NURSING

Lakukan tugas rumah & ujian kamu dengan baik sekarang menggunakan Quizwiz!

What are some disadvantages to taking a rectal temperature

Patient is not comfortable Invasive procedure Pt has rectal bleeding

eversion

moving the sole of the foot outward at the ankle

Mr. Duguay is a 68-year-old man who comes to the clinic for a routine health assessment. In the older adult: the peripheral vessels become less rigid. the number of lymph nodes increases. the lymphatic tissue decreases. the intramuscular calf veins shrink.

the lymphatic tissue decreases. In the aging adult the lymphatic tissue decreases. The number of lymph nodes decreases, not increases, in an older adult and the peripheral vessels become more rigid, not less rigid. Aging also produces a progressive enlargement, not shrinkage, of the intramuscular calf veins.

Hirsutism

excess body hair

Mobility

Gait ROM

How to take a tympanic membrane temp

Gently place the covered probe tip in the person's ear canal Not a great one to use if pt is under 6 yrs old

Stroke Volume

amount of blood that is being pumped per beat 70 ml in an adult

esotropia

one or both eyes turn inward

Lesegue's Test spine straight leg raising

reproduce back and leg pain and may confirm presence of herniated disc; straight leg raising while keeping knee extended normally produces no pain, rais just short of point where produces pain and then dorsiflex foot; test positive if produces sciatic pain, confirming presence of herniated disc

_____________takes into consideration the values, preferences, and expressed needs of the patient; how we talk to and treat our patients.

respectful care

Tinea pedis

ringworm of the foot

______ TEST IS INACCURATE AND SHOULD NOT BE USED FOR GENERALIZED SCREENING

TUNING FOR TESTS ( WEBER & RINNE)

Urticaria

(hives). Wheals coalesce to from extensive reaction, intensely pruritic

What is it called when the upper eyelid DOES NOT overlap the superior portion of the iris?

"Lid lag"

Hispanics are _____% are the largest and fastest growing population.

15.1%

Temperature Norm

96.4- 99.1 F or 35.8- 37.3 C

WHICH OF THE FOLLOWING TESTS PROVIDES A PRECISE QUANTITATIVE MEASURE OF HEARING

AUDIOMETER TEST, IT ASSESSES A PERSON'S ABILITY TO HEAR SOUNDS OF VARYING FREQUENCY

Axis

Deep Cervical Lymph Node

Deep under the Sternomastoid Muscle

Mean arterial pressure is The arithmetic average of systolic and diastolic pressures Driving force of blood during systole Diastolic pressure plus one third of the pulse pressure Corresponding to phase III Korotkoff

Diastolic pressure plus one third of the pulse pressure

Propulsion

Difficulty stopping

Variables that can influence skin color:

Emotional: fear, anger, embarrassment Environment: hot, cold, cigarette smoking Physical: prolonged elevation, dependent position, immobilization, prolonged inactivity

External variables influencing skin color

Emotions: fear, anger embarrassment Environment: hot room, chilly room, cigarette smoking Physical: prolonged elevation, dependent position, immobilization, prolonged inactivity

"Normal" eyelid and eyelash findings:

Eyelids should be symmetrical Eyelashes should be intact with an even distribution Upper eyelid should OVERLAP the superior portion of the iris Eyelids should completely close

Centripetal Obesity

Fat concentrated on the face, neck, trunk, with think extremities

Hyperthermia

Fever Cause by pyrogens secreted by bacteria during infection or from tissue breakdown (MI, trauma, surgery or malignancy) Neurological disorders can also reset the thermostat of the brain at a higher level- heat production and conservation

SKIN Anatomy

Hair shaft Horney cell layer Basal cell layer Melanocyte Sebaceous gland Eccrine sweat gland Appocrine sweat gland Blood vessels Nerve Adipose tissue Epidermis Dermis Subcutaneous tissue Connective tissue Arrector pili muscle Hair follicle

Rate

How fast it is going

4 Stages of Pressure Ulcers:

I: red, unbroken skin, does not blanch II: partial thickness skin erosion, loss of dermis / epidermis III: full thickness skin erosion, extends into subcutaneous tissue, resembles crater IV: full thickness skin erosion involving all skin layers, exposes muscle, tendon, bone - eschar or sloughing may be present

BINAURAL INTERACTION AT THE LEVEL OF THE BRAINSTEM PERMITS:

IDENTIFICATION AND LOCATION OF THE DIRECTION OF THE SOUND IN SPACE AS WELL AS IDENTIFYING THE SOUND

Learned?

It is learned across the lifespan. Learned from birth through the process of language acquisition and socialization

Dynamic?

Its always changing

Tripod position

Leaning forward with arms braced. Occurs with chronic pulmonary disease

Bradycardia

Less than 50 BPM Usually occurs in athletes

Hypothermia

Low Body Temp Usually accidental, prolonged exposure to cold.

Systolic

Max pressure felt on artery during left ventricular contraction (systole)

The American Indian/Alaskan Native Heritage have what kind of healers?

Medicine man (shaman)

Submental Lymph Node

Midline behind tip of the mandible

_________an alien who seeks temporary entry into the United States for a specific purpose

Non-immigrant

Respirations

Norm- relaxed, regular, automatic and silent. 12-22 RPM

Of what does the patient believe the amulet is protective? a. the evil eye b. being kidnapped c. exposure to bacterial infections d. an unexpected fall.

Superficial Cervical Lymph Node

Overlying the Sternomastoid Muscle

DARK OVAL AREAS OF THE TYMPANIC MEMBRANE INDICATE

PERFORATION FROM A RUPTURED TYMPANIC MEMBRANE

___________an alien admitted to the United States as a lawful, permanent resident.

Permanent resident alien

Effective care results in .....?

Positive outcomes and satisfaction for the patient

PROFORATION OF THE MEMBRANE

SEEN AS DARK OVAL AREA

Vision tests include:

Snellen eye chart Jaeger card Confrontation test

Force

Strength of hearts stroke volume 3+- Bounding 2+- Normal 1+- Weak, thready 0+- Absent

Cardiac Output

Stroke Volume * Rate Increases BP is more blood is being pumped

five functions fo the musculoskeletal system

Support, Movement, Protect inner organs, Hematopoiesis, reservoir for storage

Cachectic

Symptoms of cachexia (weakness and wasting of the body due to severe chronic illness.)

Pulse Pressure

Systolic- Diastolic= Pulse Pressure reflects stroke volume

Pulse pressure is described as: The difference between the systolic and diastolic pressure A reflection of the viscosity of the blood Another way to express the systolic pressure A measure of vasoconstriction

The difference between the systolic and diastolic pressure

CN XI

The neck muscles are innervated by which CN?

the confrontation test determines:

The patient's peripheral vision capabilities by comparing it to the testers peripheral vision.

Which factor is identified as a priority influence on a patient's health status? a. poverty b. lifestyle factors c. legislative action d. occupational status

Measurements

Weight BMI Height Waist Circumference

Which category is appropriate in a cultural assessment? a. family history b. chief complaint c. past medical history d. health-related beliefs.

Pallor

an unhealthy pale appearance

Elasticity of vessel walls

arteriosclerosis (hardening of arteries)= increased BP to push contents through

Diastolic

elastic, recoil and resting pressure of blood between each contraction

active ROM

person moves body voluntarily

Coarctation of aorta

BP in arm is excessively high, take BP in leg and screen for a narrowing of the aorta (usually BP in thigh is sign. lower)

The population of the U.S. approached about ______million in the summer 2010. About __ in __ people was an immigrant. About 1 in 3 was part of a group other than single-race-non-Hispanic white.

310,000,000/ 1 in 8/1 in 3

VERTEBRAE

33 vertebrae: 7 cervical 12 thoracic 5 lumbar 5 sacral 3 to 4 coccygeal

The median age of the total population in 2007 was _____ and one fourth of these were younger than 18 years.

36.6

The nurse is taking the history of a patient who may have a perforated eardrum. What would be an important question in this situation? 1. "Do you ever notice ringing or crackling in your ears?" 2. "When was the last time you had your hearing checked?" 3. "Have you ever been told you have any type of hearing loss?" 4. "Was there any relationship between the ear pain and the discharge you mentioned?"

Which of the following is a risk factor for ear infections in young children? 1. Family history 2. Air conditioning 3. Excessive cerumen 4. Secondhand cigarette smoke

The ankle joint is the articulation of the tibia, the fibula, and the: A) talus. B) cuboid. C) calcaneus. D) cuneiform bones.

Abnormal characteristics of pigmented lesions are summarized in the mnemonic A-B-C-D-E:

A - asymmetry (not regularly round or oval, two halves of lesion do not look the same) B - border irregularity (notching scalloping, ragged edges, poorly defined margins) C - color variation (areas of brown, tan black, blue, red, white, or combination) D - diameter greater than 6mm (the size of a pencil eraser) E - elevation or enlargement ADDITIONAL: lesion that is rapidly changing, new pigmented lesion, development of itching, burning, bleeding.

more (lymphoid tissue begins to atrophy after puberty)

A child's lymph nodes feel _____ prominent than an adult's until after puberty.

What is ptosis?

A drooping of the upper eyelid

ANS: damage to the trigeminal nerve. Facial sensations of pain or touch are mediated by cranial nerve (CN) V, which is the trigeminal nerve. Bell's palsy is associated with CN VII damage. Frostbite and scleroderma are not associated this problem.

A patient is unable to differentiate between *sharp and dull stimulation to both sides of her face*. The nurse suspects:

The nurse notices that a patient has a solid, elevated, circumscribed lesion that is less than 1 cm in diameter. When documenting this finding, the nurse would report this as a: 1.bulla. 2.wheal. 3.nodule. 4.papule.

ANS: 4 A papule is something one can feel, is solid, elevated, circumscribed, less than 1 cm diameter, and is due to superficial thickening in the epidermis.

39. During an examination of a 3-year-old child, the nurse notices a bruit over the left temporal area. The nurse should: a. Continue the examination because a bruit is a normal finding for this age. b. Check for the bruit again in 1 hour. c. Notify the parents that a bruit has been detected in their child. d. top the examination, and notify the physician.

ANS: A Bruits are common in the skull in children under 4 or 5 years of age and in children with anemia. They are systolic or continuous and are heard over the temporal area.

The nurse is examining a patient's retina with an ophthalmoscope. Which finding is considered normal?

ANS: An optic disc that is a yellow-orange color The optic disc is located on the nasal side of the retina. It is a creamy yellow-orange to pink color, and the edges are distinct and sharply demarcated, not blurred. A pigmented crescent is black, and it is due to the accumulation of pigment in the choroid.

A 65-year-old patient with a history of heart failure comes to the clinic with complaints of "being awakened from sleep with shortness of breath." Which action by the nurse is most appropriate?

ANS: Assess for other signs and symptoms of paroxysmal nocturnal dyspnea. The patient is experiencing paroxysmal nocturnal dyspnea: being awakened from sleep with shortness of breath and the need to be upright to achieve comfort.

Which of these statements is true regarding the arterial system? A) Arteries are large-diameter vessels. B) The arterial system is a high-pressure system. C) The walls of arteries are thinner than those of veins. D) Arteries can expand greatly to accommodate a large blood volume increase

ANS: B The pumping heart makes the arterial system a high-pressure system.

7. A patient's abdomen is bulging and stretched in appearance. The nurse should describe this finding as: A) obese. B) herniated. C) scaphoid. D) protuberant.

ANS: D A protuberant abdomen is rounded, bulging, and stretched. See Figure 21-7. A scaphoid abdomencaves inward

2. Which structure is located in the left lower quadrant of the abdomen? A) Liver B) Duodenum C) Gallbladder D) Sigmoid colon

ANS: D The sigmoid colon is located in the left lower quadrant of the abdomen.

Which of these veins are responsible for most of the venous return in the arm? A) Deep B) Ulnar C) Subclavian D) Superficial

ANS: D The superficial veins of the arms are in the subcutaneous tissue and are responsible for most of the venous return.

The nurse would use bimanual palpation technique in which situation?

ANS: Palpating the kidneys and uterus Bimanual palpation requires the use of both hands to envelop or capture certain body parts or organs such as the kidneys, uterus, or adnexa. The other situations are not appropriate for bimanual palpation.

When considering the biocultural differences in the respiratory systems, the nurse knows that which statement is true?

ANS: The largest chest volumes are found in whites. The largest chest volumes are found, in descending order, in whites, then African-Americans, Asians, and Native Americans. Even when the shorter height of Asians is considered, their chest volume remains significantly lower than that of whites and blacks. A disproportionately large number of tuberculosis cases are reported among blacks, most of whom were born in the United States.

During an assessment, the nurse knows that expected assessment findings in the normal adult lung include the presence of:

ANS: absent voice sounds and hyperresonant percussion tones. Normal lung findings include symmetric chest expansion, resonant percussion tones, vesicular breath sounds over the peripheral lung fields, muffled voice sounds, and no adventitious sounds.

During palpation of the anterior chest wall, the nurse notices a coarse, crackling sensation over the skin surface. On the basis of these findings, the nurse suspects:

ANS: crepitus. Crepitus is a coarse, crackling sensation palpable over the skin surface. It occurs in subcutaneous emphysema when air escapes from the lung and enters the subcutaneous tissue, as after open thoracic injury or surgery.

A patient's vision is recorded as *20/80* in each eye. The nurse interprets this finding to mean that the patient:

ANS: has poor vision. Normal visual acuity is 20/20 in each eye. The larger the denominator, the poorer the vision.

The sac that surrounds and protects the heart is called the: a. Pericardium. b. Myocardium. c. Endocardium. d. Pleural space.

ANS: pericardium. The pericardium is a tough fibrous double-walled sac that surrounds and protects the heart. It has two layers that contain a few milliliters of serous pericardial fluid.

In a patient who has *anisocoria*, the nurse would expect to observe:

ANS: pupils of unequal size Unequal pupil size is termed anisocoria. It exists normally in 5% of the population but may also be indicative of central nervous system disease.

During ocular examinations, the nurse keeps in mind that movement of the *extraocular muscles is*:

ANS: stimulated by cranial nerves III, IV, and VI. Movement of the extraocular muscles is stimulated by three cranial nerves: III, IV, and VI.

During an examination, the patient states he is *hearing a buzzing sound* and says that it is "driving me crazy!" The nurse recognizes that this symptom indicates:

ANS: tinnitus. Tinnitus is a sound that comes from within a person; it can be a ringing, crackling, or buzzing sound. It accompanies some hearing or ear disorders.

Subjective assessment of skin, hair & nails:

ASK THE FOLLOWING: * Past history of skin disease (hives, allergies, psoriasis, eczema) * Change in pigmentation * Change in mole * Excessive dryness or moisture * Pruritus * Excessive bruising * Rash or lesion * Medications * Hair loss * Change in nails * Environmental or occupational hazards * Self-care behaviors * FOR INFANT OR CHILD: ask about birthmarks, changes in skin color, diaper rash

IF A PT. SAYS THEY HAVE TROUBLE HEARING WHEN ASKED THEN DO WHAT

AUDIOMETRIC TESTING, IF THEY SAY NO DO A WHISPERED VOICE TEST.

What aspects of Physical Appearance should you be looking for?

Age, Sex, Level of Consciousness, Skin Color, Facial Features, Overall Appearance

Factors Affecting BP

Age- Older Adults have a higher BP due to arteries hardening Sex Race-BP is higher in Africa Americans and Hispanics Diurnal rhythm Weight Exercise Stress

During the ear examination of an 80-year-old patient, which of the following would be a normal finding? 1. A high-tone frequency loss 2. Increased elasticity of the pinna 3. A thin, translucent membrane 4. A shiny, pink tympanic membrane

functions of the TMJ

1 hinge action to open and close the jaws 2 gliding action forprotrusionn and retraction 3 gliding for a side-to-side movement of the lower jaw

4 point grading scale for pitting edema:

1+ mild 2+ moderate 3+ deep pitting 4+ very deep pitting, very swollen

A 40-year-old man has come into the clinic with complaints of "extreme tenderness in my toes." The nurse notices that his toes are slightly swollen, reddened, and warm to the touch. His complaints would suggest: A) osteoporosis. B) acute gout. C) ankylosing spondylitis. D) degenerative joint disease.

The ability that humans have to perform very skilled movements such as writing is controlled by the: a. Basal ganglia. b. Corticospinal tract. c. Spinothalamic tract. d. Extrapyramidal tract.

The two parts of the nervous system are the: a. Motor and sensory. b. Central and peripheral. c. Peripheral and autonomic. d. Hypothalamus and cerebral.

Elbow

3 bony articulations: humerus, radius & ulna; hinge action moves forearm on one plane allowing extension and flexion

How can you simultaneously test cranial nerves IX and X?

Have the patient say "ahh" and observe as the palate and uvula rise with speaking.

How do you test the function of cranial nerve XII?

Have the patient stick their tongue out. It should be midline and still.

Vertigo

Illusionary sensation of either room or one's own body spinning; not the same as dizziness

Preauricular Lymph Node

In front of the ear

Volume of circulating blood

Increased volume= increased BP

Supraclavicular Lymph Node

Just above and behind the Clavicle, and the Sternomastoid Muscle

Rectal Temperature

Most accurate route and the most invasive 1 degree higher than oral

sternomastoid, trapezius

Name the 2 major muscles of the neck:

The jaeger card is used to test what?

Near vision in patients over the age of 40.

_____________-was created to ensure cultural competence in the U.S. Should ensure that all patients receive from all staff members effective, understandable, and respectful care that is provided in a manner compatible with their cultural health beliefs and practices and preferred language

New National Standards

BP norms

Normal <120/<80 Hypertension 1- >140/>90 Hypertension 2- > 160/ >100 Hypotension- <90/<60 Pre-hypertension- 120-139/ 80-89

To inspect the ocular fundus you use:

Ophthalmoscope

For health restoration, The Iberian, Central, and South American Heritages believes in?

Prayers, promises to saints, herbs Anis and Manzanilla

Define PERRLA

Pupils Equal, Round, Reactive to Light and Accomodating. This means that the pupils are the same size, round, constrict to light and constrict to near vision.

A WHISPERED VOICE TEST DOES NOT TEST

SPEECH COMPREHENSION, PERCEPTION OF LOW- FREQUENCY SOUND, OR ACOUSTIC NERVE FUNCTION

what are three types of muscles

Skeletal, smooth, cardiac

What aspects of Body Structure should you be looking for?

Stature Nutrition Symmerty Posture Position Body/Build/Contour Obvious Physical Abnormalities

The Skin

The body's largest organ system. Acts as the sentry that protects the body from environmental stress and adapts to other environmental influences. THREE LAYERS: Epidermis - the thin, tough outer layer Dermis - the inner supportive layer Subcutaneous - the adipose tissue below the dermis

The major factor contributing to the need for cultural care in nursing is: a. an increasing birth rate b. limited access to health care service c. demographic change d. a decreasing rate of immigration

What is the pupillary light reflex?

The normal constriction of the pupils when bright light shines on the pupil

How does cranial nerve III regulate eye movement?

The oculomotor nerve allows the eye to look up and out, up and in, down and out, and toward the nose.

Which changes regarding height and weight occur during the 80's and 90's? Both increase Both decrease Weight increases, and height decreases Both remain the same as during the 70's

Both decrease

Tachypnea

Breathing more than 24 RPM usually occurs with exercise and anxiety Need to be sating over 95%

The area of the nervous system that is responsible for mediating reflexes is the: a. Medulla. b. Cerebellum. c. Spinal cord. d. Cerebral cortex.

An example of a primary lesion is a(n): A. Erosion B. Ulcer C. Urticaria D. Port-wine stain

C. Urticaria (hives)

An area of thin shiny skin with decreased visibility of normal skin markings is called: A. lichenification B. plaque C. atrophy D. keloid

C. atrophy

MRS. SCOTTS IS A 38-YEAR OLD PT. WHO WAS DIAGNOSED WITH A PERFORATED TYMPANIC MEMBRANE IN THE E.R. HE COMES TO THE CLINIC FOR FOLLOW-UP WHAT TYPE OF HEARING LOSS IS HE AT RISK FOR

CONDUCTIVE

When taking the health history, the pt. c/o pruritus. What is a common cause of this symptom? A. Excessive bruising B. Hyperpigmentation C. Melasma D. Drug reactions

D. Drug reactions

Olecranon process

ELBOW

Late clubbing

Elevated edge of nail, with an angle >180 degrees, because of chronic obstructive pulmonary disease

Lipoma

benign fatty tumor

What is the cause of the red reflex? a) Petechial hemorrhages in the sclera b) Diabetic retinopathy c) Light reflecting from the retina d) Blood in the vitreous

c) Light reflecting from the retina

Hip Landmarks

can feel entire iliac crest from anterior superior iliac spine to posterior; ischial tuberosity lies under butt muscle, palpable when hip flexed "sitting" felt best when person standing in flat depression on upper lateral side of thigh

Deep cervical chain (#8)

found group of cervical lymph nodes found near the internal jugular vein, is non-palpable.

Pediculosis capitis

head lice

spina bifida

incomplete closure of the posterior part of vertebrae rsults in a neural tube defect, usually occurs 4th week in gestation

Allis test

infant test for hip dislocation; flex knees, one is higher than other in dislocation

abduction

movement of a body part away from the body's midline

adduction

movement of a body part toward the midline

rotation

movement of one bone turning on another or moving the head around a central axis

inversion

movement of the ankle inward

eversion

movement of the ankle outward

plantar flexion

movement of the foot downward

pronation

movement of the forearm to place the palm downward

dorsiflexion

movement of the hand or foot upward

Subcultures are?

-religion -ethnicity -occupation -sexual preferences -age -health conditions

osteoporosis

decrease in skeletal bone mass occurring when rate of bone resorption is greater than that of bone formation

A patient states, "I can hear a crunching or grating sound when I kneel." She also states that "it is very difficult to get out of bed in the morning because of stiffness and pain in my joints." The nurse should assess for signs of what problem? A) Crepitation B) A bone spur C) A loose tendon D) Fluid in the knee joint

The nurse knows that determining whether a person is oriented to his or her surroundings will test the functioning of which structure(s)? a. Cerebrum b. Cerebellum c. CNs d. Medulla oblongata

The nurse should use which test to check for large amounts of fluid around the patella? A) Ballottement B) Tinel sign C) Phalen's test D) McMurray's test

Of the 33 vertebrae in the spinal column, there are: A. 5 lumbar. B. 12 cervical C. 7 sacral. D. 5 thoracic.

A. 5 lumbar.

THE NORMAL PATHWAY OF HEARING IS BY

AIR CONDUCTION

lymphadenopathy

enlargement, more than 1 cm, from infection, allergy, neoplasm

A patient has had a "terrible itch" for several months that he has been scratching continuously. On examination, the nurse might expect to find: 1.a keloid. 2.a fissure. 3.keratosis. 4.lichenification.

ANS: 4 Lichenification results from prolonged, intense scratching that eventually thickens the skin and produces tightly packed sets of papules.

1. The nurse is percussing the seventh right intercostal space at the midclavicular line over the liver. Which sound should the nurse expect to hear? A) Dullness B) Tympany C) Resonance D) Hyperresonance

ANS: A The liver is located in the right upper quadrant and would elicit a dull percussion note

A patient comes in for a physical examination and complains of "freezing to death" while waiting for her examination. The nurse notes that her skin is pale and cool and attributes this finding to: a. Venous pooling. b. Peripheral vasodilation. c. Peripheral vasoconstriction. d. Decreased arterial perfusion.

ANS: C A chilly or air-conditioned environment causes vasoconstriction, which results in false pallor and coolness (see Table 13-1).

The nurse is reviewing the function of the cranial nerves. Which of the cranial nerves is responsible for *conducting nerve impulses to the brain from the organ of Corti*?

ANS: CN VIII The nerve impulses are conducted by the auditory portion of CN VIII to the brain.

The nurse is auscultating the chest in an adult. Which technique is correct?

ANS: Use the diaphragm of the stethoscope held firmly against the chest. The diaphragm of the stethoscope held firmly on the chest is the correct way to auscultate breath sounds. The patient should be instructed to breathe through his or her mouth, a little deeper than usual, but not to hyperventilate.

two parts of the nervous system are the:

ANS: central and peripheral. The nervous system can be divided into two parts—central and peripheral. The central nervous system includes the brain and spinal cord. The peripheral nervous system includes the 12 pairs of cranial nerves, the 31 pairs of spinal nerves, and all their branches.

A 2-week-old infant can fixate on an object but cannot follow a light or bright toy. The nurse would:

ANS: consider this a normal finding. By 2 to 4 weeks an infant can fixate on an object. By the age of 1 month, the infant should fixate and follow a bright light or toy.

The area of the nervous system that is responsible for mediating reflexes is the:

ANS: spinal cord. The spinal cord is the main highway for ascending and descending fiber tracts that connect the brain to the spinal nerves, and it mediates reflexes.

THE EXTERNAL STRUCTURE OF THE EAR IS IDENTIFIED AS THE

AURICLE OR PINNA

How does cranial nerve VI regulate eye movement?

Abducts the eye. (The ABDUCens nerve ABDUCts the eye.)

Pulse Norm

Adults 50-95 BPM

Lichenification is/are: Select all that apply. thickening of the skin. a dry area of decreased pigmentation due to prolonged, intense scratching. tightly packed sets of papules.

All Lichenification is all of the following: a thickened, dry area of decreased pigmentation with a tightly packed sets of papules and is due to prolonged, intense scratching.

For health restoration, the African heritage believes in?

Asafoetida, herbs and roots

Occipital Lymph Node

At the base of the skull

A woman who has had rheumatoid arthritis for years is starting to notice that her fingers are drifting to the side. The nurse knows that this condition is commonly referred to as: A) radial drift. B) ulnar deviation. C) swan neck deformity. D) Dupuytren's contracture.

A 69-year-old patient has been admitted to an adult psychiatric unit because his wife thinks he is getting more and more confused. He laughs when he is found to be forgetful, saying "I'm just getting old!" After the nurse completes a thorough neurologic assessment, which findings would be indicative of Alzheimer disease? Select all that apply. a. Occasionally forgetting names or appointments b. Difficulty performing familiar tasks, such as placing a telephone call c. Misplacing items, such as putting dish soap in the refrigerator d. Sometimes having trouble finding the right word e. Rapid mood swings, from calm to tears, for no apparent reason f. Getting lost in one's own neighborhood

B, C, E, F

Functions of the skin include: A. Production of Vit. C B. Temperature regulation C. The production of new cells by melanocytes D. The secretion of a drying substance called sebum

B. Temperature regulation

When reviewing the muscloskeletal system, the nurse recalls that hematopoiesis takes place in the: A. liver B. bone marrow C. spleen D. kidneys

B. bone marrow

Bradypnea

Breathing less than 10 RPM Need to be sating over 95%

A teenage girl has arrived complaining of pain in her left wrist. She was playing basketball when she fell and landed on her left hand. The nurse examines her hand and would expect a fracture if the girl complains: A) of a dull ache. B) that the pain in her wrist is deep. C) of sharp pain that increases with movement. D) of dull throbbing pain that increases with rest.

The nurse suspects that a patient has carpal tunnel syndrome and wants to perform the Phalen's test. To perform this test, the nurse should instruct the patient to: A) dorsiflex the foot. B) plantarflex the foot. C) hold both hands back to back while flexing the wrists 90 degrees for 60 seconds. D) hyperextend the wrists with the palmar surface of both hands touching and wait for 60 seconds.

While gathering equipment after an injection, a nurse accidentally received a prick from an improperly capped needle. To interpret this sensation, which of these areas must be intact? a. Corticospinal tract, medulla, and basal ganglia b. Pyramidal tract, hypothalamus, and sensory cortex c. Lateral spinothalamic tract, thalamus, and sensory cortex d. Anterior spinothalamic tract, basal ganglia, and sensory cortex

A configuration of individual lesions arranged in circles or arcs, as occurs with ringworm, is described as a: A) Linear lesion B) Clustered lesion C) Annular Lesion D) Gyrate Lesion

C) Annular Lesion

The "A" in the ABCDE rule stands for: A. accuracy B. appearance C. asymmetry D. attenuated

C. asymmetry SKIN SELF EXAMINATION: A - asymmetry B - border C - color D - diameter E - elevation and enlargement

ON OTOSCOPIC EXAMINATION, BOTH OF PT EARS ARE IMPACTED WITH CERUMEN. WHAT DO YOU EXPECT

CONDUCTIVE HEARING LOSS ( IMPACTED CERUM INTERFERES WITH THE PASSAGE OF SOUND WAVES THROUGH THE EXTERNAL AUDITORY CANAL TO THE TYMPANIC MEMBRANE, THUS CAUSING A CONDUCTIVE HEARING LOSS.

A scooped out, shallow depression in the skin is called a(n): A. Ulcer B. Excoriation C. Fissure D. Erosion

D. Erosion

Mr. Jankowski comes to your clinic with his child, who has been studying about the thymus gland in school. She is correct when she tells you the following is/are true about the thymus gland. (Select all that apply.) Select all that apply. Develops T-lymphocytes The gland atrophies after puberty. Is vital to the immune system Develops B-lymphocytes

Develops T-lymphocytes The gland atrophies after puberty Is vital to the immune system It is relatively large in the fetus and young child and atrophies after puberty. It is important in developing the T-lymphocytes of the immune system in children. The B-lymphocytes originate in the bone marrow and mature in the lymphoid tissue.

Each culture has its own healers who usually a. own and operate specialty community clinics. b. cost less than traditional or biomedical providers. c. recommend folk practices that are dangerous. d. speak at least two languages.

TALKING IN A LOUD, NOT HIGH PITCHED VOICE MAY BE INDICITVE OF

HEARING LOSS

ORDER OF EXAM

Inspection, palpation, ROM, muscle testing, TMJ -head to toe exam, makes orderly -always do what hurts the most last

Skin rashes of childhood diseases:

MEASLES (Rubeola): red / purple blotchy rash, coppery, does not blanch GERMAN MEASLES (Rubella): pink, papular rash, paler than measles CHICKEN POX (Varicella): small tight vesicles, become pustules and then crust

Common variations on infant's skin:

MONGOLIAN SPOT: blue--black to purple macular area at sacrum (sometimes: buttocks, thighs, abdomen, shoulders, arms) CAF'E AU LAIT SPOT: large round, oval, patch of light brown pigmentation ERYTHEMA TOXICUM: rash on 3-4 day old newborns. Cheeks, trunk, chest, back, butt CUTIS MARMORATA: transient mottling of skin in trunk & extremities PHYSIOLOGIC JAUNDICE: 1/2 of all newborns, yellowing of skin, sclera, mucous membranes MILIA: tiny white papules or cheeks, nose, forehead, chin, caused by sebum occluding hair follicles

75- YEAR OLD PT. WITH COMPLAINTS OF DIFFICULTY HEARING HIGH TONES, WORDS SOUND GARBLED, CANT TELL WHERE SOUND ARE COMING FROM IS RELATED TO WHAT

PRESBYCUSIS

Dermis layer

collagen. elastic tissue

The European Heritage beliefs in health maintenance are?

Proper nutrition, exercise, cleanliness, and faith in God

TEST THAT ASSESSES THE ABILITY OF THE VESTIBULAR APPARATUS IN THE INNER EAR TO HELP MAINTAIN STANDING BALANCE

ROMBERG TEST

cornea

continuous anteriorly with the sclera, which covers the iris and the pupil. it is part of the refracting media of the eye, bending incoming light rays so they will be focused on the inner retina. this is very sensitive to touch, contact with anything will stimulate a blink in both eyes

scoliosis

curvature of the spine

SPINAL LANDMARKS

Spinous processes of C7 and T1 @ the base of the neck inferior angle of scapula normally @ level of interspace between T7 & T8 Imaginary line connecting highest point on each iliac crest crosses L4 Imaginary line joining 2 symmetric butt dimples overlie posterior suprior iliac spines crosses sacrum

Causes of changes in skin:

TEMPERATURE: hypothermia, hyperthermia MOISTURE: diaphoresis, dehydration TEXTURE: hyperthyroidism, hypothyroidism MOBILITY: edema, scleroderma (hard skin) TURGOR: dehydration or extreme weight loss

Epicondylitis

TENNIS ELBOW chronic disabling pain at the lateral epicondlye of humerous, radiates down extensor surface of forearm

Older Adults

Temp- Greater risk for hypothermia due to changes in temp regulating Weight- Body weight decreases Height- they shrink Pulse- Rhythm may be slightly irregular Resp- Decrease in vital capacity and inspiratory reserve volume BP- increases

How do you test cranial nerve I?

Test for scent identification with each nare separately.

ANS: head and neck, arms, inguinal area, and axillae. Nodes are located throughout the body, but they are accessible to examination only in four areas: head and neck, arms, inguinal region, and axillae.

The nurse is aware that the *four areas in the body where lymph nodes are accessible* are the:

ANS: VII. Facial muscles are mediated by cranial nerve (CN) VII; asymmetry of palpebral fissures may be due to CN VII damage (Bell's palsy).

The nurse notices that a patient's *palpebral fissures* are not symmetrical. On examination, the nurse may find that there has been damage to cranial nerve:

The term culturally competent implies that the nurse a. is prepared in nursing b. possesses knowledge of the traditions of diverse peoples c. applies underlying knowledge to providing nursing care. d. understands the cultural context of the patient's situation.

PERFORM WHAT TEST IF THE PT. IS HEARING IN ONE EAR BETTER THAN THE OTHER

WEBER

ANS: sternomastoid and trapezius. The major neck muscles are the sternomastoid and the trapezius. They are innervated by CN XI, the spinal accessory.

When examining a patient's cranial nerve (CN) function, the nurse remembers that the muscles in the neck that are innervated by CN XI are the:

acculturation

_________________ is the process of adopting the culture and behavior of the majority culture.

fixation

a reglex direction of the eye toward an object attracting a person's attention. the image is fixed int he center of the visual field, the fovea centralis. this consists of very rapid ocular movements to put the target back on the fovea centralis

Subcutaneous layer

aids protection by cushioning. Adipose tissue.

Eczema

atopic dermatitis

Alopecia

baldness - hair loss

flexion

bending a limb at a joint

Flexion

bending limb at the joint "flex your muscles"

flexion

bending of limb at a joint

Anasarca

bilateral edema, or edema that is generalized over the whole body

Acrocyanosis

bluish color around the lips, hands, fingernails, feet, and toenails

Cyanosis

bluish, dusky blue, mottled color to skin or mucous membranes, that signifies decreased perfusion - increased amount of unoxygenated hemoglobin. Dark skinned normally have bluish lips.

Nonsynovial joints

bones united by fibrous tissue or cargilage; immovable sutures in the skull or slightly movable vertebrae

A patient has blurred peripheral vision. You suspect glaucoma and assess the visual fields. A patient with normal vision would see your moving finger temporally at: a) 50 degrees b) 60 degrees c) 90 degrees d) 180 degrees

c) 90 degrees

The 6 eye muscles that control eye movement are innervated by cranial nerves: a) II, III, V b) IV, VI, VII c) III, IV, VI d) II, III, VI

c) III, IV, VI

Wrong cuff size

Too small or too large- higher BP due to extra pressure to compress artery

Shared?

Typically shared by members of the same cultural group

Jugulodigastric Lymph Node

Under the angle of the mandilbe

An 18 month old child is brought into the clinic for a health screening visit. To assess the height of the child: Use a tape measure Use a horizontal measuring board Have the child stand on the upright scale Measure arm span to estimate height

Use a horizontal measuring board

Why is it important to match the appropriate size of blood pressure cuff to the person's arm and shape and not to the person's age Using a cuff that is too narrow will give a false reading that is high Using a cuff that is too wide will give a false reading that is low Using a cuff that is too narrow will give a false reading that is low Using a cuff that is too wide will give a false reading that it is high

Using a cuff that is too narrow will give a false reading that is high

THE _____ TEST IS NONQUANTITAIVE, THIS TEST DOCUMENTS THE PRESNECE OF HEARING LOSS BUT DOES NOT MEASURE THE DEGREE OF LOSS.

WHISPERED VOICE TEST

Which culture would describe illness as hot and cold imbalance? a. Asian-American heritage b. African-American heritage c. Hispanic-American heritage d. American Indian heritage

While evaluating the health history, the nurse determines that the patient subscribes to the hot/cold theory of health. Which of the following would most likely describe this patient's view of wellness? a. The phlegm will be replaced with dryness. b. The humors must be balanced. c. Good is hot. d. Evil is hot.

race

____________, a means of self-identification, refers to a group of people who share similar physical characteristics.

linguistic competence

_______________ ______________ ensures that non-native English speaking patients receive care in a manner in which they linguistically understand.

Visual acuity is assessed with: a) Snellen eye chart b) Ophthalmoscope c) Hirschberg test d) Confrontation test

a) Snellen eye chart

Pallor

absence of red-pink tones from the oxygenated hemoglobin in blood, excessively pale, whitish pink color to lightly pigmented skin

cachectic appearance

accompanies chronic wasting with cancer, starvation, dehydration

KYPHOSIS

aging adults "hump back"

Torn rotator cuff

characteristic HUNCHED position and limited abduction of arm

ORTOLANIS SIGN FOR INFANTS

check hips for congenital dislocation; most reliable; done at every visit until infant is 1 yr old; click can mean displasia; rotate while the infant is laying

One of the causes of visual impairment in aging adults includes: a) Strabismus b) Glaucoma c) Amblyopia d) Retinoblastoma

b) Glaucoma

ligaments

fibrous band running from one bone to another that strengthen the joint and prevent movent in undesirable directions

frozen shoulder adhesive capsulitis

fibrous tissues from joint capsule limit ROM - gradual onset, associated with prolongedbed restt or shoulder immobility

congenital dislocated hip

head of the femur is displaced out of the cup shaped acetabulum

BMI

healthy BMI is 19-25 BMI= (weight (lbs)/ height (in)^2)* 703

Keloid

hypertrophic scar, elevated beyond site of original injury

Epidermal appendages

include hair, sebaceous (oil) glands, sweat glands, and nails

What 4 things is culture?

learned, shared, adapted, dynamic

Circumduction

move arm in circle around shoulder

joints

place of union between 2 or more bone, permit mobility

passive ROM

practitioner moves pt's body part

LORDOSIS

pregnant women, "swayback"

Phalen test

pt holds hands back to back while flexing wrists at 90 degrees for 60 secondsnormall: no pain abnormal: numbness and burning in carpal tunnel syndrome

Purpura

red-purple skin lesion due to blood in tissues from breaks in blood vessels

functional assessment A.D.L.s

screens for the safety of independent living, the need for home health services, and the quality of life ex: bathing, toileting, dressing, grooming, eating, mobility, communicating

Excoriation

self-inflicted abrasion on skin due to scratching

contracture

shortening of a muscle leading to limited ROM of a joint

Plaque

skin lesion in which papules coalesce or come together

ankylosis

stiffening or fixation of a joint

Iris

target shape of skin lesion

joint pain and loss of function

the most common musculoskeletal concerns that prompt a person to seek care

red reflex

the red glow filling the person's pupil which is caused by the reflection of your ophthalmoscope light iff the inner retina. use the red lenses for nearsighted eyes and the black for farsighted eyes.

Cranial Nerve IV

the trochlear nerve which innervates the superior oblique muscle

Erythema toxicum

tiny, punctate red macules and papules on the cheeks, trunk, chest, back, and buttocks

Bulge Sign (knee/fluid test)

to test if swelling is fluid or tissue; confirms presence of fluid as you try to move fluid from one side of joint to the other

retinal vessels

vessels of the retina which normally include a paired artery and extend to each quadrant, growing progressively smaller in caliber as they reach the periphery

Hair-line linear markings:

white linear markings that normally are visible through the and on the pink nail bed.

Peau d'orange

with edema, hair follicles are more prominent, giving a pigskin or orange-peel look

When listening to heart sounds, the nurse knows that S1: a. Is louder than the S2 at the base of the heart. b. Indicates the beginning of diastole. c. Coincides with the carotid artery pulse. d. Is caused by the closure of the semilunar valves.

ANS: coincides with the carotid artery pulse. S1 coincides with the carotid artery pulse. S1 is the start of systole and is louder than S2 at the apex of the heart; S2 is louder than S1 at the base. The nurse should feel the carotid artery pulse gently while auscultating at the apex; the sound heard as each pulse is felt is S1.

A patient with a middle ear infection asks the nurse, "What does the *middle ear* do?" The nurse responds by telling the patient that the middle ear functions to:

ANS: conduct vibrations of sounds to the inner ear. Among its other functions, the middle ear conducts sound vibrations from the outer ear to the central hearing apparatus in the inner ear. The other responses are not functions of the middle ear.

When performing a peripheral vascular assessment on a patient, the nurse is unable to palpate the ulnar pulses. The patient's skin is warm and capillary refill time is normal. The nurse should next: a. Check for the presence of claudication. b. Refer the individual for further evaluation. c. Consider this finding as normal, and proceed with the peripheral vascular evaluation. d. Ask the patient if he or she has experienced any unusual cramping or tingling in the arm.

ANS: consider this a normal finding and proceed with the peripheral vascular evaluation. It is not usually necessary to palpate the ulnar pulses. The ulnar pulses are often not palpable in the normal person. The other responses are not correct.

When percussing over the liver of a patient, the nurse notices a dull sound. The nurse should:

ANS: consider this a normal finding. Percussion over relatively dense organs, such as the liver or spleen, will produce a dull sound. The other responses are not correct.

When performing the corneal light reflex assessment, the nurse notes that the light is reflected at 2 o'clock in each eye. The nurse should:

ANS: consider this a normal finding. Reflection of the light on the corneas should be in exactly the same spot on each eye, or symmetric. If asymmetry is noted, then the nurse should administer the cover test.

The nurse is assessing a patient's skin during an office visit. What is the best technique to use to best assess the patient's skin temperature? Use the:

ANS: dorsal surface of the hand because the skin is thinner than on the palms. The dorsa (backs) of hands and fingers are best for determining temperature because the skin there is thinner than on the palms. Fingertips are best for fine, tactile discrimination; the other responses are not useful for palpation.

During a physical education class, a student is hit in the eye with the end of a baseball bat. When examined in the emergency department, the nurse notices the presence of *blood in the anterior chamber of the eye*. This finding indicates the presence of:

ANS: hyphema. Hyphema is the term for *blood in anterior chamber is a serious result of blunt trauma* (a fist or a baseball) or spontaneous hemorrhage and may indicate scleral rupture or major intraocular trauma. See Table 14-7 for descriptions of the other terms.

During percussion, the nurse knows that a dull percussion note elicited over a lung lobe most likely results from:

ANS: increased density of lung tissue. A dull percussion note indicates an abnormal density in the lungs, as with pneumonia, pleural effusion, atelectasis, or tumor. Resonance is the expected finding in normal lung tissue.

An ophthalmic examination reveals *papilledema*. The nurse is aware that this finding indicates:

ANS: increased intracranial pressure. Papilledema, or choked disk, is a serious sign of increased intracranial pressure, which is caused by a space-occupying mass such as a brain tumor or hematoma. This pressure causes venous stasis in the globe, showing redness, congestion, and elevation of the optic disc, blurred margins, hemorrhages, and absent venous pulsations. Papilledema is not associated with the conditions in the other responses.

The nurse is performing a cardiac assessment on a 65-year-old patient 3 days after her myocardial infarction. Heart sounds are normal when she is supine, but when she is sitting and leaning forward, the nurse hears a high-pitched, scratchy sound with the diaphragm of the stethoscope at the apex. It disappears on inspiration. The nurse suspects: a. Increased cardiac output. b. Another MI. c. Inflammation of the precordium. d. Ventricular hypertrophy resulting from muscle damage.

ANS: inflammation of the precordium. Inflammation of the precordium gives rise to a friction rub. The sound is high pitched and scratchy, like sandpaper being rubbed. It is best heard with the diaphragm of the stethoscope, with the person sitting up and leaning forward, and with the breath held in expiration. A friction rub can be heard any place on the precordium but usually is best heard at the apex and left lower sternal border, which are places where the pericardium comes in close contact with the chest wall.

When performing a physical assessment, the technique the nurse will always use first is:

ANS: inspection. The skills requisite for the physical examination are inspection, palpation, percussion, and auscultation. The skills are performed one at a time and in this order (with the exception of the abdominal assessment, where auscultation takes place before palpation and percussion). The assessment of each body system begins with inspection. A focused inspection takes time and yields a surprising amount of information.

The nurse knows that normal splitting of the second heart sound is associated with: a. Expiration. b. Inspiration. c. Exercise state. d. Low resting heart rate.

ANS: inspiration. Normal or physiologic splitting of the second heart sound is associated with inspiration because of the increased blood return to the right side of the heart, delaying closure of the pulmonic valve.

A 31-year-old patient tells the nurse that he has noticed *pain in his left ear when people speak loudly to him*. The nurse knows that this finding:

ANS: is a characteristic of recruitment. Recruitment is a marked loss occurring when speech is at low intensity, but sound actually becomes painful when the speaker repeats at a louder volume. The other responses are not correct

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? "Tactile fremitus:

ANS: is caused by sounds generated from the larynx." Fremitus is a palpable vibration. Sounds generated from the larynx are transmitted through patent bronchi and the lung parenchyma to the chest wall where they are felt as vibrations. Crepitus is the term for air in the subcutaneous tissues.

When examining the eye, the nurse notices that the patient's *eyelid margins approximate completely*. The nurse recognizes that this assessment finding:

ANS: is expected. The palpebral fissure is the elliptical open space between the eyelids, and, when closed, the lid margins approximate completely, which is a normal finding.

ANS: know that these are scars caused from frequent ear infections. Dense white patches on the tympanic membrane are sequelae of repeated ear infections. They do not necessarily affect hearing.

A patient has hard, nonpitting edema of the left lower leg and ankle. The right leg has no edema. Based on these findings, the nurse recalls that: a. Nonpitting, hard edema occurs with lymphatic obstruction. b. Alterations in arterial function will cause edema. c. Phlebitis of a superficial vein will cause bilateral edema. d. Long-standing arterial obstruction will cause pitting edema.

ANS: nonpitting, hard edema occurs with lymphatic obstruction Unilateral edema occurs with occlusion of a deep vein and with unilateral lymphatic obstruction. With these factors, the edema is nonpitting and feels hard to the touch (brawny edema).

The nurse is assessing the apical pulse of a 3-month-old infant and finds that the heart rate is 135 beats per minute. The nurse interprets this result as: a. Normal for this age. b. Lower than expected. c. Higher than expected, probably as a result of crying. d. Higher than expected, reflecting persistent tachycardia.

ANS: normal for this age. The heart rate may range from 100 to 180 beats per minute immediately after birth and then stabilize to an average of 120 to 140 beats per minute. Infants normally have wide fluctuations with activity, from 170 beats per minute or more with crying or being active to 70 to 90 beats per minute with sleeping. Persistent tachycardia is greater than 200 beats per minute in newborns or greater than 150 beats per minute in infants.

When examining the ear with an otoscope, the nurse notes that the *tympanic membrane* should appear:

ANS: pearly gray and slightly concave. The tympanic membrane is a translucent membrane with a pearly gray color and a prominent cone of light in the anteroinferior quadrant, which is the reflection of the otoscope light. The tympanic membrane is oval and slightly concave, pulled in at its center by the malleus, which is one of the middle ear ossicles.

When examining the ear with an otoscope, the nurse notes that the *tympanic membrane* should appear:

ANS: pearly gray and slightly concave. **IT IS THE EARDRUM The tympanic membrane is a translucent membrane with a pearly gray color and a prominent cone of light in the anteroinferior quadrant, which is the reflection of the otoscope light. The tympanic membrane is oval and slightly concave, pulled in at its center by the malleus, which is one of the middle ear ossicles.

The nurse is reviewing percussion techniques with a newly graduated nurse. Which technique, if used by the new nurse, indicates that more review is needed? The nurse:

ANS: percusses once over each area. For percussion, the nurse should percuss two times over each location. The striking finger should be lifted off quickly because a resting finger damps off vibrations. The tip of the striking finger should make contact, not the pad of the finger. The wrist must be relaxed, and it is used to make the strikes, not the arm.

In performing an examination of a 3 year old with a suspected ear infection, the nurse would:

ANS: perform the otoscopic examination at the end of the assessment In addition to its place in the complete examination, eardrum assessment is mandatory for any infant or child requiring care for illness or fever. For the infant or young child, the timing of the otoscopic examination is best toward the end of the complete examination.

A patient comes to the clinic complaining of a cough that is worse at night but not as bad during the day. The nurse recognizes that this may indicate:

ANS: postnasal drip or sinusitis. A cough that occurs mainly at night may indicate postnasal drip or sinusitis. Exposure to irritants at work causes an afternoon or evening cough. Smokers experience early morning coughing. Coughing associated with acute illnesses such as pneumonia is continuous throughout the day.

Seborrheic dermatitis

"cradle cap"

When examining a 16-year-old male teenager, the nurse should:

ANS: provide feedback that his body is developing normally and discuss the wide variation among teenagers on the rate of growth and development. During the examination, the adolescent needs feedback that his or her body is healthy and developing normally. The adolescent has a keen awareness of body image and often compares himself or herself to peers. Apprise the adolescent of the wide variation among teenagers on the rate of growth and development.

A patient comes to the emergency department after a boxing match, and his left eye is swollen almost shut. He has bruises on his face and neck. He says he is worried because he "can't see well" from his left eye. The physician suspects retinal damage. The nurse recognizes that signs of retinal detachment include:

ANS: shadow or diminished vision in one quadrant or one half of the visual field. With retinal detachment, the person has shadows or diminished vision in one quadrant or one half of the visual field. The other responses are not signs of retinal detachment.

The component of the conduction system referred to as the pacemaker of the heart is the: a. Atrioventricular (AV) node. b. Sinoatrial (SA) node. c. Bundle of His. d. Bundle branches.

ANS: sinoatrial (SA) node. Specialized cells in the SA node near the superior vena cava initiate an electrical impulse. Because the SA node has an intrinsic rhythm, it is the "pacemaker."

During an examination of the anterior thorax, the nurse keeps in mind that the trachea bifurcates anteriorly at the:

ANS: sternal angle. The sternal angle marks the site of tracheal bifurcation into the right and left main bronchi; it corresponds with the upper border of the atria of the heart, and it lies above the fourth thoracic vertebra on the back.

While discussing the history of a 6-month-old infant, the mother tells the nurse that she took a great deal of aspirin while she was pregnant. What question would the nurse want to include in the history? 1. "Does your baby seem to startle with loud noise?" 2. "Has the baby had any surgeries on the ears?" 3. "Have you noticed any drainage from her ears?" 4. "How many ear infections has your baby had since birth?"

While performing the otoscopic exam of a 3-year-old boy who has been pulling on his left ear, the nurse finds that his left tympanic membrane is bright red and the light reflex is not visible. The most likely cause is: 1. fungal infection. 2. acute otitis media. 3. rupture of the drum. 4. blood behind the drum.

Which of the following cranial nerves is responsible for conducting nerve impulses to the brain from the organ of Corti? 1. CN I 2. CN III 3. CN VIII 4. CN XI

ANS: at the level of the C7 vertebra. The C7 vertebra has a long spinous process, called the vertebra prominens, that is palpable when the head is flexed.

A physician tells the nurse that a patient's *vertebra prominens* is tender and asks the nurse to reevaluate the area in 1 hour. The area of the body the nurse will assess is the area:

The most important step that the nurse can take to prevent transmission of microorganisms in the hospital setting is to:

ANS: wash hands before and after contact with each patient. The most important step to decrease the risk of microorganism transmission is to wash hands promptly and thoroughly before and after physical contact with each patient. Stethoscopes should also be cleansed with an alcohol swab before and after each patient contact. The best routine is to combine stethoscope rubbing with hand hygiene each time hand hygiene is performed.

To assess for early jaundice, you will assess: A. sclera and hard palate B. nail beds C. lips D. all visible skin surfaces

A. sclera and hard palate

The nurse is describing a weak, thready pulse on the documentation flow sheet. Which statement is correct? a. "Is easily palpable; pounds under the fingertips." b. "Has greater than normal force, then suddenly collapses." c. "Is hard to palpate, may fade in and out, and is easily obliterated by pressure." d. "Rhythm is regular, but force varies with alternating beats of large and small amplitude."

ANS: "Hard to palpate, may fade in and out, easily obliterated by pressure." A weak, thready pulse is hard to palpate, may fade in and out, and is easily obliterated by pressure. It is associated with decreased cardiac output and peripheral arterial disease.

The nurse is taking the history of a patient who may have a *perforated eardrum*. What would be an important question in this situation?

ANS: "Was there any relationship between the ear pain and the discharge you mentioned?" Typically with perforation, ear pain occurs first, stopping with a popping sensation, and then drainage occurs

During an examination, the nurse finds that a patient has excess dryness of the skin. The best term to describe this condition is: 1.xerosis. 2.pruritus. 3.scoliosis. 4.seborritus.

ANS: 1 Xerosis is the term used to describe skin that is excessively dry.

A patient has been shown to have a sensorineural hearing loss. During the assessment, it would be important for the nurse to: 1. speak loudly so he can hear the questions. 2. assess for middle ear infection as a possible cause. 3. ask the patient what medications he is currently taking. 4. look for the source of the obstruction in the external ear.

ANS: 3 A simple increase in amplitude may not enable the person to understand words. Sensorineural hearing loss may be caused by presbycusis, a gradual nerve degenera- tion that occurs with aging and by ototoxic drugs, which affect the hair cells in the cochlea.

During an assessment of a 20-year-old Asian patient, the nurse notices that he has dry, flaky cerumen in his canal. What is the significance of this finding? 1. This is probably the result of lesions from eczema in his ear. 2. This represents poor hygiene. 3. This is a normal finding and no further follow-up is necessary. 4. This could be indicative of change in cilia; the nurse should assess for conductive hearing loss.

ANS: 3 Asians and American Indians are more likely to have dry cerumen, whereas blacks and whites usually have wet cerumen.

A 32-year-old female patient complains that she has noticed several small, slightly raised, bright red dots on her chest. On examination, the nurse expects that the spots are probably: 1.anascara. 2.scleroderma. 3.senile angiomas. 4.latent myeloma.

ANS: 3 Cherry (senile) angiomas are small, punctate, slightly raised bright red dots that commonly appear on the trunk in all adults over 30 years old.

The nurse is examining a patient's ears and notices cerumen in the external canal. Which of the following statements about cerumen is correct? 1. Sticky honey-colored cerumen is a sign of infection. 2. The presence of cerumen is indicative of poor hygiene. 3. The purpose of cerumen is to protect and lubricate the ear. 4. Cerumen is necessary for transmitting sound through the auditory canal.

ANS: 3 The ear is lined with glands that secrete cerumen, a yellow waxy material that lubricates and protects the ear.

ANS: 4 Typically with perforation, ear pain occurs first, stopping with a popping sensation, and then drainage occurs.

7. When examining a patients CN function, the nurse remembers that the muscles in the neck that are innervated by CN XI are the: a. Sternomastoid and trapezius. b. Spinal accessory and omohyoid. c. Trapezius and sternomandibular. d. Sternomandibular and spinal accessory.

ANS: A The major neck muscles are the sternomastoid and the trapezius. They are innervated by CN XI, the spinal accessory.

When examining an infant, the nurse should examine which area first?

ANS: Abdomen Perform the least distressing steps first. Save the invasive steps of examination of the eye, ear, nose, and throat until last.

28. A patient is suspected of having inflammation of the gallbladder, or cholecystitis. The nurse should conduct which of these techniques to assess for this condition? A) Obturator test B) Test for Murphy's sign C) Assess for rebound tenderness D) Iliopsoas muscle test

ANS: B Normally, palpating the liver causes no pain. In a person with inflammation of the gallbladder, orcholecystitis, pain occurs as the descending liver pushes the inflamed gallbladder onto the examining hand during inspiration (Murphy's test). The person feels sharp pain and abruptly stops inspiration midway.

The nurse has discovered decreased skin turgor in a patient and knows that this finding is expected in which condition? a. Severe obesity b. Childhood growth spurts c. Severe dehydration d. Connective tissue disorders such as scleroderma

ANS: C Decreased skin turgor is associated with severe dehydration or extreme weight loss.

10. The nurse notices that a patients submental lymph nodes are enlarged. In an effort to identify the cause of the node enlargement, the nurse would assess the patients: a. Infraclavicular area. b. Supraclavicular area. c. Area distal to the enlarged node. d. Area proximal to the enlarged node.

ANS: D When nodes are abnormal, the nurse should check the area into which they drain for the source of the problem. The area proximal (upstream) to the location of the abnormal node should be explored.

28. The nurse is assessing a patient with a history of intravenous drug abuse. In assessing his mouth, the nurse notices a dark red confluent macule on the hard palate. This could be an early sign of what disease or disorder? a. Measles b. Leukemia c. A carcinoma d. Acquired immunodeficiency syndrome (AIDS)

ANS: D This dark red confluent macule on the hard palate is an oral Kaposi's sarcoma. An oral Kaposi's sarcoma is a bruiselike, dark red or violet, confluent macule that usually occurs on the hard palate but may also appear on the soft palate or gingival margin. Oral lesions such as a Kaposi's sarcoma are among the earliest lesions to develop with AIDS.

The nurse is preparing to assess the ankle-brachial index (ABI) of a patient. Which statement about the ABI is true? A) Normal ABI indices are from 0.50 to 1.0. B) The normal ankle pressure is slightly lower than the brachial pressure. C) The ABI is a reliable measurement of peripheral vascular disease in diabetic individuals. D) An ABI of 0.90 to 0.70 indicates the presence of peripheral vascular disease and mild claudication.

ANS: D Use of the Doppler stethoscope is a noninvasive way to determine the extent of peripheral vascular disease. The normal ankle pressure is slightly greater than or equal to the brachial pressure. An ABI of 0.90 to 0.70 indicates the presence of peripheral vascular disease and mild claudication. The ABI is less reliable in patients with diabetes mellitus because of claudication, which makes the arteries noncompressible and may give a falsely high ankle pressure.

A patient's vision is recorded as 20/80 in each eye. The nurse interprets this finding to mean that the patient:

ANS: Has poor vision. Normal visual acuity is 20/20 in each eye. The larger the denominator, the poorer the vision.

The nurse is conducting a child safety class for new mothers. Which of these is a risk factor for *ear infections in young children*?

ANS: Passive cigarette smoke Exposure to passive and gestational smoke is a risk factor for ear infections in infants and children.

The nurse is preparing to assess a patient's abdomen by palpation. How should the nurse proceed?

ANS: Start with light palpation to detect surface characteristics and to accustom the patient to being touched. Light palpation is performed initially to detect any surface characteristics and to accustom the person to being touched. Tender areas should be palpated last, not first.

The nurse is preparing to perform an otoscopic examination of a newborn infant. Which statement is true regarding this examination?

ANS: The normal membrane may appear thick and opaque. During the first few days, the tympanic membrane often looks thickened and opaque. It may look "injected" and have a mild redness from increased vascularity. The other statements are not correct.

The nurse is teaching a class on basic assessment skills. Which of these statements is true regarding the stethoscope and its use?

ANS: The stethoscope does not magnify sound but does block out extraneous room noise. The stethoscope does not magnify sound but does block out extraneous room sounds. The slope of the earpieces should point forward toward the examiner's nose. Longer tubing will distort sound. The fit and quality of the stethoscope are important.

Which of these statements describes the closure of the valves in a normal cardiac cycle? a. The aortic valve closes slightly before the tricuspid valve. b. The pulmonic valve closes slightly before the aortic valve. c. The tricuspid valve closes slightly later than the mitral valve. d. Both the tricuspid and pulmonic valves close at the same time.

ANS: The tricuspid valve closes slightly later than the mitral valve. Events occur just slightly later in the right side of the heart because of the route of myocardial depolarization. As a result, two distinct components to each of the heart sounds exist, and sometimes they can be heard separately. In the first heart sound, the mitral component (M1) closes just before the tricuspid component (T1).

While auscultating heart sounds on a 7-year-old child for a routine physical, the nurse hears an S3, a soft murmur at left midsternal border, and a venous hum when the child is standing. Which of these would be a correct interpretation of these findings? a. S3 is indicative of heart disease in children. b. These findings can all be normal in a child. c. These findings are indicative of congenital problems. d. The venous hum most likely indicates an aneurysm.

ANS: These can all be normal findings in a child. Physiologic S3 is common in children. A venous hum, caused by turbulence of blood flow in the jugular venous system, is common in healthy children and has no pathologic significance. Heart murmurs that are innocent (or functional) in origin are very common through childhood.

During an assessment of an adult, the nurse has noted unequal chest expansion and recognizes that this occurs in which situation?

ANS: When part of the lung is obstructed or collapsed Unequal chest expansion occurs when part of the lung is obstructed or collapsed, as with pneumonia, or when guarding to avoid postoperative incisional pain or atelectasis.

While performing the otoscopic examination of a 3-year-old boy who has been pulling on his left ear, the nurse finds that his left tympanic membrane is bright red and that the light reflex is not visible. The nurse interprets these findings to indicate:

ANS: acute otitis media. Absent or distorted light reflex and a bright red color of the eardrum are indicative of acute otitis media. See Table 15-5 for descriptions of the other conditions.

A 70-year-old patient with a history of hypertension has a blood pressure of 180/100 mm Hg and a heart rate of 90 beats per minute. The nurse hears an extra heart sound at the apex immediately before S1. The sound is heard only with the bell while the patient is in the left lateral position. With these findings and the patient's history, the nurse knows that this extra heart sound is most likely a(n): a. Split S1. b. Atrial gallop. c. Diastolic murmur. d. Summation sound.

ANS: atrial gallop. A pathologic S4 is termed an atrial gallop or an S4 gallop. It occurs with decreased compliance of the ventricle and with systolic overload (afterload), including outflow obstruction to the ventricle (aortic stenosis) and systemic hypertension. A left-sided S4 occurs with these conditions. It is heard best at the apex with the patient in the left lateral position.

When assessing a patient's pain, the nurse knows that an example of visceral pain would be:

ANS: cholecystitis. Visceral pain originates from the larger interior organs, such as the gallbladder, liver, or kidneys.

The nurse notes hyperresonant percussion tones when percussing the thorax of an infant.

ANS: consider this a normal finding. The percussion note of hyperresonance occurs normally in the infant and young child, owing to the relatively thin chest wall. Anything less than hyperresonance would have the same clinical significance as would dullness in the adult.

A 2-week-old infant can fixate on an object but cannot follow a light or bright toy. The nurse would:

ANS: consider this a normal finding. By 2 to 4 weeks an infant can fixate on an object. By the age of 1 month, the infant should fixate and follow a bright light or toy.

During an examination, the nurse notices that the patient stumbles a bit while walking, and, when she sits down, she holds on to the sides of the chair. The patient states, "It feels like the room is spinning!" The nurse notices that the patient is experiencing:

ANS: objective vertigo. With objective vertigo, the patient feels like the room spins; with subjective vertigo, the person feels like he or she is spinning. Tinnitus is a sound that comes from within a person; it can be a ringing, crackling, or buzzing sound. It accompanies some hearing or ear disorders. Dizziness is not the same as true vertigo; the person who is dizzy may feel unsteady and lightheaded

A patient has been diagnosed with osteoporosis and asks the nurse, "What is osteoporosis?" The nurse explains to the patient that osteoporosis is defined as: A. increased bone matrix B. Loss of bone density C. New, weaker bone growth D. Increased phagocytic

A patient is able to flex his right arm forward without difficulty or pain but is unable to abduct his arm because of pain and muscle spasms; the nurse should suspect: A) crepitation. B) rotator cuff lesions. C) dislocated shoulder. D) rheumatoid arthritis.

An 85-year-old patient comments during his annual physical that he seems to be getting shorter as he ages. The nurse should explain that decreased height occurs with aging because: A. Long bones tend to shorten with age B. The vertebral column C. Significant loss of subcutaneous fat occurs D. A thickening of the intervertebral disks develops

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

During an interview the patient states, "I can feel this bump on the top of both of my shoulders—it doesn't hurt but I am curious about what it might be." The nurse should tell the patient, "That is: A) your subacromial bursa." B) your acromion process." C) your glenohumeral joint." D) the greater tubercle of your humerus."

Herpes zoster: A. caused by bacteria B. lesion on only one side of body; does not cross midline C. has absence of pain or edema D. forms pustular, umbilicated lesions

B. "shingles". Is a lesion on only one side of the body - does not cross the midline

The best description of the secretion of the eccrine glands: A. thick, milky B. dilute saline solution C. protective lipid substance D. keratin

B. dilute saline solution

An area of thin shiny skin with decreased visibility of normal skin markings is most likely: A) Lichenification B) Plaque C) Atrophy D) Keloid

C) Atrophy

You examine nail beds for clubbing. The normal angle between the nail base and the nails is: A. 60 degrees B. 100 degrees C. 160 degrees D. 180 degrees

C. 160 degrees

What cranial nerve relates to the nose?

Cranial nerve I, the olfactory nerve. It transmits smell to the temporal lobe of the brain

The nurse has completed the musculoskeletal examination of a patient's knee and has found a positive bulge sign. The nurse interprets this finding to indicate: A) irregular bony margins. B) soft tissue swelling in the joint. C) swelling from fluid in the epicondyle. D) swelling from fluid in the suprapatellar pouch.

Nevus is the medical term for: A. freckle B. a birthmark C. an infected hair follicle D. a mole

D. a mole

ANS: Using gentle pressure, palpate with both hands to compare the two sides. Use gentle pressure because strong pressure could push the nodes into the neck muscles. It is usually most efficient to palpate with both hands, to compare the two sides symmetrically.

During an examination, the nurse knows that the *best way to palpate the lymph nodes* in the neck is described by which statement?

A scooped-out, shallow depression in the skin is called a/an: ulcer. fissure. erosion. excoriation.

Erosion A scooped-out, shallow depression in the skin is called an erosion. An ulcer is a deeper depression extending into the dermis, and it has an irregular shape, may bleed, and leaves scar when it heals (e.g., stasis ulcer, pressure sore, chancre). An excoriation is a self-inflicted abrasion; it is superficial, sometimes crusted, and causes scratching from intense itching. A fissure has a linear crack with abrupt edges, extends into the dermis, and can be dry or moist (e.g., cheilosis at corners of mouth resulting from excess moisture, athlete's foot).

Which of the following symptoms is greatly influenced by a person's cultural heritage? a. food intolerance b. hearing loss c. pain d. breast lump

Ankle/Foot

ankle or tibiotalar joint, hinge joint, limited flexion, allows dorsiflexion or plantar extension in one plane

Axillary nodes drain the: anterior abdominal wall. lower extremities. hand and lower arm. breast and upper arm.

breast and upper arm. Axillary nodes drain the breast and upper arm. The inguinal nodes in the groin drain most of the lymph of the lower extremity, the external genitalia, and the anterior abdominal wall. The epitrochlear node is in the antecubital fossa and drains the hand and the lower arm.

Bulla

elevated cavity containing free fluid larger than 1cm diameter

Vesicle

elevated cavity containing free fluid up to 1 cm diameter

Obesogenic enviroment

environment that promotes weight gain and not conductive to lose it (ex US fast food)

Joints

functional units of musculoskeletal system, permitting mobility needed for ADLs

Rotator cuff

group of 4 muscles and tendons support and stabilize shoulder CAN FEEL BUMP OF SCAPULAS ACROMION PROCESS AT VERY TOP OF SHOULDER

Jaundice

increase in bilirubin in the blood causing a yellow color in the skin, palate, and sclera. Dark skinned have yellow outer sclera.

Linea nigra

increased pigment along the midline of the abdomen - seen with pregnant women.

Pruritus

itching. The most common skin symptom. Occurs with dry skin, aging, drug reactions, allergy, obstructive jaundice, uremia, lice

Elevation

raise body part

straight leg raising/lasegue test

raise leg then dorsiflex POSITIVE test produces sciatic pain = herniated nucleus pulposus - raising leg of unaffected side can also produce pain = hernia = rupture at center of intervertebral disk, usually in men ages 25-40; esp in L4-L5 and L5-S1

Wheal

raised red skin lesion due to interstitial fluid

For health restoration, the American Indian/Alaskan Native Heritage believes in?

sand paintings and herbs

Erosion

scooped out, shallow depression in skin

cartilage

specialized connective tissue that cushions the bones and provides for smooth movement

hot cold

the _______ _______ theory of health is an explanatory model with origins in the ancient greek humoral theory.

biomedical

the ________________ theory of illness assumes that all events in life have a cause and effect (example: germ theory)

naturalistic

the ________________ theory of illness is the belief that the forces of nature must be kept in natural balance or harmony (example: ying yang, hot cold)

Mrs. Gorman comes to the ambulatory health centre for a routine health assessment. On examination, you perform the modified Allen test, which assesses: early clubbing. the presence of thrombophlebitis. the degree of pedal edema. the patency of the radial and ulnar arteries.

the patency of the radial and ulnar arteries. The modified Allen test assesses the patency of the radial and ulnar arteries. Inspection and palpation of the feet is used to assess for the degree of pedal edema. Inspection and palpation of the hands are used to assess for the degree of early clubbing. The Homan's sign assesses for the presence of thrombophlebitis.

diopter

the unit of strength of each lens in the ophthalmoscope. positive, black nurmbers indicate objects nearer in space to the ophthalmoscope, and the red, negative numbers are for focusing on objects farther away.

syndactyly

webbed fingers, congenital deformity

Knee largest joint in body articulation of femur tibia patella kneecap synovial membrane is largest in the body,forms bursa stabilized by ligaments

when swelling occurs need 2 distinguish tissue swelling or increased fluid can use bulge sign confirms presence of fluid when moving 1 side to the other or ballottement of patella when lg amounts fluid present squishy patella is pushed against femer

ROM Limitations

when the patient has a ROM limitation or injury, use passive motion; anchor joint with one hand while the other moves it to it's limit,

Nevus

"mole" - circumscribed skin lesion due to excess melanocytes

The nurse needs to be familiar with the various lesions that may be identified on assessment of the skin. Match each description given below with the appropriate term. 1.Tiny punctate hemorrhages, 1-3 mm, round and discrete, dark red, purple, or brown in color 2.A large patch of capillary bleeding into tissues 3.A hypertrophic scar 4.Elevated cavity containing free fluid, up to 1 cm. Clear serum flows if wall is ruptured. 5.Also known as a friction blister 6.Solid, elevated, hard or soft, larger than 1 cm

1. Bulla 2. Petechiae 3. Nodule 4. Keloid 5. Vesicle 6. Ecchymosis (bruise) ASN: 2,6,4,5,1,3

The nurse is performing an assessment on a 65-year-old male. He reports a crusty nodule behind the pinna. It bleeds intermittently and has not healed over the past 6 months. On physical assessment, the nurse finds an ulcerated crusted nodule with an indurated base. The preliminary analysis in this situation is that this: 1. is most likely a benign sebaceous cyst. 2. is most likely a Darwin's tubercle and is not significant. 3. could be a potential carcinoma and should be referred. 4. is a tophus, which is common in the elderly and is a sign of gout.

In performing an examination of a 3-year-old with a suspected ear infection, the nurse would: 1. omit the otoscopic exam if the child has a fever. 2. pull the ear up and back before inserting the speculum. 3. ask the mother to leave the room while examining the child. 4. perform the otoscopic examination at the end of the assessment.

During the taking of the health history, a patient tells the nurse that "it feels like the room is spinning around me." The nurse would document this finding as: a. Vertigo. b. Syncope. c. Dizziness. d. Seizure activity.

In a person with an upper motor neuron lesion such as a cerebrovascular accident, which of these physical assessment findings should the nurse expect? a. Hyperreflexia b. Fasciculations c. Loss of muscle tone and flaccidity d. Atrophy and wasting of the muscles

Of the 33 vertebrae in the spinal column, there are: A) 5 lumbar. B) 5 thoracic. C) 7 sacral. D) 12 cervical.

The functional units of the musculoskeletal system are the: A) joints. B) bones. C) muscles. D) tendons.

The nurse is checking the range of motion in a patient's knee and knows that the knee is capable of which movement(s)? A) Flexion and extension B) Supination and pronation C) Circumduction D) Inversion and eversion

The nurse is examining a 6-month-old infant and places the infant's feet flat on the table and flexes his knees up. The nurse notes that the right knee is significantly lower than the left. Which of these statements is true of this finding? A) This is a positive Allis sign and suggests hip dislocation. B) The infant probably has a dislocated patella on the right. C) This is a normal finding for the Allis test for an infant of this age. D) The infant should return to the clinic in 2 weeks to see if this has changed.

Milia occur because: A. sebum occludes skin follicles B. of a vascular occlusion in the skin C. excess carotene is ingested D. of a genetic variation in skin tone

A. sebum occludes skin follicles

A semiconscious woman is brought to the emergency department after she was found on the floor in her kitchen. Her face, nail beds, lips, and oral mucosa are a bright cherry-red color. The nurse suspects that this coloring is due to: 1.polycythemia. 2.carbon monoxide poisoning. 3.carotenemia. 4.uremia.

ANS: 2 A bright cherry-red coloring in the face, upper torso, nail beds, lips, and oral mucosa appears in cases of carbon monoxide poisoning.

The nurse suspects that a patient has otitis media. Early signs of otitis media include which of the following findings of the tympanic membrane? 1. Red and bulging 2. Hypomobility 3. Retraction with landmarks clearly visible 4. Flat, slightly pulled in at the center, and moves with insufflation

ANS: 2 An early sign of otitis media is hypomobility of the tympanic membrane.

10. A patient has hypoactive bowel sounds. The nurse knows that a potential cause of hypoactive bowel sounds is: A) diarrhea. B) peritonitis. C) laxative use. D) gastroenteritis.

ANS: B Diminished or absent bowel sounds signal decreased motility from inflammation as seen with peritonitis, with paralytic ileus after abdominal surgery, or with late bowel obstruction

3. The nurse notices that a patients palpebral fissures are not symmetric. On examination, the nurse may find that damage has occurred to which cranial nerve (CN)? a. III b. V c. VII d. VIII

ANS: C Facial muscles are mediated by CN VII; asymmetry of palpebral fissures may be attributable to damage to CN VII (Bell palsy).

The nurse is performing an assessment on an adult. The adult's vital signs are normal and capillary refill time is 5 seconds. What should the nurse do next? A) Ask the patient about a past history of frostbite. B) Suspect that the patient has a venous insufficiency problem. C) Consider this a delayed capillary refill time and investigate further. D) Consider this a normal capillary refill time that requires no further assessment.

ANS: C Normal capillary refill time is less than 1 to 2 seconds. The following conditions can skew the findings: a cool room, decreased body temperature, cigarette smoking, peripheral edema, and anemia.

40. During a health history, the patient tells the nurse, "I have pain all the time in my stomach. It's worse two hours after I eat, but it gets better if I eat again!" The nurse suspects that the patient has which condition, based on these symptoms? A) Appendicitis B) Gastric ulcer C) Duodenal ulcer D) Cholecystitis

ANS: C Pain associated with duodenal ulcers occurs 2 to 3 hours after a meal, yet it is relieved by more food. Chronic pain associated with gastric ulcers occurs usually on an empty stomach. Severe, acute pain would occur with appendicitis and cholecystitis

With which of these patients would it be most appropriate for the nurse to use games during the assessment, such as, having the patient "blow out" the light on the penlight?

ANS: Preschool child When assessing preschool children, it is helpful to use games or allow them to play with the equipment to reduce their fears. Such games are not appropriate for the other age groups listed.

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, and age b. Personality type, high cholesterol, diabetes, and smoking c. Smoking, hypertension, obesity, diabetes, and high cholesterol d. Alcohol consumption, obesity, diabetes, stress, and high cholesterol

ANS: Smoking, hypertension, obesity, diabetes, high cholestero For major risk factors for coronary artery disease, collect data regarding elevated serum cholesterol, elevated blood pressure, blood glucose levels above 130 mg/dL or known diabetes mellitus, obesity, cigarette smoking, low activity level.

The nurse is assessing a patient's pain. The nurse knows that the most reliable indicator of pain would be the:

ANS: subjective report. The subjective report is the most reliable indicator of pain. Physical examination findings can lend support, but the clinician cannot base the diagnosis of pain exclusively on physical assessment findings.

A 78-year-old man has a history of a cerebrovascular accident. The nurse notes that when he walks, his left arm is immobile against the body with flexion of the shoulder, elbow, wrist, and fingers and adduction of the shoulder. His left leg is stiff and extended and circumducts with each step. What type of gait disturbance is this individual experiencing? a. Scissors gait b. Cerebellar ataxia c. Parkinsonian gait d. Spastic hemiparesis

For which problem are you assessing when you look for the "ugly duckling" sign? Tinea corporis Actinic keratosis Basal cell carcinoma Malignant melanoma

Malignant melanoma The "ugly duckling" sign is a new technique in screening for malignant melanoma in which the examiner looks for a lesion that stands out as different when compared with neighbouring nevi.

Which of the social determinants of health has the greatest influence on a person's health? a. work environment b. neighborhood c. education d. poverty

Rotation

moving head around central axis

Posterior Auricular Lymph Node

(Mastoid) Superficial to the Mastoid process (Behind Ear)

How does culture relate to nursing care?

-awareness of how your culture impacts the care you provide to others -awareness of the potential for imposing your beliefs on others -awareness of the potential for misunderstanding on both sides -recognizing clients at risk for genetic disease -recognizing risk for disease based on ethnicity -awareness of interpretations of disease based on culture -use of resources available -assessment of the impact of culture on the patient's expectations for care -assessment of the impact of culture on the patient's beliefs about his disease -Planning to meet the cultural needs of the client within the framework of your organization or adapting care.

We have to understand the person's immigration status because it can affect their ability to do what three things?

-gain employment -get healthcare benefits -effects their ability to gain money or income and can affect their healthcare practices

A 31-year-old patient tells the nurse that he has noticed a progressive loss in his hearing. He says that it does seem to help when people speak louder or if he turns up the volume. The most likely cause of his hearing loss is: 1. otosclerosis. 2. presbycusis. 3. trauma to the bones. 4. frequent ear infections.

musculoskeletal system in the pregnant woman

1. increased hormones cause increased mobility in joints esp pelvis: sacroiliac, sacrococcygeal, pubic symphysis which changes posture 2. lordosis, compensation for enlarging fetus, shifts weight farther back on the lower extremities = lower back pain

A 31-year-old patient tells the nurse that he has noticed pain in his left ear when people speak loudly to him. The nurse knows that this finding: 1. is normal for people of that age. 2. is a characteristic of recruitment. 3. may indicate a middle ear infection. 4. indicates that the patient has a cerumen impaction.

A patient in her first trimester of pregnancy is diagnosed with rubella. The nurse recognizes that the significance of this in relation to the infant's hearing is which of the following? 1. Rubella may affect the mother's hearing but not the infant's. 2. Rubella can damage the infant's organ of Corti, which will impair hearing. 3. Rubella is only dangerous to the infant in the second trimester of pregnancy. 4. Rubella can impair the development of CN VIII and thus affect hearing.

The nurse is testing the hearing of a 78-year-old man and keeps in mind the changes in hearing that occur with aging, such as: (Select all that apply.) 1. Hearing loss related to aging begins in the mid 40s. 2. The progression is slow. 3. The aging person has low-frequency tone loss. 4. The aging person may find it harder to hear consonants than vowels. 5. Sounds may be garbled and difficult to localize. 6. Hearing loss reflects nerve degeneration of the middle ear.

2, 4, 5

29. During a hearing assessment the nurse finds that sound lateralizes to the patient's left ear with the Weber test. What can the nurse conclude from this? 1. The patient has a conductive hearing loss in the right ear. 2. Lateralization is a normal finding with the Weber test. 3. The patient could have either a sensorineural or a conductive loss. 4. A mistake has occurred; the test must be repeated.

A 21-year-old patient has a head injury resulting from trauma and is unconscious. There are no other injuries. During the assessment what would the nurse expect to find when testing the patient's deep tendon reflexes? a. Reflexes will be normal. b. Reflexes cannot be elicited. c. All reflexes will be diminished but present. d. Some reflexes will be present, depending on the area of injury.

A patient has been diagnosed with a ganglion cyst over the dorsum of his left wrist. He asks the nurse, "What is this thing?" The nurse's best answer would be, "It is: A) a common benign tumor." B) a tumor that will have to be watched because it may turn malignant." C) caused by chronic repetitive motion injury." D) a skin infection that will need to be drained."

A patient tells the nurse that she is having a hard time bringing her hand to her mouth when she eats or tries to brush her teeth. The nurse knows that for her to move her hand to her mouth, she must perform which movement? A) flexion. B) abduction. C) adduction. D) extension.

During an assessment of a 62-year-old man, the nurse notices the patient has a stooped posture, shuffling walk with short steps, flat facial expression, and pill-rolling finger movements. These findings would be consistent with: a. Parkinsonism. b. Cerebral palsy. c. Cerebellar ataxia. d. Muscular dystrophy.

The nurse is reviewing a patient's medical record and notes that he is in a coma. Using the Glasgow Coma Scale, which number indicates that the patient is in a coma? a. 6 b. 12 c. 15 d. 24

The nurse is teaching a class on osteoporosis prevention to a group of postmenopausal woman. A participant shows that she needs more instruction when she states, "I will: A) start swimming to increase my weight-bearing exercise." B) try to stop smoking as soon as possible." C) check with my doctor about taking calcium supplements." D) get a bone-density test soon."

The nurse is testing the deep tendon reflexes of a 30-year-old woman who is in the clinic for an annual physical examination. When striking the Achilles heel and quadriceps muscle, the nurse is unable to elicit a reflex. The nurse's next response should be to: a. Ask the patient to lock her fingers and pull. b. Complete the examination, and then test these reflexes again. c. Refer the patient to a specialist for further testing. d. Document these reflexes as 0 on a scale of 0 to 4+.

The wife of a 65-year-old man tells the nurse that she is concerned because she has noticed a change in her husband's personality and ability to understand. He also cries very easily and becomes angry. The nurse recalls that the cerebral lobe responsible for these behaviors is the __________ lobe. a. Frontal b. Parietal c. Occipital d. Temporal

ANS: It is probably due to a combination of factors related to aging, such as decreased elasticity, subcutaneous fat, and moisture in her skin. The facial bones and orbits appear more prominent in the aging adult, and the facial skin sags owing to decreased elasticity, decreased subcutaneous fat, and decreased moisture in the skin.

A patient, an 85-year-old woman, is complaining about the fact that the bones in her face have become more noticeable. What explanation should the nurse give to her?

The components of a nail examination include: A. Contour, consistency, and color B. Shape, surface, circulation C. Clubbing, pitting, and grooving D. Texture, toughness, and translucency

A. Contour, consistency, and color

Decreased vision in an elderly patient may be due to which of the following conditions? A. Macular degeneration B. Retinoblastoma C. Fixation D. Presbyopia

A. Macular degeneration

The nurse is checking the range of motion in a patient's knee and knows that the knee is capable of which movement(s)? A. flexion and extension B. supination and pronation C. inversion and eversion D. circumduction

A. flexion and extension

The nurse is examining a 2-month-old infant and notices asymmetry of the infant's gluteal folds. The nurse should assess for other signs of what disorder? A. hip dislocation B. down syndrome C. fractured clavicle D. spina bifida

A. hip dislocation

ANS: "Does your baby seem to startle with loud noise?" Children at risk for hearing deficit include those exposed in utero to a variety of conditions, such as maternal rubella, or to maternal ototoxic drugs.

When assessing the intensity of a patient's pain, which question by the nurse is appropriate?

ANS: "How much pain do you have now?" Asking the patient "how much pain do you have?" is an assessment of the intensity of a patient's pain; various intensity scales can be used. Asking what makes one's pain better or worse assesses alleviating or aggravating factors. Asking if pain limits one's activities assesses the degree of impairment and quality of life. Asking "what does your pain feel like" assesses the quality of pain.

Which statement indicates that the nurse understands the pain experienced by an elderly person?

ANS: "Pain indicates pathology or injury and is not a normal process of aging." Pain indicates pathology or injury and should never be considered something that an elderly person should expect or tolerate. Pain is not a normal process of aging, and there is no evidence that pain perception is reduced with aging.

A 70-year-old woman tells the nurse that every time she gets up in the morning or after she's been sitting she gets "really dizzy" and feels like she is going to fall over. The nurse's best response would be:

ANS: "You need to get up slowly when you've been lying or sitting." Aging is accompanied by a progressive decrease in cerebral blood flow. In some people this causes dizziness and a loss of balance with position change. These people need to be taught to get up slowly. The other responses are incorrect.

A 75-year-old woman who has a history of diabetes and peripheral vascular disease has been trying to remove a corn on the bottom of her foot with a pair of scissors. The nurse will encourage her to stop trying to remove the corn with her scissors because: 1.the woman could be at increased risk for infection and lesions because of her chronic disease. 2.with her diabetes, she has increased circulation to her foot and it could cause severe bleeding. 3.she is 75 years old and is unable to see, so she puts herself at greater risk for self- injury with the scissors. 4.with her peripheral vascular disease, her range of motion is limited and she may not be able to reach the corn safely.

ANS: 1 A personal history of diabetes and peripheral vascular disease increases a person's risk for skin lesions in the feet or ankles.

A patient tells the nurse that he has noticed that one of his nevi has started to burn and bleed. When assessing his skin, the nurse would pay special attention to the danger signs for pigmented lesions and would be concerned with which additional finding? 1.Color variation 2.Border regularity 3.Symmetry of lesions 4.Diameter less than 6 mm

ANS: 1 Abnormal characteristics of pigmented lesions are summarized in the mnemonic ABCD: asymmetry of pigmented lesion, border irregularity, color variation, and diameter greater than 6 mm.

When performing an assessment of a 65-year-old man with a history of hypertension and coronary artery disease, the nurse notes the presence of pitting edema in the lower legs bilaterally. The skin is puffy and tight but of normal color. There is no increased redness or tenderness over his lower legs, and the peripheral pulses are equal and strong. In this situation, which of the following is the most likely cause of the edema? 1.Heart failure 2.Venous thrombosis 3.A local inflammation 4.Blockage of lymphatic drainage

ANS: 1 Bilateral edema or edema that is generalized over the entire body is caused by a central problem such as heart failure or kidney failure. Unilateral edema usually has a local or peripheral cause.

The portion of the ear that consists of movable cartilage and skin is called the: 1. auricle. 2. concha. 3. outer meatus. 4. mastoid process.

ANS: 1 The external ear is called the auricle or pinna and consists of movable cartilage and skin.

How should the nurse document mild, slight pitting edema present at the ankles of a pregnant patient? a. 1+/0-4+ b. 3+/0-4+ c. 4+/0-4+ d. Brawny edema

ANS: 1+/0-4+ If pitting edema is present, then the nurse should grade it on a scale of 1+ (mild) to 4+ (severe). Brawny edema appears as nonpitting edema and feels hard to the touch.

The nurse is assessing the skin of a patient who has AIDS and notices a widely disseminated, violet-colored tumor covering the skin and mucous membranes. The nurse would conclude that: 1.he is in the first stage of AIDS. 2.he is in the advanced stage of AIDS. 3.this person has been exposed to a viral infection. 4.these lesions indicate an advanced case of herpes zoster.

ANS: 2 In the advanced stage of AIDS, you may notice widely disseminated lesions involving the skin, mucous membranes, and visceral organs.

When examining the ear with an otoscope, the nurse remembers that the tympanic membrane should appear: 1. light pink with a slight bulge. 2. pearly gray and slightly concave. 3. pulled in at the base of the cone of light. 4. whitish with a small fleck of light in the superior portion.

ANS: 2 It is a translucent membrane with a pearly gray color and a prominent cone of light in the anteroinferior quadrant, which is the reflection of the otoscope light. The drum is oval and slightly concave, pulled in at its center by one of the middle ear ossicles, the malleus.

A few days after a summer hiking trip, a 25-year-old man comes to the clinic with a rash. On examination, the nurse notes that the rash is red, macular, with a bull's eye pattern across his midriff and behind his knees. The nurse suspects: 1.rubeola. 2.Lyme disease. 3.allergy to mosquito bites. 4.Rocky Mountain spotted fever.

ANS: 2 Lyme disease occurs in people who spend time outdoors in May through September. The first state has the distinctive bull's eye, a red macular or popular rash that radiates from the site of the tick bite with some central clearing, 5 cm or larger, usually in the axilla, midriff, inguina, or behind the knee, with regional lymphadenopathy.

A 40-year-old woman reports a change in mole size, accompanied by color changes, itching, burning, and bleeding over the past month. She has a dark complexion and has no family history of skin cancer, but she has had many blistering sunburns in the past. The nurse would would: 1.tell the patient to watch the lesion and report back in 2 months. 2.refer the patient because of the suspicion of melanoma on the basis of her symptoms. 3.ask additional questions regarding environmental irritants that may have caused this condition. 4.suspect that this is a compound nevus, which is very common in young to middle- aged adults.

ANS: 2 The ABCD danger signs of melanoma are asymmetry, border irregularity, color variation, and diameter. In addition, individuals may report a change in size, development of itching, burning, bleeding, or a new-pigmented lesion. Any of these signs raise suspicion of malignant melanoma and warrant referral.

A woman is leaving on a trip to Hawaii and has come in for a checkup. During the examination the nurse notices that she is diabetic and takes oral hypoglycemic agents. She needs to be concerned about which of the following? 1.An increased possibility of bruising 2.Skin sensitivity as a result of exposure to salt water 3.Lack of availability of glucose monitoring supplies 4.The importance of sunscreen and avoiding direct sunlight

ANS: 4 Drugs that may increase sunlight sensitivity and give burn response include sulfonamides, thiazide diuretics, oral hypoglycemic agents, and tetracycline.

The nurse is reviewing a patient's medical record and notes that he is in a coma. Using the Glasgow Coma Scale, which number indicates that the patient is in a coma?

ANS: 6 A fully alert, normal person has a score of 15, whereas a score of 7 or less reflects coma on the Glasgow Coma Scale. See Figure 23-59.

38. During a well-baby checkup, a mother is concerned because her 2-month-old infant cannot hold her head up when she is pulled to a sitting position. Which response by the nurse is appropriate? a. Head control is usually achieved by 4 months of age. b. You shouldnt be trying to pull your baby up like that until she is older. c. Head control should be achieved by this time. d. This inability indicates possible nerve damage to the neck muscles.

ANS: A Head control is achieved by 4 months when the baby can hold the head erect and steady when pulled to a vertical position. The other responses are not appropriate.

How should the nurse document mild, slight pitting edema present at the ankles of a pregnant patient? A) 1+/0-4+ B) 3+/0-4+ C) 4+/0-4+ D) Brawny edema

ANS: A If pitting edema is present, then the nurse should grade it on a scale of 1+ (mild) to 4+ (severe). Brawny edema appears as nonpitting edema and feels hard to the touch.

The nurse is examining a patient who tells the nurse, "I sure sweat a lot, especially on my face and feet but it doesn't have an odor." The nurse knows that this condition could be related to: a. Eccrine glands. b. Apocrine glands. c. Disorder of the stratum corneum. d. Disorder of the stratum germinativum.

ANS: A The eccrine glands are coiled tubules that directly open onto the skin surface and produce a dilute saline solution called sweat. Apocrine glands are primarily located in the axillae, anogenital area, nipples, and naval area and mix with bacterial flora to produce the characteristic musky body odor. The patient's statement is not related to disorders of the stratum corneum or the stratum germinativum.

30. Which of these percussion findings would the nurse expect to find in a patient with a large amount of ascites? A) Dullness across the abdomen B) Flatness in the right upper quadrant C) Hyperresonance in the left upper quadrant D) Tympany in the right and left lower quadrants

ANS: A The presence of fluid causes a dull sound to percussion. A large amount of ascitic fluid would produce a dull sound to percussion

36. During report, the student nurse hears that a patient has "hepatomegaly" and recognizes that this term refers to: A) an enlarged liver. B) an enlarged spleen. C) distended bowel. D) excessive diarrhea.

ANS: A The term hepatomegaly refers to an enlarged liver. The term splenomegaly refers to an enlarged spleen. The other responses are not correct.

A 45-year-old farmer comes in for a skin evaluation and complains of hair loss on his head. His hair seems to be breaking off in patches, and he notices some scaling on his head. The nurse begins the examination suspecting: a. Tinea capitis. b. Folliculitis. c. Toxic alopecia. d. Seborrheic dermatitis.

ANS: A Tinea capitis is rounded patchy hair loss on the scalp, leaving broken-off hairs, pustules, and scales on the skin, and is caused by a fungal infection. Lesions are fluorescent under a Wood light and are usually observed in children and farmers; tinea capitis is highly contagious. (See Table 13-12, Abnormal Conditions of Hair, for descriptions of the other terms.)

During an examination, the nurse finds that a patient has excessive dryness of the skin. The best term to describe this condition is: a. Xerosis. b. Pruritus. c. Alopecia. d. Seborrhea.

ANS: A Xerosis is the term used to describe skin that is excessively dry. Pruritus refers to itching, alopecia refers to hair loss, and seborrhea refers to oily skin.

The nurse is performing an ear examination of an 80-year-old patient. Which of these would be considered a normal finding?

ANS: A high-tone frequency loss A high-tone frequency hearing loss is apparent for those affected with presbycusis, the hearing loss that occurs with aging. The pinna loses elasticity, causing earlobes to be pendulous. The eardrum may be whiter in color and more opaque and duller than in the young adult.

The nurse knows that which statement is true regarding the pain experienced by infants?

ANS: A procedure that induces pain in adults will also induce pain in the infant. If a procedure or disease process causes pain in an adult, then it will also cause pain in an infant. Physiologic changes cannot be used exclusively to confirm or deny pain because other factors, such as medications, fluid status, or stress may cause physiologic changes. The Faces Pain Scale—Revised can be used starting at around age 4 years.

A patient has been admitted with chronic arterial symptoms. During the assessment, the nurse should expect which findings? Select all that apply. A) The patient has a history of diabetes and cigarette smoking. B) The patient's skin is pale and cool. C) The patient's ankles have two small, weeping ulcers. D) The patient works long hours sitting at a computer desk. E) The patient states that the pain gets worse when walking. F) The patient states that the pain is worse at the end of the day.

ANS: A, B, E See Table 20-3. Patients with chronic arterial symptoms often have a history of smoking and diabetes (among other risk factors). The pain has a gradual onset, with exertion, and is relieved with rest or dangling. The skin appears cool and pale. The other responses reflect chronic venous problems.

31. The physician reports that a patient with a neck tumor has a tracheal shift. The nurse is aware that this means that the patients trachea is: a. Pulled to the affected side. b. Pushed to the unaffected side. c. Pulled downward. d. Pulled downward in a rhythmic pattern.

ANS: B The trachea is pushed to the unaffected side with an aortic aneurysm, a tumor, unilateral thyroid lobe enlargement, or a pneumothorax. The trachea is pulled to the affected side with large atelectasis, pleural adhesions, or fibrosis. Tracheal tug is a rhythmic downward pull that is synchronous with systole and occurs with aortic arch aneurysm.

A semiconscious woman is brought to the emergency department after she was found on the floor in her kitchen. Her face, nail beds, lips, and oral mucosa are a bright cherry-red color. The nurse suspects that this coloring is due to: a. Polycythemia. b. Carbon monoxide poisoning. c. Carotenemia. d. Uremia.

ANS: B A bright cherry-red coloring in the face, upper torso, nail beds, lips, and oral mucosa appears in cases of carbon monoxide poisoning.

27. During an abdominal assessment, the nurse is unable to hear bowel sounds in a patient's abdomen. Before reporting this finding as "silent bowel sounds" the nurse should listen for at least: A) 1 minute. B) 5 minutes. C) 10 minutes. D) 2 minutes in each quadrant.

ANS: B Absent bowel sounds are rare. The nurse must listen for 5 minutes before deciding bowel sounds are completely absent.

The nurse is reviewing risk factors for venous disease. Which of these situations best describes a person at highest risk for development of venous disease? A) Woman in her second month of pregnancy B) Person who has been on bed rest for 4 days C) Person with a 30-year, 1 pack per day smoking history D) Elderly person taking anticoagulant medication

ANS: B At risk for venous disease are people who undergo prolonged standing, sitting, or bed rest. Hypercoagulable (not anticoagulated) states and vein wall trauma also place the person at risk for venous disease. Obesity and pregnancy are also risk factors, but not the early months of pregnancy.

31. When examining the mouth of an older patient, the nurse recognizes which finding is due to the aging process? a. Teeth appearing shorter b. Tongue that looks smoother in appearance c. Buccal mucosa that is beefy red in appearance d. Small, painless lump on the dorsum of the tongue

ANS: B In the aging adult, the tongue looks smoother because of papillary atrophy. The teeth are slightly yellowed and appear longer because of the recession of gingival margins.

A few days after a summer hiking trip, a 25-year-old man comes to the clinic with a rash. On examination, the nurse notes that the rash is red, macular, with a bull's eye pattern across his midriff and behind his knees. The nurse suspects: a. Rubeola. b. Lyme disease. c. Allergy to mosquito bites. d. Rocky Mountain spotted fever.

ANS: B Lyme disease occurs in people who spend time outdoors in May through September. The first disease state exhibits the distinctive bull's eye and a red macular or papular rash that radiates from the site of the tick bite with some central clearing. The rash spreads 5 cm or larger, and is usually in the axilla, midriff, inguinal, or behind the knee, with regional lymphadenopathy.

During an assessment, a patient tells the nurse that her fingers often change color when she goes out in cold weather. She describes these episodes as her fingers first turning white, then blue, then red with a burning, throbbing pain. The nurse suspects that she is experiencing: A) lymphedema. B) Raynaud's disease. C) deep vein thrombosis. D) chronic arterial insufficiency.

ANS: B The condition with episodes of abrupt, progressive tricolor change of the fingers in response to cold, vibration, or stress is known as Raynaud's disease. Lymphedema is described in Table 20-2; deep vein thrombosis is described in Table 20-5; chronic arterial insufficiency is described in Table 20-4.

The nurse is teaching a review class on the lymphatic system. A participant shows correct understanding of the material with which statement? A) "Lymph flow is propelled by the contraction of the heart." B) "The flow of lymph is slow compared with that of the blood." C) "One of the functions of the lymph is to absorb lipids from the biliary tract." D) "Lymph vessels have no valves, so there is a free flow of lymph fluid from the tissue spaces into the bloodstream."

ANS: B The flow of lymph is slow compared with that of the blood. Lymph flow is not propelled by the heart, but rather by contracting skeletal muscles, pressure changes secondary to breathing, and by contraction of the vessel walls. Lymph does not absorb lipids from the biliary tract. The vessels do have valves, so flow is one way from the tissue spaces to the bloodstream.

30. A mother is concerned because her 18-month-old toddler has 12 teeth. She is wondering if this is normal for a child of this age. Which is the best response by the nurse? a. "How many teeth did you have at this age?" b. "This is a normal number of teeth for an 18 month old." c. "Normally, by age 2 1/2 years, 16 deciduous teeth are expected." d. "All 20 deciduous teeth are expected to erupt by age 4 years."

ANS: B The guidelines for the number of teeth for children younger than 2 years old are as follows: the child's age in months minus the number 6 should be equal to the expected number of deciduous teeth. Normally all 20 teeth are in by 2 1/2 years old. In this instance, the child is 18 months old, minus 6, equals 12 deciduous teeth expected.

A 35-year-old man is seen in the clinic for an infection in his left foot. Which of these findings should the nurse expect to see during an assessment of this patient? A) Hard and fixed cervical nodes B) Enlarged and tender inguinal nodes C) Bilateral enlargement of the popliteal nodes D) "Pellet-like" nodes in the supraclavicular region

ANS: B The inguinal nodes in the groin drain most of the lymph of the lower extremities. With local inflammation, the nodes in that area become swollen and tender.

31. A 40-year-old man states that his physician told him that he has a hernia. He asks the nurse to explain what a hernia is. Which response by the nurse is appropriate? A) "No need to worry. Most men your age develop hernias." B) "A hernia is a loop of bowel protruding through a weak spot in the abdominal muscles." C) "This hernia is a result of prenatal growth abnormalities that are just now causing problems." D) "I'll have to have your physician explain this to you."

ANS: B The nurse should explain that a hernia is a protrusion of the abdominal viscera through an abnormal opening in the muscle wall

The nurse is reviewing an assessment of a patient's peripheral pulses and notices that the documentation states that the radial pulses are "2+." The nurse recognizes that this reading indicates what type of pulse? A) Bounding B) Normal C) Weak D) Absent

ANS: B When documenting the force, or amplitude, of pulses, 3+ indicates an increased, full, or bounding pulse, 2+ indicates a normal pulse, 1+ indicates a weak pulse, and 0 indicates an absent pulse.

A 13-year-old girl is interested in obtaining information about the cause of her acne. The nurse should share with her that acne: a. Is contagious. b. Has no known cause. c. Is caused by increased sebum production. d. Has been found to be related to poor hygiene.

ANS: C Approximately 90% of males and 80% of females will develop acne; causes are increased sebum production and epithelial cells that do not desquamate normally.

The nurse is assessing for inflammation in a dark-skinned person. Which technique is the best? a. Assessing the skin for cyanosis and swelling b. Assessing the oral mucosa for generalized erythema c. Palpating the skin for edema and increased warmth d. Palpating for tenderness and local areas of ecchymosis

ANS: C Because inflammation cannot be seen in dark-skinned persons, palpating the skin for increased warmth, for taut or tightly pulled surfaces that may be indicative of edema, and for a hardening of deep tissues or blood vessels is often necessary.

A 42-year-old woman complains that she has noticed several small, slightly raised, bright red dots on her chest. On examination, the nurse expects that the spots are probably: a. Anasarca. b. Scleroderma. c. Senile angiomas. d. Latent myeloma.

ANS: C Cherry (senile) angiomas are small, smooth, slightly raised bright red dots that commonly appear on the trunk of adults over 30 years old.

A 65-year-old patient is experiencing pain in his left calf when he exercises that disappears after resting for a few minutes. The nurse recognizes that this description is most consistent with _________ the left leg. A) venous obstruction of B) claudication due to venous abnormalities in C) ischemia caused by partial blockage of an artery supplying D) ischemia caused by complete blockage of an artery supplying

ANS: C Ischemia is a deficient supply of oxygenated arterial blood to a tissue. A partial blockage creates an insufficient supply, and the ischemia may be apparent only during exercise when oxygen needs increase.

9. While examining a patient, the nurse observes abdominal pulsations between the xiphoid and umbilicus. The nurse would suspect that these are: A) pulsations of the renal arteries. B) pulsations of the inferior vena cava. C) normal abdominal aortic pulsations. D) increased peristalsis from a bowel obstruction.

ANS: C Normally, one may see the pulsations from the aorta beneath the skin in the epigastric area, particularly in thin persons with good muscle wall relaxation.

16. The nurse is performing percussion during an abdominal assessment. Percussion notes heard during the abdominal assessment may include: A) flatness, resonance, and dullness. B) resonance, dullness, and tympany. C) tympany, hyperresonance, and dullness. D) resonance, hyperresonance, and flatness.

ANS: C Percussion notes normally heard during the abdominal assessment may include tympany, which should predominate because air in the intestines rises to the surface when the person is supine; hyperresonance, which may be present with gaseous distention; and dullness, which may be found over a distended bladder, adipose tissue, fluid, or a mass.

18. A patient is complaining of a sharp pain along the costovertebral angles. The nurse knows that this symptom is most often indicative of: A) ovary infection. B) liver enlargement. C) kidney inflammation. D) spleen enlargement.

ANS: C Sharp pain along the costovertebral angles occurs with inflammation of the kidney or paranephric area. The other options are not correct

28. A patient visits the clinic because he has recently noticed that the left side of his mouth is paralyzed. He states that he cannot raise his eyebrow or whistle. The nurse suspects that he has: a. Cushing syndrome. b. Parkinson disease. c. Bell palsy. d. Experienced a cerebrovascular accident (CVA) or stroke.

ANS: D With an upper motor neuron lesion, as with a CVA, the patient will have paralysis of lower facial muscles, but the upper half of the face will not be affected owing to the intact nerve from the unaffected hemisphere. The person is still able to wrinkle the forehead and close the eyes. (See Table 13-4, Abnormal Facial Appearances with Chronic Illnesses, for descriptions of the other responses.)

The nurse notices that a patient has a solid, elevated, circumscribed lesion that is less than 1 cm in diameter. When documenting this finding, the nurse reports this as a: a. Bulla. b. Wheal. c. Nodule. d. Papule.

ANS: D A papule is something one can feel, is solid, elevated, circumscribed, less than 1 cm in diameter, and is due to superficial thickening in the epidermis. A bulla is larger than 1 cm, superficial, and thin walled. A wheal is superficial, raised, transient, erythematous, and irregular in shape attributable to edema. A nodule is solid, elevated, hard or soft, and larger than 1 cm.

The findings from an assessment of a 70-year-old patient with swelling in his ankles include jugular venous pulsations 5 cm above the sternal angle when the head of his bed is elevated 45 degrees. The nurse knows that this finding indicates: a. Decreased fluid volume. b. Increased cardiac output. c. Narrowing of jugular veins. d. Elevated pressure related to heart failure.

ANS: D Because no cardiac valve exists to separate the superior vena cava from the right atrium, the jugular veins give information about the activity on the right side of the heart. They reflect filling pressures and volume changes. Normal jugular venous pulsation is 2 cm or less above the sternal angle. Elevated pressure is more than 3 cm above the sternal angle at 45 degrees and occurs with heart failure.

A patient comes to the clinic and states that he has noticed that his skin is redder than normal. The nurse understands that this condition is due to hyperemia and knows that it can be caused by: a. Decreased amounts of bilirubin in the blood b. Excess blood in the underlying blood vessels c. Decreased perfusion to the surrounding tissues d. Excess blood in the dilated superficial capillaries

ANS: D Erythema is an intense redness of the skin caused by excess blood (hyperemia) in the dilated superficial capillaries.

A father brings in his 2-month-old infant to the clinic because the infant has had diarrhea for the last 24 hours. He says his baby has not been able to keep any formula down and that the diarrhea has been at least every 2 hours. The nurse suspects dehydration. The nurse should test skin mobility and turgor over the infant's: a. Sternum. b. Forehead. c. Forearms. d. Abdomen.

ANS: D Mobility and turgor are tested over the abdomen in an infant. Poor turgor, or tenting, indicates dehydration or malnutrition. The other sites are not appropriate for checking skin turgor in an infant.

32. A 45-year-old man is in the clinic for a physical examination. During the abdominal assessment, the nurse percusses the abdomen and notices an area of dullness above the right costal margin of about 10 cm. The nurse should: A) document the presence of hepatomegaly. B) ask additional history questions regarding his alcohol intake. C) describe this as an enlarged liver and refer him to a physician. D) consider this a normal finding and proceed with the examination.

ANS: D The average liver span in the midclavicular line is 6 to 12 cm. Men and taller individuals are at the upper end of this range. Women and shorter individuals are at the lower end of this range. A liver span of 10 cm is within normal limits for this individual

4. What is the tissue that connects the tongue to the floor of the mouth called? a. Uvula b. Palate c. Papillae d. Frenulum

ANS: D The frenulum is a midline fold of tissue that connects the tongue to the floor of the mouth. The uvula is the free projection hanging down from the middle of the soft palate. The palate is the arching roof of the mouth. Papillae are the rough, bumpy elevations on the tongue's dorsal surface. The uvula is the free projection hanging down from the middle of the soft palate. The palate is the arching roof of the mouth. Papillae are the rough, bumpy elevations on the tongue's dorsal surface. The frenulum is a midline fold of tissue that connects the tongue to the floor of the mouth

The nurse notices that a school-aged child has bluish-white, red-based spots in her mouth that are elevated approximately 1 to 3 mm. What other signs would the nurse expect to find in this patient? a. Pink, papular rash on the face and neck b. Pruritic vesicles over her trunk and neck c. Hyperpigmentation on the chest, abdomen, and back of the arms d. Red-purple, maculopapular, blotchy rash behind the ears and on the face

ANS: D With measles (rubeola), the examiner assesses a red-purple, blotchy rash on the third or fourth day of illness that appears first behind the ears, spreads over the face, and then over the neck, trunk, arms, and legs. The rash appears coppery and does not blanch. The bluish-white, red-based spots in the mouth are known as Koplik spots.

The nurse is preparing to assess a hospitalized patient who is experiencing significant shortness of breath. How should the nurse proceed with the assessment?

ANS: Examine body areas appropriate to the problem and then complete the assessment after the problem has resolved. It may be necessary in this situation to alter the position of the patient during the examination and to collect a mini data base by examining the body areas appropriate to the problem. You may return later to complete the assessment after the distress is resolved.

The nurse is preparing to examine a 4-year-old child. Which action is appropriate for this age group?

ANS: Give the child feedback and reassurance during the examination. With preschool children use short, simple explanations. Children at this age are usually willing to undress. Examination of the head should be performed last. During the examination give the preschooler needed feedback and reassurance.

A 59-year-old patient has a herniated intervertebral disk. Which of the following findings should the nurse expect to see on physical assessment of this individual?

ANS: Hyporeflexia With a herniated intervertebral disk or lower motor neuron lesion there is loss of tone, flaccidity, atrophy, fasciculations, and hyporeflexia or areflexia. No Babinski's sign or pathologic reflexes would be seen. The other options reflect a lesion of upper motor neurons. See Table 23-7.

The nurse is preparing to examine a 6-year-old child. Which action is most appropriate?

ANS: Keep in mind that a child this age will have a sense of modesty. A 6-year-old child has a sense of modesty. The child should undress himself or herself, leaving underpants on, and use a gown or drape. A school-age child is curious to know how equipment works, and the sequence should progress from head to toes.

ANS: Nerve degeneration in the inner ear Presbycusis is a type of hearing loss that occurs in 60% of those older than 65 years of age, even in people living in a quiet environment. It is a gradual sensorineural loss caused by nerve degeneration in the inner ear. Words sound garbled, and the ability to localize sound is impaired also. This communication dysfunction is accentuated when background noise is present.

During auscultation of the lungs of an adult patient, the nurse notices the presence of bronchophony. The nurse should assess for signs of which condition?

ANS: Pulmonary consolidation Pathologic conditions that increase lung density, such as pulmonary consolidation, will enhance transmission of voice sounds, such as bronchophony. See Table 18-7.

A patient in her first trimester of pregnancy is diagnosed with *rubella*. Which of these statements is correct regarding the significance of this in relation to the infant's hearing?

ANS: Rubella can damage the infant's organ of Corti, which will impair hearing. If maternal rubella infection occurs during the first trimester, then it can damage the organ of Corti and impair hearing

A patient has had arthritic pain in her hips for several years since a hip fracture. She is able to move around in her room and has not offered any complaints so far this morning. However, when asked, she states that her pain is "bad this morning" and rates it at an 8 on a 1 to 10 scale. What does the nurse suspect?

ANS: She has experienced chronic pain for years and has adapted to it. Persons with chronic pain typically try to give little indication that they are in pain and, over time, adapt to the pain. As a result, they are at risk for underdetection.

A patient is unable to read even the largest letters on the Snellen chart. The nurse should take which action next?

ANS: Shorten the distance between the patient and the chart until it is seen and record that distance. If the person is unable to see even the largest letters, then the nurse should shorten the distance to the chart until it is seen and should record that distance (e.g., "10/200"). If visual acuity is even lower, then the nurse should assess whether the person can count fingers when they are spread in front of the eyes or can distinguish light perception from a penlight. If vision is poorer than 20/30, then a referral to an ophthalmologist or optometrist is necessary, but first the nurse must assess the visual acuity.

During assessment of a patient's pain, the nurse keeps in mind that certain nonverbal behaviors are associated with chronic pain. Which of these behaviors are associated with chronic pain? Select all that apply.

ANS: Sleeping, Bracing, Rubbing Behaviors that have been associated with chronic pain include bracing, rubbing, diminished activity, sighing, and change in appetite. In addition, those with chronic pain may sleep in an attempt at distraction. The other behaviors are associated with acute pain.

During ocular examinations, the nurse keeps in mind that movement of the extraocular muscles is:

ANS: Stimulated by cranial nerves III, IV, and VI. Movement of the extraocular muscles is stimulated by three cranial nerves: III, IV, and VI.

A patient has a severed spinal nerve as a result of trauma. Which of these statements is true in this situation?

ANS: The adjacent spinal nerves will continue to carry sensations for the dermatome served by the severed nerve. A dermatome is a circumscribed skin area that is supplied mainly from one spinal cord segment through a particular spinal nerve. The dermatomes overlap, which is a form of biologic insurance. That is, if one nerve is severed, most of the sensations can be transmitted by the spinal nerve above and spinal nerve below.

Which of these statements is true regarding the arterial system? a. Arteries are large-diameter vessels. b. The arterial system is a high-pressure system. c. The walls of arteries are thinner than those of the veins. d. Arteries can greatly expand to accommodate a large blood volume increase.

ANS: The arterial system is a high-pressure system. The pumping heart makes the arterial system a high-pressure system.

A patient's vision is recorded as 20/30 when the Snellen eye chart is used. The nurse interprets these results to indicate that:

ANS: The patient can read at 20 feet what a person with normal vision can read at 30 feet. The top number indicates the distance the person is standing from the chart; the denominator gives the distance at which a normal eye can see.

During an examination, a patient states that she was diagnosed with open-angle glaucoma 2 years ago. The nurse assesses for characteristics of *open-angle glaucoma*. Which of these are characteristics of open-angle glaucoma? Select all that apply.

ANS: The patient experiences tunnel vision in late stages., Vision loss begins with peripheral vision., There are virtually no symptoms. Open-angle glaucoma is the most common type of glaucoma; there are virtually no symptoms. Vision loss begins with the peripheral vision, which often goes unnoticed because individuals learn to compensate intuitively by turning their heads. The other characteristics are those of closed-angle glaucoma.

The nurse is testing the hearing of a 78-year-old man and keeps in mind the changes in hearing that occur with aging include which of the following? Select all that apply.

ANS: The progression is slow. The aging person may find it harder to hear consonants than vowels Sounds may be garbled and difficult to localize Presbycusis is a type of hearing loss that occurs with aging and is found in 60% of those older than 65 years. It is a gradual sensorineural loss caused by nerve degeneration in the inner ear or auditory nerve, and it slowly progresses after age 50. The person first notices a high-frequency tone loss; it is harder to hear consonants (high-pitched components of speech) than vowels. This makes words sound garbled. The ability to localize sound is impaired also.

The mother of a 2-year-old is concerned about the upcoming placement of tympanostomy tubes in her son's ears. The nurse would include which of these statements in the teaching plan?

ANS: The purpose of the tubes is to decrease the pressure and allow for drainage. Polyethylene tubes are inserted surgically into the eardrum to relieve middle ear pressure and to promote drainage of chronic or recurrent middle ear infections. Tubes extrude spontaneously in 6 months to 1 year.

ANS: This is a very ominous sign and may indicate brainstem injury. These findings are all indicative of decerebrate rigidity, which is a very ominous condition and may indicate a brainstem injury.

The nurse is preparing to perform a modified Allen test. Which is an appropriate reason for this test? a. To measure the rate of lymphatic drainage b. To evaluate the adequacy of capillary patency before venous blood draws c. To evaluate the adequacy of collateral circulation before cannulating the radial artery d. To evaluate the venous refill rate that occurs after the ulnar and radial arteries are temporarily occluded

ANS: To evaluate the adequacy of collateral circulation before cannulating the radial artery A modified Allen test is used to evaluate the adequacy of collateral circulation before the radial artery is cannulated. The other responses are not reasons for a modified Allen test.

The nurse is performing an eye assessment on an 80-year-old patient. Which of these findings is considered *abnormal*?

ANS: Unequal pupillary constriction in response to light Pupils are small in old age, and the pupillary light reflex may be slowed, but pupillary constriction should be symmetric. The assessment findings in the other responses are considered normal in older persons.

The nurse is preparing to assess the visual acuity of a 16-year-old patient. How should the nurse proceed?

ANS: Use the Snellen chart positioned 20 feet away from the patient. The Snellen alphabet chart is the most commonly used and most accurate measure of visual acuity. The confrontation test is a gross measure of peripheral vision. The Jaeger card or newspaper tests are used to test near vision.

During a clinic visit, a woman in her seventh month of pregnancy complains that her legs feel "heavy in the calf" and that she often has foot cramps at night. The nurse notices that the patient has dilated, tortuous veins in her lower legs. Which condition is reflected by these findings? a. Deep-vein thrombophlebitis b. Varicose veins c. Lymphedema d. Raynaud phenomenon

ANS: Varicose veins Superficial varicose veins are caused by incompetent distant valves on veins, which results in reflux of blood and producing dilated, tortuous veins. They are more common in women, and pregnancy can also be a cause. Symptoms include aching, heaviness in the calf, easy fatigability, and night leg or foot cramps. Dilated, tortuous veins are seen on assessment. See Table 20-5 for the description of deep vein thrombophlebitis. See Table 20-2 for descriptions of Raynaud's phenomenon and lymphedema.

The nurse is assessing voice sounds during a respiratory assessment. Which of these findings indicates a normal assessment? Select all that apply.

ANS: Voice sounds are faint, muffled, and almost inaudible when the patient whispers "one, two, three" in a very soft voice. When the patient speaks in a normal voice, the examiner can hear a sound but cannot distinguish exactly what is being said. As the patient says a long "ee-ee-ee" sound, the examiner also hears a long "ee-ee-ee" sound. As a patient says "ninety-nine" repeatedly, normally, the examiner hears sound but cannot distinguish what is being said. If a clear "ninety-nine" is auscultated, then it could indicate increased lung density, which enhances transmission of voice sounds. This is a measure of bronchophony. When a patient says a long "ee-ee-ee" sound, normally the examiner also hears a long "ee-ee-ee" sound through auscultation. This is a measure of egophony. If the examiner hears a long "aaaaaa" sound instead, this could indicate areas of consolidation or compression. With whispered pectoriloquy, as when a patient whispers a phrase such as "one-two-three," the normal response when auscultating voice sounds is to hear sounds that are faint, muffled, and almost inaudible. If the examiners hears the whispered voice clearly, as if the patient is speaking through the stethoscope, then consolidation of the lung fields may exist.

The nurse is preparing to palpate the thorax and abdomen of a patient. Which of these statements describes correct technique for this procedure? Select all that apply.

ANS: Warm the hands first before touching the patient., Start with light palpation to detect surface characteristics., Use the fingertips to examine skin texture, swelling, pulsation, and presence of lumps., Identify any tender areas, and palpate them last. Always warm the hands before beginning palpation. Use intermittent pressure rather than one long continuous palpation; identify any tender areas, and palpate them last. Fingertips are used to examine skin texture, swelling, pulsation, and presence of lumps. Use the dorsa (backs) of the hands to assess skin temperature because the skin on the dorsa is thinner than on the palms.

Behavior

Facial expression Mood and affect Speech Dress Personal Hygiene

The American Indian/Alaskan Native Heritage beliefs in health maintenance are?

Respect nature, avoid evil spirits, masks

Name the 5 components of the inner eye.

Retina Optic disc Retinal vessels General background Macula

Viscosity

Thick blood= Increased BP to push contents through

Cyanosis

a bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of the blood

spirituality

a broad term focused on a connection to something larger than oneself, and a belief in transcendence.

Hischberg test

a simple screening test for strabismus, is performed by shining a light and noting the reflection of the light on the eye of the person. if it is the reflection is in the same spot of both people, their eyes are aliigned with each other

The inguinal nodes drain the: hand and lower arm. upper arm and breast. head and neck. anterior abdominal wall.

anterior abdominal wall. The inguinal nodes drain the anterior abdominal wall. The epitrochlear node is in the antecubital fossa and drains the hand and the lower arm. The axillary nodes drain the breast and the upper arm. The cervical nodes drain the head and the neck.

dislocated shoulder

anterior dislocation (95%) = hunching of shoulder forward and tip of clavicle dislocated - due to trauma

Hip

articulation between acetabulum and head of femur; ball and socket action, wide range of motion, but less ROM than shoulder; but more stability than shoulder; VERY powerful muscles gives excellent stability; 3 bursae facilitate movement;

shape of spine in infants and children

at birth - spine has single C-shaped curve 3-4 months - raising the baby's head from prone position develops the anterior curve in the cervical neck region 1 year-18 months - standing erect develops anteriocurvitureer in lumbar region

carpal tunnel syndrom

atrophy occurs from interference with motor funciton due to comrpession of the median nerve inside the carpal tunnel, caused by chronic repetitive motion

Tinel sign

direct percussion of the location of the median never at the wrist normal: no symptoms abnormal POSITIVE sign: burning and tingling along distribution in CTS

polydactyly

extra digits

atrophy

loss of muscle mass

bulge sign

mild fluid or effusion of the knee

Retraction

move body part backward parallel to the ground

Diaphoresis

profuse perspiration

PERRLA

pupils equal, round, react to light and accomodation

elevation

raising a body part

Extension

straiten limb at joint "extend your arm"

extension

stratightening a limb at a joint to masimally increase its angle

If muscle weakness is present, the cover-uncover test will show

the uncovered eye will JUMP positions to re-establish vision

Carotenemia

yellow-orange color in light-skinned persons from large amounts of foods containing carotene

Which direction would you give a patient to assist you with palpating the femoral pulse? "Push your leg down against the examining table." "Relax your leg and turn your foot and knee inward." "Bend your knee outward like a frog." "Straighten your leg and point your toe."

"Bend your knee outward like a frog." Bending the knee outward like a frog helps expose the area of the groin through which the femoral artery runs, making palpation easier, especially in obese patients. None of the other positions facilitates palpation of the artery in the groin.

Furuncle

"boil" - suppurative inflammatory skin lesion due to infected hair follicle

Objective assessment of nails

* Inspect and palpate the nails, evaluating the shape, contour, consistency, and color. * Assess capillary refill

mcmurray test

- hold heel, and flex the knee and hip. place other hand on knee w/fingers on medial side. rotate legs in and out to listen the joint then push inward then extend - hear or feel "click" = POSITIVE test for torn meniscus

factors associated with joint pain

- joint pain 10-14 days after untreated strep throat = rheumatic fever - RA stiffness occurs in AM and after rest periods - heat, swelling, redness = acute inflammation - decreased ROM can be due to joint injury to cartilage or muscle contracture

true leg length

- measure between fixed points. should equal or w/in 1 cm if true leg lengths are equal but apparent leg length is unequal = pelvic obliquity or adduction/flexion deformity of hip

muscle pain

- myalgia usually felt as cramping or aching - pain in calf muscles suggests intermittent claudication - viral illness includes myalgia - weakness may involve musculoskeletal or neurologic systems

location of joint pain

- rheumatoid arthritis (RA) involves symmetric joints - othermusculoskeletall illnesses involve isolated or unilateral joints

What are 5 considerations when evaluating culture.

-cultural value -religious beliefs and practices -health related beliefs and practices -expression of illness/ healing -common disease or genetic disease by population

What does it look like in practice?

-learn from preceptors -learn from departments -learn how to be culturally sensitive

A colleague is assessing an 80-year-old patient who has ear pain and asks him to hold his nose and swallow. The nurse knows that which of the following is true concerning this technique? 1. This should not be used in an 80-year-old patient. 2. This technique is helpful in assessing for otitis media. 3. This is especially useful in assessing a patient with an upper respiratory infection. 4. This will cause the eardrum to bulge slightly and make landmarks more visible.

A patient states that she is unable to hear well with her left ear. The Weber test shows lateralization to the right ear. Rinne has AC>BC with ratio of 2:1 in both ears, left-AC 10 sec and BC 5 sec, right-AC 30 sec and BC 15 sec. What would be the interpretation of these results? 1. The patient may have sensorineural loss. 2. The test results are reflective of normal hearing. 3. Conduction of sound through bones is impaired. 4. These results make no sense, so further tests should be done.

A student nurse is conducting a dermatology in-service for nurses and students assigned to a medical surgical floor at the local hospital. She covers skin changes indicative of prolonged sun exposure and shows slides of precancerous lesions. Which of the following is descriptive of a precancerous keratotic lesion? Raised, thickened areas of pigmentation, which look crusted, scaly, and warty A raised, thickened, dry area of decreased pigmentation with a tightly packed set of papules A raised, thickened, crusted area of dark pigmentation that looks "stuck on" and greasy A raised, rough plaque of red-tan pigmentation with a silvery white scale

A raised, rough plaque of red-tan pigmentation with a silvery white scale A raised, rough plaque of red-tan pigmentation with a silvery white scale describes a precancerous keratotic lesion. Lichenification is caused by prolonged intense scratching eventually thickening the skin and producing tightly packed sets of papules; this looks like surface of moss (or lichen). Keratoses are lesions that are raised, thickened areas of pigmentation that look crusted, scaly, and warty. Seborrheic keratosis looks dark, greasy, and "stuck on."

During a routine visit, M.B, age 78, asks about small, round, flat, brown macule on the hands. What is your best response after assessing the areas? A) "These are the result of sun exposure and do not require treatment" B) " These are related to exposure to the sun, they may become cancerous" C) " These are the skin tags that occur with aging, no treatment is required" D) " I'm glad you brought this to my attention. I will arrange for a biopsy"

A) "These are the result of sun exposure and do not require treatment"

Lyme disease is more prevalent from: A. from May through September B. along the West Coast C. in children younger than 3 years D. in those participating in water sports

A. May through September

What term refers to a linear skin lesion that runs along a nerve route? A. Zosteriform B. Annular C. Dermatome D. Shingles

A. Zosteriform

A 70-year-old patient is scheduled for open-heart surgery. The surgeon plans to use the great saphenous vein for the coronary bypass grafts. The patient asks, "What happens to my circulation when the veins are removed?" The nurse should reply: a. "Venous insufficiency is a common problem after this type of surgery." b. "Oh, you have lots of veins—you won't even notice that it has been removed." c. "You will probably experience decreased circulation after the vein is removed." d. "This vein can be removed without harming your circulation because the deeper veins in your leg are in good condition."

ANS: "Because the deeper veins in your leg are in good condition, this vein can be removed without harming your circulation." As long as the femoral and popliteal veins remain intact, the superficial veins can be excised without harming the circulation. The other responses are not correct.

A mother asks when her newborn infant's eyesight will be developed. The nurse should reply:

ANS: "By about 3 months, infants develop more coordinated eye movements and can fixate on an object." Eye movements may be poorly coordinated at birth, but by 3 to 4 months of age, the infant should establish binocularity and should be able to fixate on a single image with both eyes simultaneously

A mother asks when her *newborn infant's eyesight* will be developed. The nurse should reply:

A 45-year-old man is in the clinic for a routine physical. During the history the patient states 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?"

ANS: "Do you have any history of problems with your heart?" Paroxysmal nocturnal dyspnea occurs with heart failure. Lying down increases volume of intrathoracic blood, and the weakened heart cannot accommodate the increased load. Classically, the person awakens after 2 hours of sleep, arises, and flings open a window with the perception of needing fresh air.

The nurse is teaching a review class on the lymphatic system. A participant shows correct understanding of the material with which statement? a. "Lymph flow is propelled by the contraction of the heart." b. "The flow of lymph is slow, compared with that of the blood." c. "One of the functions of the lymph is to absorb lipids from the biliary tract." d. "Lymph vessels have no valves; therefore, lymph fluid flows freely from the tissue spaces into the bloodstream."

ANS: "The flow of lymph is slow compared with that of the blood." The flow of lymph is slow compared with that of the blood. Lymph flow is not propelled by the heart, but rather by contracting skeletal muscles, pressure changes secondary to breathing, and by contraction of the vessel walls. Lymph does not absorb lipids from the biliary tract. The vessels do have valves, so flow is one way from the tissue spaces to the bloodstream.

When assessing the quality of a patient's pain, the nurse should ask which question?

ANS: "What does your pain feel like?" To assess the quality of a person's pain, have the patient describe the pain in his or her own words.

A woman in her 26th week of pregnancy states that she is "not really short of breath" but feels that she is aware of her breathing and the need to breathe. What is the nurse's best reply?

ANS: "What you are experiencing is normal. Some women may interpret this as shortness of breath, but it is a normal finding and nothing is wrong." During pregnancy, the woman may develop an increased awareness of the need to breathe. Some women may interpret this as dyspnea, even though structurally nothing is wrong. Estrogen increases relax the chest cage ligaments, causing an increase in transverse diameter. The growing fetus does increase the oxygen demand on the mother's body, but this is met easily by the increasing tidal volume (deeper breathing). Little change occurs in the respiratory rate.

ANS: 1 Otosclerosis is a common cause of conductive hearing loss in young adults between the ages of 20 and 40 years.

The nurse is preparing to do an otoscopic examination on a 2-year-old child. Which of the following reflects correct procedure? 1. Pull the pinna down. 2. Pull the pinna up and back. 3. Tilt the child's head slightly toward the examiner. 4. Have the child touch his chin to his chest.

ANS: 1 Pull the pinna down on an infant and a child under 3 years of age.

The nurse is performing a middle ear assessment on a 15-year-old patient who has a history of chronic ear infections. When examining the right tympanic membrane, the nurse sees the presence of dense white patches. The tympanic membrane is otherwise unremarkable. It is pearly, with the light reflex at 5 o'clock and landmarks visible. The nurse should: 1. refer the patient for the possibility of a fungal infection. 2. know that these are scars caused from frequent ear infections. 3. consider that these findings may represent the presence of blood in the middle ear. 4. be concerned about the ability to hear because of this abnormality on the tympanic membrane.

ANS: 2 Dense white patches on the tympanic membrane are sequelae of repeated ear infections. They do not necessarily affect hearing.

A 22-year-old-woman comes to the clinic because of a severe sunburn and states, "I was just out in the sun for a couple of minutes." The nurse begins a medication review with her, paying special attention to the medication she is taking for: 1.pain. 2.acne. 3.heartburn. 4.hyperthyroidism.

ANS: 2 Drugs that may increase sunlight sensitivity and give burn response include sulfonamides, thiazide diuretics, oral hypoglycemic agents, and tetracycline.

The nurse is assessing a 16-year-old patient with head injuries from a recent motor vehicle accident. Which of the following statements indicates the most important reason for assessing for any drainage from the canal? 1. If the drum has ruptured, there will be purulent drainage. 2. Bloody or clear watery drainage can indicate a basal skull fracture. 3. The auditory canal many be occluded from increased cerumen. 4. There may be occlusion of the canal caused by foreign bodies from the accident.

ANS: 2 Frank blood or clear watery drainage (cerebrospinal leak) after trauma suggests a basal skull fracture and warrants immediate referral.

ANS: 2 If maternal rubella infection occurs during the first trimester, it can damage the organ of Corti and impair hearing.

During a skin assessment, the nurse notices that a Mexican-American patient has skin that is yellowish-brown in color. However, the skin on the hard/soft palate is a pink in color. From this finding, the nurse could probably rule out: 1.pallor. 2.jaundice. 3.cyanosis. 4.iron deficiency.

ANS: 2 Jaundice is exhibited by a yellow color, indicating rising amounts of bilirubin in the blood and is first noticed in the junction of the hard and soft palate in the mouth and in the sclera.

A patient has tingling sensations in her feet and has noticed that her tongue has become very red and painful. The nurse suspects that she has: 1.polycythemia. 2.pernicious anemia. 3.micronucleus anemia. 4.iron deficiency anemia.

ANS: 2 Pernicious anemia is indicated by neurologic deficits and a red, painful tongue along with a lemon yellow tint of the face and slightly yellow sclera.

ANS: 2 Recruitment is a marked loss occurring when sound is at low intensity; sound actually may become painful when repeated at a louder volume.

A thorough skin assessment is very important because the skin holds information about: 1.support systems. 2.circulatory status. 3.socioeconomic status. 4.psychological wellness.

ANS: 2 The skin holds information about the body's circulation, nutritional status, and signs of systemic diseases as well as topical data on the integument itself.

Jaundice is exhibited by a yellow skin color, indicating rising levels of bilirubin in the blood. Which of the following findings is indicative of true jaundice? 1.Yellow patches throughout the sclera 2.Yellow color of the sclera that extends up to the iris 3.Skin that appears yellow when examined under low light 4.Yellow deposits on the palms and soles of the feet where jaundice first appears

ANS: 2 The yellow sclera of jaundice extends up to the edge of the iris. Calluses on the palms and soles of the feet often look yellow but are not classified as jaundice.

A 17-year-old student is a swimmer on her high school's swim team. She has had three bouts of otitis externa so far this season and wants to know what to do to prevent it. The nurse instructs her to: 1. use a cotton-tipped swab to dry the ear canals thoroughly after each swim. 2. use rubbing alcohol or 2% acetic acid eardrops after every swim. 3. irrigate the ears with warm water and a bulb syringe after each swim. 4. rinse the ears with a warmed solution of mineral oil and hydrogen peroxide.

ANS: 2 With otitis externa (swimmer's ear), swimming causes the external canal to become waterlogged and swell; skinfolds are set up for infection. Prevent by using rubbing alcohol or 2% acetic acid ear drops after every swim.

In performing a voice test to assess hearing, which of the following would the nurse do? 1. Shield the lips so that the sound is muffled. 2. Whisper two-syllable words and ask the patient to repeat them. 3. Ask the patient to place his finger in his ear to occlude outside noise. 4. Stand about 4 feet away to ensure that the patient can really hear at this distance.

ANS: 2 With your head 30 to 60 cm (1 to 2 ft) from the person's ear, exhale and whisper slowly some two-syllable words such as Tuesday, armchair, baseball, or fourteen. Normally, the person repeats each word correctly after you say it.

ANS: 2, 4, 5 Presbycusis is a type of hearing loss that occurs with aging; it is a gradual sorineural loss caused by nerve degeneration in the inner ear or auditory nerve. Its onset usually occurs in the fifth decade, and then it slowly progresses. The person first notices a high-frequency tone loss; it is harder to hear consonants (high-pitched components of speech) than vowels. This makes words sound garbled. The ability to localize sound is impaired also.

A patient comes in for a physical, and she complains of "freezing to death" while waiting for her examination. The nurse notes that her skin is pale and cool and attributes this finding to: 1.venous pooling. 2.peripheral vasodilation. 3.peripheral vasoconstriction. 4.decreased arterial perfusion.

ANS: 3 A chilly or air-conditioned environment causes vasoconstriction, which results in false pallor and coolness. See Table 12-1.

A 13-year old girl is interested in obtaining information about the cause of her acne. The nurse would share with her that acne is: 1.contagious. 2.caused by a poor diet. 3.found in about 70% of all teens. 4.has been found to be related to poor hygiene.

ANS: 3 About 70% of teens will have acne, and, although the cause is unknown, it is not caused by poor diet, oily complexion, or contagion.

A patient with a middle ear infection asks the nurse, "What does the middle ear do?" The nurse responds by telling the patient that the middle ear functions to: 1. maintain balance. 2. interpret sounds as they enter the ear. 3. conduct vibrations of sounds to the inner ear. 4. increase amplitude of sound for the inner ear to function.

ANS: 3 Among its other functions, the middle ear conducts sound vibrations from the outer ear to the central hearing apparatus in the inner ear.

ANS: 3 An ulcerated crusted nodule with an indurated base that fails to heal is characteristic of a carcinoma. These lesions fail to heal and bleed intermittently. Individuals with such symptoms should be referred for a biopsy.

An Inuit visiting Nevada from Anchorage has come to the clinic in July during the hottest part of the day. It so happens that the clinic's air conditioning is broken and the temperature is very hot. The nurse knows that which of the following is true about the Inuit sweating tendencies? 1.They will sweat profusely all over their bodies because they are not used to the hot temperatures. 2.They don't sweat because their diet is so high in roughage that their apocrine glands are less efficient in hot climates. 3.They will sweat more on their faces because this is an adaptation that has been made over time for survival in their environment. 4.They have an overabundance of eccrine sweat glands and so the nurse might expect them to have body odor because of the bacterial flora reacting with the apocrine sweat.

ANS: 3 Inuits have made an interesting environmental adaptation whereby they sweat less than whites on their trunks and extremities but more on their faces.

ANS: 3 It is necessary to perform the Weber and Rinne tests to determine the type of loss. With conductive loss, sound lateralizes to the "poorer" ear owing to background room noise. With sensorineural loss, sound lateralizes to the "better" ear or unaffected ear.

A patient comes to the clinic and tells the nurse that he has been confined to his recliner chair for about 3 days with his feet down and he wants the nurse to evaluate his feet. During the assessment, the nurse might expect to find: 1.pallor. 2.coolness. 3.distended veins. 4.decreased capillary filling time.

ANS: 3 Keeping the feet in a dependent position causes venous pooling, resulting in redness, warmth and distended veins. See Table 12-1.

A patient has been admitted for severe iron deficiency anemia. The nurse can expect to see what finding in the patient's fingernails? 1.Splinter hemorrhages 2.Paronchyia 3.Koilonychia (spoon nails) 4.Beau's lines

ANS: 3 Koilonychia, or spoon nails, are thin, depressed nails with lateral edges tilted up, forming a concave profile. If all nails involved, they may be due to iron deficiency anemia.

A 70-year-old woman who loves to garden has small, flat, brown macules over her arms and hands. She asks, "What causes these liver spots?" The nurse tells her: 1."They are signs of decreased hematocrit related to anemia." 2."They are due to destruction of melanin in your skin from exposure to the sun." 3."They are clusters of melanocytes that appear after extensive sun exposure." 4."They are areas of hyperpigmentation related to decreased perfusion and vasoconstriction."

ANS: 3 Liver spots, or senile lentigines, are clusters of melanocytes that appear on the forearms and dorsa of the hands after extensive sun exposure.

A black patient is in the intensive care unit because of impending shock after an accident. The nurse would expect to find what characteristics in this patient's skin? 1.Ruddy blue 2.Generalized pallor 3.Ashen, gray, or dull 4.Patchy areas of pallor

ANS: 3 Pallor in black-skinned people will appear ashen, gray, or dull. See Table 12-2.

A 70-year-old patient tells the nurse that he has noticed that he is having trouble hearing, especially in large groups. He says he "can't always tell where the sound is coming from" and the words often sound "mixed up." What might the nurse suspect as the cause for this change? 1. Atrophy of the apocrine glands 2. Cilia becoming coarse and stiff 3. Nerve degeneration in the inner ear 4. Scarring of the tympanic membrane

ANS: 3 Presbycusis is a type of hearing loss that occurs with aging, even in people living in a quiet environment. It is a gradual sensorineural loss caused by nerve degeneration in the inner ear or auditory nerve. This makes words sound garbled. The ability to localize sound is impaired also. This communication dysfunction is accentuated when background noise is present.

The nurse is performing an otoscopic examination on an adult. Which of the following is true? 1. Tilt the person's head forward during the exam. 2. Once the speculum is in the ear, release the traction. 3. Pull the pinna up and back before inserting the speculum. 4. Use the smallest speculum to decrease the amount of discomfort.

ANS: 3 Pull the pinna up and back on an adult or older child. This helps straighten the S- shape of the canal.

A physician has diagnosed a patient with purpura. After leaving the room, a nursing student asks the nurse what the physician saw that led to that diagnosis. The nurse should say: 1."He is referring to that blue dilation of blood vessels in a star-shaped linear pattern on the legs." 2."He is referring to that fiery red, star-shaped marking on the cheek that has a solid circular center." 3."He is referring to that confluent and extensive patch of petechiae and ecchymoses on the feet." 4."He is referring to those tiny little areas of hemorrhage that are less than 2 mm, round, discrete, and dark red in color."

ANS: 3 Purpura is a confluent and extensive patch of petechiae and ecchymoses and a flat macular hemorrhage seen in generalized disorders such as thrombocytopenia and scurvy.

Which of the following cranial nerves is responsible for conducting nerve impulses to the brain from the organ of Corti? 1. CN I 2. CN III 3. CN VIII 4. CN XI

ANS: 3 The nerve impulses are conducted by the auditory portion of CN VIII to the brain.

A newborn infant is in the clinic for a well-baby check. The nurse observes the infant for the possibility of fluid loss because of which of the following? 1.Subcutaneous fat deposits are high in the newborn 2.Sebaceous glands are over productive in the newborn 3.The newborn's skin is more permeable than that of the adult 4.The amount of vernix caseosa rises dramatically in the newborn

ANS: 3 The newborn's skin is thin, smooth, and elastic and is relatively more permeable than that of the adult, so the infant is at greater risk for fluid loss.

During an examination, the patient states he is hearing a buzzing sound and says that it is "driving me crazy!" The nurse recognizes that this symptom is: 1. vertigo. 2. pruritus. 3. tinnitus. 4. cholesteatoma.

ANS: 3 Tinnitus is a sound that comes from within a person; it can be a ringing, crackling, or buzzing sound. It accompanies some hearing or ear disorders.

A patient is especially worried about an area of skin on her feet that has turned white. The health care provider has told her that her condition is vitiligo. The nurse explains to her that vitiligo is: 1.caused by an excess of melanin pigment. 2.caused by an excess of apocrine glands in her feet. 3.caused by the complete absence of melanin pigment. 4.related to impetigo and that it can be treated with an ointment.

ANS: 3 Vitiligo is the complete absence of melanin pigment in patchy areas of white or light skin on the face, neck, hands, feet, body folds, and around orifices—otherwise the depigmented skin is normal.

During an otoscopic examination, the nurse notes an area of black and white dots on the tympanic membrane and ear canal wall. What does this finding suggest? 1. Malignancy 2. Viral infection 3. Blood in the middle ear 4. Yeast or fungal infection

ANS: 4 A colony of black or white dots on the drum or canal wall suggests a yeast or fungal infection (otomycosis).

The nurse is bathing an 80-year-old man and notices that his skin is wrinkled, thin, lax, and dry. This finding would be related to: 1.increased vascularity of the skin in the elderly. 2.increased numbers of sweat and sebaceous glands in the elderly. 3.an increase in elastin and a decrease in subcutaneous fat in the elderly. 4.an increased loss of elastin and a decrease in subcutaneous fat in the elderly.

ANS: 4 An accumulation of factors place the aging person at risk for skin disease and breakdown: the thinning of the skin, the decrease in vascularity and nutrients, the loss of protective cushioning of the subcutaneous layer, a lifetime of environmental trauma to skin, the social changes of aging, the increasingly sedentary lifestyle, and the chance of immobility.

A 65-year-old man with emphysema and bronchitis has come to the clinic for a follow-up appointment. On assessment of his skin, the nurse might expect to find the following: 1.anasarca. 2.scleroderma. 3.pedal erythema. 4.clubbing of the nails.

ANS: 4 Clubbing of the nails occurs with congenital, chronic, cyanotic heart disease and with emphysema and chronic bronchitis.

A patient comes to the clinic and states that he has noticed that his skin is redder than normal. The nurse understands this condition to be due to hyperemia and knows that it can be caused by: 1.decreased amounts of bilirubin in the blood. 2.excess blood in the underlying blood vessels. 3.decreased perfusion to the surrounding tissues. 4.excess blood in the dilated superficial capillaries.

ANS: 4 Erythema is an intense redness of the skin caused by excess blood (hyperemia) in the dilated superficial capillaries.

An assessment of a 23-year-old patient reveals the following: an auricle that is tender and reddish-blue in color with small vesicles. Additional information the nurse would need to know includes which of the following? 1. Any change in the ability to hear 2. Any recent drainage from the ear 3. Recent history of trauma to the ear 4. Any prolonged exposure to extreme cold

ANS: 4 Frostbite causes reddish-blue discoloration and swelling of the auricle after exposure to extreme cold. Vesicles or bullae may develop, and the person feels pain and tenderness.

During an interview, the patient states he has the sensation that "everything around him is spinning." The nurse recognizes that the portion of the ear responsible for this sensation is: 1. the cochlea. 2. cranial nerve VIII. 3. the organ of Corti. 4. the bony labyrinth.

ANS: 4 If the labyrinth ever becomes inflamed, it feeds the wrong information to the brain, creating a staggering gait and a strong, spinning, whirling sensation called vertigo.

ANS: 4 In addition to its place in the complete examination, eardrum assessment is manda- tory for any infant or child requiring care for illness or fever. For the infant or young child, the timing of the otoscopic examination is best toward the end of the complete examination.

During the aging process, the hair can look gray or white and begin to feel thin and fine. The nurse knows that this is because of a decrease in the number of functioning: 1.metrocytes. 2.fungacytes. 3.phagocytes. 4.melanocytes.

ANS: 4 In the aging hair matrix, the number of functioning melanocytes decreases so the hair looks gray or white and feels thin and fine.

Which of the following is a risk factor for ear infections in young children? 1. Family history 2. Air conditioning 3. Excessive cerumen 4. Secondhand cigarette smoke

ANS: 4 Passive or second hand smoke is a risk factor for ear infections.

A newborn infant has Down syndrome. During the skin assessment, the nurse notices a transient mottling in the trunk and extremities in response to the cooler examination room temperature. The infant's mother also notices the mottling and asks what it is. The nurse knows that this mottling is called: 1.café au lait. 2.carotenemia. 3.acrocyanosis. 4.cutis marmorata.

ANS: 4 Persistent or pronounced cutis marmorata occurs with Down syndrome or prematurity and is a transient mottling in the trunk and extremities in response to cooler room temperatures.

The mother of a 2-year-old is concerned about the upcoming placement of tympanostomy tubes in her son's ears. The nurse would include which of the following in the teaching plan? 1. The tubes are placed in the inner ear. 2. The tubes are used in children with sensorineural loss. 3. The tubes are permanently inserted during a surgical procedure. 4. The purpose of the tubes is to decrease the pressure and allow for drainage.

ANS: 4 Polyethylene tubes are inserted surgically into the eardrum to relieve middle ear pressure and promote drainage of chronic or recurrent middle ear infections. Tubes extrude spontaneously in 6 months to 1 year.

A man has come in to the clinic for a skin assessment because he is afraid he might have skin cancer. During the skin assessment the nurse notices several areas of pigmentation that look greasy, dark, and "stuck on" his skin. Which is the best prediction? 1.He probably has senile lentigines, which do not become cancerous. 2.He probably has actinic keratoses, a precursor to basal cell carcinoma. 3.He probably has acrochordons, precursors to squamous cell carcinoma. 4.He probably has seborrheic keratoses, which do not become cancerous.

ANS: 4 Seborrheic keratoses look like dark, greasy, "stuck-on" lesions that develop mostly on the trunk. These lesions do not become cancerous.

A father brings in his 2-month-old infant to the clinic because the infant has had diarrhea for the last 24 hours. He says that his baby has not been able to keep any formula down and that the diarrhea has been at least every 2 hours. The nurse suspects dehydration. Where should the nurse test skin mobility and turgor in this infant? 1.Over the sternum 2.Over the forehead 3.Over the forearms 4.Over the abdomen

ANS: 4 Test mobility and turgor over the abdomen in an infant. Poor turgor, or "tenting," indicates dehydration or malnutrition.

The nurse educator is preparing an education module for the nursing staff on the dermis layer of skin. Which of the following would be included in the module? 1.The dermis contains mostly fat cells. 2.The dermis consists mostly of keratin. 3.The dermis is replaced every 4 weeks. 4.The dermis contains sensory receptors

ANS: 4 The dermis consists mostly of collagen, has resilient elastic tissue that allows the skin to stretch, contains nerves, sensory receptors, blood vessels, and lymphatics.

The mother of a 2-year-old is concerned because her son has had three ear infections in the past year. What would be an appropriate response by the nurse? 1. "It is unusual for a small child to have frequent ear infections unless there is something else wrong." 2. "We need to check the immune system of your son to see why he is having so many ear infections." 3. "Ear infections are not uncommon in infants and toddlers because they tend to have more cerumen in the external ear." 4. "Your son's eustachian tube is shorter and wider than yours because of his age, which allows for infections to develop more easily."

ANS: 4 The infant's eustachian tube is relatively shorter and wider, and its position is more horizontal than the adult's, so it is easier for pathogens from the nasopharynx to migrate through to the middle ear.

In an individual with otitis externa, which of the following signs would the nurse expect to find on assessment? 1. Rhinorrhea 2. Periorbital edema 3. Pain over the maxillary sinuses 4. Enlarged superficial cervical nodes

ANS: 4 The lymphatic drainage of the external ear flows to the parotid, mastoid, and superficial cervical nodes. The signs are severe swelling of the canal, inflammation, and tenderness.

Which of the following assessment findings is most consistent with clubbing of the fingernails? 1.A nail base that is firm to palpation and slightly tender 2.Curved nails with a convex profile and ridges across the nail 3.A nail base that feels spongy with an angle of the nail base of 150 degrees 4.An angle of the nail base of 180 degrees or greater with a nail base that feels spongy

ANS: 4 The normal nail is firm at its base and has an angle of 160 degrees. In clubbing, the angle straightens to 180 degrees or greater and the nail base feels spongy.

A mother brings her child in to the clinic for an examination of the scalp and hair. She states that the child has developed some places where there are irregularly shaped patches with broken-off, stub-like hair and she is worried that this could be some form of premature baldness. She tells the nurse that the child's hair is always kept very short. The nurse reassures her by telling her that it is: 1.folliculitis and that it can be treated with an antibiotic. 2.traumatic alopecia that can be treated with antifungal medications. 3.tinea capitis and that it is highly contagious and needs immediate attention. 4.trichotillomania and that her child probably has a habit of twirling her hair absent- mindedly.

ANS: 4 Trichotillomania, self-induced hair loss, is usually due to habit. It forms irregularly- shaped patches with broken-off, stub-like hairs of varying lengths. A person is never completely bald. It occurs as a child rubs or twirls the area absently while falling asleep, reading, or watching television.

The nurse notices that a patient has bluish-white, red-based spots in her mouth that are elevated about 1 mm to 3 mm. What other signs would the nurse expect to find in this patient? 1.A pink, papular rash on the face and neck 2.Pruritic vesicles over her trunk and neck 3.Hyperpigmentation on the chest, abdomen, and the back of the arms 4.A red-purple, maculopapular, blotchy rash behind the ears and on the face

ANS: 4 With measles (rubeola), the examiner would assess a red-purple, blotchy rash on the third or fourth day of illness that appears first behind the ears and spreads over the face and then over the neck, trunk, arms and legs. It looks coppery and does not blanch. Koplik's spots in the mouth would also be found.

33. The nurse is performing an assessment on a 7-year-old child who has symptoms of chronic watery eyes, sneezing, and clear nasal drainage. The nurse notices the presence of a transverse line across the bridge of the nose, dark blue shadows below the eyes, and a double crease on the lower eyelids. These findings are characteristic of: a. Allergies. b. Sinus infection. c. Nasal congestion. d. Upper respiratory infection.

ANS: A Chronic allergies often develop chronic facial characteristics and include blue shadows below the eyes, a double or single crease on the lower eyelids, open-mouth breathing, and a transverse line on the nose.

21. The nurse suspects that a patient has hyperthyroidism, and the laboratory data indicate that the patients T4 and T3 hormone levels are elevated. Which of these findings would the nurse most likely find on examination? a. Tachycardia b. Constipation c. Rapid dyspnea d. Atrophied nodular thyroid gland

ANS: A T4 and T3 are thyroid hormones that stimulate the rate of cellular metabolism, resulting in tachycardia. With an enlarged thyroid gland as in hyperthyroidism, the nurse might expect to find diffuse enlargement (goiter) or a nodular lump but not an atrophied gland. Dyspnea and constipation are not findings associated with hyperthyroidism.

8. A patients laboratory data reveal an elevated thyroxine (T4) level. The nurse would proceed with an examination of the _____ gland. a. Thyroid b. Parotid c. Adrenal d. Parathyroid

ANS: A The thyroid gland is a highly vascular endocrine gland that secretes T4 and triiodothyronine (T3). The other glands do not secrete T4.

37. During an examination, the nurse knows that the best way to palpate the lymph nodes in the neck is described by which statement? a. Using gentle pressure, palpate with both hands to compare the two sides. b. Using strong pressure, palpate with both hands to compare the two sides. c. Gently pinch each node between ones thumb and forefinger, and then move down the neck muscle. d. Using the index and middle fingers, gently palpate by applying pressure in a rotating pattern.

ANS: A Using gentle pressure is recommended because strong pressure can push the nodes into the neck muscles. Palpating with both hands to compare the two sides symmetrically is usually most efficient.

27. When examining children affected with Down syndrome (trisomy 21), the nurse looks for the possible presence of: a. Ear dysplasia. b. Long, thin neck. c. Protruding thin tongue. d. Narrow and raised nasal bridge.

ANS: A With the chromosomal aberration trisomy 21, also known as Down syndrome, head and face characteristics may include upslanting eyes with inner epicanthal folds, a flat nasal bridge, a small broad flat nose, a protruding thick tongue, ear dysplasia, a short broad neck with webbing, and small hands with a single palmar crease.

A 75-year-old woman who has a history of diabetes and peripheral vascular disease has been trying to remove a corn on the bottom of her foot with a pair of scissors. The nurse will encourage her to stop trying to remove the corn with scissors because: a. The woman could be at increased risk for infection and lesions because of her chronic disease. b. With her diabetes, she has increased circulation to her foot, and it could cause severe bleeding. c. She is 75 years old and is unable to see; consequently, she places herself at greater risk for self-injury with the scissors. d. With her peripheral vascular disease, her range of motion is limited and she may not be able to reach the corn safely.

ANS: A A personal history of diabetes and peripheral vascular disease increases a person's risk for skin lesions in the feet or ankles. The patient needs to seek a professional for assistance with corn removal.

34. The nurse is reviewing statistics for lactose intolerance. In the United States, the incidence of lactose intolerance is higher in adults of which ethnic group? A) African-Americans B) Hispanics C) Whites D) Asians

ANS: A A recent study found lactose-intolerance prevalence estimates as follows: 19.5% for African-Americans, 10% for Hispanics, and 7.72% for whites

A patient tells the nurse that he has noticed that one of his moles has started to burn and bleed. When assessing his skin, the nurse pays special attention to the danger signs for pigmented lesions and is concerned with which additional finding? a. Color variation b. Border regularity c. Symmetry of lesions d. Diameter of less than 6 mm

ANS: A Abnormal characteristics of pigmented lesions are summarized in the mnemonic ABCD: asymmetry of pigmented lesion, border irregularity, color variation, and diameter greater than 6 mm.

19. A nurse notices that a patient has ascites, which indicates the presence of: A) fluid. B) feces. C) flatus. D) fibroid tumors.

ANS: A Ascites is free fluid in the peritoneal cavity, and occurs with heart failure, portal hypertension, cirrhosis, hepatitis, pancreatitis, and cancer.

29. Just before going home, a new mother asks the nurse about the infant's umbilical cord. Which of these statements is correct? A) "It should fall off by 10 to 14 days." B) "It will soften before it falls off." C) "It contains two veins and one artery." D) "Skin will cover the area within 1 week."

ANS: A At birth, the umbilical cord is white and contains two umbilical arteries and one vein inside the Wharton jelly. The umbilical stump dries within a week, hardens, and falls off by 10 to 14 days. Skin will cover the area by 3 to 4 weeks.

37. During an oral examination of a 4-year-old American-Indian child, the nurse notices that her uvula is partially split. Which of these statements is accurate? a. A bifid uvula may occur in some American-Indian groups. b. This condition is a cleft palate and is common in American Indians. c. A bifid uvula is torus palatinus, which frequently occurs in American Indians. d. This condition is due to an injury and should be reported to the authorities.

ANS: A Bifid uvula, a condition in which the uvula is split either completely or partially, occurs in some American-Indian groups. This finding is not a cleft palate, a torus palatinus (benign bony ridge running in the middle of the hard palate), or due to injury.

While performing an assessment of a 65-year-old man with a history of hypertension and coronary artery disease, the nurse notices the presence of bilateral pitting edema in the lower legs. The skin is puffy and tight but normal in color. No increased redness or tenderness is observed over his lower legs, and the peripheral pulses are equal and strong. In this situation, the nurse suspects that the likely cause of the edema is which condition? a. Heart failure b. Venous thrombosis c. Local inflammation d. Blockage of lymphatic drainage

ANS: A Bilateral edema or edema that is generalized over the entire body is caused by a central problem such as heart failure or kidney failure. Unilateral edema usually has a local or peripheral cause.

The nurse is reviewing venous blood flow patterns. Which of these statements best describes the mechanism(s) by which venous blood returns to the heart? A) Intraluminal valves ensure unidirectional flow toward the heart. B) Contracting skeletal muscles milk blood distally toward the veins. C) The high-pressure system of the heart helps to facilitate venous return. D) Increased thoracic pressure and decreased abdominal pressure facilitate venous return to the heart.

ANS: A Blood moves through the veins by (1) contracting skeletal muscles that milk the blood proximally; (2) pressure gradients caused by breathing, in which inspiration makes the thoracic pressure decrease and the abdominal pressure increase; and (3) the intraluminal valves, which ensure unidirectional flow toward the heart.

26. A 40-year-old patient who has just finished chemotherapy for breast cancer tells the nurse that she is concerned about her mouth. During the assessment the nurse finds areas of buccal mucosa that are raw and red with some bleeding, as well as other areas that have a white, cheesy coating. What do these findings indicate? a. Candidiasis b. Leukoplakia c. Koplik spots d. Aphthous ulcers

ANS: A Candidiasis is a white, cheesy, curdlike patch on the buccal mucosa and tongue. It scrapes off, leaving a raw, red surface that easily bleeds. It also occurs after the use of antibiotics or corticosteroids and in people who are immunosuppressed. Leukoplakia appears as chalky white, thick, raised patches with well-defined borders on the buccal mucosa. Koplik spots are small blue-white spots with irregular red halo scattered over mucosa opposite the molars and is an early sign of measles. Aphthous ulcers, or canker sores, first appear as a vesicle and then a small, round, "punched out" ulcer with a white base surrounded by a red halo and are quite painful and last for 1-2 weeks. The findings for this patient indicate candidiasis.

The nurse just noted from the medical record that the patient has a lesion that is confluent in nature. On examination, the nurse expects to find: a. Lesions that run together. b. Annular lesions that have grown together. c. Lesions arranged in a line along a nerve route. d. Lesions that are grouped or clustered together.

ANS: A Confluent lesions (as with urticaria [hives]) run together. Grouped lesions are clustered together. Annular lesions are circular in nature. Zosteriform lesions are arranged along a nerve route.

17. During an assessment of a 20-year-old patient with a 3-day history of nausea and vomiting, the nurse notices dry mucosa and deep vertical fissures in the tongue. What do these findings indicate? a. Dehydration b. A normal oral assessment c. Irritation from gastric juices d. Side effects from nausea medication

ANS: A Dehydration can cause dry mouth and deep vertical fissures in the tongue (due to reduced tongue volume). These finding are not normal and are not associated with irritation from gastric juices or from nausea caused by medications.

A 67-year-old patient states that he recently began to have pain in his left calf when climbing the 10 stairs to his apartment. This pain is relieved by sitting for about 2 minutes; then he is able to resume his activities. The nurse interprets that this patient is most likely experiencing: A) claudication. B) sore muscles. C) muscle cramps. D) venous insufficiency.

ANS: A Intermittent claudication feels like a "cramp" and is usually relieved by rest within 2 minutes. The other responses are not correct.

24. During an assessment of a newborn infant, the nurse recalls that pyloric stenosis would be manifested by: A) projectile vomiting. B) hypoactive bowel activity. C) palpable olive-sized mass in right lower quadrant. D) pronounced peristaltic waves crossing from right to left.

ANS: A Marked peristalsis together with projectile vomiting in the newborn suggests pyloric stenosis. After feeding, pronounced peristaltic waves cross from left to right, leading to projectile vomiting. One can also palpate an olive-sized mass in the right upper quadrant

13. The nurse is using an otoscope to assess the nasal cavity. Which of these techniques is correct? a. Avoiding touching the nasal septum with the speculum b. Inserting the speculum at least 3 cm into the vestibule c. Gently displacing the nose to the side that is being examined d. Keeping the speculum tip medial to avoid touching the floor of the nares

ANS: A The correct technique for using an otoscope to examine the nasal cavity is to insert the apparatus into the nasal vestibule, avoiding pressure on the sensitive nasal septum. The tip of the nose should be lifted up before inserting the speculum.

36. During a checkup, a 22-year-old woman tells the nurse that she uses an over-the-counter nasal spray because of her allergies. She also states that it does not work as well as it used to when she first started using it. Which is the best response by the nurse? a. "You should never use over-the-counter nasal sprays because of the risk for addiction." b. "You should try switching to another brand of medication to prevent this problem." c. "Continuing to use this spray is important to keep your allergies under control." d. "Frequent use of these nasal medications irritates the lining of the nose and may cause rebound swelling."

ANS: A The dorsal surface of the tongue is normally roughened from papillae. A thin white coating may be present. The ventral surface may show veins. Smooth, glossy areas are abnormal and may indicate atrophic glossitis.

33. When palpating the abdomen of a 20-year-old patient, the nurse notices the presence of tenderness in the left upper quadrant with deep palpation. Which of these structures is most likely to be involved? A) Spleen B) Sigmoid colon C) Appendix D) Gallbladder

ANS: A The spleen is located in the left upper quadrant of the abdomen. The gallbladder is in the right upper quadrant, the sigmoid colon is in the left lower quadrant, and the appendix is in the right lower quadrant

A patient has hard, nonpitting edema of the left lower leg and ankle. The right leg has no edema. Based on these findings, the nurse recalls that: A) nonpitting, hard edema occurs with lymphatic obstruction. B) alterations in arterial function will cause this edema. C) phlebitis of a superficial vein will cause bilateral edema. D) long-standing arterial obstruction will cause pitting edema.

ANS: A Unilateral edema occurs with occlusion of a deep vein and with unilateral lymphatic obstruction. With these factors, the edema is nonpitting and feels hard to the touch (brawny edema).

A patient has been diagnosed with venous stasis. Which of these findings would the nurse most likely observe? a. Unilateral cool foot b. Thin, shiny, atrophic skin c. Pallor of the toes and cyanosis of the nail beds d. Brownish discoloration to the skin of the lower leg

ANS: A brownish discoloration to the skin of the lower leg A brown discoloration occurs with chronic venous stasis as a result of hemosiderin deposits (a by-product of red blood cell degradation). Pallor, cyanosis, atrophic skin, and unilateral coolness are all signs associated with arterial problems.

Which of these assessment findings would the nurse expect to see when examining the eyes of a black patient?

ANS: A dark retinal background There is an ethnically based variability in the color of the iris and in retinal pigmentation, with darker irides having darker retinas behind them.

The nurse is assessing an 80-year-old patient. Which of these findings would be expected for this patient?

ANS: A decreased ability to identify odors The sense of smell may be reduced because of a decrease in the number of olfactory nerve fibers. Nasal hairs grow coarser and stiffer with aging. The gums may recede with aging, not hypertro-phy, and there is a decrease in saliva production.

A patient comes into the emergency department after an accident at work. A machine blew dust into his eyes and he was not wearing safety glasses. The nurse examines his corneas by shining a light from the side across the cornea. What findings would suggest that he has suffered a *corneal abrasion*?

ANS: A shattered look to the light rays reflecting off the cornea A corneal abrasion causes irregular ridges in reflected light, which produce a shattered look to light rays. There should be no opacities in the cornea. The other responses are not correct.

1. During an assessment, a patient mentions that "I just can't smell like I used to. I can barely smell the roses in my garden. Why is that?" For which possible causes of changes in the sense of smell will the nurse assess? (Select all that apply.) a. Aging b. Chronic allergies c. Cigarette smoking d. Chronic alcohol use e. Herpes simplex virus I f. Frequent episodes of strep throat

ANS: A, B, C The sense of smell diminishes with cigarette smoking, chronic allergies, and aging. Chronic alcohol use, a history of strep throat, and herpes simplex virus I are not associated with changes in the sense of smell. Chronic alcohol use, herpes simplex virus I, and frequent episodes of strep throat do not common causes of a diminished sense of smell. The sense of smell diminishes with cigarette smoking, chronic allergies, and aging. Chronic alcohol use, a history of strep throat, and herpes simplex virus I are not associated with changes in the sense of smell.

The nurse is preparing for a certification course in skin care and needs to be familiar with the various lesions that may be identified on assessment of the skin. Which of the following definitions are correct? Select all that apply. a. Petechiae: Tiny punctate hemorrhages, 1 to 3 mm, round and discrete, dark red, purple, or brown in color b. Bulla: Elevated, circumscribed lesion filled with turbid fluid (pus) c. Papule: Hypertrophic scar d. Vesicle: Known as a friction blister e. Nodule: Solid, elevated, and hard or soft growth that is larger than 1 cm

ANS: A, D, E A pustule is an elevated, circumscribed lesion filled with turbid fluid (pus). A hypertrophic scar is a keloid. A bulla is larger than 1 cm and contains clear fluid. A papule is solid and elevated but measures less than 1 cm.

A patient is recovering from several hours of orthopedic surgery. During an assessment of the patient's lower legs, the nurse will monitor for signs of acute venous symptoms. Signs of acute venous symptoms include which of the following? Select all that apply. A) Intense, sharp pain, with the deep muscle tender to touch B) Aching, tired pain, with a feeling of fullness C) Pain is worse at the end of the day D) Sudden onset E) Warm, red, and swollen calf F) Pain that is relieved with elevation of leg

ANS: A, D, E Signs and symptoms of acute venous problems include pain in the calf that has a sudden onset and that is intense and sharp with tenderness in the deep muscle when touched. The calf is warm, red, and swollen. The other options are symptoms of chronic venous problems.

A patient is recovering from several hours of orthopedic surgery. During an assessment of the patient's lower legs, the nurse will monitor for signs of acute venous symptoms. Signs of acute venous symptoms include which of the following? Select all that apply. a. Intense, sharp pain, with the deep muscle tender to the touch b. Aching, tired pain, with a feeling of fullness c. Pain that is worse at the end of the day d. Sudden onset e. Warm, red, and swollen calf f. Pain that is relieved with elevation of the leg

ANS: A. Intense, sharp pain, with the deep muscle tender to touch D. Sudden onset E. Warm, red, and swollen calf Signs and symptoms of acute venous problems include pain in the calf that has a sudden onset and that is intense and sharp with tenderness in the deep muscle when touched. The calf is warm, red, and swollen. The other options are symptoms of chronic venous problems.

A patient has been admitted with chronic arterial symptoms. During the assessment, the nurse should expect which findings? Select all that apply. a. Patient has a history of diabetes and cigarette smoking. b. Skin of the patient is pale and cool. c. His ankles have two small, weeping ulcers. d. Patient works long hours sitting at a computer desk. e. He states that the pain gets worse when walking. f. Patient states that the pain is worse at the end of the day.

ANS: A. The patient has a history of diabetes and cigarette smoking. B. The patient's skin is pale and cool. E. The patient states that the pain gets worse when walking. See Table 20-3. Patients with chronic arterial symptoms often have a history of smoking and diabetes (among other risk factors). The pain has a gradual onset, with exertion, and is relieved with rest or dangling. The skin appears cool and pale. The other responses reflect chronic venous problems.

The electrical stimulus of the cardiac cycle follows which sequence? a. AV node SA node bundle of His b. Bundle of His AV node SA node c. SA node AV node bundle of His bundle branches d. AV node SA node bundle of His bundle branches

ANS: AV node SA node bundle of His bundle branches Specialized cells in the SA node near the superior vena cava initiate an electrical impulse. The current flows in an orderly sequence, first across the atria to the AV node low in the atrial septum. There it is delayed slightly so that the atria have time to contract before the ventricles are stimulated. Then the impulse travels to the bundle of His, the right and left bundle branches, and then through the ventricles.

A patient is complaining of severe knee pain after twisting it during a basketball game and is requesting pain medication. Which action by the nurse is appropriate?

ANS: Administer pain medication and then proceed with the assessment. According to the American Pain Society (1992), "In cases in which the cause of acute pain is uncertain, establishing a diagnosis is a priority, but symptomatic treatment of pain should be given while the investigation is proceeding. With occasional exceptions, (e.g., the initial examination of the patient with an acute condition of the abdomen), it is rarely justified to defer analgesia until a diagnosis is made. In fact, a comfortable patient is better able to cooperate with diagnostic procedures."

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?

ANS: Allow the child to keep a security object such as a toy or blanket during the examination. The best place to examine the toddler is on the parent's lap. Toddlers understand symbols, so a security object is helpful. Initially, focus more on the parent. This allows the child to gradually adjust and become familiar with you. A 2-year-old child does not like to take off his or her clothes. Have the parent undress one body part at a time.

The nurse is reviewing *causes of increased intraocular pressure*. Which of these factors determines intraocular pressure?

ANS: Amount of aqueous produced and resistance to its outflow at the angle of the anterior chamber Intraocular pressure is determined by a balance between the amount of aqueous produced and resistance to its outflow at the angle of the anterior chamber. The other responses are incorrect.

The nurse is preparing to assess the ankle-brachial index (ABI) of a patient. Which statement about the ABI is true? a. Normal ABI indices are from 0.5 to 1.0. b. Normal ankle pressure is slightly lower than the brachial pressure. c. The ABI is a reliable measurement of peripheral vascular disease in individuals with diabetes. d. An ABI of 0.9 to 0.7 indicates the presence of peripheral vascular disease and mild claudication.

ANS: An ABI of 0.90 to 0.70 indicates the presence of peripheral vascular disease and mild claudication. Use of the Doppler stethoscope is a noninvasive way to determine the extent of peripheral vascular disease. The normal ankle pressure is slightly greater than or equal to the brachial pressure. An ABI of 0.90 to 0.70 indicates the presence of peripheral vascular disease and mild claudication. The ABI is less reliable in patients with diabetes mellitus because of claudication, which makes the arteries noncompressible and may give a falsely high ankle pressure.

A patient has a long history of chronic obstructive pulmonary disease. During the assessment, the nurse is most likely to observe which of these?

ANS: An anteroposterior-to-transverse diameter ratio of 1:1 An anteroposterior-to-transverse diameter of 1:1 or "barrel chest" is seen in individuals with chronic obstructive pulmonary disease because of hyperinflation of the lungs. The ribs are more horizontal, and the chest appears as if held in continuous inspiration. Neck muscles are hypertrophied from aiding in forced respiration. Chest expansion may be decreased but symmetric. Decreased tactile fremitus occurs from decreased transmission of vibrations.

An assessment of a 23-year-old patient reveals the following: an *auricle that is tender and reddish-blue in color with small vesicles*. Additional information the nurse would need to know includes which of these?

ANS: Any prolonged exposure to extreme cold Frostbite causes reddish-blue discoloration and swelling of the auricle after exposure to extreme cold. Vesicles or bullae may develop, and the person feels pain and tenderness.

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?

ANS: Appear unhurried and confident when examining him. Anxiety can be reduced by an examiner who is confident, self-assured, considerate, and unhurried. Familiar and relatively nonthreatening actions, such as measuring the person's vital signs, will gradually accustom the person to the examination.

When examining an aging adult, the nurse should use which technique?

ANS: Arrange the sequence to allow as few position changes as possible. When examining the aging adult, it is best to arrange the sequence of the examination to allow as few position changes as possible. Physical touch is especially important with the aging person because other senses may be diminished.

The nurse is attempting to assess the femoral pulse in an obese patient. Which of these actions would be most appropriate? a. The patient is asked to assume a prone position. b. The patient is asked to bend his or her knees to the side in a froglike position. c. The nurse firmly presses against the bone with the patient in a semi-Fowler position. d. The nurse listens with a stethoscope for pulsations; palpating the pulse in an obese person is extremely difficult.

ANS: Ask the patient to bend his or her knees to the side in a froglike position. To help expose the femoral area, particularly in obese people, the nurse should ask the person to bend his or her knees to the side in a froglike position.

Which of these techniques best describes the test the nurse should use to assess the function of cranial nerve X?

ANS: Ask the patient to say "ahhh" and watch for movement of the soft palate and uvula. Ask the person to say "ahhh" and note that the soft palate and uvula rise in the midline. This tests one function of CN X, which is the vagus nerve. Cranial nerves IX and X are tested by eliciting the gag reflex. Cranial nerve XII is tested by asking the patient to stick out his or her tongue.

During an assessment the nurse notices that an elderly patient has tears rolling down his face from his left eye. Closer examination shows that the lower lid is loose and rolling outward. The patient complains of his eye feeling "dry and itchy." Which action by the nurse is correct?

ANS: Assess for other signs of ectropion. The condition described is known as ectropion, and it occurs in aging due to atrophy of elastic and fibrous tissues. The lower lid does not approximate to the eyeball, and, as a result, the puncta cannot siphon tears effectively, and excessive tearing results. Ptosis is drooping of the upper eyelid. These are not signs of a foreign body in the eye or basal cell carcinoma.

During an admission assessment of a patient with dementia, the nurse assesses for pain because the patient has recently had several falls. Which of these are appropriate for the nurse to assess in a patient with dementia? Select all that apply.

ANS: Assess the patient's breathing independent of vocalization., Note whether the patient is calling out, groaning, or crying., Observe the patient's body language for pacing and agitation. Patients with dementia may say "no" when, in reality, they are very uncomfortable because words have lost their meaning. Patients with dementia become less able to identify and describe pain over time, even though pain is still present. People with dementia communicate pain through their behaviors. Agitation, pacing, and repetitive yelling may indicate pain and not a worsening of the dementia. See Figure 10-10 for the Pain Assessment in Advanced Dementia (PAINAD) Scale, which may also be used to assess pain in persons with dementia.

The nurse is examining an infant and prepares to elicit the Moro reflex at which time during the examination?

ANS: At the end of the examination Elicit the Moro or "startle" reflex at the end of the examination because it may cause the infant to cry.

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?

ANS: Auscultate the lungs and heart while the infant is still sleeping. When the infant is quiet or sleeping is an ideal time to assess the cardiac, respiratory, and abdominal systems. Assessment of the eye, ear, nose, and throat are invasive procedures and should be performed at the end of the examination.

When assessing a patient the nurse notes that the left femoral pulse as diminished, 1+/4+. What should the nurse do next? a. Document the finding. b. Auscultate the site for a bruit. c. Check for calf pain. d. Check capillary refill in the toes.

ANS: Auscultate the site for a bruit. If a pulse is weak or diminished at the femoral site, the nurse should auscultate for a bruit. Presence of a bruit, or turbulent blood flow, indicates partial occlusion. The other responses are not correct.

14. A patient reports excruciating headache pain on one side of his head, especially around his eye, forehead, and cheek that has lasted approximately to 2 hours, occurring once or twice each day. The nurse should suspect: a. Hypertension. b. Cluster headaches. c. Tension headaches. d. Migraine headaches.

ANS: B Cluster headaches produce pain around the eye, temple, forehead, and cheek and are unilateral and always on the same side of the head. They are excruciating and occur once or twice per day and last to 2 hours each.

32. During an assessment of an infant, the nurse notes that the fontanels are depressed and sunken. The nurse suspects which condition? a. Rickets b. Dehydration c. Mental retardation d. Increased intracranial pressure

ANS: B Depressed and sunken fontanels occur with dehydration or malnutrition. Mental retardation and rickets have no effect on the fontanels. Increased intracranial pressure would cause tense or bulging and possibly pulsating fontanels.

4. A patient is unable to differentiate between sharp and dull stimulation to both sides of her face. The nurse suspects: a. Bell palsy. b. Damage to the trigeminal nerve. c. Frostbite with resultant paresthesia to the cheeks. d. Scleroderma.

ANS: B Facial sensations of pain or touch are mediated by CN V, which is the trigeminal nerve. Bell palsy is associated with CN VII damage. Frostbite and scleroderma are not associated with this problem.

35. The nurse has just completed a lymph node assessment on a 60-year-old healthy female patient. The nurse knows that most lymph nodes in healthy adults are normally: a. Shotty. b. Nonpalpable. c. Large, firm, and fixed to the tissue. d. Rubbery, discrete, and mobile.

ANS: B Most lymph nodes are nonpalpable in adults. The palpability of lymph nodes decreases with age. Normal nodes feel movable, discrete, soft, and nontender.

9. A patient says that she has recently noticed a lump in the front of her neck below her Adams apple that seems to be getting bigger. During the assessment, the finding that leads the nurse to suspect that this may not be a cancerous thyroid nodule is that the lump (nodule): a. Is tender. b. Is mobile and not hard. c. Disappears when the patient smiles. d. Is hard and fixed to the surrounding structures.

ANS: B Painless, rapidly growing nodules may be cancerous, especially the appearance of a single nodule in a young person. However, cancerous nodules tend to be hard and fixed to surrounding structures, not mobile.

19. A patient has come in for an examination and states, I have this spot in front of my ear lobe on my cheek that seems to be getting bigger and is tender. What do you think it is? The nurse notes swelling below the angle of the jaw and suspects that it could be an inflammation of his: a. Thyroid gland. b. Parotid gland. c. Occipital lymph node. d. Submental lymph node.

ANS: B Swelling of the parotid gland is evident below the angle of the jaw and is most visible when the head is extended. Painful inflammation occurs with mumps, and swelling also occurs with abscesses or tumors. Swelling occurs anterior to the lower ear lobe.

6. A patient comes to the clinic complaining of neck and shoulder pain and is unable to turn her head. The nurse suspects damage to CN ______ and proceeds with the examination by _____________. a. XI; palpating the anterior and posterior triangles b. XI; asking the patient to shrug her shoulders against resistance c. XII; percussing the sternomastoid and submandibular neck muscles d. XII; assessing for a positive Romberg sign

ANS: B The major neck muscles are the sternomastoid and the trapezius. They are innervated by CN XI, the spinal accessory. The innervated muscles assist with head rotation and head flexion, movement of the shoulders, and extension and turning of the head.

12. A mother brings her newborn in for an assessment and asks, Is there something wrong with my baby? His head seems so big. Which statement is true regarding the relative proportions of the head and trunk of the newborn? a. At birth, the head is one fifth the total length. b. Head circumference should be greater than chest circumference at birth. c. The head size reaches 90% of its final size when the child is 3 years old. d. When the anterior fontanel closes at 2 months, the head will be more proportioned to the body.

ANS: B The nurse recognizes that during the fetal period, head growth predominates. Head size is greater than chest circumference at birth, and the head size grows during childhood, reaching 90% of its final size when the child is age 6 years.

20. A male patient with a history of acquired immunodeficiency syndrome (AIDS) has come in for an examination and he states, I think that I have the mumps. The nurse would begin by examining the: a. Thyroid gland. b. Parotid gland. c. Cervical lymph nodes. d. Mouth and skin for lesions.

ANS: B The parotid gland may become swollen with the onset of mumps, and parotid enlargement has been found with human immunodeficiency virus (HIV).

11. The nurse is watching a new graduate nurse perform auscultation of a patient's abdomen. Which statement by the new graduate shows a correct understanding of the reason auscultation precedes percussion and palpation of the abdomen? A) "We need to determine areas of tenderness before using percussion and palpation." B) "It prevents distortion of bowel sounds that might occur after percussion and palpation." C) "It allows the patient more time to relax and therefore be more comfortable with the physical examination." D) "This prevents distortion of vascular sounds such as bruits and hums that might occur after percussion and palpation."

ANS: B Auscultation is performed first (after inspection) because percussion and palpation can increase peristalsis, which would give a false interpretation of bowel sounds.

A 52-year-old woman has a papule on her nose that has rounded, pearly borders and a central red ulcer. She said she first noticed it several months ago and that it has slowly grown larger. The nurse suspects which condition? a. Acne b. Basal cell carcinoma c. Melanoma d. Squamous cell carcinoma

ANS: B Basal cell carcinoma usually starts as a skin-colored papule that develops rounded, pearly borders with a central red ulcer. It is the most common form of skin cancer and grows slowly. This description does not fit acne lesions. (See Table 12-11 for descriptions of melanoma and squamous cell carcinoma.)

12. The nurse is listening to bowel sounds. Which of these statements is true of bowel sounds? A) They are usually loud, high-pitched, rushing, tinkling sounds. B) They are usually high-pitched, gurgling, irregular sounds. C) They sound like two pieces of leather being rubbed together. D) They originate from the movement of air and fluid through the large intestine.

ANS: B Bowel sounds are high-pitched, gurgling, cascading sounds that occur irregularly from 5 to 30 times per minute. They originate from the movement of air and fluid through the small intestine.

A patient has a positive Homans' sign. The nurse knows that a positive Homans' sign may indicate: A) venous insufficiency. B) deep vein thrombosis. C) severe edema. D) problems with arterial circulation.

ANS: B Calf pain on dorsiflexion of the foot is a positive Homans' sign, which occurs in about 35% of deep vein thromboses. It also occurs with superficial phlebitis, Achilles tendinitis, and gastrocnemius and plantar muscle injury.

A 22-year-old woman comes to the clinic because of severe sunburn and states, "I was out in the sun for just a couple of minutes." The nurse begins a medication review with her, paying special attention to which medication class? a. Nonsteroidal antiinflammatory drugs for pain b. Tetracyclines for acne c. Proton pump inhibitors for heartburn d. Thyroid replacement hormone for hypothyroidism

ANS: B Drugs that may increase sunlight sensitivity and give a burn response include sulfonamides, thiazide diuretics, oral hypoglycemic agents, and tetracycline.

17. An older patient has been diagnosed with pernicious anemia. The nurse knows that this condition could be related to: A) increased gastric acid secretion. B) decreased gastric acid secretion. C) delayed gastrointestinal emptying time. D) increased gastrointestinal emptying time.

ANS: B Gastric acid secretion decreases with aging, and this may cause pernicious anemia (because it interferes with vitamin B12 absorption), iron deficiency anemia, and malabsorption of calcium.

When assessing a patient the nurse notes that the left femoral pulse as diminished, 1+/4+. What should the nurse do next? A) Document the finding. B) Auscultate the site for a bruit. C) Check for calf pain. D) Check capillary refill in the toes.

ANS: B If a pulse is weak or diminished at the femoral site, the nurse should auscultate for a bruit. Presence of a bruit, or turbulent blood flow, indicates partial occlusion. The other responses are not correct.

A mother has noticed that her son, who has been to a new babysitter, has some blisters and scabs on his face and buttocks. On examination, the nurse notices moist, thin-roofed vesicles with a thin erythematous base and suspects: a. Eczema. b. Impetigo. c. Herpes zoster. d. Diaper dermatitis.

ANS: B Impetigo is moist, thin-roofed vesicles with a thin erythematous base and is a contagious bacterial infection of the skin and most common in infants and children. Eczema is characterized by erythematous papules and vesicles with weeping, oozing, and crusts. Herpes zoster (i.e., chickenpox or varicella) is characterized by small, tight vesicles that are shiny with an erythematous base. Diaper dermatitis is characterized by red, moist maculopapular patches with poorly defined borders.

23. The nurse is assessing the abdomen of an aging adult. Which of these statements regarding the aging adult and abdominal assessment is true? A) The abdominal tone is increased. B) The abdominal musculature is thinner. C) Abdominal rigidity with acute abdominal conditions is more common. D) The aging person complains of more pain with an acute abdominal condition than a younger person would.

ANS: B In the aging person, the abdominal musculature is thinner and has less tone than that of the younger adult, and abdominal rigidity with acute abdominal conditions is less common in aging. The aging person often complains less of pain than a younger person would with an acute abdominal condition.

During an assessment the nurse has elevated a patient's legs 12 inches off the table and has had him wag his feet to drain off venous blood. After helping him to sit up and dangle his legs over the side of the table, the nurse should expect a normal finding at this point would be: A) marked elevational pallor. B) venous filling within 15 seconds. C) no change in coloration of the skin. D) color returning to the feet within 20 seconds of assuming a sitting position

ANS: B In this test it normally takes 10 seconds or less for the color to return to the feet and 15 seconds for the veins of the feet to fill. Marked elevational pallor as well as delayed venous filling occurs with arterial insufficiency.

During a skin assessment, the nurse notices that a Mexican-American patient has skin that is yellowish-brown; however, the skin on the hard and soft palate is pink and the patient's scleras are not yellow. From this finding, the nurse could probably rule out: a. Pallor b. Jaundice c. Cyanosis d. Iron deficiency

ANS: B Jaundice is exhibited by a yellow color, which indicates rising levels of bilirubin in the blood. Jaundice is first noticed in the junction of the hard and soft palate in the mouth and in the scleras.

The nurse is assessing the skin of a patient who has acquired immunodeficiency syndrome (AIDS) and notices multiple patchlike lesions on the temple and beard area that are faint pink in color. The nurse recognizes these lesions as: a. Measles (rubeola). b. Kaposi's sarcoma. c. Angiomas. d. Herpes zoster.

ANS: B Kaposi's sarcoma is a vascular tumor that, in the early stages, appears as multiple, patchlike, faint pink lesions over the patient's temple and beard areas. Measles is characterized by a red-purple maculopapular blotchy rash that appears on the third or fourth day of illness. The rash is first observed behind the ears, spreads over the face, and then spreads over the neck, trunk, arms, and legs. Cherry (senile) angiomas are small (1 to 5 mm), smooth, slightly raised bright red dots that commonly appear on the trunk in all adults over 30 years old. Herpes zoster causes vesicles up to 1 cm in size that are elevated with a cavity containing clear fluid.

The nurse is examining the lymphatic system of a healthy 3-year-old child. Which finding should the nurse expect? A) Excessive swelling of the lymph nodes B) The presence of palpable lymph nodes C) No nodes palpable because of the immature immune system of a child D) Fewer numbers and a smaller size of lymph nodes compared with those of an adult

ANS: B Lymph nodes are relatively large in children, and the superficial ones often are palpable even when the child is healthy.

During an assessment, the nurse notices that a patient's left arm is swollen from the shoulder down to the fingers, with nonpitting brawny edema. The right arm is normal. The patient had a left-sided mastectomy 1 year ago. The nurse suspects which problem? A) Venous stasis B) Lymphedema C) Arteriosclerosis D) Deep vein thrombosis

ANS: B Lymphedema after breast cancer causes unilateral swelling and nonpitting brawny edema, with overlying skin indurated. It is caused by the removal of lymph nodes with breast surgery or damage to lymph nodes and channels with radiation therapy for breast cancer, and it can impede drainage of lymph. The other responses are not correct.

A patient complains of leg pain that wakes him at night. He states that he "has been having problems" with his legs. He has pain in his legs when they are elevated that disappears when he dangles them. He recently noticed "a sore" on the inner aspect of the right ankle. On the basis of this history information, the nurse interprets that the patient is most likely experiencing: A) pain related to lymphatic abnormalities. B) problems related to arterial insufficiency. C) problems related to venous insufficiency. D) pain related to musculoskeletal abnormalities.

ANS: B Night leg pain is common in aging adults. It may indicate the ischemic rest pain of peripheral vascular disease. Alterations in arterial circulation cause pain that becomes worse with leg elevation and is eased when the extremity is dangled.

15. The nurse is assessing the abdomen of a pregnant woman who is complaining of having "acid indigestion" all the time. The nurse knows that esophageal reflux during pregnancy can cause: A) diarrhea. B) pyrosis. C) dysphagia. D) constipation.

ANS: B Pyrosis, or heartburn (not constipation), is caused by esophageal reflux during pregnancy. The other options are not correct

During a clinic visit, a woman in her seventh month of pregnancy complains that her legs feel "heavy in the calf" and that she often has foot cramps at night. The nurse notices that the patient has dilated, tortuous veins in her lower legs. Which condition is reflected by these findings? A) Deep vein thrombophlebitis B) Varicose veins C) Lymphedema D) Raynaud's phenomenon

ANS: B Superficial varicose veins are caused by incompetent distant valves on veins, which results in reflux of blood and producing dilated, tortuous veins. They are more common in women, and pregnancy can also be a cause. Symptoms include aching, heaviness in the calf, easy fatigability, and night leg or foot cramps. Dilated, tortuous veins are seen on assessment. See Table 20-5 for the description of deep vein thrombophlebitis. See Table 20-2 for descriptions of Raynaud's phenomenon and lymphedema.

A 40-year-old woman reports a change in mole size, accompanied by color changes, itching, burning, and bleeding over the past month. She has a dark complexion and has no family history of skin cancer, but she has had many blistering sunburns in the past. The nurse would: a. Tell the patient to watch the lesion and report back in 2 months. b. Refer the patient because of the suggestion of melanoma on the basis of her symptoms. c. Ask additional questions regarding environmental irritants that may have caused this condition. d. Tell the patient that these signs suggest a compound nevus, which is very common in young to middle-aged adults.

ANS: B The ABCD danger signs of melanoma are asymmetry, border irregularity, color variation, and diameter. In addition, individuals may report a change in size, the development of itching, burning, and bleeding, or a new-pigmented lesion. Any one of these signs raises the suggestion of melanoma and warrants immediate referral.

39. The nurse is preparing to examine a patient who has been complaining of right lower quadrant pain. Which technique is correct during the assessment? The nurse should: A) examine the tender area first. B) examine the tender area last. C) avoid palpating the tender area. D) palpate the tender area first and then auscultate for bowel sounds.

ANS: B The nurse should save the examination of any identified tender areas until last. This method avoids pain and the resulting muscle rigidity that would obscure deep palpation later in the examination. Auscultation is done before percussion and palpation because percussion and palpation can increase peristalsis, which would give a false interpretation of bowel sounds

During an assessment, the nurse uses the "profile sign" to detect: A) pitting edema. B) early clubbing. C) symmetry of the fingers. D) insufficient capillary refill.

ANS: B The nurse should use the profile sign (viewing the finger from the side) to detect early clubbing.

15. The nurse is palpating the sinus areas. If the findings are normal, then the patient should report which sensation? a. No sensation b. Firm pressure c. Pain during palpation d. Pain sensation behind eyes

ANS: B The person should feel firm pressure but no pain. Sinus areas are tender to palpation in persons with chronic allergies or an acute infection (sinusitis). A normal finding when palpating the sinus areas is for the patient to feel firm pressure, not no sensation at all, pain during palpation, or pain behind the eyes. Sinus areas that are tender to palpation may indicate chronic allergies or an acute infection (sinusitis). Feeling firm pressure but no pain is a normal finding.

The nurse keeps in mind that a thorough skin assessment is extremely important because the skin holds information about a person's: a. Support systems. b. Circulatory status. c. Socioeconomic status. d. Psychological wellness.

ANS: B The skin holds information about the body's circulation, nutritional status, and signs of systemic diseases, as well as topical data on the integumentary system itself.

5. In assessing the tonsils of a 30-year-old, the nurse notices that they are involuted, granular in appearance, and appear to have deep crypts. What is the correct response to these findings? a. Refer the patient to a throat specialist. b. No response is needed; this appearance is normal for the tonsils. c. Continue with the assessment, looking for any other abnormal findings. d. Obtain a throat culture on the patient for possible streptococcal (strep) infection

ANS: B The tonsils are the same color as the surrounding mucous membrane, although they look more granular and their surface shows deep crypts. Tonsillar tissue enlarges during childhood until puberty and then involutes. There is no need to refer the patient to a throat specialist, obtain a throat culture, or look for other abnormal findings because the findings in this question are normal. Although the tonsils look more granular and their surface shows deep crypts, they are the same color as the surrounding mucous membrane and tonsillar tissue enlarges during childhood until puberty and then involutes.

The nurse is assessing a patient who has liver disease for jaundice. Which of these assessment findings is indicative of true jaundice? a. Yellow patches in the outer sclera b. Yellow color of the sclera that extends up to the iris c. Skin that appears yellow when examined under low light d. Yellow deposits on the palms and soles of the feet where jaundice first appears

ANS: B The yellow sclera of jaundice extends up to the edge of the iris. Calluses on the palms and soles of the feet often appear yellow but are not classified as jaundice. Scleral jaundice should not be confused with the normal yellow subconjunctival fatty deposits that are common in the outer sclera of dark-skinned persons.

The nurse is attempting to assess the femoral pulse in an obese patient. Which of these actions would be most appropriate? A) Have the patient assume a prone position. B) Ask the patient to bend his or her knees to the side in a froglike position. C) Press firmly against the bone with the patient in a semi-Fowler position. D) Listen with a stethoscope for pulsations because it is very difficult to palpate the pulse in an obese person.

ANS: B To help expose the femoral area, particularly in obese people, the nurse should ask the person to bend his or her knees to the side in a froglike position.

14. During an abdominal assessment, the nurse would consider which of these findings as normal? A) The presence of a bruit in the femoral area B) A tympanic percussion note in the umbilical region C) A palpable spleen between the ninth and eleventh ribs in the left midaxillary line D) A dull percussion note in the left upper quadrant at the midclavicular line

ANS: B Tympany should predominate in all four quadrants of the abdomen because air in the intestines rises to the surface when the person is supine. Vascular bruits are not usually present. Normally the spleen is not palpable. Dullness would not be found in the area of lung resonance (left upper quadrant at the midclavicular line)

9. While obtaining a health history, a patient tells the nurse that he has frequent nosebleeds and asks the best way to get them to stop. What would be the nurse's best response? a. "While sitting up, place a cold compress over your nose." b. "Sit up with your head tilted forward and pinch your nose." c. "Allow the bleeding to stop on its own, but don't blow your nose." d. "Lie on your back with your head tilted back and pinch your nose."

ANS: B With a nosebleed, the person should sit up with the head tilted forward and pinch the nose between the thumb and forefinger for 5 to 15 minutes.

19. A 10-year-old is at the clinic for "a sore throat that has lasted 6 days." Which of these findings would be consistent with an acute infection? a. Tonsils 3+/1-4+ with pale coloring b. Tonsils 3+/1-4+ with large white spots c. Tonsils 2+/1-4+ with small plugs of white debris d. Tonsils 1+/1-4+ and pink; the same color as the oral mucosa

ANS: B With an acute infection, tonsils are bright red and swollen and may have exudate or large white spots. Tonsils are enlarged to 2+, 3+, or 4+ with an acute infection.

24. While performing an assessment of the mouth, the nurse notices that the patient has a 1-cm ulceration that is crusted with an elevated border and located on the outer third of the lower lip. What other information would be most important for the nurse to assess? a. Nutritional status b. When the patient first noticed the lesion c. Whether the patient has had a recent cold d. Whether the patient has had any recent exposure to sick animals

ANS: B With carcinoma, the initial lesion is round and indurated, but then it becomes crusted and ulcerated with an elevated border. Most cancers occur between the outer and middle thirds of the lip. Any lesion that is still unhealed after 2 weeks should be referred. Therefore, the nurse should try to establish how long the lesion has been there and ask the patient when the patient first noticed the lesion.

20. The nurse knows that during an abdominal assessment, deep palpation is used to determine: A) bowel motility. B) enlarged organs. C) superficial tenderness. D) overall impression of skin surface and superficial musculature.

ANS: B With deep palpation, the nurse should notice the location, size, consistency, and mobility of any palpable organs and the presence of any abnormal enlargement, tenderness, or masses.

An older adult woman is brought to the emergency department after being found lying on the kitchen floor for 2 days; she is extremely dehydrated. What would the nurse expect to see during the examination? a. Smooth mucous membranes and lips b. Dry mucous membranes and cracked lips c. Pale mucous membranes d. White patches on the mucous membranes

ANS: B With dehydration, mucous membranes appear dry and the lips look parched and cracked. The other responses are not found in dehydration.

41. The nurse suspects that a patient has appendicitis. Which of these procedures are appropriate for use when assessing for appendicitis or a perforated appendix? Select all that apply. A. Test for Murphy's sign. B. Test for Blumberg's sign. C. Test for shifting dullness. D. Perform iliopsoas muscle test. E. Test for fluid wave.

ANS: B, D Testing for Blumberg's sign (rebound tenderness) and performing the iliopsoas muscle test should be used to assess for appendicitis. Murphy's sign is used to assess for an inflamed gallbladder or cholecystitis. Testing for a fluid wave and shifting dullness is done to assess for ascites

1. The nurse is assessing a 1-month-old infant at his well-baby checkup. Which assessment findings are appropriate for this age? Select all that apply. a. Head circumference equal to chest circumference b. Head circumference greater than chest circumference c. Head circumference less than chest circumference d. Fontanels firm and slightly concave e. Absent tonic neck reflex f. Nonpalpable cervical lymph nodes

ANS: B, D, F An infants head circumference is larger than the chest circumference. At age 2 years, both measurements are the same. During childhood, the chest circumference grows to exceed the head circumference by 5 to 7 cm. The fontanels should feel firm and slightly concave in the infant, and they should close by age 9 months. The tonic neck reflex is present until between 3 and 4 months of age, and cervical lymph nodes are normally nonpalpable in an infant.

A patient has been admitted to a hospital after the staff in the nursing home noticed a pressure ulcer in his sacral area. The nurse examines the pressure ulcer and determines that it is a stage II ulcer. Which of these findings are characteristic of a stage II pressure ulcer? Select all that apply. a. Intact skin appears red but is not broken. b. Partial thickness skin erosion is observed with a loss of epidermis or dermis. c. Ulcer extends into the subcutaneous tissue. d. Localized redness in light skin will blanch with fingertip pressure. e. Open blister areas have a red-pink wound bed. f. Patches of eschar cover parts of the wound.

ANS: B, E Stage I pressure ulcers have intact skin that appears red but is not broken, and localized redness in intact skin will blanche with fingertip pressure. Stage II pressure ulcers have partial thickness skin erosion with a loss of epidermis or also the dermis; open blisters have a red-pink wound bed. Stage III pressure ulcers are full thickness, extending into the subcutaneous tissue; subcutaneous fat may be seen but not muscle, bone, or tendon. Stage IV pressure ulcers involve all skin layers and extend into supporting tissue, exposing muscle, bone, and tendon. Slough (stringy matter attached to the wound bed) or eschar (black or brown necrotic tissue) may be present.

The nurse is presenting a class on risk factors for cardiovascular disease. Which of these are considered modifiable risk factors for myocardial infarction (MI)? Select all that apply. a. Ethnicity b. Abnormal lipids c. Smoking d. Gender e. Hypertension f. Diabetes g. Family history

ANS: B. Abnormal lipids C, Smoking E. Hypertension F. Diabetes Nine modifiable risk factors for MI, as identified by a recent study, include abnormal lipids, smoking, hypertension, diabetes, abdominal obesity, psychosocial factors, consumption of fruits and vegetables, alcohol use, and regular physical activity.

During the history of a 78-year-old man, his wife states that he occasionally has problems with short-term memory loss and confusion: "He can't even remember how to button his shirt." In doing the assessment of his sensory system, which action by the nurse is most appropriate?

ANS: Before testing, the nurse would assess the patient's mental status and ability to follow directions at this time. The nurse should ensure validity of the sensory system testing by making sure the patient is alert, cooperative, comfortable, and has an adequate attention span. Otherwise, the nurse may obtain misleading and invalid results.

When assessing tactile fremitus, the nurse recalls that it is normal to feel tactile fremitus most intensely over which location?

ANS: Between the scapulae Normally, fremitus is most prominent between the scapulae and around the sternum. These are sites where the major bronchi are closest to the chest wall. Fremitus normally decreases as one progress down the chest because more tissue impedes sound transmission.

The nurse is preparing for a class on risk factors for hypertension, and reviews recent statistics. Which racial group has the highest prevalence of hypertension in the world? a. Blacks b. Whites c. American Indians d. Hispanics

ANS: Blacks According to the American Heart Association, the prevalence of hypertension is higher among African-Americans than in other racial groups.

During an otoscopic examination, the nurse notices an area of *black and white dots on the tympanic membrane and ear canal wall*. What does this finding suggest?

ANS: Blood in the middle ear A colony of black or white dots on the drum or canal wall suggests a yeast or fungal infection (otomycosis).

The nurse is assessing a 16-year-old patient who has suffered head injuries from a recent motor vehicle accident. Which of these statements indicates the most important reason for assessing for any drainage from the ear canal?

ANS: Bloody or clear watery drainage can indicate a basal skull fracture. Frank blood or clear watery drainage (cerebrospinal leak) after trauma suggests a basal skull fracture and warrants immediate referral. Purulent drainage indicates otitis externa or otitis media.

24. The nurse notices that an infant has a large, soft lump on the side of his head and that his mother is very concerned. She tells the nurse that she noticed the lump approximately 8 hours after her babys birth and that it seems to be getting bigger. One possible explanation for this is: a. Hydrocephalus. b. Craniosynostosis. c. Cephalhematoma. d. Caput succedaneum.

ANS: C A cephalhematoma is a subperiosteal hemorrhage that is the result of birth trauma. It is soft, fluctuant, and well defined over one cranial bone. It appears several hours after birth and gradually increases in size.

26. During an admission assessment, the nurse notices that a male patient has an enlarged and rather thick skull. The nurse suspects acromegaly and would further assess for: a. Exophthalmos. b. Bowed long bones. c. Coarse facial features. d. Acorn-shaped cranium.

ANS: C Acromegaly is excessive secretion of growth hormone that creates an enlarged skull and thickened cranial bones. Patients will have elongated heads, massive faces, prominent noses and lower jaws, heavy eyebrow ridges, and coarse facial features. Exophthalmos is associated with hyperthyroidism. Bowed long bones and an acorn-shaped cranium result from Paget disease.

30. During an examination of a female patient, the nurse notes lymphadenopathy and suspects an acute infection. Acutely infected lymph nodes would be: a. Clumped. b. Unilateral. c. Firm but freely movable. d. Firm and nontender.

ANS: C Acutely infected lymph nodes are bilateral, enlarged, warm, tender, and firm but freely movable. Unilaterally enlarged nodes that are firm and nontender may indicate cancer.

25. A mother brings in her newborn infant for an assessment and tells the nurse that she has noticed that whenever her newborns head is turned to the right side, she straightens out the arm and leg on the same side and flexes the opposite arm and leg. After observing this on examination, the nurse tells her that this reflex is: a. Abnormal and is called the atonic neck reflex. b. Normal and should disappear by the first year of life. c. Normal and is called the tonic neck reflex, which should disappear between 3 and 4 months of age. d. Abnormal. The baby should be flexing the arm and leg on the right side of his body when the head is turned to the right.

ANS: C By 2 weeks, the infant shows the tonic neck reflex when supine and the head is turned to one side (extension of same arm and leg, flexion of opposite arm and leg). The tonic neck reflex disappears between 3 and 4 months of age.

22. A visitor from Poland who does not speak English seems to be somewhat apprehensive about the nurse examining his neck. He would probably be more comfortable with the nurse examining his thyroid gland from: a. Behind with the nurses hands placed firmly around his neck. b. The side with the nurses eyes averted toward the ceiling and thumbs on his neck. c. The front with the nurses thumbs placed on either side of his trachea and his head tilted forward. d. The front with the nurses thumbs placed on either side of his trachea and his head tilted backward.

ANS: C Examining this patients thyroid gland from the back may be unsettling for him. It would be best to examine his thyroid gland using the anterior approach, asking him to tip his head forward and to the right and then to the left.

17. During a well-baby checkup, the nurse notices that a 1-week-old infants face looks small compared with his cranium, which seems enlarged. On further examination, the nurse also notices dilated scalp veins and downcast or setting sun eyes. The nurse suspects which condition? a. Craniotabes b. Microcephaly c. Hydrocephalus d. Caput succedaneum

ANS: C Hydrocephalus occurs with the obstruction of drainage of cerebrospinal fluid that results in excessive accumulation, increasing intracranial pressure, and an enlargement of the head. The face looks small, compared with the enlarged cranium, and dilated scalp veins and downcast or setting sun eyes are noted. Craniotabes is a softening of the skulls outer layer. Microcephaly is an abnormally small head. A caput succedaneum is edematous swelling and ecchymosis of the presenting part of the head caused by birth trauma.

23. A patients thyroid gland is enlarged, and the nurse is preparing to auscultate the thyroid gland for the presence of a bruit. A bruit is a __________ sound that is heard best with the __________ of the stethoscope. a. Low gurgling; diaphragm b. Loud, whooshing, blowing; bell c. Soft, whooshing, pulsatile; bell d. High-pitched tinkling; diaphragm

ANS: C If the thyroid gland is enlarged, then the nurse should auscultate it for the presence of a bruit, which is a soft, pulsatile, whooshing, blowing sound heard best with the bell of the stethoscope.

29. A woman comes to the clinic and states, Ive been sick for so long! My eyes have gotten so puffy, and my eyebrows and hair have become coarse and dry. The nurse will assess for other signs and symptoms of: a. Cachexia. b. Parkinson syndrome. c. Myxedema. d. Scleroderma.

ANS: C Myxedema (hypothyroidism) is a deficiency of thyroid hormone that, when severe, causes a nonpitting edema or myxedema. The patient will have a puffy edematous face, especially around the eyes (periorbital edema); coarse facial features; dry skin; and dry, coarse hair and eyebrows. (See Table 13-4, Abnormal Facial Appearances with Chronic Illnesses, for descriptions of the other responses.)

34. While performing a well-child assessment on a 5 year old, the nurse notes the presence of palpable, bilateral, cervical, and inguinal lymph nodes. They are approximately 0.5 cm in size, round, mobile, and nontender. The nurse suspects that this child: a. Has chronic allergies. b. May have an infection. c. Is exhibiting a normal finding for a well child of this age. d. Should be referred for additional evaluation.

ANS: C Palpable lymph nodes are normal in children until puberty when the lymphoid tissue begins to atrophy. Lymph nodes may be up to 1 cm in size in the cervical and inguinal areas but are discrete, movable, and nontender.

1. A physician tells the nurse that a patients vertebra prominens is tender and asks the nurse to reevaluate the area in 1 hour. The area of the body the nurse will assess is: a. Just above the diaphragm. b. Just lateral to the knee cap. c. At the level of the C7 vertebra. d. At the level of the T11 vertebra.

ANS: C The C7 vertebra has a long spinous process, called the vertebra prominens, which is palpable when the head is flexed.

13. A patient, an 85-year-old woman, is complaining about the fact that the bones in her face have become more noticeable. What explanation should the nurse give her? a. Diets low in protein and high in carbohydrates may cause enhanced facial bones. b. Bones can become more noticeable if the person does not use a dermatologically approved moisturizer. c. More noticeable facial bones are probably due to a combination of factors related to aging, such as decreased elasticity, subcutaneous fat, and moisture in her skin. d. Facial skin becomes more elastic with age. This increased elasticity causes the skin to be more taught, drawing attention to the facial bones.

ANS: C The facial bones and orbits appear more prominent in the aging adult, and the facial skin sags, which is attributable to decreased elasticity, decreased subcutaneous fat, and decreased moisture in the skin.

18. The nurse needs to palpate the temporomandibular joint for crepitation. This joint is located just below the temporal artery and anterior to the: a. Hyoid bone. b. Vagus nerve. c. Tragus. d. Mandible.

ANS: C The temporomandibular joint is just below the temporal artery and anterior to the tragus.

36. During an examination of a patient in her third trimester of pregnancy, the nurse notices that the patients thyroid gland is slightly enlarged. No enlargement had been previously noticed. The nurse suspects that the patient: a. Has an iodine deficiency. b. Is exhibiting early signs of goiter. c. Is exhibiting a normal enlargement of the thyroid gland during pregnancy. d. Needs further testing for possible thyroid cancer.

ANS: C The thyroid gland enlarges slightly during pregnancy because of hyperplasia of the tissue and increased vascularity.

5. When examining the face of a patient, the nurse is aware that the two pairs of salivary glands that are accessible to examination are the ___________ and ___________ glands. a. Occipital; submental b. Parotid; jugulodigastric c. Parotid; submandibular d. Submandibular; occipital

ANS: C Two pairs of salivary glands accessible to examination on the face are the parotid glands, which are in the cheeks over the mandible, anterior to and below the ear; and the submandibular glands, which are beneath the mandible at the angle of the jaw. The parotid glands are normally nonpalpable.

40. During an examination, the nurse finds that a patients left temporal artery is tortuous and feels hardened and tender, compared with the right temporal artery. The nurse suspects which condition? a. Crepitation b. Mastoiditis c. Temporal arteritis d. Bell palsy

ANS: C With temporal arteritis, the artery appears more tortuous and feels hardened and tender. These assessment findings are not consistent with the other responses.

27. The nurse is assessing a patient in the hospital who has received numerous antibiotics for a lung infection and notices that his tongue appears to be black and hairy. In response to his concern, what would the nurse say? a. "We will need to get a biopsy to determine the cause." b. "This is an overgrowth of hair and will go away in a few days." c. "Black, hairy tongue is a fungal infection caused by all the antibiotics you have received." d. "This is probably caused by the same bacteria you had in your lungs."

ANS: C A black, hairy tongue is not really hair but the elongation of filiform papillae and painless overgrowth of mycelial threads of fungus infection on the tongue. It occurs after the use of antibiotics, which inhibit normal bacteria and allow a proliferation of fungus. It is not caused by the same bacteria as his lung infection but occurred after the use of antibiotics, which inhibit normal bacteria and allow a proliferation of fungus. There is no need to get a biopsy.

The nurse is assessing the pulses of a patient who has been admitted for untreated hyperthyroidism. The nurse should expect to find a(n) _____ pulse. A) normal B) absent C) bounding D) weak, thready

ANS: C A full, bounding pulse occurs with hyperkinetic states (such as exercise, anxiety, fever), anemia, and hyperthyroidism. Absent pulse occurs with occlusion. Weak, thready pulses occur with shock and peripheral artery disease.

The nurse is preparing to perform a modified Allen test. Which is an appropriate reason for this test? A) To measure the rate of lymphatic drainage B) To evaluate the adequacy of capillary patency before venous blood draws C) To evaluate the adequacy of collateral circulation before cannulating the radial artery D) To evaluate the venous refill rate that occurs after the ulnar and radial arteries are temporarily occluded

ANS: C A modified Allen test is used to evaluate the adequacy of collateral circulation before the radial artery is cannulated. The other responses are not reasons for a modified Allen test.

The nurse is describing a weak, thready pulse on the documentation flow sheet. Which statement is correct? A) "Easily palpable, pounds under the fingertips." B) "Greater than normal force, then collapses suddenly." C) "Hard to palpate, may fade in and out, easily obliterated by pressure." D) "Rhythm is regular, but force varies with alternating beats of large and small amplitude."

ANS: C A weak, thready pulse is hard to palpate, may fade in and out, and is easily obliterated by pressure. It is associated with decreased cardiac output and peripheral arterial disease.

During a routine office visit, a patient takes off his shoes and shows the nurse "this awful sore that won't heal." On inspection, the nurse notes a 3-cm round ulcer on the left great toe, with a pale ischemic base, well-defined edges, and no drainage. The nurse should assess for other signs and symptoms of: A) varicosities. B) a venous stasis ulcer. C) an arterial ischemic ulcer. D) deep vein thrombophlebitis.

ANS: C Arterial ischemic ulcers occur at toes, metatarsal heads, heels, and lateral ankle, and they are characterized by a pale ischemic base, well-defined edges, and no bleeding. See Table 20-5 for a description of varicose veins and deep vein thrombophlebitis. See Table 20-4 for a description of venous stasis ulcers.

21. The nurse notices that a patient has had a black, tarry stool and recalls that a possible cause would be: A) gallbladder disease. B) overuse of laxatives. C) gastrointestinal bleeding. D) localized bleeding around the anus.

ANS: C Black stools may be tarry as a result of occult blood (melena) from gastrointestinal bleeding. Redblood in stools occurs with localized bleeding around the anus

22. The nurse is assessing a 3-year-old for "drainage from the nose." On assessment, a purulent drainage that has a very foul odor is noted from the left naris and no drainage is observed from the right naris. The child is afebrile with no other symptoms. What should the nurse do next? a. Refer to the physician for an antibiotic order. b. Have the mother bring the child back in 1 week. c. Perform an otoscopic examination of the left nares. d. Tell the mother that this drainage is normal for a child of this age.

ANS: C Children are prone to put an object up the nose, producing unilateral purulent drainage with a foul odor. Because some risk for aspiration exists, removal should be prompt.

23. During an assessment of a 26-year-old for "a spot on my lip I think is cancer," the clinic nurse notices a group of clear vesicles with an erythematous base around them located at the lip-skin border. The patient mentions that she just returned from Hawaii. What is the most appropriate action by the nurse? a. Tell the patient she needs to see a skin specialist. b. Discuss the benefits of having a biopsy performed on any unusual lesion. c. Tell the patient that these vesicles are indicative of herpes simplex I or cold sores and that they will heal in 4 to 10 days. d. Tell the patient that these vesicles are most likely the result of a riboflavin deficiency and discuss nutrition.

ANS: C Cold sores are groups of clear vesicles with a surrounding erythematous base. These evolve into pustules or crusts and heal in 4 to 10 days. The most likely site is the lip-skin junction. Infection often recurs in the same site. Recurrent herpes infections may be precipitated by sunlight, fever, colds, or allergy.

20. Immediately after birth, the nurse is unable to suction the nares of a crying newborn. An attempt is made to pass a catheter through both nasal cavities with no success. What should the nurse do next? a. Attempt to suction again with a bulb syringe. b. Wait a few minutes, and try again once the infant stops crying. c. Recognize that this situation requires immediate intervention. d. Contact the physician to schedule an appointment for the infant at his or her next hospital visit.

ANS: C Determining the patency of the nares in the immediate newborn period is essential because most newborns are obligate nose breathers. Nares blocked with amniotic fluid are gently suctioned with a bulb syringe. If obstruction is suspected, then a small lumen (5 to 10 Fr) catheter is passed down each naris to confirm patency. The inability to pass a catheter through the nasal cavity indicates choanal atresia, which requires immediate intervention.

3. 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.

ANS: C Dysphagia is a condition that occurs with disorders of the throat or esophagus and results in difficulty swallowing. Aphasia and dysphasia are speech disorders. Anorexia is a loss of appetite

7. The nurse is assessing an 80-year-old patient. Which of these findings would be expected for this patient? a. Hypertrophy of the gums b. Increased production of saliva c. Decreased ability to identify odors d. Finer and less prominent nasal hair

ANS: C Dysphagia is difficulty with swallowing and may occur with a variety of disorders, including stroke and other neurologic diseases. Rhinorrhea is a runny nose, epistaxis is a bloody nose, and xerostomia is a dry mouth. Rhinorrhea is a runny nose, epistaxis is a bloody nose, and xerostomia is a dry mouth; none of which are expected findings in a patient who had a stroke with drooping on the right side of the face. Dysphagia is difficulty with swallowing and may occur with a variety of disorders, including stroke and other neurologic diseases.

A 35-year-old pregnant woman comes to the clinic for a monthly appointment. During the assessment, the nurse notices that she has a brown patch of hyperpigmentation on her face. The nurse continues the skin assessment aware that another finding may be: a. Keratoses. b. Xerosis. c. Chloasma. d. Acrochordons.

ANS: C In pregnancy, skin changes can include striae, linea nigra (a brownish-black line down the midline), chloasma (brown patches of hyperpigmentation), and vascular spiders. Keratoses are raised, thickened areas of pigmentation that look crusted, scaly, and warty. Xerosis is dry skin. Acrochordons, or skin tags, occur more often in the aging adult.

The nurse is performing a peripheral vascular assessment on a bedridden patient and notices the following findings in the right leg: increased warmth, swelling, redness, tenderness to palpation, and a positive Homan's sign. The nurse should: A) reevaluate the patient in a few hours. B) consider this a normal finding for a bedridden patient. C) seek emergency referral because of the risk of pulmonary embolism. D) ask the patient to raise his leg off of the bed and check for pain on elevation.

ANS: C Increased warmth, swelling, redness, and tenderness in the lower extremities require emergency referral because of the risk of pulmonary embolism from a deep vein thrombosis.

When performing a peripheral vascular assessment on a patient, the nurse is unable to palpate the ulnar pulses. The patient's skin is warm and capillary refill time is normal. The nurse should next: A) check for the presence of claudication. B) refer the individual for further evaluation. C) consider this a normal finding and proceed with the peripheral vascular evaluation. D) ask the patient if he or she has experienced any unusual cramping or tingling in the arm.

ANS: C It is not usually necessary to palpate the ulnar pulses. The ulnar pulses are often not palpable in the normal person. The other responses are not correct.

A patient comes to the clinic and tells the nurse that he has been confined to his recliner chair for approximately 3 days with his feet down and he asks the nurse to evaluate his feet. During the assessment, the nurse might expect to find: a. Pallor b. Coolness c. Distended veins d. Prolonged capillary filling time

ANS: C Keeping the feet in a dependent position causes venous pooling, resulting in redness, warmth, and distended veins. Prolonged elevation would cause pallor and coolness. Immobilization or prolonged inactivity would cause prolonged capillary filling time (see Table 13-1).

A 70-year-old woman who loves to garden has small, flat, brown macules over her arms and hands. She asks, "What causes these liver spots?" The nurse tells her, "They are: a. "Signs of decreased hematocrit related to anemia." b. "Due to the destruction of melanin in your skin from exposure to the sun." c. "Clusters of melanocytes that appear after extensive sun exposure." d. "Areas of hyperpigmentation related to decreased perfusion and vasoconstriction."

ANS: C Liver spots, or senile lentigines, are clusters of melanocytes that appear on the forearms and dorsa of the hands after extensive sun exposure. The other responses are not correct.

26. The nurse is reviewing the assessment of an aortic aneurysm. Which of these statements is true regarding an aortic aneurysm? A) A bruit is absent. B) Femoral pulses are increased. C) A pulsating mass is usually present. D) Most are located below the umbilicus.

ANS: C Most aortic aneurysms are palpable during routine examination and feel like a pulsating mass. A bruit will be audible, and femoral pulses are present but decreased. Such aneurysms are located in the upper abdomen just to the left of midline

A black patient is in the intensive care unit because of impending shock after an accident. The nurse expects to find what characteristics in this patient's skin? a. Ruddy blue. b. Generalized pallor. c. Ashen, gray, or dull. d. Patchy areas of pallor.

ANS: C Pallor attributable to shock, with decreased perfusion and vasoconstriction, in black-skinned people will cause the skin to appear ashen, gray, or dull (see Table 13-2).

The nurse is performing a well-child check on a 5-year-old boy. He has no current history that would lead the nurse to suspect illness. His medical history is unremarkable, and he received immunizations 1 week ago. Which of these findings should be considered normal in this situation? A) Enlarged, warm, tender nodes B) Lymphadenopathy of the cervical nodes C) Palpable firm, small, shotty, mobile, nontender lymph nodes D) Firm, rubbery, large nodes, somewhat fixed to the underlying tissue

ANS: C Palpable lymph nodes are often normal in children and infants. They are small, firm, shotty, mobile, and nontender. Vaccinations can produce lymphadenopathy. Enlarged, warm, tender nodes indicate current infection.

During an assessment of an older adult, the nurse should expect to notice which finding as a normal physiologic change associated with the aging process? A) Hormonal changes causing vasodilation and a resulting drop in blood pressure B) Progressive atrophy of the intramuscular calf veins, causing venous insufficiency C) Peripheral blood vessels growing more rigid with age, producing a rise in systolic blood pressure D) Narrowing of the inferior vena cava, causing low blood flow and increases in venous pressure resulting in varicosities

ANS: C Peripheral blood vessels grow more rigid with age, resulting in a rise in systolic blood pressure. Aging produces progressive enlargement of the intramuscular calf veins, not atrophy. The other options are not correct.

A physician has diagnosed a patient with purpura. After leaving the room, a nursing student asks the nurse what the physician saw that led to that diagnosis. The nurse should say, "The physician is referring to the: a. "Blue dilation of blood vessels in a star-shaped linear pattern on the legs." b. "Fiery red, star-shaped marking on the cheek that has a solid circular center." c. "Confluent and extensive patch of petechiae and ecchymoses on the feet." d. "Tiny areas of hemorrhage that are less than 2 mm, round, discrete, and dark red in color."

ANS: C Purpura is a confluent and extensive patch of petechiae and ecchymoses and a flat macular hemorrhage observed in generalized disorders such as thrombocytopenia and scurvy. The blue dilation of blood vessels in a star-shaped linear pattern on the legs describes a venous lake. The fiery red, star-shaped marking on the cheek that has a solid circular center describes a spider or star angioma. The tiny areas of hemorrhage that are less than 2 mm, round, discrete, and dark red in color describes petechiae.

A patient has been admitted for severe psoriasis. The nurse expects to see what finding in the patient's fingernails? a. Splinter hemorrhages b. Paronychia c. Pitting d. Beau lines

ANS: C Sharply defined pitting and crumbling of the nails, each with distal detachment characterize pitting nails and are associated with psoriasis. (See Table 12-13 for descriptions of the other terms.)

16. During an oral assessment of a 30-year-old black patient, the nurse notices bluish lips and a dark line along the gingival margin. What action would the nurse perform in response to this finding? a. Check the patient's Hb for anemia. b. Assess for other signs of insufficient oxygen supply. c. Proceed with the assessment, this appearance is a normal finding. d. Ask if he has been exposed to an excessive amount of carbon monoxide.

ANS: C Some blacks may have bluish lips and a dark line on the gingival margin; this appearance is a normal finding so the nurse should proceed with the assessment. Some blacks may have bluish lips and a dark line on the gingival margin, so this is a normal finding and there is no need to check the Hb for anemia, assess for other signs of insufficient oxygen supply, or ask if he has been exposed to an excessive amount of carbon monoxide. Instead, the nurse should continue with the assessment.

22. During an abdominal assessment, the nurse elicits tenderness on light palpation in the right lower quadrant. The nurse interprets that this finding could indicate a disorder of which of these structures? A) Spleen B) Sigmoid C) Appendix D) Gallbladder

ANS: C The appendix is located in the right lower quadrant, and when the iliopsoas muscle is inflamed (which occurs with an inflamed or perforated appendix), pain is felt in the right lower quadrant

The nurse is reviewing the blood supply to the arm. The major artery supplying the arm is the _____ artery. A) ulnar B) radial C) brachial D) deep palmar

ANS: C The major artery supplying the arm is the brachial artery. The brachial artery bifurcates into the ulnar and radial arteries immediately below the elbow. In the hand, the ulnar and radial arteries form two arches known as the superficial and deep palmar arches.

1. What is the primary purpose of the ciliated mucous membrane in the nose? a. To warm the inhaled air b. To filter out dust and bacteria c. To filter coarse particles from inhaled air d. To facilitate the movement of air through the nares

ANS: C The nasal hairs, or cilia, filter the coarsest matter from inhaled air, whereas the mucous blanket filters out dust and bacteria. The rich blood supply of the nasal mucosa warms the inhaled air. The rich blood supply of the nasal mucosa warms the inhaled air, not the ciliated mucous membrane. The mucous blanket, not the cilia, filters out dust and bacteria. The cilia in the nose do not facilitate the movement of air through the nares. Instead, the nasal hairs, or cilia, filter the coarsest matter from inhaled air.

A newborn infant is in the clinic for a well-baby checkup. The nurse observes the infant for the possibility of fluid loss because of which of these factors? a. Subcutaneous fat deposits are high in the newborn. b. Sebaceous glands are overproductive in the newborn. c. The newborn's skin is more permeable than that of the adult. d. The amount of vernix caseosa dramatically rises in the newborn.

ANS: C The newborn's skin is thin, smooth, and elastic and is relatively more permeable than that of the adult; consequently, the infant is at greater risk for fluid loss. The subcutaneous layer in the infant is inefficient, not thick, and the sebaceous glands are present but decrease in size and production. Vernix caseosa is not produced after birth.

21. The nurse notices that the mother of a 2-year-old boy brings him into the clinic quite frequently for various injuries and suspects there may be some child abuse involved. What should the nurse look for during an inspection of this child's mouth? a. Swollen, red tonsils b. Ulcerations on the hard palate c. Bruising on the buccal mucosa or gums d. Small yellow papules along the hard palate

ANS: C The nurse should notice any bruising or laceration on the buccal mucosa or gums of an infant or young child. Trauma may indicate child abuse from a forced feeding of a bottle or spoon.

2. What are the projections in the nasal cavity that increase the surface area are called? a. Meatus b. Septum c. Turbinates d. Kiesselbach plexus

ANS: C The projections in the nasal cavity that increases the surface area are called turbinates. The lateral walls of each nasal cavity contain three parallel bony projections: the superior, middle, and inferior turbinates. These increase the surface area, making more blood vessels and mucous membrane available to warm, humidify, and filter the inhaled air. A meatus is the passageway or canal underlying each turbinate that collects drainage. The septum is what divides the nasal cavity into two slitlike air passages. The Kiesselbach plexus is a rich vascular network in the anterior part of the septum.

37. During an assessment the nurse notices that a patient's umbilicus is enlarged and everted. It is midline, and there is no change in skin color. The nurse recognizes that the patient may have which condition? A) Intra-abdominal bleeding B) Constipation C) Umbilical hernia D) An abdominal tumor

ANS: C The umbilicus is normally midline and inverted, with no signs of discoloration. With an umbilical hernia, the mass is enlarged and everted. The other responses are incorrect.

A patient is especially worried about an area of skin on her feet that has turned white. The health care provider has told her that her condition is vitiligo. The nurse explains to her that vitiligo is: a. Caused by an excess of melanin pigment b. Caused by an excess of apocrine glands in her feet c. Caused by the complete absence of melanin pigment d. Related to impetigo and can be treated with an ointment

ANS: C Vitiligo is the complete absence of melanin pigment in patchy areas of white or light skin on the face, neck, hands, feet, body folds, and around orifices—otherwise, the depigmented skin is normal.

When using a Doppler ultrasonic stethoscope, the nurse recognizes venous flow when which sound is heard? A) Low humming sound B) Regular "lub, dub" pattern C) Swishing, whooshing sound D) Steady, even, flowing sound

ANS: C When using the Doppler ultrasonic stethoscope, the pulse site is found when one hears a swishing, whooshing sound.

14. The nurse is performing an assessment on a 21-year-old patient and notices that his nasal mucosa appears pale, gray, and swollen. What would be the most appropriate question to ask the patient? a. "Have you had any symptoms of a cold?" b. "Do you have an elevated temperature?" c. "Are you aware of having any allergies?" d. "Have you been having frequent nosebleeds?"

ANS: C With chronic allergies, the mucosa looks swollen, boggy, pale, and gray. Elevated body temperature, colds, and nosebleeds do not cause these mucosal changes. Elevated body temperature, colds, and nosebleeds do not cause the nasal mucosa to appear pale, gray, and swollen. Chronic allergies do cause the mucosa to look swollen, boggy, pale, and gray.

The nurse is preparing to perform a manual compression test on a patient. Which of these statements is true about this procedure? A) Rapid filling of the veins indicates incompetent veins. B) Competent valves in the veins will transmit a wave to the distal fingers. C) A palpable wave transmission occurs when the valves are incompetent. D) The test assesses whether the valves of varicosity are competent when the person is in the supine position.

ANS: C With the manual compression test, a palpable wave transmission occurs when the valves are incompetent. Competent veins will prevent a wave transmission and the nurse's distal (lower) fingers will feel no change. The test is performed while the patient is standing.

The nurse is examining a patient's ears and notices cerumen in the external canal. Which of these statements about cerumen is correct?

ANS: Cerumen is necessary for transmitting sound through the auditory canal. The ear is lined with glands that secrete cerumen, which is a yellow waxy material that lubricates and protects the ear.

A patient has been admitted to the emergency department with a possible medical diagnosis of pulmonary embolism. The nurse expects to see which assessment findings related to this condition?

ANS: Chest pain that is worse on deep inspiration, dyspnea Findings for pulmonary embolism include chest pain that is worse on deep inspiration, dyspnea, apprehension, anxiety, restlessness, PaO2 less than 80, diaphoresis, hypotension, crackles, and wheezes.

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?

ANS: Children at this age like to say "No." The examiner should not offer a choice when there is none. Children at this age like to say "No." Do not offer a choice when there really is none. If the child says "No," and the nurse does it anyway, then the nurse loses trust. Autonomy is enhanced by offering a limited option, "Shall I listen to your heart next or your tummy?"

The nurse is performing an assessment on an adult. The adult's vital signs are normal and capillary refill time is 5 seconds. What should the nurse do next? a. Ask the patient about a history of frostbite. b. Suspect that the patient has venous insufficiency. c. Consider this a delayed capillary refill time, and investigate further. d. Consider this a normal capillary refill time that requires no further assessment.

ANS: Consider this a delayed capillary refill time and investigate further. Normal capillary refill time is less than 1 to 2 seconds. The following conditions can skew the findings: a cool room, decreased body temperature, cigarette smoking, peripheral edema, and anemia.

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?

ANS: Consider this a normal finding for a child this age and proceed with the examination. Percussion notes that are louder in amplitude, lower in pitch, of a booming quality, and longer in duration are normal over a child's lung.

A patient has a normal pupillary light reflex. The nurse recognizes that this reflex indicates that:

ANS: Constriction of both pupils occurs in response to bright light. The pupillary light reflex is the normal constriction of the pupils when bright light shines on the retina. The other responses are not correct.

The nurse is assessing a patient's eyes for the accommodation response and would expect to see which normal finding?

ANS: Convergence of the axes of the eyes The accommodation reaction includes pupillary constriction and convergence of the axes of the eyes. The other responses are not correct.

2. A mother brings her 2-month-old daughter in for an examination and says, My daughter rolled over against the wall, and now I have noticed that she has this spot that is soft on the top of her head. Is something terribly wrong? The nurses best response would be: a. Perhaps that could be a result of your dietary intake during pregnancy. b. Your baby may have craniosynostosis, a disease of the sutures of the brain. c. That soft spot may be an indication of cretinism or congenital hypothyroidism. d. That soft spot is normal, and actually allows for growth of the brain during the first year of your babys life.

ANS: D Membrane-covered soft spots allow for growth of the brain during the first year of life. They gradually ossify; the triangular-shaped posterior fontanel is closed by 1 to 2 months, and the diamond-shaped anterior fontanel closes between 9 months and 2 years.

15. A patient complains that while studying for an examination he began to notice a severe headache in the frontotemporal area of his head that is throbbing and is somewhat relieved when he lies down. He tells the nurse that his mother also had these headaches. The nurse suspects that he may be suffering from: a. Hypertension. b. Cluster headaches. c. Tension headaches. d. Migraine headaches.

ANS: D Migraine headaches tend to be supraorbital, retroorbital, or frontotemporal with a throbbing quality. They are severe in quality and are relieved by lying down. Migraines are associated with a family history of migraine headaches.

11. The nurse is aware that the four areas in the body where lymph nodes are accessible are the: a. Head, breasts, groin, and abdomen. b. Arms, breasts, inguinal area, and legs. c. Head and neck, arms, breasts, and axillae. d. Head and neck, arms, inguinal area, and axillae.

ANS: D Nodes are located throughout the body, but they are accessible to examination only in four areas: head and neck, arms, inguinal region, and axillae.

16. A 19-year-old college student is brought to the emergency department with a severe headache he describes as, Like nothing Ive ever had before. His temperature is 40 C, and he has a stiff neck. The nurse looks for other signs and symptoms of which problem? a. Head injury b. Cluster headache c. Migraine headache d. Meningeal inflammation

ANS: D The acute onset of neck stiffness and pain along with headache and fever occurs with meningeal inflammation. A severe headache in an adult or child who has never had it before is a red flag. Head injury and cluster or migraine headaches are not associated with a fever or stiff neck.

During an assessment, the nurse notes that the patient's apical impulse is displaced laterally, and it is palpable over a wide area. This indicates: a. Systemic hypertension. b. Pulmonic hypertension. c. Pressure overload, as in aortic stenosis. d. Volume overload, as in heart failure.

ANS: D With volume overload, as in heart failure and cardiomyopathy, cardiac enlargement laterally displaces the apical impulse and is palpable over a wider area when left ventricular hypertrophy and dilation are present.

A patient has been diagnosed with venous stasis. Which of these findings would the nurse most likely observe? A) A unilateral cool foot B) Thin, shiny, atrophic skin C) Pallor of the toes and cyanosis of the nail beds D) A brownish discoloration to the skin of the lower leg

ANS: D A brown discoloration occurs with chronic venous stasis as a result of hemosiderin deposits (a by-product of red blood cell degradation). Pallor, cyanosis, atrophic skin, and unilateral coolness are all signs associated with arterial problems.

When auscultating over a patient's femoral arteries the nurse notices the presence of a bruit on the left side. The nurse knows that: A) bruits are often associated with venous disease. B) bruits occur in the presence of lymphadenopathy. C) hypermetabolic states will cause bruits in the femoral arteries. D) bruits occur with turbulent blood flow, indicating partial occlusion.

ANS: D A bruit occurs with turbulent blood flow and indicates partial occlusion of the artery. The other responses are not correct.

29. A mother brings her 4-month-old infant to the clinic with concerns regarding a small pad in the middle of the upper lip that has been there since 1 month of age. The infant has no health problems. On physical examination, the nurse notices a 0.5-cm, fleshy, elevated area in the middle of the upper lip. No evidence of inflammation or drainage is observed. What would the nurse tell this mother? a. "This area of irritation is caused from teething and is nothing to worry about." b. "This finding is abnormal and should be evaluated by another health care provider." c. "This area of irritation is the result of chronic drooling and should resolve within the next month or two." d. "This elevated area is a sucking tubercle caused from the friction of breastfeeding or bottle-feeding and is normal."

ANS: D A normal finding in infants is the sucking tubercle, a small pad in the middle of the upper lip from the friction of breastfeeding or bottle-feeding. This condition is not caused by irritation, teething, or excessive drooling, and evaluation by another health care provider is not warranted.

25. A pregnant woman states that she is concerned about her gums because she has noticed they are swollen and have started to bleed. What would be an appropriate response by the nurse? a. "Your condition is probably due to a vitamin C deficiency." b. "I'm not sure what causes swollen and bleeding gums, but let me know if it's not better in a few weeks." c. "You need to make an appointment with your dentist as soon as possible to have this checked." d. "Swollen and bleeding gums can be caused by a change in hormonal balance during pregnancy."

ANS: D Although with gingivitis (which can be caused by a vitamin C deficiency) gum margins are red and swollen and easily bleed, a changing hormonal balance during puberty or pregnancy may also cause these symptoms. Since this patient is pregnant, a change in hormonal balance is likely the cause.

The nurse is bathing an 80-year-old man and notices that his skin is wrinkled, thin, lax, and dry. This finding would be related to which factor in the older adult? a. Increased vascularity of the skin b. Increased numbers of sweat and sebaceous glands c. An increase in elastin and a decrease in subcutaneous fat d. An increased loss of elastin and a decrease in subcutaneous fat

ANS: D An accumulation of factors place the aging person at risk for skin disease and breakdown: the thinning of the skin, a decrease in vascularity and nutrients, the loss of protective cushioning of the subcutaneous layer, a lifetime of environmental trauma to skin, the social changes of aging, a increasingly sedentary lifestyle, and the chance of immobility.

A 70-year-old patient is scheduled for open-heart surgery. The surgeon plans to use the great saphenous vein for the coronary bypass grafts. The patient asks, "What happens to my circulation when the veins are removed?" The nurse should reply: A) "Venous insufficiency is a common problem after this type of surgery." B) "Oh, we have lots of veins—you won't even notice that it has been removed." C) "You will probably experience decreased circulation after the veins are removed." D) "Because the deeper veins in your leg are in good condition, this vein can be removed without harming your circulation."

ANS: D As long as the femoral and popliteal veins remain intact, the superficial veins can be excised without harming the circulation. The other responses are not correct.

13. The physician comments that a patient has abdominal borborygmi. The nurse knows that this term refers to: A) a loud continuous hum. B) a peritoneal friction rub. C) hypoactive bowel sounds. D) hyperactive bowel sounds.

ANS: D Borborygmi is the term used for hyperperistalsis when the person actually feels his or her stomach growling.

A 65-year-old man with emphysema and bronchitis has come to the clinic for a follow-up appointment. On assessment, the nurse might expect to see which finding? a. Anasarca b. Scleroderma c. Pedal erythema d. Clubbing of the nails

ANS: D Clubbing of the nails occurs with congenital cyanotic heart disease and neoplastic and pulmonary diseases. The other responses are assessment findings not associated with pulmonary diseases.

8. The nurse is describing a scaphoid abdomen. To the horizontal plane, a scaphoid contour of the abdomen depicts a _____ profile. A) flat B) convex C) bulging D) concave

ANS: D Contour describes the profile of the abdomen from the rib margin to the pubic bone; a scaphoid contour is one that is concave from a horizontal plane. See Figure 21-7.

25. To detect diastasis recti, the nurse should have the patient perform which of these maneuvers? A) Relax in the supine position. B) Raise the arms in the left lateral position. C) Raise the arms over the head while supine. D) Raise the head while remaining supine.

ANS: D Diastasis recti is a separation of the abdominal rectus muscles, which can occur congenitally, as a result of pregnancy, or from marked obesity. This is assessed by having the patient raise the head while remaining supine.

A woman is leaving on a trip to Hawaii and has come in for a checkup. During the examination the nurse learns that she has diabetes and takes oral hypoglycemic agents. The patient needs to be concerned about which possible effect of her medications? a. Increased possibility of bruising b. Skin sensitivity as a result of exposure to salt water c. Lack of availability of glucose-monitoring supplies d. Importance of sunscreen and avoiding direct sunlight

ANS: D Drugs that may increase sunlight sensitivity and give a burn response include sulfonamides, thiazide diuretics, oral hypoglycemic agents, and tetracycline.

4. The nurse suspects that a patient has a distended bladder. How should the nurse assess for this condition? A) Percuss and palpate in the lumbar region. B) Inspect and palpate in the epigastric region. C) Auscultate and percuss in the inguinal region. D) Percuss and palpate the midline area above the suprapubic bone.

ANS: D Dull percussion sounds would be elicited over a distended bladder, and the hypogastric area would seem firm to palpation.

18. A 32-year-old woman is at the clinic for "little white bumps in my mouth." During the assessment, the nurse notes that she has a 0.5-cm white, nontender papule under her tongue and one on the mucosa of her right cheek. What would the nurse tell the patient? a. "These spots indicate an infection such as strep throat." b. "These bumps could be indicative of a serious lesion, so I will refer you to a specialist." c. "This condition is called leukoplakia and can be caused by chronic irritation such as with smoking." d. "These bumps are Fordyce granules, which are sebaceous cysts and are not a serious condition."

ANS: D Fordyce granules are small, isolated white or yellow papules on the mucosa of the cheek, tongue, and lips. These little sebaceous cysts are painless and are not significant. Chalky white, thick, raised patches would indicate leukoplakia. In strep throat, the examiner would see tonsils that are bright red, swollen, and may have exudates or white spots. In strep throat, the examiner would see tonsils that are bright red, swollen, and may have exudates or white spots and leukoplakia would appear as chalky white, thick, raised patches. These findings are not indicative of a serious lesion but are fordyce granules. Fordyce granules are small, isolated white or yellow papules on the mucosa of the cheek, tongue, and lips. These little sebaceous cysts are painless and are not significant.

5. The nurse is aware that one change that may occur in the gastrointestinal system of an aging adult is: A) increased salivation. B) increased liver size. C) increased esophageal emptying. D) decreased gastric acid secretion.

ANS: D Gastric acid secretion decreases with aging. As one ages, salivation decreases, esophageal emptying is delayed, and liver size decreases

6. A 22-year-old man comes to the clinic for an examination after falling off his motorcycle and landing on his left side on the handlebars. The nurse suspects that he may have injured his spleen. Which of these statements is true regarding assessment of the spleen in this situation? A) The spleen can be enlarged as a result of trauma. B) The spleen is normally felt upon routine palpation. C) If an enlarged spleen is noticed, then the nurse should palpate thoroughly to determine size. D) An enlarged spleen should not be palpated because it can rupture easily.

ANS: D If an enlarged spleen is felt, then the nurse should refer the person but should not continue to palpate it. An enlarged spleen is friable and can rupture easily with overpalpation

38. During an abdominal assessment, the nurse tests for a fluid wave. A positive fluid wave test occurs with: A) splenomegaly. B) distended bladder. C) constipation. D) ascites.

ANS: D If ascites (fluid in the abdomen) is present, then the examiner will feel a fluid wave when assessing the abdomen. A fluid wave is not present with splenomegaly, a distended bladder, or constipation

When assessing a patient's pulse, the nurse notes that the amplitude is weaker during inspiration and stronger during expiration. When the nurse measures the blood pressure, the reading decreases 20 mm Hg during inspiration and increases with expiration. This patient is experiencing pulsus: A) alternans. B) bisferiens. C) bigeminus. D) paradoxus.

ANS: D In pulsus paradoxus, beats have a weaker amplitude with inspiration and a stronger amplitude with expiration. It is best determined during blood pressure measurement; reading decreases (>10 mm Hg) during inspiration and increases with expiration.

During the aging process, the hair can look gray or white and begin to feel thin and fine. The nurse knows that this occurs because of a decrease in the number of functioning: a. Metrocytes. b. Fungacytes. c. Phagocytes. d. Melanocytes.

ANS: D In the aging hair matrix, the number of functioning melanocytes decreases; as a result, the hair looks gray or white and feels thin and fine. The other options are not correct.

6. The nurse is obtaining a health history on a 3-month-old infant. During the interview, the mother states, "I think she is getting her first tooth because she has started drooling a lot." What is the best response by the nurse? a. "You're right, drooling is usually a sign of the first tooth." b. "It would be unusual for a 3-month-old to be getting her first tooth." c. "This could be the sign of a problem with the salivary glands." d. "She is just starting to salivate and hasn't learned to swallow the saliva."

ANS: D In the infant, salivation starts at 3 months. The baby will drool for a few months before learning to swallow the saliva. This drooling does not herald the eruption of the first tooth, although many parents think it does. Although many parents think the start of drooling signals the eruption of the first tooth, it does not. Although teeth usually erupt between 6 and 24 months, the nurse should not just say it would be unusual for a 3-month-old to be getting her first tooth as that does not address the issue of the drooling. It is also not a sign of a problem.

A patient has had a "terrible itch" for several months that he has been continuously scratching. On examination, the nurse might expect to find: a. A keloid. b. A fissure. c. Keratosis. d. Lichenification.

ANS: D Lichenification results from prolonged, intense scratching that eventually thickens the skin and produces tightly packed sets of papules. A keloid is a hypertrophic scar. A fissure is a linear crack with abrupt edges, which extends into the dermis; it can be dry or moist. Keratoses are lesions that are raised, thickened areas of pigmentation that appear crusted, scaly, and warty.

39. A woman who is in the second trimester of pregnancy mentions that she has had "more nosebleeds than ever" since she became pregnant. What is the likely reason for this? a. Inappropriate use of nasal sprays b. A problem with the patient's coagulation system c. Increased susceptibility to colds and nasal irritation d. Increased vascularity in the upper respiratory tract as a result of the pregnancy

ANS: D Nasal stuffiness and epistaxis may occur during pregnancy as a result of increased vascularity in the upper respiratory tract. Inappropriate use of nasal sprays often causes rebound congestion or swelling, but not usually nosebleeds. Nasal stuffiness and epistaxis may occur during pregnancy as a result of increased vascularity in the upper respiratory tract so this patient's nose bleeds are more likely to be due to the increased vascularity in the upper respiratory tract than to a problem with the coagulation system or an increased susceptibility to colds and nasal irritation.

3. The nurse is reviewing the development of the newborn infant. Regarding the sinuses, which statement is true in relation to a newborn infant? a. Sphenoid sinuses are full size at birth. b. Maxillary sinuses reach full size after puberty. c. Frontal sinuses are fairly well developed at birth. d. Maxillary and ethmoid sinuses are the only sinuses present at birth.

ANS: D Only the maxillary and ethmoid sinuses are present at birth. The sphenoid sinuses are minute at birth and develop after puberty. The frontal sinuses are absent at birth, are fairly well developed at age 7 to 8 years, and reach full size after puberty. The sphenoid sinuses are minute at birth and develop after puberty. The frontal sinuses are absent at birth, are fairly well developed at age 7 to 8 years, and reach full size after puberty. Only the maxillary and ethmoid sinuses are present at birth but the maxillary sinus does not reach full size until all permanent teeth have erupted (not after puberty).

35. The nurse is assessing a patient for possible peptic ulcer disease and knows that which condition often causes this problem? A) Hypertension B) Streptococcus infections C) History of constipation and frequent laxative use D) Frequent use of nonsteroidal antiinflammatory drugs

ANS: D Peptic ulcer disease occurs with frequent use of nonsteroidal antiinflammatory drugs, alcohol use, smoking, and Helicobacter pylori infection.

A newborn infant has Down syndrome. During the skin assessment, the nurse notices a transient mottling in the trunk and extremities in response to the cool temperature in the examination room. The infant's mother also notices the mottling and asks what it is. The nurse knows that this mottling is called: a. Café au lait. b. Carotenemia. c. Acrocyanosis. d. Cutis marmorata.

ANS: D Persistent or pronounced cutis marmorata occurs with infants born with Down syndrome or those born prematurely and is a transient mottling in the trunk and extremities in response to cool room temperatures. A café au lait spot is a large round or oval patch of light-brown pigmentation. Carotenemia produces a yellow-orange color in light-skinned persons. Acrocyanosis is a bluish color around the lips, hands and fingernails, and feet and toenails.

11. While obtaining a health history from the mother of a 1-year-old child, the nurse notices that the baby has had a bottle in his mouth the entire time. The mother states, "It makes a great pacifier." What is the best response by the nurse? a. "You're right. Bottles make very good pacifiers." b. "Using a bottle as a pacifier is better for the teeth than thumb-sucking." c. "It's okay to use a bottle as long as it contains milk and not juice." d. "Prolonged use of a bottle can increase the risk for tooth decay and ear infections."

ANS: D Prolonged bottle use during the day or when going to sleep places the infant at risk for tooth decay and middle ear infections.

32. When examining the nares of a 45-year-old patient who is experiencing rhinorrhea, itching of the nose and eyes, and sneezing, the nurse notices the following: pale turbinates, swelling of the turbinates, and clear rhinorrhea. Which of these conditions is most likely the cause? a. Nasal polyps b. Acute rhinitis c. Acute sinusitis d. Allergic rhinitis

ANS: D Rhinorrhea, itching of the nose and eyes, and sneezing are manifestations of allergic rhinitis. On physical examination, serous edema is noted, and the turbinates usually appear pale with a smooth, glistening surface. Nasal polyps appear as smooth, pale gray nodules which are overgrowths of mucosa most commonly caused by chronic allergic rhinitis and often cause absence of sense of smell and a sensation of a "valve that moves" in the nose when breathing. Acute rhinitis initially presents with clear, watery discharge (rhinorrhea) which later become purulent, with sneezing nasal itching, stimulation of cough reflex, and inflamed mucosa with dark red and swollen turbinates which cause nasal obstruction. With sinusitis, there is usually mucopurulent drainage, nasal obstruction, facial pain or pressure, and may have fever, chills, and malaise. This patient's symptoms of rhinorrhea, itching of the nose and eyes, and sneezing are manifestations of allergic rhinitis. On physical examination, serous edema is noted, and the turbinates usually appear pale with a smooth, glistening surface.

A man has come in to the clinic for a skin assessment because he is worried he might have skin cancer. During the skin assessment the nurse notices several areas of pigmentation that look greasy, dark, and "stuck on" his skin. Which is the best prediction? a. Senile lentigines, which do not become cancerous b. Actinic keratoses, which are precursors to basal cell carcinoma c. Acrochordons (skin tags), which are precursors to squamous cell carcinoma d. Seborrheic keratoses, which do not become cancerous

ANS: D Seborrheic keratoses appear like dark, greasy, "stuck-on" lesions that primarily develop on the trunk. These lesions do not become cancerous. Senile lentigines are commonly called liver spots and are not precancerous. Actinic (senile or solar) keratoses are lesions that are red-tan scaly plaques that increase over the years to become raised and roughened. They may have a silvery-white scale adherent to the plaque. They occur on sun-exposed surfaces and are directly related to sun exposure. They are premalignant and may develop into squamous cell carcinoma. Acrochordons are skin tags and are not precancerous.

38. A patient comes into the clinic complaining of facial pain, fever, and malaise. On examination, the nurse notes swollen turbinates and purulent discharge from the nose. The patient also complains of a dull, throbbing pain in his cheeks and teeth on the right side and pain when the nurse palpates the areas. What do these findings indicate? a. Nasal polyps b. Frontal sinusitis c. Posterior epistaxis d. Maxillary sinusitis

ANS: D Signs of maxillary sinusitis include facial pain after upper respiratory infection, red swollen nasal mucosa, swollen turbinates, and purulent discharge. The person also has fever, chills, and malaise. With maxillary sinusitis, dull throbbing pain occurs in the cheeks and teeth on the same side, and pain with palpation is present. With frontal sinusitis, pain is above the supraorbital ridge. Nasal polyps appear as smooth, pale gray nodules which are overgrowths of mucosa most commonly caused by chronic allergic rhinitis and often cause absence of sense of smell and a sensation of a "valve that moves" in the nose when breathing. Epistaxis is a nosebleed and the most common site of bleeding is the Kiesselbach plexus in the anterior septum. With frontal sinusitis, pain is above the supraorbital ridge. This patient's signs and symptoms are indicative of maxillary sinusitis. Signs of maxillary sinusitis include facial pain after upper respiratory infection, red swollen nasal mucosa, swollen turbinates, and purulent discharge. The person also has fever, chills, and malaise. With maxillary sinusitis, dull throbbing pain occurs in the cheeks and teeth on the same side, and pain with palpation is present.

The nurse educator is preparing an education module for the nursing staff on the dermis layer of skin. Which of these statements would be included in the module? The dermis: a. Contains mostly fat cells. b. Consists mostly of keratin. c. Is replaced every 4 weeks. d. Contains sensory receptors.

ANS: D The dermis consists mostly of collagen, has resilient elastic tissue that allows the skin to stretch, and contains nerves, sensory receptors, blood vessels, and lymphatic vessels. It is not replaced every 4 weeks.

The nurse is preparing to assess the dorsalis pedis artery. Where is the correct location for palpation? A) Behind the knee B) Over the lateral malleolus C) In the groove behind the medial malleolus D) Lateral to the extensor tendon of the great toe

ANS: D The dorsalis pedis artery is located on the dorsum of the foot. The nurse should palpate just lateral to and parallel with the extensor tendon of the big toe. The popliteal artery is palpated behind the knee. The posterior tibial pulse is palpated in the groove between the malleolus and the Achilles tendon. There is no pulse palpated at the lateral malleolus.

The nurse educator is preparing an education module for the nursing staff on the epidermal layer of skin. Which of these statements would be included in the module? The epidermis is: a. Highly vascular. b. Thick and tough. c. Thin and nonstratified. d. Replaced every 4 weeks.

ANS: D The epidermis is thin yet tough, replaced every 4 weeks, avascular, and stratified into several zones.

When performing an assessment of a patient, the nurse notices the presence of an enlarged right epitrochlear lymph node. What should the nurse do next? A) Assess the patient's abdomen, and notice any tenderness. B) Carefully assess the cervical lymph nodes, and check for any enlargement. C) Ask additional history questions regarding any recent ear infections or sore throats. D) Examine the patient's lower arm and hand, and check for the presence of infection or lesions.

ANS: D The epitrochlear nodes are located in the antecubital fossa and drain the hand and lower arm. The other actions are not correct for this assessment finding.

The nurse is assessing for clubbing of the fingernails and expects to find: a. Nail bases that are firm and slightly tender. b. Curved nails with a convex profile and ridges across the nails. c. Nail bases that feel spongy with an angle of the nail base of 150 degrees. d. Nail bases with an angle of 180 degrees or greater and nail bases that feel spongy.

ANS: D The normal nail is firm at its base and has an angle of 160 degrees. In clubbing, the angle straightens to 180 degrees or greater and the nail base feels spongy.

A mother brings her child into the clinic for an examination of the scalp and hair. She states that the child has developed irregularly shaped patches with broken-off, stublike hair in some places; she is worried that this condition could be some form of premature baldness. The nurse tells her that it is: a. Folliculitis that can be treated with an antibiotic. b. Traumatic alopecia that can be treated with antifungal medications. c. Tinea capitis that is highly contagious and needs immediate attention. d. Trichotillomania; her child probably has a habit of absentmindedly twirling her hair.

ANS: D Trichotillomania, self-induced hair loss, is usually due to habit. It forms irregularly shaped patches with broken-off, stublike hairs of varying lengths. A person is never completely bald. It occurs as a child absentmindedly rubs or twirls the area while falling asleep, reading, or watching television. (See Table 13-12, Abnormal Conditions of Hair, for descriptions of the other terms.)

34. The nurse is performing an assessment. Which of these findings would cause the greatest concern? a. A painful vesicle inside the cheek for 2 days b. The presence of moist, nontender Stensen's ducts c. Stippled gingival margins that snugly adhere to the teeth d. An ulceration on the side of the tongue with rolled edges

ANS: D Ulceration on the side or base of the tongue or under the tongue raises the suspicion of cancer and must be investigated. The risk for early metastasis is present because of rich lymphatic drainage. The vesicle may be an aphthous ulcer, which is painful but not dangerous. The other responses are normal findings. The presence of moist, nontender Stensen's ducts and stippled gingival margins that snugly adhere to the teeth are normal findings. Although a painful vesicle inside the cheek for 2 days is not that uncommon or concerning, but an ulceration on the side, base, or under the tongue raises the suspicion of cancer and must be investigated. The risk for early metastasis is present because of rich lymphatic drainage. The vesicle may be an aphthous ulcer, which is painful but not dangerous.

12. A 72-year-old patient has a history of hypertension and chronic lung disease. Which is an important question for the nurse to include in this patient's health history? a. "Do you use a fluoride supplement?" b. "Have you had tonsillitis in the last year?" c. "At what age did you get your first tooth?" d. "Have you noticed any dryness in your mouth?"

ANS: D With a history of hypertension and chronic lung disease, this patient is likely on medications and a side effect of antihypertensive and bronchodilator medication (and many other drugs such as antidepressants, anticholinergics, antispasmodics, and antipsychotics) is dry mouth, or xerostomia. The nurse should ask the patient if they've noticed dryness in their mouth.

During an ophthalmoscopic examination of the eye, the nurse notices areas of *exudate that look like "cotton wool" or fluffy gray-white cumulus clouds*. This finding indicates which possible problem?

ANS: Diabetes Soft exudates or "cotton wool" areas look like fluffy gray-white cumulus clouds, They occur with diabetes, hypertension, subacute bacterial endocarditis, lupus, and papilledema of any cause. These exudates are not found with hyperthyroidism, glaucoma, or hypotension.

A 35-year-old man is seen in the clinic for an infection in his left foot. Which of these findings should the nurse expect to see during an assessment of this patient? a. Hard and fixed cervical nodes b. Enlarged and tender inguinal nodes c. Bilateral enlargement of the popliteal nodes d. Pelletlike nodes in the supraclavicular region

ANS: Enlarged and tender inguinal nodes The inguinal nodes in the groin drain most of the lymph of the lower extremities. With local inflammation, the nodes in that area become swollen and tender.

In an individual with otitis externa, which of these signs would the nurse expect to find on assessment?

ANS: Enlarged superficial cervical nodes The lymphatic drainage of the external ear flows to the parotid, mastoid, and superficial cervical nodes. The signs are severe swelling of the canal, inflammation, and tenderness. Rhinorrhea, periorbital edema, and pain over the maxillary sinuses do not occur with otitis externa.

When performing an assessment of a patient, the nurse notices the presence of an enlarged right epitrochlear lymph node. What should the nurse do next? a. Assess the patient's abdomen, and notice any tenderness. b. Carefully assess the cervical lymph nodes, and check for any enlargement. c. Ask additional health history questions regarding any recent ear infections or sore throats. d. Examine the patient's lower arm and hand, and check for the presence of infection or lesions.

ANS: Examine the patient's lower arm and hand, and check for the presence of infection or lesions. The epitrochlear nodes are located in the antecubital fossa and drain the hand and lower arm. The other actions are not correct for this assessment finding.

During an assessment of a healthy adult, where would the nurse expect to palpate the apical impulse? a. Third left intercostal space at the midclavicular line b. Fourth left intercostal space at the sternal border c. Fourth left intercostal space at the anterior axillary line d. Fifth left intercostal space at the midclavicular line

ANS: Fifth left intercostal space at the midclavicular line The apical impulse should occupy only one intercostal space, the fourth or fifth, and it should be at or medial to the midclavicular line.

A patient with pleuritis has been admitted to the hospital and complains of pain with breathing. What other key assessment finding would the nurse expect to find upon auscultation?

ANS: Friction rub A patient with pleuritis will exhibit a pleural friction rub upon auscultation. This is the sound made when pleurae become inflamed and rub together during respiration. The sound is superficial, coarse, and low-pitched, as if two pieces of leather are being rubbed together. Stridor is associated with croup, acute epiglottitis in children, and foreign body inhalation. Crackles are associated with several diseases, such as pneumonia, heart failure, chronic bronchitis, and others (see Table 18-6). Wheezes are associated with diffuse airway obstruction caused by acute asthma or chronic emphysema.

During a cardiac assessment on a 38 year-old patient in the hospital for "chest pain," the nurse finds the following: jugular vein pulsations 4 cm above sternal angle when he is elevated at 45 degrees, blood pressure 98/60 mm Hg, heart rate 130 beats per minute, ankle edema, difficulty in breathing when supine, and an S3 on auscultation. Which of these conditions best explains the cause of these findings? a. Fluid overload b. Atrial septal defect c. MI d. Heart failure

ANS: Heart failure Heart failure causes decreased cardiac output when the heart fails as a pump and the circulation becomes backed up and congested. Signs and symptoms include dyspnea, orthopnea, paroxysmal nocturnal dyspnea, decreased blood pressure, dependent and pitting edema; anxiety; confusion; jugular vein distention; and fatigue. The S3 is associated with heart failure and is always abnormal after age 35. The S3 may be the earliest sign of heart failure.

The nurse suspects that a patient has otitis media. Early signs of otitis media include which of these findings of the tympanic membrane?

ANS: Hypomobility An early sign of otitis media is hypomobility of the tympanic membrane. As pressure increases, the tympanic membrane begins to bulge.

A patient has been admitted to the emergency department for a suspected drug overdose. His respirations are shallow, with an irregular pattern, with a rate of 12 per minute. The nurse interprets this respiration pattern as which of the following?

ANS: Hypoventilation Hypoventilation is characterized by an irregular, shallow pattern, and can be caused by an overdose of narcotics or anesthetics. Bradypnea is slow breathing, with a rate less than 10 respirations per minute. See Table 18-4 for descriptions of Cheyne-Stokes respirations and chronic obstructive breathing.

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

ANS: Increase in systolic blood pressure With aging, there is an increase in systolic blood pressure. No significant change in diastolic pressure occurs with age. No change in resting heart rate occurs with aging. Cardiac output at rest is not changed with aging.

The nurse is unable to identify any changes in sound when percussing over the abdomen of an obese patient. What should the nurse do next?

ANS: Increase the amount of strength used when attempting to percuss over the abdomen. The thickness of the person's body wall will be a factor. The nurse will need a stronger percussion stroke for persons with obese or very muscular body walls. The force of the blow determines the loudness of the note. The other actions are not correct.

A patient states that the pain medication is "not working" and rates his postoperative pain at a 10 on a 1 to 10 scale. Which of these assessment findings indicates an acute pain response to poorly controlled pain?

ANS: Increased blood pressure and pulse Responses to poorly controlled acute pain include tachycardia, elevated blood pressure, and hypoventilation. Confusion and depression are associated with poorly controlled chronic pain. See Table 10-1.

The nurse is preparing to perform a physical assessment. Which statement is true about the inspection phase of the physical assessment?

ANS: Inspection takes time and reveals a surprising amount of information. A focused inspection takes time and yields a surprising amount of information. Initially, the examiner may feel uncomfortable "staring" at the person without also "doing something." A focused assessment is much more than a "quick glance."

The nurse is reviewing venous blood flow patterns. Which of these statements best describes the mechanism(s) by which venous blood returns to the heart? a. Intraluminal valves ensure unidirectional flow toward the heart. b. Contracting skeletal muscles milk blood distally toward the veins. c. High-pressure system of the heart helps facilitate venous return. d. Increased thoracic pressure and decreased abdominal pressure facilitate venous return to the heart.

ANS: Intraluminal valves ensure unidirectional flow toward the heart. Blood moves through the veins by (1) contracting skeletal muscles that milk the blood proximally; (2) pressure gradients caused by breathing, in which inspiration makes the thoracic pressure decrease and the abdominal pressure increase; and (3) the intraluminal valves, which ensure unidirectional flow toward the heart.

The nurse is reviewing the structures of the ear. Which of these statements concerning the *eustachian tube* is true?

ANS: It helps equalize air pressure on both sides of the tympanic membrane. The eustachian tube allows equalization of air pressure on each side of the tympanic membrane so that the membrane does not rupture (e.g., during altitude changes in an airplane). The tube is normally closed, but it opens with swallowing or yawning.

The nurse is assessing a patient who may have hearing loss. Which of these statements is true concerning *air conduction*?

ANS: It is the normal pathway for hearing. The normal pathway of hearing is air conduction, which starts when sound waves produce vibrations on the tympanic membrane. Conductive hearing loss results from a mechanical dysfunction of the external or middle ear.

The nurse is preparing to assess the dorsalis pedis artery. Where is the correct location for palpation? a. Behind the knee b. Over the lateral malleolus c. In the groove behind the medial malleolus d. Lateral to the extensor tendon of the great toe

ANS: Lateral to the extensor tendon of the great toe The dorsalis pedis artery is located on the dorsum of the foot. The nurse should palpate just lateral to and parallel with the extensor tendon of the big toe. The popliteal artery is palpated behind the knee. The posterior tibial pulse is palpated in the groove between the malleolus and the Achilles tendon. There is no pulse palpated at the lateral malleolus.

When the nurse is auscultating the carotid artery for bruits, which of these statements reflects correct technique? a. While listening with the bell of the stethoscope, the patient is asked to take a deep breath and hold it. b. While auscultating one side with the bell of the stethoscope, the carotid artery is palpated on the other side to check pulsations. c. While lightly applying the bell of the stethoscope over the carotid artery and listening, the patient is asked to take a breath, exhale, and briefly hold it. d. While firmly placing the bell of the stethoscope over the carotid artery and listening, the patient is asked to take a breath, exhale, and briefly hold it.

ANS: Lightly apply the bell of the stethoscope over the carotid artery, and while listening, have the patient take a breath, exhale, and hold it briefly. The correct technique for auscultating the carotid artery for bruits involves the nurse lightly applying the bell of the stethoscope over the carotid artery at three levels. While listening, the nurse asks the patient take a breath, exhale, and briefly hold it. Holding the breath on inhalation will also tense the levator scapulae muscles, which makes it hard to hear the carotid arteries. Examining only one carotid artery at a time will avoid compromising arterial blood flow to the brain. Pressure over the carotid sinus, which may lead to decreased heart rate, decreased blood pressure, and cerebral ischemia with syncope, should be avoided.

The nurse is preparing to auscultate for heart sounds. Which technique is correct? a. Listening to the sounds at the aortic, tricuspid, pulmonic, and mitral areas b. Listening by inching the stethoscope in a rough Z pattern, from the base of the heart across and down, then over to the apex c. Listening to the sounds only at the site where the apical pulse is felt to be the strongest d. Listening for all possible sounds at a time at each specified area

ANS: Listen by inching the stethoscope in a rough Z pattern, from the base of the heart across and down, then over to the apex. Do not limit auscultation of breath sounds to only four locations. Sounds produced by the valves may be heard all over the precordium. Inch the stethoscope in a rough Z pattern from the base of the heart across and down, then over to the apex. Or, start at the apex and work your way up. See Figure 19-22. Listen selectively to one sound at a time.

During auscultation of breath sounds, the nurse should use the stethoscope correctly, in which of the following ways?

ANS: Listen to at least one full respiration in each location. During auscultation of breath sounds with a stethoscope, it is important to listen to one full respiration in each location. During the examination, the nurse should monitor the breathing and offer times for the person to breathe normally to prevent possible dizziness.

The nurse is reviewing for a class in *age-related changes* in the eye. Which of these physiological changes is responsible for presbyopia?

ANS: Loss of lens elasticity The lens loses elasticity and decreases its ability to change shape to accommodate for near vision. This condition is called presbyopia.

The nurse is reviewing for a class in age-related changes in the eye. Which of these physiological changes is responsible for presbyopia?

ANS: Loss of lens elasticity The lens loses elasticity and decreases its ability to change shape to accommodate for near vision. This condition is called presbyopia.

During an assessment, the nurse notices that a patient's left arm is swollen from the shoulder down to the fingers, with nonpitting brawny edema. The right arm is normal. The patient had a left-sided mastectomy 1 year ago. The nurse suspects which problem? a. Venous stasis b. Lymphedema c. Arteriosclerosis d. Deep-vein thrombosis

ANS: Lymphedema Lymphedema after breast cancer causes unilateral swelling and nonpitting brawny edema, with overlying skin indurated. It is caused by the removal of lymph nodes with breast surgery or damage to lymph nodes and channels with radiation therapy for breast cancer, and it can impede drainage of lymph. The other responses are not correct.

Which of these findings would the nurse expect to notice during a cardiac assessment on a 4-year-old child? a. S3 when sitting up b. Persistent tachycardia above 150 beats per minute c. Murmur at the second left intercostal space when supine d. Palpable apical impulse in the fifth left intercostal space lateral to midclavicular line

ANS: Murmur at second left intercostal space when supine Some murmurs are common in healthy children or adolescents and are termed innocent or functional. The innocent murmur is heard at the second or third left intercostal space and disappears with sitting, and the young person has no associated signs of cardiac dysfunction.

The nurse is reviewing principles of pain. Which type of pain is due to an abnormal processing of the pain impulse through the peripheral or central nervous system?

ANS: Neuropathic Neuropathic pain implies an abnormal processing of the pain message. The other types of pain are named according to their sources.

While counting the apical pulse on a 16-year-old patient, the nurse notices an irregular rhythm. His rate speeds up on inspiration and slows on expiration. What would be the nurse's response? a. Talk with the patient about his intake of caffeine. b. Perform an electrocardiogram after the examination. c. No further response is needed because sinus arrhythmia can occur normally. d. Refer the patient to a cardiologist for further testing.

ANS: No further response is needed because this is normal. The rhythm should be regular, although sinus arrhythmia occurs normally in young adults and children. With sinus arrhythmia, the rhythm varies with the person's breathing, increasing at the peak of inspiration, and slowing with expiration.

ANS: Normal When documenting the force, or amplitude, of pulses, 3+ indicates an increased, full, or bounding pulse, 2+ indicates a normal pulse, 1+ indicates a weak pulse, and 0 indicates an absent pulse.

A patient has been admitted after an accident at work. During the assessment, the patient is having trouble hearing and states, "I don't know what the matter is. All of a sudden, I can't hear you out of my left ear!" What should the nurse do next?

ANS: Notify the patient's health care provider. Any sudden loss of hearing in one or both ears, that is not associated with an upper respiratory infection, needs to be reported at once to the patient's health care provider. Hearing loss associated with trauma is often sudden. It is not appropriate to irrigate the ear or remove cerumen at this time.

A 60-year-old man is at the clinic for an eye examination. The nurse suspects that he has *ptosis of one eye*. How should the nurse check for this?

ANS: Observe the distance between the palpebral fissures . Ptosis is drooping of the upper eyelid that would be apparent by observing the distance between the upper and lower eyelids. The confrontation test measures peripheral vision. Measuring near vision or the corneal light test does not check for ptosis.

The nurse is performing a well-child check on a 5-year-old boy. He has no current history that would lead the nurse to suspect illness. His medical history is unremarkable, and he received immunizations 1 week ago. Which of these findings should be considered normal in this situation? a. Enlarged, warm, and tender nodes b. Lymphadenopathy of the cervical nodes c. Palpable firm, small, shotty, mobile, and nontender lymph nodes d. Firm, rubbery, and large nodes, somewhat fixed to the underlying tissue

ANS: Palpable firm, small, shotty, mobile, nontender lymph nodes Palpable lymph nodes are often normal in children and infants. They are small, firm, shotty, mobile, and nontender. Vaccinations can produce lymphadenopathy. Enlarged, warm, tender nodes indicate current infection.

Which of these techniques uses the sense of touch to assess texture, temperature, moisture, and swelling when the nurse is assessing a patient?

ANS: Palpation Palpation uses the sense of touch to assess the patient for these factors. Inspection involves vision; percussion assesses through the use of palpable vibrations and audible sounds; and auscultation uses the sense of hearing.

The nurse will use which technique of assessment to determine the presence of crepitus, swelling, and pulsations?

ANS: Palpation Palpation applies the sense of touch to assess these factors: texture, temperature, moisture, organ location and size, as well as any swelling, vibration or pulsation, rigidity or spasticity, crepitation, presence of lumps or masses, and presence of tenderness or pain.

The nurse is performing the diagnostic positions test. Normal findings would be which of these results?

ANS: Parallel movement of both eyes A normal response for the diagnostic positions test is parallel tracking of the object with both eyes. Eye movement that is not parallel indicates weakness of an extraocular muscle or dysfunction of the cranial nerve innervating it.

The nurse is performing the *diagnostic positions test*. Normal findings would be which of these results?

The nurse is reviewing the principles of nociception. During which phase of nociception does the conscious awareness of a painful sensation occur?

ANS: Perception Perception is the third phase of nociception and indicates the conscious awareness of a painful sensation. During this phase, the sensation is recognized by higher cortical structures and identified as pain.

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?

ANS: Percuss the thorax bilaterally, noting any differences in percussion tones. Percussion is always available, portable, and gives instant feedback regarding changes in underlying tissue density, which may yield clues of the patient's physical status.

During an assessment of an older adult, the nurse should expect to notice which finding as a normal physiologic change associated with the aging process? a. Hormonal changes causing vasodilation and a resulting drop in blood pressure b. Progressive atrophy of the intramuscular calf veins, causing venous insufficiency c. Peripheral blood vessels growing more rigid with age, producing a rise in systolic blood pressure d. Narrowing of the inferior vena cava, causing low blood flow and increases in venous pressure resulting in varicosities

ANS: Peripheral blood vessels growing more rigid with age, producing a rise in systolic blood pressure Peripheral blood vessels grow more rigid with age, resulting in a rise in systolic blood pressure. Aging produces progressive enlargement of the intramuscular calf veins, not atrophy. The other options are not correct

The nurse is reviewing risk factors for venous disease. Which of these situations best describes a person at highest risk for development of venous disease? a. Woman in her second month of pregnancy b. Person who has been on bed rest for 4 days c. Person with a 30-year, 1 pack per day smoking habit d. Older adult taking anticoagulant medication

ANS: Person who has been on bed rest for 4 days At risk for venous disease are people who undergo prolonged standing, sitting, or bed rest. Hypercoagulable (not anticoagulated) states and vein wall trauma also place the person at risk for venous disease. Obesity and pregnancy are also risk factors, but not the early months of pregnancy.

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. 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

ANS: Presence of dyspnea or diaphoresis when sucking To screen for heart disease in an infant, focus on feeding. Note fatigue during feeding. An infant with heart failure takes fewer ounces each feeding, becomes dyspneic with sucking, may be diaphoretic and then falls into exhausted sleep and awakens after a short time hungry again.

During a morning assessment, the nurse notices that the patient's sputum is frothy and pink. Which condition could this finding indicate?

ANS: Pulmonary edema Sputum alone is not diagnostic, but some conditions have characteristic sputum production. Pink, frothy sputum indicates pulmonary edema (or it may be a side effect of sympathomimetic medications). Croup is associated with a "barking" cough, not sputum production. Tuberculosis may produce rust-colored sputum. Viral infections may produce white or clear mucoid sputum.

The nurse is testing a patient's *visual accommodation*, which refers to which action?

ANS: Pupillary constriction when looking at a near object The muscle fibers of the iris contract the pupil in bright light and accommodate for near vision, which also results in pupil constriction. The other responses are not correct.

The nurse is testing a patient's visual accommodation, which refers to which action?

To assess the head control of a 4-month-old infant, the nurse lifts the infant up in a prone position while supporting his chest. The nurse looks for what normal response?

ANS: Raises head and arches back At 3 months of age, the infant raises the head and arches the back as if in a swan dive. This is the Landau reflex, which persists until 1 1/2 years of age. The other responses are incorrect. See Figure 23-43.

During an assessment, a patient tells the nurse that her fingers often change color when she goes out in cold weather. She describes these episodes as her fingers first turning white, then blue, then red with a burning, throbbing pain. The nurse suspects that she is experiencing: a. Lymphedema. b. Raynaud disease. c. Deep-vein thrombosis. d. Chronic arterial insufficiency.

ANS: Raynaud's disease. The condition with episodes of abrupt, progressive tricolor change of the fingers in response to cold, vibration, or stress is known as Raynaud's disease. Lymphedema is described in Table 20-2; deep vein thrombosis is described in Table 20-5; chronic arterial insufficiency is described in Table 20-4.

The direction of blood flow through the heart is best described by which of these? a. Vena cava right atrium right ventricle lungs pulmonary artery left atrium left ventricle b. Right atrium right ventricle pulmonary artery lungs pulmonary vein left atrium left ventricle c. Aorta right atrium right ventricle lungs pulmonary vein left atrium left ventricle vena cava d. Right atrium right ventricle pulmonary vein lungs pulmonary artery left atrium left ventricle

ANS: Right atrium right ventricle pulmonary artery lungs pulmonary vein left atrium left ventricle Returning blood from the body empties into the right atrium and flows into the right ventricle and then goes to the lungs through the pulmonary artery. The lungs oxygenate the blood and it is then returned to the left atrium by the pulmonary vein. It goes from there to the left ventricle and then out to the body through the aorta.

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?

ANS: Rotating the lens selector dial to bring the object into focus The ophthalmoscope is used to examine the internal eye structures. It can compensate for nearsightedness or farsightedness, but it will not correct for astigmatism. The grid is used to assess size and location of lesions on the fundus. The large full spot of light is used to assess dilated pupils. Rotating the lens selector dial brings the object into focus.

When assessing the pupillary light reflex, the nurse should use which technique?

ANS: Shine a light across the pupil from the side and observe for direct and consensual pupillary constriction. To test the pupillary light reflex, the nurse should advance a light in from the side and note the direct and consensual pupillary constriction.

A 70-year-old patient is being seen in the clinic for severe exacerbation of his heart failure. Which of these findings is the nurse most likely to observe in this situation?

ANS: Shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, ankle edema Heart failure often presents with increased respiratory rate, shortness of breath on exertion, orthopnea, paroxysmal nocturnal dyspnea, nocturia, ankle edema, and pallor in light-skinned individuals. A patient with rasping cough, thick mucoid sputum, and wheezing may have bronchitis. Productive cough, dyspnea, weight loss, and dyspnea are seen with tuberculosis; fever, dry nonproductive cough, and diminished breath sounds may indicate Pneumocystis jiroveci (P. carinii) pneumonia. See Table 18-8.

Which of these statements is true regarding the use of standard precautions in the health care setting?

ANS: Standard precautions are intended for use with all patients regardless of their risk or presumed infection status. Standard precautions are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources. They are intended for use for all patients, regardless of their risk or presumed infection status. They apply to blood and all other body fluids, secretions and excretions except sweat—regardless of whether they contain visible blood, nonintact skin, or mucous membranes. Hands should be washed with soap and water if visibly soiled with blood or body fluids; alcohol-based hand rubs can be used if hands are not visibly soiled.

The nurse is examining a patient who has possible cardiac enlargement. Which statement about percussion of the heart is true? a. Percussion is a useful tool for outlining the heart's borders. b. Percussion is easier in patients who are obese. c. Studies show that percussed cardiac borders do not correlate well with the true cardiac border. d. Only expert health care providers should attempt percussion of the heart.

ANS: Studies show that percussed cardiac borders do not correlate well with the true cardiac border. Numerous comparison studies have shown that the percussed cardiac border correlates "only moderately" with the true cardiac border. Percussion is of limited usefulness with the female breast tissue or in an obese person, or a person with a muscular chest wall. Chest x-rays or echocardiogram examinations are much more accurate in detecting heart enlargement.

Which of these veins are responsible for most of the venous return in the arm? a. Deep b. Ulnar c. Subclavian d. Superficial

ANS: Superficial The superficial veins of the arms are in the subcutaneous tissue and are responsible for most of the venous return.

When using a Doppler ultrasonic stethoscope, the nurse recognizes venous flow when which sound is heard? a. Low humming sound b. Regular "lub, dub" pattern c. Swishing, whooshing sound d. Steady, even, flowing sound

ANS: Swishing, whooshing sound When using the Doppler ultrasonic stethoscope, the pulse site is found when one hears a swishing, whooshing sound.

The mother of a 10-month-old infant tells the nurse that she has noticed that her son becomes blue when he is crying and that the frequency of this is increasing. He is also not crawling yet. During the examination the nurse palpates a thrill at the left lower sternal border and auscultates a loud systolic murmur in the same area. What would be the most likely cause of these findings? a. Tetralogy of Fallot b. Atrial septal defect c. Patent ductus arteriosus d. Ventricular septal defect

ANS: Tetralogy of Fallot Tetralogy of Fallot subjective findings include (1) severe cyanosis, not in the first months of life but developing as the infant grows, and right ventricle outflow (i.e., pulmonic) stenosis gets worse; (2) cyanosis with crying and exertion at first, then at rest; and (3) slowed development. Objective findings include (1) thrill palpable at left lower sternal border; (2) S1 normal, S2 has A2 loud and P2 diminished or absent; and (3) murmur is systolic, loud, crescendo-decrescendo.

A 4-year-old boy is brought to the emergency department by his mother. She says he points to his stomach and says, "It hurts so bad." Which pain assessment tool would be the best choice when assessing this child's pain?

ANS: The Faces Pain Scale—Revised (FPS-R) Rating scales can be introduced at the age of 4 or 5 years. The Faces Pain Scale—Revised (FPS-R) is designed for use by children and asks the child to choose a face that shows "how much hurt (or pain) you have now." Young children should not be asked to rate pain by using numbers.

During an examination of the eye, the nurse would expect what normal finding when assessing the lacrimal apparatus?

ANS: The absence of drainage from the puncta when pressing against the inner orbital rim There should be no swelling, redness, or drainage from the puncta when it is pressed. Regurgitation of fluid from the puncta, when pressed, indicates duct blockage. The lacrimal glands are not functional at birth.

The nurse is reviewing anatomy and physiology of the heart. Which statement best describes what is meant by atrial kick? a. The atria contract during systole and attempt to push against closed valves. b. Contraction of the atria at the beginning of diastole can be felt as a palpitation. c. Atrial kick is the pressure exerted against the atria as the ventricles contract during systole. d. The atria contract toward the end of diastole and push the remaining blood into the ventricles.

ANS: The atria contract toward the end of diastole and push the remaining blood into the ventricles. Toward the end of diastole, the atria contract and push the last amount of blood (about 25% of stroke volume) into the ventricles. This active filling phase is called presystole, or atrial systole, or sometimes the "atrial kick."

While auscultating heart sounds, the nurse hears a murmur. Which of these should be used to assess this murmur?

ANS: The bell of the stethoscope The bell of the stethoscope is best for soft, low-pitched sounds such as extra heart sounds or murmurs. The diaphragm of the stethoscope is best used for high-pitched sounds such as breath, bowel, and normal heart sounds.

The nurse is conducting a visual examination. Which of these statements regarding *visual pathways and visual fields* is true?

ANS: The image formed on the retina is upside down and reversed from its actual appearance in the outside world. The image formed on the retina is upside down and reversed from its actual appearance in the outside world. The light rays are refracted through the transparent media of the eye before striking the retina, and the nerve impulses are conducted through the optic nerve tract to the visual cortex of the occipital lobe of the brain. The left side of the brain interprets vision for the right eye.

The nurse assesses the hearing of a 7-month-old by clapping hands. What is the expected response?

ANS: The infant turns the head to localize sound. With a loud sudden noise, the nurse should notice the infant turning his or her head to localize sound and responding to his or her own name. A startle reflex and acoustic blink reflex is expected in newborns; at age 3 to 4 months, the infant stops movements and appears to listen.

The nurse is assessing a patient with possible cardiomyopathy and assesses the hepatojugular reflux. If heart failure is present, then the nurse should see which finding while pushing on the right upper quadrant of the patient's abdomen, just below the rib cage? a. The jugular veins will rise for a few seconds and then recede back to the previous level if the heart is properly working. b. The jugular veins will remain elevated as long as pressure on the abdomen is maintained. c. An impulse will be visible at the fourth or fifth intercostal space at or inside the midclavicular line. d. The jugular veins will not be detected during this maneuver.

ANS: The jugular veins will remain elevated as long as pressure on the abdomen is maintained. When performing hepatojugular reflux, the jugular veins will rise for a few seconds and then recede back to the previous level if the heart is able to pump the additional volume created by the pushing; however, with heart failure, the jugular veins remain elevated as long as pressure on the abdomen is maintained.

The nurse is assessing the lungs of an older adult. Which of these describes normal changes in the respiratory system of the older adult?

ANS: The lungs are less elastic and distensible, which decreases their ability to collapse and recoil. In the aging adult the lungs are less elastic and distensible, which decreases their ability to collapse and recoil. There is a decreased vital capacity and a loss of intraalveolar septa, causing less surface area for gas exchange. The lung bases become less ventilated, and the older person is at risk for dyspnea with exertion beyond his or her usual workload.

The nurse is performing an external eye examination. Which statement regarding the *outer layer of the eye* is true?

ANS: The outer layer of the eye is very sensitive to touch. The cornea and the sclera make up the outer layer of the eye. The cornea is very sensitive to touch. The middle layer, the choroid, has dark pigmentation to prevent light from reflecting internally. The trigeminal (CN V) and facial (CN VII) are stimulated when the outer surface of the eye is stimulated. The retina, in the inner layer of the eye, is where light waves are changed into nerve impulses.

When assessing the respiratory system of a 4-year-old child, which of these findings would the nurse expect?

ANS: The presence of bronchovesicular breath sounds in the peripheral lung fields Bronchovesicular breath sounds in the peripheral lung fields of the infant and young child up to age 5 or 6 years are a normal finding. Their thin chest walls with underdeveloped musculature do not dampen the sound, as do the thicker chest walls of adults, so breath sounds are louder and harsher.

The nurse is examining the lymphatic system of a healthy 3-year-old child. Which finding should the nurse expect? a. Excessive swelling of the lymph nodes b. Presence of palpable lymph nodes c. No palpable nodes because of the immature immune system of a child d. Fewer numbers and a smaller size of lymph nodes compared with those of an adult

ANS: The presence of palpable lymph nodes Lymph nodes are relatively large in children, and the superficial ones often are palpable even when the child is healthy.

During an assessment of the *sclera of an African-American* patient, the nurse would consider which of these an expected finding?

ANS: The presence of small brown macules on the sclera In dark-skinned people, one normally may see small brown macules in the sclera.

When inspecting the anterior chest of an adult, the nurse should include which assessment?

ANS: The shape and configuration of the chest wall Inspection of the anterior chest includes shape and configuration of the chest wall; assessment of the patient's level of consciousness, skin color and condition; quality of respirations; presence or absence of retraction and bulging of the intercostal spaces; and use of accessory muscles. Symmetric chest expansion is assessed by palpation. Diaphragmatic excursion is assessed by percussion of the posterior chest. Breath sounds are assessed by auscultation.

When assessing a newborn infant who is 5 minutes old, the nurse knows that which of these statements would be true? a. The left ventricle is larger and weighs more than the right ventricle. b. The circulation of a newborn is identical to that of an adult. c. Blood can flow into the left side of the heart through an opening in the atrial septum. d. The foramen ovale closes just minutes before birth, and the ductus arteriosus closes immediately after.

ANS: There is an opening in the atrial septum where blood can flow into the left side of the heart. First, about two thirds of the blood is shunted through an opening in the atrial septum, the foramen ovale into the left side of the heart, where it is pumped out through the aorta. The foramen ovale closes within the first hour because the pressure in the right side of the heart is now lower than in the left side.

During the assessment of an 80-year-old patient, the nurse notices that his hands show tremors when he reaches for something and his head is always nodding. There is no associated rigidity with movement. Which of these statements is most accurate?

ANS: These are normal findings resulting from aging. Senile tremors occasionally occur. These benign tremors include an intention tremor of the hands, head nodding (as if saying yes or no), and tongue protrusion. Tremors associated with Parkinson disease include rigidity, slowness, and weakness of voluntary movement. The other responses are incorrect.

During an assessment of a 20-year-old Asian patient, the nurse notices that he has *dry, flaky cerumen* in his canal. What is the significance of this finding?

ANS: This is a normal finding and no further follow-up is necessary. Asians and Native Americans are more likely to have dry cerumen, whereas African Americans and Caucasians usually have wet cerumen.

A 25-year-old woman in her fifth month of pregnancy has a blood pressure of 100/70 mm Hg. In reviewing her previous exam, the nurse notes that her blood pressure in her second month was 124/80 mm Hg. In evaluating this change, what does the nurse know to be true? a. This decline in blood pressure is the result of peripheral vasodilatation and is an expected change. b. Because of increased cardiac output, the blood pressure should be higher at this time. c. This change in blood pressure is not an expected finding because it means a decrease in cardiac output. d. This decline in blood pressure means a decrease in circulating blood volume, which is dangerous for the fetus.

ANS: This is the result of peripheral vasodilatation and is an expected change. Despite the increased cardiac output, arterial blood pressure decreases in pregnancy because of peripheral vasodilatation. The blood pressure drops to its lowest point during the second trimester and then rises after that.

A colleague is assessing an 80-year-old patient who has ear pain and asks him to hold his nose and swallow. The nurse knows that which of the following is true concerning this technique?

ANS: This should not be used in an 80-year-old patient. The eardrum is flat, slightly pulled in at the center, and flutters when the person performs the Valsalva maneuver or holds the nose and swallows (insufflation). One may elicit these maneuvers to assess drum mobility. However, these maneuvers should be avoided with an aging person because they may disrupt equilibrium.

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?

ANS: Wash hands before and after every physical patient encounter. The nurse should wash his or her hands before and after every physical patient encounter; after contact with blood, body fluids, secretions, and excretions; after contact with any equipment contaminated with body fluids; and after removing gloves. Hands should be washed after gloves have been removed, even if the gloves appear to be intact. Gloves should be worn when there is potential contact with any body fluids.

The nurse is examining a patient's lower leg and notices a draining ulceration. Which of these actions is most appropriate in this situation?

ANS: Wash hands, put on gloves, and continue with the examination of the ulceration. The examiner should wear gloves when there is potential contact with any body fluids. In this situation, the nurse should wash his or her hands, put on gloves, and continue examining the ulceration.

During the cardiac auscultation the nurse hears a sound occurring immediately after S2 at the second left intercostal space. To further assess this sound, what should the nurse do? a. Have the patient turn to the left side while the nurse listens with the bell of the stethoscope. b. Ask the patient to hold his or her breath while the nurse listens again. c. No further assessment is needed because the nurse knows this sound is an S3. d. Watch the patient's respirations while listening for the effect on the sound.

ANS: Watch the patient's respirations while listening for effect on the sound. A split S2 is a normal phenomenon that occurs toward the end of inspiration in some people. A split S2 is heard only in the pulmonic valve area, the second left interspace. When the split S2 is first heard, the nurse should not be tempted to ask the person to hold his or her breath so that the nurse can concentrate on the sounds. Breath holding will only equalize ejection times in the right and left sides of the heart and cause the split to go away. Instead, the nurse should concentrate on the split while watching the person's chest rise up and down with breathing.

The nurse is listening to the breath sounds of a patient with severe asthma. Air passing through narrowed bronchioles would produce which of these adventitious sounds?

ANS: Wheezes Wheezes are caused by air squeezed or compressed through passageways narrowed almost to closure by collapsing, swelling, secretions, or tumors, such as with acute asthma or chronic emphysema.

A teenage patient comes to the emergency department with complaints of an inability to breathe and a sharp pain in the left side of his chest. The assessment findings include cyanosis, tachypnea, tracheal deviation to the right, decreased tactile fremitus on the left, hyperresonance on the left, and decreased breath sounds on the left. The nurse interprets that these assessment findings are consistent with:

ANS: a pneumothorax. With a pneumothorax, free air in the pleural space causes partial or complete lung collapse. If the pneumothorax is large, then tachypnea and cyanosis are seen. Unequal chest expansion, decreased or absent tactile fremitus, tracheal deviation to the unaffected side, decreased chest expansion, hyperresonant percussion tones, and decreased or absent breath sounds are found with the presence of pneumothorax. See Table 18-8 for descriptions of the other conditions.

During a cardiovascular assessment, the nurse knows that a "thrill" is: a. Vibration that is palpable. b. Palpated in the right epigastric area. c. Associated with ventricular hypertrophy. d. Murmur auscultated at the third intercostal space.

ANS: a vibration that is palpable. A thrill is a palpable vibration. It signifies turbulent blood flow and accompanies loud murmurs. The absence of a thrill does not rule out the presence of a murmur.

During an examination of a patient's abdomen, the nurse notes that the abdomen is rounded and firm to the touch. During percussion, the nurse notes a drum-like quality of the sound across the quadrants. This type of sound indicates:

ANS: air-filled areas. A musical or drum-like sound (tympany) is the sound heard when percussion occurs over an air-filled viscus, such as the stomach or intestines.

During a routine office visit, a patient takes off his shoes and shows the nurse "this awful sore that won't heal." On inspection, the nurse notes a 3-cm round ulcer on the left great toe, with a pale ischemic base, well-defined edges, and no drainage. The nurse should assess for other signs and symptoms of: a. Varicosities. b. Venous stasis ulcer. c. Arterial ischemic ulcer. d. Deep-vein thrombophlebitis.

ANS: an arterial ischemic ulcer. Arterial ischemic ulcers occur at toes, metatarsal heads, heels, and lateral ankle, and they are characterized by a pale ischemic base, well-defined edges, and no bleeding. See Table 20-5 for a description of varicose veins and deep vein thrombophlebitis. See Table 20-4 for a description of venous stasis ulcers.

When listening to heart sounds, the nurse knows that the valve closures that can be heard best at the base of the heart are: a. Mitral and tricuspid. b. Tricuspid and aortic. c. Aortic and pulmonic. d. Mitral and pulmonic.

ANS: aortic and pulmonic. The second heart sound (S2) occurs with closure of the semilunar (aortic and pulmonic) valves and signals the end of systole. Although it is heard over all the precordium, S2 is loudest at the base of the heart.

The nurse notices the presence of *periorbital edema* when performing an eye assessment on a 70-year-old patient. The nurse should:

ANS: ask the patient if he or she has a history of heart failure. Periorbital edema occurs with local infections, crying, and systemic conditions such as heart failure, renal failure, allergy, and hypothyroidism. Periorbital edema is not associated with blepharitis.

The nurse notices the presence of periorbital edema when performing an eye assessment on a 70-year-old patient. The nurse should:

A patient has been shown to have a *sensorineural hearing loss*. During the assessment, it would be important for the nurse to:

ANS: ask the patient what medications he is currently taking. A simple increase in amplitude may not enable the person to understand words. *Sensorineural hearing loss may be caused by presbycusis*, which is a gradual nerve degeneration that occurs with aging and by ototoxic drugs, which affect the hair cells in the cochlea.

An adult patient with a history of allergies comes to the clinic complaining of wheezing and difficulty in breathing when working in his yard. The assessment findings include tachypnea, use of accessory neck muscles, prolonged expiration, intercostal retractions, decreased breath sounds, and expiratory wheezes. The nurse interprets that these assessment findings are consistent with:

ANS: asthma. Asthma is allergic hypersensitivity to certain inhaled particles that produces inflammation and a reaction of bronchospasm, which increases airway resistance, especially during expiration. Increased respiratory rate, use of accessory muscles, retraction of intercostal muscles, prolonged expiration, decreased breath sounds, and expiratory wheezing are all characteristic of asthma. See Table 18-8 for descriptions of the other conditions.

The nurse is auscultating the lungs of a patient who had been sleeping and notices short, popping, crackling sounds that stop after a few breaths. The nurse recognizes that these breath sounds are:

ANS: atelectatic crackles, and that they are not pathologic. One type of adventitious sound, atelectatic crackles, is not pathologic. They are short, popping, crackling sounds that sound like fine crackles but do not last beyond a few breaths. When sections of alveoli are not fully aerated (as in people who are asleep or in the elderly), they deflate slightly and accumulate secretions. Crackles are heard when these sections are expanded by a few deep breaths. Atelectatic crackles are heard only in the periphery, usually in dependent portions of the lungs, and disappear after the first few breaths or after a cough.

The nurse needs to pull the portion of the ear that consists of movable cartilage and skin down and back when administering eardrops. This portion of the ear is called the:

ANS: auricle. The external ear is called the auricle or pinna and consists of movable cartilage and skin.

In assessing for an S4 heart sound with a stethoscope, the nurse would listen with the: a. Bell of the stethoscope at the base with the patient leaning forward. b. Bell of the stethoscope at the apex with the patient in the left lateral position. c. Diaphragm of the stethoscope in the aortic area with the patient sitting. d. Diaphragm of the stethoscope in the pulmonic area with the patient supine.

ANS: bell at the apex with the patient in the left lateral position. The S4 is a ventricular filling sound. It occurs when atria contract late in diastole. It is heard immediately before S1. This is a very soft sound with a very low pitch. The nurse needs a good bell and must listen for it. It is heard best at the apex, with the person in the left lateral position.

During an assessment of a 68-year-old man with a recent onset of right-sided weakness, the nurse hears a blowing, swishing sound with the bell of the stethoscope over the left carotid artery. This finding would indicate: a. Valvular disorder. b. Blood flow turbulence. c. Fluid volume overload. d. Ventricular hypertrophy.

ANS: blood flow turbulence. A bruit is a blowing, swishing sound indicating blood flow turbulence; normally none is present.

The nurse is assessing the pulses of a patient who has been admitted for untreated hyperthyroidism. The nurse should expect to find a(n) _____ pulse. a. Normal b. Absent c. Bounding d. Weak, thready

ANS: bounding A full, bounding pulse occurs with hyperkinetic states (such as exercise, anxiety, fever), anemia, and hyperthyroidism. Absent pulse occurs with occlusion. Weak, thready pulses occur with shock and peripheral artery disease.

The nurse is reviewing the blood supply to the arm. The major artery supplying the arm is the _____ artery. a. Ulnar b. Radial c. Brachial d. Deep palmar

ANS: brachial The major artery supplying the arm is the brachial artery. The brachial artery bifurcates into the ulnar and radial arteries immediately below the elbow. In the hand, the ulnar and radial arteries form two arches known as the superficial and deep palmar arches.

When auscultating over a patient's femoral arteries the nurse notices the presence of a bruit on the left side. The nurse knows that: a. Are often associated with venous disease. b. Occur in the presence of lymphadenopathy. c. In the femoral arteries are caused by hypermetabolic states. d. Occur with turbulent blood flow, indicating partial occlusion.

ANS: bruits occur with turbulent blood flow, indicating partial occlusion. A bruit occurs with turbulent blood flow and indicates partial occlusion of the artery. The other responses are not correct.

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:

ANS: build rapport and increase the patient's confidence in the examiner. Sharing of information builds rapport and increases the patient's confidence in the examiner. It also gives the patient a little more control in a situation in which it is easy to feel completely helpless.

Before auscultating the abdomen for the presence of bowel sounds on a patient, the nurse should:

ANS: check the temperature of the room and offer blankets to the patient if he or she feels cold. The examination room should be warm. If the patient shivers, then the involuntary muscle contractions can make it difficult to hear the underlying sounds. The end of the stethoscope should be warmed between the examiner's hands, not with water. The nurse should never listen through a gown. The diaphragm of the stethoscope should be used to auscultate for bowel sounds.

A 67-year-old patient states that he recently began to have pain in his left calf when climbing the 10 stairs to his apartment. This pain is relieved by sitting for about 2 minutes; then he is able to resume his activities. The nurse interprets that this patient is most likely experiencing: a. Claudication. b. Sore muscles. c. Muscle cramps. d. Venous insufficiency.

ANS: claudication. Intermittent claudication feels like a "cramp" and is usually relieved by rest within 2 minutes. The other responses are not correct.

In using the ophthalmoscope to assess a patient's eyes, the nurse notices a *red glow in the patient's pupils*. On the basis of this finding, the nurse would:

ANS: consider this a normal reflection of the ophthalmoscope light off the inner retina. The red glow filling the person's pupil is the red reflex, and it is a normal finding caused by the reflection of the ophthalmoscope light off the inner retina. The other responses are not correct.

When assessing a patient's lungs, the nurse recalls that the left lung:

ANS: consists of two lobes. The left lung has two lobes, and the right lung has three lobes. The right lung is shorter than the left lung because of the underlying liver. The left lung is narrower than the right lung because the heart bulges to the left. The posterior chest is almost all lower lobe.

The nurse is performing an assessment on a 65-year-old male patient. He reports a crusty nodule behind the pinna. It bleeds intermittently and has not healed over the past 6 months. On physical assessment, the nurse finds an ulcerated crusted nodule with an indurated base. The preliminary analysis in this situation is that this:

ANS: could be a potential carcinoma and should be referred. An ulcerated crusted nodule with an indurated base that fails to heal is characteristic of a carcinoma. These lesions fail to heal and bleed intermittently. Individuals with such symptoms should be referred for a biopsy. The other responses are not correct. See Table 15-2.

A patient comes into the clinic complaining of pain in her right eye. On examination, the nurse sees a *pustule at the lid margin that is painful to touch, red, and swollen*. The nurse recognizes that this is

ANS: dacryocystitis. A hordeolum, or stye, is a painful, red, and swollen pustule at the lid margin. A chalazion is a nodule protruding on the lid, toward the inside, and is nontender, firm, with discrete swelling. Dacryocystitis is an inflammation of the lacrimal sac. Blepharitis is inflammation of the eyelids. See Table 14-3.

The nurse knows that a normal finding when assessing the respiratory system of an elderly adult is:

ANS: decreased mobility of the thorax. The costal cartilages become calcified with aging, resulting in a less mobile thorax. Chest expansion may be somewhat decreased, and the chest cage commonly shows an increased anteroposterior diameter.

A patient has been admitted to the hospital with vertebral fractures related to osteoporosis. She is in extreme pain. This type of pain would be classified as:

ANS: deep somatic. Deep somatic pain comes from sources such as the blood vessels, joints, tendons, muscles, and bone. Referred pain is felt at one site but originates from another location. Cutaneous pain is derived from the skin surface and subcutaneous tissues. Visceral pain originates from the larger, interior organs.

The nurse is preparing to percuss the abdomen of a patient. The purpose of the percussion is to assess the underlying tissue:

ANS: density. Percussion yields a sound that depicts the location, size, and density of the underlying organ. Turgor and texture are assessed with palpation.

The primary muscles of respiration include the:

ANS: diaphragm and intercostals. The major muscle of respiration is the diaphragm. The intercostal muscles lift the sternum and elevate the ribs during inspiration, increasing the anteroposterior diameter. Expiration is primarily passive. Forced inspiration involves the use of other muscles, such as the accessory neck muscles (sternomastoids, scalene, trapezii). Forced expiration involves the abdominal muscles.

The nurse is preparing to use an otoscope for an examination. Which statement is true regarding the otoscope? The otoscope:

ANS: directs light into the ear canal and onto the tympanic membrane. The otoscope directs light into the ear canal and onto the tympanic membrane that divides the external and middle ear. A short, broad speculum is used to visualize the nares.

During the precordial assessment on an patient who is 8 months pregnant, the nurse palpates the apical impulse at the fourth left intercostal space lateral to the midclavicular line. This finding would indicate: a. Right ventricular hypertrophy. b. Increased volume and size of the heart as a result of pregnancy. c. Displacement of the heart from elevation of the diaphragm. d. Increased blood flow through the internal mammary artery.

ANS: displacement of the heart from elevation of the diaphragm. Palpation of the apical impulse is higher and more lateral compared with the normal position because the enlarging uterus elevates the diaphragm and displaces the heart up and to the left and rotates it on its long axis.

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:

ANS: dullness. A dull percussion note signals an abnormal density in the lungs, as with pneumonia, pleural effusion, atelectasis, or tumor.

During an assessment, the nurse uses the "profile sign" to detect: a. Pitting edema. b. Early clubbing. c. Symmetry of the fingers. d. Insufficient capillary refill.

ANS: early clubbing. The nurse should use the profile sign (viewing the finger from the side) to detect early clubbing.

ANS: elevated pressure related to heart failure. Because no cardiac valve exists to separate the superior vena cava from the right atrium, the jugular veins give information about activity on the right side of the heart. They reflect filling pressures and volume changes. Normal jugular venous pulsation is 2 cm or less above the sternal angle. Elevated pressure is more than 3 cm above the sternal angle at 45 degrees and occurs with heart failure.

When examining a patient's eyes, the nurse recalls that *stimulation of the sympathetic branch of the autonomic nervous system*:

ANS: elevates the eyelid and dilates the pupil. Stimulation of the sympathetic branch of the autonomic nervous system dilates the pupil and elevates the eyelid. Parasympathetic nervous system stimulation causes the pupil to constrict. The muscle fibers of the iris contract the pupil in bright light to accommodate for near vision. The ciliary body controls the thickness of the lens.

During inspection of the precordium of an adult patient, the nurse notices the chest moving in a forceful manner along the sternal border. This finding most likely suggests: a. Normal heart. b. Systolic murmur. c. Enlargement of the left ventricle. d. Enlargement of the right ventricle.

ANS: enlargement of the right ventricle. Normally, the examiner may or may not see an apical impulse; when visible, it occupies the fourth or fifth intercostal space at or inside the midclavicular line. A heave or lift is a sustained forceful thrusting of the ventricle during systole. It occurs with ventricular hypertrophy as a result of increased workload. A right ventricular heave is seen at the sternal border; a left ventricular heave is seen at the apex.

The nurse is reviewing the characteristics of breath sounds. Which statement about bronchovesicular breath sounds is true? They are:

ANS: expected near the major airways. Bronchovesicular sounds are heard over major bronchi where fewer alveoli are located: posteriorly, between the scapulae, especially on the right; anteriorly, around the upper sternum in the first and second intercostal spaces. The other responses are not correct.

Which statement about the apices of the lungs is true? The apices of the lungs:

ANS: extend 3 to 4 cm above the inner third of the clavicles. The apex of the lung on the anterior chest is 3 to 4 cm above the inner third of the clavicles. On the posterior chest, the apices are at the level of C7.

When preparing to perform a physical examination on an infant, the nurse should:

ANS: have the parent remove all clothing except the diaper on a boy. The parent should always be present to increase the child's feeling of security and to understand normal growth and development. Timing of the examination should be 1 to 2 hours after feeding when the baby is neither too drowsy nor too hungry. Infants do not object to being nude; clothing should be removed but a diaper should be left on a boy.

During a cardiovascular assessment, the nurse knows that an S4 heart sound is: a. Heard at the onset of atrial diastole. b. Usually a normal finding in the older adult. c. Heard at the end of ventricular diastole. d. Heard best over the second left intercostal space with the individual sitting upright.

ANS: heard at the end of ventricular diastole. An S4 heart sound is heard at the end of diastole when the atria contract (atrial systole) and when the ventricles are resistant to filling. The S4 occurs just before the S1.

The nurse is preparing to use a stethoscope for auscultation. Which statement is true regarding the diaphragm of the stethoscope? The diaphragm:

ANS: is used to listen for high-pitched sounds. The diaphragm of the stethoscope is best for listening to high-pitched sounds such as breath, bowel, and normal heart sounds. It should be held firmly against the person's skin, firmly enough to leave a ring. The bell of the stethoscope is best for soft, low-pitched sounds such as extra heart sounds or murmurs.

A 65-year-old patient is experiencing pain in his left calf when he exercises that disappears after resting for a few minutes. The nurse recognizes that this description is most consistent with _________ the left leg. a. Venous obstruction of b. Claudication due to venous abnormalities in c. Ischemia caused by a partial blockage of an artery supplying d. Ischemia caused by the complete blockage of an artery supplying

ANS: ischemia caused by partial blockage of an artery supplying Ischemia is a deficient supply of oxygenated arterial blood to a tissue. A partial blockage creates an insufficient supply, and the ischemia may be apparent only during exercise when oxygen needs increase.

When evaluating a patient's pain, the nurse knows that an example of acute pain would be:

ANS: kidney stones. Acute pain is short-term and dissipates after an injury heals, such as with kidney stones. The other conditions are examples of chronic pain where the pain continues for 6 months or longer and does not stop when the injury heals.

A 52-year-old patient describes the presence of occasional "*floaters*" or "spots" moving in front of his eyes. The nurse should:

ANS: know that floaters are usually not significant and are caused by condensed vitreous fibers. Floaters are a common sensation with myopia or after middle age owing to condensed vitreous fibers. Usually they are not significant, but acute onset of floaters may occur with retinal detachment.

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. Simultaneously palpate both arteries to compare amplitude. d. Instruct the patient to take slow deep breaths during auscultation.

ANS: listen with the bell of the stethoscope to assess for bruits. If cardiovascular disease is suspected, then the nurse should auscultate each carotid artery for the presence of a bruit. The nurse should avoid compressing the artery because this could create an artificial bruit, and it could compromise circulation if the carotid artery is already narrowed by atherosclerosis. Avoid excessive pressure on the carotid sinus area higher in the neck; excessive vagal stimulation here could slow down the heart rate, especially in older adults. Palpate only one carotid artery at a time to avoid compromising arterial blood to the brain.

A 30-year-old woman with a history of mitral valve problems states that she has been "very tired." She has started waking up at night and feels like her "heart is pounding." During the assessment, the nurse palpates a thrill and lift at the fifth left intercostal space midclavicular line. In the same area the nurse also auscultates a blowing, swishing sound right after S1. These findings would be most consistent with: a. Heart failure. b. Aortic stenosis. c. Pulmonary edema. d. Mitral regurgitation.

ANS: mitral regurgitation. Mitral regurgitation subjective findings include fatigue, palpitation, and orthopnea. Objective findings are (1) a thrill in systole at apex, (2) lift at apex, (3) apical impulse displaced down and to the left, (4) S1 diminished, S2 accentuated, S3 at apex often present, and (5) murmur: pansystolic, often loud, blowing, best heard at apex, radiating well to the left axilla.

The nurse is preparing to perform a physical assessment. The correct action by the nurse is reflected by which statement? The nurse:

ANS: organizes the assessment so that the patient does not change positions too often. The steps of the assessment should be organized so that the patient does not change positions too often. The sequence of the steps of the assessment may differ depending on the age of the person and the examiner's preference. Tender or painful areas should be assessed last.

A *31-year-old patient* tells the nurse that he has noticed a progressive loss in his hearing. He says that it does seem to help when people speak louder or if he turns up the volume. The most likely cause of his hearing loss is:

ANS: otosclerosis. Otosclerosis is a common cause of conductive hearing loss in young adults between the ages of 20 and 40 years. Presbycusis is a type of hearing loss that occurs with aging. Trauma and frequent ear infections are not a likely cause of his hearing loss.

When assessing a patient's pulse, the nurse notes that the amplitude is weaker during inspiration and stronger during expiration. When the nurse measures the blood pressure, the reading decreases 20 mm Hg during inspiration and increases with expiration. This patient is experiencing pulses: a. Alternans. b. Bisferiens. c. Bigeminus. d. Paradoxus.

ANS: paradoxus. In pulsus paradoxus, beats have a weaker amplitude with inspiration and a stronger amplitude with expiration. It is best determined during blood pressure measurement; reading decreases (>10 mm Hg) during inspiration and increases with expiration.

A patient complains of leg pain that wakes him at night. He states that he "has been having problems" with his legs. He has pain in his legs when they are elevated that disappears when he dangles them. He recently noticed "a sore" on the inner aspect of the right ankle. On the basis of this history information, the nurse interprets that the patient is most likely experiencing: a. Pain related to lymphatic abnormalities. b. Problems related to arterial insufficiency. c. Problems related to venous insufficiency. d. Pain related to musculoskeletal abnormalities.

ANS: problems related to arterial insufficiency. Night leg pain is common in aging adults. It may indicate the ischemic rest pain of peripheral vascular disease. Alterations in arterial circulation cause pain that becomes worse with leg elevation and is eased when the extremity is dangled.

A mother brings her 3-month-old infant to the clinic for evaluation of a cold. She tells the nurse that he had "a runny nose for a week." When performing the physical assessment, the nurse notes that the child has nasal flaring and sternal and intercostal retractions. The nurse's next action should be to:

ANS: recognize that these are serious signs and contact the physician. The infant is an obligatory nose breather until the age of 3 months. Normally there is no flaring of the nostrils and no sternal or intercostal retraction. Marked retractions of the sternum and intercostal muscles and nasal flaring indicate increased inspiratory effort, as in pneumonia, acute airway obstruction, asthma, and atelectasis; therefore, immediate referral to the physician is warranted. These signs do not indicate heart failure, and assessment of the infant's feeding is not a priority at this time.

A 68-year-old woman is in the eye clinic for a checkup. She tells the nurse that she has been having trouble with reading the paper, sewing, and even seeing the faces of her grandchildren. On examination, the nurse notes that she has some *loss of central vision but her peripheral vision is normal*. These findings suggest that:

ANS: she may have macular degeneration. Macular degeneration is the most common cause of blindness. It is characterized by loss of central vision. Cataracts would show lens opacity. Chronic open-angle glaucoma, the most common type of glaucoma, involves a gradual loss of peripheral vision.

A 68-year-old woman is in the eye clinic for a checkup. She tells the nurse that she has been having trouble with reading the paper, sewing, and even seeing the faces of her grandchildren. On examination, the nurse notes that she has some loss of central vision but her peripheral vision is normal. These findings suggest that:

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.

ANS: side-to-side Side-to-side comparison is most important when auscultating the chest. The nurse should listen to at least one full respiration in each location. The other techniques are incorrect.

The nurse is assessing color vision of a male child. Which statement is correct? The nurse should:

ANS: test for color vision once between the ages of 4 and 8. Test only boys for color vision once between the ages of 4 and 8 years. It is not tested in females because it is rare in females. Testing is done with the Ishihara test, which is a series of polychromatic cards.

The nurse is performing an eye-screening clinic at a daycare center. When examining a 2-year-old child, the nurse suspects that the child has "lazy eye" and should:

ANS: test for strabismus by performing the corneal light reflex test. Testing for strabismus is done by performing the corneal light reflex test as well as the cover test. The Snellen eye chart and confrontation test are not used to test for strabismus.

The nurse knows that auscultation of fine crackles would most likely be noticed in:

ANS: the immediate newborn period. Fine crackles are commonly heard in the immediate newborn period as a result of the opening of the airways and clearing of fluid. Persistent fine crackles would be noticed with pneumonia, bronchiolitis, or atelectasis.

During an interview, the patient states he has the sensation that "*everything around him is spinning*." The nurse recognizes that the portion of the ear responsible for this sensation is:

ANS: the labyrinth. If the labyrinth ever becomes inflamed, it feeds the wrong information to the brain, creating a staggering gait and a strong, spinning, whirling sensation called vertigo.

A patient's vision is recorded as 20/30 when the Snellen eye chart is used. The nurse interprets these results to indicate that:

ANS: the patient can read at 20 feet what a person with normal vision can read at 30 feet. The top number indicates the distance the person is standing from the chart; the denominator gives the distance at which a normal eye can see.

When a light is directed across the iris of a patient's eye from the temporal side, the nurse is assessing for:

ANS: the presence of shadows, which may indicate glaucoma. The presence of shadows in the anterior chamber may be a sign of acute angle-closure glaucoma. The normal iris is flat and creates no shadows. This is not the correct method for assessment for dacryocystitis, conjunctivitis, or cataracts.

A 60-year-old woman has developed reflexive sympathetic dystrophy after arthroscopic repair of her shoulder. A key feature of this condition is that:

ANS: the slightest touch, such as a sleeve brushing against her arm, causes severe, intense pain. A key feature of reflexive sympathetic dystrophy is that a typically innocuous stimulus can create a severe, intensely painful response. The affected extremity becomes less functional over time.

Which of these statements is true regarding the vertebra prominens? The vertebra prominens is:

ANS: the spinous process of C7. The spinous process of C7 is the vertebra prominens. It is the most prominent bony spur protruding at the base of the neck. Counting ribs and intercostal spaces on the posterior thorax is difficult because of the muscles and soft tissue. The vertebra prominens is easier to identify and is used as a starting point in counting thoracic processes and identifying landmarks on the posterior chest.

When performing an otoscopic examination of a 5-year-old child with a history of chronic ear infections, the nurse sees that his *right tympanic membrane is amber-yellow in color and that there are air bubbles behind the tympanic membrane*. The child reports occasional hearing loss and a popping sound with swallowing. The preliminary analysis based on this information is that:

ANS: this is most likely a serous otitis media. An amber-yellow color to the tympanic membrane suggests serum or pus in the middle ear. Often air or fluid or bubbles behind the tympanic membrane are visible. The patient may have feelings of fullness, transient hearing loss, and a popping sound with swallowing. The other responses are not correct.

A 35-year-old recent immigrant is being seen in the clinic for complaints of a cough that is associated with rust-colored sputum, low-grade afternoon fevers, and night sweats for the past 2 months. The nurse's preliminary analysis, based on this history, is that this patient may be suffering from:

ANS: tuberculosis. Sputum is not diagnostic alone, but some conditions have characteristic sputum production. Tuberculosis often produces rust-colored sputum in addition to other symptoms of night sweats and low-grade afternoon fevers. See Table 18-8.

The nurse is unable to palpate the right radial pulse on a patient. The best action would be to:

ANS: use a Doppler device to check for pulsations over the area. Doppler devices are used to augment pulse or blood pressure measurements. Goniometers measure joint range of motion. A fetoscope is used to auscultate fetal heart tones. Stethoscopes are used to auscultate breath, bowel, and heart sounds.

A 17-year-old student is a swimmer on her high school's swim team. She has had three bouts of otitis externa so far this season and wants to know what to do to prevent it. The nurse instructs her to:

ANS: use rubbing alcohol or 2% acetic acid eardrops after every swim. With otitis externa (swimmer's ear), swimming causes the external canal to become waterlogged and swell; skinfolds are set up for infection. Prevent by using rubbing alcohol or 2% acetic acid eardrops after every swim.

During an assessment the nurse has elevated a patient's legs 12 inches off the table and has had him wag his feet to drain off venous blood. After helping him to sit up and dangle his legs over the side of the table, the nurse should expect a normal finding at this point would be: a. Significant elevational pallor. b. Venous filling within 15 seconds. c. No change in the coloration of the skin. d. Color returning to the feet within 20 seconds of assuming a sitting position.

ANS: venous filling within 15 seconds. In this test it normally takes 10 seconds or less for the color to return to the feet and 15 seconds for the veins of the feet to fill. Marked elevational pallor as well as delayed venous filling occurs with arterial insufficiency.

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:

ANS: vesicular breath sounds and are normal in that location. Vesicular breath sounds are low-pitched, soft sounds with inspiration being longer than expiration. These breath sounds are expected over peripheral lung fields where air flows through smaller bronchioles and alveoli.

The nurse just noted from a patient's medical record that the patient has a lesion that is confluent in nature. On examination, the nurse would expect to find: 1.lesions that run together. 2.annular lesions that have grown together. 3.lesions arranged in a line along a nerve route. 4.lesions that are grouped or clustered together.

ANS:1 Grouped lesions are clustered together. Polycyclic lesions are annular in nature. Zosteriform lesions are arranged along a nerve route. Confluent lesions run together.

A patient's mother has noticed that her son, who has been to a new babysitter, has some blisters and scabs on his face and buttocks. On examination, the nurse notices moist, thin-roofed vesicles with a thin erythematous base and suspects: 1.eczema. 2.impetigo. 3.herpes zoster. 4.diaper dermatitis.

ANS:2 Impetigo is moist, thin-roofed vesicles with a thin erythematous base. This is a contagious bacterial infection of the skin and most common in infants and children.

Essential components of a patient history for dermatology disorders include: Select all that apply. substance use. a previous history of skin disorders self-care behaviours symptom analysis of current problems allergies. occupation and hobbies. prescribed medications, over-the-counter medications herbs

All Essential components of a patient history for dermatology disorders include all of the following: a previous history of skin disorders plus symptom analysis of current problems and allergies, self-care behaviours, occupation, and hobbies, and prescribed medications, over-the-counter medications, herbs, and substance use.

You are conducting in-service teaching on the effects of aging on the skin for nurses and students assigned to a medical floor at the local hospital. Which of the following pieces of information is essential for your in-service teaching to include? Select all that apply. The loss of collagen increases the risk of shearing, tearing injuries. Thinning and flattening of the stratum corneum increases absorption of chemicals. Diminished vascularity and increased vascular fragility lead to senile purpura. Decreased number and function of sebaceous and sweat glands contribute to dry skin.

All The effects of aging on the skin include all of the following: The loss of collagen increases the risk of shearing, tearing injuries, thinning and flattening of the stratum corneum increases absorption of chemicals, diminished vascularity and increased vascular fragility lead to senile purpura, and decrease in the number and function of sebaceous and sweat glands, resulting in dry skin.

A student nurse has been assigned to teach Grade 4 students about hygiene. Part of her lesson will focus on the apocrine glands. Which of the following statements is true? Select all that apply. Apocrine glands secrete with emotion and with sexual stimulation. The apocrine glands become active during puberty and decrease functioning in aging adults. The apocrine glands, a type of sweat gland, are mainly located in the axillae, anogenital area, nipples, and navel. Apocrine gland secretions give the body a musky odor. These glands produce a thick, milky secretion and open into the hair follicles.

All of the following statements are true of the apocrine glands: The apocrine glands, a type of sweat gland, are mainly located in the axillae, anogenital area, nipples, and navel, these glands produce a thick, milky secretion and open into the hair follicles, and the apocrine glands become active during puberty and decrease functioning in aging adults. Apocrine glands secrete with emotion and with sexual stimulation and give the body a musky odor.

The blood is returned to the heart through the veins by means of: All of the options. breathing. unidirectional valves. walking.

All of the options. Blood is returned to the heart through the veins by means of: walking, breathing, and unidirectional valves.

Lymph nodes are palpable in: adults with infections. All of the options. children with infections. healthy children.

All of the options. Lymph nodes are palpable in children with or without infections and in healthy adults.

What does cranial nerve IX do?

Allows for swallowing

What does cranial nerve X do?

Allows for talking and phonation

Posterior Cervical Lymph Node

Along the edge of the Trapezius Muscle

The nurse is conducting a health fair for older adults. Which statement is true regarding vital sign measurements in aging adults The pulse is more difficult to palpate because of the stiffness of the blood vessels An increased resp. rate and a shallower inspiratory phase are possible findings A decreased pulse pressure occurs from changes in systolic and diastolic pressures Changes in body's temp regulatory mechanism leave the aging person more likely to develop a fever

An increased resp. rate and a shallower inspiratory phase are possible findings

The term used to describe the shape of a lesion as being circular is: zosteriform. annular. scaphoid. confluent.

Annular The term used to describe the shape of a lesion as being circular is annular. Confluent lesions run together (e.g., urticaria [hives]). A zosteriform linear arrangement runs along a nerve route (e.g., herpes zoster). Scaphoid is not a term used to describe a lesion.

The nurse records that the patient's pulse is 3+ or full and bounding. Which of the following could be the cause? Dehydration Shock Bleeding Anxiety

Anxiety A full, bounding pulse (3+) reflects an increased stroke volume, as with anxiety and exercise. A weak, thready pulse may reflect a decreased stroke volume, as with dehydration. A weak, thready pulse may reflect a decreased stroke volume, as with shock. A weak, thready pulse reflects a decreased stroke volume, as with bleeding.

A patient tells the nurse that "all my life I've been called 'knock knees.'" The nurse knows that another term for "knock knees" is: A) genu varum. B) genu valgum. C) pes planus. D) metatarsus adductus.

A patient's annual physical examination reveals a lateral curvature of the thoracic and lumbar segments of his spine; however, this curvature disappears with forward bending. The nurse knows that this abnormality of the spine is called: A) structural scoliosis. B) functional scoliosis. C) herniated nucleus pulposus. D) dislocated hip.

An 80-year-old woman is visiting the clinic for a checkup. She states, "I can't walk as much as I used to." The nurse is observing for motor dysfunction in her hip and should have her: A) internally rotate her hip while she is sitting. B) abduct her hip while she is lying on her back. C) adduct her hip while she is lying on her back. D) externally rotate her hip while she is standing.

During an examination, the nurse notices severe nystagmus in both eyes of a patient. Which conclusion by the nurse is correct? Severe nystagmus in both eyes: a. Is a normal occurrence. b. May indicate disease of the cerebellum or brainstem. c. Is a sign that the patient is nervous about the examination. d. Indicates a visual problem, and a referral to an ophthalmologist is indicated.

The nurse is assessing a patient's ischial tuberosity. To palpate the ischial tuberosity, the nurse knows that it is best to have the patient: A. standing B. flexing the hip C. flexing the knee D. Lying in the supine position

The nurse is assessing the neurologic status of a patient who has a late-stage brain tumor. With the reflex hammer, the nurse draws a light stroke up the lateral side of the sole of the foot and inward, across the ball of the foot. In response, the patient's toes fan out, and the big toe shows dorsiflexion. The nurse interprets this result as: a. Negative Babinski sign, which is normal for adults. b. Positive Babinski sign, which is abnormal for adults. c. Clonus, which is a hyperactive response. d. Achilles reflex, which is an expected response.

The nurse places a key in the hand of a patient and he identifies it as a penny. What term would the nurse use to describe this finding? a. Extinction b. Astereognosis c. Graphesthesia d. Tactile discrimination

When performing a musculoskeletal assessment, the nurse knows that the correct approach for the examination should be: A. anterior to posterior B. proximal to distal C. distal to proximal D. posterior to anterior

B. proximal to distal

man who has gout 4 several years come to with a problem with his toe On examination the nurse notices the presence of hard painless nodules over great toe one has burst open with a chalky discharge finding is known as A a bunion B tophi C a plantar wart D a callus

B. tophi

Select the best description of an accurate assessment of a pt' pulse Count for 15 secs if the pulse is regular Begin counting with zero; count for 30 secs Count for 30 sec and multiply by 2 for all cases Count for 1 full minute; begin counting with zero

Begin counting with zero; count for 30 secs

When assessing a patient with very dark brown skin, where would you look for petechiae? Buttocks Buccal mucosa Abdomen Back of the hands

Buccal mucosa In dark-skinned people, petechiae are best visualized in areas of lighter pigmentation (e.g., the abdomen, buttocks, and volar surface of the forearm). When the skin is black or very dark brown, petechiae cannot be seen in the skin. Therefore, you should inspect for petechiae in the mouth, particularly the buccal mucosa, and in the conjunctivae.

Mr. Verdana is a 41-year-old who presents with a complaint of skin problems. On examination you note single-chambered, superficial lesions containing free fluid greater than 1 cm in diameter, which are called: vesicles. bullae. furuncles. wheals.

Bullae The single-chambered, superficial lesions containing free fluid greater than 1 cm in diameter are called bullae. A furuncle is a red, swollen, hard, tender, pus-filled lesion caused by acute localized bacterial (usually staphylococcal) infection, usually occurring on the back of neck, buttocks, occasionally on wrists or ankles. Furuncles are caused by infected hair follicles. A vesicle is an elevated cavity containing free fluid, up to 1 cm; also known as a "blister." Clear serum flows if the wall is ruptured. A wheal is a superficial, raised, transient, and erythematous lesion; it is slightly irregular shape because of edema (fluid held diffusely in the tissues).

A 14-year-old boy who has been diagnosed with Osgood-Schlatter disease reports painful swelling just below the knee for the past 5 months. Which response by the nurse is appropriate? A) "If these symptoms persist, you may need arthroscopic surgery." B) "You are experiencing degeneration of your knee, which may not resolve." C) "Your disease is due to repeated stress on the patellar tendon. It is usually self-limited, and your symptoms should resolve with rest." D) "Increasing your activity and performing knee-strengthening exercises will help to decrease the inflammation and maintain mobility in the knee."

A 68-year-old woman has come in for an assessment of her rheumatoid arthritis, and the nurse notices raised, firm, nontender nodules at the olecranon bursa and along the ulna. These nodules are most commonly diagnosed as: A) epicondylitis. B) gouty arthritis. C) olecranon bursitis. D) subcutaneous nodules.

A man who was found wandering in a park at 2 AM has been brought to the emergency department for an examination; he said he fell and hit his head. During the examination, the nurse asks him to use his index finger to touch the nurse's finger, then his own nose, then the nurse's finger again (which has been moved to a different location). The patient is clumsy, unable to follow the instructions, and overshoots the mark, missing the finger. The nurse should suspect which of the following? a. Cerebral injury b. Cerebrovascular accident c. Acute alcohol intoxication d. Peripheral neuropathy

A mother brings her newborn baby boy in for a checkup; she tells the nurse that he doesn't seem to be moving his right arm as much as his left and that he seems to have pain when she lifts him up under the arms. The nurse suspects a fractured clavicle and would observe for: A) a negative Allis test. B) a positive Ortolani's sign. C) limited range of motion during the Moro's reflex. D) limited range of motion during Lasègue's test

A patient is being assessed for range of joint movement. The nurse asks him to move his arm in toward the center of his body. This movement is called: A) flexion. B) abduction. C) adduction. D) extension.

A patient is complaining of pain in his joints that is worse in the morning, is better after he has moved around for awhile, and then gets worse again if he sits for long periods of time. The nurse should assess for other signs of what problem? A) Tendinitis B) Osteoarthritis C) Rheumatoid arthritis D) Intermittent claudication

A patient is visiting the clinic for an evaluation of a swollen, painful knuckle. The nurse notices that the knuckle above his ring on the left hand is swollen and that he is unable to remove his wedding ring. This joint is called the _____ joint. A) interphalangeal B) tarsometatarsal C) metacarpophalangeal D) tibiotalar

A patient who has had rheumatoid arthritis for years comes to the clinic to ask about changes in her fingers. The nurse will assess for signs of what problems? A) Heberden's nodes B) Bouchard's nodules C) Swan neck deformities D) Dupuytren's contractures

During a neonatal examination, the nurse notices that the newborn infant has six toes. This finding is documented as: A) unidactyly. B) syndactyly. C) polydactyly. D) multidactyly.

During an examination, the nurse asks a patient to bend forward from the waist and notices that the patient has lateral tilting. When his leg is raised straight up, he complains of a pain going down his buttock into his leg. The nurse suspects: A) scoliosis. B) meniscus tear. C) herniated nucleus pulposus. D) spasm of paravertebral muscles.

The articulation of the mandible and the temporal bone is known as the: A) intervertebral foramen. B) condyle of the mandible. C) temporomandibular joint. D) zygomatic arch of the temporal bone.

The nurse is assessing a 1-week-old infant and is testing his muscle strength. The nurse lifts the infant with hands under the axillae and notices that the infant starts to "slip" between the hands. The nurse should: A) suspect a fractured clavicle. B) suspect that the infant may have a deformity of the spine. C) suspect that the infant may have weakness of the shoulder muscles. D) consider this a normal finding because the musculature of an infant this age is undeveloped.

The nurse is explaining the mechanism of the growth of long bones to a mother of a toddler. Where does lengthening of the bones occur? A) Bursa B) Calcaneus C) Epiphyses D) Tuberosities

To palpate the temporomandibular joint, the nurse's fingers should be placed in the depression _____ of the ear. A) distal to the helix B) proximal to the helix C) anterior to the tragus D) posterior to the tragus

The capillary beds should refill after being depressed in: A. <1 second B. >2 seconds C. 1-2 seconds D. time is not significant as long as color returns

C. 1 - 2 seconds

When inspecting the eyeballs of an African-American individual, which of the following might the examiner expect to observe? A. A slight misalignment of the eyeballs B. A slight yellow discoloration of the sclera C. Small brown macules on the sclera. D. A slight amount of drainage around the lacrimal apparatus

C. Small brown macules on the sclera.

The configuration for individual lesions arranged in circles or arcs, as occurs with ringworm, is called: A. linear B. clustered C. annular D. gyrate

C. annular

To palpate the temporomandibular joint, the nurse's finger should be placed in the depression______of the ear. A. distal to the helix B. proximal to the helix C. anterior to the tragus D. posterior to the tragus

C. anterior to the tragus

The nurse is assessing a patient's ischial tuberosity. To palpate the ischial tuberosity, the nurse knows that it is best to have the patient: A. in the supine position B. stand C. flex the hip D. flex the knee

C. flex the hip

A patient tells the nurse that she is having a hard time brining her hand to her mouth when she eats or tries to brush her teeth. The nurse knows that for her to move her hand to her mouth, she must perform which movement? A. abduction B. adduction C. flexion D. extension

C. flexion

Select the best description of an accurate assessment of a pt's respiration Count for a full minute before taking the pulse Count for 15 sec and multiply by 4 Count after informing the patient where you are in the assessment process Count for 30 secs after pulse assessment

Count for 30 secs after pulse assessment

How to assess respiration

Count for a full minute each breath (rise and fall) no abnormals- 30 sec x2 Abnormals- count for full minute

Cover-uncover test

Cover one eye; Watch the uncovered eye for a steady, fixed gaze. Uncover the first eye and observe the uncovered eye for any movement

What cranial nerves are associated with the mouth?

Cranial nerve IX--glossopharyngeal nerve Cranial nerve X--Vagus nerve

The muscles of the eyes are innervated by three cranial nerves. Name the three nerves.

Cranial nerve VI: Abducens nerve Cranial nerve IV: Trochlear nerve Cranial nerve III: Oculomotor nerve

When observing the optic disc, what are normal findings?

Creamy yellow-orange to pink in color Shape: round or oval Position: NASAL side of the background Edges: distinct

________________caregivers apply background knowledge that must be possessed to provide given person with the best possible health care.

Culturally appropriate

_____________caregivers understand and attend to the total context of the individual's situation, including awareness or immigration status, stress factors, other social factors, and cultural similarities and differences.

Culturally competent

________________means understanding both yours and the patients culture.

Culturally competent assessment

What are the three parts of culturally competent assessment?

Culturally sensitive, culturally appropriate, culturally competent

Nail Anatomy

Cuticle Lunula Lateral nail fold Posterior nail fold Nail matrix Nail bed Nail Plate

A 32-year-old woman tells the nurse that she has noticed "very sudden, jerky movements" mainly in her hands and arms. She says, "They seem to come and go, primarily when I am trying to do something. I haven't noticed them when I'm sleeping." This description suggests: a. Tics. b. Athetosis. c. Myoclonus. d. Chorea.

A 50-year-old woman is in the clinic for weakness in her left arm and leg that she has noticed for the past week. The nurse should perform which type of neurologic examination? a. Glasgow Coma Scale b. Neurologic recheck examination c. Screening neurologic examination d. Complete neurologic examination

A man who has had gout for several years comes to the clinic with a problem with his toe. On examination, the nurse notices the presence of hard, painless nodules over the great toe; one has burst open with a chalky discharge. This finding is known as: A) a callus. B) a plantar wart. C) a bunion. D) tophi.

A professional tennis player comes into the clinic complaining of a sore elbow. The nurse will assess for tenderness at the: A) olecranon bursa. B) annular ligament. C) base of the radius. D) medial and lateral epicondyle.

A young swimmer comes to the sports clinic complaining of a very sore shoulder. He was running at the pool, slipped on some wet concrete, and tried to catch himself with his outstretched hand. He landed on his outstretched hand and has not been able to move his shoulder since then. The nurse suspects: A) joint effusion. B) tear of rotator cuff. C) adhesive capsulitis. D) dislocated shoulder.

During an assessment of a 32-year-old patient with a recent head injury, the nurse notices that the patient responds to pain by extending, adducting, and internally rotating his arms. His palms pronate, and his lower extremities extend with plantar flexion. Which statement concerning these findings is most accurate? This patient's response: a. Indicates a lesion of the cerebral cortex. b. Indicates a completely nonfunctional brainstem. c. Is normal and will go away in 24 to 48 hours. d. Is a very ominous sign and may indicate brainstem injury.

During the taking of the health history of a 78-year-old man, his wife states that he occasionally has problems with short-term memory loss and confusion: "He can't even remember how to button his shirt." When assessing his sensory system, which action by the nurse is most appropriate? a. The nurse would not test the sensory system as part of the examination because the results would not be valid. b. The nurse would perform the tests, knowing that mental status does not affect sensory ability. c. The nurse would proceed with an explanation of each test, making certain that the wife understands. d. Before testing, the nurse would assess the patient's mental status and ability to follow directions.

Fibrous bands running directly from one bone to another that strengthen the joint and help prevent movement in undesirable directions are called: A) bursa. B) tendons. C) cartilage. D) ligaments.

The nurse is examining a 2-month-old infant and notices asymmetry of the infant's gluteal folds. The nurse should assess for other signs of what disorder? A) Fractured clavicle B) Down syndrome C) Spina bifida D) Hip dislocation

The nurse is examining a 3-month-old infant. While holding the thumbs on the infant's inner mid thighs and the fingers outside on the hips, touching the greater trochanter, the nurse adducts the legs until the nurse's thumbs touch and then abducts the legs until the infant's knees touch the table. The nurse does not notice any "clunking" sounds and is confident to record a: A) positive Allis test. B) negative Allis test. C) positive Ortolani's sign. D) negative Ortolani's sign.

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.

The nurse notices that a woman in an exercise class is unable to jump rope. The nurse knows that to jump rope, one's shoulder has to be capable of: A) inversion. B) supination. C) protraction. D) circumduction.

When assessing muscle strength, the nurse observes that a patient has complete range of motion against gravity with full resistance. What Grade should the nurse record using a 0 to 5 point scale? A) 2 B) 3 C) 4 D) 5

When reviewing the musculoskeletal system, the nurse recalls that hematopoiesis takes place in the: A) liver. B) spleen. C) kidneys. D) bone marrow.

Xerosis

DRY: excessive dryness. the skin loses moisture and it may crack and peel. Bathing or hand washing too frequently, especially if one is using harsh soaps, may also contribute to xeroderma. Xeroderma can also be caused by a deficiency of vitamin A, vitamin D, systemic illness, severe sunburn, or some medication

Factors that influence Temperature

Diurnal cycle- Trough 5 am (lowest temp) Peak in late afternoon Menstrual cycle- Ovulating (temp rises), if not temp is lower Exercise- Basal metabolic rate increase Age- Infants/ young kids dont know how to regulate body temp. Older Adults have a lower temp.

Orthostatic Hypotension

Drop in BP occurs when pt is changing positions quickly

THE LABYRINTH OF THE INNER EAR IS RESPONSIBLE FOR MAINTAINING THE BODY'S

EQUILIBRIUM

THE ______ TUBE ALLOWS EQUALIZATION OF AIR PRESSURE ON EACH SIDE OF THE TYMPANIC MEMBRANE

EUSTACHIAN

Which of the following statements about sweat glands is correct? The apocrine glands produce sebum, a protective oily substance that prevents water loss from the skin. Sweat glands are located everywhere on the skin except the palms and soles. Sweat glands are eccrine glands that produce a thick, milky secretion and open into the hair follicles. Eccrine glands mature by the time an infant is 2 months old.

Eccrine glands mature by the time an infant is 2 months old. Eccrine glands mature by the time an infant is 2 months old. Sebaceous glands, not sweat glands, are located everywhere on the skin except the palms and soles, they produce sebum, a protective oily substance that prevents water loss. Apocrine glands, not eccrine glands, produce a thick, milky secretion and open into the hair follicles.

HEARING LOSS IS INDICATIVE WHEN THE PT. DOES WHAT

FREQUENTLY ASKS TO HAVE STATEMENTS REPEATED, LIP READS OR WATCHES FACES AND LIPS CLOSELY, WHEN A PERSON HAS A FLAT, MONOTONOUS TONE OF VOICE, WHEN SPEECH SOUNDS ARE GARBLED, VOWEL SOUNDS ARE DISTORED, AND THE PERSON USES INAPPROPRIATELY LOUD VOICE

Differentiate abscess & furuncle

FURUNCLE: infected hair follicles ABSCESS: traumatic introduction of bacteria. Abcesses are usually large and deeper than furuncles.

The Iberian, Central, and South American Heritages have what kind of healers?

Folk healers, such as santro/a, partera, or curandero/a

Mr. Holman is a 54-year-old patient who comes to the clinic for an initial dermatology assessment. On examination, you note a suppurative, inflammatory skin lesion due to an infected hair follicle. Which of the following terms best describes this lesion? Fissure Pustule Acne Furuncle

Furuncle A furuncle is best described as a suppurative, inflammatory skin lesion due to an infected hair follicle. A a pustule has turbid fluid (pus) in the cavity and is circumscribed and elevated (e.g., impetigo, acne). A fissure has a linear crack with abrupt edges, extends into the dermis and can be dry or moist (e.g., cheilosis at corners of mouth as a result of excess moisture, athlete's foot). Acne is caused by increased sebaceous gland activity, which leads to increased oiliness. This increased activity can present as mild or severe and usually appears on the face and sometimes on the chest, back, and shoulders. The milder form presents as open comedones (blackheads) or closed comedones (whiteheads). Severe acne includes papules, pustules, and nodules.

You are assessing a pt's gait. What do you expect to find? Gait is varied, depending on the height of the person Gait is equal to the length of the arm Gait is wide as the shoulder width Gait is half the height of the person

Gait is wide as the shoulder width

Sinus arrhythmia

HR increases with inspiration and decreases with expiration

Malignant melanoma

Half rise from preexisting nevi. Usually brown, but can be tan, black, pink-red, purple, or of mixed pigmentation. Often have irregular or notched borders. May have scaling, flaking, oozing texture. Commonly located on trunk and back in males & females, legs in females, and on the palms, soles of feet and nails of blacks.

Submandibular Lymph Node

Halfway between the angle and the tip of the mandible

Differences of skin at various developmental stages:

INFANTS: the immature skin cannot effectively prevent fluid loss o regulate temperature PREGNANCY: causes pigment changes and stretch marks AGING: causes changes in the stratum corneum that give chemicals easier access to the body, and causes other changes that lead to wrinkling

HEARING LOSS W/ A GRADUAL HARDENING THAT CAUSES THE FOOTPLATE OF THE STAPES TO BECOME FIXED IN THE OVAL WINDOW, IMPEDING THE TRANSMISSION OF SOUND AND CAUSING PROGRESSIVE DEAFNESS.

IS NOT RELATED TO A RUPTURED TYMPANIC MEMBRANE

Rhythm

If it has a normal, even tempo

Adapted?

If you move from one country to another, you are going to bring your culture with you, but you have to adapt to the new environment

Assessment of the sclera and conjunctiva

Inspect for color change, swelling, lesions, or foreign body Should appear moist and glossy Conjunctiva is clear; Sclera is white

During the initial home visit, the patient's temperature is noted to be 97.4 F. How would you interpret this? It cannot be evaluated w/o knowledge of the person's age It is below normal. The person should be assessed for possible hypothermia It should be retaken by the rectal route, because this best reflects core body temperature It should be reevaluated at the next visit before a decision is made

It cannot be evaluated w/o knowledge of the person's age

Conditions of the nails:

KOILONYCHIA: thin, concave, raised edges. "Spooning". Caused by iron deficiency & anemia. CLUBBING: inner edges of nail bed is elevated. PARONYCHIA: Red, swollen, tender inflammation of nail folds. BEAU'S LINE: transverse furrow or grove; extends down to nail bed SPLINTER HEMORRHAGES: red brown, linear streaks, embolic lesions ONYCHOLYSIS: fungus infection, green, thick, crumbling

INFANTS & CHILDREN 3 months fetus has formed skeleton of cartilage bone growth continues rapidly thru infancy steady childhood until adolescent growth spurt increase width or diameter is by deposition of new bony tissues around shafts

LENGTHENING occurs @ epiphysis or growth plates continues thru age of 20 any trauma or infection @ these locations puts growing child @ risk for bone deformity bowlegged stance normal 4 1 year after child begins walking knock knees normal between 2 and 3 1/2

Common variations on aging adult's skin:

LENTIGINES: liver spots SEBORRHEIC KERATOSIS: dark, greasy, "stuck on" - trunk, face, hands ACTINIC KERATOSIS" scaly, silver-white plaques - pre-malignant ACROCHORDONS: Skin tags, over growth of normal skin SEBACEOUS HYPERPLASIA: raised yellow papules w/central depression (mostly men), over forehead, nose, cheeks, pebbly look

A student nurse has been assigned to teach Grade 4 students about hygiene. While preparing, she adds information about the sweat glands. Which of the following will she include while discussing this topic? There are two types of sweat glands: the eccrine and the sebaceous. Newborn infants do not sweat; they use compensatory mechanisms to control body temperature. Eccrine glands produce sweat and are mainly located in the axillae, anogenital area, and navel. The evaporation of sweat, which is a dilute saline solution, increases body temperature.

Newborn infants do not sweat; they use compensatory mechanisms to control body temperature. Newborn infants do not sweat; they use compensatory mechanisms to control body temperature. There are two types of sweat glands: the eccrine and the apocrine glands, not the sebaceous glands. The evaporation of sweat, which is a dilute saline solution, decreases (not increases) body temperature. Apocrine glands, not eccrine glands, produce sweat and are mainly located in the axillae, anogenital area, and navel.

Seborrhea

OILY: an inflammatory skin disorder affecting the scalp, face, and torso. Typically, seborrheic dermatitis presents with scaly, flaky, itchy, and red skin. It particularly affects the sebaceous-gland-rich areas of skin. In adolescents and adults, seborrhoeic dermatitis usually presents as scalp scaling similar to dandruff or as mild to marked erythema of the nasolabial fold

NOTES purpose of musculoskeletal physical exam is to assess function 4 ADL's age specific screening measures such as

ORTOLANIS SIGN FOR INFANTS newborn hip displasia scoliosis screeing 4 adolescents make patient comfortable don't confuse crepitation with normal discrete crack heard as tendon ligament slips over bone during ROM

When do you take a rectal temperature

Operating room Critical care units When other routes are unavailable 6-36 months (3 yrs old) children that you suspect have a fever or infection

Different Routes for taking Temperature

Oral Tympanic Membrane Temporal Artery Axillary (1 degree cooler than oral) Rectal (1 degree warmer than oral)

Purpuric lesions

PETECHIAE: superficial capillaries, not caused by mechanical injury BRUISE: contusion, mechanical injury, hemorrhage to tissues HEMATOMA: bruise that can be felt, mechanical injury, raised, swollen

A 75- YEAR OLD WHO LIVES IN AN ASSISTED-LIVING APARTMENT SHOULD BE SCREENED FOR

PRESBYCUSIS, WHICH IS FOUND IN MORE THAN 60 % OF PERSONS OVER AGE 65

Distinguish skin lesion terms:

PRIMARY: lesion develops on previously unaltered skin SECONDARY: when a lesion changes over time, and changes because of a factor (scratching, infection)

Primary skin lesions:

PUSTULE: Circular, elevated cavity filled with fluid or pus. MACULE: color change, flat. "Freckle" PAPULE: solid, elevated. Circumscribed PLAQUE: elevated. Wider than 1cm. NODULE: solid, elevated. hard or soft. larger than 1cm. TUMOR: firm or soft. larger than a few cm. Benign or malignant. WHEAL: superficial, raised, slightly irregular due to edema. VESICLE: elevated, contains free fluid. "blister"

How do you take an oral temperature

Place thermometer in one of the posterior sublingual pockets Instruct patient to close their lips wait 15 mins if the person drank something hot or iced wait 2 mins if pt smoked

The examiner suspects a patient has coarctation of the aorta. Which assessment findings support this suspicion? Thigh pressure is higher than in the arm Thigh pressure is equal to that in the arm Thigh pressure is unrelated to the arm pressure. There is no constant relationship' findings are highly individual Pressure is lower than in the arm

Pressure is lower than in the arm

In previewing the medical record of a patient, you find documentation of pulsus alternans. On the basis of this fact, what do you expect when you assess the patient? Pulse with a regular rhythm, but the force of the pulse varies with alternating beats. Pulse with weaker amplitude with respiratory inspiration and stronger amplitude with expiration. Deficiency of oxygenated arterial blood to a body part. Pulse with coupled rhythm; every other beat is premature.

Pulse with a regular rhythm, but the force of the pulse varies with alternating beats. In pulsus alternans, the rhythm is regular, but the force of the pulse varies with alternating beats. In pulsus bigeminus, the rhythm is coupled, and every other beat is premature. Ischemia is deficient supply of oxygenated arterial blood to a tissue caused by obstruction of a blood vessel. Pulsus paradoxus occurs when beats have weaker amplitude with respiratory inspiration and stronger amplitude with expiration.

Which of the following terms describes "compact, desiccated flakes of skin from shedding of dead skin cells"? Plaque Scale Crust Dandruff

Scale Scales are compact, desiccated flakes of skin from shedding of dead skin cells. Seborrhea (dandruff) is indicated by loose, white flakes. Plaque is a plateau-like, disk-shaped lesion from papules that coalesce to form surface elevation wider than 1 cm. The term crust refers to a hard covering of the lesion.

Tympanic Membrane Temperature

Shares the same vascular supply that perfuse the hypothalamus

How to take a Temporal Artery Temp

Slide probe across the forehead and behind the ear Record temp in Celsius- 104 F= 40 C; 98.6 F= 37 C; 95 F= 35 C

Peripheral Vascular resistance

Smaller vessels- BP increases due to pressure needed to push the contents Larger vessels- BP decreases due to less pressure needed to push the contents

Spirituality is defined as a. a social group that claims to possess variable traits. b. participating in religious services on a regular basis. c. the process of being raised within a culture. d. a personal effort to find meaning and purpose in life.

Which changes in head circumference measurements in relation to chest measurements will occur from infancy through early childhood? A newborns head should be approx 5 cm larger than the chest circumference, but by age 2, they should be equal The chest grows at a faster rate than the cranium, but by age 1, the measurements will be the same, and after age 2, the chest should be approx 5 cm larger The newborn's head will be 2 cm larger than the chest circumference, but between 6 months to 2 yrs, they will be about the same The head and circumference should be very similar, but between 6 months and 2 yrs, the chest size will increase and remain that way

The newborn's head will be 2 cm larger than the chest circumference, but between 6 months to 2 yrs, they will be about the same

ANS: not palpable. Most lymph nodes are not palpable in adults. The palpability of lymph nodes decreases with age. Normal nodes feel movable, discrete, soft, and nontender.

The nurse has just completed a lymph node assessment on a 60-year-old healthy female patient. The nurse knows that *most lymph nodes in healthy adults* are normally:

ANS: area proximal to the enlarged node. When nodes are abnormal, the nurse should check the area they drain for the source of the problem. Explore the area proximal (upstream) to the location of the abnormal node.

The nurse notices that a patient's submental lymph nodes are enlarged. In an effort to identify the cause of the node enlargement, the nurse would assess the patient's:

A student nurse has been assigned to teach Grade 4 students about hygiene. He decides that the teaching module will cover the oil-producing glands. Which of the following will he include while discussing the skin's sebaceous glands? The sebaceous glands produce sebum, a protective oily substance that prevents water loss from the skin. Sebaceous glands are located everywhere on the skin; they are most abundant in the scalp, forehead, face, and chin. Sebaceous glands mature by the time an infant is 2 months old. Dry skin results from the loss of oil and is treated by moisturizers.

The sebaceous glands produce sebum, a protective oily substance that prevents water loss from the skin. The sebaceous glands produce sebum, a protective oily substance that prevents water loss from the skin. Dry skin results from loss of water, not directly from loss of oil. Sebaceous glands are located everywhere on the skin except the palms and soles. Eccrine glands, not sebaceous glands, mature by the time an infant is 2 months old.

For health restoration, the Asian heritage believes in ?

Traditional remedies such as ginseng root. Acupuncture, moxibustion, cupping

An example of a primary lesion is a(n): ulcer. urticaria. port-wine stain. erosion.

Urticaria An example of a primary lesion is a urticaria. A port-wine stain is a hemangioma, not a primary lesion. An erosion is a break in the continuity of the surface of the skin with a scooped out but shallow depression that is moist but no does not have bleeding and heals without scar because the erosion does not extend into the dermis. An ulcer is a deeper depression extending into the dermis; the ulcer has an irregular shape, may bleed, and leaves a scar when it heals. Examples: stasis ulcer, pressure sore, chancre.

How do you test cranial nerve function of the eyes?

Utilize the six cardinal positions of gaze

Two types of human hair:

VELLUS HAIR: fine, faint, covers most of the body except - palms, soles, dorsa of distal parts of fingers, umbilicus, glans penis, inner labia. TERMINAL HAIR: darker, thicker hair on scalp, eyebrows, axillae, pubic area, and face and chest in a male

When completing a health assessment, which of the following actions most demonstrates cultural competence? a. Ask about family history of diseases. b. Ask about use of traditional, herbal, or folk remedies. c. Make sure the blood pressure cuff fits appropriately. d. Measure height and weight in a private room.

a, c, d, e

When considering cultural competence, the nurse must develop knowledge of discrete areas to understand the health care needs of others. These discrete areas include understanding of (Select all that apply.) a. his or her own heritage b. cultural and ethnic values c. heritage of the health system d. heritage of the nursing profession e. the heritage of the patient

Which health belief practice is associated with patients who are of American Indian heritage? a. wearing bangle bracelets to ward off evil spirits b. believing that forces of nature must be kept in natural balance c. using swamp root as a traditional home remedy d. believing in a shaman as a traditional healer.

Which of the following statements regarding language barriers and health care is true? a. English proficiency is associated with a lower quality of care. b. Patients with language barriers have a decreased risk for nonadherence to medication regimens. c. Standards have been identified that are important to eliminate health disparities. d. LEP is associated with a higher quality of care.

Which statement best describes ethnocentrism? a. the government description of various cultures b. a central belief that accepts all cultures as one's own c. the tendency to view your own way of life as the most desirable. d. the tendency to impose your beliefs, values, and patterns of behavior on an individual from another culture.

Which statement best describes religion? a. an organized system of beliefs concerning the cause, nature, and purpose, of the universe. b. belief in a divine and superhuman spirit to be obeyed and worshipped c. affiliation with one of the 1200 recognized religions in the United States d. The following of established rituals, especially in conjunction with health-seeking behaviors

Which statement best illustrates the difference between religion and spirituality? a. religion reflects an individual's reaction to life events whereas spirituality is based on whether the individual attends religious services. b. religion is characterized by identification of a higher being shaping one's destiny, whereas spirituality reflects an individual's perception of one's life having worth or meaning. d. religion is the active interpretation of one's spirituality.

Which statement best reflects the magicoreligious causation of illness? a. each being is but part of a larger structure in the world of nature as it relates to health and illness b. causality relationships exist, leading to expression of illness c. belief in the struggle between good and evil is reflected in the regulation of health and illness d. illness occurs as a result of disturbances between hot and cold reactions.

Which statement is most appropriate to use when initiating an assessment of cultural beliefs with an older American Indian patient? a. "Are you of Christian faith?" b. "Do you want to see a medicine man? c. "How often do you seek help from medical providers?" d. "What cultural or spiritual beliefs are important to you?"

Which theory has been expanded in an attempt to study the degree to which a person's lifestyle reflects his or her traditional heritage? a. Congruence mechanism b. Heritage consistency c. Behavior theory d. Socialization experience

Mr. Shea is a 51-year-old patient who presents with complaints of a skin lesion. On examination, you note a linear skin lesion that runs along a nerve route. Which of the following terms best describes this lesion? Shingles Gyrate Annular Zosteriform

Zosteriform Zosteriform is a linear skin lesion that runs along a nerve route. The term used to describe the shape of a lesion as being circular is annular. The term gyrate refers to a twisted, coiled, spiral-shaped lesion. The term shingles refers to small, grouped vesicles that emerge along the route of the cutaneous sensory nerve and turn into pustules and then crusts.

presbyopia

a condition found in aging adults where the pupil size decreases, the lens loses its elasticity and becomes hard and glasslike. this decreases the lens' ability to change shape in order to accomodate for near vision. average age of onset is 40

nystagumus

a fine oscillating movement best seen around the iris.

arcus senilis

a gray-white arc or circle around the limbu; it is due to the deposition of lipid material in the aging adult. as lipids accumulate, the cornea may look thickened and raised. but this has no effect on vision

confrontation test

a gross measure of peripheral vision

Jaundice

a medical condition with yellowing of the skin or whites of the eyes, arising from excess of the pigment bilirubin and typically caused by obstruction of the bile duct, by liver disease, or by excessive breakdown of red blood cells.

An aneurysm is: a fatty plaque deposited in the intima of the arteries. a thickening and loss of elasticity of the arterial walls. a sac formed by dilation in the arterial wall. a variation from the heart's normal rhythm.

a sac formed by dilation in the arterial wall. An aneurysm is a sac formed by dilation in the arterial wall. A variation from the heart's normal rhythm is called arrhythmia, not aneurysm. Peripheral blood vessels grow more rigid with age, resulting in a condition called arteriosclerosis, not an aneurysm. Atherosclerosis, not an aneurysm, is the deposition of fatty plaques on the intima of the arteries.

macula

a slightly darker pigmented region surrounding the fovea centralis. this receives and transduces light from the center of the visual field.

ethnicity

a social group within the social system that claims to possess variable traits such as common geographic origin, migratory status, and religion.

wrist and hand assessment normal no swelling tenderness nodules, full muscles, thenar eminence (round mound on palm near thumb - atrophies w/carpal tunnel), no bogginess, no synovial thickening, normal ROM muscle testing - can flex wrist against your resistance, normal Phalen test and Tinel sign

abnormal: - subluxation = partial dislocation of wrist - ulnar deviation = fingers list to ulnar side - ankylosis = wrist in extreme flexion - synovial swelling on dorsum - Heberden and Bouchard nodules are hard and nontender = osteoarthritis - loss of ROM, pain

hip assessment

abnormal: pain, crepitation, limited ROM, flexion flattens the lumbar spine, positive Thomas test flexion deformity, limited internal rotation and abduction of hip hip disease

accomodation

an adaptation of the eye for near vision by increasing the curvature of the lens through movement of the ciliary muscles. test this reflex by asking the person to focus on a distant object, which dilates the pupils, then have them shift gaze to a close object. A normal response is papillary constriction and convergence of the axes of the eyes.

abnormal crepitation

an audible and palpable crunching or grating that accompanies movement - it occurs when the articular surfaces of the joints are roughened (ex: RA)

bursa

an enclosed sac filled with viscous synovial fluid located in areas of potential friction subacromial bursa of the shoulder, prepatellar bursa of the knee - help tendons and muscles glide smoothly over bone

Chloasma

an irregular brown patch of hyperpigmentation on the face that may occur with pregnancy

religion

an organized system of beliefs concerning the cause, nature, and purpose of the universe, as well as attendance at regular services.

anterior and posterior stability provided to the knee joint by

anterior and posterior cruciate ligaments

dislocated shoulder

anterior dislocation (95%) is exhibited as a hollow where it would normally look rounded

Mr. Harris comes to the clinic for a follow-up appointment. On examination, you note a full "bounding" pulse. This is associated with: (Select all that apply.) Select all that apply. anxiety. aortic valve stenosis. elevated temperature. hyperthyroidism. anemia. patent ductus arteriosus.

anxiety. anemia hyperthroidism elevated temperature A full "bounding" pulse is associated with hyperkinetic states (exercise, anxiety, and fever), anemia, and hyperthyroidism. A weak, "thready", not full "bounding," pulse occurs with decreased cardiac output, peripheral arterial disease, and/or aortic valve stenosis. A water-hammer "Corrigan's" pulse is associated with aortic valve regurgitation and patent ductus arteriosus.

Mrs. Schneider comes to the office for a routine health assessment and without complaints. On examination, you note a water-hammer "Corrigan's" pulse. This is associated with: hyperkinetic states. aortic valve regurgitation. conduction disturbance. decreased cardiac output.

aortic valve regurgitation. A water-hammer "Corrigan's" pulse is associated with aortic valve regurgitation. Pulsus bigeminus is associated with conduction disturbance. A full "bounding" pulse is associated with hyperkinetic states (exercise, anxiety, and fever), anemia, and hyperthyroidism. A weak, "thready" pulse occurs with decreased cardiac output, peripheral arterial disease, and/or aortic valve stenosis.

a complete musculoskeletal examination

appropriate for persons with articular disease, a history of musculoskeletal symptoms, any issues with ADLs

Mrs. Lukianchuk is a 65-year-old patient who presents to the ambulatory health centre with a complaint of bilateral foot pain. On examination, you note delayed venous filling. This occurs with: incompetent valves. anemia. arterial insufficiency. aortic valve stenosis.

arterial insufficiency. Delayed venous filling occurs with arterial insufficiency. Incompetent valves can lead to venous stasis, causing increased venous pressure, which then causes the red blood cells (RBCs) to leak out of veins and into the skin. Anemia is associated with hyperkinetic states, and this results in a full "bounding" pulse. A weak, "thready" pulse occurs with aortic valve stenosis.

Tempromandibular joint

articulation of mandible and temporal bone, can feel it in the depression anterior to tragus of the ear; permits jaw function of speaking & chewing 3 MOTIONS: hinge - open/close mouth; gliding action for protrusion, retraction and side to side movement of mandible; -when performing exam, audible/palpable snap or crack occurs in many healthy people as mouth opens

corneal light reflex

assess the parallel alignment of the eye axes by shining a light toward the person's eyes. direct the person to stare straight ahead as you hold the light about 12 inches away. note the reflection of the light on the corneas, it shoudl be in exactly the same spot on each eye

Data collection for the general survey begins: at the first encounter at the beginning of the physical examination while taking vital signs. during the mental status examination

at the first encounter. The general survey is initiated at the first encounter with the patient.

tendons

attach muscle to bone, composed of a strong fibrous cord

Functions of the skin include: Select all that apply. communication and identification perception and temperature regulation production of vitamin D. protection and prevention

communication and identification perception and temperature regulation production of vitamin D. protection and prevention The functions of the skin include all of the following: protection, prevention, perception, and production of vitamin D, and temperature regulation, communication, and identification.

Pulsus bigeminus is associated with: aortic valve regurgitation. hyperkinetic states. heart failure. conduction disturbance.

conduction disturbance. Pulsus bigeminus is associated with conduction disturbance. Aortic valve regurgitation is associated with a water-hammer "Corrigan's" pulse and is associated with aortic valve regurgitation. Pulsus alternans is associated with heart failure. A full "bounding" pulse is associated with hyperkinetic states (exercise, anxiety, and fever), anemia, and hyperthyroidism.

club foot talipes equinovarus

congenital 1. inversion 2. forefoot adduction 3 foot pointing downward

Ligaments

connect BONE TO BONE ; strengthen joint and prevent movement in undesirable directions

To perform an accurate assessment of respirations, the examiner should: inform the person of the procedure and count for 1 minute count for 15 seconds while keeping fingers on the pulse and then multiply by four count for 30 seconds after completing a pulse assessment and multiply by two. assess respirations for a full 2 minutes if an abnormality is suspected.

count for 30 seconds after completing a pulse assessment and multiply by two. Respirations should be counted for 30 seconds (if regular) and multiplied by two. The respirations should be counted after the pulse assessment. Patients have conscious control over respirations; the examiner should not mention that respirations will be counted. Avoid counting respirations for 15 seconds because the results can vary +4 or -4 with such a small number. Respirations should be counted for 1 minute if abnormalities are suspected.

What cranial nerve innervates the tongue?

cranial nerve XII, the hypoglossal nerve.

competent

culturally ___________ means that caregivers understand all aspects of the patient's cultural being, and this include this information in the patient's care.

appropriate

culturally _____________ implies that caregivers apply their knowledge of culture to provide the best patient care possible.

sensitive

culturally _______________ means that caregivers are aware of different cultures in the health care setting.

_____________implies that the caregivers possess some basic knowledge of and constructive attitudes toward diverse cultural populations found in the setting they are practicing; caregiver will have different knowledge of different cultures.

culturally sensitive

The thickening and yellowing of the lens due to aging is described as: a) Presbyopia b) Floaters c) Macular degeneration d) Senile cataract

d) Senile cataract

osteoporosis transcultural consideration

decreased incidence in african americans, increased incicence in chinese, japanese, and inuits

Mr. Kimbel is a 59-year-old patient who comes to the clinic for a routine health assessment at the request of his son. On examination, you note a positive profile sign. This indicates: early clubbing. the patency of the radial and ulnar arteries. the presence of thrombophlebitis. the degree of pedal edema.

early clubbing. A positive profile sign indicates early clubbing. Assessment findings of thrombophlebitis would include increased warmth, swelling, tenderness to palpation, with a positive Homan's sign present in only a few cases. The modified Allen test is used to assess the patency of the radial and ulnar arteries. Inspection and palpation of the feet are used to assess the degree of pedal edema.

Lymphadenopathy

enlargement of the lymph nodes due to infection, allergy, or neoplasm, larger than 1cm

PREGNANT WOMEN hormones increased mobility joint estrogin relaxin corticosteroids noticeable changes maternal posture LORDOSIS by the

enlarging fetus shifts weight farther back on lower extremeties body compensates w/ anterior flexion of neck & slumping shoulder girdle low back pain common upper back change put pressure on ULNAR & MEDIAN NERVES during 3rd trimester create aching numbness & weakness upper extremeties

Macule

flat skin lesion with only a color change - freckles

during examination of spine ask patient to:

flex, extend, abduct, rotate

bulge sign

for swelling of the suprapatellar pouch confirms presence of small amounts of fluid as you try to move the fluid from one side of joint to the other - firmly stroke up medial aspect of knee and tap lateral aspect for fluid wave

Blood pressure

force that blood pushing against the side of the vessel wall Korotkoff I- systolic (tapping) Korotkoff IV- muffling of sound Korotkoff V- diastolic pressure (no sound)

motions in the examination of the shoulder

forward flexion, internal rotation, abduction, external rotation

Occipital (#3)

found at the base of the skull, is non-palpable.

Submandibular (#5)

found halfway between the angle and the tip of the mandible, is non-palpable.

Posterior cervical (#9)

found in the posterior triangle along the edge of the trapezius muscle, is non-palpable.

Supraclavicular (#10)

found just above and behind the clavicle at the sternomastoid muscle, is non-palpable.

Submental (#4)

found midline, behind the tip of the mandible, is non-palpable.

Superficial cervical (#7)

found overlying the sternomastoid muscle, is non-palpable.

Posterior auricular (#2)

found superficial to the mastoid process, is non-palpable.

Jugulodigastric (#6)

found under the angle of the mandible, is non-palpable.

synovial joints

freely movable joints that are separated from each other and enclosed in a joint cavity filled with lubricating synovial fluid

scoliosis

functional - flexible; apparent w/standing but disappears w/forward bending. may be compensatory for other abnormalities structural - fixed: curvature at standing and bendingunequalal shoulder and scapulae and hip level. greatest risk = females at growth spurt

Hyperthermia

generalized hyperthermia occurs with increased metabolic rate, causing warm, moist skin, such as with fever, or after heavy exercise. Localized hyperthermia occurs with trauma, infection or sunburn.

Hypothermia

generalized hypothermia accompanies central circulatory problems, such as shock. Localized hypothermia occurs in peripheral arterial insufficiency

The cervical nodes drain the: upper arm and breast. external genitalia. head and neck. hand and lower arm.

head and neck. The cervical nodes drain the head and neck. The axillary nodes drain the breast and the upper arm. The epitrochlear node is in the antecubital fossa and drains the hand and the lower arm. The inguinal nodes in the groin drain most of the lymph of the lower extremity, the external genitalia, and the anterior abdominal wall.

Mr. Worrigan is a 67-year-old patient who comes with his son to the ambulatory health centre. On examination of Mr. Worrigan, you note a pulsus alternans. This is associated with: heart failure. pulmonary embolisms. hyperkinetic states. decreased cardiac output.

heart failure. Pulsus alternans is associated with heart failure. A full "bounding" pulse is associated with hyperkinetic states (exercise, anxiety, and fever), anemia, and hyperthyroidism. Pulsus paradoxus is associated with cardiac tamponade and acute asthma. A weak, "thready" pulse occurs with decreased cardiac output, peripheral arterial disease, and/or aortic valve stenosis.

tear of rotator cuff

hunched position and limited abduction of arm from trauma - positive drop test: if arm is passively raised, person cannot sustain it alone so arm drops towaiste

crepitus in knee

if otherwise asymptomatic, this is normal - pronounced crepitisoccurss with degenerative diseases of knee - irregular bony margins occur w/osteoarthritis

yin yang

in the ________ __________ theory of health, health exists when all aspects of the person are in perfect balance.

subacrimonial bursitis

inflammation and swelling over shoulder = pain and limited ROM - via direct trauma, strain during sports, inflammation, repetitive motion with injury

Erythema

intense redness of the skin due to excess blood in the dilated superficial capillaries, as in fever or inflammation. Dark skinned can not see erythema, so must palpate skin for warmth, edema, hardening

Gouty arthritis

joint effusion or synovial thickening; characterized by redness, heat, soft, boggy or fluctuant fullness to palation and limited ROM

nonsynovial joints

joints where bones are united by fibrous tissue or cartilage and are immovable ex: sutures of the skull or only slightly movable ex: the vertebrae

Mrs. Freitas is a 65-year-old patient who presents with complaints of skin spots during a dermatology follow-up. As the health care provider, you note some hyperpigmentation in this aging adult. On examination, you would expect to see: linea nigra and chloasma. café au lait spots and hemangioma. keratosis and lentigines. acrochordons and comedones

keratosis and lentigines. Hyperpigmentation in the aging adult would consist of keratosis and lentigines. Linea nigra and chloasma would be seen in the pregnant woman. Acrochordons are skin tags, and comedones are acne lesions. Café au lait spots and hemangiomas would be seen in newborns.

Cafe' au lait

large round or oval patch of light brown usually present at birth

diagnostic positions test

lead the eyes through the six cardinal positions of gaze will elicit any muscle weakness during movement. ask person to hold head steady and follow finger. progress clockwise in each direction. a normal response is parallel tracking of the object with both eyes

_________are persons who were granted lawful, permanent residence

legal residents

Mrs. Nero, a 29-year-old patient who is pregnant, comes to the office with concerns about skin changes. As the health care provider, you know that some skin changes occur during pregnancy as a result of increased pigmentation, including: café-au-lait spots. linea nigra. keratosis. lentigines.

linea nigra Skin changes occur during pregnancy as a result of increased pigmentation, include linea nigra. Senile lentigines are also known as liver spots, which are small, flat, brown macules that form as a person ages. Café-au-lait spots are seen in newborns. Keratosis are raised, thickened areas of pigmentation that look crusted, scaly, and warty, and they are not associated with pregnancy.

Fissure

linear crack in skin extending into dermis

Zosteriform

linear shape of skin lesion along a nerve route

depression

lower body part

Harlequin

lower half of body turns red, upper half blanches

depression

lowering a body part

five steps to prevent osteoporosis

milk fish greens soy limit caffeine onions exercise weight-bearing 30 min 3 x week lifestyle avoid smoking 2 x risk alcohol less Ca absorption depression = lower bone densitymedical options loss of 1-2 inches early sign confirm with bone density tests supplements adult 1000mg Ca 200 D

Protraction

move body part forward, paralell to the ground "protractor"

Synovial Joints

move freely because bones are seperated and enclosed in a "sac" BURSA of synovial fluids, which allows sliding and movement SHOULDERS, KNEES

Abduction

move limb away from body

Adduction

move limb toward body "add"

Inversion

move sole of foot inward at ankle "move in"

Eversion

move sole of foot outward at ankle "exit"

retraction

moving a body part backward and parallel to the ground, moves toward vertebral column

protraction

moving a body part forward and parallel to the ground

protraction

moving a body part forward and parallel to the ground, moves away from vertebral column

retraction

moving a body party backward and parallel to the ground

abduction

moving a limb away from the midline of the body

adduction

moving a limb towards the midline of the body

circumduction

moving the arm in a circle around the shoulder

circumduction

moving the arm in a circle around the shoulder (sequence of flexion, adbduction, external rotation, and adduction)

rotation

moving the head around a central axis

inversion

moving the sole of the foot inward at the ankle

_______the conferring, by any means, of citizenship upon a person after birth

naturalization

Wrist & Carpals many complex joints Phalen's test for carpel tunnel ask person to hold both hands back to back while flexing wrist 90 degrees 4 60 seconds should produce

no sympoms normal hand numbness and burning in person w/ carpal tunnel Tinels Sign 4 carpel tunnel direct percussion on median nerve @ wrist no symptoms in normal hand burning and tingling if carpal tunnel is present

osteoarthritis degenerative joint disease

noninflammatory localized progressive disorder deterioration of articular cartilages & subchondral bone w/formation of new bone at joint sites most ppl 60+ have signs of osteoarthritis joints are stiff swelling w/ hard bony protuberances pain w/ motion and limited ROM

osteoarthritis

noninflammatory, localized, progressive disorder involving DETERIORATION of articular cartilages and subchondral bone, and formation of new bone at joint surfaces; affected joints have stiffness, swelling with hard bony protuberances, pain with motion, an dlimitation of motion

TMJ assessment

normal: audible/palpable snap or click, can achieve 3 movements, can push against your resistance CN 5 abnormal: swelling looks like a round bulge, crepitus, pain, reduced ROM lateral lost earlier than vertical

Nurse maids elbow

occurs most common between 2 and 4, elbow dislocates

Aging Adultbone remodeling more rapid after 40 causing loss of bone density osteoporosis postural changes such as decreased height caused by shortening of vertebral column loss

of water content thinning intervertebral discs lose subcut fat loss in muscle mass produces weakness sedentary lifestyle musculoskeletal changes of agingphysical exercise increases skeletal muscle mass and helps prevent or delay osteoporosis WALKING

Tachycardia

over 100 BPM Usually occurs with exercise and anxiety

osgood schlatter disease

painful swelling of the tibial tubercle just below the knee, due to repeated stess on the patellar tendon

phalen's test

patient holds hands back to back while flexing the wrists 90 degrees for 60 seconds

McMurray's test

patient supine, hold the heel and flex the knee and hip, place hand on medial side of knee, rotate the left in and out, then rotate the leg in and out and push on the knee. If you hear or feel a click, test is positive for torn meniscus

Ausculatory gap

period where Korotkoff sounds disappear Usually occurs in people w/ hypertension

The general survey consists of four distinct areas. These areas include: mental status, speech, behavior, and mood and affect gait, range of motion, mental status, and behavior physical appearance, body structure, mobility, and behavior level of consciousness, personal hygiene, mental status, and physical condition

physical appearance, body structure, mobility, and behavior. The general survey is a study of the whole person, covering the general health state and any obvious physical characteristics. The four areas of the general survey are physical appearance, body structure, mobility, and behavior. A general survey does not include assessment of mental status and physical condition.

Atherosclerosis is defined as: a swooshing sound heard through a stethoscope when an artery is partially occluded. a thickening and loss of elasticity of the arterial walls. plaques of fatty deposits forming in the intima of the arteries. a sac formed by dilation in the arterial wall.

plaques of fatty deposits forming in the intima of the arteries. Atherosclerosis is defined as plaques of fatty deposits forming in the intima of the arteries. A bruit is a swooshing sound heard through a stethoscope when an artery is partially occluded. An aneurysm is a sac formed by dilation in the arterial wall. Arteriosclerosis refers to thickening and loss of elasticity of the arterial walls.

One of the leg's deep veins is the: great saphenous. popliteal. small saphenous. tibial.

popliteal. One of the leg's deep veins is the popliteal. The other options are incorrect because the great and small saphenous and tibial veins are not deep, but superficial.

Mean arterial pressure

pressure forcing blood into the tissues averaged over the cardiac cycle What perfuses the tissue MAP= (diastolic+ 1/3 pulse pressure) MAP= (diastolic + 1/3 (systolic-diastolic)

The African Heritage beliefs in health maintenance are___________?

prevent disharmony; respect cleanliness, religion, avoid sick people.

what is hematopoiesis

production of red blood cells in the bone marrow

The tympanic membrane thermometer (TMT): provides an accurate measurement of core body temperature senses the infrared emissions of the cerebral cortex. is not used in unconscious patients accurately measures temperature in 20 to 30 seconds

provides an accurate measurement of core body temperature. The TMT accurately measures core body temperature. The TMT senses the infrared emissions of the tympanic membrane; the tympanic membrane shares the same vascular supply that perfuses the hypothalamus. The TMT is used with unconscious patients or patients in the emergency department, recovery areas, and labor and delivery units. The temperature is displayed in 2 to 3 seconds.

A flat macular hemorrhage is called a(n): ecchymosis. petechiae. purpura. hemangioma.

purpura A flat macular hemorrhage is called a purpura. Ecchymosis is bruising. Petechiae are tiny punctate hemorrhages, 1 to 3 mm, round and discrete, dark red, purple, or brown in colour caused by bleeding from superficial capillaries. A hemangioma is caused by a benign proliferation of blood vessels in the dermis.

Mrs. Ling, a 42-year-old patient, presents to the dermatology clinic with a confluent and extensive patch of petechiae and ecchymoses, flat macular hemorrhage is called a: purpura. hemangioma. telangiectasia. hematoma.

purpura Purpura is a confluent and extensive patch of petechiae and ecchymoses, greater than 3 mm flat, red to purple, macular hemorrhage. It is seen in generalized disorders such as thrombocytopenia and scurvy. Also occurs in old age as blood leaks from capillaries in response to minor trauma and diffuses through the dermis. A hemangioma is caused by a benign proliferation of blood vessels in the dermis. A hematoma is a bruise that can be felt. It elevates the skin and is seen as swelling. A telangiectasia is caused by vascular dilatation, and permanently enlarged and dilated blood vessels are visible on the skin surface.

An elevated cavity containing thick, turbid fluid is a: bulla. pustule. vesicle. cyst.

pustule An elevated cavity containing thick, turbid fluid is a pustule. Acyst is an encapsulated fluid-filled cavity in dermis or subcutaneous layer, tensely elevating skin. A vesicle is an elevated cavity containing free fluid, up to 1 cm; also known as a "blister". Clear serum flows if the wall is ruptured. The single-chambered, superficial lesions containing free fluid greater than 1 cm in diameter are called bullae.

visual acuity

recorded as a fraction. the numerator is the distance from the chart and the denominator represents the last line read correctly

__________is any person who is outside of his or her own country of nationality who is unable or unwilling to return to that country because of persecution or a well-founded fear.

refugee

ballottement of the patella

reliable 4 large fluid present in knee use L hand to compress suprapatellar pouch to move fluid in knee joint w/ R hand push patella sharply against femur no fluid patella snug against femur fluid your tap on patella moves through fluid so you will hear a tap as patella bumps the femoral condyles

ballottement of the patella

reliable when larger amounts of fluid are present, use left hand to compress the suprapatellar pouch to move fluid and right hand push the patella against femur

____________play a most significant role in the way that people view their health practices: benefits health behavior and lifestyles, offers social support that at as a buffer for stress and isolation, and leads to thoughts of hope and optimism.

religion

The African Heritage has what kind of healers?

root worker, spiritualists "old lady"

pupil

round and regular. its size is determined by a balance between the para/sympathetic chains of the autonomic nervous system

ganglion cyst

round cystic, nontender nodule overlying a tendon sheath or joint capsule, usually on dorsume of wrist

musculoskeletal system in the aging adult bone remodeling favors resorption after 40 loss > formation net effect gradual loss bone density osteoporosiss decreased height mosnoticeablele due 2

shortening vertebral column long bones DON'T shorten begin @ 40 men & 43 women distribution of subQ fat change move from the periphery sedentary lifestyle hast musculoskeletal change physical activity delays prevents bone loss postmenopausal

Hemangioma

skin lesion due to benign proliferation of blood vessels in the dermis

Telangiectasia

skin lesion due to permanently enlarged and dilated blood vessels that are visible

Confluent

skin lesions that run together

Ulcer

sloughing of necrotic inflammatory tissue that causes a deep depression in skin, extending into dermis

Cherry (senile) angiomas

small 1mm to 5 mm, smooth, slightly raised bright red dots that commonly appear on the trunk in all adults older than 30 years. They normally increase in size and number with aging.

Freckles

small, flat macules of brown melanin pigment that occur on sun-exposed skin

Maceration

softening of tissue by soaking

Papule

solid, elevated, circumscribed skin lesion, palpable, <1 cm diameter

Nodule

solid, elevated, hard or soft skin lesion, >1 cm diameter

vertebrae landmarks

spinous processes C7 & T1 r prominent @ base of the neck inferior angle of the scapula normally @ level interspace T7 T8 an imaginary line connecting the highest point on each iliac crest crosses L4 imaginary line joining 2 symmetric dimples that overlie the posterior iliac spines crosses sacrum

strabismus

squint, crossed eye. Causes disconjugate vision because one eye deviates off the fixation point

Physical appearance includes statements that compare appearance with: mood and affect stated age gait. nutrition.

stated age Physical appearance includes statements that compare appearance with age, sex, level of consciousness, skin color, and facial features. Behavior is compared with mood and affect. Mobility is compared with gait. Body structure is compared with nutrition.

extension

straightening a limb at a joint

Striae gravidarum

stretch marks. May develop in the skin of the abdomen, breasts, thighs, upper arms

You are preparing the equipment that will be used to examine patients in the dermatology clinic. The equipment needed to assess the skin, its appendages and, if necessary, lesions include: strong direct lighting (natural daylight preferred), ruler, pen light, monometer, gloves, filtered ultraviolet light, glass slide, and KOH. strong direct lighting (artificial light preferred), ruler, pen light, goniometer, gloves, filtered ultraviolet light, glass slide, and KOH. strong direct lighting (natural daylight preferred), ruler, pen light, magnifier, gloves, filtered ultraviolet light, glass slide, and KOH. strong direct lighting (artificial light preferred), ruler, pen light, microscope, gloves, filtered ultraviolet light, glass slide, and KOH.

strong direct lighting (natural daylight preferred), ruler, pen light, magnifier, gloves, filtered ultraviolet light, glass slide, and KOH. The equipment needed to assess the skin, its appendages and, if necessary, lesions include: strong direct lighting (natural daylight preferred), ruler, pen light, magnifier, gloves, filtered ultraviolet light, glass slide, and KOH. Natural light, not artificial light, and a magnifier, not a goniometer, a microscope, or a monometer, are needed.

Erythema

superficial reddening of the skin, usually in patches, as a result of injury or irritation causing dilatation of the blood capillaries.

Diaphoresis

sweating, especially to an unusual degree

joint effusion

swelling from excess FLUID in joint capsule

Phalen's Test (wrist/carpal tunnel)

test for carpel tunnel: ask person to hold both hands back to back while flexing wrist 90 degrees, for 60 seconds - should produce no symptoms in normal hand - numbness and burning in person with carpal tunnel

Tinel's Sign (wrist/carpal tunnel)

test for carpel tunnel: direct percussion on median nerve at wrist - no symptoms in normal hand - burning and tingling if carpal tunnel is present

Ballottement of patella knee/fluid test

test reliable when lg amounts of fluid; use left hand to compress suprapatellar pouch to move any fluid into knee joint, w/right hand, push patella sharply against femur, if no fluid present, patella is already snug againt femur

magicoreligious

the __________________ perspective of illness depends on supernatural forces of good and evil.

Cranial Nerve VI

the abducens nerve which innervates the lateral rectus muscle (abducts the eye)

General inspection is:

the ability to see around the room and follow directions without squinting or craning forward to see

media

the anterior chamber, lens, and vitreous of the eye which can be viewed by the ophthalmoscope

optic disc

the area in which fibers from the retina converge to form the optic nerve

fovea centralis

the area of the retina which has the sharpest and keenest vision.

palpebral fissure

the elliptical open space between the eyelids

Hypertrophy

the enlargement of an organ or tissue from the increase in size of its cells

Uremia

the illness accompanying kidney failure (also called renal failure), in particular the nitrogenous waste products associated with the failure of this organ.

retina

the inner nervous layer of the eye. This visual receptive layer of the eye changes light waves into nerve impulses. these impulses are conducted through the optic nerve and the optic tract to the cisual cortex of the occipital lobe. the image formed on this area of the eye is upside down and inversed form its actual appearance in the outside world.

ocular fundus

the internal surface of the retina that can be seen by the ophthalmoscope.

choroid

the middle vascular layer of the eye which has dark pigmentation to prevent light from reflecting internally and is heavily vascularized to deliver blood to the retina. this layer is ontinuous with the ciliary body (control the thickness of the lens) and the iris (functions as a diaphragm, varying the opening at its center and controls the amount of light admitted into the retina

Snellen Alphabet chart

the most commonly used and accurate measure of visual accuity. it contains lines of letters in decreasing size. have the person sand 20' away. the top number indicates the distance the person is standing from the chart, while the denominator gives the distance at which a normal eye could have read that particular line

abnormal limitation in ROM

the most sensitive sign of joint disease - articular disease inside joint capsule ex: arthritis limits both active and passive TOM - extra-articular disease injury to specific tendon, ligament, nerve affects only certain planes of ROM esp during voluntary motion

pupillary light reflex

the normal constriction of the pupils when bright light shines on the retina. the afferent link is CN II, the optic nerve, and the efferent path is CN III, the oculomotor nerve. In order to test this reflex, darken the room, ask the person to gaze into the distance, and advance a light from the side and note response. A constriction of the same-sided pupil is a direct light reflex, and a simultaneous constriction of the other pupil is a consensual light reflex.

Cranial Nerve III

the oculomotor nerve. innervates all the rext (superior, ingerior and medial rectus and the inferior oblique muscles

sclera

the outer fibrous layer of the eye. a tough, protective white covering

The corneal light reflex assesses:

the parallel alignment of the eyes

socialization

the process of being raised within a culture and acquiring the characteristics of that group

In pulsus bigeminus: there is a deficiency of oxygenated arterial blood to a body part. the rhythm is regular, but the force of the pulse varies with alternating beats. the rhythm is coupled-every other beat is premature. beats have weaker amplitude with respiratory inspiration and stronger amplitude with expiration.

the rhythm is coupled-every other beat is premature. In pulsus bigeminus the rhythm is coupled-every other beat is premature. Ischemia is deficient supply of oxygenated arterial blood to a tissue caused by obstruction of a blood vessel. Pulsus paradoxus occurs when beats have weaker amplitude with respiratory inspiration and stronger amplitude with expiration. With pulsus alternans, the rhythm is regular, but the force of the pulse varies with alternating beats.

When providing his health history, Mr. Meier sates that his mother had lymphedema and then says, "Just what is that?" Your best reply would be that lymphedema is: the swelling of an extremity due to an obstructed lymph channel. an inflammation of the vein associated with thrombus formation. the indentation left after the examiner depresses the skin over swollen edematous tissue. a thickening and loss of elasticity of the arterial walls.

the swelling of an extremity due to an obstructed lymph channel. Lymphedema is the swelling of an extremity caused by an obstructed lymph channel. The indentation left after the examiner depresses the skin over swollen edematous tissue is referred to as a pit. Arteriosclerosis refers to thickening and loss of elasticity of the arterial walls. Venous thrombophlebitis is inflammation of the vein associated with thrombus formation.

conjunctiva

the transparent protective covering over the exposed part of the eye. a thin mucus membrane folded like an envelop between the eyelids and eyeball.

Crust

thick, dried-out exudate left on skin when vesicles / pustules burst or dry up

Arteriosclerosis refers to: a deposition of fatty plaques along the intima of the arteries. thickening and loss of elasticity of the arterial walls. a sac formed by dilation in the arterial wall. a variation from the heart's normal rhythm.

thickening and loss of elasticity of the arterial walls. Arteriosclerosis refers to thickening and loss of elasticity of the arterial walls. Atherosclerosis, not arteriosclerosis, is the deposition of fatty plaques on the intima of the arteries. A variation from the heart's normal rhythm is arrhythmia, not arteriosclerosis. An aneurysm is a sac formed by dilation in the arterial wall.

Lichenification

tightly packed set of papules that thickens skin, from prolonged intense scratching

Petechiae

tiny punctate hemorrhages, 1 - 3 mm, round and discrete, dark red, purple, or brown

Palatine, pharyngeal, and lingual are specific names for: cervical lymph nodes. tonsils. epitrochlear lymph nodes. axillary lymph nodes.

tonsils. Palatine, pharyngeal, and lingual are specific names for tonsils.

Cutis marmorata

transient mottling on trunk and extremities

Pronation

turn forearm so that palm is down

Supination

turn forearm so that palm is facing up

pronation

turning the forearm so the palm is down

supination

turning the forearm so the palm is up

A common error in blood pressure measurement is: taking the blood pressure in an arm that is at the level of the heart waiting less than 1 to 2 minutes before repeating the blood pressure reading on the same arm deflating the cuff about 2 mm Hg per heartbeat using a blood pressure cuff whose bladder length is 80% of the arm circumference

waiting less than 1 to 2 minutes before repeating the blood pressure reading on the same arm. Waiting less than 1 to 2 minutes before repeating the blood pressure reading on the same arm will result in a falsely high diastolic pressure related to venous congestion in the forearm. The patient's arm should be positioned at the level of the heart when obtaining a blood pressure measurement. The cuff should be deflated at a rate of 2 mm Hg per heartbeat. The blood pressure cuff bladder length should be about 80% of the arm circumference.

abnormal cervical nodes

warm, fixed, firm

How do you take a rectal temperature

wear gloves and insert lubricated probe into the rectum about 2-3 cm directed toward the umbilicus Do not let go of the probe

Cerumen

yellow waxy material that lubricates and protects the ear canal

Physiologic jaundice

yellowing of skin, sclera, and mucous membranes due to increased numbers of red blood cells hemolyzed following birth

The nurse assesses the hearing of a 7-month-old by clapping hands. What is the expected response? 1. The infant turns the head to localize sound. 2. No obvious response to noise 3. A startle and acoustic blink reflex 4. The infant stops movement and appears to listen.

Ephelides

"freckles" - small, flat macules of brown melanin pigment that occur on sun-exposed skin

Scleroderma

"hard skin". a chronic connective tissue disorder associated with decreased mobility

The portion of the ear that consists of movable cartilage and skin is called the: 1. auricle. 2. concha. 3. outer meatus. 4. mastoid process.

When performing an otoscopic examination of a 5-year-old child with a history of chronic ear infections, the nurse sees that his right tympanic membrane is amber- yellow in color and there are air bubbles behind the tympanic membrane. The child reports occasional hearing loss and a popping sound with swallowing. The preliminary analysis based on this information is that: 1. this is most likely a serous otitis media. 2. the child has an acute purulent otitis media. 3. there is evidence of a resolving cholesteatoma. 4. the child is experiencing the early stages of perforation.

Which of the following statements is true concerning air conduction? 1. It is the most efficient pathway for hearing. 2. It is caused by the vibrations of bones in the skull. 3. The amplitude of sound determines the pitch that is heard. 4. A loss of air conduction is called a conductive hearing loss.

CORRECT GUIDELINE TO ASSESS FOR NORMAL EAR POSTION AND ALIGNMENT OF THE HEAD

THE TOP OF THE PINNA SHOULD MATCH AN IMAGINARY LINE EXTENDING FROM THE CORNER OF THE EYE TO TEH OCCIPUT, AND THE EAR SHOULD BE WITHIN 10 DEGREES OF VERTICAL

McMurray's Test knee

special test for meniscal tears; perform when person has history of trauma followed by knee locking, giving way or local pain in knee; position person supine, stand on affected side, hold heel and flex knee and hip,

subluxation

two bones in a joint stay in contact but their alignment is off

______________all foreign born non-citizens who are not legal residents

unauthorized residents

The nurse is examining the hip area of a patient and palpates a flat depression on the upper, lateral side of the thigh when the patient is standing. The nurse interprets this finding as the: A) ischial tuberosity. B) greater trochanter. C) iliac crest. D) gluteus maximus muscle.

Key properties of skin

* Protects the body * Prevents penetration * Allows perception of touch, pain, temperature, and pressure * Regulates temperature * Allows identification of people * Allows communication of emotions * Repairs wounds * Absorbs and excretes substances * Produces vitamin D

culture and genetics on musculoskeletal system

- AA adults have decreased risk for fracture vs W - greater bone mass and bone mineral density (BMD) among AA vs W

timing of joint pain

- RA pain is worse in the morning when arising (movement decreases RA pain) - osteoarthritis is worse later in the day - tendinitis is worse in the morning, improves during the day

abnormal swelling

- excess joint fluid effusion - thickening of the synovialliningg - inflammation of surrounding soft tissue bursae, tendons - bony enlargement

Objective assessment of hair

* Inspect and palpate the hair, noting the color, texture, distribution. * Inspect for scalp lesions * Inspect for infestations

Objective assessment of skin

* Observe color & general pigmentation. * Observe subtle skin tone changes: symmetrical skin tone * Observe for color changes that may not be visible: mucous membranes, lips, nail beds, sclera * Assess skin temperature, moisture, texture, thickness, edema, mobility, turgor, vascularity or bruising, and lesions. * If a lesion is observed, note: color, elevation, shape, size, location and distribution on the body, and any exudate

Risk factors that may lead to skin disease and breakdown include: A. Loss of protective cushioning of the dermal skin layer B. Decreased vascular fragility C. A lifetime of environmental trauma D. Increased thickness of the skin

C. A lifetime of environmental trauma

40. The nurse has discovered decreased skin turgor in a patient and knows that this is an expected finding in which of the following conditions? 1.Cases of severe obesity 2.During childhood growth spurts 3.In an individual who is severely dehydrated 4.With conditions of connective tissue disorders such as scleroderma

ANS: 3 Decreased skin turgor is associated with severe dehydration, aging, or extreme weight loss.

Subjective Data: Head, Face, & Neck, Incl Regional Lymphatics

1. Headache 2. Head Injury 3. Dizziness 4. Neck Pain, Limitation of Motion 5. Lumps or Swelling 6. History of Head or Neck Injury

How to assess pulse

1. Listen for a full min in the Point of maximal impulse (Mitral Area) If rate and rhythm are normal- can take pulse radial for 30 sec and multiply by 2 If irregular rhythm- have to listen for a full minute

function of the musculoskeletal system

1. support to stand erect 2. movement 3. encase and protect the inner vital organs 4. produce red blood cells in bone marrow 5. storage reservoir of essential minerals (ex calcium+phosphate)

Which of the following would be true regarding otoscopic examination of a newborn? 1. Immobility of the drum is a normal finding. 2. An injected membrane would indicate infection. 3. The normal membrane may appear thick and opaque. 4. The appearance of the membrane is identical to that of an adult.

ANS: 3 During the first few days, the tympanic membrane often looks thickened and opaque. It may look "injected" and have a mild redness from increased vascularity.

The nurse is discussing epidermal appendages with a patient. Which of the following would be included in the discussion? 1.Skin 2.Arms 3.Sweat glands 4.Parotid glands

ANS: 3 Epidermal appendages include hair, sebaceous glands, sweat glands, and nails.

Because hair for humans is no longer needed for protection from cold or trauma, it is called: 1.vellus. 2.vagus. 3.vestigial. 4.vestibule.

ANS: 3 Hair is vestigial for humans. It no longer is needed for protection from cold or trauma.

Which statement concerning the areas of the brain is true? a. The cerebellum is the center for speech and emotions. b. The hypothalamus controls body temperature and regulates sleep. c. The basal ganglia are responsible for controlling voluntary movements. d. Motor pathways of the spinal cord and brainstem synapse in the thalamus.

During auscultation of a patient's heart sounds, the nurse hears an unfamiliar sound. What should the nurse do next?

ANS: Ask another nurse to double-check the finding. If an abnormal finding is not familiar, then the nurse may ask another examiner to double-check the finding. The other responses do not help to identify the unfamiliar sound.

A 35-year-old pregnant woman comes to the clinic for a monthly appointment. During the assessment, the nurse notices that she has a brown patch of hyperpigmentation on her face. The nurse continues the skin assessment aware that another finding may be: 1.keratosis. 2.mitoasma. 3.linea nigra. 4.linea gravida.

ANS: 3 In pregnancy, skin changes can include striae, linea nigra, chloasma (brown patches of hyperpigmentation), and vascular spiders.

When assessing inflammation in a dark-skinned person, the nurse may need to: 1.assess the skin for cyanosis and swelling. 2.assess the oral mucosa for generalized erythema. 3.palpate the skin for edema and increased warmth. 4.palpate for tenderness and local areas of ecchymosis.

ANS: 3 Inflammation is not easily recognized, and it is often necessary to palpate the skin for increased warmth, taut surfaces that may be indicative of edema, and hardening of deep tissues or blood vessels.

After assessing the pt's pulse, the practitioner determines it to be 'normal'. This would be recorded as: 3+ 2+ 1+ 0

The nurse educator is preparing an education module for the nursing staff on the epidermal layer of skin. Which of the following would be included in the module? 1.The epidermis is very vascular. 2.The epidermis is thick and tough. 3.The epidermis is thin and non-stratified. 4.The epidermis is replaced every 4 weeks.

ANS: 4 The epidermis is thin, replaced every 4 weeks, avascular, and stratified into several zones.

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?

ANS: "Your pulse is 80 beats per minute. This is within the normal range." Sharing of some information builds rapport as long as the patient is able to understand the terminology.

Herpes Zoster Infection is characterized by: A) A bacterial cause B) Lesion on only one side of the body; doesn't cross midline C) Absence of pain or edema D) Pustular, umbilicate lesions

B) Lesion on only one side of the body; doesn't cross the midline

A 60-year-old man is at the clinic for an eye examination. The nurse suspects that he has ptosis of one eye. How should the nurse check for this?

ANS: Observe the distance between the palpebral fissures. Ptosis is drooping of the upper eyelid that would be apparent by observing the distance between the upper and lower eyelids. The confrontation test measures peripheral vision. Measuring near vision or the corneal light test does not check for ptosis.

The mother of a 2-year-old is concerned because her son has had three ear infections in the past year. What would be an appropriate response by the nurse?

ANS: "Your son's eustachian tube is shorter and wider than yours because of his age, which allows for infections to develop more easily." The infant's eustachian tube is relatively shorter and wider, and its position is more horizontal than the adult's, so it is easier for pathogens from the nasopharynx to migrate through to the middle ear. The other responses are not appropriate.

ANS: 1 A high-tone frequency hearing loss is apparent for those affected with presbycusis, the hearing loss that occurs with aging.

ANS: 1 The eardrum is flat, slightly pulled in at the center, and flutters when the person performs the Valsalva maneuver or holds the nose and swallows (insufflation). One may elicit these maneuvers to assess drum mobility. Avoid these with an aging person because they may disrupt equilibrium.

The nurse is examining a patient who tells the nurse, "I sure sweat a lot, especially on my face and feet but it doesn't have an odor." The nurse knows that this could be related to: 1.the eccrine glands. 2.the apocrine glands. 3.a disorder of the stratum corneum. 4.a disorder of the stratum germinativum.

ANS: 1 The eccrine glands are coiled tubules that open directly onto the skin surface and produce a dilute saline solution called sweat. Apocrine glands are located mainly in the axillae, anogenital area, nipples, and naval and mix with bacterial flora to produce characteristic musky body odor.

The nurse is preparing to do an *otoscopic examination on a 2-year-old child*. Which of these reflects correct procedure?

ANS: Pull the pinna down. For an otoscopic examination, pull the pinna down on an infant and a child under 3 years of age. The other responses are not part of the correct procedure.

The nurse is providing patient education for a man who has been diagnosed with a rotator cuff injury. The nurse knows that a rotator cuff injury involves the: A) nucleus pulposus. B) articular process. C) medial epicondyle. D) glenohumeral joint.

The nurse is performing an *otoscopic examination on an adult*. Which of these actions is correct?

ANS: Pull the pinna up and back before inserting the speculum. Pull the pinna up and back on an adult or older child. This helps straighten the S-shape of the canal. Traction should not be released on the ear until the examination is completed and the otoscope is removed.

The nurse is caring for a black child who has been diagnosed with marasmus. The nurse would expect to find: 1.the hair to be less kinky and to be a copper-red color. 2.the head to be larger than normal, with wide-set eyes. 3.the skin on the hands and feet to be scaly and tender. 4.the lymph nodes in the groin to be enlarged and tender.

ANS: 1 The hair of black children with severe malnutrition (e.g., marasmus) frequently changes not only in texture but in color—the child's hair becomes less kinky and assumes a copper-red color.

ANS: 1 The normal pathway of hearing is air conduction, and it is the most efficient.

A 45-year-old farmer comes in for a skin evaluation and complains of hair loss on his head. He has noticed that his hair seems to be breaking off in patches and that he has some scaling on his head. The nurse would begin the examination suspecting: 1.tinea capitis. 2.tinea corporis. 3.toxic alopecia. 4.seborrheic dermatitis.

ANS: 1 Tinea capitis is rounded patchy hair loss on scale, leaving broken-off hairs, pustules, and scales on the skin. It is due to fungal infection. Lesions are fluorescent under a Wood's light. It is usually seen in children and farmers and is highly contagious.

fibromyalgia syndrome

unknown cause with widespread pain for 3+ months (90% women) 1. pain on both sides of body, above and below waist, axial skeletal pain 2. point tenderness on digital palpation

The Iberian, Central, and South American Heritages beliefs in health maintenance are?

use proper diet to maintain balance of "hot and cold faith"

ANS: 1 With a loud sudden noise, you should note these responses: 6 to 8 months—infant turns head to localize sound, responds to own name.

During auscultation of the lungs, the nurse expects decreased breath sounds to be heard in which situation?

ANS: When the bronchial tree is obstructed Decreased or absent breath sounds occur when the bronchial tree is obstructed, as in emphysema, and when sound transmission is obstructed, as in pleurisy, pneumothorax, or pleural effusion.

Which of the following statements concerning the eustachian tube is true? 1. It is responsible for the production of cerumen. 2. It remains open except when swallowing or yawning. 3. It allows passage of air between the middle and outer ear. 4. It helps equalize air pressure on both sides of the tympanic membrane.

ANS: 4 The eustachian tube allows equalization of air pressure on each side of the tympanic membrane so that the membrane does not rupture (e.g., during altitude changes in an airplane). The tube is normally closed, but it opens with swallowing or yawning.

ANS: 1 With sensorineural loss, sound lateralizes to "better" ear or unaffected ear. Normal ratio of AC>BC is intact but is reduced overall. That is, the person hears poorly both ways.

The nurse is assessing a patient's pulses and notices a difference between the patient's apical pulse and radial pulse. The apical pulse was 118 beats per minute, and the radial pulse was 105 beats per minute. What is the pulse deficit?

ANS: 13 The nurse should count a serial measurement (one after the other) of apical beat and then the radial pulse. Normally every beat heard at the apex should perfuse to the periphery and be palpable. The two counts should be identical. If different, the nurse should subtract the radial rate from the apical and record the remainder as the pulse deficit.

ANS: 2 Absent or distorted light reflex and a bright red color of the eardrum are indicative of acute otitis media.

WHAT ACTIONS DO YOU TAKE WHEN PREPARING TO EXAM AN ADULT PT. EARS WITH AN OTOSCOPE

TILT THE PT. HEAD SLIGHTLY AWAY FROM YOU, SLIGHTLY TOWARD THE OPPOSITE SHOULDER AND PULL THE PINNA UP AND BACK THIS ALLOWS YOU TO STRAIGHTEN THE EXTERNAL AUDITORY CANAL

ANS: 1 An amber-yellow color to the tympanic membrane suggests serum in the middle ear. Often an air/fluid level or bubbles behind the tympanic membrane are visible. The patient may have feelings of fullness, transient hearing loss, and a popping sound with swallowing.

WHY WOULD YOU PERFORM A WHISPERED VOICE TEST ON A PT

TO DETECT HIGH-TONE HEARING LOSS

In performing a voice test to assess hearing, which of these actions would the nurse do?

ANS: Whisper a set of random numbers and letters and ask the patient to repeat them. With your head 30 to 60 cm (1 to 2 ft) from the person's ear, exhale and whisper slowly a set of random numbers and letters, such as "5, B, 6." Normally, the person repeats each number and letter correctly after you say it.

ANS: 1 Children at risk for hearing deficit include those exposed in utero to a variety of conditions, such as maternal rubella, or to maternal ototoxic drugs.

Vital Signs

Temperature Pulse Respiration Blood Pressure

When performing a respiratory assessment on a patient, the nurse notices a costal angle of approximately 90 degrees. This characteristic is:

ANS: a normal finding in a healthy adult. The right and left costal margins form an angle where they meet at the xiphoid process. Usually, this angle is 90 degrees or less. The angle increases when the rib cage is chronically overinflated, as in emphysema.

During a routine visit, M.B. age 78, asks about small, round, flat, brown macules on the hands. The best response is: A. "these are the result of sun exposure and do not require treatment" B. "these are related to exposure to the sun. they may become cancerous." C. "these are the skin tags that occur with aging. No treatment is required." D. "I'm glad you brought this to my attention. I will arrange for a biopsy."

A. "age spots" - the result of sun exposure and do no require treatment

A 52-year-old woman has a papule on her nose that has rounded, pearly borders and a central red ulcer. She said she has noticed it for several months and it has slowly grown larger. The nurse suspects which condition? 1.Acne 2.Basal cell carcinoma 3.Malignant melanoma 4.Squamous cell carcinoma

ANS: 2 Basal cell carcinoma usually starts as a skin-colored papule that develops rounded, pearly borders with a central red ulcer. It is the most common form of skin cancer, and it grows slowly.

A patient has a *normal pupillary light reflex*. The nurse recognizes that this reflex indicates that:

ANS: constriction of both pupils occurs in response to bright light. The pupillary light reflex is the normal constriction of the pupils when bright light shines on the retina. The other responses are not correct.

grading system for muscle strength and ROM

5 (100% normal) - full ROM and resistance 4 (75% - good) - full ROM, some resistance 3 (50% - fair) - full ROM with gravity, no resistance 2 (25% - poor) - passive ROM 1 (10% - trace) - slight contraction 0 (0% zero) - no contraction

A woman who is 8 months pregnant comments that she has noticed a change in posture and is having lower back pain. The nurse tells her that during pregnancy women have a posture shift to compensate for the enlarging fetus. This shift in posture is known as: A) lordosis. B) scoliosis. C) ankylosis. D) kyphosis.

When performing a musculoskeletal assessment, the nurse knows that the correct approach for the examination should be: A) proximal to distal. B) distal to proximal. C) posterior to anterior. D) anterior to posterior.

To determine if a dark skinned person is pale, the nurse should assess the color of the: A. Conjunctivae B. Ear lobes C. Palms of the hands D. Skin in the antecubital space

A. Conjunctivae

A flat macular hemorrhage is called a(n): A. Purpura B. Ecchymosis C. Petechiae D. Hemangioma

A. Purpura

Clubbing can be assessed by: A. observing for transverse ridges in the nails B. the presence of pits in the nails C. noting a change in the angle of the nail base D. palpating a rigid nail base

C. noting a change in the angle of the nail base

Johann, a baby boy, is admitted to the transition nursery for a comprehensive physical, medications, and a bath prior to being transferred to the postpartum floor. Before you conduct the physical assessment, you review common skin variations of the newborn. Which of the following conditions requires further evaluation by the in-house neonatal nurse practitioner? Harlequin pattern, a condition that causes one side of the body to appear deep red and the other side pale, with a distinct demarcation down the midline Cutis marmorata, which is a mottling of the trunk and extremities A grouping of café au lait spots Erythema toxicum, a condition that causes punctuate macular-papular rash on cheeks, truck, back, and buttocks

A grouping of café au lait spots A grouping of six or more café au lait macules, each more than 1.5 cm in diameter, in a newborn requires further evaluation by the in-house neonatal nurse practitioner as they are diagnostic of neurofibromatosis, an inherited neurocutaneous disease. Erythema toxicum is a common rash that appears in the first 3 to 4 days of life. Sometimes called the "flea bite" rash or newborn rash, it consists of tiny, punctate, red macules and papules on the cheeks, trunk, chest, back, and buttocks. The cause is unknown; no treatment is needed. Cutis marmorata is a transient mottling on the trunk and extremities in response to cooler room temperatures. It forms a reticulated red or blue pattern over the skin. Persistent or pronounced cutis marmorata occurs with Down syndrome or prematurity. Harlequin colour change occurs when the baby is in the side-lying position. The lower half of the body turns red, and the upper half blanches, with a distinct demarcation line down the midline. The cause is unknown, and the occurrence is transient.

ANS: XI; asking the patient to shrug her shoulders against resistance The major neck muscles are the sternomastoid and the trapezius. They are innervated by CN XI, the spinal accessory. The innervated muscles assist with head rotation and head flexion, movement of the shoulders, and extension and turning of the head.

A patient comes to the clinic complaining of neck and shoulder pain and is unable to turn her head. The nurse suspects damage to cranial nerve (CN) _____ and proceeds with the examination by _____.

To assess for early jaundice, you will assess: A) Sclera and hard palate B) Nail beds C) Lips D) All visible skin surfaces

A) Sclera and hard palate

Squamous cell carcinoma

Arise from actinic keratosis or de novo. Erythematous scaly patch with sharp margins, >1cm. Develops central ulcer and surrounding erythema. Usually on hands or head, areas exposed to UV radiation. Grows rapidly.

Atlas

The nurse is assessing the joints of a woman who has stated, "I have a long family history of arthritis, and my joints hurt." The nurse suspects that she has osteoarthritis. Which of these are symptoms of osteoarthritis? Select all that apply. A. symmetric joint involvement B. asymmetric joint involvement C. pain with motion of affected joints D. affected joints are swollen with hard, bony protuberances E. affected joint may have heat, redness, and swelling

B C D

Select the best description of the secretion of the eccrine glands. A) Thick, milky B) Dilute saline solution C) Protective lipid substance D) Keratin

B) Dilute saline solution

Which of the following statements regarding the results obtained from use of the Snellen chart is true? A. The smaller the denominator, the poorer the vision. B. The larger the denominator, the poorer the vision. C. The larger the numerator, the better the vision. D. The smaller the numerator, the poorer the vision

B. The larger the denominator, the poorer the vision.

Skin turgor is assessed by picking up a large fold of skin on the anterior chest under the clavicle. This is done to determine the presence of: A. edema B. dehydration C. vitiligio D. scleroderma

B. dehydration

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. intervertebral disks. C. vertebral foramen. D. nucleus pulposus.

B. intervertebral disks.

When taking the health history on a patient with a seizure disorder, the nurse assesses whether the patient has an aura. Which of these would be the best question for obtaining this information? a. "Does your muscle tone seem tense or limp?" b. "After the seizure, do you spend a lot of time sleeping?" c. "Do you have any warning sign before your seizure starts?" d. "Do you experience any color change or incontinence during the seizure?"

When the nurse is testing the triceps reflex, what is the expected response? a. Flexion of the hand b. Pronation of the hand c. Extension of the forearm d. Flexion of the forearm

A risk factor for melanoma is: A. brown eyes B. darkly pigmented skin C. skin that freckles or burns before tanning D. use of sunscreen products

C. skin that freckles or burns before tanning

Secondary skin lesions:

CRUST: thickened, dried out exudate left when vesicles or pustules burst or dry up SCALE: compact desiccated flakes of skin. dry or greasy, silvery or white, dead skin FISSURE: linear crack with abrupt edges, extends into dermis, dry or moist EROSION: scooped out, but shallow depression, superficial ULCER: deeper depression extending into dermis, irregular shape, may bleed

The Asian heritage has what kind of healers?

Chinese physicians and herbalists

Which should be included while teaching 4th graders about the sweat glands, during a hygiene lesson? A. There are two types of sweat glands: the eccrine and the sebaceous B. The evaporation of sweat, a dilute saline solution, increases body temperature. C. Eccrine glands produce sweat and are mainly located in the axillae, anogenital area, and naval D. Newborn infants do not sweat and use compensatory mechanisms to control body temperature

D. Newborn infants do not sweat and use compensatory mechanisms to control body temperature

You note a lesion during an examination. The most complete description: A. raised, irregular lesion the size of a quarter, located on dorsum of left hand B. open lesion with no drainage or odor, approximately 1/4 inch in diameter C. pedunculated lesion below left scapula with consistent red color, no drainage or odor D. dark brown, raised lesion, with irregular border, on dorsum of right foot, 3 cm in size with no drainage

D. dark brown, raised lesion, with irregular border, on dorsum of right foot, 3 cm in size with no drainage

Flattening of the angle between the nail and its base is: A. found in subacute bacterial endocarditis. B. a description of spoon-shaped nails. C. related to calcium deficiency D. described as clubbing

D. described as clubbing

Checking for skin temperature is best accomplished by using: A. palmar surface of the hands B. ventral surface of the hands C. fingertips D. dorsal surface of the hands

D. dorsal surface of the hands

The nurse is providing patient education for a man who has been diagnosed with a rotator cuff injury. The nurse knows that a rotator cuff injury involves the: A. medial epicondyle B. articular process C. nucleus pulposus D. glenohumeral joint

D. glenohumeral joint

patient visiting clinic 4 an evaluation of swollen painful knuckle nurse notices that knuckle above his ring on the left hand is swollen & that he is unable to remove his wedding ring joint is called what joint A tibiotalar B metacarpophalangeal C tarsometatarsal D interphalangeal

D. interphalangeal

to assessing a 1 week old infant & is testing muscle strength by lifts infant with hands under the axillae & notices that infant starts to slip between hands nurse should A suspect that the infant may have a deformity of the spine C suspect fractured clavicle D suspect that the infant may have weakness of shoulder muscles

D. suspect that the infant may have weakness of the shoulder muscles.

What are the two types of pupillary light reflexes?

Direct light reflex--the eye is exposed to bright light constricts Consensual light reflex--the opposite eye from the one exposed to the light still constricts

Pulse

Force that is exerted on the arterial walls and generates a pressure wave

Depending on the heritage of the person, there may be wide variations in the information that you gather in the assessments and in the findings of the physical examination. Therefore a _______ _________ must be an integral part of the physical examination.

Heritage Assessment

Thomas test

Hip flexion of 120 degrees and should keep opposite thigh on the table - if this reveals a flexion deformity in the opposite hip = POSITIVE Thomas test

For health restoration, the European heritage believes in?

Home remedies, such as swamp root and Olbas

The European Heritage has what kind of healers?

Homeopathic physicians, brauchers

WHICH FUNCTION IS DEPENDENT ON BINAURAL INTERACTION AT THE LEVEL OF THE BRAIN STEM

LOCALIZATION OF SOUND AND IDENTIFCATION OF SOUND

IN CHILDREN THE ESUTACHIAN TUBES ARE SHORT AND WIDE AND RUN RELATIVELY HORIZONTALLY FROM MIDDLE EAR TO NASOPHARYNX

MAKE IT EASIER FOR PATHOGENS TO MIGRATE UP TO THE TUBE FROM THE NASOPHARNYX TO THE MIDDLE EAR.

Oral Temperature

Most convenient and accurate site sublingual pocket has rich blood supply from carotid arteries that quickly respond to changes in inner core

________an alien, appearing to be inadmissible to the inspecting officer, allowed into the United States for urgent humanitarian reasons or when that alien's allowed entry is determined to be significant.

Parolee

When giving her health history, Ms. Baker states that she was diagnosed with vitiligo a year and a half ago. What do you expect to see when you assess her? Small brown macules on sun-exposed areas Scalding red, moist patches in intertriginous areas Irregular areas of balding on the scalp Patchy, milky white spots

Patchy, milky white spots Vitiligo is an acquired condition in which complete absence of melanin pigment results in patchy areas of white or light skin on the face, neck, hands, feet, and body folds and around orifices. Senile lentigines are small brown macules that are clusters of melanocytes that appear after extensive sun exposure. Toxic alopecia, which accompanies severe illness or chemotherapy, is a patchy, asymmetric balding. Monilial infection—which has a predilection for the intertriginous areas, which are warm, dark, and moist—is characterized by scalding red, moist patches with clearly demarcated borders.

General Survey is composed of:

Physical Appearance, Body structure, Mobility, Behavior

There are 4 areas to consider during the general survey include: Ethnicity, gender, age, and socioeconomic status Physical appearance, gender, ethnicity and affect Dress, affect, nonverbal behavior and mobility Physical appearance, body structure, mobility and behavior

Physical appearance, body structure, mobility and behavior

The Asian Heritage believes in health maintenance are __________?

Prevent imbalances "yin and yang" and changes in climate.

Function of the eyelids:

Protect the eyes from injury, strong light, and dust.

Five functions of the skin:

Protection Perception Identification Communication Temperature regulation Wound repair Absorption & excretion Production of Vit. D

A pt is being seen in the clinic for complaints of 'fainting episodes that started last week' How should you proceed with the exam Take the blood pressure in both arms and thighs Ask the person to walk a few paces and then tale the blood pressure Record the blood pressure in the lying, sitting and standing positions Record the blood pressure in the lying and sitting positions and average these numbers to obtain a mean blood pressure

Record the blood pressure in the lying, sitting and standing positions

SPINE

S-shaped, cervical and lumbar are concave, thoracic and sacrococcygeal are convex

Difference between sebaceous, eccrine, and apocrine glands:

SEBACEOUS: Oil glands - secrete protective lipid substances. Located everywhere except palms and soles. Mostly in scalp, forehead, face & chin. ECCRINE: sweat glands - dilute saline solution. APOCRINE: sweat glands - thick, milky secretion, opens to hair follicles (axillae, anogenital area, nipple, nasal

25 YEAR OLD WHO FREQUENTS ROCK CONCERTS IS AT RISK FOR

SENSORINERUAL HEARING LOSS, BUT NOT AGE RELATED PRESBYCUSIS

Glenohumeral joint

SHOULDER joint articulation of humerus with glenoid fossa of scapula ball & socket action if person reports shoulder pain, ask him to point to spot with unaffected arm shoulder pain may be from local causes or could be referred pain from hiatal hernia or cardiac or pleural condition which could be serious pain from local cause should be reproducible

Basal cell carcinoma

Starts as a skin-colored papule (may be deeply pigmented) with a pearly translucent top and overlying telangiectasia (broken blood vessel). Develops rounded, pearly borders with central red ulcer, or looks like a large open pore with central yellowing. This is the most common form of skin cancer. Occur on sun exposed areas of face, ears, scalp, shoulders. Grows slowly.

Which statement is true in regards to pain? a. Nurse's attitudes toward their patients' pain are unrelated to their own experiences with pain b. The cultural background of a patient is important in a nurse's assessment of that patient's pain c. A nurse's area of clinical practice is most likely to determine his or her assessment of a patient's pain d. A nurse's years of clinical experience and current position are a strong indicator of his or her response to patient pain.

WHICH STATEMENT INDICATES THAT THE PT IS EXPERIENCING VERTIGO

THE ROOM IS SPINNING AROUND ME

The first step to cultural competency by a nurse is to: a. identify the meaning of health to the patient b. understand how a health care delivery system works c. develop a frame of reference to traditional health care practices d. understand your own heritage and its basis in cultural values.

How does cranial nerve IV regulate eye movement?

The trochlear nerve allows the eye to look downward and inward

Senile purpura

The vascular fragility increases in the aging adult, where a minor trauma may produce dark red discolored areas on the skin

Today is your last day of an emergency department (ED) rotation. A mother brings her 3-year-old child to the ED to be examined after a fall. The child is dressed in clothing that, although clean, is worn and wrinkled. The child sits quietly without fidgeting, arms in her lap, staring at the floor; she remains silent when you try to engage her. As her mother explains the circumstances of the fall and the resulting injuries, you wonder about the possibility of physical abuse. An x-ray is ordered to rule out fracture of the left arm. Which of the following physical findings might suggest abuse? Three bite marks on the right upper arm/shoulder area A skinned knee with torn pants midway down same leg An x-ray depicting a simple fracture of the left arm Red-blue bruising of the left shoulder area.

Three bite marks on the right upper arm/shoulder area The physical findings of three bite marks on the right upper arm/shoulder area might suggest abuse. An untreated fracture with deformity, not a simple fracture, would be a possible sign of abuse. A skinned knee with pants torn, indicating the cause of the injury, does not suggest abuse but an injury appropriate to the age of the child. Red-blue is the colour of fresh bruises, and the location on the same side as the arm injury is consistent with the reported accident.

What is the yin/yang theory of health? a. Health exists in the absence of illness. b. Health exists when all aspects of the person are in perfect balance. c. Health exists when physical, psychological, spiritual, and social needs are met. d. Health exists when there is optimal functioning.

You are the triage nurse in the emergency department and perform the initial intake assessment on a patient who does not speak English. Based on your understanding of linguistic competence, which action would present as a barrier to effective communication? a. Maintaining a professional respectful demeanor b. allowing for additional time to complete the process c. providing the patient with a paper and pencil so he or she can write down the answers to the questions you are going to ask d. seeing is there are any family members present who may assist with the interview process.

lens

a biconvex disc located just posterior to the pupil. serves as a refracting medium keeping a viewed object in continual focus on the retina

elbow assessment normal hollows present at olecranon bursa soft fat pads &tissues normal ROM muscle strength can resist u

abnormal subluxation shows if forearm dislocated posteriorly swelling+redness of olecranon bursa effusion or synovial thickening is bulge on grove of process occurs w/gouty arthritis boggy inflammation of epicondyles head of radius in tennis elbow subQ nodules are raised, firm, nontender in RA

shoulder assessment normal no redness muscular atrophy deformity or swelling no adenopathy or masses present at axilla no crepitation normal ROM shoulder shrug against your resistance CN 10

abnormal redness inequality of bony landmarks atrophy is lack of fullness dislocated shoulder looks flattened laterally excess fluid best seen anteriorly unless considerably swollen swelling of aubacrimonial bursa undedeltoidod hard muscles w/spasm pain tender limited ROM

spine assessment normal: enhanced thoracic curve kyphosis common in older people, concave lumbar curve disappears when touching toes

abnormal: difference in shoulder elevation and level oscapulaeae and iliac crests occurs with scoliosis - chronic axial skeletal pain in fibromyalgia syndrome - dots drawn from toe touch are s-shaped when standing = spinal curve

Emaciated

abnormally thin or weak, especially because of illness or a lack of food.

The Doppler technique used to assess the apical pulse augments Korotkoff sounds during blood pressure measurement provides an easy and accurate measurement of the diastolic pressure measures arterial oxygenation saturation

augments Korotkoff sounds during blood pressure measurement The Doppler technique may be used to locate peripheral pulse sites and for blood pressure measurement to augment Korotkoff sounds. A stethoscope is used to assess an apical pulse. The systolic blood pressure is more easily identified with the Doppler technique than the diastolic pressure. A pulse oximeter measures arterial oxygenation saturation.

A patient is known to be blind in the left eye. What happens to the pupils when the right eye is illuminated by a penlight beam? a) No response in both pupils b) Both pupils constrict c) Right pupil constricts, left has no response d) Left pupil constricts, right has no response

b) Both pupils constrict

A patient comes into the clinic complaining of pain in her right eye. On examination, the nurse sees a pustule at the lid margin that is painful to touch, red, and swollen. The nurse recognizes that this is a: a. Chalazion. b. Hordeolum (stye). c. Dacryocystitis. d. Blepharitis.

b. Hordeolum (stye).

Epidermis layer

basal cell layer. Uniformly thin. Stratum corneum. The thin, tough, outer layer of the skin

An adult patient's pulse is 46 beats per minute. The term used to describe this rate is: tachycardia. bradycardia weak and thready. sinus arrhythmia

bradycardia. A heart rate of less than 50 beats per minute in an adult is bradycardia. A heart rate of greater than 90 beats per minute in an adult is tachycardia. Weak and thready describes the force of the pulse reflecting a decreased stroke volume. Sinus arrhythmia is a pulse that is irregular; the heart rate varies with the respiratory cycle.

You must be alert for which eye emergency symptoms? a) Floaters b) Epiphora c) Sudden onset of vision change d) Photophobia

c) Sudden onset of vision change

muscle strength

normal: equal bilaterally and fully resist opposing force abnormal: unilateral could mean neuro issue

Endogenous obesity is: due to inadequate secretion of cortisol by the adrenal glands caused by excess adrenocorticotropin production by the pituitary gland characterized by evenly distributed excess body fat a result of excessive secretion of growth hormone in adulthood

caused by excess adrenocorticotropin production by the pituitary gland Endogenous obesity is caused by either the administration of adrenocorticotropin or excessive production of adrenocorticotropin by the pituitary. Adrenocorticotropin stimulates the adrenal cortex to secrete excess cortisol and causes Cushing syndrome, which is characterized by weight gain and edema with central trunk and cervical obesity. Excessive catabolism causes muscle wasting with thin arms and legs. Body fat is evenly distributed in exogenous obesity because of excessive caloric intake. Acromegaly is caused by an excessive secretion of growth hormone in adulthood.

rheumatoid arthritis (RA)

chronic, systemic inflammatory disease of joints and surrounding connective tissue: thickening then fibrosis then bony ankylosis of synovial membrane -symmetricc and bilateral

rheumatoid arthritis

chronic, systemic inflammatory disease of joints and surrounding connective tissue; characterized by heat, redness, swelling, and painful motion of the affected joints

Annular

circular shape to skin lesion

opacities

cloudiness of the cornea and lens

Scale

compact desiccated flakes of skin from shedding of dead skin cells

dislocation

complete loss of contact between the two bones in a joint

Tendons

connect MUSCLE TO BONE

cervical spine assessment

normal: spine straight, head erect, spinous processes firm, normal ROM, maintain flexion against your resistance CN 10 abnormalal: head tilted to one side, asymmetry of muscles, tenderness+hard muscles with spasm, limited ROM, pain, inability to hold flexion

palpation of a joint

normal: synovial membrane and joint fluid not palpable abnormal: warmth and tenderness = inflammation palpable fluid (doughy or boggy) is abnormal b/c it is contained in a closed sac - fluid will shift and cause visible bulging on other side

ankle and foot assessment

normal: weight-bearing falls on middle of foot. - most feel have longitudinal arch though "flat feet" ok abnormal: hallux valgus - distal part of great toe is directed away from body midline

a screening musculoskeletal examination

normally sufficient, includes: - inspection and palpation of jointsintegratedd with each body region - observation of ROM - age-specific screening measures (ex: Ortolani sign for infants or scoliosis for adolescents)

tinel's sign

direct percussion of the median nerve at the wrist

INTERVERTEBREAL DISCS

elastic fibrocartilaginous plates; consittute one fourth the length of spinal column; each disk center has nucleus pulposus, made of soft, semifluid mucoid material; cushion the spine like a shock absorber

Pustule

elevated cavity containing thick, turbid fluid

A 59-year-old patient has a herniated intervertebral disk. Which of the following findings should the nurse expect to see on physical assessment of this individual? a. Hyporeflexia b. Increased muscle tone c. Positive Babinski sign d. Presence of pathologic reflexes

During the assessment of an 80-year-old patient, the nurse notices that his hands show tremors when he reaches for something and his head is always nodding. No associated rigidity is observed with movement. Which of these statements is most accurate? a. These findings are normal, resulting from aging. b. These findings could be related to hyperthyroidism. c. These findings are the result of Parkinson disease. d. This patient should be evaluated for a cerebellar lesion.

When taking the history on a patient with a seizure disorder, the nurse assesses whether the patient has an aura. Which of these would be the best question for obtaining this information?

ANS: "Do you have any warning sign before your seizure starts?" Aura is a subjective sensation that precedes a seizure; it could be auditory, visual, or motor. The other questions are not correct regarding asking about an aura.

In obtaining a history on a 74-year-old patient the nurse notes that he drinks alcohol daily and that he has noticed a tremor in his hands that affects his ability to hold things. With this information, what should the nurse's response be?

ANS: "Does the tremor change when you drink the alcohol?" Senile tremor is relieved by alcohol, although this is not a recommended treatment. The nurse should assess whether the person is abusing alcohol in an effort to relieve the tremor.

During the assessment of deep tendon reflexes, the nurse finds that a patient's responses are normal bilaterally. What number is used to indicate "normal" deep tendon reflexes when the documenting this finding. _____+

ANS: 2 Responses to assessment of deep tendon reflexes are graded on a 4-point scale. A rating of 2+ indicates normal or average response. A rating of 0 indicates no response, and a rating of 4+ indicates very brisk, hyperactive response with clonus, which is indicative of disease.

A man who was found wandering in a park at 2 AM has been brought to the emergency department for an examination because he said he fell and hit his head. During the examination, the nurse asks him to use his index finger to touch the nurse's finger, then his own nose, then the nurse's finger again (which has been moved to a different location). The patient is clumsy, unable to follow the instructions, and overshoots the mark, missing the finger. The nurse should suspect which of the following?

ANS: Acute alcohol intoxication During the finger-to-finger test, if the person has clumsy movement with overshooting the mark, either a cerebellar disorder or acute alcohol intoxication should be suspected. The person's movements should be smooth and accurate. The other options are not correct.

To test for gross motor skill and coordination of a 6-year-old child, which of these techniques would be appropriate?

ANS: Ask child to hop on one foot. Normally a child can hop on one foot and can balance on one foot for about 5 seconds by 4 years of age, and can balance on one foot for 8 to 10 seconds at 5 years of age. Children enjoy performing these tests. Failure to hop after 5 years of age indicates incoordination of gross motor skill. Touching the finger to the nose checks fine motor coordination. Having the child make "funny" faces tests cranial nerve VII. It is not appropriate to ask a child to stand on his or her head.

The nurse places a key in the hand of a patient and he identifies it as a penny. What term would the nurse use to describe this finding?

ANS: Astereognosis Stereognosis is the person's ability to recognize objects by feeling their forms, sizes, and weights. Astereognosis is an inability to identify objects correctly, and it occurs in sensory cortex lesions. Tactile discrimination tests fine touch. Extinction tests the person's ability to feel sensations on both sides of the body at the same point.

A 30-year-old woman tells the nurse that she has been very unsteady and has had difficulty in maintaining her balance. Which area of the brain would the nurse be concerned about with these findings?

ANS: Cerebellum The cerebellar system coordinates movement, maintains equilibrium, and helps maintain posture. The thalamus is the main relay station where sensory pathways of the spinal cord, cerebellum, and brainstem for synapses on their way to the cerebral cortex. The brainstem consists of the midbrain, pons, and medulla and has various functions, especially concerning autonomic centers. The extrapyramidal tract maintains muscle tone for gross automatic movements, such as walking.

The nurse knows that determining whether a person is oriented to his or her surroundings will test the functioning of which of these structures?

ANS: Cerebrum The cerebral cortex is responsible for thought, memory, reasoning, sensation, and voluntary movement. The other options structures are not responsible for a person's level of consciousness.

A 50-year-old woman is in the clinic for weakness in her left arm and leg that she has noticed for the past week. The nurse should perform which type of neurologic examination?

ANS: Complete neurologic examination The nurse should perform a complete neurologic examination on persons who have neurologic concerns (e.g., headache, weakness, loss of coordination) or who have shown signs of neurologic dysfunction. The Glasgow Coma scale is used to define a person's level of consciousness. The neurologic recheck examination is appropriate for persons with demonstrated neurologic deficits. The screening neurologic examination is performed on seemingly well persons who have no significant subjective findings from the history.

Which of these tests would the nurse use to check the motor coordination of an 11-month-old infant?

ANS: Denver II To screen gross and fine motor coordination, the nurse should use the Denver II with its age-specific developmental milestones. Stereognosis tests a person's ability to recognize objects by feeling them, and is not appropriate for an 11-month-old infant. Testing of the deep tendon reflexes is not appropriate for checking motor coordination. Testing rapid alternating movements is appropriate for testing coordination in adults.

ANS: Difficulty performing familiar tasks, such as placing a telephone call Misplacing items, such as putting dish soap in the refrigerator Rapid mood swings, from calm to tears, for no apparent reason Getting lost in one's own neighborhood Difficulty performing familiar tasks, misplacing items, rapid mood swings, and getting lost in one's own neighborhood can be warning signs of Alzheimer's disease. Occasionally forgetting names or appointments, and sometimes having trouble finding the right word are part of normal aging. For other examples see Table 23-2.

The nurse is doing an assessment on a 29-year-old woman who visits the clinic complaining of "always dropping things and falling down." While testing rapid alternating movements, the nurse notices that the woman is unable to pat both her knees. Her response is very slow and she misses frequently. What should the nurse suspect?

ANS: Dysfunction of the cerebellum When a person performs rapid, alternating movements, slow, clumsy, and sloppy responses occur with cerebellar disease. The other responses are incorrect.

When the nurse is testing the triceps reflex, what is the expected response?

ANS: Extension of the forearm The normal response of the triceps reflex is extension of the forearm. The normal response of the biceps reflex causes flexion of the forearm. The other responses are incorrect.

In assessing a 70-year-old patient who has had a recent cerebrovascular accident, the nurse notices right-sided weakness. What might the nurse expect to find when testing his reflexes on the right side?

ANS: Hyperactive reflexes Hyperreflexia is the exaggerated reflex seen when the monosynaptic reflex arc is released from the influence of higher cortical levels. This occurs with upper motor neuron lesions (e.g., a cerebrovascular accident). The other responses are incorrect.

In a person with an upper motor neuron lesion such as a cerebrovascular accident, which of these physical assessment findings should the nurse expect to see?

ANS: Hyperreflexia Hyperreflexia, diminished or absent superficial reflexes, and increased muscle tone or spasticity can be expected with upper motor neuron lesions. The other options reflect a lesion of lower motor neurons. See Table 23-7.

During an assessment of a 22-year-old woman who has a head injury from a car accident 4 hours ago, the nurse notices the following change: pupils were equal, but now the right pupil is fully dilated and nonreactive, left pupil is 4 mm and reacts to light. What does finding this suggest?

ANS: Increased intracranial pressure In a brain-injured person, a sudden, unilateral, dilated, and nonreactive pupil is ominous. Cranial nerve III runs parallel to the brainstem. When increasing intracranial pressure pushes the brainstem down (uncal herniation), it puts pressure on cranial nerve III, causing pupil dilation. The other responses are incorrect.

While gathering equipment after an injection, a nurse accidentally received a prick from an improperly capped needle. To interpret this sensation, which of these areas must be intact?

ANS: Lateral spinothalamic tract, thalamus, and sensory cortex The spinothalamic tract contains sensory fibers that transmit the sensations of pain, temperature, and crude or light touch. Fibers carrying pain and temperature sensations ascend the lateral spinothalamic tract, whereas those of crude touch form the anterior spinothalamic tract. At the thalamus, the fibers synapse with another sensory neuron, which carries the message to the sensory cortex for full interpretation. The other options are not correct.

The nurse is caring for a patient who has just had neurosurgery. To assess for increased intracranial pressure, what would the nurse include in the assessment?

ANS: Level of consciousness, motor function, pupillary response, and vital signs Some hospitalized persons have head trauma or a neurologic deficit from a systemic disease process. These people must be monitored closely for any improvement or deterioration in neurologic status and for any indication of increasing intracranial pressure. The nurse should use an abbreviation of the neurologic examination in the following sequence: level of consciousness, motor function, pupillary response, and vital signs.

ANS: Mild, even resistance to movement Tone is the normal degree of tension (contraction) in voluntarily relaxed muscles. It shows a mild resistance to passive stretch. Normally, the nurse will notice a mild, even resistance to movement. The other responses are not correct.

During an assessment of the cranial nerves, the nurse finds the following: asymmetry when the patient smiles or frowns, uneven lifting of eyebrows, sagging of the lower eyelids, and escape of air when the nurse presses against the right puffed cheek. This would indicate dysfunction of which of these cranial nerves?

ANS: Motor component of VII The findings listed reflect a dysfunction of the motor component of cranial nerve VII, the facial nerve.

The nurse is performing a neurologic assessment on a 41-year-old woman with a history of diabetes. When testing her ability to feel the vibrations of a tuning fork, the nurse notices that the patient is unable to feel vibrations on the great toe or ankle bilaterally, but she is able to feel vibrations on both patellae. Given this information, what would the nurse suspect?

ANS: Peripheral neuropathy Loss of vibration sense occurs with peripheral neuropathy (e.g., diabetes and alcoholism). Peripheral neuropathy is worse at the feet and gradually improves as the examiner moves up the leg, as opposed to a specific nerve lesion, which has a clear zone of deficit for its dermatome.

ANS: Plantar reflex present With the same instrument, the nurse should draw a light stroke up the lateral side of the sole of the foot and across the ball of the foot, like an upside-down "J." The normal response is plantar flexion of the toes and sometimes of the whole foot. A positive Babinski sign is abnormal and occurs with the response of dorsiflexion of the big toe and fanning of all toes. The plantar reflex is not graded on a 0 to 4+ scale.

In the assessment of a 1-month-old infant, the nurse notices a lack of response to noise or stimulation. The mother reports that in the last week he has been sleeping all the time, and when he is awake all he does is cry. The nurse hears that the infant's cries are very high pitched and shrill. What should be the nurse's appropriate response to these findings?

ANS: Refer the infant for further testing. A high-pitched, shrill cry or cat-sounding screech occurs with central nervous system damage. Lethargy, hyporeactivity, hyperirritability, and parent's report of significant change in behavior all warrant referral. The other options are not correct responses.

While obtaining a history of a 3-month-old infant from the mother, the nurse asks about the infant's ability to suck and grasp the mother's finger. What is the nurse assessing?

ANS: Reflexes Questions regarding reflexes include such questions as "What have you noticed about the infant's behavior," "Do the infant's sucking and swallowing seem coordinated," and "Does the infant grasp your finger?" The other responses are incorrect.

ANS: Reflexes will be normal. A reflex is a defense mechanism of the nervous system. It operates below the level of conscious control and permits a quick reaction to potentially painful or damaging situations.

A 78-year-old man has a history of a cerebrovascular accident. The nurse notes that when he walks his left arm is immobile against the body with flexion of the shoulder, elbow, wrist, and fingers and adduction of the shoulder. His left leg is stiff and extended and circumducts with each step. What type of gait disturbance is this individual experiencing?

ANS: Spastic hemiparesis With spastic hemiparesis, the arm is immobile against the body. There is flexion of the shoulder, elbow, wrist, and fingers and adduction of the shoulder, which does not swing freely. The leg is stiff and extended and circumducts with each step. Causes of this type of gait include cerebrovascular accident. See Table 23-6 for more information and for descriptions of the other abnormal gaits.

Which of these statements concerning areas of the brain is true?

ANS: The hypothalamus controls temperature and regulates sleep. The hypothalamus is a vital area with many important functions: temperature controller, sleep center, anterior and posterior pituitary gland regulator, and coordinator of autonomic nervous system activity and emotional status. The cerebellum controls motor coordination, equilibrium, and balance. The basal ganglia control autonomic movements of the body. The motor pathways of the spinal cord synapse in various areas of the spinal cord, not the thalamus.

Which of these statements about the peripheral nervous system is correct?

ANS: The peripheral nerves carry input to the central nervous system by afferent fibers and away by efferent fibers. A nerve is a bundle of fibers outside the central nervous system. The peripheral nerves carry input to the central nervous system by their sensory afferent fibers and deliver output from the central nervous system by the efferent fibers.

A patient with lack of oxygen to his heart will have pain in his chest and possibly the shoulder, arms, or jaw. The nurse knows that the statement that best explains why this occurs is which of these?

ANS: The sensory cortex does not have the ability to localize pain in the heart, so the pain is felt elsewhere. The sensory cortex is arranged in a specific pattern, forming a corresponding "map" of the body. Pain in the right hand is perceived at a specific spot on the map. Some organs are absent from the brain map, such as the heart, liver, and spleen. Pain originating in these organs is referred because no felt image exists in which to have pain. Pain is felt "by proxy" by another body part that does have a felt image. The other responses are not correct explanations.

The assessment of a 60-year-old patient has taken longer than anticipated. In testing his pain perception the nurse decides to complete the test as quickly as possible. When the nurse applies the sharp point of the pin on his arm several times, he is only able to identify these as one "very sharp prick." What would be the most accurate explanation for this?

ANS: This is most likely the result of the summation effect. Let at least 2 seconds elapse between each stimulus to avoid summation. With summation, frequent consecutive stimuli are perceived as one strong stimulus. The other responses are incorrect.

During an examination, the nurse notices severe nystagmus in both eyes of a patient. Which of these conclusions by the nurse is correct?

ANS: This may indicate disease of the cerebellum or brainstem. End-point nystagmus at an extreme lateral gaze occurs normally. The nurse should assess any other nystagmus carefully. Severe nystagmus occurs with disease of the vestibular system, cerebellum, or brainstem.

While assessing a 7-month-old infant, the nurse makes a loud noise and notices the following response: abduction and flexion of arms and legs; fanning of fingers, and curling of index and thumb in a C position followed by infant bringing in arms and legs to body. What does the nurse know about this response?

ANS: This reflex should have disappeared between 1 and 4 months of age. The Moro reflex is present at birth and disappears at 1 to 4 months. Absence of the Moro reflex in the newborn or persistence after 5 months of age indicates severe central nervous system injury. The other responses are incorrect.

ANS: a positive Babinski's sign, which is abnormal for adults. Dorsiflexion of the big toe and fanning of all toes is a positive Babinski's sign, also called "upgoing toes." This occurs with upper motor neuron disease of the corticospinal (or pyramidal) tract and is an abnormal finding for adults.

The nurse is testing the deep tendon reflexes of a 30-year-old woman who is in the clinic for an annual physical examination. When striking the Achilles and quadriceps, the nurse is unable to elicit a reflex. The nurse's next response should be to:

ANS: ask the patient to lock her fingers and "pull." Sometimes the reflex response fails to appear. It is too soon to document this as "absent" reflexes. Try further encouragement of relaxation, varying the person's position or increasing the strength of the blow. Reinforcement is another technique to relax the muscles and enhance the response. Ask the person to perform an isometric exercise in a muscle group somewhat away from the one being tested. For example, to enhance a patellar reflex, ask the person to lock the fingers together and "pull."

ANS: chorea. Chorea is characterized by sudden, rapid, jerky, purposeless movements that involve the limbs, trunk, or face. Chorea occurs at irregular intervals, and the movements are all accentuated by voluntary actions. See Table 23-5 for descriptions of athetosis, myoclonus, and tics.

The ability that humans have to perform very skilled movements such as writing is controlled by the:

ANS: corticospinal tract. Corticospinal fibers mediate voluntary movement, particularly very skilled, discrete, purposeful movements, such as writing. The corticospinal tract (also known as the pyramidal tract) is a newer, "higher" motor system that humans have that permits very skilled and purposeful movements. The other responses are not related to skilled movements.

ANS: decreased level of consciousness. A change in consciousness may be subtle. The nurse should notice any decreasing level of consciousness, disorientation, memory loss, uncooperative behavior, or even complacency in a previously combative person. The other responses are incorrect.

The wife of a 65-year-old man tells the nurse that she is concerned because she has noticed a change in her husband's personality and ability to understand. He also cries and becomes angry very easily. The nurse recalls that the cerebral lobe responsible for these behaviors is the _____ lobe.

ANS: frontal The frontal lobe has areas concerned with personality, behavior, emotions, and intellectual function. The parietal lobe has areas concerned with sensation; the occipital lobe is responsible for visual reception; and the temporal lobe is concerned with hearing, taste and smell.

The nurse is testing the function of cranial nerve XI. Which of these best describes the response the nurse should expect if the nerve is intact? The patient:

ANS: moves the head and shoulders against resistance with equal strength. These are the expected normal findings when testing cranial nerve XI (spinal accessory nerve): The patient's sternomastoid and trapezius muscles are of equal size; the person can rotate the head both ways forcibly against resistance applied to the side of the chin with equal strength; the patient can shrug the shoulders against resistance with equal strength on both sides. Checking the patient's ability to hear normal conversation checks the function of CN VIII. Having the patient stick out the tongue checks the function of CN XII. Testing the eyes for nystagmus or strabismus is done to check CN III, IV, and VI.

A mother of a 1-month-old infant asks the nurse why it takes so long for infants to learn to roll over. The nurse knows that the reason for this is that:

ANS: myelin is needed to conduct the impulses, and the neurons of a newborn are not yet myelinated. The infant's sensory and motor development proceeds along with the gradual acquisition of myelin because myelin is needed to conduct most impulses. Very little cortical control exists, and the neurons are not yet myelinated. The other responses are not correct.

During an assessment of an 80-year-old patient, the nurse notices the following: inability to identify vibrations at the ankle and to identify position of big toe, slower and more deliberate gait, and slightly impaired tactile sensation. All other neurologic findings are normal. The nurse should interpret that these findings indicate:

ANS: normal changes due to aging. Some aging adults show a slower response to requests, especially for those calling for coordination of movements. The findings listed are normal in the absence of other significant abnormal findings. The other responses are incorrect.

During an assessment of a 62-year-old man the nurse notices the patient has a stooped posture, shuffling walk with short steps, flat facial expression, and pill-rolling finger movements. These findings would be consistent with:

ANS: parkinsonism. The stooped posture, shuffling walk, short steps, flat facial expression, and pill-rolling finger movements are all found in parkinsonism. See Table 23-8 for more information and for descriptions of the other options.

The nurse knows that testing kinesthesia is a test of a person's:

ANS: position sense. Kinesthesia, or position sense, is the person's ability to perceive passive movements of the extremities. The other options are incorrect.

When the nurse asks a 68-year-old patient to stand with feet together and arms at his side with his eyes closed, he starts to sway and moves his feet farther apart. The nurse would document this finding as a(n):

ANS: positive Romberg sign. Abnormal findings for Romberg test include swaying, falling, and widening base of feet to avoid falling. Positive Romberg sign is loss of balance that is increased by closing of the eyes. Ataxia is uncoordinated or unsteady gait. Homans' sign is used to test the legs for deep vein thrombosis.

A patient is not able to perform rapid alternating movements such as patting her knees rapidly. The nurse should document this as:

ANS: the presence of dysdiadochokinesia. Slow clumsy movements and the inability to perform rapid alternating movements occur with cerebellar disease. The condition is termed dysdiadochokinesia. Ataxia is uncoordinated or unsteady gait. Astereognosis is the inability to identify an object by feeling it. Kinesthesia is the person's ability to perceive passive movement of the extremities, or the loss of position sense.

During the history, a patient tells the nurse that "it feels like the room is spinning around me." The nurse would document this as:

ANS: vertigo. True vertigo is rotational spinning caused by neurologic dysfunction or a problem in the vestibular apparatus or the vestibular nuclei in the brainstem. Dizziness is a lightheaded, swimming sensation. Syncope is a sudden loss of strength or a temporary loss of consciousness. Seizure activity is characterized by altered or loss of consciousness, involuntary muscle movements, and sensory disturbances.

During an assessment of a 22-year-old woman who sustained a head injury from an automobile accident 4 hours earlier, the nurse notices the following changes: pupils were equal, but now the right pupil is fully dilated and nonreactive, and the left pupil is 4 mm and reacts to light. What do these findings suggest? a. Injury to the right eye b. Increased intracranial pressure c. Test inaccurately performed d. Normal response after a head injury

During an assessment of the CNs, the nurse finds the following: asymmetry when the patient smiles or frowns, uneven lifting of the eyebrows, sagging of the lower eyelids, and escape of air when the nurse presses against the right puffed cheek. This would indicate dysfunction of which of these CNs? a. Motor component of CN IV b. Motor component of CN VII c. Motor and sensory components of CN XI d. Motor component of CN X and sensory component of CN VII

During the neurologic assessment of a "healthy" 35-year-old patient, the nurse asks him to relax his muscles completely. The nurse then moves each extremity through full range of motion. Which of these results would the nurse expect to find? a. Firm, rigid resistance to movement b. Mild, even resistance to movement c. Hypotonic muscles as a result of total relaxation d. Slight pain with some directions of movement

In obtaining a health history on a 74-year-old patient, the nurse notes that he drinks alcohol daily and that he has noticed a tremor in his hands that affects his ability to hold things. With this information, what response should the nurse make? a. "Does your family know you are drinking every day?" b. "Does the tremor change when you drink alcohol?" c. "We'll do some tests to see what is causing the tremor." d. "You really shouldn't drink so much alcohol; it may be causing your tremor."

The assessment of a 60-year-old patient has taken longer than anticipated. In testing his pain perception, the nurse decides to complete the test as quickly as possible. When the nurse applies the sharp point of the pin on his arm several times, he is only able to identify these as one "very sharp prick." What would be the most accurate explanation for this? a. The patient has hyperesthesia as a result of the aging process. b. This response is most likely the result of the summation effect. c. The nurse was probably not poking hard enough with the pin in the other areas. d. The patient most likely has analgesia in some areas of arm and hyperalgesia in others.

The nurse knows that testing kinesthesia is a test of a person's: a. Fine touch. b. Position sense. c. Motor coordination. d. Perception of vibration.

A 30-year-old woman tells the nurse that she has been very unsteady and has had difficulty in maintaining her balance. Which area of the brain that is related to these findings would concern the nurse? a. Thalamus b. Brainstem c. Cerebellum d. Extrapyramidal tract

A patient has a severed spinal nerve as a result of trauma. Which statement is true in this situation? a. Because there are 31 pairs of spinal nerves, no effect results if only one nerve is severed. b. The dermatome served by this nerve will no longer experience any sensation. c. The adjacent spinal nerves will continue to carry sensations for the dermatome served by the severed nerve. d. A severed spinal nerve will only affect motor function of the patient because spinal nerves have no sensory component.

A patient is unable to perform rapid alternating movements such as rapidly patting her knees. The nurse should document this inability as: a. Ataxia. b. Astereognosis. c. Presence of dysdiadochokinesia. d. Loss of kinesthesia.

A patient with a lack of oxygen to his heart will have pain in his chest and possibly in the shoulder, arms, or jaw. The nurse knows that the best explanation why this occurs is which one of these statements? a. A problem exists with the sensory cortex and its ability to discriminate the location. b. The lack of oxygen in his heart has resulted in decreased amount of oxygen to the areas experiencing the pain. c. The sensory cortex does not have the ability to localize pain in the heart; consequently, the pain is felt elsewhere. d. A lesion has developed in the dorsal root, which is preventing the sensation from being transmitted normally.

During an assessment of an 80-year-old patient, the nurse notices the following: an inability to identify vibrations at her ankle and to identify the position of her big toe, a slower and more deliberate gait, and a slightly impaired tactile sensation. All other neurologic findings are normal. The nurse should interpret that these findings indicate: a. CN dysfunction. b. Lesion in the cerebral cortex. c. Normal changes attributable to aging. d. Demyelination of nerves attributable to a lesion.

The nurse is caring for a patient who has just had neurosurgery. To assess for increased intracranial pressure, what would the nurse include in the assessment? a. CNs, motor function, and sensory function b. Deep tendon reflexes, vital signs, and coordinated movements c. Level of consciousness, motor function, pupillary response, and vital signs d. Mental status, deep tendon reflexes, sensory function, and pupillary response

The nurse is performing an assessment on a 29-year-old woman who visits the clinic complaining of "always dropping things and falling down." While testing rapid alternating movements, the nurse notices that the woman is unable to pat both of her knees. Her response is extremely slow and she frequently misses. What should the nurse suspect? a. Vestibular disease b. Lesion of CN IX c. Dysfunction of the cerebellum d. Inability to understand directions

The nurse is testing superficial reflexes on an adult patient. When stroking up the lateral side of the sole and across the ball of the foot, the nurse notices the plantar flexion of the toes. How should the nurse document this finding? a. Positive Babinski sign b. Plantar reflex abnormal c. Plantar reflex present d. Plantar reflex 2+ on a scale from "0 to 4+"

A 70-year-old woman tells the nurse that every time she gets up in the morning or after she's been sitting, she gets "really dizzy" and feels like she is going to fall over. The nurse's best response would be: a. "Have you been extremely tired lately?" b. "You probably just need to drink more liquids." c. "I'll refer you for a complete neurologic examination." d. "You need to get up slowly when you've been lying down or sitting."

The nurse is testing the function of CN XI. Which statement best describes the response the nurse should expect if this nerve is intact? The patient: a. Demonstrates the ability to hear normal conversation. b. Sticks out the tongue midline without tremors or deviation. c. Follows an object with his or her eyes without nystagmus or strabismus. d. Moves the head and shoulders against resistance with equal strength.

When the nurse asks a 68-year-old patient to stand with his feet together and arms at his side with his eyes closed, he starts to sway and moves his feet farther apart. The nurse would document this finding as: a. Ataxia. b. Lack of coordination. c. Negative Homans sign. d. Positive Romberg sign.

Which of these statements about the peripheral nervous system is correct? a. The CNs enter the brain through the spinal cord. b. Efferent fibers carry sensory input to the central nervous system through the spinal cord. c. The peripheral nerves are inside the central nervous system and carry impulses through their motor fibers. d. The peripheral nerves carry input to the central nervous system by afferent fibers and away from the central nervous system by efferent fibers.

While the nurse is taking the history of a 68-year-old patient who sustained a head injury 3 days earlier, he tells the nurse that he is on a cruise ship and is 30 years old. The nurse knows that this finding is indicative of a(n): a. Great sense of humor. b. Uncooperative behavior. c. Inability to understand questions. d. Decreased level of consciousness.

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