdominal pulsations between the xiphoid and umbilicus. The nurse would suspect that these are: a. pulsations of the renal arteries. b. pulsations of the inferior vena cava. c. normal abdominal aortic pulsations. d. increased peristalsis from a bowel obstruction.
ANS: C Normally, one may see the pulsations from the aorta beneath the skin in the epigastric area, particularly in thin persons with good muscle wall relaxation.
During a bimanual examination, the nurse detects a solid tumor on the ovary that is heavy and fixed, with a poorly defined mass. This finding is suggestive of: a. an ovarian cyst. b. endometriosis. c. ovarian cancer. d. an ectopic pregnancy.
ANS: C Ovarian tumors that are solid, heavy, and fixed, with poorly defined mass are suggestive of malignancy. Benign masses may feel mobile and solid. An ovarian cyst may feel smooth, round, fluctuant, mobile, and nontender. With an ectopic pregnancy, the examiner may feel a palpable, tender pelvic mass that is solid, mobile, and unilateral. Endometriosis may have masses (in various locations in the pelvic area) that are small, firm, nodular and tender to palpation, with enlarged ovaries.
During a health history, the patient tells the nurse, "I have pain all the time in my stomach. It's worse two hours after I eat, but it gets better if I eat again!" The nurse suspects that the patient has which condition, based on these symptoms? a. Appendicitis b. Gastric ulcer c. Duodenal ulcer d. Cholecystitis
ANS: C Pain associated with duodenal ulcers occurs 2 to 3 hours after a meal, yet it is relieved by more food. Chronic pain associated with gastric ulcers occurs usually on an empty stomach. Severe, acute pain would occur with appendicitis and cholecystitis.
The nurse is teaching a class on osteoporosis prevention to a group of postmenopausal women. Which of these actions is the best way to prevent or delay bone loss in this group? a. Taking calcium and vitamin D supplements b. Taking medications to prevent osteoporosis c. Performing physical activity, such as fast walking d. Assessing bone density annually
ANS: C Physical activity, such as fast walking, delays or prevents bone loss in perimenopausal wom-en. The faster the pace of walking, the higher the preventive effect on the risk of hip fracture. The other options are not correct.
During a neonatal examination, the nurse notices that the newborn infant has six toes. This finding is documented as: a. unidactyly. b. syndactyly. c. polydactyly. d. multidactyly.
ANS: C Polydactyly is the presence of extra fingers or toes. Syndactyly is webbing between adjacent fingers or toes. The other terms are not correct.
A patient is complaining of pain in his joints that is worse in the morning, is better after he has moved around for awhile, and then gets worse again if he sits for long periods of time. The nurse should assess for other signs of what problem? a. Tendinitis b. Osteoarthritis c. Rheumatoid arthritis d. Intermittent claudication
ANS: C Rheumatoid arthritis is worse in the morning when arising. Movement increases most joint pain, except in rheumatoid arthritis, in which movement decreases pain. The other options are not correct.
A woman states that 2 weeks ago she had a urinary tract infection that was treated with an antibiotic. As a part of the interview, the nurse should ask, "Have you noticed: a. a change in your urination patterns?" b. any excessive vaginal bleeding?" c. any unusual vaginal discharge or itching?" d. any changes in your desire for intercourse?"
ANS: C Several medications may increase the risk of vaginitis. Broad-spectrum antibiotics alter the balance of normal flora, which may lead to the development of vaginitis. The other questions are not correct.
A patient is complaining of a sharp pain along the costovertebral angles. The nurse knows that this symptom is most often indicative of: a. ovary infection. b. liver enlargement. c. kidney inflammation. d. spleen enlargement.
ANS: C Sharp pain along the costovertebral angles occurs with inflammation of the kidney or paranephric area. The other options are not correct.
A patient is not able to perform rapid alternating movements such as patting her knees rapidly. The nurse should document this as: a. ataxia. b. astereognosis. c. the presence of dysdiadochokinesia. d. loss of kinesthesia.
ANS: C Slow clumsy movements and the inability to perform rapid alternating movements occur with cerebellar disease. The condition is termed dysdiadochokinesia. Ataxia is uncoordinated or unsteady gait. Astereognosis is the inability to identify an object by feeling it. Kinesthesia is the person's ability to perceive passive movement of the extremities, or the loss of position sense.
During an assessment of an 80-year-old patient, the nurse notices the following: inability to identify vibrations at the ankle and to identify position of big toe, slower and more deliberate gait, and slightly impaired tactile sensation. All other neurologic findings are normal. The nurse should interpret that these findings indicate: a. cranial nerve dysfunction. b. lesion in the cerebral cortex. c. normal changes due to aging. d. demyelinization of nerves due to a lesion.
ANS: C Some aging adults show a slower response to requests, especially for those calling for coordination of movements. The findings listed are normal in the absence of other significant abnormal findings. The other responses are incorrect.
The nurse is caring for a patient who has just had neurosurgery. To assess for increased intracranial pressure, what would the nurse include in the assessment? a. Cranial nerves, motor function, and sensory function b. Deep tendon reflexes, vital signs, and coordinated movements c. Level of consciousness, motor function, pupillary response, and vital signs d. Mental status, deep tendon reflexes, sensory function, and pupillary response
ANS: C Some hospitalized persons have head trauma or a neurologic deficit from a systemic disease process. These people must be monitored closely for any improvement or deterioration in neurologic status and for any indication of increasing intracranial pressure. The nurse should use an abbreviation of the neurologic examination in the following sequence: level of consciousness, motor function, pupillary response, and vital signs.
The nurse notices that a patient has had a pale, yellow, greasy stool, or steatorrhea, and recalls that this is caused by: a. occult bleeding. b. absent bile pigment. c. increased fat content. d. ingestion of bismuth preparations.
ANS: C Steatorrhea (pale, yellow, greasy stool) is caused by increased fat content in the stools, as in malabsorption syndrome. Occult bleeding and ingestion of bismuth products cause black stool, and absent bile pigment causes gray, tan stool.
A 45-year-old mother of two children is seen at the clinic for complaints of "losing my urine when I sneeze." The nurse documents that she is experiencing: a. urinary frequency. b. enuresis. c. stress incontinence. d. urge incontinence.
ANS: C Stress incontinence is involuntary urine loss with physical strain, sneezing, or coughing that occurs due to weakness of the pelvic floor. Urinary frequency is urinating more times than usual (more than 5 to 6 times per day). Enuresis is involuntary passage of urine at night after age 5 to 6 years (bed wetting). Urge incontinence is involuntary urine loss from overactive detrusor muscle in the bladder. It contracts, causing an urgent need to void.
When the nurse is testing the triceps reflex, what is the expected response? a. Flexion of the hand b. Pronation of the hand c. Extension of the forearm d. Flexion of the forearm
ANS: C The normal response of the triceps reflex is extension of the forearm. The normal response of the biceps reflex causes flexion of the forearm. The other responses are incorrect.
Which statement would be most appropriate when the nurse is introducing the topic of sexual relationships during an interview? a. "Now it is time to talk about your sexual history. When did you first have intercourse?" b. "Women often feel dissatisfied with their sexual relationships. Would it be okay to discuss this now?" c. "Often women have questions about their sexual relationship and how it affects their health. Do you have any questions?" d. "Most women your age have had more than one sexual partner. How many would you say you have had?"
ANS: C The nurse should begin with an open-ended question to assess individual needs. The nurse should include appropriate questions as a routine part of the history, because doing so communicates that the nurse accepts the individual's sexual activity and believes it is important. The nurse's comfort with discussion prompts the patient's interest and possibly relief that the topic has been introduced. This establishes a database for comparison with any future sexual activities and provides an opportunity to screen sexual problems.
While assessing a hospitalized, bedridden patient, the nurse notices that the patient has been incontinent of stool. The stool is loose and gray-tan in color. The nurse recognizes that this finding indicates which of the following? a. Occult blood b. Inflammation c. Absent bile pigment d. Ingestion of iron preparations
ANS: C The presence of gray, tan stool indicates absent bile pigment, which can occur with obstructive jaundice. Ingestion of iron preparations and presence of occult blood would turn the stools to a black color. Jelly-like mucus shreds mixed in the stool would indicate inflammation.
While gathering equipment after an injection, a nurse accidentally received a prick from an improperly capped needle. To interpret this sensation, which of these areas must be intact? a. Corticospinal tract, medulla, and basal ganglia b. Pyramidal tract, hypothalamus, and sensory cortex c. Lateral spinothalamic tract, thalamus, and sensory cortex d. Anterior spinothalamic tract, basal ganglia, and sensory cortex
ANS: C The spinothalamic tract contains sensory fibers that transmit the sensations of pain, temperature, and crude or light touch. Fibers carrying pain and temperature sensations ascend the lateral spinothalamic tract, whereas those of crude touch form the anterior spinothalamic tract. At the thalamus, the fibers synapse with another sensory neuron, which carries the message to the sensory cortex for full interpretation. The other options are not correct
To palpate the temporomandibular joint, the nurse's fingers should be placed in the depres-sion _____ of the ear. a. distal to the helix b. proximal to the helix c. anterior to the tragus d. posterior to the tragus
ANS: C The temporomandibular joint can be felt in the depression anterior to the tragus of the ear. The other locations are not correct.
During an assessment the nurse notices that a patient's umbilicus is enlarged and everted. It is midline, and there is no change in skin color. The nurse recognizes that the patient may have which condition? a. Intra-abdominal bleeding b. Constipation c. Umbilical hernia d. An abdominal tumor
ANS: C The umbilicus is normally midline and inverted, with no signs of discoloration. With an umbilical hernia, the mass is enlarged and everted. The other responses are incorrect.
During an examination, the nurse notices that a male patient has a red, round, superficial ulcer with a yellowish serous discharge on his penis. On palpation, the nurse finds a nontender base that feels like a small button between the thumb and fingers. At this point the nurse suspects that this patient has: a. genital warts. b. a herpes infection. c. a syphilitic chancre. d. a carcinoma lesion.
ANS: C This lesion indicates syphilitic chancre, which begins within 2 to 4 weeks of infection. See Table 24-4 for descriptions of the other options.
During an assessment of the newborn, the nurse expects to see which finding when the anal area is slightly stroked? a. A jerking of the legs b. Flexion of the knees c. A quick contraction of the sphincter d. Relaxation of the external sphincter
ANS: C To assess sphincter tone, the nurse should check the anal reflex by gently stroking the anal area and noticing a quick contraction of the sphincter. The other responses are not correct.
When the nurse is interviewing a preadolescent girl, which opening statement would be least threatening? a. "Do you have any questions about growing up?" b. "What has your mother told you about growing up?" c. "When did you notice that your body was changing?" d. "I remember being very scared when I got my period. How do you think you'll feel?"
ANS: C Try the open-ended, "When did you ... ?" rather than "Do you ... ?" This is less threatening because it implies that the topic is normal and unexceptional.
An 18-year-old patient is having her first pelvic examination. Which action by the nurse is appropriate? a. Invite her mother to be present during the examination. b. Avoid the lithotomy position this first time because it can be uncomfortable and embarrassing. c. Raise the head of the examination table and give her a mirror so that she can view the exam. d. Drape her fully, leaving the drape between her legs elevated to avoid embarrassing her with eye contact.
ANS: C Use the techniques of the educational or mirror pelvic examination. This is a routine examination with some modifications in attitude, position, and communication. First, the woman is considered an active participant, one who is interested in learning and in sharing decisions about her own health care. The woman props herself up on one elbow, or the head of the table is raised. Her other hand holds a mirror between her legs, above the examiner's hands. The woman can see all that the examiner is doing and has a full view of her genitalia. The mirror works well for teaching normal anatomy and its relationship to sexual behavior. You can ask her if she would like to have a family member, friend, or chaperone present for the examination. The drape should be pushed down between the woman's legs so that the nurse can see her face.
The nurse is doing an assessment on a 29-year-old woman who visits the clinic complaining of "always dropping things and falling down." While testing rapid alternating movements, the nurse notices that the woman is unable to pat both her knees. Her response is very slow and she misses frequently. What should the nurse suspect? a. Vestibular disease b. Lesion of cranial nerve IX c. Dysfunction of the cerebellum d. Inability to understand directions
ANS: C When a person performs rapid, alternating movements, slow, clumsy, and sloppy responses occur with cerebellar disease. The other responses are incorrect.
A 46-year-old woman is in the clinic for her annual gynecologic examination. She voices a concern about ovarian cancer because her mother and sister died of it. The nurse knows that which of these statements is correct regarding ovarian cancer? a. Ovarian cancer rarely has any symptoms. b. The Pap smear detects the presence of ovarian cancer. c. Women at high risk for ovarian cancer should have annual transvaginal ultrasonography for screening. d. Women over age 40 years should have a thorough pelvic examination every 3 years.
ANS: C With ovarian cancer, the patient may have abdominal pain, pelvic pain, increased abdominal size, bloating, and nonspecific gastrointestinal symptoms, or she may be asymptomatic. The Pap smear does not detect the presence of ovarian cancer. Annual transvaginal ultrasonography may detect ovarian cancer at an earlier stage in women who are at high risk for it.
The nurse is testing superficial reflexes on an adult patient. When stroking up the lateral side of the sole and across the ball of the foot, the nurse notices the plantar flexion of the toes. How should the nurse document this finding? a. Positive Babinski sign b. Plantar reflex abnormal c. Plantar reflex present d. Plantar reflex "2+" on a scale from "0 to 4+"
ANS: C With the same instrument, the nurse should draw a light stroke up the lateral side of the sole of the foot and across the ball of the foot, like an upside-down "J." The normal response is plantar flexion of the toes and sometimes of the whole foot. A positive Babinski sign is abnormal and occurs with the response of dorsiflexion of the big toe and fanning of all toes. The plantar reflex is not graded on a 0 to 4+ scale.
A 30-year-old woman tells the nurse that she has been very unsteady and has had difficulty in maintaining her balance. Which area of the brain would the nurse be concerned about with these findings?
ANS: Cerebellum The cerebellar system coordinates movement, maintains equilibrium, and helps maintain posture. The thalamus is the main relay station where sensory pathways of the spinal cord, cerebellum, and brainstem for synapses on their way to the cerebral cortex. The brainstem consists of the midbrain, pons, and medulla and has various functions, especially concerning autonomic centers. The extrapyramidal tract maintains muscle tone for gross automatic movements, such as walking.
The nurse knows that determining whether a person is oriented to his or her surroundings will test the functioning of which of these structures?
ANS: Cerebrum The cerebral cortex is responsible for thought, memory, reasoning, sensation, and voluntary movement. The other options structures are not responsible for a person's level of consciousness.
A 50-year-old woman is in the clinic for weakness in her left arm and leg that she has noticed for the past week. The nurse should perform which type of neurologic examination?
ANS: Complete neurologic examination The nurse should perform a complete neurologic examination on persons who have neurologic concerns (e.g., headache, weakness, loss of coordination) or who have shown signs of neurologic dysfunction. The Glasgow Coma scale is used to define a person's level of consciousness. The neurologic recheck examination is appropriate for persons with demonstrated neurologic deficits. The screening neurologic examination is performed on seemingly well persons who have no significant subjective findings from the history.
While the nurse is taking the history of a 68-year-old patient who sustained a head injury 3 days earlier, he tells the nurse that he is on a cruise ship and is 30 years old. The nurse knows that this finding is indicative of: a. a great sense of humor. b. uncooperative behavior. c. inability to understand questions. d. decreased level of consciousness.
ANS: D A change in consciousness may be subtle. The nurse should notice any decreasing level of consciousness, disorientation, memory loss, uncooperative behavior, or even complacency in a previously combative person. The other responses are incorrect.
The nurse knows that a common assessment finding in a boy younger than 2 years old is: a. an inflamed and tender spermatic cord. b. the presence of a hernia in the scrotum. c. a penis that looks large in relation to the scrotum. d. the presence of a hydrocele, or fluid in the scrotum.
ANS: D A common scrotal finding in boys younger than 2 years of age is a hydrocele, or fluid in the scrotum. The other options are not correct
While performing a rectal examination, the nurse notices a firm, irregularly shaped mass. What should the nurse do next? a. Continue with the examination and document the finding in the chart. b. Instruct patient to return for repeat assessment in 1 month. c. Tell the patient that a mass was felt but it is nothing to worry about. d. Report the finding and refer the patient to a specialist for further examination.
ANS: D A firm or hard mass with irregular shape or rolled edges may signify carcinoma. Promptly report any mass that is discovered for further examination. The other responses are not correct.
During an assessment of a 20-year-old man, the nurse finds a small palpable lesion with a tuft of hair located directly over the coccyx. The nurse knows that this lesion would most likely be a: a. polyp. b. pruritus ani. c. carcinoma. d. pilonidal cyst.
ANS: D A pilonidal cyst or sinus is a hair-containing cyst or sinus located in the midline over the coccyx or lower sacrum. It often opens as a dimple with a visible tuft of hair and, possibly, an erythematous halo. See Table 25-1 for more information, and also for description of pruritus ani. See Table 25-2 for descriptions of rectal polyps and carcinoma.
A patient's abdomen is bulging and stretched in appearance. The nurse should describe this finding as: a. obese. b. herniated. c. scaphoid. d. protuberant.
ANS: D A protuberant abdomen is rounded, bulging, and stretched. See Figure 21-7. A scaphoid abdomen caves inward.
The nurse is providing patient education for a man who has been diagnosed with a rotator cuff injury. The nurse knows that a rotator cuff injury involves the: a. nucleus pulposus. b. articular process. c. medial epicondyle. d. glenohumeral joint.
ANS: D A rotator cuff injury involves the glenohumeral joint, which is enclosed by a group of four powerful muscles and tendons that support and stabilize it. The nucleus pulposus is located in the center of each intervertebral disk. The medial epicondyle is located at the elbow.
A 15-year-old boy is seen in the clinic for complaints of "dull pain and pulling" in the scrotal area. On examination the nurse palpates a soft, irregular mass posterior to and above the testis on the left. This mass collapses when the patient is supine and refills when he is upright. This description is consistent with: a. epididymitis. b. spermatocele. c. testicular torsion. d. varicocele.
ANS: D A varicocele consists of dilated, tortuous varicose veins in the spermatic cord caused by incompetent valves within the vein. Symptoms include dull pain or constant pulling or dragging feeling, or the individual may be asymptomatic. When palpating the mass, the examiner will feel a soft, irregular mass posterior to and above the testis that collapses when the individual is supine and refills when the individual is upright. See Table 24-6 for more information and for descriptions of the other options.
When the nurse asks a 68-year-old patient to stand with feet together and arms at his side with his eyes closed, he starts to sway and moves his feet farther apart. The nurse would document this finding as a(n): a. ataxia. b. lack of coordination. c. negative Homans' sign. d. positive Romberg sign.
ANS: D Abnormal findings for Romberg test include swaying, falling, and widening base of feet to avoid falling. Positive Romberg sign is loss of balance that is increased by closing of the eyes. Ataxia is uncoordinated or unsteady gait. Homans' sign is used to test the legs for deep vein thrombosis.
A 70-year-old woman tells the nurse that every time she gets up in the morning or after she's been sitting she gets "really dizzy" and feels like she is going to fall over. The nurse's best response would be: a. "Have you been extremely tired lately?" b. "You probably just need to drink more liquids." c. "I'll refer you for a complete neurologic examination." d. "You need to get up slowly when you've been lying or sitting."
ANS: D Aging is accompanied by a progressive decrease in cerebral blood flow. In some people this causes dizziness and a loss of balance with position change. These people need to be taught to get up slowly. The other responses are incorrect.
Which of these statements is true regarding the penis? a. The urethral meatus is located on the ventral side of the penis. b. The prepuce is the fold of foreskin covering the shaft of the penis. c. The penis is composed of two cylindrical columns of erectile tissue. d. The corpus spongiosum expands into a cone of erectile tissue called the glans.
ANS: D At the distal end of the shaft, the corpus spongiosum expands into a cone of erectile tissue, the glans. The penis is composed of three cylindrical columns of erectile tissue. The prepuce is skin that covers the glans of the penis. The urethral meatus forms at the tip of the glans.
A 32-year-old woman tells the nurse that she has noticed "very sudden, jerky movements" mainly in her hands and arms. She says, "They seem to come and go, primarily when I am trying to do something. I haven't noticed them when I'm sleeping." This description suggests: a. tics. b. athetosis. c. myoclonus. d. chorea.
ANS: D Chorea is characterized by sudden, rapid, jerky, purposeless movements that involve the limbs, trunk, or face. Chorea occurs at irregular intervals, and the movements are all accentuated by voluntary actions. See Table 23-5 for descriptions of athetosis, myoclonus, and tics.
The nurse notices that a woman in an exercise class is unable to jump rope. The nurse knows that to jump rope, one's shoulder has to be capable of: a. inversion. b. supination. c. protraction. d. circumduction.
ANS: D Circumduction is defined as moving the arm in a circle around the shoulder.
The nurse is describing a scaphoid abdomen. To the horizontal plane, a scaphoid contour of the abdomen depicts a _____ profile. a. flat b. convex c. bulging d. concave
ANS: D Contour describes the profile of the abdomen from the rib margin to the pubic bone; a scaphoid contour is one that is concave from a horizontal plane. See Figure 21-7.
To detect diastasis recti, the nurse should have the patient perform which of these maneuvers? a. Relax in the supine position. b. Raise the arms in the left lateral position. c. Raise the arms over the head while supine. d. Raise the head while remaining supine.
ANS: D Diastasis recti is a separation of the abdominal rectus muscles, which can occur congenitally, as a result of pregnancy, or from marked obesity. This is assessed by having the patient raise the head while remaining supine.
A young swimmer comes to the sports clinic complaining of a very sore shoulder. He was running at the pool, slipped on some wet concrete, and tried to catch himself with his out-stretched hand. He landed on his outstretched hand and has not been able to move his shoulder since then. The nurse suspects: a. joint effusion. b. tear of rotator cuff. c. adhesive capsulitis. d. dislocated shoulder.
ANS: D Dislocated shoulder occurs with trauma involving abduction, extension, and external rotation (e.g., falling on an outstretched arm or diving into a pool). See Table 22-2 for a description of the other conditions.
The nurse suspects that a patient has a distended bladder. How should the nurse assess for this condition? a. Percuss and palpate in the lumbar region. b. Inspect and palpate in the epigastric region. c. Auscultate and percuss in the inguinal region. d. Percuss and palpate the midline area above the suprapubic bone.
ANS: D Dull percussion sounds would be elicited over a distended bladder, and the hypogastric area would seem firm to palpation.
Fibrous bands running directly from one bone to another that strengthen the joint and help prevent movement in undesirable directions are called: a. bursa. b. tendons. c. cartilage. d. ligaments.
ANS: D Fibrous bands running directly from one bone to another that strengthen the joint and help prevent movement in undesirable directions are called ligaments.
The nurse has completed the musculoskeletal examination of a *patient's knee and has found a positive bulge sign*. The nurse interprets this finding to indicate: a. irregular bony margins. b. soft tissue swelling in the joint. c. swelling from fluid in the epicondyle. d. swelling from fluid in the suprapatellar pouch.
ANS: D For swelling in the suprapatellar pouch, the bulge sign confirms the presence of fluid. The other options are not correct.
The nurse is aware that one change that may occur in the gastrointestinal system of an aging adult is: a. increased salivation. b. increased liver size. c. increased esophageal emptying. d. decreased gastric acid secretion.
ANS: D Gastric acid secretion decreases with aging. As one ages, salivation decreases, esophageal emptying is delayed, and liver size decreases.
A 22-year-old woman is being seen at the clinic for problems with vulvar pain, dysuria, and fever. On physical examination, the nurse notices clusters of small, shallow vesicles with surrounding erythema on the labia. There is also inguinal lymphadenopathy present. The most likely cause of these lesions is: a. pediculosis pubis. b. contact dermatitis. c. human papillomavirus. d. herpes simplex virus type 2.
ANS: D Herpes simplex virus type 2 presents with clusters of small, shallow vesicles with surrounding erythema that erupt on the genital areas. There is also the presence of inguinal lymphadenopathy. The individual reports local pain, dysuria, and fever. See Table 26-2 for more information and descriptions of the other conditions.
During a health history, a patient tells the nurse that he has trouble in starting his urine stream. This problem is known as: a. urgency. b. dribbling. c. frequency. d. hesitancy.
ANS: D Hesitancy is trouble in starting the urine stream. Urgency is the feeling that one cannot wait to urinate. Dribbling is the lost of urine before or after the main act of urination. Frequency is urinating more often than usual.
During an abdominal assessment, the nurse tests for a fluid wave. A positive fluid wave test occurs with: a. splenomegaly. b. distended bladder. c. constipation. d. ascites.
ANS: D If ascites (fluid in the abdomen) is present, then the examiner will feel a fluid wave when assessing the abdomen. A fluid wave is not present with splenomegaly, a distended bladder, or constipation.
The nurse is performing a genital examination on a male patient and notices urethral drainage. When collecting urethral discharge for microscopic examination and culture, the nurse should: a. ask the patient to urinate into a sterile cup. b. ask the patient to obtain a specimen of semen. c. insert a cotton-tipped applicator into the urethra. d. compress the glans between the examiner's thumb and forefinger and collect any discharge.
ANS: D If urethral discharge is noticed, then the examiner should collect a smear for microscopic examination and culture by compressing the glans anteroposteriorly between the thumb and forefinger. The other options are not correct actions.
During an examination, the nurse asks the patient to perform the Valsalva maneuver and notices that the patient has a moist, red, doughnut-shaped protrusion from the anus. The nurse knows that this would be consistent with: a. a rectal polyp. b. hemorrhoids. c. a rectal fissure. d. rectal prolapse.
ANS: D In rectal prolapse, the rectal mucous membrane protrudes through the anus, appearing as a moist red doughnut with radiating lines. It occurs following a Valsalva maneuver, such as straining at stool, or with exercise. See Table 25-1. For a description of rectal polyps, see Table 25-2. See Table 25-1 for descriptions of rectal fissure and hemorrhoids.
A 65-year-old woman is in the office for routine gynecologic care. She had a complete hysterectomy 3 months ago after cervical cancer was detected. The nurse knows that which of these statements is true with regard to this visit? a. Her cervical mucosa will be red and dry looking. b. She will not need to have a Pap smear done. c. The nurse can expect to find that her uterus will be somewhat enlarged and her ovaries small and hard. d. The nurse should plan to lubricate the instruments and the examining hand well to avoid a painful examination.
ANS: D In the aging adult woman, natural lubrication is decreased; to avoid a painful examination, the nurse should take care to lubricate instruments and the examining hand adequately. Menopause, with the resulting decrease in estrogen production, shows numerous physical changes. The cervix shrinks and looks pale and glistening. With the bimanual examination, the uterus feels smaller and firmer and the ovaries are not palpable normally. Women should continue cervical cancer screening up to age 70 years if they have an intact cervix and are in good health. Women who have had a total hysterectomy for benign gynecologic disease do not need cervical cancer screening, but if the hysterectomy was done for cervical cancer, then Pap tests should continue until the patient has a 10-year history of no abnormal results.
The nurse is explaining to a patient that there are "shock absorbers" in his back to cushion the spine and to help it move. The nurse is referring to his: a. vertebral column. b. nucleus pulposus. c. vertebral foramen. d. intervertebral disks.
ANS: D Intervertebral disks are elastic fibrocartilaginous plates that cushion the spine like shock ab-sorbers and help it move. The vertebral column is the spinal column itself. The nucleus pul-posus is located in the center of each disk. The vertebral foramen is the channel, or opening, for the spinal cord in the vertebrae.
The nurse is assessing a patient for possible peptic ulcer disease and knows that which condition often causes this problem? a. Hypertension b. Streptococcus infections c. History of constipation and frequent laxative use d. Frequent use of nonsteroidal antiinflammatory drugs
ANS: D Peptic ulcer disease occurs with frequent use of nonsteroidal antiinflammatory drugs, alcohol use, smoking, and Helicobacter pylori infection.
The nurse is providing patient teaching about an erectile dysfunction drug. One of the drug's potential side effects is prolonged, painful erection of the penis without sexual stimulation, which is known as: a. orchitis. b. stricture. c. phimosis. d. priapism.
ANS: D Priapism is prolonged, painful erection of the penis without sexual desire. Orchitis is inflammation of the testes. Stricture is a narrowing of the opening of the urethral meatus. Phimosis is the inability to retract the foreskin.
A woman who is 8 weeks pregnant is in the clinic for a checkup. The nurse reads on her chart that her cervix is softened and looks cyanotic. The nurse knows that the woman is exhibiting _____ sign and _____ sign. a. Tanner's; Hegar's b. Hegar's; Goodell's c. Chadwick's; Hegar's d. Goodell's; Chadwick's
ANS: D Shortly after the first missed menstrual period, the female genitalia show signs of the growing fetus. The cervix softens (Goodell's sign) at 4 to 6 weeks, and the vaginal mucosa and cervix look cyanotic (Chadwick's sign) at 8 to 12 weeks. These changes occur because of increased vascularity and edema of the cervix and hypertrophy and hyperplasia of the cervical glands. Hegar's sign occurs when the isthmus of the uterus softens at 6 to 8 weeks. Tanner's sign is not a correct response.
When the nurse is conducting sexual history from a male adolescent, which statement would be most appropriate to use at the beginning of the interview? a. "Do you use condoms?" b. "You don't masturbate, do you?" c. "Have you had sex in the last 6 months?" d. "Often boys your age have questions about sexual activity."
ANS: D Start the interview with a permission statement. This conveys that it is normal and all right to think or feel a certain way. Avoid sounding judgmental.
A 68-year-old woman has come in for an assessment of her rheumatoid arthritis, and the nurse notices raised, firm, nontender nodules at the olecranon bursa and along the ulna. These nodules are most commonly diagnosed as: a. epicondylitis. b. gouty arthritis. c. olecranon bursitis. d. subcutaneous nodules.
ANS: D Subcutaneous nodules are raised, firm, and nontender and occur with rheumatoid arthritis in the olecranon bursa and along the extensor surface of the ulna. See Table 22-3 for a descrip-tion of the other conditions.
A 59-year-old patient has a herniated intervertebral disk. Which of the following findings should the nurse expect to see on physical assessment of this individual?
ANS: Hyporeflexia With a herniated intervertebral disk or lower motor neuron lesion there is loss of tone, flaccidity, atrophy, fasciculations, and hyporeflexia or areflexia. No Babinski's sign or pathologic reflexes would be seen. The other options reflect a lesion of upper motor neurons. See Table 23-7.
During a health history, a 22-year old woman asks, "Can I get that vaccine for HPV? I have genital warts and I'd like them to go away!" What is the nurse's best response? a. "The HPV vaccine is for girls and women ages 9 to 26, so we can start that today." b. "This vaccine is only for girls who have not started to have intercourse yet." c. "Let's check with the physician to see if you are a candidate for this vaccine." d. "The vaccine cannot protect you if you already have an HPV infection."
ANS: D The HPV (human papillomavirus) vaccine is appropriate for girls and women age 9 to 26 and is given to prevent cervical cancer by preventing HPV infections before girls become sexually active. However, it cannot protect the woman if an HPV infection is already present.
Which of these statements about the anal canal is true? The anal canal: a. is about 2 cm long in the adult. b. slants backward toward the sacrum. c. contains hair and sebaceous glands. d. is the outlet for the gastrointestinal tract.
ANS: D The anal canal is the outlet for the gastrointestinal tract, and it is about 3.8 cm long in the adult. It is lined with a modified skin that does not contain hair or sebaceous glands, and it slants forward toward the umbilicus.
While doing an assessment of the perianal area of a patient, the nurse notices that the pigmentation of anus is darker than surrounding skin, the anal opening is closed, and there is a skin sac that is shiny and blue. The patient mentioned that he has had pain with bowel movements and has noted some spots of blood occasionally. What would this assessment and history be most likely to indicate? a. Anal fistula b. Pilonidal cyst c. Rectal prolapse d. Thrombosed hemorrhoid
ANS: D The anus normally looks moist and hairless, with coarse folded skin that is more pigmented than the perianal skin. The anal opening is tightly closed. The shiny blue skin sac indicates a thrombosed hemorrhoid
A professional tennis player comes into the clinic complaining of a sore elbow. The nurse will assess for tenderness at the: a. olecranon bursa. b. annular ligament. c. base of the radius. d. medial and lateral epicondyle.
ANS: D The epicondyles, the head of radius, and tendons are common sites of inflammation and local tenderness, or "tennis elbow." The other locations are not affected.
The nurse is examining the glans and knows that which of these is a normal finding for this area? a. The meatus may have a slight discharge when the glans is compressed. b. Hair is without pest inhabitants. c. The skin is wrinkled and without lesions. d. Smegma may be present under the foreskin of an uncircumcised male.
ANS: D The glans looks smooth and without lesions and does not have hair. The meatus should not have any discharge when the glans is compressed. Some cheesy smegma may have collected under the foreskin of an uncircumcised male.
During the assessment of an 18-month-old child, the mother expresses concern to the nurse about the infant's inability to toilet train. What would be the nurse's best response? a. "Some children are just more difficult to train, so I wouldn't worry about it yet." b. "Have you considered reading any of the books on toilet training? They can be very helpful." c. "This could mean there is a problem in your baby's development. We'll watch her closely for the next few months." d. "The nerves that will allow your baby to have control over the passing of stools are not developed until at least 18 to 24 months of age."
ANS: D The infant passes stools by reflex. Voluntary control of the external anal sphincter cannot occur until the nerves supplying the area have become fully myelinated, usually around 1 1/2 to 2 years of age. Toilet training usually starts after the age of 2
During the history of a 78-year-old man, his wife states that he occasionally has problems with short-term memory loss and confusion: "He can't even remember how to button his shirt." In doing the assessment of his sensory system, which action by the nurse is most appropriate? a. The nurse would not do this part of the examination because results would not be valid. b. The nurse would perform the tests, knowing that mental status does not affect sensory ability. c. The nurse would proceed with the explanations of each test, making sure the wife understands. d. Before testing, the nurse would assess the patient's mental status and ability to follow directions at this time.
ANS: D The nurse should ensure validity of the sensory system testing by making sure the patient is alert, cooperative, comfortable, and has an adequate attention span. Otherwise, the nurse may obtain misleading and invalid results.
A 50-year-old woman is in the clinic for weakness in her left arm and leg that she has noticed for the past week. The nurse should perform which type of neurologic examination? a. Glasgow Coma Scale b. Neurologic recheck examination c. Screening neurologic examination d. Complete neurologic examination
ANS: D The nurse should perform a complete neurologic examination on persons who have neurologic concerns (e.g., headache, weakness, loss of coordination) or who have shown signs of neurologic dysfunction. The Glasgow Coma scale is used to define a person's level of consciousness. The neurologic recheck examination is appropriate for persons with demonstrated neurologic deficits. The screening neurologic examination is performed on seemingly well persons who have no significant subjective findings from the history.
A 60-year-old man has just been told he has benign prostatic hypertrophy. He has a friend who just died from cancer of the prostate, and he is concerned this will happen to him. How should the nurse respond? a. "The swelling in your prostate is only temporary and will go away." b. "We will treat you with chemotherapy so we can control the cancer." c. "It would be very unusual for a man your age to have cancer of the prostate." d. "The enlargement of your prostate is caused by hormone changes and not cancer."
ANS: D The prostate gland commonly starts to enlarge during the middle adult years. This benign prostatic hypertrophy (BPH) is present in 1 out of 10 males at the age of 40 years and increases with age. It is thought that the hypertrophy is caused by hormonal imbalance that leads to the proliferation of benign adenomas. The other responses are not appropriate.
The nurse is testing the function of cranial nerve XI. Which of these best describes the response the nurse should expect if the nerve is intact? The patient: a. demonstrates ability to hear normal conversation. b. sticks tongue out midline without tremors or deviation. c. follows an object with eyes without nystagmus or strabismus. d. moves the head and shoulders against resistance with equal strength.
ANS: D These are the expected normal findings when testing cranial nerve XI (spinal accessory nerve): The patient's sternomastoid and trapezius muscles are of equal size; the person can rotate the head both ways forcibly against resistance applied to the side of the chin with equal strength; the patient can shrug the shoulders against resistance with equal strength on both sides. Checking the patient's ability to hear normal conversation checks the function of CN VIII. Having the patient stick out the tongue checks the function of CN XII. Testing the eyes for nystagmus or strabismus is done to check CN III, IV, and VI.
During an assessment of a 32-year-old patient with a recent head injury, the nurse notices that the patient responds to pain by extending, adducting, and internally rotating his arms. His palms pronate and his lower extremities extend with plantar flexion. Which of these statements about these findings is accurate? a. This indicates a lesion of the cerebral cortex. b. This indicates a completely nonfunctional brainstem. c. This is a normal response that will go away in 24 to 48 hours. d. This is a very ominous sign and may indicate brainstem injury.
ANS: D These findings are all indicative of decerebrate rigidity, which is a very ominous condition and may indicate a brainstem injury.
A 25-year-old woman comes to the emergency department with a sudden fever of 101° F and abdominal pain. Upon examination, the nurse notices that she has rigid, boardlike lower abdominal musculature. When the nurse tries to perform a vaginal examination, the patient has severe pain when the uterus and cervix are moved. The nurse knows that these signs and symptoms are suggestive of: a. endometriosis. b. uterine fibroids. c. ectopic pregnancy. d. pelvic inflammatory disease.
ANS: D These signs and symptoms are suggestive of acute pelvic inflammatory disease, also known as acute salpingitis. See Table 26-7. For description of endometriosis and uterine fibroids, see Table 26-6; for description of ectopic pregnancy, see Table 26-7.
During a history, the patient states, "It really hurts back there, and sometimes it itches, too. I have even seen blood on the tissue when I have a bowel movement. Is there something there?" The nurse should expect to see which of these upon examination of the anus? a. Rectal prolapse b. Internal hemorrhoid c. External hemorrhoid that has resolved d. External hemorrhoid that is thrombosed
ANS: D These symptoms are consistent with an external hemorrhoid. An external hemorrhoid, when thrombosed, contains clotted blood and becomes a painful, swollen, shiny blue mass that itches and bleeds with defecation. When the external hemorrhoid resolves, it leaves a flabby, painless skin sac around the anal orifice. An internal hemorrhoid is not palpable, but may appear as a red mucosal mass when the person performs a Valsalva maneuver. A rectal prolapse appears as a moist, red doughnut with radiating lines
A man who has had gout for several years comes to the clinic with a problem with his toe. On examination, the nurse notices the presence of hard, painless nodules over the great toe; one has burst open with a chalky discharge. This finding is known as: a. a callus. b. a plantar wart. c. a bunion. d. tophi.
ANS: D Tophi are collections of sodium urate crystals resulting from chronic gout in and around the joint that cause extreme swelling and joint deformity. They appear as hard, painless nodules (tophi) over the metatarsophalangeal joint of the first toe and they sometimes burst with a chalky discharge (See Table 22-6). See Table 22-6 for descriptions of the other conditions.
The nurse is examining a 2-month-old infant and notices asymmetry of the infant's gluteal folds. The nurse should assess for other signs of what disorder? a. Fractured clavicle b. Down syndrome c. Spina bifida d. Hip dislocation
ANS: D Unequal gluteal folds may accompany hip dislocation after 2 to 3 months of age, but some asymmetry may occur in healthy children. Further assessment is needed. The other responses are not correct.
Which of these statements about the testes is true? a. The lymphatics of the testes drain into the abdominal lymph nodes. b. The vas deferens is located along the inferior portion of each testis. c. The right testis is lower than the left because the right spermatic cord is longer. d. The cremaster muscle contracts in response to cold and draws the testicles closer to the body.
ANS: D When it is cold, the cremaster muscle contracts, which raises the scrotal sac and brings the testes closer to the body to absorb heat necessary for sperm viability. The lymphatics of the testes drain into the inguinal lymph nodes. The vas deferens is located along the upper portion of each testis. The left testis is lower than the right because the left spermatic cord is longer.
When the nurse is performing a genital examination on a male patient, which of these actions is correct? a. Auscultate for the presence of a bruit over the scrotum. b. Palpate for the vertical chain of lymph nodes along the groin inferior to the inguinal ligament. c. Palpate the inguinal canal only if there is a bulge present in the inguinal region during inspection. d. Have the patient shift his weight onto the left (unexamined) leg when palpating for a hernia on the right side.
ANS: D When palpating for the presence of a hernia on the right side, ask the male patient to shift his weight onto the left (unexamined) leg. It is not appropriate to auscultate for a bruit over the scrotum. When palpating for lymph notes, palpate the horizontal chain. The inguinal canal should be palpated whether or not a bulge is present.
When testing stool for occult blood, the nurse is aware that a false-positive result may occur with: a. absent bile pigment. b. increased fat content. c. increased ingestion of iron medication. d. a large amount of red meat within the last 3 days.
ANS: D When testing for occult blood, a false-positive finding may occur if the person has ingested significant amounts of red meat within 3 days of the test. Absent bile pigment causes the stools to be gray or tan in color. Increased fat content causes the stool to be pale, yellow, and greasy. Increased ingestion of iron medication causes the stool to be black in color.
During an assessment of the cranial nerves, the nurse finds the following: asymmetry when the patient smiles or frowns, uneven lifting of eyebrows, sagging of the lower eyelids, and escape of air when the nurse presses against the right puffed cheek. This would indicate dysfunction of which of these cranial nerves?
ANS: Motor component of VII The findings listed reflect a dysfunction of the motor component of cranial nerve VII, the facial nerve.
When the nurse is performing a genital examination on a male patient, the patient has an erection. The nurse's most appropriate action or response is to: a. ask the patient if he would like someone else to examine him. b. continue with the examination as though nothing has happened. c. stop the examination, leave the room while stating that the examination will resume at a later time. d. reassure the patient that this is a normal response and continue with the examination.
ANS: D When the male patient has an erection, the nurse should reassure the patient that this is a normal physiologic response to touch and proceed with the rest of the examination. The other responses are not correct and may be perceived as judgmental.
When performing a genitourinary assessment on a 16-year-old boy, the nurse notices a swelling in the scrotum that increases with increased intra-abdominal pressure and decreases when he is lying down. The patient complains of pain when straining. The nurse knows that this description is most consistent with a(n) _____ hernia. a. femoral b. incisional c. direct inguinal d. indirect inguinal
ANS: D With indirect inguinal hernias there is pain with straining and a soft swelling that increases with increased intra-abdominal pressure, which may decrease when the patient lies down. These findings do not describe the other hernias. See Table 24-7 for descriptions of femoral and direct inguinal hernias.
A 78-year-old man has a history of a cerebrovascular accident. The nurse notes that when he walks his left arm is immobile against the body with flexion of the shoulder, elbow, wrist, and fingers and adduction of the shoulder. His left leg is stiff and extended and circumducts with each step. What type of gait disturbance is this individual experiencing? a. Scissors gait b. Cerebellar ataxia c. Parkinsonian gait d. Spastic hemiparesis
ANS: D With spastic hemiparesis, the arm is immobile against the body. There is flexion of the shoulder, elbow, wrist, and fingers and adduction of the shoulder, which does not swing freely. The leg is stiff and extended and circumducts with each step. Causes of this type of gait include cerebrovascular accident. See Table 23-6 for more information and for descriptions of the other abnormal gaits.
Which of these tests would the nurse use to check the motor coordination of an 11-month-old infant?
ANS: Denver II To screen gross and fine motor coordination, the nurse should use the Denver II with its age-specific developmental milestones. Stereognosis tests a person's ability to recognize objects by feeling them, and is not appropriate for an 11-month-old infant. Testing of the deep tendon reflexes is not appropriate for checking motor coordination. Testing rapid alternating movements is appropriate for testing coordination in adults.
A 69-year-old patient has been admitted to an adult psychiatric unit because his wife thinks he is getting more and more confused. He laughs when he is found to be forgetful, saying "I'm just getting old!" After the nurse completes a thorough neurologic assessment, which findings would be indicative of Alzheimer's disease? Select all that apply.
ANS: Difficulty performing familiar tasks, such as placing a telephone call Misplacing items, such as putting dish soap in the refrigerator Rapid mood swings, from calm to tears, for no apparent reason Getting lost in one's own neighborhood Difficulty performing familiar tasks, misplacing items, rapid mood swings, and getting lost in one's own neighborhood can be warning signs of Alzheimer's disease. Occasionally forgetting names or appointments, and sometimes having trouble finding the right word are part of normal aging. For other examples see Table 23-2.
The nurse is doing an assessment on a 29-year-old woman who visits the clinic complaining of "always dropping things and falling down." While testing rapid alternating movements, the nurse notices that the woman is unable to pat both her knees. Her response is very slow and she misses frequently. What should the nurse suspect?
ANS: Dysfunction of the cerebellum When a person performs rapid, alternating movements, slow, clumsy, and sloppy responses occur with cerebellar disease. The other responses are incorrect.
When the nurse is testing the triceps reflex, what is the expected response?
ANS: Extension of the forearm The normal response of the triceps reflex is extension of the forearm. The normal response of the biceps reflex causes flexion of the forearm. The other responses are incorrect.
In assessing a 70-year-old patient who has had a recent cerebrovascular accident, the nurse notices right-sided weakness. What might the nurse expect to find when testing his reflexes on the right side?
ANS: Hyperactive reflexes Hyperreflexia is the exaggerated reflex seen when the monosynaptic reflex arc is released from the influence of higher cortical levels. This occurs with upper motor neuron lesions (e.g., a cerebrovascular accident). The other responses are incorrect.
In a person with an upper motor neuron lesion such as a cerebrovascular accident, which of these physical assessment findings should the nurse expect to see?
ANS: Hyperreflexia Hyperreflexia, diminished or absent superficial reflexes, and increased muscle tone or spasticity can be expected with upper motor neuron lesions. The other options reflect a lesion of lower motor neurons. See Table 23-7.
During an assessment of a 22-year-old woman who has a head injury from a car accident 4 hours ago, the nurse notices the following change: pupils were equal, but now the right pupil is fully dilated and nonreactive, left pupil is 4 mm and reacts to light. What does finding this suggest?
ANS: Increased intracranial pressure In a brain-injured person, a sudden, unilateral, dilated, and nonreactive pupil is ominous. Cranial nerve III runs parallel to the brainstem. When increasing intracranial pressure pushes the brainstem down (uncal herniation), it puts pressure on cranial nerve III, causing pupil dilation. The other responses are incorrect.
During an examination, the nurse notes a supernumerary nipple just under the patient's left breast. The patient tells the nurse that she always thought it was a mole. Which statement about this finding is correct? a. This variation is normal and not a significant finding. b. This finding is significant and needs further investigation. c. A supernumerary nipple also contains glandular tissue and may leak milk during pregnancy and lactation. d. The patient is correct—a supernumerary nipple is actually a mole that happens to be located under the breast.
ANS: It is a normal variation and not a significant finding. A supernumerary nipple looks like a mole, but close examination reveals a tiny nipple and areola. It is not a significant finding.
The nurse is caring for a patient who has just had neurosurgery. To assess for increased intracranial pressure, what would the nurse include in the assessment?
ANS: Level of consciousness, motor function, pupillary response, and vital signs Some hospitalized persons have head trauma or a neurologic deficit from a systemic disease process. These people must be monitored closely for any improvement or deterioration in neurologic status and for any indication of increasing intracranial pressure. The nurse should use an abbreviation of the neurologic examination in the following sequence: level of consciousness, motor function, pupillary response, and vital signs.
During the neurologic assessment of a "healthy" 35-year-old patient, the nurse asks him to relax his muscles completely. The nurse then moves each extremity through full range of motion. Which of these results would the nurse expect to find?
ANS: Mild, even resistance to movement Tone is the normal degree of tension (contraction) in voluntarily relaxed muscles. It shows a mild resistance to passive stretch. Normally, the nurse will notice a mild, even resistance to movement. The other responses are not correct.
The nurse is assessing the breasts of a 68-year-old woman and discovers a mass in the upper outer quadrant of the left breast. When assessing this mass, the nurse keeps in mind that characteristics of a cancerous mass include which of the following? Select all that apply. a. Nontender mass b. Dull, heavy pain on palpation c. Rubbery texture and mobile d. Hard, dense, and immobile e. Regular border f. Irregular, poorly delineated border
ANS: Nontender mass Hard, dense, and immobile Irregular,poorly delineated border Cancerous breast masses are solitary, unilateral, nontender, masses. They are solid, hard, dense, and fixed to underlying tissues or skin as cancer becomes invasive. Their borders are irregular and poorly delineated. They are often painless, although the person may have pain. They are most common in upper outer quadrant. A dull, heavy pain on palpation and a mass with a rubbery texture and a regular border are characteristics of benign breast disease.
A 54-year-old man comes to the clinic with a "horrible problem." He tells the nurse that he has just discovered a lump on his breast and is fearful of cancer. The nurse knows that which statement about breast cancer in males is true? a. Breast masses in men are difficult to detect because of minimal breast tissue. b. Breast cancer in men rarely spreads to the lymph nodes. c. One percent of all breast cancers occurs in men. d. Most breast masses in men are diagnosed as gynecomastia.
ANS: One percent of all breast cancer occurs in men. One percent of all breast cancer occurs in men. Early spread to axillary lymph nodes occurs due to minimal breast tissue.
The nurse is performing a neurologic assessment on a 41-year-old woman with a history of diabetes. When testing her ability to feel the vibrations of a tuning fork, the nurse notices that the patient is unable to feel vibrations on the great toe or ankle bilaterally, but she is able to feel vibrations on both patellae. Given this information, what would the nurse suspect?
ANS: Peripheral neuropathy Loss of vibration sense occurs with peripheral neuropathy (e.g., diabetes and alcoholism). Peripheral neuropathy is worse at the feet and gradually improves as the examiner moves up the leg, as opposed to a specific nerve lesion, which has a clear zone of deficit for its dermatome.
The nurse is testing superficial reflexes on an adult patient. When stroking up the lateral side of the sole and across the ball of the foot, the nurse notices the plantar flexion of the toes. How should the nurse document this finding?
ANS: Plantar reflex present With the same instrument, the nurse should draw a light stroke up the lateral side of the sole of the foot and across the ball of the foot, like an upside-down "J." The normal response is plantar flexion of the toes and sometimes of the whole foot. A positive Babinski sign is abnormal and occurs with the response of dorsiflexion of the big toe and fanning of all toes. The plantar reflex is not graded on a 0 to 4+ scale.
To assess the head control of a 4-month-old infant, the nurse lifts the infant up in a prone position while supporting his chest. The nurse looks for what normal response?
ANS: Raises head and arches back At 3 months of age, the infant raises the head and arches the back as if in a swan dive. This is the Landau reflex, which persists until 1 1/2 years of age. The other responses are incorrect. See Figure 23-43.
In the assessment of a 1-month-old infant, the nurse notices a lack of response to noise or stimulation. The mother reports that in the last week he has been sleeping all the time, and when he is awake all he does is cry. The nurse hears that the infant's cries are very high pitched and shrill. What should be the nurse's appropriate response to these findings?
ANS: Refer the infant for further testing. A high-pitched, shrill cry or cat-sounding screech occurs with central nervous system damage. Lethargy, hyporeactivity, hyperirritability, and parent's report of significant change in behavior all warrant referral. The other options are not correct responses.
While obtaining a history of a 3-month-old infant from the mother, the nurse asks about the infant's ability to suck and grasp the mother's finger. What is the nurse assessing?
ANS: Reflexes Questions regarding reflexes include such questions as "What have you noticed about the infant's behavior," "Do the infant's sucking and swallowing seem coordinated," and "Does the infant grasp your finger?" The other responses are incorrect.
A 21-year-old patient has a head injury resulting from trauma and is unconscious. There are no other injuries. During the assessment what would the nurse expect to find when testing the patient's deep tendon reflexes?
ANS: Reflexes will be normal. A reflex is a defense mechanism of the nervous system. It operates below the level of conscious control and permits a quick reaction to potentially painful or damaging situations.
A 78-year-old man has a history of a cerebrovascular accident. The nurse notes that when he walks his left arm is immobile against the body with flexion of the shoulder, elbow, wrist, and fingers and adduction of the shoulder. His left leg is stiff and extended and circumducts with each step. What type of gait disturbance is this individual experiencing?
ANS: Spastic hemiparesis With spastic hemiparesis, the arm is immobile against the body. There is flexion of the shoulder, elbow, wrist, and fingers and adduction of the shoulder, which does not swing freely. The leg is stiff and extended and circumducts with each step. Causes of this type of gait include cerebrovascular accident. See Table 23-6 for more information and for descriptions of the other abnormal gaits.
The nurse is palpating a female patient's breasts during an examination. Which of these positions is most likely to make significant lumps more distinct during breast palpation? a. Supine with the arms raised over her head b. Sitting with the arms relaxed at her sides c. Supine with the arms relaxed at her sides d. Sitting with the arms flexed and fingertips touching her shoulders
ANS: Supine with arms raised over her head The nurse should help the woman to a supine position, tuck a small pad under the side to be palpated, and help the woman raise her arm over her head. These maneuvers will flatten the breast tissue and displace it medially. Any significant lumps will then feel more distinct.
A 22-year-old woman comes to the clinic because of a severe sunburn and states, "I was just out in the sun for a couple of minutes." The nurse begins a medication review with her, paying special attention to which medication class?
ANS: Tetracyclines for acne Drugs that may increase sunlight sensitivity and give a burn response include sulfonamides, thiazide diuretics, oral hypoglycemic agents, and tetracycline.
A patient has a severed spinal nerve as a result of trauma. Which of these statements is true in this situation?
ANS: The adjacent spinal nerves will continue to carry sensations for the dermatome served by the severed nerve. A dermatome is a circumscribed skin area that is supplied mainly from one spinal cord segment through a particular spinal nerve. The dermatomes overlap, which is a form of biologic insurance. That is, if one nerve is severed, most of the sensations can be transmitted by the spinal nerve above and spinal nerve below.
Which of these statements concerning areas of the brain is true?
ANS: The hypothalamus controls temperature and regulates sleep. The hypothalamus is a vital area with many important functions: temperature controller, sleep center, anterior and posterior pituitary gland regulator, and coordinator of autonomic nervous system activity and emotional status. The cerebellum controls motor coordination, equilibrium, and balance. The basal ganglia control autonomic movements of the body. The motor pathways of the spinal cord synapse in various areas of the spinal cord, not the thalamus.
Which of these statements about the peripheral nervous system is correct?
ANS: The peripheral nerves carry input to the central nervous system by afferent fibers and away by efferent fibers. A nerve is a bundle of fibers outside the central nervous system. The peripheral nerves carry input to the central nervous system by their sensory afferent fibers and deliver output from the central nervous system by the efferent fibers.
A patient with lack of oxygen to his heart will have pain in his chest and possibly the shoulder, arms, or jaw. The nurse knows that the statement that best explains why this occurs is which of these?
ANS: The sensory cortex does not have the ability to localize pain in the heart, so the pain is felt elsewhere. The sensory cortex is arranged in a specific pattern, forming a corresponding "map" of the body. Pain in the right hand is perceived at a specific spot on the map. Some organs are absent from the brain map, such as the heart, liver, and spleen. Pain originating in these organs is referred because no felt image exists in which to have pain. Pain is felt "by proxy" by another body part that does have a felt image. The other responses are not correct explanations.
During the assessment of an 80-year-old patient, the nurse notices that his hands show tremors when he reaches for something and his head is always nodding. There is no associated rigidity with movement. Which of these statements is most accurate?
ANS: These are normal findings resulting from aging. Senile tremors occasionally occur. These benign tremors include an intention tremor of the hands, head nodding (as if saying yes or no), and tongue protrusion. Tremors associated with Parkinson disease include rigidity, slowness, and weakness of voluntary movement. The other responses are incorrect.
An Inuit visiting Nevada from Anchorage has come to the clinic in July during the hottest part of the day. It so happens that the clinic's air conditioning is broken and the temperature is very hot. The nurse knows that which of these statements is true about the Inuit sweating tendencies? a. They will sweat profusely all over their bodies because they are not used to the hot temperatures. b. They don't sweat because their apocrine glands are less efficient in hot climates. c. They will sweat more on their faces and less on their trunks and extremities. d. There is no difference in their sweating tendencies when compared to other ethnic groups.
ANS: They will sweat more on their faces and less on their trunks and extremities. Inuits have made an interesting environmental adaptation whereby they sweat less than whites on their trunks and extremities but more on their faces.
During an assessment of a 32-year-old patient with a recent head injury, the nurse notices that the patient responds to pain by extending, adducting, and internally rotating his arms. His palms pronate and his lower extremities extend with plantar flexion. Which of these statements about these findings is accurate?
ANS: This is a very ominous sign and may indicate brainstem injury. These findings are all indicative of decerebrate rigidity, which is a very ominous condition and may indicate a brainstem injury.
The assessment of a 60-year-old patient has taken longer than anticipated. In testing his pain perception the nurse decides to complete the test as quickly as possible. When the nurse applies the sharp point of the pin on his arm several times, he is only able to identify these as one "very sharp prick." What would be the most accurate explanation for this?
ANS: This is most likely the result of the summation effect. Let at least 2 seconds elapse between each stimulus to avoid summation. With summation, frequent consecutive stimuli are perceived as one strong stimulus. The other responses are incorrect.
During an examination, the nurse notices severe nystagmus in both eyes of a patient. Which of these conclusions by the nurse is correct?
ANS: This may indicate disease of the cerebellum or brainstem. End-point nystagmus at an extreme lateral gaze occurs normally. The nurse should assess any other nystagmus carefully. Severe nystagmus occurs with disease of the vestibular system, cerebellum, or brainstem.
While assessing a 7-month-old infant, the nurse makes a loud noise and notices the following response: abduction and flexion of arms and legs; fanning of fingers, and curling of index and thumb in a C position followed by infant bringing in arms and legs to body. What does the nurse know about this response?
ANS: This reflex should have disappeared between 1 and 4 months of age. The Moro reflex is present at birth and disappears at 1 to 4 months. Absence of the Moro reflex in the newborn or persistence after 5 months of age indicates severe central nervous system injury. The other responses are incorrect.
The nurse is assessing a patient who has *liver disease for jaundice*. Which of these assessment findings is indicative of true jaundice? a. Yellow patches in the outer sclera b. Yellow color of the sclera that extends up to the iris c. Skin that appears yellow when examined under low light d. Yellow deposits on the palms and soles of the feet where jaundice first appears
ANS: Yellow color of the sclera that extends up to the iris The yellow sclera of jaundice extends up to the edge of the iris. Calluses on the palms and soles of the feet often look yellow but are not classified as jaundice. Do not confuse scleral jaundice with the normal yellow subconjunctival fatty deposits that are common in the outer sclera of dark-skinned persons.
The nurse is assessing the neurologic status of a patient who has a late-stage brain tumor. With the reflex hammer, the nurse draws a light stroke up the lateral side of the sole of the foot and inward, across the ball of the foot. In response, the patient's toes fan out, and the big toe shows dorsiflexion. The nurse interprets this result as:
ANS: a positive Babinski's sign, which is abnormal for adults. Dorsiflexion of the big toe and fanning of all toes is a positive Babinski's sign, also called "upgoing toes." This occurs with upper motor neuron disease of the corticospinal (or pyramidal) tract and is an abnormal finding for adults.
The nurse is testing the deep tendon reflexes of a 30-year-old woman who is in the clinic for an annual physical examination. When striking the Achilles and quadriceps, the nurse is unable to elicit a reflex. The nurse's next response should be to:
ANS: ask the patient to lock her fingers and "pull." Sometimes the reflex response fails to appear. It is too soon to document this as "absent" reflexes. Try further encouragement of relaxation, varying the person's position or increasing the strength of the blow. Reinforcement is another technique to relax the muscles and enhance the response. Ask the person to perform an isometric exercise in a muscle group somewhat away from the one being tested. For example, to enhance a patellar reflex, ask the person to lock the fingers together and "pull."
two parts of the nervous system are the:
ANS: central and peripheral. The nervous system can be divided into two parts—central and peripheral. The central nervous system includes the brain and spinal cord. The peripheral nervous system includes the 12 pairs of cranial nerves, the 31 pairs of spinal nerves, and all their branches.
Which of the following statements is true regarding the internal structures of the breast? The breast is: a. Primarily muscle with very little fibrous tissue. b. Fibrous, glandular, and adipose tissues. c. Primarily milk ducts, known as lactiferous ducts. d. Glandular tissue, which supports the breast by attaching to the chest wall.
ANS: composed of fibrous, glandular, and adipose tissue. The breast is composed of glandular tissue, fibrous tissue (including the suspensory ligaments), and adipose tissue.
The ability that humans have to perform very skilled movements such as writing is controlled by the:
ANS: corticospinal tract. Corticospinal fibers mediate voluntary movement, particularly very skilled, discrete, purposeful movements, such as writing. The corticospinal tract (also known as the pyramidal tract) is a newer, "higher" motor system that humans have that permits very skilled and purposeful movements. The other responses are not related to skilled movements.
While the nurse is taking the history of a 68-year-old patient who sustained a head injury 3 days earlier, he tells the nurse that he is on a cruise ship and is 30 years old. The nurse knows that this finding is indicative of:
ANS: decreased level of consciousness. A change in consciousness may be subtle. The nurse should notice any decreasing level of consciousness, disorientation, memory loss, uncooperative behavior, or even complacency in a previously combative person. The other responses are incorrect.
If a patient reports a recent breast infection, then the nurse should expect to find _____ node enlargement. a. Nonspecific b. Ipsilateral axillary c. Contralateral axillary d. Inguinal and cervical
ANS: ipsilateral axillary The breast has extensive lymphatic drainage. Most of the lymph, more than 75%, drains into the ipsilateral, or same side, axillary nodes.
The nurse is testing the function of cranial nerve XI. Which of these best describes the response the nurse should expect if the nerve is intact? The patient:
ANS: moves the head and shoulders against resistance with equal strength. These are the expected normal findings when testing cranial nerve XI (spinal accessory nerve): The patient's sternomastoid and trapezius muscles are of equal size; the person can rotate the head both ways forcibly against resistance applied to the side of the chin with equal strength; the patient can shrug the shoulders against resistance with equal strength on both sides. Checking the patient's ability to hear normal conversation checks the function of CN VIII. Having the patient stick out the tongue checks the function of CN XII. Testing the eyes for nystagmus or strabismus is done to check CN III, IV, and VI.
A mother of a 1-month-old infant asks the nurse why it takes so long for infants to learn to roll over. The nurse knows that the reason for this is that:
ANS: myelin is needed to conduct the impulses, and the neurons of a newborn are not yet myelinated. The infant's sensory and motor development proceeds along with the gradual acquisition of myelin because myelin is needed to conduct most impulses. Very little cortical control exists, and the neurons are not yet myelinated. The other responses are not correct.
During an assessment of an 80-year-old patient, the nurse notices the following: inability to identify vibrations at the ankle and to identify position of big toe, slower and more deliberate gait, and slightly impaired tactile sensation. All other neurologic findings are normal. The nurse should interpret that these findings indicate:
ANS: normal changes due to aging. Some aging adults show a slower response to requests, especially for those calling for coordination of movements. The findings listed are normal in the absence of other significant abnormal findings. The other responses are incorrect.
A patient states during the interview that she noticed a new lump in the shower a few days ago. It was on her left breast near her axilla. The nurse should plan to: a. Palpate the lump first. b. Palpate the unaffected breast first. c. Avoid palpating the lump because it could be a cyst, which might rupture. d. Palpate the breast with the lump first but plan to palpate the axilla last.
ANS: palpate the unaffected breast first. If the woman mentions a breast lump she has discovered herself, the nurse should examine the unaffected breast first to learn a baseline of normal consistency for this individual.
During an assessment of a 62-year-old man the nurse notices the patient has a stooped posture, shuffling walk with short steps, flat facial expression, and pill-rolling finger movements. These findings would be consistent with:
ANS: parkinsonism. The stooped posture, shuffling walk, short steps, flat facial expression, and pill-rolling finger movements are all found in parkinsonism. See Table 23-8 for more information and for descriptions of the other options.
The nurse knows that testing kinesthesia is a test of a person's:
ANS: position sense. Kinesthesia, or position sense, is the person's ability to perceive passive movements of the extremities. The other options are incorrect.
The nurse educator is preparing an education module for the nursing staff on the *epidermal* layer of skin. Which of these statements would be included in the module? The epidermis is: A- highly vascular. B- thick and tough. C- thin and nonstratified. D- replaced every 4 weeks.
ANS: replaced every 4 weeks The epidermis is thin yet tough, replaced every 4 weeks, avascular, and stratified into several zones.
The nurse is performing a breast examination. Which of these statements best describes the correct procedure to use when screening for nipple and skin retraction during a breast examination? Have the woman: a. Bend over and touch her toes. b. Lie down on her left side and notice any retraction. c. Shift from a supine position to a standing position, and note any lag or retraction. d. Slowly lift her arms above her head, and note any retraction or lag in movement.
ANS: slowly lift her arms above her head and note any retraction or lag in movement Direct the woman to change position while checking the breasts for skin retraction signs. First ask her to lift her arms slowly over her head. Both breasts should move up symmetrically. Retraction signs are due to fibrosis in the breast tissue, usually caused by growing neoplasms. The nurse should notice if there is a lag in movement of one breast.
When a breastfeeding mother is diagnosed with a breast abscess, which of these instructions from the nurse is correct? The mother needs to: a. Continue to nurse on both sides to encourage milk flow. b. Immediately discontinue nursing to allow for healing. c. Temporarily discontinue nursing on the affected breast, and manually express milk and discard it. d. Temporarily discontinue nursing on affected breast, but manually express milk and give it to the baby.
ANS: temporarily discontinue nursing on affected breast and manually express milk and discard it. With a breast abscess, the patient must temporarily discontinue nursing on the affected breast, manually express the milk, and discard it. Nursing can continue on the unaffected side.
A patient is not able to perform rapid alternating movements such as patting her knees rapidly. The nurse should document this as:
ANS: the presence of dysdiadochokinesia. Slow clumsy movements and the inability to perform rapid alternating movements occur with cerebellar disease. The condition is termed dysdiadochokinesia. Ataxia is uncoordinated or unsteady gait. Astereognosis is the inability to identify an object by feeling it. Kinesthesia is the person's ability to perceive passive movement of the extremities, or the loss of position sense.
During the history, a patient tells the nurse that "it feels like the room is spinning around me." The nurse would document this as:
ANS: vertigo. True vertigo is rotational spinning caused by neurologic dysfunction or a problem in the vestibular apparatus or the vestibular nuclei in the brainstem. Dizziness is a lightheaded, swimming sensation. Syncope is a sudden loss of strength or a temporary loss of consciousness. Seizure activity is characterized by altered or loss of consciousness, involuntary muscle movements, and sensory disturbances.
ANS: ligaments. Fibrous bands running directly from one bone to another that strengthen the joint and help prevent movement in undesirable directions are called ligaments.
Fibrous bands running directly from one bone to another that strengthen the joint and help prevent movement in undesirable directions are called: A) bursa. B) tendons. C) cartilage. D) ligaments.
Functions of the skin include: A. Production of Vit. C B. Temperature regulation C. The production of new cells by melanocytes D. The secretion of a drying substance called sebum
B. Temperature regulation
The best description of the secretion of the eccrine glands: A. thick, milky B. dilute saline solution C. protective lipid substance D. keratin
B. dilute saline solution
benign (fibrocystic) breast disease
multiple tender masses that occur with numerous symptoms and physical findings: swelling and tenderness (cyclic discomfort), mastalgia (severe pain, both cyclic and noncyclic), nodularity (significant lumpiness, both cyclic and noncyclic), dominant lumps (including cysts and fibroadenomas), infections and inflammations (including subareolar abscess, lactational mastitis, breast abscess, and mondor disease), many women have some form of benign breast disease, nodularity occurs bilaterally; regular, firm nodules are mobile, well demarcated, and feel rubbery like small water balloons, pain may be dull, heavy, and cyclic as nodules enlarge, cysts are discrete, fluid filled sacs,
An area of thin shiny skin with decreased visibility of normal skin markings is called: A. lichenification B. plaque C. atrophy D. keloid
C. atrophy
________ is prolonged arching of back, with head & heels bent backward & meningeal irritation
opisthotonos
peau d'orange
orange peel appearance of breast due to edema which thickens the skin and exaggerates the hair follicles, giving a pigskin or orange-peel look, suggest cancer, usually begins in the skin around and beneath the areola the most dependent area of the breast
Being overweight in childhood
overweight in adulthood
66% of adults are
overweight or obese
Checking for skin temperature is best accomplished by using: A. palmar surface of the hands B. ventral surface of the hands C. fingertips D. dorsal surface of the hands
D. dorsal surface of the hands
lump location
use breast as a clock face to describe distance from nipple in centimeters (use diagram to locate)
Differences of skin at various developmental stages:
INFANTS: the immature skin cannot effectively prevent fluid loss o regulate temperature PREGNANCY: causes pigment changes and stretch marks AGING: causes changes in the stratum corneum that give chemicals easier access to the body, and causes other changes that lead to wrinkling
Phonation, swallowing, tasting posterior third of tongue
IX: Glossopharyngeal
Normal vs. Abnormal inguinal lymph nodes
It's normal to palpate an isolated node on occasion; it feels small (<1cm), soft, discrete & moveable Abnormal: enlarged, hard, matted, fixed nodes
Macule:
Just skin color change; flat and circumscribed; less than 1 cm Ex: freckles, flat nevi, measles, scarlet fever
Conditions of the nails:
KOILONYCHIA: thin, concave, raised edges. "Spooning". Caused by iron deficiency & anemia. CLUBBING: inner edges of nail bed is elevated. PARONYCHIA: Red, swollen, tender inflammation of nail folds. BEAU'S LINE: transverse furrow or grove; extends down to nail bed SPLINTER HEMORRHAGES: red brown, linear streaks, embolic lesions ONYCHOLYSIS: fungus infection, green, thick, crumbling
ANS: suspect that the infant may have weakness of the shoulder muscles. An infant who starts to "slip" between the nurse's hands shows weakness of the shoulder muscles. An infant with normal muscle strength wedges securely between the nurse's hands. The other responses are not correct.
The nurse is assessing a 1-week-old infant and is testing his muscle strength. The nurse lifts the infant with hands under the axillae and notices that the infant starts to "slip" between the hands. The nurse should: A) suspect a fractured clavicle. B) suspect that the infant may have a deformity of the spine. C) suspect that the infant may have weakness of the shoulder muscles. D) consider this a normal finding because the musculature of an infant this age is undeveloped.
Male with enlarged testicle sac, taut pitting. likely not able to contents-- what is the condition and do you do?
Scrotal Edema
Causes of changes in skin:
TEMPERATURE: hypothermia, hyperthermia MOISTURE: diaphoresis, dehydration TEXTURE: hyperthyroidism, hypothyroidism MOBILITY: edema, scleroderma (hard skin) TURGOR: dehydration or extreme weight loss
Cranial Nerve VII --> Facial Nerve Normal Abnormal
Testing motor functions *NORMAL* - Patient puffs cheeks + press down = air escapes both sides EQUALLY - Face = symmetrical *ABNORMAL* - Drooping of one side of face - Lower eyelid sagging - Escaping of one side of cheek when both sides are pressed on - Muscle weakness - Asymmetry of face *POSSIBLE CAUSES ...* - Stroke - Bell Palsy
Stereognosis Test
Testing the person's ability to recognize everyday items using sense of touch and also with closed eyes
ANS: swelling from fluid in the suprapatellar pouch. For swelling in the suprapatellar pouch, the bulge sign confirms the presence of fluid. The other options are not correct.
The nurse has completed the musculoskeletal examination of a patient's knee and has found a positive bulge sign. The nurse interprets this finding to indicate: A) irregular bony margins. B) soft tissue swelling in the joint. C) swelling from fluid in the epicondyle. D) swelling from fluid in the suprapatellar pouch.
ANS: greater trochanter.
The nurse is examining the hip area of a patient and palpates a flat depression on the upper, lateral side of the thigh when the patient is standing. The nurse interprets this finding as the: A) ischial tuberosity. B) greater trochanter. C) iliac crest. D) gluteus maximus muscle.
ANS: Epiphyses Lengthening occurs at the epiphyses, or growth plates. The other options are not correct.
The nurse is explaining the mechanism of the growth of long bones to a mother of a toddler. Where does lengthening of the bones occur? A) Bursa B) Calcaneus C) Epiphyses D) Tuberosities
ANS: intervertebral disks. Intervertebral disks are elastic fibrocartilaginous plates that cushion the spine like shock absorbers and help it move. The vertebral column is the spinal column itself. The nucleus pulposus is located in the center of each disk. The vertebral foramen is the channel, or opening, for the spinal cord in the vertebrae.
The nurse is explaining to a patient that there are "shock absorbers" in his back to cushion the spine and to help it move. The nurse is referring to his: A) vertebral column. B) nucleus pulposus. C) vertebral foramen. D) intervertebral disks.
Papule:
You can feel (palpate) Solid, elevated, circumscribed, less than 1 cm Ex: mole, wart
screen for retraction
ask patient to: lift arms slowly above head, both breast should move up symmetrically, push hands into hip, push palms together, lean forward
glandular tissue
contains 15 to 20 lobes radiating from the nipple and these are composed of lobules, each lobe has alveoli that produce milk
Hyperthermia
generalized hyperthermia occurs with increased metabolic rate, causing warm, moist skin, such as with fever, or after heavy exercise. Localized hyperthermia occurs with trauma, infection or sunburn.
Hypothermia
generalized hypothermia accompanies central circulatory problems, such as shock. Localized hypothermia occurs in peripheral arterial insufficiency
My plate
grains and vegetables most... fruits and proteins 2nd, dairy
_________ is the ability to read a number by having it traced on the skin
graphesthesia
inguinal area
groin, is the juncture of the lower abdominal wall and the thigh its diagonal borders are the anterior superior iliac spine and the syphysis pubis
Vitamins and minerals
have indirect roles as catalysts
Overnutrition
heart disease... consumption of nutrients such as sodium and fat in excess
Similar symptoms BPH and prostate cancer
hesitant interrupted weak urinary stream urinary urgency leaking or dribbling inc frequency
central axillary node
high up in the middle of the axilla, over the ribs and serratus anterior muscle. these receive lymph from the other three groups of nodes
Adulthood
important to educate chronic disease in later life
lump size
in centimeters
Word salad
incoherent mixture of words, phrases, and sentences; illogical, disconnected, includes neologisms
Jaundice
increase in bilirubin in the blood causing a yellow color in the skin, palate, and sclera. Dark skinned have yellow outer sclera.
Proteinuria
indicates glomerluar disease
Epididymitis
indurated, swollen, tender/exquisitely painful epididymis; acute infection of epididymis commonly caused by prostatitis, surgical trauma or STD; severe sudden onset of pain relieved by elevation (positive Prehn sign) with rapid swelling, fever, enlarged red scrotum, tender to touch, epididymis swollen & hard to distinguish from testicle
Urethritis
infection of urethra --> painful, burning urination or pruritis; meatus edges reddened, everted, swollen with purulent drainage; 50% are chlamydia
mammary duct ectasia
paste like matter in subareolar ducts produces sticky, purulent discharge that may be white, gray, brow, green, or bloody. caused by stagnation of cellular debris and secretions in the ducts, leading to obstruction, inflammation, and infection, usually occurs in perimenopause. itching, burning, or drawing pain occurs around the nipple, may have subareolar redness and swelling, ducts are palpable as rubbery, twisted tubules under areola, may have palpable mass, soft or firm, poorly delineated not malignant but needs biopsy
Priapism
prolonged painful erection without sexual stimulation & unrelieved by intercourse or masturbation, lasting more than 4 hours; more common in ages 30s & 40s. Adverse effect of some drugs, with sickle cell disease, leukemia, malignancy, local trauma, autonomic dysfunction with spinal cord injury.
priapism
prolonged, painful erection of penis without sexual desire
Keloid Scar
raised above, excessive collagen synthesis
chancre
red, round, superficial ulcer with a yellowish serous discharge that ia a sign of syphilis
Purpura
red-purple skin lesion due to blood in tissues from breaks in blood vessels
involuntary defense mechanisms of CNS
reflexes
spermatocele
retention cyst in epididymis filled with milky fluid that contains sperm
Undernutrition
risk for imparied growth, development, immunity, lowered resistance to infection, higher healthcare costs
ipsilateral
same side, more than 75% of lymph drain into the ipsilateral side
Excoriation
self-inflicted abrasion on skin due to scratching
intraductal papilloma
serosanguineous nipple discharge
dimpling
shallow dimple or skin tether, is a sign of skin retraction, cancer causes fibrosis, which contracts the suspensory ligaments, the dimple may be apparent at rest, with compression or with lifting of the arms, also note the distortion of the areola
Loosening associations
shifting from one topic to an unrelated topic; person seems unaware that topics are unconnected
Cherry (senile) angiomas
small 1mm to 5 mm, smooth, slightly raised bright red dots that commonly appear on the trunk in all adults older than 30 years. They normally increase in size and number with aging.
genital warts
soft, pointed, moist, fleshy painless papules occurring in single or multiple cauliflower-like patches; color may be pale yellow, pink, gray in White males or black or translucent gray-black in Black males; occur on shaft of penis, behind corona, and around anus; caused by HPV (STI; Gardasil vaccine)
Maceration
softening of tissue by soaking
cancer
solitary, unilateral, non-tender mass, single focus in one area, although it may be interspersed with other nodules, solid, hard, dense, and fixed to underlying tissues or skin as cancer becomes invasive, boarders are irregular and poorly delineated, grows constantly, often painless, althought hte person may have pain, most common in upper outer quadrant, found in women 30-80 years of age, increased risk across all ages until age 80, as cancer advances signs include firm or hard irregular axillary nodes; skin dimpling; nipple retraction, elevation, and discharge
____________ is continuous resistance to stretching by a muscle due to abnormally increased tension, with increased DTR
spasticity
Patellar reflex
strike tendon just below patella. knee should jerk
Decreased or unequal sensation on the face upon touch indicates what?
stroke
cooper ligaments
suspensory ligaments; fibrous bands extending from the inner breast surface tot he chest wall muscles, extending vertically from the skin surface to attach on chest wall muscles, support the breast tissue
Circumstantiality
talks with excessive and unnecessary detail, delays reaching point; sentences have a meaningful connection but are irrelevant (this occurs normally in some people)
Iris
target shape of skin lesion
self breast exam
teaching positions 1. standing in front of mirror, 2. in the shower, soap and water assist palpation, 3. supine, keep teaching simple demonstrate to patient and use return demonstration
Uremia
the illness accompanying kidney failure (also called renal failure), in particular the nitrogenous waste products associated with the failure of this organ.
rugae
thin skin lying in folds of the scrotal wall and underlying cremaster muscle
colostrum
thin, yellow fluid, precursor of mild, secreted for a few days after birth
Lichenification
tightly packed set of papules that thickens skin, from prolonged intense scratching
Petechiae
tiny punctate hemorrhages, 1 - 3 mm, round and discrete, dark red, purple, or brown
Erythema toxicum
tiny, punctate red macules and papules on the cheeks, trunk, chest, back, and buttocks
Cutis marmorata
transient mottling on trunk and extremities
________ is involuntary contraction of opposing muscle groups resulting in rhythmic movement of one or more joints
tremor
Gyrate:
twisted, coiled spiral, snakelike -looks like you have a parasite
four quadrants
upper inner quadrant, upper outer quadrant, lower inner quadrant, lower outer quadrant
Hypospadias
urethral meatus opens on ventral (under) side of glans or shaft congenital abnormality in which the male urethral opening is on the undersurface of the penis
