Maryville AHA NURS 612 Exam 3

Cranial Nerve 6 and test

Abducens (6): o Motor: lateral eye movement. Assessment: Tested with CN III.

dysphonia

difficulty producing speech sounds, usually due to hoarseness

Cullen sign

ecchymosis around umbilicus -hemoperitoneum, pancreatitis, ectopic pregnancy

Cystic, round, nontender swelling along tendon sheaths or joint capsules that are more prominent with flexion may indicate

ganglia

aphasia

impairment of language, usually caused by left hemisphere damage either to Broca's area (impairing speaking) or to Wernicke's area (impairing understanding).

The examiner observes venous return on the abdomen of the patient that moves upward from the pubis to the chest. This finding should make the examiner consider

inferior vena cava obstruction

Abdominal assessment order

inspection, auscultation, percussion, palpation Always auscultate prior to percussion and palpation as it can change sound.

temporomandibular joint abnormal

o An audible or palpable snapping or clicking in the temporomandibular joints is not unusual, but pain, crepitus ,locking or popping may indicate mandibular joint dysfunction.

How to percuss to estimate the liver span

o First, determine the lower border of the liver by percussing up from an area of tympany along the right midclavicular line. Mark the point where tympany changes to dullness, which usually occurs at or slightly below the costal margin. o Second, determine the upper border of the liver by percussing down from an area of resonance along the right midclavicular line. Mark the point where resonance changes to dullness, which usually is in the fifth intercostal space. o Third, measure the distance between the marks. The vertical liver span usually ranges from 6 to 12 cm.

Obturator sign

pain in the lower abdomen or inside of thigh when the hip is flexed and internally rotated; a sign of appendicitis or abdominal abscess

Pancreatitis S/S

pain localized to the left upper quadrant or may radiate to the back or the epigastric region, nausea, uncontrolled vomiting and retching that can further aggravate the hemorrhage, ecchymosis and swelling of the LUQ, diaphoresis tachycardia, possible hypotension dependent on the size hemorrhage

Mr. Manns is a 48-year-old who presents for the examination of his knee. On examination, you note excessive hyperextension of his knee. This may indicate

weakness in the quadriceps muscle

Cranial Nerve 8 and test

Acoustic (8): Hearing: Whisper, Weber, Rhine o Sensory: hearing and equilibrium. Assessment: Test by performing the whisper test. Also perform the weber and Rhine test to assess bone or air conduction

Cranial Nerve 7 and test

Facial (7): facial movements and taste o Motor: movement of facial expression muscles except jaw, close eyelids, labial speech sounds (b, m, w, and rounded vowels). Sensory: taste—anterior two thirds of tongue, sensation to pharynx. Parasympathetic: secretion of saliva and tears. Assessment: Ask pt to raise eyebrows, squeeze the eyes shut, wrinkle the forehead, frown, smile, show the teeth, purse the lips to whistle. And puff out the cheeks.

Cranial Nerve 9 and test

Glossopharyngeal (9): Swallow & gag o Motor: voluntary muscles for swallowing and phonation (guttural speech sounds). Sensory: sensation of nasopharynx, gag reflex, taste—posterior one third of tongue. Parasympathetic: secretion of salivary glands, carotid reflex. Assessment: Assess the patient's ability to swallow and test the gag reflex. Inspect palate and uvula for symmetry with gag reflex.

Cranial nerve 12 and test

Hypoglossal (12) o Motor: tongue movement for speech sound articulation (l, t, d, n) and swallowing. Assessment: Inspect pt's tongue while at rest on the floor of mouth and while protruded. Have pt move tongue in and out of mouth, side to side, and up towards the nose and down to chin. Have pt push tongue against cheek while you apply resistance.

Cranial Nerve 3 and test

Oculomotor (3): PERELLA & Extraocular movements o Motor: raise eyelids, most extraocular movements. Parasympathetic: pupillary constriction, change lens shape. Assessment: Inspect eyelids for drooping. Inspect pupils' size for equality and their direct and consensual response to light and accommodation. Test extraocular eye movements.

Cranial nerve 1 and test

Olfactory (1): Smell o Sensory: smell reception and interpretation. Assessment: Occlude one naris at a time and have the patient breathe in and out while their eyes are closed. Use a different odor to test the other side.

Cranial Nerve 2 and test

Optic (2): Visual Acuity - distant, near, confrontation (peripheral) o Sensory: visual acuity and visual fields. Assessment: Test distant and near vision. Perform ophthalmoscopic examination of fundi. Test visual fields by confrontation & extinction of vision.

Cranial Nerve 11 and test

Spinal accessory (11): o Motor: turn head, shrug shoulders, some actions for phonation. Assessment: Test trapezius muscle strength (shrug shoulders against resistance). Test sternocleidomastoid muscle strength (turn head to each side against resistance)

Cranial Nerve 5 and test

Trigeminal (5): Jaw movement and facial sensory o Motor: jaw opening and clenching, chewing, and mastication. Sensory: sensation to cornea, iris, lacrimal glands, conjunctiva, eyelids, forehead, nose, nasal and mouth mucosa, teeth, tongue, ear, facial skin. Assessment: Observe the face for muscle atrophy, deviation of the jaw to one side, and fasciculation. Have patient tightly clench teeth and palpate the muscles over the jaw, evaluating tone. With eyes closed, touch each side of the face at the scalp, cheek and chin areas, alternating using sharp and smooth edge of a broke tongue blade. Ask pt to report the sensation. Then use a cotton wisp in the same six areas.

Cranial Nerve 4 and test

Trochlear (4): o Motor: downward, inward eye movement. Assessment: Tested with CN III

Cranial nerve 10 and test

Vagus (10): o Sensory: sensation behind ear and part of external ear canal. Parasympathetic: secretion of digestive enzymes; peristalsis; carotid reflex; involuntary action of heart, lungs, and digestive tract. Assessment: Tested with CN IX

inspection of abdomen

-Abdominal contour -Symmetry -Umbilicus -Skin Color -Vascularity -Scars -Striae -Lesions or rashes -Abdominal movement when breathing -Aortic pulsation -Have patient raise head while laying down and look for masses hernia or muscle separation

Romberg test

-ask client to stand with feet at comfortable distance apart, arms at sides, and eyes closed -expected finding: client should be able to stand with minimal swaying for at least 5 seconds

What degree of knee flexion is considered normal?

130

In which of the following patients would a slight pulsation of the epigastric area be considered a normal finding? A. a very thin patient B. an obese patient C. a patient with ascites D. an older patient

A.

The functional ability of the gastrointestinal tract most severely affected by aging is A. motility B. metabolism c. digestion d. catabolism

A.

Which of the following examination findings is indicative of peritoneal irritation or appendicitis? A. Palpation of rebound tenderness B. Percussion of shifting dullness over the abdomen C. Auscultation of a bruit over the abdominal aorta D. Percussion of dullness over the suprapubic area

A.

Kehr's sign

Abdominal pain radiated to the left shoulder, splenic rupture, renal calculi, ectopic pregnancy

Dance sign

Absence of bowel sounds, RLQ, intussusception, bowel obstruction

Diverticulitis S/S

Acute onset of LLQ pain Nausea and vomiting Low grade fever Chills Tachycardia ESR & WBC increased (sign of infection) Hgb & Hct decreased

Sensory neurologic testing is not usually done with children until they are a. preschool age. b. kindergarten age. c. middle school age. d. high school age.

B

Which questions would be most helpful in understanding a patient complaining of acute back pain? A. What medication do you currently take? B. Was there any activity or injury that occurred before the onset of pain? C. Were you born with any congenital deformities of the spine?D. Have you recently lost weight?

B

A 5-week-old male infant is brought to the clinic for 2-day history of projectile vomiting. For what specific finding should the examiner assess? A. abdominal pain with palpation b. palpation of small round mass c. auscultation of tinkering bowel sounds D. Auscultation of a bruit over renal artery

B.

Which of the following questions would help an examiner determine whether a patient has an intrabdominal infection? A. Where is the pain? B. Would you like something to eat? C. What does your urine look like? D. Is there a history of this problem in your family?

B.

Which rule states that the farther away from the navel abdominal pain occurs, the more likely it is to be of physical importance? A. Reglan law B. Apley rule C. Applegate rule D. Romberg rule

B.

Abdomen Auscultation

Bowel sounds in all four quadrants- note frequency and character listen for friction rubs over liver and spleen listen for bruits over the aortic, renal, illiac and femoral arteries listen for venous hum around epigastric area above the belly button

What spinal finding would be considered normal for a 72-year-old patient? A. Meningocele B. Myelomeningocele C. Kyphosis D. Scoliosis

C

A 32-year-old female patient tells the examiner that when she goes running, she dribbles urine. Which type of problem should be considered? A. Hydronephrosis B. Renal abscess C. Stress incontinence D. Overflow incontinence

C.

A 61-year-old man has a presenting complaint of frequent constipation. He tells you there has been a change in his bowel movement habits - he gets constipated easily, the stool is very "skinny looking", and it is a different color than normal. What do these symptoms suggest? A. Diverticulitis B. Hepatitis B C. Colon or rectal cancer D. Pancreatitis

C.

Abdominal pain radiating to the left shoulder is indicative of which of the following? A. Appendicitis B. Intussusception C. Pancreatitis D. Splenic rupture

C.

Peritoneal irritation is associated with which of the follow? A. Aaron B. Balance C. Blumberg D. Dance

C.

Which of the following techniques is used to confirm presence of abdominal ascites? A. Auscultation of fluid movement in abdomen B. palpation of rebound tenderness c. palpation of pitting edema on the abdomen D. Percussion of dullness over the dependent areas of the abdomen

D.

Jack is a 52-year-old man with a history of poorly controlled diabetes. He also smokes. Based on these data, the examiner should recognize that Jack has several risk factors for

CVA

What would the abnormal findings regarding the range of motion and testing the strength of the joints of the upper extremities indicate for possible differential diagnoses?

Carpal Tunnel Syndrome Ganglion Cysts Osteoarthritis Rheumatoid Arthritis

you note that the midclavicular liver span of an adult male patient is 18 cm. With palpation you note that the liver is enlarged, hard, and nontender. What does this suggest?

Cirrhosis

What data from a patient's history indicates an increased risk of osteomyelitis? A. Severe gout B. RA C. Severe osteoporosis D. Open fracture of the radius

D

Which question may help determine prevention strategies for seizures that a patient has been experiencing? A. Where do your seizures typically begin?" B. "How do you feel after the seizure?" C. "What goes through your mind during a seizure?" D. "Are there any factors or activities that seem to start the seizures?"

D

An absence of bowel sounds in the right lower quadrant is referred to as the ________________ sign. a. Cullen b. Striae c. Ballance d. Dance

D.

In which age group is abdominal palpation easiest and most accurate? A. young children B. adolescents c. young adults D. older adults

D.

The examiner is unable to palpate the liver or kidney on the patient. Which of the following techniques will help assess tenderness to these organs? A. Direct, continuous firm pressure of the organ for several minutes B. Percussion for tympany c. Percussion for size D. Indirect fist percussion

D.

Mrs. Cody is 36 weeks pregnant and states her stomach muscle feels like its splitting. A light protrusion of the abdomen midline is observed. This is recognized as

Diastasis Recti

Cystitis S/S

Dysuria. Frequency. Urgency. Nocturia. Pyuria. Foul odor. Hematuria. Suprapubic discomfort.

Grey Turner's sign

Ecchymosis of the flanks. Possible rupture of the spleen. Hemoperitoneum, pancreatitis, pain may radiate to the left shoulder

Tests for MS system

Examine each major joint for active and passive range of motion. · Normal- . ROM with AROM and PROM maneuvers should be equal between contralateral joints. · Abnormal-discrepancies between active and passive range ROM may indicate true muscle weakness or a joint disorder. No crepitation or tenderness with movement should be apparent. Test muscle strength by applying resistance as the patient moves. Grade muscle strength from 0 (for no movement) to 5 (for full range of motion against gravity and full resistance).

What would be assess as part of ROM during assessment of thoracic and lumbar spine?

Extend, flex, and rotate

Phyleonephritis vs UTI

Fever and costovertebral angle tenderness distinguish pyelonephritis from uncomplicated urinary tract infection

Which statement helps differentiate between osteoarthritis and RA?

I get extremely tired by mid-morning, even when I sleep well.

The patient states, "I sometimes feel like the whole room is spinning." What type of neurological dysfunction should you suspect?

Inner ear dysfunction affecting the acoustic nerve

What is considered a normal finding for a woman in her 8th month of pregnancy?

Lordosis

What test would detect a torn meniscus?

McMurray

When assessing for carpal tunnel syndrome, the Tinel sign can be performed by tapping the

Median Nerve

A hiatal hernia is best described as

Meeting resistance while performing deep palpation

Give a statement and patient repeats - what are you testing?

Memory Immediate recall - ask the pt to listen and then repeat a sentence or a series of numbers. Five to eight numbers forward or four numbers to six numbers backwards can usually be repeated. Recent memory - give the pt a short time to view four or five test objects, telling him or her that you will ask them about in a few minutes. Ten minutes later ask them to list the objects. Remote memory - ask the pt about verifiable past events or information such as siblings name, high school, or subject of common knowledge.

CN not tested unless you find what s/s:

Ordinally taste (CN VII) and smell (CN I) are not routinely tested unless a problem is suspected. Taste is rarely evaluated in the routine neurologic examination. Taste acuity decreases with advanced aging, but the extent of decline varies for the four different tastes—salty, sweet, sour, bitter that are tested. Most individuals who describe a loss of taste sensation actually have a dysfunction of olfactory sensation.

Bouchard's nodes

Osteoarthritis (PIP swelling 2° to osteophytes)

Bony overgrowth in the distal interphalangeal joints, hard, nontender nodules usually 2-3 mm in diameter that sometimes encompass the entire joint is associated with

Osteoarthritis. Ø Heberden nodes - located along the distal interphalangeal joints Ø Buchard's nodes - located along the proximal interphalangeal joints

Palpation of the MS system

Palpate the bones, joints, and surrounding muscles to evaluate muscle tone and detect any heat, tenderness, swelling, joint fluctuation, crepitus, pain, or resistance to pressure. · Normal- no discomfort should occur when you apply pressure to bones and joints. Muscle tone should be firm not hard and doughy. Abnormal- Synovial thickening can sometimes be felt in joints that are close to the skin surface when the synovium is edematous and hypertrophied because of inflammation. Crepitus can be felt when to two irregular bone surfaces rub together or when two rough edges of a broken bone rub together, or with the movement of a tendon inside the tendon sheath.

A history of chest pain is collected as part of an abdominal history because it may be...

Perceived as esophagus and stomach pain

The examiner palpates an organ in the left costal margin. Which technique should be used to differentiate between an enlarged left kidney and an enlarged spleen

Percussion, listening for dullness

The examiner asks the patient to close her eyes and then places a vibrating tuning fork on her ankle and ask her to indicate what is felt. What is being assessed?

Primary sensory function

Rapid hand movement what are you assessing?

Proprioception and cerebellar function. Observe for any involuntary movements such as tremors, tics, or fasciculations.

Deviation of the fingers to the ulnar side and swan neck or boutonniere deformities of the fingers usually indicate

RA

Rovsing's sign

RLQ pain increases with LLQ pressure. Appendicitis, peritoneal irritation

Appendicitis S/S

RLQ pain, low grade fever, nausea, rebound tenderness at McBurney's point.

Blumberg Sign

Rebound tenderness, RLQ, appendicitis, peritoneal irritation

Differential diagnosis for Spine abnormalities

Spinal Stenosis Ø Herniated intervertebral Disk Ø Compression Fracture Spinal Infection

The extension of the patient's head against the examiner's hand is a test of

Sternocleidomastoid muscle strength

Epicondylitis tendonitis

Suspect epicondylitis or tendonitis when a boggy, soft, or fluctuant swelling; point tenderness at the lateral epicondyle or along the grooves of the olecranon process and epicondyles; and increased pain with pronation and supination of the elbow are found

Heberden's nodes

Swelling of distal interphalangeal finger joints, characteristic of osteoarthritis

Markle Sign (heel jar)

Tests for peritoneal irritation, appendicitis, jarring to the body. Stand with straight legs, then stand on your toes, then relax. Positive if this causes pain.

The patient is able to touch each finger to his thumb in rapid sequence. What odes this finding mean?

The patient has appropriate cerebellar function

Field of gaze response (what would pt have based on exam)

When assessing patient's with severe, unremitting headaches, the experienced examiner evaluates movement of the eyes for the presence or absence of lateral (temporal) gaze. The sixth cranial nerve is commonly one of the first to lose function in the presence of increased intracranial pressure.

Phalen test

ask patient to hold both wrists in a fully palmar-flexed position with the dorsal surfaces pressed together for 1 minute. Numbness and paresthesia in the distribution of the median nerve are suggestive of carpal tunnel syndrome

McMurray Test

compression of the meniscus of the knee combined with internal and external rotation while the patient is face-up to assess the integrity of the meniscus

Mr. Davids presents to the office for a follow-up because of RA. When you ask him to explain his fatigue, his response would be

it is severe with the onset 4-5 hours after rising.

diastasis recti

midline longitudinal ridge in the abdomen, a separation of abdominal rectus muscles

McBurney's sign

rebound tenderness to the epigastric area associated with appendicitis

Cholecystitis S/S

severe midepigastric or right upper quadrant pain radiating to back and referred to right scapula usually after meals fat intolerance flatulence indigestion diaphoresis n/v chills low grade fever possible jaundice clay-colored stools with common bile duct obstruction

Tineal sign

tested by striking the patient's wrist with your index or middle finger where the median nerve passes under the flexor retinaculum and volar carpal ligament. A tingling sensation radiating from the wrist to the hand in a distribution of the median nerve is a positive Tineal sign and is suggestive of carpal tunnel syndrome

What are some appropriate HPI questions you would ask a patient with a chief complaint of a musculoskeletal problem?

· Ask about joint stiffiness and decrease range of motion. · The location of the joint pain? · Is there a specific time of day when the pain is worse? · How have you been using to treat the discomfort? · What medications have you used to treat the joint discomfort? Have every had a joint injury?

Normal and abnormal inspection for MS System

· Inspect the skin and subcutaneous tissues over the muscles and joints, noting the skin color and number of skin folds. Normal: Expect to find bilateral symmetry in length, circumference, alignment, and the position and number of skin folds. Abnormal- Observe for any discoloration, swelling, or masses. · Inspect the muscles and compare contralateral sides for size and symmetry. Normal-Muscle size should be approximate symmetry bilaterally, without atrophy or hypertrophy. Abnormal Stay alert for gross hypertrophy or atrophy, fasciculations, and spasms.

Differential diagnosis for hip abnormalities

Ø Osteoarthritis Ø Trochanteric Bursitis Ø Tendonitis

Risk factors for osteoporosis

Ø Race (white, Asian, native American/American Indian); northwestern European descent Ø Light body frame, thin Ø Increasing age Ø Family history of osteoporosis, previous fractures Ø Nulliparous Ø Amenorrhea or menopause before 45 years of age, postmenopausal Ø Sedentary lifestyle, lack of aerobic or weight bearing exercise Ø Constant dieting or inadequate calcium and vitamin d intake. Excessive carbonated soft drinks per day Ø Scoliosis, rheumatoid arthritis, cancer, multiple sclerosis, chronic illness, previous fractures Ø Metabolic disorders (DM, hypercortisolism, malabsorption, hypogonadism, hyperthyroidism) Ø Drugs that decrease bone density (thyroxine, corticosteroids, heparin, lithium, anticonvulsants, antacids with aluminum) Ø Cigarette smoking or heavy alcohol use

HPI questions for chief complaint of abdominal issue

○Abdominal pain-OLDCARTS ○When did the pain start? ○Where is the pain in your stomach? ○Does the pain radiate to other locations? ○Have experience nausea/vomiting, indigestion or increase in belching. ○What medications have you used to treat your symptoms? ○Have you had any diarrhea or constipation? ○Do you have to use laxative frequently? ○What is your regular dietary habits?

Abdominal findings abdomen

○Bruits- A swishing sound heard over the aortic, renal iliac, and femoral arteries, indicating narrowing or aneurysm. ○Pop/Tinkles- High pitch sound suggesting intestinal fluid and air under pressure, as in early obstruction. ○Rushes- Rushes of high-pitched sounds that coincide with cramping suggests intestinal obstruction. ○Borborygmi- Increased prolonged gurgles occur with gastroenteritis, early intestinal obstruction, and hunger. ○Rubs- Grating sounds that vary with respiration. Indicate inflammation of the peritoneal surface of an organ from tumor, infection, or splenic infarct. ○Venous Hum- A soft humming noise often heard in hepatic cirrhosis that is caused by increased collateral circulation between portal and systemic venous system. ○Succussion splash- A splashing noise produced by shaking the body when there is both gas and fluid in a cavity or free air in the peritoneum or thorax. ○Decreased/absent bowel sounds- Occurs with peritonitis or paralytic ileus.

Ballottement technique related to musculoskeletal

◘Used to determine the presence of an effusion on the knee form excess fluid ◘ With knee extended, apply downward pressure on the suprapatellar pouch with the web or the thumb and forefinger of one hand, and then puss the patella quickly downward against the femur with a finger of your other hand. If effusion present, a tapping or clicking sound will be sensed when the patella is pushed against the femur ◘Release the pressure against the patella but keep your finger lightly touching it. If effusion present the patella will float out as if a fluid wave were pushing it.

McMurray Test

◘used to detect a torn meniscus. Have pt lie supine and flex one knee. Position your thumb and fingers on either side of the joint space. Hold the heel with your other hand, fully flexing the knee, and rotate the foot and knee outward to a lateral position. Extend and then flex the patient. ◘Any palpable or audible click, pain, or the limited extension of the knee is a positive sign of a torn medial meniscus. ◘Repeat procedure, rotating the foot and knee inward ◘A palpable or audible click, pain, or lack of extension is a positive sign of a torn lateral meniscus