Exam Fundamentals VS/Assessment what I remember is on the test and most likely the right answers

dyspnea

difficult or labored breathing

Ecchymosis

discoloration of the skin resulting from bleeding underneath, typically caused by bruising

extraocular eye movements

eye movements control by several pairs of eye muscles

advantages of body systems approach

findings tend to be clustered making it more easily identifiable

Rubs

grating, leathery sounds caused by two dry pleural surfaces moving over each other

what body part promotes sweating

hypothalamus

crackles (rales)

intermittent, high pitched popping, heard in distance areas of the lungs, primarily during inspiration fine if softbrief or course if louder and last longer rice crisps in milk

Prodromal phase of fever

nonspecific signs and symptoms just before temperature rises ~mild headache ~muscle aches ~decreased appetite ~general malaise

what do you do first if pt went from 102 to a 103 temperature

notify physician and give acetaminophen

ulcer

open crater like area

Systolic measurement

pressure within the arterial system when the heart contracts

Scoliosis

pronounced lateral curvature of the spine

nutrient that regulates body temperature

protein

oral temperature can be obtained in which of the pts

pt with a nasogastric tube

ask if pt has drank water, smoked, chewed gum within the past 30 minutes?

reassess after 30 minutes

what is noticeable on the anus if a client has history of chronic constipation

rectal fissures

Erythema

red coloration caused by superficial burns, local inflammation, carbon monoxide poisoning, allergic reaction

auscultating a patent sitting up is easier why

reduces the noise from air turbulence

turgor

resiliency of the skin; fullness or lack thereof

which pt needs assessed first?

respiratory rate above 20 or below 12 remember ABC's

hypoactive bowel sounds

Occur after long intervals of silence, and absent if no sound is heard for 2 to 5 minutes

pt is shivering what do you do

cover the client with light blanket

fissure

crack in the skin, especially in or near mucous membranes

wound

break in the skin

orthopnea

breathing facilitated by sitting upright or standing

apnea

breathing stops

consensual response

brisk, equal, and simultaneous constriction of both pupils when one eye then the other is stimulated with light

why is draping important and what does it provide

1. Ensures privacy 2. Provides warmth and more modesty

How to perform a breast examination

1. Examine the breasts monthly about 1 week after menstrual period or on a specific date post-menopause 2. Begin the examination in the shower 3. Next, stand in front of mirror 4. Look at both breasts with the arms relaxed at the side, with the hands pressing on the hips, and with the hands elevate above the head 5. Looking for dimpling in the skin or retraction of either nipple 6. Lie down for the remainder of the examination 7. Put a pillow or folded towel under the shoulder on the side where the first breast will be examined; reverse the pillow before examining the second breast 8.. Use the right hand to examine the left breast and the left hand to examine the right breast 9. Use the flat surface of the fingers in an up-and-down pattern from the underarm and across the breast from the clavicle to the base of the ribs to feel for changes in any area of the breast 10. Feel upward toward the axilla of each arm 11. Determine if there are any lumps of hard or thickened areas. Squeeze the nipple gently between the thumb and the index finger to determine if there is any clear or bloody discharge 12. Repeat the examination in the opposite breast and axilla 13. Report any unusual findings or changes to physician 14. Breast self-examination may be combined with a clinical examination and mammography to ensure early diagnosis and treatment of cancerous tumors

where is apex of heart located

5th intercostal space, midclavicular line slightly below the nipple line

wheal

Elevated, irregular border, no free fluid such as hives

papule

Elevated, palpable, solid such as wart

vesicle

Elevated, round, filled with serum like fluid such as blister

macule

Flat, round, colored, non palpable area such as freckles

A nurse is caring for a newborn. The nurse knows that the body temperature of infants and older adults is prone to fluctuations. Which is the most probable cause for fluctuations in infant's body temperature?

Greater surface area from which heat is lost and very high metabolic rate

Rhine test

an assessment technique for comparing air versus bone conduction of sound

abrasion

area that has been rubbed away by friction

palpating

assessing for moisture and temperature

Weber test

assessment technique for determining equality or disparity of bone-conducted sound

when do you collect objective data during a mental status assessment if a pt comes in after an accident

client who is overdosed on drugs

healthier and people who exercise more have what with their heart

easier for them their arterial walls to elasticity and easily stretch and recoil to accommodate changing volume larger cardiac muscle and strength

pustule

elevated, raised border, filled with pus such as boil

nodule

elevated, solid mass, deeper and firmer than papule such as enlarged lymph nodes

cyst

encapsulated, round, fluid-filled, or solid mass beneath the skin such as tissue growth

if a pt has a fever from 99.3 to 102 what should the nurse do first

encourage oral fluid

pt bp is the same every time what you should do first?

let pt show you how they are performing bp

gurgles (rhonci)

low pitched, continuous, bubbling, and heard in larger airways more prominent during expiration wet snoring may be clear with deep breathing or coughing

scar

mark left by the healing of wound or lesion takes place after wound is healed

onset or invasion of fever

mechanisms for increasing body temperature are displayed ~shivering develops ~pale ~feels cold

postural hypotension is reduced form falling by

restore adequate hydration increase consumption of sodium enriched foods supply compression stockings to the lower extremities to reduce the pooling of blood upon standing eating smaller and more frequent meals avoid sitting or standing for prolonged periods of time

what is a pupillary reflux test assessing

same as consensual response shine a light for both pupils to constrict at same time

person turning yellow what would you look at

sclera and mucous membranes

cotton ball against the foot is asking what

sensory skin perception (soft)

Snellen eye chart

tool for assessing far vision

laceration

torn jagged wound

use what kind of thermometer is person is hypothermic

tympanic (infrared)

jaeger chart

visual assessment tool with small print or newsprint with varying sizes of letters, used to test near vision

what conducts warming of the internal organs if a pt has hypothermia

warm fluids

20/30 vision what does this mean

what you see comfortably at 20 feet, can be seen by a person with "normal" vision at 30 feet. Your vision is weaker, in other words.

Wheezes

whistling or squeaking sounds caused by air moving through a narrowed passage can be heard anywhere in chest during inspiration or expiration audible without a stethoscope if wheeze suddenly stops it could mean airway is occluded

resolution phase of fever

~temperature returns to normal ~sweating begins

stationary phase of fever

~the fever is sustained ~flushed skin/warm to touch