NCLEX 4000 Questions with answers Health Assessment
normal slight protrusion of the eyeballs in
African Americans
normal to see small brown macules on the sclera in
African Americans
Yin Yang
all aspects in perfect harmony the balance of the opposite forces of nature (light/dark; male/female; good/evil)
Open ended Question
" tell me more about your pain" responses are more narrative and elicit longer responses
Starting at what age does the nurse speak directly to the child
7
Fat consumption percentage of diet
20%-35%
location of aortic stenosis
2nd intercostal R
Best place to auscultate for pulmonic valve
2nd left intercostal space
Pulmonic area is best ausculated at
2nd left intercostal space
Transmission
2nd phase pain impulses move from spinal cord to brain
Aortic stenosis would be labeled:
2nd right intercostal
Erbs point is best ausculated at:
3rd left intercostal space
Perception
3rd phase awareness of the pain
Extraocular muscles in the eye consist of 4______ and 2________
4 slanting rectus 2 slanting obliques
Modulation
4th phase neurotransmitters
A client who is blind is admitted for treatment of gastroenteris. Which nursing diagnosis is the highest priority for this client? a) deficient fluid volume b) risk for injury c) activity intolerance d) impaired physical mobility
A) deficient fluid volume dehyrdation is a sign of gastroenteris
a nurse is providing preoperative teaching to a client. Which type of evaluation should the nurse use in this situation? a) formative b) retrospective c) summative d) informative
A) formative (also called concurrent) which occurs continuously throughout the teaching and learning process informative is not a type of evaluation
The nurse is performing a vision examination. Which of these charts is most widely used for vision examinations? A)Snellen B)Shetllen C)Smoollen D)Schwellon
A)Snellen
After the health history has been obtained, and before beginning the physical examination, the nurse should ask the patient to first: A)empty the bladder. B)completely disrobe. C)lie on the examination table. D)walk around the room.
A)empty the bladder.
The cardiac output is defined as the: A. Amount of blood pumped by the heart in 1 min. B. Amount of blood pumped by the heart in 30 sec. C. Amount of wbc pumped D. Amount of hemoglobin
A. Amount of blood pumped by the heart in 1 min.
The epitrochlear nodes drain the: A. Hand and lower arm B. Anterior abdominal wall C. Breast and upper arm D. Head and neck
A. Hand and lower arm
An aneurysm is a: A. Sac formed by dilation in the arterial wall. B. Variation from the heart's normal rhythm. C. Thickening and loss of elasticity of the arterial walls. D. Fatty plaque deposited in the intima of the arteries
A. Sac formed by dilation in the arterial wall.
4 main concepts ABCT
Appearance Behavior Cognition Thought Process
A nurse is assessing a clients pulse. Which pulse feature should the nurse document? a) timing in the cycle b) amplitude c) pitch d) intensity
B) amplitude (ARR) Amplitude, Rate, Rhythm
A nurse determines that a client has 20/40 vision. Which statement about this clients vision is true? a) the client can read the entire vision chart at a distance of 40' b) the client can read from a distance of 20' what a person with normal vision can read at 40' c) the client can read the vision chart from a distance of 20' with the right eye and from 40' with the left eye d) the client can read at a distance of 30' what a person can read at a distance of 40'
B) the client can read from a distance of 20' what a person with normal vision can read at 40' the smaller the denominator the worse the vision the numerator is always 20, the distance in feet between the chart and person the denominator indicates what distance normal vision can read the chart
An 85-year-old man has come in for a physical examination, and the nurse notices that he uses a cane. When documenting general appearance, the nurse should document this information under the section that covers: A)posture. B)mobility. C)mood and affect. D)physical deformity.
B)mobility.
During isometric or isovolumic relaxation of the ventricles, which of the following takes place? A. All four valves are opened. B. All four valves are closed C. Stenotic valves D. Regurgitative valves
B. All four valves are closed
A split S2 heart sound is generally best heard: A. At the beginning of inhalation B. At the end of inhalation C. End of expiration D. Beginning of expiration
B. At the end of inhalation`
When palpating the chest wall of a 24-year-old male with well-developed chest muscles, which of the following would you expect to find? A. Palpable base pulse B. Nonpalpable apex pulse C. Palpable apex pulse D. Nonpalpable base pulse
B. Nonpalpable apex pulse
Pulsus paradoxus is associated with: A. Aortic valve regurgitation B. Pulmonary embolisms C. Aortic valve stenosis D. Heart failure
B. Pulmonary embolisms
In adults, the thymus gland: A. Develops T-lymphocytes B. Serves no purpose C. Is vital to immune system D. Develops B-lymphocytes
B. Serves no purpose
Pitting edema is defined as: A. Inflammation of the vein associated with thrombus formation B. The indentation left after the examiner depresses the skin over swollen edematous tissue C. A deficiency of arterial blood to a body part D. Plaques of fatty deposits forming in the intima of the arteries
B. The indentation left after the examiner depresses the skin over swollen edematous tissue
The Allen test assesses: A. The presence of thrombophlebitis B. The patency of the radial and ulnar arteries C. The degree of pedal edema D. Early clubbing
B. The patency of the radial and ulnar arteries
During ventricular diastole, which of the ff activities takes place? A. Blood pours rapidly into the atrium B. Blood repulse C. Blood pours rapidly into the ventricles. D. Blood travel to the mainstream
C. Blood pours rapidly into the ventricles.
Arteriosclerosis refers to: A. A variation from the heart's normal rhythm B. A sac formed by dilation in the arterial walls C. Thickening and loss of elasticity of the arterial walls D. Deposition of fatty plaques along the intima of the arteries
C. Thickening and loss of elasticity of the arterial walls
Palatine, adenoid, and lingual are specific names for: A. Axillary lymph nodes. B. Epitrochlear lymph nodes C. Tonsils D. Cervical lymph nodes
C. Tonsils
A heave or lift that is visible on the anterior precordium occurs in the presence of: A. Atrial hyperthropy B. Dorsal hypertrophy C. Ventricular hyperthropy D. Pulmonary hyperthropy
C. Ventricular hyperthropy
Which of the ff. is a characteristic of a fixed split? A.Inspiration and expiration B.Inhalation and exhalation C.It is unaffected by respiration D.Respiration is affected
C.It is unaffected by respiration
It is common to see pursed lip breathing in
COPD
When examining the nail you look for
Contour, consistency and color
CAGE test
Cut down Annoyed Guilt Eye Opener
A patient states, "Whenever I open my mouth real wide, I feel this popping sensation in front of my ears." To further examine this, the nurse would: A)place the stethoscope over the temporomandibular joint and listen for bruits. B)place the hands over his ears and ask him to open his mouth "really wide." C)place one hand on his forehead and the other on his jaw and ask him to try to open his mouth. D)place a finger on his temporomandibular joint and ask him to open and close his mouth.
D)place a finger on his temporomandibular joint and ask him to open and close his mouth.
The blood is returned to the heart through the veins by means of: A. Walking B. Breathing C. Unidirectional valves D. All of the above
D. All of the above
Thrombophlebitis is defined as: A. Swelling of an extremity due to an obstructed lymph channel. B. Dusky blue mottling of the skin and mucous membranes due to significantly reduced amounts of hemoglobin in the blood C. A deficiency of arterial blood to a body part D. An inflammation of the vein associated with thrombus formation
D. An inflammation of the vein associated with thrombus formation
In pulsus paraxodus: A. The rhythm is irregular; every other beat is premature B. There is a deficiency of arterial blood to a body part C. The rhythm is regular, but the force of the pulse varies with alternating beats D. Beats have weaker amplitude with respiratory inspiration and stronger with expiration
D. Beats have weaker amplitude with respiratory inspiration and stronger with expiration
A weak or "thready" pulse is associated with: A. Hyperkinetic states B. Decreased cardiac output C. Aortic valve regurgitation D. Heart failure
D. Heart failure
The jugular venous pressure is an indirect reflection of the: A. Cardiac output produced B. Stroke volume C. Mitral valve D. Heart's efficiency as a pump
D. Heart's efficiency as a pump
Which of the following is true regarding the venous pulse wave? A. It results to increase cardiac volume and a decrease in blood pressure B. It results to increase blood pressure and decrease cardiac volume. C. None D. It results from a backwash of pressure from events that occur in the heart.
D. It results from a backwash of pressure from events that occur in the heart.
Kyphosis
Elderly, extend jaw and head forward to compensate Humpback
This sinus is absent at birth and fully developed at puberty
Frontal
Binural Interaction and brainstem and sound
ID and locate the direction of the sound
Cardiac alterations during pregnancy
Increase in cardiac volume by 30%-40% Increase in stroke volume Increase in Cardiac Output Increase in Heart Rate Decrease in blood pressure due to peripheral vasodilation
Medical Diagnosis vs Nursing Diagnosis
Medical Diagnosis: is used to evaluate the cause or etiology of disease Nursing Diagnosis: clinical judements about a persons response to an actual or potential health state
Metabolic Alkalosis
Metabloic alkalosis = high ph and high HC03
Metabolic Acidosis
Metabolic acidosis : low ph and low HC03
PQRSTU
Pain presentation Provacative factors Quality Region Scale Time Understand/Empathy
Respiratory Acidosis
Respiratory acidosis = low ph and high C02 Hypoventilation
Respiratory Alkalosis
Respiratory alkalosis : high ph and low C02 Hyperventilation
A nurse is auscultating a clients lungs. Where is the area on the vertebrae where the nurse would expect to hear breath sounds at the end of the expiration
T10 between the lungs
Risk factors that may lead to skin disease/ skin breakdown
a lifetime of environmental trauma
Extremely important part of the exam in intimate partner violence or elderly abuse is
a mental exam
Comprehensive Nutritional Assessment
always includes anthropocentric measures Instruction or training leading to in-depth nutrition-related knowledge or skills (purpose of the nutrition education, recommended modifications, advanced or related topics, and result interpretation).
Ausculatory gap
a silent internal that may be present between the systolic and diastolic pressures; may lead to serious underestimation of systolic pressure; can be associated with arterial stiffness and atherosclerotic disease absence of Kortotkoff sounds between phase 1 and phase 2 while obtaining blood pressure readings
Rombergs sign
a swaying (falling) when a person stands with feet together and eyes closed. Indicates the person has lost a sense of position
During a mental status examination, the nurse wants to assess a patient's affect. The nurse should ask the patient which question? a) "How do you feel today?" b) "Would you please repeat the following words?" c) "Have these medications had any effect on your pain?" d) "Has this pain affected your ability to get dressed by yourself?"
a) "How do you feel today?"
A man is at the clinic for a physical examination. He states that he is "very anxious" about the physical examination. What steps can the nurse take to make him more comfortable? a) Appear unhurried and confident when examining him. b) Stay in the room when he undresses in case he needs assistance. c) Ask him to change into an examining gown and take off his undergarments. d) Defer measuring vital signs until the end of the examination, which allows him time to become comfortable
a) Appear unhurried and confident when examining him.
A 6-month-old infant has been brought to the well-child clinic for a check-up. She is currently sleeping. What should the nurse do first when beginning the examination? a) Auscultate the lungs and heart while the infant is still sleeping. b) Examine the infant's hips because this procedure is uncomfortable. c) Begin with the assessment of the eye and continue with the remainder of the examination in a head-to-toe approach. d) Wake the infant before beginning any portion of the examination to obtain the most accurate assessment of body systems.
a) Auscultate the lungs and heart while the infant is still sleeping.
The nurse is percussing over the lungs of a patient with pneumonia. The nurse knows that percussion over an area of atelectasis in the lungs would reveal: a) Dullness b) Tympany c) Resonance d) Hyperresonance
a) Dullness
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
a) Dullness
An Asian-American woman is experiencing diarrhea, which is felt to be "cold" or "yin." The nurse expects that the woman is likely to try to treat it with: a) Foods that are "hot" or "yang" b) Readings and Eastern medicine meditations c) High doses of medicines thought to be "cold" d) No treatment at all because diarrhea is an expected part of life
a) Foods that are "hot" or "yang"`
When preparing to perform a physical examination on an infant, the nurse should: When preparing to perform a physical examination on an infant, the nurse should: a) Have the parent remove all clothing except the diaper on a boy b) Instruct the parent to feed the infant immediately before the examination c) Encourage the infant to suck on a pacifier during the abdominal examination d) Ask the parent to briefly leave the room when assessing the infant's vital signs
a) Have the parent remove all clothing except the diaper on a boy
Illness is seen as a part of life's rhythmic course and as an outward sign of disharmony within. This statement most accurately reflects the views about illness from the _____ theory. a) Naturalistic b) Biomedical c) Reductionist d) Magicoreligious
a) Naturalistic
In an interview, the nurse may find it necessary to take notes to aid his or her memory later. Which statement is true regarding note-taking? a) Note-taking may impede the nurse's observation of the patient's nonverbal behaviors. b) Note-taking allows the patient to continue at his or her own pace as the nurse records what is said. c) Note-taking allows the nurse to shift attention away from the patient, resulting in an increased comfort level. d) Note-taking allows the nurse to break eye contact with the patient, which may increase his or her level of comfort.
a) Note-taking may impede the nurse's observation of the patient's nonverbal behaviors.
to evaluate a clients atrial depolarization the nurse observes which part of the ECG waveform? a) P wave b) PR interval c) QRS complex d) T wave
a) P wave p wave is atrial depolarization PR interval is the impule sprading QRS is ventricular depolarization T wave is ventricular repolarization
The nurse will use which technique of assessment to determine the presence of crepitus, swelling, and pulsations? a) Palpation b)Inspection c) Percussion d)Auscultation
a) Palpation
The nurse is observing the auscultation technique of another nurse. The correct method to use when progressing from one auscultatory site on the thorax to another is ____ comparison. a) Side-to-side b) Top-to-bottom c) Posterior-to-anterior d) Interspace-by-interspace
a) Side-to-side
The nurse is preparing to use a stethoscope for auscultation. Which statement is true regarding the diaphragm of the stethoscope? a) The diaphragm is used to listen for high-pitched sounds. b) The diaphragm is used to listen for low-pitched sounds. c) The diaphragm should be held lightly against the person's skin to block out low-pitched sounds. d) The diaphragm should be held lightly against the person's skin to listen for extra heart sounds and murmurs.
a) The diaphragm is used to listen for high-pitched sounds.
A woman brings her husband to the clinic for an examination. She is particularly worried because after a recent fall, he seems to have lost a great deal of his memory of recent events. Which statement reflects the nurse's best course of action? a) The nurse should plan to perform a complete mental status examination. b) The nurse should refer him to a psychometrician. c) The nurse should plan to integrate the mental status examination into the history and physical examination. d) The nurse should reassure his wife that memory loss after a physical shock is normal and will subside soon.
a) The nurse should plan to perform a complete mental status examination.
A nurse is caring for a client who is exhibiting signs and symptoms charachteristic of a myocardial infarction (MI). Which statement describes priorities the nurse should establish while performing the physical assessment? a) assess the clients level of pain and administer prescribed analgesics b) assess the clients level of anxiety and provide emotional support c) prepare the client for pulmonary artery catheterization d) ensure that the clients family is kept informed of his status
a) assess the pain level and administer prescribed analgesics
To evaluate a clients cerebellar function a nurse should ask a) do you have any problems with balance? b) do you have difficulty speaking? c) do you have trouble swallowing d) have you noticed any changes in your muscle strenght
a) cerebellar function is about balance and coordination
A client undergoes a total abdominal hysterectomy. When assessing the client 10 hours later the nurse identifies what as a sign of shock a) confusion b) pale warm and dry skin c) heat rate of 110 beats per minute d) urine output of 30 ml/ hr
a) confusion skin would be pale, warm and clammy not dry
What is the most appropriate nursing diagnosis for a client with acute pancreatitis? a) deficient fluid volume b) excess fluid volume c) decreased cardiac output d) innefective GI tissue perfussion
a) deficient fluid volume
Which component of the clients medical record is the major source of subjective data about the clients health status? a) health history b) physical finding c) lab test results d) radiological findings
a) health history only the health history provides subjective data
a client is admitted to the hospital with pneumonia. He has a history of parkinsons disease. Which assessment should the nurse expect a) impaired speech b) muscle flaccidity c) pleasant and smiling demeanor d) tremors in the fingers`
a) impaired speech
a nurse is assessing a client using light palpation. How does a nurse preform light palpation? a) indenting skin 1/2 to 3/4 inth (1.3-1.9 cm) b)indenting 1 inch to 2 inches c) by indenting the skin 1 inch using both hands d) intending the skin 1 inch then releasing the pressure quickly
a) indenting the skin 1/2 to 3/4 inch or 1.3-1.9 cm using the tips and pads of the finger tups 1.5 inches when preforming deep palpation
While performing an abdominal assessment a nurse should follow which examination sequence a) inspection, ausculation, percussion, palpation b) inspection, ausculation, palpation, percussion c) inspection, percussion, palpation, ausculation d) inspection, palpation, percussion, ausculation
a) inspection, ausculation, percussion, palpation all other sequencing would be inspection, palpation, percussion and then ausculation
a nurse is caring for a client who has suffered a severe stroke. During routine assessment the nurse notices cheyne- strokes respirations which are: a) progressively deeper breaths followed by shallower breaths with apneic sounds b) rapid deep breaths with abrupt pauses between breaths c) rapid deep breaths and irregular breathing without pauses d) shallow breaths with an increased respiratory rate
a) progessively deeper breaths followed by shallower breaths with apneic periods
The ear canal of an infant or young child a) slants upward b) slants downward c) is horizontal d) slants backwards
a) slants upwards slants downward in an adult or older child
a nurse is caring for a client who has experienced an acute exacerbation of Crohns diseaes. which statement best indicates that the disease process is under control a) the client exhibits signs of adequate GI perfussion b) the client expresses positive feelings about himself c) the client verbalizes a manageable level of discomfort d) the client maintains skin integrity
a) the client exhibits signs of adequate GI perfusion
During a physical examination, a nurse asks a client to hold their breath briefly and then uses a stethescope to ausculate over their carotid arteries. Which finding is normal when ausculating over these arteries? a) no sounds over either carotid artery b) faint swishing sounds c) throbbing pulsations bilaterally d) louder over the right carotid artery than over the left
a) there should be no sounds over either carotid artery
When routinely evaluating an elderly client for atypical signs or symptoms the nurse should rememeber that a) aging can reduce an individuals ability to regulate body temperature b) aging can increase pain perception c) anesthesia usually causes postoperative psychotic behavior in a geriatric client d) the risk of developing emphesema is highest in elderly people
a)aging can reduce an individuals ability to regulate body temperature d is not the answer because smokers have the highest risk of developing emphesema
Western traditional view
absence of disease
Pain signals are carried to the CNS by
afferent fibers
Remote memory is not affected by
aging
TWEAK test
alcohol test in @ risk woman (pregnancy)
SMAST G
alcohol test in elderly
Lordosis
an abnormal increase in the forward curvature of the lumbar spine (swayback) pregnant woman
Abdominal Fat
android obesity
Atrioventricular valves seperate the
atria from the ventricles
Doppler Technique
augments Korotkoff sounds during BP measurements
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: a) "That is your subacromial bursa." b) "That is your acromion process." c) "That is your glenohumeral joint." d) "That is the greater tubercle of your humerus."
b) "That is your acromion process."
The nurse is examining an infant and prepares to elicit the Moro reflex at which time during the examination? a) When the infant is sleeping b) At the end of the examination c) Before auscultation of the thorax d) Halfway through the examination
b) At the end of the examination
The nurse keeps in mind that the most important reason to share information and offer brief teaching while performing the physical examination is to help: a) The examiner feel more comfortable and gain control of the situation b) Build rapport and increase the patient's confidence in the examiner c) The patient understand his or her disease process and treatment modalities d) The patient identify questions about his or her disease and potential areas of patient education
b) Build rapport and increase the patient's confidence in the examiner
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
b) Fourth lumbar
In assessing a 70-year-old man, the nurse finds the following: blood pressure 140/100 mm Hg; heart rate 104 and slightly irregular; split S2. Which of these findings can be explained by expected hemodynamic changes related to age? a) Increase in resting heart rate b) Increase in systolic blood pressure c) Decrease in diastolic blood pressure d) Increase in diastolic blood pressure
b) Increase in systolic blood pressure
In assessing the carotid arteries of an older patient with cardiovascular disease, the nurse would: a) Palpate the artery in the upper one third of the neck b) Listen with the bell of the stethoscope to assess for bruits c) Palpate both arteries simultaneously to compare amplitude d) Instruct patient to take slow deep breaths during auscultation
b) Listen with the bell of the stethoscope to assess for bruits
A patient has suddenly developed shortness of breath and appears to be in significant respiratory distress. After putting a call in to the physician and placing the patient on oxygen, which of these is the best action for the nurse to take when assessing the patient further? a) Count the patient's respirations. b) Percuss the thorax bilaterally, noting any differences in percussion tones. c) Call for a chest x-ray and wait for the results before beginning an assessment. d) Inspect the thorax for any new masses and bleeding associated with respirations.
b) Percuss the thorax bilaterally, noting any differences in percussion tones.
The nurse is teaching a class on basic assessment skills. Which of these statements is true regarding the stethoscope and its use? a) The slope of the earpieces should point posteriorly (toward the occiput). b) The stethoscope does not magnify sound but does block out extraneous room noise. c) The fit and quality of the stethoscope are not as important as its ability to magnify sound. d) The ideal tubing length should be 22 inches to dampen distortion of sound.
b) The stethoscope does not magnify sound but does block out extraneous room noise.
When performing a physical examination, safety must be considered to protect the examiner and the patient against the spread of infection. Which of these statements describes the most appropriate action the nurse should take when performing a physical examination? a) There is no need to wash one's hands after removing gloves, as long as the gloves are still intact. b) Wash hands before and after every physical patient encounter. c) Wash hands between the examination of each body system to prevent the spread of bacteria from one part of the body to another. d) Wear gloves throughout the entire examination to demonstrate to the patient concern regarding the spread of infectious diseases.
b) Wash hands before and after every physical patient encounter.
which client best fits into the middle old population? a) 68 year old with coronary artery disease b) 76 year old with hypertension c) 80 year old with end stage renal disease d) 88 year old with osteoarthiritis
b) a 76 year old with hypertension young old is 65-74 middle old is 75-84 old old is 85 and older
When determining appropriate nursing interventions for a client with medical diagnosis the nurse uses a) developmental anatomy b) applied anatomy c) regional anatomy d) descriptive anatomy
b) applied anatomy developmental anatomy to study structural changes from conception through old age regional anatomy refers to a limited portion of the body descriptive anatomy describes individual body parts in an orderly fashion
A nurse prepares to perform an otoscopic examination on an adult. For proper visualization the nurse should position the clients ear by pullung the: a) lobule down and forward b) auricle up and back c) auricle up and forward d) lobule down and back`
b) auricle up and back for the child pull the auricle down
A nurse is taking the health history of an 85 year old client. Which information will be the most useful to the nurse for planning care? a) general health for the last 10 years b) current health promotion activities c) family history of disease d) marital status
b) current health promotion activities are most important
A nurse is assesing a 47 year old client who has come to the clinic for his annual physical. One of the first physical signs of aging is a) having more frequent aches and pains b) failing eyesight, especially close vision c) increasing loss of muscle tone d) accepting limitations while developing assets
b) failing eyesight, especially close vision is one of the first signs of aging in middle life more frequent aches and pains occur around age 65 loss of muscle tone increases around age 80 accepting limitations while developing assets occurs around age 31-45
When a nurse enters a clients room, the client complains that she is spitting up blood when she coughs. When the nurse takes a quick health history it will include: a) history of the present problem, medications, review of symptoms and major recent operations b) history of the present problem, medications, allergies, and recent major surgeries c) history of the present problem, medications, psychosocial history, and review of systems d) history of the present problem, allergies, medications, review of symptoms, and recent major operatoins
b) history of the present problem, allergies, medications and recent major operations
Using Maslows hierarchy of needs model the nurse assigns the highest priority to: a) arranging a visit from a support group member b) inserting a foley catheter c) raising the side rails on the clients bed d) placing the client in a double room with another client the same age
b) inserting the foley catheter
A nurse is assessing a clients abdomen. Which examination technique should the nurse use first a) ausculation b) inspection c) percussion d) palpation
b) inspection
A client comes in to the clinic for a routine checkup. To assess the clients gag reflex, the nurse should use which method? a) place a tongue blade on the front of the tongue and ask patient to say "ahh" b) place a tongue blade lightly on the posterior aspect of the pharynx c) place a tongue blade on the middle of the tongue and ask the client to cough d) place a tongue blade on the uvula
b) place a tongue blade lightly on the posterior aspect of the pharynx
A client has been receiving an IV solution. What is an appropriate expected outcome for this client a) monitor fluid intake and output every 4 hours b) the client remains free of signs and symptoms of phlebitis c) edema and warmth are noted at IV insertion site d) there is a risk of infection related to IV insertion
b) the client remains free of signs and symptoms of phlebitis
a nurse uses a stethescope to auscultate a clients chest. Which statement about a stethescope with a bell and diaphragm is true? a) the bell detects high pitched sounds best b) the diaphragm detects high pitched sounds best c) the bell detects thrills best d) the diaphragm detects low pitched sounds best
b) the diaphragm detects high pitched sounds the best bell detects low pitch sounds best palpation detect thrills best
When developing the teaching plan for a client who uses a walker, which principle should a nurse consider a) the hand bar of the walker should be well below the clients waist b) when maximum support is required, the walker should be moved ahead around 6''while both legs support the clients weight c) if one leg is weaker than the other, the walker and the stronger leg should move together. The clients weight is supported by his weaker leg d) a standard walker neednt be picked up when moved
b) to prevent falls, the client should move the walker ahead 6''
A nurse is assessing tactile fremitus in a client with pneumonia. For this examination the nurse should use: a) fingertips b) ulnar surface of hand c) dorsal surface of her hand d) finger pads
b) ulnar surface ulnar for tactile fremitus, thrills, and vocal vibrations dorsal for temperature finger tips and finger pads for texture and shape
a nurse is assessing tactile fremitus in a client with pneumonia. For this examination the nurse should use: a) fingertips b) ulnar surface c) dorsal surface d) finger pads
b) ulnar surface ( for tactile fremitus, vocal vibrations and thrills) dorsal for temperature fingertips and pads for texture and shape
Lablity
biplor disorder
Vitamin C deficiency
bleeding gums nails splinter joint pain
Cephelhematoma
bleeding into the periosteum during birth
Deep somatic pain sources:
blood vessels joints tendons muscles bones
Allergies
boggy pale and gray mucosa
Halitosis
breath odor
A 45-year-old man is in the clinic for a routine physical. During the history the patient states that he's been having difficulty sleeping. "I'll be sleeping great and then I wake up and feel like I can't get my breath." The nurse's best response to this would be: a) "When was your last electrocardiogram?" b) "It's probably because it's been so hot at night." c) "Do you have any history of problems with your heart?" d) "Have you had a recent sinus infection or upper respiratory infection?"
c) "Do you have any history of problems with your heart?"
A patient has finished giving the nurse information about the reason he is seeking care. When reviewing the data, the nurse finds that some information about past hospitalizations is missing. At this point, which statement by the nurse would be most appropriate to gather these data? a) "Mr. Y., at your age, surely you have been hospitalized before!" b) "Mr. Y., I just need permission to get your medical records from County Medical." c) "Mr. Y., you mentioned that you have been hospitalized on several occasions. Would you tell me more about that?" d) "Mr. Y., I just need to get some additional information about your past hospitalizations. When was the last time you were admitted for chest pain?"
c) "Mr. Y., you mentioned that you have been hospitalized on several occasions. Would you tell me more about that?"
The nurse is reviewing the technique of palpating for tactile fremitus with a new graduate. Which statement by the graduate nurse reflects a correct understanding of tactile fremitus? a) "Tactile fremitus is caused by moisture in the alveoli." b) "Tactile fremitus indicates that there is air in the subcutaneous tissues." c) "Tactile fremitus is caused by sounds generated from the larynx." d) "Tactile fremitus reflects the blood flow through the pulmonary arteries."
c) "Tactile fremitus is caused by sounds generated from the larynx."
During the examination, it is often appropriate to offer some brief teaching about the patient's body or the examiner's findings. Which of these statements by the nurse is most appropriate? a) "Your atrial dysrhythmias are under control." b) "You have pitting edema and mild varicosities." c) "Your pulse is 80 beats per minute. This is within the normal range." d) "I'm using my stethoscope to listen for any crackles, wheezes, or rubs."
c) "Your pulse is 80 beats per minute. This is within the normal range."
A 2-year-old child has been brought to the clinic for a well-child check-up. The best way for the nurse to begin the assessment is reflected by which statement? a) Ask the parent to place the child on the examining table. b) Have the parent remove all of the child's clothing before the examination. c) Allow the child to keep a security object such as a toy or blanket during the examination. d) Initially focus interactions on the child, essentially "ignoring" the parent, until the child's trust has been obtained.
c) Allow the child to keep a security object such as a toy or blanket during the examination.
Which of these statements represents subjective data the nurse obtained from the patient regarding the patient's skin? a) Skin appears dry. b) No obvious lesions. c) Denies color change. d) Lesion noted lateral aspect right arm.
c) Denies color change.
A patient is having difficulty in swallowing medications and food. The nurse would document that this patient has: a) Aphasia b) Dysphasia c) Dysphagia d) Anorexia
c) Dysphagia
The nurse is planning to assess new memory with a patient. The best way for the nurse to do this would be to: a) Administer the FACT test. b) Ask him to describe his first job. c) Give him the Four Unrelated Words test. d) Ask him to describe what television show he was watching before coming to the clinic.
c) Give him the Four Unrelated Words test.
The nurse is taking a family history. Important diseases or problems to ask the patient about specifically include: a) Emphysema b) Head trauma c) Mental illness d) Fractured bones
c) Mental illness
In assessing a patient's major risk factors for heart disease, which would the nurse want to include when taking a history? a) Family history, hypertension, stress, age b) Personality type, high cholesterol, diabetes, smoking c) Smoking, hypertension, obesity, diabetes, high cholesterol d) Alcohol consumption, obesity, diabetes, stress, high cholesterol
c) Smoking, hypertension, obesity, diabetes, high cholesterol
The nurse is unable to palpate the right radial pulse on a patient. The best action would be to: a) Auscultate over the area with a fetoscope b) Use a goniometer to measure the pulsations c) Use a Doppler device to check for pulsations over the area d) Check for the presence of pulsations with a stethoscope
c) Use a Doppler device to check for pulsations over the area
The nurse is auscultating the chest in an adult. Which technique is correct? a) Instruct the patient to take deep, rapid breaths. b) Instruct the patient to breathe in and out through his or her nose. c) Use the diaphragm of the stethoscope held firmly against the chest. d) Use the bell of the stethoscope held lightly against the chest to avoid friction.
c) Use the diaphragm of the stethoscope held firmly against the chest.
58) When auscultating the lungs of an adult patient, the nurse notes that over the posterior lower lobes low-pitched, soft breath sounds are heard, with inspiration being longer than expiration. The nurse interprets that these are: a) Sounds normally auscultated over the trachea b) Bronchial breath sounds and are normal in that location c) Vesicular breath sounds and are normal in that location d) Bronchovesicular breath sounds and are normal in that location
c) Vesicular breath sounds and are normal in that location
The nurse is examining a patient's lower leg and notices a draining ulceration. Which of these actions is most appropriate in this situation? a) Wash hands and contact the physician. b) Continue to examine the ulceration and then wash hands. c) Wash hands, put on gloves, and continue with the examination of the ulceration. d) Wash hands, proceed with rest of the physical examination, and then continue with the examination of the leg ulceration.
c) Wash hands, put on gloves, and continue with the examination of the ulceration.
A patient has been in the intensive care unit for 10 days. He has just been moved to the medicalsurgical unit, and the admitting nurse is planning to perform a mental status examination on him. During the tests of cognitive function the nurse would expect that he: a) May display some disruption in thought content b) Will state, "I am so relieved to be out of intensive care" c) Will be oriented to place and person but may not be certain of the date d) May show evidence of some clouding of his level of consciousness
c) Will be oriented to place and person but may not be certain of the date
When palpating the bladder of an adult the nurse would indentify which finding as normal a) soft smooth bladder b) hard, rough bladder c) nonpalpable bladder d) a palpable bladder located 3'' to 5 '' above the symphasis pubis
c) a nonpalpable bladder or it would be FIRM and smooth and located 1'' to 2'' above the symphasis pubis
To access the effectiveness of cardiac compressions during adult CPR, the nurse should palpate which site? a) radial b) apical c) caratid d) bronchial
c) carotid is the most palpable and assessible
When testing a clients pupils for accomodation a nurse should interpret which finding as normal? a) constriction and divergence b) dialation and convergence c) constriction and convergence d) dilation and divergence
c) constriction and convergence
when developing a care plan for a client with a do not resuscicate (DNR) order a nurse should: a) withhold foods and fluids b) discontinue pain medications as ordered c) ensure assess to individuals who can provide spiritual care with a clients request d) administer lethal doses of medications when requested to do so by a competent terminally ill client
c) ensure assess to individuals who can provide spiritual care
a nurse is developing a nursing diagnosis for a client. Which information should she include a) actions to achieve goals b) expected outcomes c) factors influencing the clients problem d) nursing history
c) factors influencing the clients problem
A nurse must assess skin turgor on an elderly patient. When evaluatin skin turgor, the nurse should remember that: a) overhydration causes the skin to tent b) dehydration causes the skin to appear edamatous and spongey c) inelastic skin turgor is a normal part of aging d) normal skin turgor is moist and boggy
c) it is a normal part of aging to have nonelastic skin turgor normal skin is dry and firm
When assessing the facial lacerations of a middle aged client admitted into the facility 1 week earlier, a nurse observes scabs around the lacerations. Scabs indicate which phase of wound healing? a) contraction b) fibronoplastic c) lag d) inflammation
c) lag the fibrin network dries out and forms a scab
When examining a client who has abdominal pain, a nurse should assess a) any quadrant first b) the symptomatic quadrant first c) the symptomatic quadrant last d) the symptomatic quadrant second or third
c) last
When ausculating a clients abdomen, a nurse detects high pitched gurgles over the lower Right quadrant. Based on this finding,m the nurse suspects a) decreased bowel motility b) increased bowel motility c) nothing abnormal d) abdominal cramping
c) nothing abnormal high pitch gurgles are normal findings
When percussing a clients chest, the nurse should expect to hear: a) hyperresonance b) tympany c) resonance d) dullness
c) resonance is a normal finding over the lung tissue in the chest
When assessing a clients abdomen which finding should the nurse report as abmormal a) dullness over the liver b) bowel sounds occuring every 10 seconds c) shifting dullness over the abdomen d) vascular sound over the renal arteries
c) shifting dullness over the abdomen would indicate ascites which is abnormal dullness over the liver, bowel sounds every 10 seconds and vascular sounds over the renal arteries are all normal sounds in the abdomen
a nurse prepares to auscultate a clients carotid arteries for bruits. For this procedure the nurse should a) have the client inhale b) palpate the radial artery c) use the bell of the stethescope d) use the diaphragm of the stethescope
c) the bell is for bruits the patient should be holding their breath not inhaling
Which sentence correctly describes the prone position? a) the body is supine b) arms are elevated at shoulder level c) the body is face down d) the body is facing backwards
c) the body is face down (with the head on the side)
what is a common source of airway obstuction in an unconscious client? a) foreign object b) saliva or mucus c) tongue d) edema
c) tongue
a 2 year old child is being examined in the ER for epiglottiditis. Which assessment finding supports the diagnosis a) mid fever b) clear speech c) tripod position d) gradual onset of symptoms
c) tripod position ( to help with breathing
A nurse correctly identifies which items as belonging in the dorsal cavity? a) mediastinum b) mouth c) vertebral canal d) reproductive organs
c) vertebral canal dorsal canal consists of the cranial and vertebral canal
When inspecting a clients skin, a nurse finds a circumscribed elevated area filled with serous fluid. What term should the nurse use to document this finding? a) macule b) papule c) vesicle d) pustule
c) vesicle macule is a flat nonpalpable spot papule is a mole pustule is acne
Amplitude
intensity (soft or loud)
a nurse prepares to measure a clients blood pressure. What is the correct procedure for measuring blood pressure? a) wrapping the cuff around the limb with the uninflated bladder covering about 1/4th the limb circumference b) measuring the arm 2'' above the antecubital space c) wrapping the cuff around the limb with the uninflated bladder covering about 3 quarters of the limb circumference d) using a bladder that is 6''
c) wrapping the cuff around the limb with the uninflated bladder, covering about 3 quarters of the limb circumference
A client comes into the clinic for diagnositc allergy testing. The nurse understands that intradermal injections are administered on which principle a) intradermal injection is less painful b) intradermal drugs are easier to administer c) intradermal drugs diffuse more rapidly d) intradermal drugs diffuse slower
c)diffuse slower because it they did go fast then it could be dangerous if they were allergic
Valves are anchored by
chordae tendinae to papillary muscles
Annular
circular lesion, begins in center, spreads to periphery
Complete Database
complete health history plus a full physical exam describes current plus past health and forms baseline to measure future changes
To determine if a black person is pale (pallor) assess the color of the
conjuctiva
To count respirations
count for 30 seconds and multiply by 2
Incision
cut or wound
A 29-year-old woman tells the nurse that she has "excruciating pain" in her back. Which would be an appropriate response by the nurse to the woman's statement? a) "How does your family react to your pain?" b) "That must be terrible. You probably pinched a nerve." c) "I've had back pain myself, and it can be excruciating." d) "How would you say the pain affects your ability to do your daily activities?"
d) "How would you say the pain affects your ability to do your daily activities?"
A woman has just entered the emergency department after being battered by her husband. The nurse needs to get some information from her to begin treatment. What is the best choice for an opening with this patient? a) "Hello, Nancy, my name is Mrs. C." b) "Hello, Mrs. H., my name is Mrs. C. It sure is cold today!" c) "Mrs. H., my name is Mrs. C. How are you?" d) "Mrs. H., my name is Mrs. C. I'll need to ask you a few questions about what happened
d) "Mrs. H., my name is Mrs. C. I'll need to ask you a few questions about what happened
A patient tells the nurse that he is allergic to penicillin. What would be the nurse's best response to this information? a) "Are you allergic to any other drugs?" b) "How often have you received penicillin?" c) "I'll write your allergy on your chart so you won't receive any penicillin." d) "Please describe what happens to you when you take penicillin."
d) "Please describe what happens to you when you take penicillin."
Before auscultating the abdomen for the presence of bowel sounds on a patient, the nurse should: a) Warm the end piece of the stethoscope by placing it in warm water b) Leave the gown on so that the patient does not get chilled during the examination c) Make sure that the bell side of the stethoscope is turned to the "on" position d) Check the temperature of the room and offer blankets to the patient if he or she feels cold
d) Check the temperature of the room and offer blankets to the patient if he or she feels cold
The nurse is examining a 2-year-old child and asks, "May I listen to your heart now?" Which critique of the nurse's technique is most accurate? a) Asking questions enhances the child's autonomy. b) Asking the child for permission helps to develop a sense of trust. c) This is an appropriate statement because children at this age like to have choices. d) Children at this age like to say "No." The examiner should not offer a choice when there is none
d) Children at this age like to say "No." The examiner should not offer a choice when there is none
The nurse hears bilateral louder, longer, and lower tones when percussing over the lungs of a 4-year old child. What should the nurse do next? a) Palpate over the area for increased pain and tenderness. b) Ask the child to take shallow breaths and percuss over the area again. c) Refer the child immediately because of an increased amount of air in the lungs. d) Consider this a normal finding for a child this age and proceed with the examination.
d) Consider this a normal finding for a child this age and proceed with the examination.
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
d) Decreased gastric acid secretion
The review of systems provides the nurse with: a) Physical findings related to each system b) Information regarding health promotion practices c) An opportunity to teach the patient medical terms d) Information necessary for the nurse to diagnose the patient's medical problem
d) Information necessary for the nurse to diagnose the patient's medical problem
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
d) Intervertebral disks
During an interview, the nurse states, "You mentioned shortness of breath. Tell me more about that." Which verbal skill is used with this statement? a) Reflection b) Facilitation c) Direct question d) Open-ended question
d) Open-ended question
The nurse asks, "I would like to ask you some questions about your health and your usual daily activities so that we can better plan your stay here." This question is found at the _____ phase of the interview process. a) Summary b) Closing c) Body d) Opening or introduction
d) Opening or introduction
In recording the childhood illnesses of a patient who denies having had any, which note by the nurse would be most accurate? a) Patient denies usual childhood illnesses. b) Patient states he was a "very healthy" child. c) Patient states sister had measles, but he didn't. d) Patient denies measles, mumps, rubella, chickenpox, pertussis, and strep throat.
d) Patient denies measles, mumps, rubella, chickenpox, pertussis, and strep throat.
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.
d) Percuss and palpate the midline area above the suprapubic bone.
The mother of a 3-month-old infant states that her baby has not been gaining weight. With further questioning, the nurse finds that the infant falls asleep after nursing and wakes up after a short amount of time, hungry again. What other information would the nurse want to have? a) The infant's sleeping position b) Sibling history of eating disorders c) Amount of background noise when eating d) Presence of dyspnea or diaphoresis when sucking
d) Presence of dyspnea or diaphoresis when sucking
An examiner is using an ophthalmoscope to examine a patient's eyes. The patient has astigmatism and is nearsighted. The use of which of these techniques would indicate that the examination is being performed correctly? a) Using the large full circle of light when assessing pupils that are not dilated b) Rotating the lens selector dial to the black numbers to compensate for astigmatism c) Using the grid on the lens aperture dial to visualize the external structures of the eye d) Rotating the lens selector dial to bring the object into focus
d) Rotating the lens selector dial to bring the object into focus
Which structure is located in the left lower quadrant of the abdomen? a) Liver b) Duodenum c) Gallbladder d) Sigmoid colon
d) Sigmoid colon
A 19-year-old woman comes to the clinic at the insistence of her brother. She is wearing black combat boots and a black lace nightgown over the top of her other clothes. Her hair is dyed pink with black streaks throughout. She has several pierced holes in her nares and ears and is wearing an earring through her eyebrow and heavy black makeup. The nurse concludes: a) She probably doesn't have any problems at all. b) She is just trying to shock people and her dress should be ignored. c) She has manic syndrome because of her abnormal dress and grooming. d) That more information should be gathered to decide whether her dress is appropriate
d) That more information should be gathered to decide whether her dress is appropriate
The nurse is preparing to perform a physical assessment. The correct action by the nurse is reflected by which statement? a) The nurse performs the examination from the left side of the bed. b) The nurse examines tender or painful areas first to help relieve the patient's anxiety. c) The nurse follows the same examination sequence regardless of the patient's age or condition. d) The nurse organizes the assessment so that the patient does not change positions too often
d) The nurse organizes the assessment so that the patient does not change positions too often
The nurse is preparing to use an otoscope for an examination. Which statement is true regarding the otoscope? a) The otoscope is often used to direct light onto the sinuses. b) The otoscope uses a short, broad speculum to help visualize the ear. c) The otoscope is used to examine the structures of the internal ear. d) The otoscope directs light into the ear canal and onto the tympanic membrane.
d) The otoscope directs light into the ear canal and onto the tympanic membrane.
After a stroke the client develops aphasia. The nurse expects to see which assessment finding? a) arm and leg weakness b) absence of a gag reflex c) difficulty swallowing d) inability to speak clearly
d) aphasia is loss of language skills
When ausculating over a clients chest, a nurse assesses a second heart sound (s2) This sound results from a) opening of the mitral and tricuspid vales b) closing of the mitral and tricuspid valves c) opening of the aortic and pulmonic valves d) closing of the aortic and pulmonic valves
d) closing of the aortic and pulmonic valves indicate s2 s1 is the closing of the mitral and tricuspid valves
What description about crackles are true? a) they are grating sounds b) they are high pitched musical squeaks c) they are low pitched noises that sound like snoring d) they may be fine or course
d) crackles can be fine or course they result from air moving through airways that contain fluid and are audiable during both inspiration and expiration plueral fiction sounds like a grating sound wheezes are high pitched musical squeaks
When assessing an elderly patient, the nurse expects to find various aging related physciologic changes that include: a) increased coronary artery flow b) decreased posterior thoracic curve c) decreased peripheral resistance d) delayed gastric emptying
d) delayed gastric emptying (also decreased coronary artery flow, increased posterior thoracic curve and increased peripheral resistance)
When assessing an elderly patient the nurse expects to find various aging related physiologic changes such as a) increased coronary artery blood flow b) decreased posterior thoracic curve c) decreased peripheral resistance d) delayed gastric emptying
d) delayed gastric emptying also decreased coronary artery blood flow, increased thoracic curve, increased peripheral resistance
What complication does a third heart sound s3 indicate? a) ventricular dilation b) systematic hypertension c) aortic valve malfunction d) increased atrial contraction
d) increased atrial contraction rapid filling of the ventricle causes vasodilation that a nurse will ausculatate as s3 increased atrial hypertension is s4 aortic valve malfunction is a murmur
A client is diagnosed with deep vein thrombosis (DVT) Which nursing diagnosis should receive the highest priority at this time? a) impaired gas exchange due to increased blood flow b) excess fluid volume related to peripheral vascular disease c) risk for injury related to edema d) ineffective peripheral tissue perfusion related to venous congestion
d) ineffective peripheral tissue perfusion is highest priority due to clot formation impeding blood flow in DVT
Blocking
interruption of the train of thought
A nurse is taking a clients blood pressure and fails to recognize an ausculatory gap. What should the nurse do to avoid recording a low systolic blood pressure a) have the client lie down while taking their blood pressure b) inflate the cuff to at least 200 mm Hg c) take blood pressure readings in both clients arms d) inflate the cuff at least 30 mm Hg after she cannot palpate the radial pulse
d) inflate the cuff at least 30 mm Hg after she cannot palpate the radial pulse
A nurse is evaluating a clients auditory function. To compare air conduction to bone conduction the nurse should use which test a) whispered voice test b) webers test c) watch tick test d) rinne test
d) rinne test compares air conduction to bone conduction whispered voice test is for low pitched tones watch tick assesses high pitched sounds webers evaluates bone conduction only
Which statement regarding the heart sounds is correct? a) s1 and s2 sound equally loud over the entire cardiac area b) s1 and s2 sound fainter at the apex than at the base c) s1 and s2 are fainter at the base than at the apex d) s1 is loudest at the apex and s2 is loudest at the base
d) the s1 sound (lub) is loudest at the apex and the s2 (dub) is loudest at the base
A 10 year old with rheumatic fever must have his heart rate measured while he is awake and while he is sleeping. Why are the two readings necessary? a) to obtain a heart rate that is not affected by medication b) to eleminate interference from the jerky movement of the chorea c) to ensure that the child cannot consciously raise or lower his heart rate d) to compensate for activities effects on the childs heart rate
d) to compensate for activities on the childs heart rate. also to detect tachycardia which would be detected when he is asleep
A client tells a nurse that he has a rash on his back and right flank. The nurse observes elevated, round blisterlike lesions filled with clear fluid. When documenting the findings what medical term should the nurse use to describe this finding? a) pustule b) papules c) plague d) vescicle
d) vesicle (chicken pox, shingles)
Decrease in alveoli in the lungs would lead to
decreased SA for gas exchange
Elderly have higher blood alcohol levels because
decreased liver metabolism decreased kidney function decreased GI motility decreased muscle mass which leads to less tissue to absorb and more in the blood
Inspiration is facilitated by
diaphragm, intercostals
Self Esteem/ Self concept
education, financial status, values and belief system
Purpura
flat macular red purple hemorrhage
Parkinson disease
flat, expressionless, mask like face
Abrasion
friction wound
Hand wash instead of alcohol rub if the patient
has Clostridium difficile (C. diff)
Eccymosis
hemmorhagic spot that forms a non elevated blue/ purple spot
Biomedical/ scientific
high level of wellness exists with optimal functioning of body
Stridor
high pitch, upper airway obstruction
To be culturally competent a nurse must understand
his or her own heritage culture or nursing process culture of the patient culture of health care system
Hold/ cold theory
humoral theory must balance the humors blood, phlegm, black bile, yellow bile + to - wet to dry to balance humors
Chronic alcohol use can lead to
hypertension tachycardia atrial fibrillation
Agnosia
impaired ability to identify objects
Apraxia
impaired mobile ability
Neuropathic Pain
implies abnormal pain message processing
Increase in estrogen in pregnancy
increases the diameter of the chest cage
Acute Otitis Media
indicates a tympanic membrane that is bulging and red
Jugular venous pressure
is a reflection of the hearts pump efficiency
Review of Systems
is an evaluation of past and present health state of each body system. document the presence or absence of all symptoms under the system heading Orderly and systematic check of each organ and system of the body by questions.
Empathy
is viewing the world from another persons inner frame of reference
Aphasia
language disturbance
Duration
length
Horner Syndrome
lesion of the sympathetic nerve and will lead to a unilateral pupil that reacts to light accomation
Episodic Database
limited or short term problem concerns 1 problem or complex or system
Zosterform
linear lesion along a nerve route
Degrading vision in elderly due to
macular degeneration glaucoma cataracts
Dementia
memory/ cogntive distrubance short term/ long term memory
Mental status exam assesses
mental health strenghts and coping skills screens for dysfunctions
Neonate tympanic membrane
more horizontal
fetal alcohol syndrome
narrow palpebral fissures, epicanthal fold, midfacial hyperplasia
Bifid Uvula
normal to find in American Indian
Alchohol dependence
not being able to quit withdrawl symptoms having to drink more to get the same affect
mental status abnormality in children includes
not reaching expected developmental milestones
Pitch
number of vibrations high or low
Most important detail for gathering an infant history
nutritional data
Energy Requirements for elderly decrease because
of loss of lean body mass
Increased bleeding and bruising in elderly because
of nonsteriodial anti inflammatory drugs
Most abused opiod pain medication
oxycodone
Spirituality
personal effort to find purpose and meaning in life
Judgment assesses
persons job plans, obligations, plans for the future
External ear
pinna or auricle
Increased tactile fremitus is evident in
pneumonia
Audiometer test is a
precise quantitative measure of hearing
Craniosynostosis
premature closing of the sutures
urticaria
primary lesion Hives or wheals which are either redder or paler than the surrounding area and are often attended by itching
Socialization
process of being raised within a culture and acquiring the group characteristics
Tympanic Membrane thermometer
provides an accurate measurement of core body temperature
Emergency database
rapid collection of data often obtained concurrently with life saving measures
Documenting a history source is
recording who is giving the information and how reliable they are
Rhinitis
red and swollen nasal mucosa normally red and smooth and moist
Reflection
repeating what they just said
Compulsion
repetitive purposeful acts
Optic Disc
retina fibers converge to form optic nerve
Fovea Centralis
retina, keenest vision
At the end of the examination
review the findings with the patient
When the trachea is deviated to the left
right pneumothorax
Tennitus
ringing in the ears
When you are auscultating for murmurs
roll the patient to their left
erosion
secondary lesion
ulcer
secondary lesion an open lesion of the skin or mucous membrane resulting in tissue loss around the edges
Nutrition Status is best determined by
serum albumin
Acute Pain
short, self limiting disipates after injury heals
Dermatome
skin area supplied by a single spinal nerve
Nocireceptors
specialized nerve endings
Vertigo
spinning room
Parotid gland duct:
stenson duct
Percussion is when you
strike the stationary finger @ distal interphalangeal joint
Clarification
summarize or simplify the information
Tympanic membrane has white dense areas
suspect that it indicates scarring from recurrent ear infections
Avulsion
tear away
Transduction
the 1st phase of nocireceptive pain pain signals move from the site of orgin to the spinal cord
Eye cover Test
the covered eye should maintain its position when uncovered
Heritage Consitency
the degree a persons lifestyle reflects their traditional heritage
fundoscopic examination is for
the internal examination of the eye
Optic Chiasm is
the location where the nerve fibers cross over
take a full mental exam if
the patient has a behavior or effect change family member is concerned brain lesion aphasia
Chief complaint
the reason for seeking care
When you are ausculating a newborn heart and hear continuous sound that mimics the sound of the machine
this is a normal sound because the ductus arterious has not closed all the way yet
Myxedema
thryoid hormone deficiency Hypothyroidism
Petichae
tiny hemorrhage caused by capillary bleeding
Elevated Gamma Glutamyl Transference (GGT)
us a lab that indicates chronic alcohol use
Decreased saliva production in elderly is due to
use of anticholinergic medications
Follow up database
used to follow up short term or chronic health problems Status of identified problems evaluated at intervals
port wine stain
vascular lesion
Semilunar valves seperate the
ventricles from the arteries
Submandibular gland duct
whartons duct
Tympanic membrane in older adults
whiter than young adult
Normal color of the optic disk is
yellow orange to pink
Closed/ Direct Question
yes or no, few words specific info and shorter
