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Adult Health 1 - P&P Ch. 30 Review

Terms in this set (172)

The nurse prepares to conduct a general survey on an adult patient. Which assessment is performed first while the nurse initiates the nurse-patient relationship?

1 Appearance and behavior

2 Measurement of vital signs

3 Observing specific body systems

4 Conducting a detailed health history
Appearance and behavior
The nurse is teaching a young mother to palpate her 8-year-old child to quickly evaluate if the child has a fever. Which information is important for the nurse to include?

1 Place the palm of the hand on the child's back.

2 Lightly touch the child's forehead with the fingertips.

3 Place the back of your hand against the child's forehead and then on the back of the neck.

4 Use the pads of your fingers and press against the child's neck and over the thorax.
Place the back of your hand against the child's forehead and then on the back of the neck.
While assessing the adult patient's lungs, the nurse identifies the following assessment findings. Which finding should be reported to the health care provider?

1 Respiratory rate: 14

2 Pain reported when palpating posterior lower thorax

3 Thorax rising and falling symmetrically for right and left lungs

4 Vesicular breath sounds heard with auscultation of peripheral lung fields
Pain reported when palpating posterior lower thorax
The nurse is teaching a young female patient to practice good skin health. Which information is important for the nurse to include?

1 Avoid sunbathing between 3 PM and 7 PM.

2 Oral contraceptives and antiinflammatories make the skin more sensitive to the sun.

3 Call the health care provider for the presence of a mole on an arm or leg that appears uniformly brown.

4 Wear sunscreen with an SPF of 30 or greater if using a sunlamp or tanning parlor.
Oral contraceptives and antiinflammatories make the skin more sensitive to the sun.
As a nurse prepares to provide morning care and treatments, it is important to question a patient about a latex allergy before which intervention? (Select all that apply.)

1 Applying adhesive tape to anchor a nasogastric tube

2 Inserting a rubber Foley catheter into the patient's bladder

3 Providing oral hygiene using a standard toothbrush and toothpaste

4 Giving an injection using plastic syringes with rubber-coated plungers

5 Applying a transparent wound dressing
-Applying adhesive tape to anchor a nasogastric tube
-Inserting a rubber Foley catheter into the patient's bladder
-Giving an injection using plastic syringes with rubber-coated plungers
The nurse is assessing a patient who returned 3 hours ago from a cardiac catheterization, during which the large catheter was inserted into the patient's femoral artery in the right groin. Which assessment finding would require immediate follow-up?

1 Palpation of a femoral pulse with a heart rate of 76

2 Auscultation of a heart murmur over the left thorax

3 Identification of mild bruising at the catheter insertion site

4 Palpation of a right dorsalis pedis pulse with strength of +1
Palpation of a right dorsalis pedis pulse with strength of +1
The patient reports having a sore throat, coughing, and sneezing. While performing a focused assessment, which finding supports the patient's reported symptoms related to upper respiratory infection?

1 Buccal mucosa is moist and dark pink.

2 Respiratory rate is 18, rhythm is even.

3 Retropharyngeal lymph nodes are enlarged and firm.

4 Inspection with a tongue depressor on the posterior tongue causes gagging.
Retropharyngeal lymph nodes are enlarged and firm.
The nurse is teaching a patient with poor arterial circulation about checking blood flow in the legs. Which information should the nurse include? (Select all that apply.)

1 A normal pulse on the top of the foot indicates adequate blood flow to the foot.

2 To locate the dorsalis pedis pulse, take the fingers and palpate behind the knee

3 When there is poor arterial blood flow, the leg is generally warm to the touch.

4 Loss of hair on the lower leg indicates a long-term problem with arterial blood flow
-A normal pulse on the top of the foot indicates adequate blood flow to the foot.
-Loss of hair on the lower leg indicates a long-term problem with arterial blood flow.
How should the patient be positioned to best palpate for lumps or tumors during an examination of the right breast?

1 Supine with both arms overhead with palms upward

2 Sitting with hands clasped just above the umbilicus

3 Supine with the right arm abducted and hand under the head and neck

4 Lying on the right side, adducting the right arm on the side of the body
Supine with the right arm abducted and hand under the head and neck
The nurse is planning a staff education conference about abdominal assessment. Which point is important for the nurse to include?

1 The aorta can be felt using deep palpation in the upper abdomen near the midline.

2 The patient should be sitting to best determine the contour and shape of the abdomen.

3 Always wear gloves when palpating the skin on the patient's abdomen.

4 Avoid palpating the abdomen if the patient reports any discomfort or feelings of fullness.
The aorta can be felt using deep palpation in the upper abdomen near the midline.
The nurse is teaching a patient how to perform a testicular self-examination. Which statement by the nurse is correct?

1 "The testes are normally round and feel smooth and rubbery."

2 "The best time to do a testicular self-examination is before your bath or shower."

3 "Perform a testicular self-examination weekly to detect signs of testicular cancer."

4 "Since you are over 40 years old, you are in the highest risk group for testicular cancer."
"The testes are normally round and feel smooth and rubbery."
The patient is assessed for range of joint movement. He or she is unable to move the right arm above the shoulder. How should the nurse document this finding?

1 Patient was not able to flex arm at shoulder.

2 Extension of right arm is limited.

3 Patient's abduction of right arm was limited to 100 degrees.

4 Internal rotation of right arm is limited to less than 90 degrees.
Patient's abduction of right arm was limited to 100 degrees.
The nurse plans to assess the patient's abstract reasoning. Which task should the nurse ask the patient to perform?

1 "Tell me where you are."

2 "What can you tell me about your illness?"

3 "Repeat these numbers back to me: 7...5...8."

4 "What does this mean: 'A stitch in time saves nine?'
"What does this mean: 'A stitch in time saves nine?'"
The nurse teaches a patient about cranial nerves to help explain why the patient's right side of the mouth droops instead of moving up into a smile. What nerve does the nurse explain to the patient?

1 VII—Facial

2 V—Trigeminal

3 XII—Hypoglossal

4 XI—Spinal accessory
VII—Facial
The nurse is planning to teach the student nurse how to assess the hydration status of an older adult. Which techniques are appropriate for this situation? (Select all that apply.)

1 Inspect the lips and mucous membranes to determine if they are moist.

2 Pinch the skin on the back of the hand to see if the skin tents.

3 Check the patient's pulse and blood pressure.

4 Weigh the patient daily
-Inspect the lips and mucous membranes to determine if they are moist.
-Check the patient's pulse and blood pressure.
-Weigh the patient daily.
List the five nursing purposes for performing a physical assessment:
1. Gather baseline data about the patient's health status
2. Support or refute subjective data obtained in the nursing history
3. Identify and confirm nursing diagnoses
4. Make clinical decisions about a patient"s changing health status and management
5. Evaluate the outcomes of care
List the principles related to the nurse performing daily physical examinations
1. A head to toe physical assessment is required daily
2. Reassessment is performed when the patient's conditions changes as it improves or worsens
3. The environment, equipment, and patient are properly prepared
4. Safety for confused patients should be a priority
Proper preparation for examination should include:
1. Infection control
2. Environment
3. Equipment
4. Physical preparation of the patient
5. Psychological preparation of the patient
List seven variations in the nurse's individual style that are appropriate when examining children:
1. Gather all or part of the histories of infants and children from patients
2. Perform the examination in a nonthreatening area and provide time for play
3. Offer support to the parents during the examination and do not pass judgement
4. Call children by their first names and address parents as Mr. and Mrs.
5. Use open-ended questions to allow parents to share more information
6. Treat adolescents as adults
7. Provide confidentiality for adolescents; speak alone with them
List seven variations in the nurse's individual style that are appropriate when examining older adults:
1. Do not stereotype about aging patients' level of cognition
2. Be sensitive to sensory or physical limitations (more time)
3. Adequate space is needed
4. Use patience, allow for pauses, and observe for details
5. Certain types of information may be stressful to give
6. Perform the examination near bathroom facilities
7. Be alert for signs of increasing fatigue
Identify the principles to follow to keep an examination well organized:
1. Compare both sides for symmetry
2. If a patient is ill, first assess the systems of the body part most at risk
3. Offer rest periods if the patient becomes fatigued
4. Perform painful procedures near the end of the examination
5. Record assessments in specific terms in the record
6. Use common and accepted medical terms and abbreviations
7. Record quick notes during the examinations to avoid delays
Define: Inspection
Inspection is looking, listening, and smelling to distinguish normal from abnormal findings
Identify the guidelines to achieve the best results during inspection:
1. Adequate lighting is available
2. Use a direct light source
3. Inspect each area for size, shape, color symmetry, position and abnormality
4. Position and expose body parts as needed, maintaining privacy
5. Check for side-to-side symmetry
6. Validate findings with the patient
Define: Palpation
Palpation involves using the hands to touch body parts
Explain the difference between:

1. Light palpation
2. Deep palpation
1.Light palpation involves pressing inward 1cm (superficial)

2. Deep palpation involves depressing the area 4cm to assess the condition of organs
Define: Auscultation
Auscultation is listening to the internal sounds the body makes
The following are sounds that are described when auscultating. Please explain each one.
1. Frequency
2. Amplitude
3. Quality
4. Duration
1. Frequency indicates the number of sound wave cycles generated per second by a vibrating object
2. Amplitude describes loudness, soft to loud.
3. Quality describes sounds of similar frequency and loudness.
4. Duration describes the length of time that sound vibrations last.
List at least 12 specific observations of the patient's general appearance and behavior that should be reviewed:
1. Gender and race
2. Age
3. Signs of distress
4. Body type
5. Posture
6. Gait
7. Body movements
8. Hygiene and grooming
9. Dress
10. Body odor
11. Affect and mood
12. Speech
Identify some signs of patient abuse:
Physical injury or neglect are signs of possible abuse (evidence of malnutrition or presence of bruising). Also watcher for fear of spouse or partner, caregiver, or parent.
Identify the following acronym related to alcohol use:
C
A
G
E
C - Have you ever felt the need to Cut down on your use?
A - Have people Annoyed you by criticizing your use?
G - Have you ever felt bad or Guilty about your use?
E - Have you ever used or had a drink first thing in the morning as an "Eye-opener" to steady nerves or feel normal?
List three actions that should be taken to ensure accurate weigh measurement of a hospitalized patient:
1. Weigh patients at the same time of day
2. Weigh patients on the same scale
3. Weigh patients in the same clothes
Assessment of the skin reveals the patient's health status related to:
1. Oxygenation
2. Circulation
3. Nutrition
4. Local Tissue Damage
5. Hydration
List the risks for skin lesions in hospitalized patient's:
1. Exposure to pressure during immobilization
2. Various medications
3. Neurologic impairment
4. Chronic illness
5. Orthopedic injury
6. Diminished mental status
7. Poor tissue oxygenation
8. Low cardiac output
9. Inadequate nutrition
Define: Pigmentation
Pigmentation is skin color. It is usually uniform over the body.
For each skin color variation, identify the mechanism that produces color change, common causes of the variation, and the optimal sites for assessment:
Cyanosis
Cyanosis:

Condition-

Causes-

Assessment locations-
For each skin color variation, identify the mechanism that produces color change, common causes of the variation, and the optimal sites for assessment:
Pallor
Pallor

Condition-

Causes-

Assessment locations-
For each skin color variation, identify the mechanism that produces color change, common causes of the variation, and the optimal sites for assessment:
Loss of pigmentation
Loss of pigmentation:

Condition-

Causes-

Assessment locations-
For each skin color variation, identify the mechanism that produces color change, common causes of the variation, and the optimal sites for assessment:
Jaundice
Jaundice:

Condition-

Causes-

Assessment locations-
For each skin color variation, identify the mechanism that produces color change, common causes of the variation, and the optimal sites for assessment:
Erythema
Erythema:

Condition-

Causes-

Assessment locations-
For each skin color variation, identify the mechanism that produces color change, common causes of the variation, and the optimal sites for assessment:
Tan-brown
Tan-brown

Condition-

Causes-

Assessment locations-
Identify the physical findings of the skin that are indicative of substance abuse:
1. Diaphoresis
2. Spider angiomas
3. Burns (especially on fingers)
4. Needle marks
5. Contusions, abrasions, cuts, scars
6. "Homemade" tattoos
7. Vasculitis
8. Red, dry skin
Define: Indurated
Indurated means hardened
Define: Turgor
Turgor is the skins elasticity
Define: Edema
Edema means areas of the skin that are swollen or edematous from buildup of fluid in the tissues
Define: Senile keratosis
Senile Keratosis is a thickening of the skin
Define: Cherry angiomas
Cherry Angiomas are ruby red papules
Briefly describe the following primary skin lesions and give an example of each.
Macule
...
Briefly describe the following primary skin lesions and give an example of each.
Papule
...
Briefly describe the following primary skin lesions and give an example of each.
Nodule
...
Briefly describe the following primary skin lesions and give an example of each.
Tumor
...
Briefly describe the following primary skin lesions and give an example of each.
Wheal
...
Briefly describe the following primary skin lesions and give an example of each.
Vesicle
...
Briefly describe the following primary skin lesions and give an example of each.
Pustule
...
Briefly describe the following primary skin lesions and give an example of each.
Ulcer
...
Briefly describe the following primary skin lesions and give an example of each.
Atrophy
...
Explain the following skin malignancies.
Basal Cell Carcinoma
...
Explain the following skin malignancies.
Squamous Cell Carcinoma
...
Explain the following skin malignancies.
Melanoma
...
Name the three types of lice:
1. Pediculus Humanus Capitis (head lice)
2. Pediculus Humanus Corporis (body lice)
3. Pediculus Pubis (crab lice)
Briefly describe the following abnormalities of the nail bed.
Clubbing
Clubbing is a change in the angle between the nail and nail base, including softening, flattening, and enlargement of the fingertips
Briefly describe the following abnormalities of the nail bed.
Beau Lines
Beau Lines are transverse depressions in the nails
Briefly describe the following abnormalities of the nail bed.
Koilonychia
Koilonychia are concave curves
Briefly describe the following abnormalities of the nail bed.
Splinter Hemorrhages
Splinter Hemorrhages are red or brown linear streaks in the nail bed
Briefly describe the following abnormalities of the nail bed.
Paronychia
Paronychia is inflammation of the skin at base of the the nail
Define: Hydrocephalus
Hydrocephalus is the buildup of cerebrospinal fluid in the ventricles
Define: Acromegaly
Acromegaly is a condition that causes enlarged jaws and facial bones in adults
Define the following common eye and visual abnormalities.
Hyperopia
Hyperopia is a refractive error causing farsightedness
Define the following common eye and visual abnormalities.
Myopia
Myopia is a refractive error causing nearsightedness
Define the following common eye and visual abnormalities.
Presbyopia
Presbyopia is impaired near vision in middle-age and older adults caused by loss of elasticity of the lens
Define the following common eye and visual abnormalities.
Retinopathy
Retinopathy is a noninflammatory eye disorder resulting from changes in retinal blood vessels
Define the following common eye and visual abnormalities.
Strabismus
Strabismus is a congenital condition in which both eyes do not focus on an object simultaneously
Define the following common eye and visual abnormalities.
Cataract
A cataract is an increased opacity of the lens
Define the following common eye and visual abnormalities.
Glaucoma
Glaucoma is intraocular structural damage resulting from increased intraocular pressure
Define the following common eye and visual abnormalities.
Macular Degeneration
Macular Degeneration is blurred central vision often occurring suddenly caused by progressive degeneration of the center of the retina
Examination of the eye includes assessment of five areas. Name them.
1. Visual Acuity
2. Visual fields
3. Extraocular movements
4. External eye structures
5. Internal eye structures
Identify the structures of the external eye that you would inspect.
1. Position and alignment
2. Eyebrows
3. Eyelids
4. Lacrimal apparatus
5. Conjunctivae and sclera
6. Corneas
7. Pupils and irises
Define the following terms related to the external eye.
Exophthalmos
Exophthalmos is a bulging of the eye
Define the following terms related to the external eye.
Ectropion
An Ectropion is an eyelid margin that turns out
Define the following terms related to the external eye.
Entropion
An Entropion is an eyelid margins that turns in
Define the following terms related to the external eye.
Conjunctivitis
Conjuctivitis is the presense of redness, which indicates an allergy or infection
Define the following terms related to the external eye.
Ptosis
A Ptosis is an abnormal dropping of the eyelid over the pupil
Define the following terms related to the external eye.
PERRLA
Pupils equal, round, and reactive to light and accomadation
Identify the internal eye structures that you would examine with an opthalmoscope.
1. Retina
2. Choroids
3. Optic nerve disc
4. Macula
5. Fovea centralis
6. Retinal vessels
Identify the three parts of the ear canal and list the structures contained within each:
1. External ear (auricle, outer ear canal, and tympanic membrane)
2. Middle ear (three bony ossicles)
3. Inner ear (cochlea, vestibule, and semicircular canals)
The normal tympanic membrane appears:
The normal tympanic membrane appears translucent, shiny, and pearly gray
Identify three types of hearing loss:
1. Conduction
2. Sensorineural
3. Mixed
Explain how to perform the Weber test:
1. Hold the fork at its base and tap it lightly against the heel of the palm
2. Place the base of the vibrating fork on the midline vertex of the patient's head or middle of forehead
3. Ask the patient if he or she hears the sound equally in both ears or better in one ear
Explain how to perform the Rinne test:
1. Place the stem of the vibrating tuning fork against the patient's mastoid process
2. Begin counting the interval with your watch
3. Ask the patient to tell you when he or she no longer hears the sound; note number of seconds
4. Quickly place still-vibrating tines 1 to 2 cm from ear canal and ask the patient to tell you when he or she no longer hears the sound
5. Continue counting time the sound is heard by air conduction
6. Compare the number of seconds the sound is heard by bone conduction versus air conduction
Define: Excoriation
Excoriation is skin breakdown characterized by redness and skin sloughing
Define: Polyps
Polyps are tumor-like growths
Define the following terms that relate to the nose.
Leukoplakia
Leukoplakia are thick white patches that are often precancerous lesions seen in heavy smokers and people with alcoholism
Define the following terms that relate to the nose.
Varicosities
Varicosities are swollen, tortuous veins that are common in older adults
Define the following terms that relate to the nose.
Exostosis
Exostosis is extra bony growth between the two palates
Structures examined during assessment of the neck include:
1. Neck muscles
2. Lymph nodes of the head and neck
3. Carotid arteries
4. Jugular veins
5. Thyroid gland
6. Trachea
List the sequences for assessing the nodes of the neck:
1. Occipital nodes at the base of the skull
2. Postauricular nodes over the mastoid
3. Preauricular nodes at the base of the skull
4. Retropharyngeal nodes at the angle of the mandible
5. Submandibular nodes
6. Submental nodes
Identify the key landmarks of the chest:
1. Patient's nipples
2. Angle of Louis
3. Suprasternal notch
4. Costal Angle
5. Clavicles
6. Vertebrae
Chest excursion is normally ________
Reduced chest excursions may be caused by _________________________________________
Symmetrical, separating thumbs 3 to 5 cm; reduced chest excursion may be caused by pain, postural deformity, or fatigue
Define: Vocal or Tactile Fremitus
Vocale of tactile fremitus are vibrations that you can palpate externally caused by sound waves
Define the following normal breath sounds heard over the posterior thorax.
Vesicular
Vesicular sounds are soft, breezy, and low pitched that are created by air moving through smaller airways
Define the following normal breath sounds heard over the posterior thorax.
Bronchovesicular
Bronchovesicular sounds are blowing sounds that are medium pitched and of medium intensity that are created by air moving through smaller airways
Define the following normal breath sounds heard over the posterior thorax.
Bronchial
Bronchial sounds are loud and high pitched with a hollow quality that are created by air moving through trachea close to chest wall
Explain the following terms related to assessment of the heart.
Point of maximal impulse
Point of maximal impulse is where the apex of the heart is touching the anterior chest wall at approximately the fourth to fifth intercostal space just medial to the left midclavicular line
Explain the following terms related to assessment of the heart.
S1
Mitral and tricuspid valve closure causes the first heart sound (S1)
Explain the following terms related to assessment of the heart.
S2
Aortic and pulmonic valve closure causes the second heart sound (S2)
Explain the following terms related to assessment of the heart.
S3
When the heart attempts to fill an already distended ventricle, a third heart sound (S3) can be heard
Explain the following terms related to assessment of the heart.
S4
When the atria contract to enhance ventricular filling, a fourth sound is heard (S4)
Identify the appropriate sites for inspection and palpation of the following.
Angle of Louis
Lies between the sternal body and manubrium and feels the ridge in the sternum approximately 5 cm below the sternal notch
Identify the appropriate sites for inspection and palpation of the following.
Aortic Area
Second intercostal space on the right
Identify the appropriate sites for inspection and palpation of the following.
Pulmonic Area
Left second intercostal space
Identify the appropriate sites for inspection and palpation of the following.
Secondary Pulmonic Area
Left third intercostal space
Identify the appropriate sites for inspection and palpation of the following.
Tricuspid Area
Fourth or fifth intercostal space along the sternum
Identify the appropriate sites for inspection and palpation of the following.
Mitral Area
Fifth intercostal space just to the left of the sternum; left midclavicular line
Identify the appropriate sites for inspection and palpation of the following.
Epigastric Area
Tip of the sternum
Define: Murmur
A murmur is a sustained swishing or blowing sounds heard at the beginning, middle, or end of the systolic or diastolic phase
List six factors to consider when assessing a murmur:
1. Auscultate all valve areas for placement in the cardiac cycle (timing), where best heard (location), radiation, loudness, pitch, and quality
2. Distinguish between systolic and diastolic murmurs by determining if they occur between S1 and S2 (systolic) and S2 and S1 (diastolic)
3. The location is not necessarily over the valves
4. Listen over areas besides where the murmur is heard best to assess for radiation
5. Feel for a thrust or intermittent palpable sensation at the auscultation site in serious murmurs and rate the intensity
6. Low-pitched murmur best heard with the bell of the stethoscope; a high-pitched murmur is best heard with the diaphragm
Describe the sounds auscultated by the following murmurs.
Grade 1= barely audible in a quiet room
Grade 2 = clearly audible but quiet
Grade 3 = moderately loud
Grade 4 = loud with associated thrill
Grade 5 = very loud thrill easily palpable
Grade 6 = louder; heart without a stethoscope
Syncope is caused by _________
Syncope is caused by a drop in heart rate and blood pressure
An occlusion is ________________
An occlusion is a blockage of a vessel (artery or vein)
Atherosclerosis is indicated by __________
Atherosclerosis is indicated by diminished or unequal carotid pulsations
A(n) ___________ is the blowing sound caused by turbulence in a narrowed section of a blood vessel
A BRUIT is the blowing sounds caused by turbulence in a narrowed section of a blood vessel
Explain the steps the nurse would use to assess venous pressure.
1. Place patient in a semi-fowler position
2. Expose neck; align the head
3. Lean the patient back into a supine position; the level of venous pulsations begins to rise as the patient reaches a 45-degree angle
4. Use two rulers to measure
5. Repeat the same measurement on the other side
Describe how you would assess for phlebitis.
Inspect the calves for localized redness, tenderness, and swelling over vein sites
The American Cancer Society (2010) recomments the following guidelines for early detection of breast cancer:
1. Monthly BSE for women in their 20's
2. Women ages 20 years and older need to report any breast changes
3. Women need to have a clinical breast examination every 3 years (ages 20-40 years) and yearly after the age of 40 years
4. Women with a family history need a yearly examination
5. Asymptomatic women need a screening mammogram by age 40 years. Women older then age 40 years need an annual mammogram
6. For women with increased risk, additional testing should be discussed with the health care provider
Identify the three systematic approaches to palpation of the breast.
1. Clockwise or counterclockwise
2. Vertical technique
3. Center of the breast in a radial fashion
When palpating abnormal masses in the breast, you should note:
1. Location in relation to the quadrant
2. Diameter
3. Shape
4. Consistency
5. Tenderness
6. Mobility
7. Discreteness
Benign (fibrocystic) breast disease is characterized by:
Benign (fibrocystic) breast disease is characterized by bilateral lumpy, painful breast, sometimes with nipple discharge
Define the following terms related to the abdomen.
Striae
Striae are stretch marks
Define the following terms related to the abdomen.
Hernias
A hernia is a protrusion of abdominal organs through the muscle wall
Define the following terms related to the abdomen.
Distention
Distention is swelling by intestinal gas, tumor, or fluid in the abdominal cavity
Define the following terms related to the abdomen.
Peristalsis
Peristalsis is movement of contents through the intestines, which is a normal function of the small and large intestine
Define the following terms related to the abdomen.
Borborygmi
Borborygmi are growling sounds, which are hyperactive bowel sounds
Define the following terms related to the abdomen.
Rebound Tenderness
Rebound tenderness is the pain a patient may experience when the nurse quickly lifts his or her hand away after pressing it deeply into the involved area
Define the following terms related to the abdomen.
Aneurysm
An aneurysm is a localized dilation of a vessel wall
Chancres are:
Chancres are syphilitic lesions, which appear as small, open ulcers that drain serous material
A Papanicolaou specimen is used to:
A Papanicolaou specimen is used to test for cervical and vaginal cancer
Identify the common symptoms of testicular cancer:
Common symptoms include painless enlargement of one testis and the appearance of a palpable, small, hard lump on the side of the testicle
The purpose of digital examination of the rectum and anus is:
Digital examination is used to detect colorectal cancer in the early stages and prostatic tumors
Define: Kyphosis
A Kyphosis is a hunchback, an exaggeration of the posterior curvature of the thoracic spine
Define: Lordosis
Lordosis is a sway back, an increased lumbar curvature
Define: Scoliosis
Scoliosis is a lateral spinal curvature
Define: Osteoporosis
Osteoporosis is a metabolic bone disease that causes a decrease in quality and quantity of the bone
Define: Goniometer
A goniometer is an instrument that measure the precise degree of motion in a particular joint.
Identify the correct range of motion for the following terms.
Flexion
Flexion = movement decreasing angle between two adjoining bones
Identify the correct range of motion for the following terms.
Extension
Extension = increasing angle between two adjoining bones
Identify the correct range of motion for the following terms.
Hyperextension
Hyperextension = beyond its normal resting extended position
Identify the correct range of motion for the following terms.
Pronation
Pronation = that the frontal or ventral surface face downward
Identify the correct range of motion for the following terms.
Supination
Supination = Front or ventral surface faces upward
Identify the correct range of motion for the following terms.
Abduction
Abduction = away from the midline
Identify the correct range of motion for the following terms.
Adduction
Adduction = toward the midline
Identify the correct range of motion for the following terms.
Internal Rotation
Internal rotation = rotation of the joint inward
Identify the correct range of motion for the following terms.
External Rotation
External rotation = rotation of the joint outward
Identify the correct range of motion for the following terms.
Eversion
Eversion = turning of the body part away from the midline
Identify the correct range of motion for the following terms.
Inversion
Inversion = turning of the body part toward the midline
Identify the correct range of motion for the following terms.
Dorsiflexion
Dorsiflexion = flexion of the toes and foot upward
Identify the correct range of motion for the following terms.
Plantar Flexion
Plantar flexion = bending of toes and foot downward
Define the following terms related to muscle tone and strength.
Hypertonicity
Hypertonicity is increased muscle tone
Define the following terms related to muscle tone and strength.
Hypotonicity
Hypotonicity is a muscle with little tone
Define the following terms related to muscle tone and strength.
Atrophied
Atrophied muscles are reduced in size; they feel soft and boggy
The purpose of the Mini-Mental State Examination is to measure:
The Mini-Mental State Examination measures orientation and cognitive function
Delirium is characterized by:
Delirium is characterized by confusion, disorientation, and restlessness
The purpose of the Glasgow Coma Scale is to:
The Glasgow Coma Scale provides an objective measurement of consciousness on a numerical scale over time
Briefly describe the two types of aphasia:
1. Receptive
2. Expressive
1. Receptive: A person cannot understand written or verbal speech

2. Expressive: A person understand written and verbal speech but cannot write or speak appropriately when attempting to communicate
Identify the 12 cranial nerves:
1. Olfactory
2. Optic
3. Oculomotor
4. Trochlear
5. Trigeminal
6. Abducens
7. Facial
8. Auditory
9. Glossopharyngeal
10. Vagus
11. Spinal accessory
12. Hypoglossal
The sensory pathways of the central nervous system conduct what type of sensations?
1. Pain
2. Temperature
3. Position
4. Vibration
5. Crude and finely localized touch
Identify the functions of the cerebellum:
The cerebellum controls muscular activity, maintains balance and equilibrium, and helps to control pressure
Identify the two types of normal reflexes and provide an example of each:
1. Deep tendon reflexes (biceps, triceps, patellar, Achilles)
2. Cutaneous reflexes (plantar, gluteal, abdominal)
Select the appropriate answer, and cite the rationale for choosing that particular answer.
The component that should receive the highest priority before a physical examination is:
1. Preparation of the equipment
2. Preparation of the environment
3. Physical preparation of the patient
4. Psychological preparation of the patient
Answer:
4. Psychological preparation of the patient

Rationale:
A thorough explanation of the purpose and steps of each assessment lets patients know what to expect and what to do so they can cooperate
Select the appropriate answer, and cite the rationale for choosing that particular answer.
The nurse assesses the skin turgor of the patient by:
1. Inspecting the buccal mucosa with a penlight
2. Palpating the skin with the dorsum of the hand
3. Grasping a fold of skin on the back of the forearm and releasing
4. Pressing the skin for 5 seconds, releasing, and noting each centimeter of depth
Answer:
3. Grasping a fold of skin on the back of the forearm and releasing

Rationale:
Normally, the skin lifts easily and snaps back immediately to its resting position; the back of the hand is not the best place to test for turgor
Select the appropriate answer, and cite the rationale for choosing that particular answer.
While examining Mr. Parker, the nurse notes a circumscribed elevation of the skin filled with serous fluid on his upper lip. The lesion is 0.4cm in diameter. This type of lesion is called:
1. Macule
2. Nodule
3. Vesicle
4. Pustule
Answer:
3. Vesicle

Rationale:
Circumscribed elevation of skin filled with serous fluid, smaller than 1cm
Select the appropriate answer, and cite the rationale for choosing that particular answer.
When assessing the patient's thorax, the nurse should:
1. Complete the left side and then the right side
2. Compare symmetrical areas from side to side
3. Begin with the posterior lobes on the right side
4. Change the position of the stethoscope between inspiration and expiration
Answer:
2. Compare symmetrical areas from side to side

Rationale:
Use a systematic pattern when comparing the right and left sides. You need to compare lung sounds in one region on one side of the body with sounds in the same region on the opposite side of the body
Select the appropriate answer, and cite the rationale for choosing that particular answer.
In a patient with pneumonia, the nurse hears high-pitched, continuous musical sounds over the bronchi on expiration. These sounds are called:
1. Rhonchi
2. Crackles
3. Wheezes
4. Friction Rubs
Answer:
3. Wheezes

Rationale:
High-velocity airflow through severely narrowed or obstructed airway
Select the appropriate answer, and cite the rationale for choosing that particular answer.
The second heart sound (S2) occurs when:
1. Systole begins
2. There is rapid ventricular filling
3. The mitral and tricuspid valves close
4. The aortic and pulmonic valves close
Answer:
4. The aortic and pulmonic valves close

Rationale:
After the ventricles empty, ventricular pressure falls below that in the aorta and pulmonary artery, allowing the valves to close and causing the second heart sound
Sets found in the same folder