NUR 220A Final Exam

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Which color of cerebrospinal fluid (CSF) may indicate subarachnoid hemorrhage in the client?

Yellow

Cranial Nerve IV (4)

Trochlear (6 cardinal gazes)

Which finding is considered abnormal during late pregnancy? a. Watery vaginal discharge b. Hemorrhoids c. Lordosis d. Abdominal striae

which structure connects muscle to bone? a. tendon b. cartilage c. ligament d. contracture

Which patient condition increases the risk of osteomyelitis? a. Severe gout b. Rheumatoid arthritis (RA) c. Severe osteoporosis d. An open fracture of the radius

loss of pigmentation in the eyes, skin and hair

albinism

what is a synarthroidal joint

an immovable joint

older adult temperature

avg 97.2 degrees F - due to decreased metabolism and less physical activity

A patient with a missed menstrual period and nausea has which signs and symptoms of pregnancy? a. Questionable b. Presumptive c. Probable d. Positive

The nurse explains that a Pap test involves the provider taking a sample of: a. vaginal discharge. b. endocervical cells. c. cervical tissue. d. uterine tissue.

Which body system controls balance? a. musculoskeletal b. nervous c. pulmonary d. cardiovascular

Which finding does the nurse recognize as abnormal when examining a male patient? a. Testes that are palpable and firm within the scrotal sac bilaterally b. Discharge from the penis when the glans is compressed c. Foreskin that lies loosely over the penis d. Glans a lighter skin tone than the rest of the penis

Which finding of a preschooler during a cardiovascular system examination is abnormal? a. Heart rate of 106 beats/min b. Failure to gain weight because of fatigue while eating c. Continuous low-pitched vibration heard over the jugular vein d. Pulse increasing on inspiration and decreasing on expiration

which factor does the braden scale evaluate for? a. skin integrity at bony prominences, including any wounds b. risk factors that place the patient at risk for skin breakdown c. the amount of repositioning that the patient can tolerate d. the factors that place the patient at risk for poor healing

A 36-year-old man is admitted to the hospital following a motor vehicle accident. He has sustained multiple injuries on the forehead, right elbow, and left knee. On his forehead, there is a full-thickness loss of skin. The patient is given first aid and is treated with antibiotics. Arrange the phases of the healing process in appropriate order. a. maturation phase b. inflammatory phase c. proliferative phase

b, c, a

bathing, toileting, eating, and ambulating are all which activities

basic activities of daily living (BADLs)

The nurse recognizes which symptom as commonly associated with prostate enlargement? a. Constipation b. Rectal bleeding c Weak urinary stream d. Penile discharge

The nurse suspects that a male patient has syphilis. Which finding suggests this diagnosis? a. A syphilis lesion on the skin in the pubic hair b. A syphilis lesion on the shaft of the penis near the base c. A syphilis lesion on the glans penis d. A syphilis lesion on the underside of the scrotal sac

Which action supports proper body mechanics when lifting or carrying objects? a. keeping the knees in a locked position b. bending at the waist c. elevating work surfaces to elbow height d. holding objects away from the body

dysmenorrhea

difficult or painful menses

swelling

edema

the outermost layer of the skin

epidermis

range of motion: fingers straighten fingers

extension

range of motion: knee bringing heel toward back of thigh

flexion

range of motion: neck and cervical spine bringing chin to rest on chest

flexion

range of motion: shoulder raise arm from side position forward to position above head

flexion

range of motion: thumb moving thumb across palmar surface of hand

flexion

range of motion: toes curl toes downward

flexion

____ are needed for production and secretion of fluid that makes up the semen

glands

range of motion: foot turn sole of foot medially

inversion

a yellow hue to the skin

jaundice

what is the most common musculoskeletal symptom for which patients seek treatment

joint pain

venous hum is normal for _______, and located in the _______vein.

kids, jugular

tissue integrity - pressure ulcers

known as bedsores or decubitus ulcers; localized to injury to the skin and underlying tissue usually over bony prominence as a result of pressure; at risk patients include those who are immobile or bed bound

the internal spinchter

lined with smooth muscle and is under involuntary control

what do sebaceous glands do

lipid rich (sebum) substance that keeps the skin and hair lubricated; found everywhere but the palms and soles

skeletal muscles are attached to bones to facilitate ____

movement

atrophy

muscle wasting

scar in light skinned patients

narrow scar line

what age group has their hip joints and feet assessed for abnormalities

newborns

significant changes in what age group occur with regard to skin and hair

older adults

range of motion: thumb touch thumb to each finger of the same hand

opposition

what is the most common infection in children

otitis media

the primary functions of the ______ include ovulation and secretion of reproductive hormones

ovaries

pale skin tone

pallor

paraplegia

paralysis from the waist down

quadriplegia

paralysis of all four limbs

hemiplegia

paralysis of one side of the body

what is menopause

permanent cessation of menses and is considered complete after a woman has experienced an entire year with no menses

contracture

permanent fixation of joint

foot drop

permanent plantar flexion

localized injury to the skin over a bony prominence

pressure ulcer

bleeding under the skin

purpura

wound cultures

sample wound for bacterial or fungal growth

drainage that is pink to pale red

serosanguineous

what is the most common cancer

skin cancer

mobility - spine

•Inspect cervical, thoracic, and lumbar spine for alignment and symmetry •Observe range of motion of the lumbar and thoracic spine •Scoliosis - ask patient to touch toes and observe spinal column for straightness

tissue integrity - personal

•Skin care •Sun exposure

mobility - present health status

- chronic diseases can affect mobility and ability to do ADLs - many meds for musculoskeletal diseases can have adverse effects and increase risk of injury

Bilirubin

0.3-1.0

creatine range for female

0.5-1.1

creatine range for males

0.6-1.2

normal INR range

0.8-1.1

What would be an abnormal finding for a 7-year-old African American boy? 1. Abdominal distention 2. Umbilical hernia 3. Abdominal breathing 4. Tenseness of abdominal muscles

Which finding on a 2-month-old baby is considered abnormal and requires further follow-up? 1. The anterior fontanelle is not palpable. 2. The thyroid gland cannot be palpated. 3. The head circumference is slightly greater than the chest circumference. 4. Head lag is observed when the shoulders are lifted off the examination table.

which age group has the following fine motor skills: follows with eyes to midline, hands predominantly closed, strong grasp reflex

1 month old

which age group has the following gross motor skills: turns head to side, keeps knees tucked under abdomen when pulled to sitting position, has gross head lag and rounded, swayed back

1 month old

reproduction - laboratory tests

•Amniocentesis - used to detect birth defects •MSAFP - alpha fetal protein (assessing for trisomy 21, trisomy 18, neural tube defects) - performed 16-18 weeks of gestation

prenatal visits are recommended every 2 weeks from _____

28-36 weeks

Sublingual nitroglycerin tablets are prescribed to control periodic episodes of chest pain in the patient with stable angina. Which instruction should the nurse include when teaching the client about sublingual nitroglycerin? 1. once the tablet is dissolved, spit out the saliva 2. take tablets 3 minutes apart up to a maximum of five tablets 3. common side effects include headache and low blood pressure 4. once opened, the tablets should be refrigerated to prevent deterioration

preschool

3-5 years

Albumin range

3.5-5

which age group has the following fine motor skills: able to build 8 block tower, scribbling techniques continue, feeds self with increased neatness, dumps raisins from bottle spontaneously

30 month old (2 1/2 years)

which age group has the following gross motor skills: able to jump from object, walking becomes more stable; wide-based gait decreases, throws ball overhanded

30 month old (2 1/2 years)

PTT (partial thromboplastin time)

30-40 sec

newborn RR

30-60

Hct for females

37-47

A client with impaired peripheral pulses and signs of chronic hypoxia in a lower extremity is scheduled for a femoral angiogram. What would be appropriate for the nurse to include in the postprocedure plan of care? 1. elevate the foot of the bed 2. perform urinary catheter care every 12 hours 3. place in the high-fowler position 4. perform a neurovascular assessment every 2 hours

A nurse is developing a teaching plan for a client with lower extremity arterial disease (LEAD). Which information will the nurse include in the teaching plan? 1. trimming toenails so that they are short and rounded 2. checking bathwater temperature by putting the toes in first 3. using alcohol to rub hands, feet, legs, and arms at least two times a day 4. seeking professional treatment for any injuries to the extremities

On assessment of the neurologic status of a 4-month-old infant, the nurse notes which finding as abnormal? 1. The infant abducts and extends arms and legs when startled. 2. When the infant's sole is touched, the toes flex tightly in an attempt to grasp. 3. When stroking the infant's foot from sole to great toes, there is fanning of the toes. 4. The infant steps in place when held upright with feet on a flat surface.

The nurse instructs the client admitted for an acute exacerbation of chronic obstructive pulmonary disease (COPD) about the importance of assessing for right-sided heart failure after discharge. What does the nurse instruct the client to assess for? 1. increased appetite 2. clubbing of the nail beds 3. hypertension 4. weight gain

The nurse notes which finding as abnormal during a thoracic assessment of an older adult? 1. A skeletal deformity affecting curvature of the spine 2. Shortness of breath on exertion 3. An increase in anteroposterior diameter 4. Bronchovesicular breath sounds in the peripheral lung fields

What is an expected finding of the newborn's vision that the nurse teaches the parents? 1. Small tears will be noted when their newborn cries. 2. Peripheral sight does not develop until age 3 or 4 months. 3. The newborn can only distinguish the colors of blue and green. 4. The newborn is nearsighted and cannot see items unless they are close.

Which risk is associated with estrogen therapy in a client who smokes? 1. hypcalcemia 2. vaginal bleeding 3. multiple pregnancies 4. thromboembolic disorders

the internal structures of the female reproductive system is supported by _____ pairs of ligaments

5 locations to auscultate for heart sounds

1. apical 2. pulmonary 3. erbs 4. tricuspid 5. mitral

what are the signs of pregnancy

1. presumptive symptoms (symptoms experienced by the woman) 2. probable signs (changes observed by the nurse) 3. positive signs (findings that prove the presence of a fetus)

the musculoskeletal system does 4 important things:

1. support and mobility for body 2. protection for internal organs 3. produces blood cells 4. stores minerals - calcium and phosphorus

how are joints classified

1. type of material 2. degree of movement

BUN range

10-20 mg/dL

adult BP

110-120/60-79

which age group has the following fine motor skills: may hold cup and spoon and feed self fairly well with practice, can offer toys and release them, releases cube in cup

12 month old

which age group has the following gross motor skills: able to twist and turn and maintain posture, able to sit from standing position, may stand alone - at least momentarily

12 month old

adolescent RR

12-16

normal Hgb for females

12-16

adolescent

12-18 years

which age group has the following fine motor skills: can put raisins into bottle, take off shoes and pulls toys, builds tower of 2 cubes, scribbles, uses cup well but rotates spoon

15 month old

which age group has the following gross motor skills: walks alone well, able to seat self in chair, creeps upstairs, cannot throw ball without falling

15 month old

Nagele's Rule

1st day of last period + 7 days - 3 months

A 2-month-old infant is being treated with sequential casts for bilateral clubfoot (talipes equinovarus). New casts have just been applied. What should the nurse evaluate to determine that circulation to the feet remains sufficient? 1. alignment of legs on x-ray 2. warmth of the toes of both feet 3. mobility of the knees when flexed 4. presence of posterior tibial pulses

A Foley catheter was placed with an urimeter for a client with heart failure receiving furosemide. The output is 45 mL/hour, cloudy, and has sediment. How should the nurse interpret these findings? 1. the furosemide is causing dehydration 2. cloudy urine may be indicative of infection 3. the client has inadequate urine output 4. all of the indications are within normal findings

The nurse instructs a pregnant woman in labor that she must avoid lying on her back. The nurse bases this instruction on the information that the supine position is primarily avoided because it can do what? 1. prolong the course of labor 2. cause decreased placental perfusion 3. lead to transient episodes of hypertension 4. interfere with free movement of the coccyx

normal RBC range for females

4.2-5.4

normal RBC range for males

4.7-6.1

normal RBC range for newborns

4.8-7.1

normal RBC range for 8-12 y/o's

4.o-5.5

triglycerides for males

40-160 mg/dl

murmurs normal up to _____ hours after birth

which age group has the following fine motor skills: can reach and pick up object, may play with toes

5 month old

the menstrual cycle has how many stages within what time frame

5 stages within a 28 day cycle

school age

6-12 years

adult HR

60-100

HDL for men

>45mg/dl

HDL range for women

>55mg/dl

mobility - personal/psychosocial history

- exercise - smoking (inhibits bone growth) - sports (weekend warrior) or repetitive work injury (push/pull/lift), protection (stretching, helmets vs proper body mechanics)

infant

1-12 months

toddler

1-3 years

Cranial Nerve X

Vagus (senses aortic blood pressure & slows heart rate & stimulates digestive organs & taste)

A nurse has difficulty palpating the pedal pulse of a client with venous insufficiency. What action should the nurse take next?

Verify the pulse by using a Doppler.

During inspection of the mouth of a 72-year-old male patient, the nurse notices a red lesion at the base of his tongue. What additional information does the nurse obtain from this patient? a. Alcohol and tobacco use b. Date of his last dental examination c. How well his dentures fit d. history of gum disease

The nurse is caring for a patient with loss of voluntary motor function following a head injury. Which area of the cerebrum is likely to be affected? a. the frontal lobes b. the parietal lobes c. the occipital lobes d. the temporal lobes

Which assessment finding does the nurse expect to observe in a child with cerebral palsy? a. spasticity b. paraplegia c. quadriplegia d. osteoarthritis

Which assessment finding would be most important to document in a patient with known liver disease who has a distended, taut abdomen? a. Abdominal girth b. Dentition condition c. Benign cardiac murmurs d. Daily ambulatory distance

Which device is most appropriate for preventing foot drop in a patient on bed rest? a. splint b. trapeze bar c. transfer belt d. antiembolism hose

Which device is most helpful for repositioning and transferring patients with functional upper body strength? a. trapeze bar b. mechanical lift c. transfer board d. lateral assist device

Which finding is expected during a rectal exam? a. The rectal wall is smooth. b. Severe pain is reported when the finger is introduced through the anus. c. Hard stool is present in the rectum. d. The anus is surrounded by white flat lesions

Which stage of pressure ulcer is noted to have intact skin and may include changes in one or more of the following: skin temperature (warmth or coolness), tissue consistency (firm or soft), and pain? a. I b. II c. III d. IV

A nurse notices cyanosis in a client with heart disease. Which site would the nurse assess to confirm cyanosis? 1. lips 2. sclera 3. conjunctiva 4. mucus membrane

what are the types of bones in the cranium

1 frontal 2 parietal 2 temporal 1 occipital

The nurse knows that the functions of the skin include which of the following? Select all that apply. a. Sensory input b. Protection c. Production of vitamin D d. Temperature regulation e. Production of vitamin C f. Sensory output

a, b, c, d

The nurse is caring for an elderly patient. During the assessment the nurse finds that the patient is susceptible to developing a decubitus ulcer. Which interventions would the nurse follow to prevent decubitus ulcer in this patient? Select all that apply. a. change the patient's position once every 2 hours b. elevate the head of the bed to a 50-degree angle c. prevent the patient's inner knees from pressing onto each other d. avoid using pillows to elevate the patient's legs e. avoid placing the patient in positions that increase stress on bony prominences

a, c, e

A client who had a myocardial infarction receives 15 mg of morphine sulfate for chest pain. Fifteen minutes after receiving the drug, the client complains of feeling dizzy. What action should the nurse take?

Place the client in the supine position and take the vital signs

tissue integrity - infant/newborn findings

Expected Findings - Skin • Preterm infants generally appear redder • Neonate may appear cyanotic in the lips, nail-beds, and feet - resolves with warming • Light skin and dark skinned newborns should have a pink tone (dark skin most easily accessed on their palms) • Newborns - skin, mucous membranes, and sclera may appear yellow Expected Findings - Hair and Nails • Scalp hair is fine and soft • Scaly crust may appear • Lanugo hair - fine hair all over the newborn's body

gravidity and parity using a five-digit (gtpal) system

G - gravida T - term birth P - preterm birth A - abortions L - living children

Cranial Nerve XII

Hypoglossal (tongue movement)

state the infantile reflex: stroke the lateral surface of infants sole and the infant will fan toes

babinski

skin conditions such as cellulitis, impetigo, folliculitis, and abscesses are caused by

bacterial infections

removal of a sample of cells to detect skin cancer

biopsy

what is the age range of pediatric nursing

birth through adolescence

neonate/newborn

birth-28 days

woods light

black light used to test for infectious organisms and proteins

spider bites from what two spiders can cause significant symptoms

black widow or brown recluse

tension due to fluid content

bullae

The nurse is counseling an adolescent on preventing sexually transmitted diseases (STDs). The patient understands this when he states, "The most common STD in the United States is__." a. gonorrhea b. syphilis c. chlamydia d. trichomoniasis

range of motion: fingers spread fingers apart

abduction

range of motion: hip moving leg laterally

abduction

range of motion: shoulder raise arm to side position above head with palm away from head

abduction

range of motion: thumb extending thumb laterally

abduction

range of motion: toes spread toes apart

abduction

pruritus is can be caused by

allergy, exposure to chemicals, infestation (scabies, lice, insect bites) or can be systemic disease

permanent or temporary hair loss

alopecia

hair, nails, and glands are known as _____ which are formed at the junction of the epidermis and dermis

appendages

cyanosis in dark skinned patients

ashen-gray color; mostly seen in conjunctiva of the eye, oral mucous membranes, and nail beds

A 35-year-old woman comes to the clinic for her general health checkup. She is the mother of a 6-year-old girl. The patient wants to know about various nonprescriptive methods of contraception. Which method of contraception does not require a prescription and can be independently taught by the nurse? a. intrauterine device b. condom c. vaginal ring d. subdermal implant

A female patient says to the nurse, "I experience severe pelvic pain during intercourse." Which condition would the nurse infer from the patient's statement? a. vaginismus b. dyspareunia c. anorgasmia d. amenorrhea

A patient complains of pain and clicking in the jaw with movement. These symptoms are consistent with: a. gout in the jaw. b. temporomandibular joint syndrome. c. rheumatoid arthritis of the jaw. d. bursitis of the temporomandibular joint.

A patient who has been on bed rest for several days prepares to walk with assistance. Upon standing, the patient's blood pressure changes from 120/80 to 96/68 mm Hg, and heart rate changes from 88 to 112 bpm. Based on these findings, the nurse knows that the patient is experiencing which condition? a. rebound hypertension b. orthostatic hypotension c. dysfunctional proprioception d. disuse osteoporosis

A pregnant patient in her sixth month asks the nurse why her breasts are getting so big. The nurse's best response is, "The breasts enlarge during pregnancy because of": a. increased fat deposits within the breast tissue b. an increase in the size and number of lactiferous ducts and breast alveoli c. engorgement of blood vessels as a result of increased vascularization d. increased pigmentation of the areolae and protrusion of the nipple

A pregnant patient who is worried about having a second caesarean delivery is told by the nurse, "You likely won't require a caesarean delivery this time" in order to reduce the patient's anxiety. Which thought process is the nurse using? a. personal bias b. illogical thinking c. open mindedness d. erroneous assumption

A woman in her seventh month of pregnancy reports that her gums bleed easily. What is the significance of this data? a. this is a common finding and is caused by elevated estrogen levels b. this is a common finding and is caused by increased vascularity and proliferation of the gums c. this is an abnormal finding and indicates a risk of hemorrhage d. this is an abnormal finding and indicates gum atrophy

During a health history interview, a patient reports a painless, solid mass on the anterior aspect of one testicle. Which condition would the nurse suspect in this patient? a. inguinal hernia b. testicular cancer c. sexually transmitted disease d. undescended testicle

The nurse begins the assessment of patient breath sounds and notes diminished breath sounds at the base of the right lung. What action should the nurse take next? a. Refer the patient for a chest x-ray. b. Listen to the base of the patient's left lung. c. Notify the patient's primary care provider. d. Palpate the patient's lung fields bilaterally.

The nurse enters a patient's room, and the patient asks if he can get out of bed and transfer to a chair. The nurse takes precautions to use safe patient handling techniques and transfers the patient. This is an example of which physical care technique? a. indirect care measure b. protecting a patient from injury c. meeting the patients expressed wishes d. staying organized when implementing a procedure

The nurse is making rounds with the primary health care provider, who prescribes cold therapy. Which adaptation is the effect of cold therapy? a. vasodilation b. decreased pain c. wound debridement d. decreased joint stiffness

The nurse is performing a skin assessment on a patient in pain. Which skin layer contains sensory fibers that react to touch, pain, and temperature? a. The epidermis b. The dermis c. The hypodermis d. The subcutaneous tissue

The nurse observes multiple red circular lesions with central clearing that are scattered all over the abdomen and thorax. How does the nurse document the shape and pattern of these lesions? a. Gyrate and linear b. Annular and generalized c. Iris and discrete d. Oval and clustered

The nurse is assessing the housing needs of an older adult with severe arthritis who has recently undergone knee replacement surgery. Which characteristics of a dwelling would be most appropriate for this patient? Select all that apply. a. multiple pets b. single level home c. smooth shiny flooring d. dwelling with no exterior steps e. many throw rugs

b, d

Which nursing interventions promote lung expansion in an immobile patient? Select all that apply. a. range of motion exercises b. routine coughing c. kegel exercises d. incentive spirometry e. deep breathing exercises

b, d, e

Which parts belong to the external female reproductive system? Select all that apply. a. uterus b. clitoris c. vagina d. mons pubis e. labia majora

b, d, e

Which conditions are diagnosed more frequently in infancy and childhood than in adulthood? Select all that apply. a. spina bifida b. osteoporosis c. osteoarthritis d. cerebral palsy e. rheumatoid arthritis

a, d

Which risks are associated with testicular cancer? Select all that apply. a. Multiple sex partners b. Men age 60 and over c. Men age 20 to 34 d. Family history of testicular cancer e. Cryptorchidism f. Caucasian men

c, d, e, f

steps of cardiac assessment

1. inspect- symmetry, color, warmth 2. palpate- apical pulse- look for lumps 3. auscultate @ erbs point

normal PT time

11-12.5 sec

adult RR

12-20

newborn HR

120-160

how many bones does the face have

14 - they protect facial structures

Hgb for males

14-18 g/dL

normal platelet count

150,000-400,000/mm3

which age group has the following fine motor skills: builds tower of 3-4 cubes, turns pages in book 2-3 at a time, manages spoon without rotating

18 month old

school age child RR

18-30

which age group has the following fine motor skills: able to turn doorknob, able to take off shoes and socks, able to build 7-8 block tower, dumps raisins from bottle following demonstration

24 month old (2 years)

which age group has the following gross motor skills: may walk up stairs by self, step 2 ft each step, able to walk backward, able to kick ball

24 month old (2 years)

toddler RR

24-40

_____ health of the pediatric patient is affected by maternal substance abuse in pregnancy, perinatal hypoxia, neurologic illness, developmental delays, family problems, and violence witnessed

mental

what are common skin lesions in children

milia, erythemia toxicum, diaper rash, rashes associated with allergens

_____ depends on the delivery of oxygenated blood to tissues and coordination of movement regulated by the brain, spinal cord, and peripheral nerves

mobility

the vulva includes:

mons pubis, labia majora, labia minora, clitoris, fourchette

state the infantile reflex: you startle an infant and the infant pulls its legs and arms against trunk as if trying to protect itself

moro

what is the primary function of the _______ system is to facilitate motion; it provides support for the body, protection of internal organs, production of blood cells, and storage of minerals

musculoskeletal

death of cells, tissues, or organs

necrosis

basal cell carcinoma, squamous cell carcinoma, melanoma, and kaposi sarcoma are the most common _____ skin conditions

neoplastic

rash in dark skinned patients

not easily visualized but may be felt with light palpation

to maintain tissue integrity, the body needs adequate _____ and _____ to carry nutrients to the tissue

nutrition and oxygenation

kyphosis

outward curvature of the thoracic spine - may alter respiratory pattern

menstrual cycle: stage 3

ovulation - day 13 or 14 steep rise in estrogen and luteinizing hormone (LH); egg is expelled from follicle and drawn into fallopian tube; rise in progesterone causes thickening in uterine wall

state the infantile reflex: touching object against ulnar side of infants hand and then placing finger in palm of hand, infant should grasp the finger and should be tight

palmar grasp

tissue integrity - diagnostics

patch testing, wound cultures, tissue biopsy, woods light

this type of nursing encompasses birth through adolescence

pediatric

the ____ serves the functions of excreting urine from the body and introducing sperm into the vagina during intercourse

penis

what are the external structures of the male reproductive system

penis (corpus cavernosa, corpus spongiosum, glans penis, corona, erection), scrotum (spermatic cord)

state the infantile reflex: touch object to sole of infants foot and the toes will flex slightly downward in attempt to grasp

plantar grasp

questions directed at the adolescent patient should be approached with _____ when discussing pubertal changes, menstruation, and sexuality

sensitivity

drainage that contains clear watery fluid

serous

appendicular skeleton consists of

shoulder girdle, pelvic girdle, extremities

what is objective data

signs, observations, measurable

the external spinchter

skeletal muscle, voluntary control, allows for control of defecation

the primary function of the _____ is to protect the body from invasion by bacteria and foreign substances

skin

patients with hemiplegia, paraplegia, or quadriplegia are at high risk for _____

skin breakdown

what are common skin lesions in older adults

skin cancer increases with age and inspection of sun exposed areas

pallor in dark skinned patients

skin tone appears lighter than normal; light skinned african americans may have yellowish-brown skin; dark skinned african americans may appear ashen; specifically evident is a loss of the underlying healthy red tones of the skin

axial skeleton consists of

skull neck, ribs, sternum, trunk, pelvis

the bones within the skeleton provide support for ______ and ____

soft tissues and organs

oral contraceptives and _____ alter the normal vaginal flora

some antibiotics (eeek!!)

Cranial Nerve XI (11)

spinal accessory (shoulder shrug - with and without resistance)

state the infantile reflex: infant held upright with feet flat on surface, infant will pace alternating steps

step in place

upper ribs are connected to the ____ by cartilage

sternum

state the infantile reflex: touch the infants lips and the sucking motion should follow with lips and tongue

sucking

what is subjective data

symptoms, from patient

what holds muscle to bones

tendons

the primary function of _____ is to produce sperm

testes

what are the internal structures of the male reproductive system

testes and ducts (epididymis, vas deferens, ejaculatory duct, urethera), glands (seminal vesicles, prostate gland, bulbourethral gland)

DEXA

tests for bone mineral density

describe cultural competence

the ability to interact with and appreciate people of different cultures and beliefs; intentional effort

state the infantile reflex: rotate head to side while infant is supine, arms and legs should extend to which side the head is turned to while opposite arms and legs flex

tonic neck

what is the most common infection of the oropharynx in children

tonsillitis

gravidity

total number of pregnancies

range of motion: wrist bend wrist laterally toward 5th finger (radial/ulnar deviation)

ulnar flexion

reproduction - diagnostics

ultrasound •5 weeks = visualization of the fetus •6 weeks = fetal heart rate activity •8 weeks = auscultated fetal heart tones •19 weeks = palpable fetal movements

Allis sign

unequal leg length you want a NEGATIVE allis sign

what does it mean if your stool is tarry black

upper intestinal tract bleeding or excessive iron or bismuth ingestion

tissue biopsy

used to diagnose malignancy (change in moles or skin abnormalities)

tissue integrity - braden scale

used to predict pressure ulcers, the lower the score, the more at risk the patient is for a pressure ulcers *Lower the number = the greater risk for pressure ulcer development*

patch testing

used to test allergens

the _____ is a muscular organ suspended by ligaments between the bladder and the rectum

uterus

internal structures of the female reproductive tract

vagina (uterine cervix, fornix), uterus (cervix, cervical opening, corpus), fallopian tubes, ovaries

skin lesions caused by ________ are warts, herpes simplex, herpes varicella and herpes zoster

viral infections

what are examples of positive signs of pregnancy

visualization of fetus by ultrasound, auscultation of fetal heart tones, doppler, fetoscope, palpation of fetal movements, observable fetal movements

loss of pigment

vitiligo

tissue integrity - toddlers/children

• Expected Findings - Skin • Smooth with consistent color and no lesions • Bruising is common on the lower legs • Skin turgor - same as adult

tissue integrity - wounds

•Assess if explanation matches discoloration •Poor wound healing can indicate underlying issues •Decreased BP can alter skin - hair distribution, temperature,

reproduction - past health history

•Benign changes (cysts) or breast cancer (increased risk of recurrence) •Cysts make it difficult to detect breast cancer - already lumpy •History of ovarian/endometrial/colon cancer - increase breast cancer risk •Breast surgery •Age at first menstruation •Pregnancy history (no children or first after age 30 is increased risk of breast cancer)

mobility - upper extremities

•Inspect shoulders for symmetry and height •Inspect joints of wrist, fingers, and hands for symmetry and alignment •Palpate muscles and bones for masses and tenderness •Palpate elbow for tenderness •Test muscle and joint strength of shoulder, elbow, wrist and fingers

reproduction - pregnancy examination

•Inspect the abdomen for surface movements and fetal movement •Palpate the abdomen for fetal movement and uterine contraction •Fetal movement should be present at 20 weeks, absent after 22 weeks is abnormal •Fundus •Measure from the top of the symphysis pubis to the top of the fundus •Week 20-36 weeks, fundal height should increase 1 cm per week

what are the common problems associated with bones

fractures and osteoporosis

scar in dark skinned patients

frequently has keloid development, resulting in a thickened, raised scar

tinea infectoins and candidiasis are lesions of a ______ nature

fungal

this patient has no evidence of contractility, how would you grade this and how would you record it on the lovett scale

grade: 0 lovett scale: zero (0)

this patient has evidence of slight contractility, how would you grade this and how would you record it on the lovett scale

grade: 1 lovett scale: trace (T)

this patient has complete range of motion with gravity eliminated, how would you grade this and how would you record it on the lovett scale

grade: 2 lovett scale: poor (P)

this patient has complete range of motion with gravity, how would you grade this and how would you record it on the lovett scale

grade: 3 lovett scale: fair (F)

this patient has complete range of motion against gravity with some resistance, how would you grade this and how would you record this on the lovett scale

grade: 4 lovett scale: good (G)

jugular distention in adults is an indication of

heart failure

menorrhagia

heavy menses

range of motion: neck and cervical spine bending head back as far as possible

hyperextension

range of motion: shoulder move arm behind body, keeping elbow straight

hyperextension

the _____ is a subcutaneous layer composed of fat; fatty cells help with heat regulation and provide protection against injury

hypodermis

the menstrual cycle is regulated by the _____

hypothalamus

state the infantile reflex: pinch the sole of the foot just under the toes

clonus

what are two alternative medicine practices used by some ethnic groups on the skin

coining and cupping

_____ and mineral composition are in a state of continuous renewal to accommodate stress

collagen

bluish discoloration of the skin and mucous membranes

cyanosis

The nurse is caring for a patient who has undergone ankle surgery. The primary health care provider places a Jackson-Pratt device in the patient. Which nursing action by the nurse indicates a need for further teaching? a. recompresses the device after emptying b. wears gloves while emptying the reservoir c. uses a medication cup to collect the drainage d. places the container above the level of the wound

The nurse is developing a teaching plan for a pregnant patient. One of the interventions in the plan of care is to wear sunscreen and avoid the sun. What is the rationale for the recommendation? a. decreased blood flow to the hands and feet causes occasional cyanosis b. a decreased number of sebaceous lands cause conservation of body heart c. thickness of the skin decreases d. pigmentation of the skin increases

The nurse is performing a skin check on a patient. In which age group is seborrheic keratosis an expected finding? a. Newborns b. Young children c. Adolescents d. Older adults

The nurse testing the patient's muscle strength finds that the patient has full resistance to opposition. Using Table 14-3, how would this finding be documented? a. Poor or 2/5 b. Fair or 3/5 c. Good or 4/5 d. Normal or 5/5

lordosis

increase in lumbar curve just above the buttocks

rash in light skinned patients

may be visualized and felt with light palpation

the five stages of the _______ cycle are: 1. menstrual 2. postmenstrual 3. ovulation 4. secretory 5. premenstrual

menstrual

state or quality of being mobile or movable

mobility

what does it mean if your stool is light tan or gray

obstruction of the biliary tract (obstructive jaundice)

which age group is slower at performing range of motion exercises

older adults

pallor in light skinned patients

pale skin color that may appear white

range of motion: ankle moving foot so toes point downward

plantar flexion

menstrual cycle: stage 5

premenstrual phase - days 21-28 if fertilization do not occur, progesterone production decreases, estrogen levels rise, and when the thickened uterine wall begins to shed, menstruation starts again, as does the beginning of a new cycle

ecchymosis (bruise) in light skinned patients

dark red, purple, yellow, or green color, depending on bruise age

MSAFP

detects alpha fetal protein (trisomy 21, trisomy 18, neural tube defects)

range of motion: forearm turns lower arm and hand so palm is down

pronation

menstrual cycle: stage 2

prostmenstrual or preovulatory phase - days 5-12 follicle stimulating hormone (FSH) stimulates hair growth; ovary and maturing follicle produce estrogen which supports egg development

what does hair consist of

root, shaft, and follicle (root and its covering)

scoliosis

sideways "S" curve of the spine

stretch marks

striae

range of motion: forearm turns lower arm and hand so palm is up

supination

this system is comprised of the skin, hair, nails, sweat glands, and sebaceous glands

the integumentary system

the primary purposes of ______ is to carry menstrual flow from the uterus, serve as a receptive organ during intercourse, and to serve as the birth canal during delivery

the vagina

The state of structurally intact and physiologically functioning epithelial tissues such as the integument (including skin and subcutaneous tissue) and mucous membranes

tissue integrity

the intactness and function of the skin, hair, and nails refers to

tissue integrity

what is the purpose of nagele's rule

to determine the estimated date of delivery

the vaginal vestibule includes:

urethral meatus, vaginal introitus (vaginal opening), hymen

X-rays

used to diagnose bone abnormalities (ex. fracture)

calcium

weight bearing activities increase calcium absorption by bones

disruptions in the skins integrity that lead to a loss of the skins normal functioning

wound

jaundice in light skinned patients

yellowish color of the skin, sclera of eyes, fingernails, palms of hands, and oral mucosa

jaundice in dark skinned patients

yellowish-green color most obviously seen in sclera of eye (do not confuse with yellow eye pigmentation), palms of hands, and soles of feet

Cranial Nerve II

Optic - vision

triglycerides for females

35-135

when does hormonal function start to decrease for women

35-40

prenatal visits are recommended weekly after ____

36 weeks

When developing a plan of care for a client who had a cardiac catheterization via a femoral insertion site, what should the nurse include? 1. ambulating the client 2 hours after the procedure 2. checking the vital signs every 15 minutes for 8 hours 3. keeping the client nothing by mouth for 4 hours after the procedure 4. maintaining the supine position for a minimum of 4 hours

When examining the genitalia of a 3-year-old boy, which position is ideal? 1. Prone position with legs flexed in a frog leg position 2. Supine position with knees spread and ankles spread apart 3. Lithotomy position with knees and ankles spread apart 4. Sitting position with knees spread and ankles crossed

Which are expected findings of a newborn's respiratory assessment? 1. Thoracic breathing 2. A 1:2 ratio of anteroposterior-to-lateral diameter 3. Flaring of the nares noted on inspiration 4. Bronchovesicular breath sounds in the peripheral lung fields

tissue integrity - nail palpation

•Capillary refill - discussed during perfusion

Hct for males

42-52%

WBC for children and adults

5000-10000

what is the average age of a women going through menopause

how many bones are in the cranium

which age group has the following fine motor skills: holds spoon or rattle, drops object and reaches for 2nd offered object, holds bottle

6 month old

which age group has the following gross motor skills: begins to raise abdomen off of table, sits but still shaky posture, may sit with legs apart, holds arms straight between legs, supports almost full body weight when pulled to standing

6 month old

What is the minimum heart rate of a 14 year old? Record your answer using a whole number. _____________ beats per minute

60 bpm

Cranial Nerve VI (6)

Abducens (6 cardinal gazes, lateral movement)

Cranial Nerve VIII (8)

Acoustic (hearing and equilibrium)

A client is admitted to the hospital and benazepril is prescribed for hypertension. Which is an appropriate nursing action for clients taking this medication?

Assess for dizziness.

Cranial Nerve VII (7)

Facial (smiling, taste for 2/3 of the tongue)

Cranial Nerve IX (9)

Glossopharyngeal (taste, speech, gag reflex)

A healthcare provider prescribes a diuretic for a client with hypertension. What should the nurse include in the teaching when explaining how diuretics reduce blood pressure?

Reduces the circulating blood volume

Which heart sound is normally heard in a toddler that is considered abnormal in an adult over 30-years-old?

A client arrives in the emergency department with multiple crushing wounds of the chest, abdomen, and legs. Which are the priority nursing assessments?

Quality of respirations and presence of pulses

Cranial Nerve I

Olfactory (smell)

overall mobility inespection

- inspect axial skeleton for symmetry and alignment - inspect muscles for size and symmetry - observe gait for conformity, symmetry, and rhythm - observe any use of assistive devices

Cranial Nerve III

Oculomotor (eye movement, pupil constriction)

adolescent HR

60-90

newborn BP

60-90/20-60

young-old

65-74

list the bones of the spine

7 cervical 12 thoracic 5 lumbar 5 sacral

Glucose range

74-106

school age child HR

75-100

middle-old

75-84

what does it mean if your stool is pale yellow

malabsorption syndrome

which age group has the following fine motor skills: beginning thumb-finger grasping, releases object at will, grasps for toys out of reach

8 month old

which age group has the following gross motor skills: sits securely without support, bears weight on legs when supported, may stand holding on

8 month old

Which would be an abnormal finding during an abdominal examination of an older adult? 1. Report of incontinence when sneezing or coughing 2. Loss of abdominal muscle tone 3. Bowel sounds every 15 seconds in all quadrants 4. Silver-white striae and a very faint vascular network

A nurse is palpating the lymph nodes of an 18-month-old toddler and finds enlarged postauricular and occipital nodes. What is the significance of this finding? 1. This is a normal finding at this age. 2. The toddler may have an ear infection. 3. The toddler may have an inflammation of the scalp. 4. The toddler needs to be referred to a pediatrician.

toddler BP

80-112/50-80

During inspection of the mouth of a 72-year-old male patient, the nurse notices a red lesion at the base of his tongue. What additional information does the nurse obtain from this patient? 1. Alcohol and tobacco use 2. Date of his last dental examination 3. How well his dentures fit 4. A history of gum disease

Each patient has had consistent blood pressure readings during the last three clinic visits. Which patient has a blood pressure consistent with expected findings? 1. Mr. P, whose blood pressure has been 110/78 2. Ms. J, whose blood pressure has been 140/90 3. Mr. Q, whose blood pressure has been 130/76 4. Ms. Y, whose blood pressure has been 120/80

school age child BP

84-120/54-80

The nurse is caring for a client who is experiencing signs and symptoms of a cardiac dysrhythmia and is scheduled to wear a Holter monitor for 24 hours. What should the client should be instructed to do during the test? 1. keep a diary of activities 2. stay away from microwave ovens 3. avoid taking any nitroglycerin that day 4. take both blood pressure and pulse every 2 hours

To prepare a client for surgery, which explanation by a nurse would be accurate related to pneumatic compression devices? 1. they help the venous blood return to the heart 2. they will not cause discomfort, but gently massage the legs 3. they are used instead of anticoagulant therapy 4. they must be worn until the first time the client gets out of bed

old-old

85 years and older

Barlow-Ortolani maneuver

- To detect hip dislocation in newborn - performed on every child in newborn nursery to assess hip dislocation what you'd hear if positive for barlow-ortolani: clicking or rough movement you want a NEGATIVE barlow-ortolani

mobility - past health history

- accidents/trauma/surgery to bones/joints/muscles - any residual issues from accidents/trauma/surgery

mobility - family history

- vertebral disorders and arthritis

A client with heart failure has anxiety. Which effect of anxiety makes it particularly important for the nurse to reduce the anxiety of this client? 1. increases the cardiac workload 2. interferes with usual respirations 3. produces an elevation in temperature 4. decreases the amount of oxygen

what are the functions of the skin

1. protect body from microbial, foreign substance invasion, and trauma to internal structures 2. retain body fluids and electrolytes 3. sensory input with the outside words, detects temperature and surface texture 4. produces vitamin D 5. excretes sweat, urea, lactic acid 6. expresses emotion (blushing) 7. repairs itself through cell replacement

which age group has the following gross motor skills: may walk up and down stairs holding hand, may show running ability

18 month old

A client with a diagnosis of anemia is receiving packed red blood cells. What is the most important action by the nurse when administering the transfusion? 1. warning the client about the possibility of fluid overload 2. monitoring the clients response, particularly within the first 10 minutes 3. adjusting the clients transfusion flow rate so that it infuses a consistent rate during the procedure 4. having the client tested for human immunodeficiency virus (HIV) before administering the blood transfusion

A client's monitor shows a PQRST wave for each beat and indicates a rate of 120 beats/minute. The rhythm is regular. What does the nurse conclude that the client is experiencing? 1. atrial fibrillation 2. sinus tachycardia 3. ventricular fibrillation 4. first-degree ventricular block

A nurse administers a parenteral preparation of potassium slowly and cautiously to avoid which complication? 1. acidosis 2. cardiac arrest 3. psychotic like reactions 4. edema of the extremities

A patient complains of pain in the calf when walking. Which question should the nurse ask for further data? 1. "Does your calf also swell when this pain occurs?" 2. "Does the pain go away when you stop walking?" 3. "Do you become short of breath when you're walking?" 4. "Do you feel dizzy when the pain occurs?"

In assessing the mood of older adult patients, a nurse documents which finding as abnormal? 1. Sadness and grief after returning from the funeral of a long-time friend 2. Depression that interferes with the ability to perform activities of daily living 3. Frustration about rearranging the day's schedule to attend a grandson's birthday party 4. Crying about the unexpected death of a pet that had been with the family 12 years

On inspection of the eye of an 82-year-old woman, the nurse notes which finding as normal? 1. Opaque coloring of the lens 2. Clear cornea with a gray-white ring around the limbus 3. Dilated pupils when looking at an item in her hand 4. Impaired perception of the colors yellow and red

The nurse applies fetal and uterine monitors to the abdomen of a client in active labor. When the client has contractions, the nurse notes a 15 beats/min deceleration of the fetal heart rate below the baseline lasting 15 seconds. What is the next nursing action? 1. calling the primary healthcare provider 2. changing the maternal position 3. obtaining the maternal blood pressure 4. preparing the environment for an immediate birth

When a patient complains of chest pain, which question is pertinent to ask to gain additional data? 1. "What were you doing when the pain first occurred?" 2. "What does the pain feel like?" 3. "Do you have episodes of shortness of breath?" 4. "Has anyone in your family ever had a similar pain?"

Where does a nurse palpate to assess the posterior tibial pulse? 1. Behind the knee in the popliteal fossa 2. The inner aspect of the ankle below and slightly behind the medial malleolus 3. Over the dorsum of the foot between the extension tendons of the first and second toes 4. The outer side of the ankle below and slightly behind the lateral malleolus

Which finding of a preschooler during a cardiovascular system examination is abnormal? 1. Heart rate of 106 beats/min 2. Failure to gain weight because of fatigue while eating 3. Continuous low-pitched vibration heard over the jugular vein 4. Pulse increasing on inspiration and decreasing on expiration

Each year, a client takes many trips to other countries. The client reports leg swelling during the long flights. How should the nurse best advise this client when traveling? 1. relax in a reclining position 2. sit upright with legs extended 3. walk around at least every hour 4. sit in any position that relieves pressure on the legs

prenatal visits are recommended every 4 weeks up to _____

28 weeks

3. Which patient has the greatest risk for hypertension? 1. An Asian man who is 5 ft 5 in (165 cm) tall, weighs 125 lbs (56.7 kg), and complains of a headache over his forehead and eyes 2. A Cheyenne Indian woman who complains of a gnawing, burning epigastric pain radiating to her neck and jaw 3. An African American man who has type 2 diabetes mellitus, exercises once a month, and drinks two-to-three alcoholic drinks a night with dinner 4. A Caucasian woman who has a family history of heart disease and complains of pain in her chest when she takes a deep breath

A client with a coronary occlusion is experiencing chest pain and distress. Why does the nurse administer oxygen? 1. to prevent dyspnea 2. to prevent cyanosis 3. to increase oxygen concentration to heart cells 4. to increase oxygen tension in the circulating blood

A client with chronic obstructive pulmonary disease (COPD) has a blood pH of 7.25 and a PCO 2 of 60 mm Hg. What complication does the nurse conclude the client is experiencing? 1. metabolic acidosis 2. metabolic alkalosis 3. respiratory acidosis 4. respiratory alkalosis

An adolescent tells a nurse that, while he was riding in a friend's car, the friend was stopped by the police for driving while intoxicated. Which assessment tool would be most appropriate to use with this adolescent? 1. Faces Pain Scale 2. Pediatric Symptom Checklist (PSC) 3. Guidelines for Adolescent Prevention (GAP) 4. Oucher Scales

How does a nurse determine jugular vein pulsations? 1. Elevates the head of the bed about 90 degrees and looks for the jugular vein pulsation parallel to the sternocleidomastoid muscle as the head of the bed is slowly lowered 2. Looks for jugular vein pulsations at the jaw line as the patient turns from supine to a side-lying position 3. Elevates the head of the bed until the external jugular vein pulsation is seen above the clavicle 4. Positions the patient supine and asks him or her to cough; looks for jugular vein pulsations during the cough

On auscultation of the heart, the nurse recognizes which expected finding? 1. A low-pitched blowing sound is heard over the abdominal aorta. 2. A high-pitched vibration is heard over the base of the heart. 3. The S1 heart sound is louder at the apex of the heart. 4. The S3 heart sound sounds like "Ken-tuck-y."

Which finding is an expected age-related change for a woman 80 years old? 1. Kyphosis 2. Back pain 3. Loss of height 4. Depression

Which patient has the greatest risk for hypertension? 1. An Asian man who is 5 ft 5 in (165 cm) tall, weighs 125 lbs (56.7 kg), and complains of a headache over his forehead and eyes 2. A Cheyenne Indian woman who complains of a gnawing, burning epigastric pain radiating to her neck and jaw 3. An African American man who has type 2 diabetes mellitus, exercises once a month, and drinks two-to-three alcoholic drinks a night with dinner 4. A Caucasian woman who has a family history of heart disease and complains of pain in her chest when she takes a deep breath

While examining the ear of an infant with an otoscope, the nurse pulls down on the ear for which reason? 1. Increases the depth that the otoscope can be inserted 2. Stabilizes the ear to avoid injury if the infant moves the head suddenly 3. Enhances visualization of the tympanic membrane by straightening the ear canal 4. Facilitates drainage of cerumen from the ear canal, allowing better visualization of inner ear structures

While inspecting the legs of a male patient, the nurse notes that the skin is shiny and taut with little hair growth. Which additional data would the nurse find to indicate that this patient has peripheral arterial disease? 1. Pitting edema of one or both feet or legs 2. Increased circumference in the thighs bilaterally 3. Pale, cool legs with diminished-to-absent dorsalis pulses 4. Pain when legs are dependent that is relieved when legs are elevated

The nurse is listening to the patient's heart at the left sternal border (LSB) at the second intraclavicular space (ICS). Which area is being auscultated? 1. Erb's point 2. Mitral area 3. Aortic area 4. Pulmonic area

What is the most accurate technique for detecting a venous thrombosis at the bedside? 1. Dorsiflex the calf and note if the patient complains of pain. 2. Elevate one leg above the level of the heart to determine if the veins empty. 244 3. Palpate the pulses distal to the areas of the suspected thrombosis. 4. Measure the thigh circumference to detect an increase from the baseline.

which age group has the following fine motor skills: grasps rattle, plays with hands together, inspect hands, carries object to mouth

4 month old

which age group has the following gross motor skills: actively lifts head up and looks around, rolls from prone to supine, no head lag when pulled to sitting position, when pulled into sitting position, shows only slight head lag

4 month old

which age group has the following gross motor skills: able to push up from prone and maintain weight on forearms, rolls from prone to supine, remains straight back when sitting

5 month old

toddler HR

90-140

WBC for newborns

9000-30000

adolescent BP

94-139/62-88

troponin T range

< 0.1 ng/dl

Troponin I range

<0.03 ng/dl

LDL value

<130mg/dl

cholesterol range

<200 mg/dL

The nurse is assessing a patient's muscle strength of the trapezius muscle. The nurse will apply resisting force while the patient: a. shrugs her shoulders. b. moves her jaw laterally. c. flexes her elbow. d. extends her knee.

what are examples of presumptive signs and symptoms of pregnancy

breast fullness/tenderness, amenorrhea, nausea and vomiting, urinary frequency, quickening (fetal movement)

The nurse is caring for a bedridden patient. During the physical examination, the nurse observes that the patient has intact, nonblistered skin with nonblanchable erythema at the sacral area. Which stage of pressure injury does the nurse suspect in the patient? a. I b. II c. III d. IV

sacs containing synovial fluid that provide lubricant for the shoulder and knee joints are known as

bursae

. Which finding is an expected age-related change for a woman 80 years old? a. Kyphosis b. Back pain c. Loss of height d. Depression

skin is composed of what 3 layers

epidermis - avascular, provides pigment dermis - vascular subcutaneous layer (hypodermis) - anchor for upper layers

necrotic tissue

eschar

what are the female sex hormones

estrogen and progestin

range of motion: foot turn sole of foot laterally

eversion

the permanent cessation of menses and is complete after a period of 1 year without menses

menopause

meal prepping, shopping, safe medication use, management of finances, and traveling are all which activities

instrumental activities of daily living (IADLs)

range of motion: hip turning knee inward

internal rotation

range of motion: shoulder with elbow fixed, rotate shoulder by moving arm until thumb is turned inward and turned back

internal rotation

reduced blood flow

ischemia

the point where 2 or more bones come together are

joints

menstrual cycle: stage 1

menstrual phase - days 1-4 estrogen and progestin levels decrease; triggers shedding of endometrium layers and menstrual bleeding

The nurse believes a male patient has a sexually transmitted disease. Which symptom is commonly associated with STDs? a. Penile discharge b. Difficulty maintaining an erection c. Difficulty initiating a urine stream d. A heavy feeling in the scrotum

tissue integrity - laboratory findings

NONE

Trendelenburg sign

Occurs with severe subluxation of one hip When the child stands on the good leg, the pelvis looks level. When the child stands on the affected leg the pelvis drops toward the good side if there is a tilt present the child has hip dysplasia

range of motion: neck and cervical spine tilt head as far as possible towards each shoulder

lateral flexion

A patient has a herpes lesion on her vulva. While examining her, the nurse should take which measures? a. Wear examination gloves while in contact with the genitalia. b. Place the patient in an isolation room. c. Wash the genitalia with alcohol or povidone-iodine (Betadine) before the examination. d. Inspect the genitalia only; reschedule the patient for a full examination after the lesion has healed

The nurse is assessing a patient using a goniometer. What is this instrument used for? a. Range of motion b. Muscle strength c. Joint symmetry d. Length of extremity

A nurse determines that the client's apical pulse rate is higher than the radial pulse and documents the pulse deficit. What does the nurse consider is the primary reason for the pulse deficit?

The client may have atrial fibrillation.

A patient has multiple solid, red, raised lesions on her legs and groin that she describes as "itchy insect bites." How does the nurse document these lesions? a. Wheals b. Bullae c. Tumors d. Plaques

A patient is prescribed long-term therapy of an antihistamine drug for allergies. Which possible side effect should the nurse inform the patient? a. vaginal dryness b. orgasmic disorder c. erectile dysfunction d. ejaculatory dysfunction

Cranial Nerve V (5)

Trigeminal - chewing face & mouth touch & pain

A patient with darkly pigmented skin has been admitted to the hospital with hepatitis. What is the best way for the nurse to assess for jaundice in this patient? a. Inspect the color of the sclera. b. Inspect genitalia for color. c. Blanch the fingernails. d. Jaundice cannot be assessed in patients with darkly pigmented skin.

petechaie in light skinned patients

lesions appear as small, reddish-purple pinpoints

During an assessment, the nurse finds that a pregnant patient consumes alcohol. Which nursing intervention is the most effective approach for dealing with values conflict? a. use a matter-of-fact, real approach with the patient b. ignore an unrealistic display of optimism from the patient c. use direct, challenging statements regarding substance abuse d. do not provide up-front information the patient

A 22-year-old white male comes to the emergency department with a concern about a mass in his testicle. In addition to his age and race, which fact is a known risk factor for testicular cancer? a. He had an undescended testicle at birth. b. His mother had breast cancer. c. He was treated for gonorrhea 18 months ago. d. He had a hydrocele during infancy.

A male patient tells the nurse, "I am unable to maintain an erection during sexual intercourse." Which question would the nurse ask the patient during the interview? a. do you drink alcohol frequently b. do you take phenytoin c. do you take diclofenac d. do you take any oral antihistamines

A nurse is palpating the lymph nodes of an 18-month-old toddler and finds enlarged postauricular and occipital nodes. What is the significance of this finding? a. This is a normal finding at this age. b. The toddler may have an ear infection. c. The toddler may have an inflammation of the scalp. d. The toddler needs to be referred to a pediatrician

A nurse is preparing to auscultate a patient's chest. In which area should the nurse listen to evaluate the patient's aortic valve? a. Second right intercostal space b. Third left intercostal space c. Fifth right intercostal space d. Fifth left intercostal space along the midclavicular line

what holds bones to bones

ligaments

The nurse is caring for a pregnant patient with diabetes mellitus. Which intervention performed by the nurse may increase the risk of skin breakdown in the patient? a. providing warm water for the patient to soak the feet b. inspecting both of the feet for redness or dry areas c. not using pediculicidal shampoos on the patient d. giving the patient a back massage using effleurage

The nurse is explaining the prostate exam to a male patient. The nurse explains that the __ surface is palpated during the examination. a. anterior rectal surface b. anorectal junction c. anterior prostate surface d. deep external sphincter surface

The nurse is performing a skin assessment and finds that the patient has milia. In which age group would this be an expected finding? a. Newborns b. Young children c. Adolescents d. Older adults

The nurse is reading a report from the patient's chart and sees a note stating the prostate is hard and irregular. The nurse suspects: a. prostate cancer. b. benign prostate hypertrophy (BPH). c. prostatitis. d. rectal cancer.

The nurse is teaching a parent about risk factors associated with the skin for their school-age child. What would the nurse include as the most common cause of skin lesions for this age group? a. Communicable disease and bacterial infection b. Changes in skin turgor and skin tone c. Maturation of melanocytes, causing changes in skin color d. Skin inflammation from sebaceous gland activity

The nurse uses the PLISSIT model while working with a couple experiencing sexual health problems. Which action would the nurse take first? a. ask the couple permission to begin a discussion on sexuality b. refer the couple to make an appointment with a sex therapist c. recommend methods to improve the couple's sexual health d. inform the couple about all of the available treatment options

The primary health care provider instructs the nurse to apply a bandage on a patient's injured leg. The nurse finds that the patient is anxious. Which nursing action would be taken first in this situation? a. explain the procedure to the patient b. notify the primary health care provider c. apply the bandage to the patient immediately d. elevate the patient's leg for 15 minutes before applying the bandage

What does the nurse assess for during each prenatal visit? a. Blood pressure b. Hemorrhoids c. Personal habits (smoking, alcohol consumption) d. Visual acuity

What would be an abnormal finding for a 7-year-old African American boy? a. Abdominal distention b. Umbilical hernia c. Abdominal breathing d. Tenseness of abdominal muscles

Which finding on a 2-month-old baby is considered abnormal and requires further follow-up? a. The anterior fontanelle is not palpable. b. The thyroid gland cannot be palpated. c. The head circumference is slightly greater than the chest circumference. d. Head lag is observed when the shoulders are lifted off the examination table

Which measurement is appropriate in determining the correct length of a cane for a patient? a. the floor to the hip joint b. the floor to the elbow c. the shoulder to the hip joint d. the great toe to the lesser trochanter

Which patient's description of pain is consistent with injury to a bone? a. "Deep, dull, and boring" b. "Cramping even when not moving" c. "Intermittent, sharp, and radiating" d. "Numbness and tingling with movement"

Which would be an abnormal finding during an abdominal examination of an older adult? a. Report of incontinence when sneezing or coughing b. Loss of abdominal muscle tone c. Bowel sounds every 15 seconds in all quadrants d. Silver-white striae and a very faint vascular network

While assessing the range of motion of the patient's knee, the nurse expects the patient to be able to perform which movements? a. Flexion, extension, and hyperextension b. Circumduction, internal rotation, and external rotation c. Adduction, abduction, and rotation d. Flexion, pronation, and supination

info on table: faith - abrahamic faith spiritual observance - friday night to saturday night ritual - if a male child is born, the child will be circumcised on the eighth day in a ritual called a bris Which diet does the nurse provide for a pregnant patient whose subjective assessment findings are described on the table? a. kosher diet b. pork and fish c. vegetarian d. meat and dairy products

the nurse is assessing a patient in the 8 month of pregnancy. the nurse would expect to find: a. the position of the heart changes slightly b. the lower legs have 3+ edema c. her blood pressure is 150/118 mm Hg d. auscultation of the heart reveals an S4 heart sound

what is an diarthrodial joint

a freely moveable joint

capillary refill should be less than ____ for newborns

a second

what is an amphiarthrodial joint

a slightly moveable joint

objective data can be gathered from the patient during which aspects of the physical assessment process (select all that apply) a. patient interview b. health history c. general survey d. physical examination e. laboratory testing

a, b, c, d, e

A nurse is managing wound care for a patient with a stage III pressure ulcer on the elbow. The nurse cleans the area and removes all the dead, nonviable tissue from the wound. Which term is used to describe this process? a. irrigation b. debridement c. hemostasis d. cleansing

The nurse understands that dehiscence of a wound may occur if there is partial or total separation of the wound layers. Which patients would be at increased risk of wound dehiscence? Select all that apply. a. a malnourished patient b. an obese patient c. a young adult d. a female patient e. a patient with wound infection

a, b, e

Which teaching would the nurse include when explaining to a patient how hormonal contraceptives work? Select all that apply a. they alter the uterine environment b. they prevent ovulation c. they reduce sperm motility d. they act as a spermicidal barrier e. they thicken the cervical mucus

a, b, e

Which body mechanics principles should the nurse adopt to prevent injury at work? Select all that apply. a. bend at the knees b. pull rather than push patients or objects c. keep the spine in natural alignment while lifting or transferring d. get assistance when moving patients e. keep the weight to be lifted as close to the body as possible

a, c, d, e

The nurse is caring for a postsurgical patient. During a follow-up visit, the nurse finds that the patient has an infection at the surgical site. Which findings are consistent with the nurse's conclusion? Select all that apply. a. increase in pain b. absence of pulse c. tingling sensation d. increase in drainage e. elevation in temperature

a, d, e

What actions should the nurse take to assess whether a patient with a left above-the-knee amputation has adequate lower extremity circulation to the stump? (Select all that apply.) a. Palpate the stump for warmth. b. Assess pedal pulses bilaterally. c. Evaluate the left popliteal pulse rate. d. Inspect the stump and right leg for color. e. Check the left femoral pulse for strength.

a, d, e

A nurse caring for an infertile couple learns that the couple is experiencing symptoms of chlamydia. Which statements by the nurse about chlamydia are appropriate? Select all that apply. a. it affects the genitourinary tract b. there is no cure for this disorder c. it does not cause ectopic pregnancy d. the rectum is resistant to chlamydia infection e. it may cause infection of the eyes and lungs in newborns

a, e

A nurse is educating a couple about sexually transmitted infections. Which sexually transmitted infections cannot be cured? Select all that apply. a. herpes b. syphilis c. chlamydia d. gonorrhea e. human papillomavirus infection

a, e

A parent of a 3-year-old child reports to the nurse, "It embarrasses me when my child explores his body parts in front of everyone." Which nursing response is best ? a. isolate the child from others for some time b. provide the necessary guidance for the child c. consult with the health care provider d. punish the child appropriately for such behavior

The nurse is trying to assess a patient's risk of osteoporosis. The nurse knows that the following groups have the highest incidence of osteoporosis. Select all that apply. a. Asian females b. White males c. American Indian males d. African-American males e. Postmenopausal women f. Patients who had fractures in the past

a, e, f

amenorrhea

absence of menses

injuries to the skin involving infants and children are recognized as signs of ____

abuse

what is the most common skin concern in adolescences

acne

what are common skin lesions in adolescents

acne due to increased sebaceous activity

range of motion: fingers bring fingers together

adduction

range of motion: hip moving leg back to medial position

adduction

range of motion: shoulder lower arm sideways and across body as far as possible

adduction

range of motion: thumb move thumb back to normal position

adduction

range of motion: toes bring toes together

adduction

Which activities are examples of anaerobic exercise? Select all that apply. a. walking b. heavy weight lifting c. squat jumps d. fast stair climbing e. moderate swimming

b, c, d

A patient complains of her jaw popping when chewing. Which examination techniques are appropriate for the nurse to use with this patient? a. Inspecting the musculature of the face and neck for symmetry b. Observing the range of motion of and palpating each temporomandibular joint for movement, sounds, and pain c. Asking the patient to move her chin to her chest, hyperextend her head, and move her head from the right side to the left side d. Asking the patient to open her mouth as widely as possible and inspecting the lower jaw for redness, edema, or broken teeth

A patient tells the nurse that her stools have bright red blood in them. The nurse suspects which problem? a. Gallbladder disease b. Hemorrhoids c. Rectal polyps d. Upper intestinal bleeding

In assessing the mood of older adult patients, a nurse documents which finding as abnormal? a. Sadness and grief after returning from the funeral of a long-time friend b. Depression that interferes with the ability to perform activities of daily living c. Frustration about rearranging the day's schedule to attend a grandson's birthday party d. Crying about the unexpected death of a pet that had been with the family 12 years

On inspection of the eye of an 82-year-old woman, the nurse notes which finding as normal? a. Opaque coloring of the lens b. Clear cornea with a gray-white ring around the limbus c. Dilated pupils when looking at an item in her hand d. Impaired perception of the colors yellow and red

The edges of a patient's appendectomy incision are approximated, and no drainage is noted. Which type of healing would be applied? a. granulation b. primary intention c. tertiary intention d. secondary intention

The nurse asks an elderly patient to get out of the bed slowly, sit, and then stand up to prevent orthostatic hypotension. Which rationale explains the purpose of giving these instructions to the patient? a. to develop short term memory b. to warm up the core body temperature c. to improve the bodys protective barrier d. to avert falls from blood pressure changes

The nurse is teaching a group of adolescents about the use of condoms. Which statement made by a learner indicates the need for further teaching? a. i should check the expiration date found b. i should use oil base lubricants along with the condoms c. i should not reuse a condom after sexual intercourses d. i should use condoms made of laxtex or polyurethane

The patient tells the nurse that she has clay-colored stools. Stool of this color results from: a. intestinal tract bleeding. b. lack of bile pigment. c. excessive dietary beef. d. insufficient fluid intake.

The student nurse is studying the changes a woman goes through during pregnancy. The student nurse knows that which body system undergoes the most dramatic physiologic changes during pregnancy? a. the skin b. the cardiovascular system c. the urinary system d. the gastrointestinal system

What is the definition of proprioception? a. orientation to time, place, and person b. awareness of posture and movement c. perception of pressure over the palmar and plantar surfaces d. perception of abnormal thermal sensation on the skin

Which assessment finding is most commonly observed in patients who have suffered strokes? a. spasticity b. hemiplegia c. paraplegia d. quadriplegia

Which condition is most commonly associated with damage to the lower spinal cord? a. hemiparesis b. paraplegia c. quadriplegia d. hemiplegia

Which mineral supplement is most likely to be included in the medication list for a patient with osteoporosis? a. zinc b. calcium c. sodium d. iron

Which nursing intervention would prevent venous stasis in a patient who has a lower limb wound? a. raising the bed height to a higher level b. elevating the patient's leg for 30 minutes c. ensuring the bandage is clean and rolled d. exposing the wound for some time before wrapping it

Which statement regarding the comparison of the circumference between the right and left extremities is true? a. Measurements between the right and left sides should be identical. b. Measurement differences are less than 1 cm. c. Measurement differences are within 2 cm. d. Measurement differences are within 2 inches.

While taking the health history of a 23-year-old female patient, the nurse considers risk factors for STD. Which data from the patient suggest a need for patient education? a. She has been in a monogamous sexual relationship for 2 years; she uses a condom to prevent pregnancy. b. She has been sexually involved with one man for the last 2 weeks; she uses spermicidal gel to prevent pregnancy. c. She has a Pap test each year and the results have been negative. d. She uses oral contraceptives to prevent pregnancy.

While testing a patient's bicep muscle strength, the nurse applies resistance and asks the patient to perform which motion? a. Extension of the arm b. Flexion of the arm c. Adduction of the arm d. Abduction of the arm

A 50-year-old male patient comes for a follow-up visit a few months after a myocardial infarction. The nurse plans to interview the patient to assess his sexual health using the PLISSIT model. Which components are included in the PLISSIT model of assessment? Select all that apply. a. palliation b. permission c. limited information d. specific suggestions e. intravenous therapy

b, c, d

A patient presents with decreased libido, depression, and difficulty coping. Which nursing interventions would be helpful for the patient? Select all that apply. a. formulate a nutrition plan for the patient b. assess the causes of coping difficulties c. help the patient to set realistic goals d. encourage the patient to express the feelings e. explain to the patient about the condoms

b, c, d

The nurse is caring for a patient who has received the medication haloperidol. Which side effects would the nurse expect in the patient? Select all that apply. a. vaginal dryness b. erectile dysfunction c. loss of sexual desire d. ejaculation dysfunction e. increased testosterone levels

b, c, d

Arrange the assessments in the order a pregnant patient would receive them, beginning with prenatal screening and continuing through the third trimester. a. obtain a vaginal smear for group B streptococci b. check for human immunodeficiency virus (HIV), neissseria gonorrhoeae, and human papillomavirus (HPV) c. test for gestational diabetes d. screen for any neural tube defects and trisomy 21 e. get a tuberculin skin test

b, d, e, c, a

A 48-year-old woman asks the nurse how to best protect herself from excessive sun exposure while at the beach. Which response would be most appropriate? a. "Limit your time in the sun to 5 minutes every hour." b. "Wear a wet suit that covers your arms and legs." c. "Apply a waterproof sunscreen (SPF 15 or higher) to exposed skin surfaces; reapply at least every 2 hours." d. "Apply sunscreen with a minimum SPF 50 to all skin surfaces before leaving for the beach; this will provide all-day coverage."

A nurse is using the Braden Scale. Which characteristic about a patient is the nurse assessing? a. perception of pain b. fall risk c. risk for skin breakdown d. risk of venous thrombosis

A patient comes to the clinic for a skin check. Which finding by the nurse indicates a need to further investigate a lesion? a. The lesion is dark brown. b. The lesion has been present for 20 years. c. The lesion bleeds easily when it is touched. d. The lesion is slightly raised and circumscribed.

A patient has edema and redness of the skin surrounding the nail on his right index finger. Which data elicited from his history best explains this condition? a. He has a family history of liver disease. b. There has been a scabies outbreak among his family members. c. He has a new full-time position as a dishwasher at a local restaurant. d. He had several warts removed from his hands 2 years ago.

A patient is concerned because the dermatologist diagnosed macules all over the skin. The patient asks the nurse what could be causing this? The nurse's best response is: a. "Macules need to be watched closely for signs of skin cancer." b. "Macules are warts and should be removed." c. "Macules are freckles are considered normal on the skin." d. "You have an infection and will need an antibiotic."

A pregnant patient in her first trimester is complaining of nausea. The patient asks why she feels so sick. The nurse explains that anorexia and nausea are common to the first trimester of pregnancy because of which of the following? a. low iron levels b. nocturia c. elevated levels of human chorionic gonadotropin d. heartburn and constipation

A woman comes to the clinic for a general health checkup. The patient wants more information about intrauterine devices (IUDs). Which information would the nurse include when teaching the patient about IUDs? a. it is an oral medication to be consumed regularly b. it is a surgery in which fallopian tubes are ligated c. it is a copper or plastic contraceptive device that is inserted in the uterus through the cervical opening d. it is a round rubber dome that is inserted in the vagina with spermicide and acts as barrier during intercourse

After surgery the patient with a closed abdominal wound reports a sudden "pop" after coughing. When the nurse examines the surgical wound site, the sutures are open, and pieces of small bowel are noted at the bottom of the now-opened wound. Which corrective intervention should the nurse do first? a. allow the area to be exposed to air until all drainage has stopped b. place several cold packs over the area, protecting the skin around the wound c. cover the area with sterile, saline-soaked towels and immediately notify the surgical team; this is likely to indicate a wound evisceration d. cover the area with sterile guaze, place a tight binder over it, and ask the patient to remain in bed for 30 minutes because this is a minor opening in the surgical wound and should reseal quickly

The nurse is caring for a pregnant patient who is nervous about having a cesarean delivery. The nurse says, "Don't worry. You may not need a cesarean section." Which action is the nurse performing? a. acting defensively b. advising the patient c. giving false reassurance d. giving a generalized response

An adolescent tells a nurse that, while he was riding in a friend's car, the friend was stopped by the police for driving while intoxicated. Which assessment tool would be most appropriate to use with this adolescent? a. Faces Pain Scale b. Pediatric Symptom Checklist (PSC) c. Guidelines for Adolescent Prevention (GAP) d. Oucher Scales

During an examination the nurse palpates the Skene's glands. Which technique best describes this process? a. Exerting pressure over the clitoris, slide the finger downward (posteriorly) toward the vaginal opening. b. Palpate the fourchette and slide the finger forward (anteriorly) toward the vaginal opening. c. Exert pressure on the anterior vaginal wall and slide the finger outward toward the vaginal opening. d. Grasp the labia majora between the index finger and thumb and milk the labia outward

During examination of a patient's neck with the bell of the stethoscope, the nurse identifies a carotid bruit. When are bruits audible in the neck? a. When jugular vein distention is present b. During normal examination of the neck c. When the carotid artery is partially occluded d. With complete occlusion of both carotid arteries

The nurse is assessing a 72-year-old's spinal column. Which spinal finding would be considered normal for a 72-year-old patient? a. Meningocele b. Myelomeningocele c. Kyphosis d. Scoliosis

The nurse is assessing a newborn and hears a click when the Barlow-Ortolani maneuver is performed. What would this finding indicate? a. An indication of Erb's palsy b. A possible indication of spina bifida c. An indication of congenital hip dislocation d. A normal finding in the newborn

The nurse is assessing a patient's internal rotation of the shoulder joint. How should the nurse direct the patient? a. "Place your right hand behind the left side of your head." b. "Elevate your right arm over your head." c. "Place your right hand against the small of your back." d. "Rotate the palm of your hand up and down."

The nurse is assessing an African-American patient for cyanosis. Cyanosis in dark pigmented skin appears as a(n): a. yellowish-green skin. b. deeper tone of brown or purple. c. Ashen gray color to the skin. d. cluster of dark spots over the skin surface.

The nurse is assessing the risks of colorectal cancer for a group of patients. Which patient has a known risk factor for colorectal cancer? a. Steven, a 21-year-old college student who is a vegetarian b. Marie, a 22-year-old mother who has multiple hemorrhoids c. Susan, a 38-year-old female with a 15-year history of ulcerative colitis d. Jack, a 40-year-old man with frequent constipation

The nurse is caring for a child with quadriplegia and observes that the child shows interest in playing computer games. Which device can help the child engage in this activity? a. eyeglasses b. hearing aid c. voice activated computer d. power operated wheelchair

The nurse is comparing the right and left legs of a patient and notices that they are asymmetric. Which additional data does the nurse collect at this time? a. Passively moves each leg through range of motion and compares the findings b. Observes the patient's gait and legs as he or she walks across the room c. Measures the length of each leg and compares the findings d. Palpates the joints and muscles of each leg and compares the findings

The nurse is palpating the fundal height of a pregnant patient. The nurse knows that to determine fundal height, one needs to measure from the__ to the top of the fundus. a. umbilicus b. perineum c. symphysis pubis d. xiphoid process

To inspect the glans penis of the uncircumcised male, the nurse retracts the foreskin. After inspection she is unable to replace the foreskin over the glans. The nurse recognizes that this situation could potentially lead to which complication? a. Decreased sperm production b. Urinary tract infection c. Tissue necrosis of the penis d. Testicular cancer

Which action by a patient with a family history of macular degeneration would demonstrate use of a prevention strategy that has been found to help prevent deterioration of the macula? a. Using medicated eyedrops b. Avoiding the use of sunglasses c. Taking vitamin B6 and B12 supplements d. Minimizing dietary intake of antioxidants

Which action by the nurse would be most effective in determining whether a patient has muscle hypertonicity? a. Watching the patient walk to the bathroom b. Asking the patient to squeeze both hands of the nurse c. Performing passive range-of-motion exercises with the patient d. Checking the patient's spine for the presence of postural irregularities

Which device should the nurse use to reduce the risk of external hip rotation in a patient recovering from hip surgery? a. quad cane b. trapeze bar c. trochanter roll d. ankle foot orthotic (AFO) splint

Which primary contraceptive action is indicative of an intrauterine device (IUD)? a. it prevents ovulation b. it acts as a physical barrier c. it prevents fertilization d. it kills sperm cells

While examining the ear of an infant with an otoscope, the nurse pulls down on the ear for which reason? a. Increases the depth that the otoscope can be inserted b. Stabilizes the ear to avoid injury if the infant moves the head suddenly c. Enhances visualization of the tympanic membrane by straightening the ear canal d. Facilitates drainage of cerumen from the ear canal, allowing better visualization of inner ear structures

With the patient in a supine position, how does a nurse test the external rotation of the patient's right hip? a. Asking the patient to move the right leg laterally with the right knee straight b. Asking the patient to flex the right knee and turn medially toward the left side (inward) c. Asking the patient to place the right heel on the left patella d. Asking the patient to raise the right leg straight up and perpendicular to the body

what factor increases the risk of wound infection? a. absence of necrotic tissue b. absence of foreign body in wound c. reduced local tissue defenses d. adequate blood supply

which findings characterize contracture? a. muscle wasting b. altered awareness of posture and movement c. permanent fixation of a joint d. spontaneous bone break without trauma

A patient with multiple fractures has casts that make it difficult to move voluntarily. A nurse notices red skin in the spinal area that blanches on applying pressure. Which measures does the nurse take to decrease the risk of development of pressure ulcers in this patient? Select all that apply. a. position the patient in the most comfortable position and do not move b. cover the hyperemic skin area with a sterile dressing and apply antiseptics c. check the skin around the casts regularly for any signs of impaired skin integrity d. take care to avoid friction injuries during repositioning, bathing, or transferring of the patient e. use good hygiene techniques to ensure the patient's skin is clean and dry after bowel movements

c, d, e

A 60-year-old male patient states that he has a sore above his lip that has not healed and is getting bigger. The nurse observes a red scaly patch with an ulcerated center and sharp margins. These findings are commonly associated with which malignancy? a. Kaposi's sarcoma b. Malignant melanoma c. Basal cell carcinoma d. Squamous cell carcinoma

which sequence best identifies the order in which the nurse should complete an abdominal assessment? a. Inspection, palpation, percussion, auscultation b. Auscultation, inspection, palpation, percussion c. Auscultation, palpation, percussion, inspection d. Inspection, auscultation, palpation, percussion

Which complications does the nurse anticipate in the client who has blue-colored nail beds?

cardiopulmonary disease

problems linked with ligament or muscle conditions are known as

carpal tunnel syndrome

what are examples of probable signs of pregnancy

chadwicks sign (violet blue color to cervix), goodell's sign (softening of the cervix), hegar's sign (softening of lower uterine segment), positive pregnant test (hCG), serum, urine, ballottement

range of motion: hip moving leg in a circle

circumduction

range of motion: shoulder move arm in full circle; combination of all movements of ball and socket joint

circumduction

what is the most common eye condition in children

conjunctivitis

most common skin conditions encountered

corns, dermatitis, psoriasis

The nurse that is examining a patient with normal muscle strength would document Grade __. a. 0 b. 1 c. 3 d. 5

A male patient indicates that he has sex with multiple partners and that he does not use protection. The most appropriate response is: a. "Are your partners using birth control?" b. "You should avoid sex until you are married." c. "How well do you know your partners?" d. "Many men use condoms to protect themselves from disease and pregnancy."

A nurse administers an analgesic medication to a patient with a stage IV pressure ulcer who needs to have a dressing change. When does the nurse perform the dressing change in relation to administering the analgesic? a. before the administration b. 90 minutes after administration c. immediately after administration d. 30 minutes after administration

A nurse assesses a patient who comes to the pulmonary clinic. "I see that it's been over 6 months since you've been in, but your appointment was for every 2 months. Tell me about that. Also I see from your last visit that the doctor recommended routine exercise. Can you tell me how successful you have been following his plan?" Which functional health pattern in Gordon's model does the nurse's assessment cover? a. value-belief b. cognitive-perceptual c. coping-stress-tolerance d. health perception-health management

A nurse is caring for a patient who is a sex worker. Which sexually transmitted diseases can the patient be vaccinated against? a. human immunodeficiency virus (HIV) b. herpes c. chlamydia d. human papillomavirus (HPV) infection

A patient is prescribed antihypertensive therapy. Which information should the nurse provide to the patient about sexual activity? a. the patient may have delayed ejaculation b. the patients sexual desire may increase c. the medication may lessen vaginal lubrication d. the medication may cause erectile dysfunction

During an assessment of a young adult, the nurse notes that the patient's shoulders are uneven. Which examination would the nurse perform for further data? a. Ask the patient to rotate each shoulder to assess for range of motion. b. Ask the patient to push against the nurse's hands with his or her forearm to test muscle strength. c. Ask the patient to shrug his or her shoulders while the nurse pushes them down to test the muscle strength. d. Ask the patient to bend forward at the waist while the nurse checks the alignment of the patient's vertebrae

During an initial prenatal visit the nurse identifies which factor as consistent with a high-risk pregnancy? a. Patient is 18 years old. b. Patient height is 5 feet 4 inches. c. Birth weight of infant with last pregnancy was 2800 g. d. Patient smokes one-half pack of cigarettes a day.

How does the nurse determine if a patient's musculoskeletal examination is normal? a. By reading the examination findings documented in the patient's chart b. By comparing findings from other patients in the same age group c. By reading descriptions in health assessment books d. By comparing the patient's left side with the right side

On assessment of the neurologic status of a 4-month-old infant, the nurse notes which finding as abnormal? a. The infant abducts and extends arms and legs when startled. b. When the infant's sole is touched, the toes flex tightly in an attempt to grasp. c. When stroking the infant's foot from sole to great toes, there is fanning of the toes. d. The infant steps in place when held upright with feet on a flat surface

The nurse assesses that a woman in her eighth month of pregnancy has a wide thoracic cage. What best explains this finding? a. she may have a lung disease such as emphysema b. she may be hypoxic and may require oxygen c. this is a finding seen only in women carrying multiple fetuses d. this is considered a normal finding with advanced pregnancy

The nurse fits elastic stockings on a patient following major abdominal surgery. The nurse explains to the patient that the stockings help prevent which condition? a. varicose veins b. muscular atrophy c. joint contractures d. deep vein thrombosis

The nurse is assessing a patient for nail clubbing. Where should the nurse focus the exam? a. The width of the nail base b. The color of the nail c. The thickness of the nail d. The angle of the nail base

The nurse is assessing a patient's skin turgor. Skin turgor is assessed by: a. auscultating the skin to note the presence of motility sounds. b. pressing on the skin and observing the depression. c. stretching the skin and observing for a degree of flexibility. d. pinching the skin and watching the skin return to place.

The nurse makes an introduction and explains the procedure of wound care to the patient. The nurse then performs hand hygiene and checks the patient's treatment plan. Which specific intervention facilitates the patient's cooperation with wound care? a. making an introduction b. performing hand hygiene c. checking the care plan of the patient d. explaining the wound care procedure

The nurse notes the presence of ptosis when assessing an adult patient's eyes. Which potential cause would be considered of most concern, requiring further evaluation as soon as possible? a. Loss of skin elasticity b. Levator muscle weakness c. Congenital ocular abnormality d. Oculomotor cranial nerve III paralysis

The nurse notes which finding as abnormal during a thoracic assessment of an older adult? a. A skeletal deformity affecting curvature of the spine b. Shortness of breath on exertion c. An increase in anteroposterior diameter d. Bronchovesicular breath sounds in the peripheral lung fields

the _____ is the outermost layer and provides no blood supply

epidermis

What is an expected finding of the newborn's vision that the nurse teaches the parents? a. Small tears will be noted when their newborn cries. b. Peripheral sight does not develop until age 3 or 4 months. c. The newborn can only distinguish the colors of blue and green. d. The newborn is nearsighted and cannot see items unless they are close.

What is the nurse assessing when measuring from the patient's symphysis pubis to the top of the fundus? a. Fetal development b. Fetal lie and position c. Attitude of the fetus d. Gestational age

When a nurse asks a patient to place the right arm behind the head, the nurse is testing for which range of motion? a. Flexion of the elbow b. Hyperextension of the shoulder c. Internal rotation and adduction of the shoulder d. External rotation and abduction of the shoulder

When examining a 16-year-old male patient, the nurse notes multiple pustules and comedones on the face. The nurse recognizes that increased activity of which cells or glands produce these manifestations? a. Epidermal cells b. Eccrine glands c. Apocrine glands d. Sebaceous glands

When examining the genitalia of a 3-year-old boy, which position is ideal? a. Prone position with legs flexed in a frog leg position b. Supine position with knees spread and ankles spread apart c. Lithotomy position with knees and ankles spread apart d. Sitting position with knees spread and ankles crossed

When repositioning an immobile patient, the nurse notices redness over a bony prominence. Which condition is indicated when a reddened area blanches on fingertip touch? a. a local skin infection requiring antibiotics b. sensitive skin that requires special bed linen c. a stage III pressure ulcer needing the appropriate dressing d. blanching, hyperemia, indicating the attempt by the body to overcome the ischemic episode

Which are expected findings of a newborn's respiratory assessment? a. Thoracic breathing b. A 1:2 ratio of anteroposterior-to-lateral diameter c. Flaring of the nares noted on inspiration d. Bronchovesicular breath sounds in the peripheral lung fields

Which data collected from the history of a 32-year-old female patient should be followed with a symptom analysis? a. Has never had a mammogram. b. Experiences light to moderate bleeding during menstrual cycle. c. Periods began at age 12; has never been pregnant. d. Has pelvic pain and vaginal discharge.

Which disorder is an example of a vascular lesion? a. Dermatofibroma b. Vitiligo c. Sebaceous cyst d. Port wine stain

Which process occurs during the proliferative phase of wound healing in a patient? a. homeostasis b. wound cleaning c. scar tissue formation d. granulation tissue formation

Which topic would the nurse discuss with senior citizens about the leading cause of injury in older adults? a. drowning b. illicit drug use c. work related hazards d. complications from falls

a bite from an infected tick can give you

lyme disease

ecchymosis (bruise) in dark skinned patients

deeper bluish or black tone; difficult to see unless it occurs in an area of light pigmentation

erythema in dark skinned patients

deeper brown or purple skin tone with evidence of increased skin temperature secondary to inflammation

thick middle layer of skin between the epidermis and the deeper subcutaneous layer

dermis

amniocentesis

detects birth defects

the ___ history of a pediatric patient includes typical diet, intolerances, allergies, supplements, meal time routines, snacks, and any concerns about diet or weight

diet

mobility - pain

differentiate b/w joint pain vs bone pain vs muscle pain

petechaie in dark skinned patients

difficult to see; may be evident in the buccal mucosa of the mouth or sclera of the eye

range of motion: ankle moving foot so toes point upward

dorsiflexion

the _____ are responsible for transporting sperm

ducts

what are skene's glands

during sexual intercourse, they secrete a lubricating fluid

what are nails

epidermal cells converted to hard plates of keratin

the _____ is a layer which is highly vascular, regulates temperature, and contains nerve fibers that provide reactions to touch, pain, and temperature

epidermis

reddened skin color, dusky coloring of lips and feet, fine hair covering skin, asymmetric head due to molding, edema to eyelids, symmetric ears, pink moist mucosa, rounded thorax, faster HR and RR, equal movement and length of extremities

expected newborn findings

range of motion: elbow straighten elbow by lowering hand

extension

range of motion: hip moving leg back beside other leg

extension

range of motion: knee returning heel to floor

extension

range of motion: neck and cervical spine returning head to erect position

extension

range of motion: shoulder return arm to position at side of body

extension

range of motion: thumb moving thumb straight away from hand

extension

range of motion: toes straighten toes

extension

range of motion: wrist moving fingers, hand, and forearm into same place

extension

range of motion: hip turning knee outward

external rotation

range of motion: shoulder with elbow fixed, move arm until thumb is upward and lateral to head

external rotation

the ________ capture and draw ova into the tube for fertilization

fallopian tubes

older individuals are at greater risk for what in regards to mobility

falls

________ pulses should be felt in children

femoral

abnormal connections between two organs or between an internal organ and through the skin

fistula

range of motion: elbow bend elbow so lower arm moves towards shoulder joints and hand is level with shoulder

flexion

range of motion: hip moving leg forward and up

flexion

range of motion: wrist moving palms towards inner aspect of the arm

flexion

range of motion: fingers make fist

flextion

this patient has complete range of motion against gravity with full resistance, how would you grade this and how would you record this on the lovett scale

grade: 5 lovett scale: normal (N)

cyanosis in light skinned patients

grayish-blue tone in nail beds, earlobes, lips, mucous membranes, palms, soles of feet

what does it mean if your stool is bright red

hemorrhoidal or lower rectal bleeding

what are common conditions related to the spine

herniated nucleus pulposus and scoliosis

range of motion: elbow bend lower arm back as far as possible, not all elbows hyperextend

hyperextension

range of motion: fingers bend fingers back as far as possible

hyperextension

range of motion: hip moving leg behind body

hyperextension

range of motion: wrist bringing dorsal surface of hand back as far as possible

hyperextension

blanching includes..

pressing on nail bed, color should come back in less than 3 seconds

preventive measures should be taken immediately if the patient is at risk for developing this skin integrity problem

pressure ulcer

the most commonly reported skin condition is ______

pruritus (itching)

itching

purritis

containing pus; green drainage

purulent

range of motion: wrist bend wrist medially towards thumbs

radial flexion

describe cultural sensitivity

recognition of the often pronounced differences among cultures

the ___ and ____ make up the end of the gastrointestinal tract and are considered to be included in the perineal structures

rectum and anus

erythema in light skinned patients

reddish tone with evidence of increased skin temperature secondary to inflammation

what do eccrine sweat glands do

regulate body temperature by water secretion through the surface of the skin; found in palms of hands, soles of feet, and forehead

what is ovulation

release of an ovum (egg); occurs as part of the monthly menstrual cycle

what are common problems associated with joints

rheumatoid arthritis, osteoarthritis, bursitis, and gout

state the infantile reflex: brush the infants cheek near corner of mouth and infant will turn head toward stimulus and open mouth slightly

rooting response (awake)

range of motion: neck and cervical spine turning head as far as possible to left and right

rotation

a skin condition associated with a mite and is highly contagious is known as

scabies

the _____ is the pouch that contains the testis, epididymis, and spermatic cord

scrotum

what are bartholin's glands

secrete a mucoid material into the vaginal orifice for lubrication during sexual excitement

what do apocrine sweat glands do

secretion begins at puberty and is influenced by hormones; odorless fluid is secreted containing protein, carbs, and other substances

menstrual cycle: stage 4

secretory phase - days 15-20 after ovulation, FSH and LH decline; egg moves into uterus; secretion of progesterone rises and estrogen declines; uterine wall continues to thicken

describe culturally congruent care

sensitive, creative, safe, and meaningful ways to promote the health and well being of individual people or groups and improve their ability to face death, disability, or difficult human life conditions

reproduction - family history

•Breast cancer

reproduction - personal/psychosocial

•Breast self-exam (BSE) monthly at same point in cycle (menopausal women just pick a day of the month, like birthday) - actually more helpful than Clinical breast exam (CBE) because patient knows own breasts, MD examines them once/year •Should include examination of armpits (lymph nodes located there) •Use a thorough pattern of palpation to be sure all areas are checked •Clinical breast exam (CBE) once/year

tissue integrity - family history

•Cancer •Autoimmune disorders, may manifest with symptoms like skin rash or alopecia

tissue integrity - moles

•Changing or irregular mole may be a sign of malignancy (cancer) - changes in color, size, or shape

tissue integrity - present health status

•Chronic illness: liver failure (jaundice), renal failure, autoimmune diseases cause changes to the skin (i.e., pruritus, dryness, skin lesions) •Meds can cause side effects that are manifested in skin, including allergic reactions (i.e., hives, rashes, photosensitivity, acne, thinning of skin, stretch marks) •Occupational exposure to chemicals - can be absorbed through the skin

tissue integrity - inspection skin

•Color - should be consistent as the rest of the body •Moles, Freckles, Birthmark, Striae - all considered normal variations

tissue integrity - nail inspection

•Color - should be pinkish •Cleanliness - should be relatively free of dirt •Markings - should be smooth •Shape - slight rounded is normal •Angle - assess for clubbing

reproduction - pregnancy monitoring

•First & Second Trimester - visits are monthly •Third Trimester (at 28 weeks) - visits are every 2 weeks •Third Trimester (at 36 weeks) - visits are weekly

tissue integrity - hair distribution

•Hair that is dry, easily pluckable can be stress or systemic disease (i.e., protein deficiency, alopecia)

mobility - lower extremities

•Inspect hips for symmetry and height •Inspect knees for symmetry and alignment •Inspect ankles and feet for symmetry and alignment •Observe range of motion of hips, knees, and ankles •Test muscle and joint strength of hips, knees, and ankles

mobility - head

•Inspect musculature of the face for symmetry •Ask patient to open and close mouth, and to smile •Palpate the temporomandibular joint for movement, sounds, and tenderness •Audible sound or palpable snapping or clicking without other symptoms is normal •Observe jaw motion

mobility - neck

•Inspect neck for symmetry and musculature •Palpate the anterior and posterior neck for tenderness •Observe neck range of motion (passive) •Test neck strength

reproduction - gynecologic and obstetric history

•Last menstrual Period (LMP) •Nagele's Rule: (LMP - 3 months) + 7 days = helps determine approximate due date •Gravidity (G) = number of pregnancies, including current •Full term births (T) = number of full term births •Preterm births (P) = number of preterm births •Abortions (A) = number of abortions •Living children (L) = number of living children

tissue integrity assessment

•Location - clear anatomical terminology •Size - use a measuring device (i.e. ruler, etc.) •Presence of Tunneling •Drainage - color, consistency, odor, amount •Conditions of wound edges and surrounding tissue •Wound bed

mobility - children and toddlers

•Motor Development Tables - compare data with tables of normal age and sequence of motor development •Measure height and compare values to tables of percentiles for growth •Trendelenburg Sign - test for hip dysplasia •Stand on one leg •Pelvis should NOT tilt downwards on opposite leg •**If tilt is noted = hip dysplasia*

mobility - newborn and infants

•Positioning - undressed and lying supine •Clavicles - palpate for fractures •Stable and smooth clavicles without crepitus •Arms and legs should have equal and spontaneous movement •Arms and legs should be equal in length •Hips •Barlow and Ortlani Maneuver - performed until 3 months •The infant is supine •Flex the infant's knees holding inner thighs with thumbs •Adduct the legs exerting downward pressure •Abduct the legs by moving the knees apart and down toward the table •**Should feel smooth with NO CLICKS •Allis' Sign •Infant is lying supine •Flex the knees with the feet flat on the table and align the femurs •Knees should be the same height

reproduction - general health history

•Present Health Status - current illnesses, medications. Allergies •Past Health History - medical and surgical •Family History •Personal and Psychosocial History •Attitude toward pregnancy •Nutritional history •Tobacco, alcohol, and illicit drug use •Environment

reproduction - high risk pregnancies

•Smoking •Sexually transmitted diseases (STDs) •Cancer •Diabetes

reproduction - present health status

•Some meds can cause breast discomfort or discharge •Caffeine-containing foods (chocolate)/ coffee can cause benign breast disease (cysts)

tissue integrity - pressure ulcer stages (4)

•Stage 1 - intact, non-blistered skin with non-blanchable erythema •Stage 2 - a partial thickness that involves the epidermis and/or dermis, but does not extend below the dermis •Stage 3 - full thickness wounds that extend into the subcutaneous tissue but do not extend through the fascia to muscle, bone, or connective tissue •Stage 4 - involves exposure of muscle, bone, or connective tissue •Unstageable - full thickness where the necrotic tissue, or eschar, in the wound bed makes it impossible to assess the depth - deep tissue - area of intact skin that is purple or maroon or a blood filled blister

tissue integrity - palpate skin

•Texture - should be smooth, soft, intact, and even •Temperature - dorsal aspect of the hand, should be warm (hands and feet may be cooler) •Turgor - previously discussed during perfusion •Edema - previously discussed during perfusion •Moisture - dry, minimal perspiration

tissue integrity - skin color

•Vitiligo (Michael Jackson) •Also poor perfusion, interpersonal violence •Assess if explanation matches discoloration (i.e., "fell into a door" but bruises in the shape of an open hand) •Cyanosis/pallor - can indicate poor perfusion (decreased BP) or poor gas exchange (decreased SpO2)

NUR 220A Final Exam

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