Nursing > Assessment Final UPDATE > Flashcards

Assessment Final UPDATE Flashcards

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1
Q

Which cranial nerves control the extraocular muscles (EOM)?

A
  • Oculomotor (II),
  • Abducens (VI),
  • Trochlear (IV)
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2
Q

Documenting Heart Sounds x4

A
  1. Frequency/Pitch
  2. Intensity/Loudness
  3. Duration
  4. Timing: systole/diastole
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3
Q

Striae which occur when elastic fibers in the reticular layers of the skin are broken after rapid or prolonged stretching, have a distinct color when of long duration. What is this color?

A

Silvery White

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4
Q
A
  • Keloid
    • hypertrophic scar
    • elevetated skin by excess scar tisue
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5
Q

All Patients Take Meds..

A
  • Aortic (2nd Rt, ICS)
  • Pulmonary (2nd Left, ICS)
  • Tricuspid (Lt lower sternum)
  • Mitral (5th ICS midclavical)
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6
Q

Cranial Nerve Mneumonic Sensory, Motor or Both

A
  • Some Say Marry Money But My Brother Says Bad Business Marry Money
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7
Q

degeneration of joint cartilage and the underlying bone, most common from middle age onward. It causes pain and stiffness, especially in the hip, knee, and thumb joints.

A

Osteoarthritis

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8
Q
A
  • Keloid
    • hypertrophic scar
    • elevetated skin by excess scar tisue
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9
Q
A
  • Polycyclic
  • i.e. psoriasis
  • anular lesions grow together
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10
Q

Define a Lymph Node

A
  • Small oval clumps of lymphatic tissue located at intervals along the vessels.
  • Filter fluid before returned to bloodstream
  • remove harmful organisms.
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11
Q
A

Compound Nevus

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12
Q

Which of the following options is not a change that comes with menopause?

A
  • The vaginal pH becomes more alkalotic
  • The vagina becomes shorter and narrower
  • The cervix shrinks
  • The ovaries hypertrophy
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13
Q
A

junctional nevus

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14
Q
A
  • Scale
  • compact flakes of skin
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15
Q
A
  • Scale
  • compact flakes of skin
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16
Q

During assessment of the spine, what do you ask the patient?

A
  • Flex
  • Extend
  • Abduct
  • Rotate
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17
Q

Characteristics of Osteoarthritis?

A
  • Joints ache and may be tender but have little or no swelling.
  • Symptoms often begin on one side of the body and may spread to the other side.
  • Onset develops slow over the years
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18
Q
A
  • Meta-tarso-phangeal joint
  • Redness, swelling, heat, tenderness
  • metabolic disorder, elevated serum uric acid
  • More predominant in men older than 40 yrs
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19
Q

What 4 areas do you auscultate when listening to the heart?

A
  • Aortic, Pulmonic, Tricuspid, Mitral
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20
Q

Describe the Cervical Node

A
  • Drains the head and neck
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21
Q

A murmur heard after S1 and before S2 is classified as

A

systolic (possibly benign)

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22
Q
A
  • zosteriform
  • linear around unilateral nerve
  • ex: herpes
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23
Q

Describe the Epitrochlear Node

A
  • In the Antecubital fossa
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24
Q

3 Common types of birthmarks

A
  1. freckles
  2. junctional nevus
  3. compound nevus
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25
moving the sole of the foot outward at the ankle
eversion
26
3 Common types of birthmarks
1. freckles 2. junctional nevus 3. compound nevus
27
* Confluent Lesion * ex hives//uriticaria
28
The nurse assess a patient with osteoarthritis, what would be an expected sign/symptom?
* stiff knees, hips, fingers, and vertebrae
29
Describe the Left Lung
* narrower than the right w/ 2 lobes
30
moving the arm in a circle around the shoulder
circumduction
31
Melena
really dark stools b/c of blood
32
* Discrete lesion * Skin tags//acne
33
3 areas of the Glasgow Coma Scale
1. eye opening 2. motor response to stimuli 3. verbal response
34
Swan-neck, boutonnière deformity, and ulnar deviation are conditions associated with
rheumatoid arthritis
35
Cerebellar function is assesed by which of the following tests?
coordination, hop on one foot
36
Often seen with history of trauma or obesity, and can be genetic
osteoarthritis
37
junctional nevus
38
Arterial Insufficiency Characteristics
* coolness/pallor * Diminished pulses * shiny, thin skin * well defined edges NO bleeding * pale ischemic base * occur at toes, heels, lateral ankle
39
Cranial Nerve Mneumonic Oh Oh Oh To Touch And Feel Very Good Velvet AH!
* Olfactoryoptic * Oculomotor * Trochlear * Trigeminal * Abducens * Facial * Vestibulocochlear * Glossopharyngeal * Vagus * Accessory * Hypoglossal
40
What is the parietal lobe concerned with?
* post-central gyrus * primary center for sensation
41
The group of axillary lymph nodes that drains the other three groups of nodes is the:
Central Nodes
42
An area of the body that is supplied mainly from one spinal segment through a particular spinal nerve is identified as a:
dermatone
43
Why are children more at risk for ear infections?
They have shorter, wider, more horizontal Eustachian tubes
44
Each half of the cerebrum is a
hemisphere
45
characterized by hard, nontender nodules, 2 to 3 mm or more
Osteoarthritis
46
* **Wheal** * Urticaria-hives * raised irregular shape due to edema * mosquito bites, allergies
47
control of body temperature
hypothalamus
48
* Discrete lesion * Skin tags//acne
49
Describe the inguinal nodes
* in the groin
50
* Macule * Patch larger than 1 cm * flat not raised
51
Where is S1 louder than S2
at the apex
52
Gyrate Lesion
53
Where do arteries carry blood from?
from the heart
54
Temporal Lobe Function?
* Auditory reception center * Hearing, taste, and smell * Wernicke's Area= language comprehension
55
Gyrate Lesion
56
* Polycyclic * i.e. psoriasis * anular lesions grow together
57
This occurs when the pulmonic valve stays open a little bit longer during inspiration.
Split S2 (lub-T-dub)
58
Objective Findings for Osteoarthritis
* Limited ROM in the affected joint * fluid is easily moved around the joint space
59
Turning the forearm so the palm is out
Pronation
60
* **Vesicle** * Bulla- larger than 1cm * a blister, herpes chicken pox, shingles
61
Subjective Data for Osteoarthritis
* Pain (worse later in the day) * stiffness * reported limited ROM
62
Signs/Symptoms of Hemorrhoids
* Swollen and inflamed veins in the rectum and anus that cause discomfort and bleeding * Painless flabby papules, varicose vein of the hemorrhoidal plexus * Occurs from straining at stool, pregnancy, obesity, liver disease, or low fiber diet.
63
A 78 year old male comes into the office and the nurse assesses that he has a greying/white arc/circle around his cornea with no vision loss. She should conclude that the patient has:
Arcus Senillis
64
Moving the body part forward and parallel to the ground
protraction
65
A newborn’s nail beds may be blue (cyanotic) for the first few hours of life, then they turn what color?
pink
66
Neurological Changes in the Older Adult
* loss of muscle bulk * general atrophy * nerve conduction decrease 5-10% * Slower Reaction Time * Touch, Smell Taste, Pain sensation diminished * decrease blood flow / oxygen
67
* **Vesicle** * Bulla- larger than 1cm * a blister, herpes chicken pox, shingles
68
Turning the forearm so the palm is up
supination
69
What is the function of the occipital lobe?
Visual Receptor Center
70
Describe the Axillary Nodes
* drain the breast and upper arm
71
What is the best position for inspecting the breasts for retraction?
Sitting with hand pushing onto hips
72
Signs/Symptoms of Fecal Impaction
* Decreased Bowel Motility * A collection of hard, desiccated feces in the rectum * May complain of constipatior or of diarrhea as a fecal stream passes around the impaction
73
Venous Insufficiency Characteristics
* Brawny edema * brown pigment deposits * pulses are normal * Bleeding uneven edges
74
What do veins do?
drain deoxygenation blood from the tissues and return it to the heart
75
Straightening a limb at a joint
extension
76
RAM
* Roy's Adaption Model * the individual as a set of interrelated systems (biological, psychological and social). * strives to maintain a balance between these systems and the outside world,
77
During neurologic examination the tendon reflex fails to appear. Before striking the tendon again, the examiner might use what type of technique?
reinforcement
78
Bending a limb at a joint
flexion
79
* zosteriform * linear around unilateral nerve * ex: herpes
80
* Confluent Lesion * ex hives//uriticaria
81
When is the best time to perform a breast self examination?
on the 4th - 7th day of the cycle
82
* **Papule** * Plaque larger than 1 cm * can feel, slightly elevated * mole wart
83
Influences Body Temperature
Diurnal Cycle
84
Where is the most common site for breast tumors
upper outer quadrant
85
moving a body part backward and parallel to the ground
retraction
86
Compound Nevus
87
Dehydration Assessment
* Dry mucous membranes * lips cracked * Skin is fissured * Tenting w/ turgor
88
skin normal findings seen mostly in infants? x3
1. Cafe Au Lait Spot 2. Mongolian Spot 3. Lanugo
89
Which of the following vital signs are characteristic of an aging adult?
1. Decreased temperature 2. Decreased sweating 3. Increased risk of orthostatic hypotension
90
What are the 4 main lymph nodes accessible to inspection and palpation?
1. Cervical Node 2. Axillary Node 3. Epitrochlear Node 4. Inguinal Node
91
How often should males 15 y/o+ do a testicular self exam?
Once a month
92
What is genu valgum?
Knocked Knees
93
* **Papule** * Plaque larger than 1 cm * can feel, slightly elevated * mole wart
94
* Macule * Patch larger than 1 cm * flat not raised
95
Older Adult Expected Finding During Breast Exam
* lactiferous ducts are more palpable * feel firm and stringy b/c of fibrosis and calcification.
96
What does a “normal” tympanic membrane look like?
Shiny, translucent, pearly grey
97
An Area not commonly associated with pain
inramuscular
98
* Nodule * tumor larger than 3 cm
99
What is the Frontal Lobe concerned with?
* Personality * Behavior * Emotions * Intellectual Function * Broca's Area- Motor Speech
100
* **Wheal** * Urticaria-hives * raised irregular shape due to edema * mosquito bites, allergies
101
Pronation and supination of the hand and forearm are hte result of the articulation of the
* Radius * Ulna
102
Characteristics of rheumatoid arthritis?
* Joints are painful, **swollen**, and stiff. * It often affects small and large joints on both sides of the body (symmetrical) * Onset is rapid * Begins *at any* time in life
103
* Nodule * tumor larger than 3 cm
Nursing
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