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N383 Exam 4
Terms in this set (127)
85 yr old, he uses a cane. documenting what under gender appearance
performing vision examination. which chart is most widely used?
after health history has been obtained, nurse should ask patient to do what for physical examination
empty the bladder
how to test patients hearing
using the whispered voice test
whenever I open my mouth real wide, I feel this popping sensation in front of my ears, how to further examine?
place finger on TMJ and ask him to open and close his mouth
completed extra ocular muscles. nurse should document the assessments of which cranial nerves
patients uvula raises midline when she says ahh, has positive gag reflex. nurse tested what cranial nerves?
nine and ten
patient s unable to stick out tongue, which nerve
patient is unable to shrug shoulders
during an examination, completed finger-to-nose and the rapid-alternation mocemtnet to run each heel down the opposite shit.
patients cerebellar function is in tact
confrontation test, assesses what
which statement is true regarding the complete physical assessment
the patient should be in the sitting position for examination of the head and neck
which of these is included in an assessment of general appearane
the nurse should wear gloves for which examination
palpation of mouth and tongue
use location for eliciting deep tendon reflexes
during an inspection of a patients face, the nurse notices that the facial features are symmetric. this finding indicates which cranial nerve is intact
posterior chest, inspect for what
symmetry of the shoulders and muscles
feels like objects spinning around her
small, flat, Macules on posterior portion of the thorax. 1 cm wide
legs turn white when lifted above head
chronic arterial insufficiency
the nurse documents that a patient has coarse, thickened skin and brown discoloration oner the lower legs. pulses are present
chronic venous insufficiency
patient has ulcerations on the tips of the toes on the lateral aspect of the ankles. finding indicated?
nurse recorded a positive iliopsoas test with a patient with abdominal pain. confirm what
the nurse will measure a patients near vision with which tool
nurse records the results to the Hirschberg test, the nurse has
tested the corneal light reflex
during assessment of mouth, bony ridge in middle of hard palate. finding as?
patient is unable to distinguish objects placed in his hand. the nurse would document?
after the examination of an infant, document opisthotonos
female patient. less colored soft pointed moist papule in a cauliflower-like patch around her Introits. most likely?
human papilloma virus
while recording nurse notices that a patients hematest results are positive: means what?
occult blood in stool
the sac that surrounds and protects the heart?
the direction of blood flow through the heart is best describes by which of these
right atrium, right ventricle, pulmonary artery, lungs, pulmonary vein, left atrium, left ventricle
the nurse is reviewing the anatomy and physiologic functioning of the heart. which statement best describes what is meant by atrial kick?
the atria contracts toward the end of diastole and pushes the remaining blood into the ventricles
when listening to heart sounds, nurse knows that the valve closures that can be heard best at the base of the heart are"
aortic and pulmonic
which of these statements describes the closure of the valves in a normal cardiac cycle
the tricuspid valve closes slightly later than the mitral valve
the component of the conduction system referred to as the pacemaker of the heart is the
the electrical stimulus of the cardiac cycle follows which sequence
AV node SA node bundle, bundle branches
the findings from an assessment of a 70 yr old patient with swelling in his ankles include jugular venous pulsations 5 cm avocet the sternal angle when the head of his bed is elevated 45 degrees. the nurse knows that this finding indicuaties
elevated pressure related to heart failure
when assessing a newborn infant who is 5 mins old, the nurse knows which of these statements to be true
blood can flow into the left side of the heart through an opening in the atrial septum
25 yr old, 5th month of pregnancy, bp of 100/70, second month 124-80, what is true
the decline in bp is due to peripheral vasodilation and is an expected change
in assessing a 70 yr old, bp 140/100, hr 104, slightly irregular, split s2, explained by expected hemodynamic changes related to age?
increase in systolic blood pressure
45 yr old, been having difficulty sleeping, wakes up and cannot breathe, best response?
do you have any history of problems with your heart
in assessing a patients major risk factors for HD, include what in the history
smoking, hypertension, obesity, diabetes, and high cholesterol
mother of a 3 month old, baby isn't gaining wait, baby sleeps and wakes up hungry shortly after. what information would the nurse want?
prescence of dyspnea of diaphoresis when sucking
assessing carotid arteries, older patient with cardiovascular disease, nurse would?
listen with the bell of the stethoscope to assess for bruits
during an asessment of a 68 yr old man, ride sided weakness, nurse hears blowing, swishing sound with the bell over left carotid artery, this indicates
blood flow turbulence
during an insepection of the precordium of an adult patient, the nurse notices the chest moving in a forceful manner along the sternal border. finding suggests>
enlargement of the right ventricle
during an assessment of a healthy adult, where would the nurse expect to palpate the apical impulse?
fifth left intercostal space at the anterior axillary line
nurse is examining a patient who has possible cardiac enlargement, which statement about percussion of the heart is true
studies show that percussed cardiac borders do not correlate well with the true cardiac border
the nurse is preparing to auscultate for heart sounds, what technique is correct
listening by inching the stethoscope in z pattern, from the base of the heart across and down, then over the apex
while counting the apical pulse on 16 yr old, irregular rhythm, rate speeds up with insipriatin and slows on expiration, nurses response
no further response is needed because sinus arrhythmia can occur normally
when listening to heart sounds, nurse knows that S1
coincides with the carotid artery pulse
during cardiac auscultations, the nurse hears a sound immediately occurring after the S2 at the second left intercostal space, further assess?
watch the patients respirations while listening for the effect
findings would you expect on cardiac assessment of 4 yr old>
murmur at the second left intercostal space when supine
auscultating heart sounds on 7 yr old, routine physical examination, nurse hears and s3, a soft murmur at the left midsternal border, venous hum when the child is standing, interpretation?
the findings can all be normal in a child
precordial assessment, 8 months pregame's, nurse palpates apical impulse on fourth left intercostal space, lateral to midclavicular line, indicate?
displacement of the heart from elevation of the diaphragm
assessing for an S4 sound with stethoscope, nurse would listen with the
bell of the stethoscope at the apex with the patient in left lateral position
70 yr old main, bp 180/100, hx of htn, hr 90,extra sound before s1, herd with bell, left lateral position,
atrial gallop (S4)
nurse is performing cardiac assessment on 65 yr old 3 days after MI. heart sounds normal supine, sitting leaning forward, high ptiched scratchy sounds with diaphragm of the sthetoscope of apex, disappears w insipriation
inflammation of the precordial
10 month old becomes blue when crying, frequency is increasing, not crawling. nurse palpates a thrill at the left lower sternal border and auscultates a loud systolic murmur in the same area. likely cause?
tetralogy of Fallot
30 yr old woman, history of mitral valve problems, been tired, feels like heart is pounding at night, thrill and lift on fifth left intercostal space midclavicular line. auscultates a blowing, swishing sound right after S1, indicates?
38 yr old, chest pain, jugular vein pulsations 4 cm above sternal angle, when patient is at 45 degrees, bp is 98/60, hr 130, ankle edema, difficulty breathing, s3, indicates?
normal splitting of s2 associated with
cardiovascular assessment, nurse knows a thrill is
vibration that is palpable
cardio assessment, S4 sounds are:
heard at the end of ventricular diastole
apical pulse is laterally displaced and is palpable over a wide area, indicates?
volume overload, as in heart failure
nurse is auscultating the cartid artery for bruits, reflects correct technique
while lightly applying the bell over carotid artery and listening, patient is asked to take a breath, exhale, and brief hold it
risk factors for HTN, racial group with highest
assessing patient with possible cardiomyopathy and assess the hepatojugular reflex, if heart failure is present, nurse should recognize which finding when pushing on upper right quad of abdomen,
the jugular vein will remain elevated as long as pressure on the abdomen is tainted
hr of baby is 135 bpm
normal ( 100-180) then stabilize (120-140)
modifiable risk factors for MI
abnormal lipids, smoking, hypertension, diabetes
which statement is true regarding the aterial system
the arterial system is a high pressure system
the nurse is reviewing the blood supply to the arm is
assess dorsals pedis artery, correct location
lateral to the extensor tendon of the great toe
a 64 yr old, pain in left calf when exercising, consistent with
ischemia caused by a partial blockage of an artery supplying
venous blood flow patterns, describes mechanism by which venous blood returns to the heart
intraluminal valves ensure unidirectional flow toward the heart
which vein is responsible for the most of the venous return in the arm
70 yr old patient is schedules for open heart surgery, use great saphenous vein for the coronary bypass graft. what happens to my circulation when this vein is removed
this vein can be removed without harming your circulation because the deeper veins in your legs are in good condition
the nurse is reviewing the risk factors for venous disease. best describes a person at the highest risk for development of venous disease
person who has been on bed rest for 4 days
lymphatic system, correct understanding
the flow of lymph is slow, compared with that of the blood
performing an assessment of a patient enlarged right epitrochlear lymph node, nurse do next?
examine the patients lower arm and hand, and check fir the rpresence of infection of lesions
35 yr old man is seen in the clinical for an infection in his left foot, findings should nurse expect to see during an assessment of this patient
enlarged and tender inguinal node
examining lymphatic system of 3 yr old, expect what
presence of palpable lymph nodes
assessment of older adult nurse should expect what normal physiologic change?
peripheral blood vessels growing more rigid with age, producing a rise in systolic blood pressure
67 yr old, left calf pain the climbing the stairs, goes away,
a patient complains of leg pain that wake him at night, sore on inner aspect of right ankle worse with elevation
problems related to arterial insufficiency
profile sign to detect
normal vitals, 5 sec cap refill
consider this a delayed cap refill time, investigate further
left femoral pulse is dimished,
auscultate for bruit
peripheral vascular assessment, unable to palpate ulnar pulses, skin is warm and cap refill is norm, next?
consider this finding as normal, and precede with th peripheral vascular eval
assessing the pulses of a patient who has been admitted for untreated hyperthyroidism, find a pulse
a bounding pulse
evaluate the adequacy of collateral circulation before cannulating the radial artery
venous stasis. findings would the nurse most likely observe?
brownish discoloration to the skin of the lower leg
assess femoral pulse in obese patient, which action would be appropriate
the patient is asked to bend his knee to the side in a frog like position
auscultating a patients femoral arterties, presence of a bruit on left side,
occurs with turbulent blood flow, indication partial occlusion
mild, slight, pitting edema, pregnant woman
patient has hard, non pitting edema on the left lower leg and ankle, right leg has no edema. nurse recalls that?
non pitting, hard edema occurs with lymphatic obstruction
patients pulse, amplitude is weaker during inspiration and stronger during expiration, 20 mmhm less with inspiration, experienceing pulus:
plus paradoxus (beats have weaker amplitude with inspiration)
elevated a patients legs 12 inches of table to drain venous blood, normal finding would be after dandlin them
venous filling within 15 second
woman 7 month preg, legs feel heavy in the calc, dilated tortuous veins apparent in the lower llegs
left arm is swollen from the shoulder down tot the fingers, brawny edema, right is normal, had left mastectomy a year ago
assess ankle-brachial index of a patient, abi is
an abi of .9 to .7 indicates the presence of peripheral vascular disease and mild claudication
nurse is performing a check up on 5 yr old, normal findings with shots one week ago
palpable firm small shots mobile and contender lymph nodes
doppler ultrasonic stethoscope, venous flow is heard with what sound
swishing, whooshing sound
weak thready pulse, what statement is correct
hard to palpate, may fade in and out, is easily obliterated by pressure
finger change color in the cold
routine office visit, patient takes off shoes and shows sore on heal, 3 cm round ulcer on the left great toe, pale ischemic base, well defined edges, no drainage, signs of??
arterial ischemic user
nurse is reviewing an assessment of a patient peripheral pulse and notices the documentation states the radial pulse are 2, what's this mean
signs of acute venous symptoms
intense sharp pain, sudden onset, warm red swollen calf
chronic arterial symptoms, so find what
history of diabetes and cig smoking, skin of the patient is pale and cool, the pain gets worse when walking
first heart sound (S1) is produce by the
AV valves closing
ability of heart to contract independently of any signals or stimulation due to
continuous sound in newborns heart
normal caused by non closure of the ductus arteriosus
bruit heard when auscultating the carotid artery of a 65 yr old patient is caused by
turbulent blood flow through the carotid artery
jugular venous pressure is an indirect reflection of the
heart's efficiency as a pump
which are following guidelines may be used to identify which heart sound is S1
coincides w carotid artery
which of the following is appropriate position to have a patient assume when auscultating for extra heart sounds or murmurs
roll toward the left side
what shows that the student does not know how to assess the cartid artery
pressing the blue into the artery is wrong
palpable inguinal lymph nodes are
normal if small, movable, and nontender
a water hammer or corrigan pulse is associated with
aortic valve regurgitation
claudication is caused by
signs of caregiver burnout
headaches and epigastric pain
prevention and treatment of what may be one way to reduce functional decline in an older adult
dangerous for cog change to be attributed to the normal aging process because
this may delay the diagnosis of an underlying disease process
bloody show occurs with
onset of labor
uterus becomes globular in shape, softens, and flexes easily over the cervix, what term describes this change
last w an infant
otoscopic examination of the tympanic membrane
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