Nursing School Pt 1 > Assessment Final UPDATE > Flashcards

Assessment Final UPDATE Flashcards

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1
Q

Which cranial nerves control the extraocular muscles (EOM)?

A
  • Oculomotor (III),
  • Trochlear (IV)
  • Abducens (VI),
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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

How often should males 15 y/o+ do a testicular self exam?

A

Once a month

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4
Q

skin normal findings seen mostly in infants? x3

A
  1. Cafe Au Lait Spot
  2. Mongolian Spot
  3. Lanugo
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5
Q

Where is the most common site for breast tumors

A

upper outer quadrant

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6
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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7
Q
A
  • Keloid
    • hypertrophic scar
    • elevetated skin by excess scar tisue
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8
Q

Straightening a limb at a joint

A

extension

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9
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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10
Q

What is the best position for inspecting the breasts for retraction?

A

Sitting with hand pushing onto hips

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11
Q

Turning the forearm so the palm is up

A

supination

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12
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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13
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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14
Q
A
  • Keloid
    • hypertrophic scar
    • elevetated skin by excess scar tisue
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15
Q
A
  • Polycyclic
  • i.e. psoriasis
  • anular lesions grow together
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16
Q

A newborn’s nail beds may be blue (cyanotic) for the first few hours of life, then they turn what color?

A

pink

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17
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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18
Q
A

Compound Nevus

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19
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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20
Q
A

junctional nevus

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21
Q
A
  • Scale
  • compact flakes of skin
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22
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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23
Q

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

A
  • Flex
  • Extend
  • Abduct
  • Rotate
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24
Q

A murmur heard after S1 and before S2 is classified as

A

systolic (possibly benign)

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25
* Meta-tarso-phangeal joint * Redness, swelling, heat, tenderness * metabolic disorder, elevated serum uric acid * More predominant in men older than 40 yrs
26
What 4 areas do you auscultate when listening to the heart?
* Aortic, Pulmonic, Tricuspid, Mitral
27
Describe the Cervical Node
* Drains the head and neck
28
* zosteriform * linear around unilateral nerve * ex: herpes
29
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
30
Describe the Epitrochlear Node
* In the Antecubital fossa
31
Cerebellar function is assesed by which of the following tests?
coordination, hop on one foot
32
3 Common types of birthmarks
1. freckles 2. junctional nevus 3. compound nevus
33
moving the sole of the foot outward at the ankle
eversion
34
3 areas of the Glasgow Coma Scale
1. eye opening 2. motor response to stimuli 3. verbal response
35
The nurse assess a patient with osteoarthritis, what would be an expected sign/symptom?
* stiff knees, hips, fingers, and vertebrae
36
* Confluent Lesion * ex hives//uriticaria
37
Describe the Left Lung
* narrower than the right w/ 2 lobes
38
moving the arm in a circle around the shoulder
circumduction
39
Melena
really dark stools b/c of blood
40
* Discrete lesion * Skin tags//acne
41
Swan-neck, boutonnière deformity, and ulnar deviation are conditions associated with
rheumatoid arthritis
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
Often seen with history of trauma or obesity, and can be genetic
osteoarthritis
44
Arterial Insufficiency Characteristics
* coolness/pallor * Diminished pulses * shiny, thin skin * well defined edges NO bleeding * pale ischemic base * occur at toes, heels, lateral ankle
45
What is the parietal lobe concerned with?
* post-central gyrus * primary center for sensation
46
Cranial Nerve Mneumonic Oh Oh Oh To Touch And Feel Very Good Velvet AH!
* Olfactory * optic * Oculomotor * Trochlear * Trigeminal * Abducens * Facial * Vestibulocochlear * Glossopharyngeal * Vagus * Accessory * Hypoglossal
47
The group of axillary lymph nodes that drains the other three groups of nodes is the:
Central Nodes
48
Why are children more at risk for ear infections?
They have shorter, wider, more horizontal Eustachian tubes
49
Each half of the cerebrum is a
hemisphere
50
characterized by hard, nontender nodules, 2 to 3 mm or more
Osteoarthritis
51
* **Wheal** * Urticaria-hives * raised irregular shape due to edema * mosquito bites, allergies
52
control of body temperature
hypothalamus
53
Where do arteries carry blood from?
from the heart
54
Subjective Data for Osteoarthritis
* Pain (worse later in the day) * stiffness * reported limited ROM
55
Describe the inguinal nodes
* in the groin
56
* Macule * Patch larger than 1 cm * flat not raised
57
Where is S1 louder than S2
at the apex
58
Gyrate Lesion
59
Temporal Lobe Function?
* Auditory reception center * Hearing, taste, and smell * **Wernicke's Area= language comprehension**
60
Objective Findings for Osteoarthritis
* Limited ROM in the affected joint * fluid is easily moved around the joint space
61
This occurs when the pulmonic valve stays open a little bit longer during inspiration.
Split S2 (lub-T-dub)
62
Turning the forearm so the palm is out
Pronation
63
* **Vesicle** * Bulla- larger than 1cm * a blister, herpes chicken pox, shingles
64
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.
65
Moving the body part forward and parallel to the ground
protraction
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
What is the function of the occipital lobe?
Visual Receptor Center
68
Describe the Axillary Nodes
* drain the breast and upper arm
69
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
70
Venous Insufficiency Characteristics
* Brawny edema * brown pigment deposits * pulses are normal * Bleeding uneven edges
71
What do veins do?
drain deoxygenation blood from the tissues and return it to the heart
72
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,
73
During neurologic examination the tendon reflex fails to appear. Before striking the tendon again, the examiner might use what type of technique?
* **reinforcement** * perform a muscle group away from the one being tested, if patient cannot relax
74
Bending a limb at a joint
flexion
75
When is the best time to perform a breast self examination?
on the 4th - 7th day of the cycle
76
* **Papule** * Plaque larger than 1 cm * can feel, slightly elevated * mole wart
77
Influences Body Temperature
Diurnal Cycle
78
moving a body part backward and parallel to the ground
retraction
79
Dehydration Assessment
* Dry mucous membranes * lips cracked * Skin is fissured * Tenting w/ turgor
80
Which of the following vital signs are characteristic of an aging adult?
1. Decreased temperature 2. Decreased sweating 3. Increased risk of orthostatic hypotension
81
What are the 4 main lymph nodes accessible to inspection and palpation?
1. Cervical Node 2. Axillary Node 3. Epitrochlear Node 4. Inguinal Node
82
What is genu valgum?
Knocked Knees
83
Older Adult Expected Finding During Breast Exam
* lactiferous ducts are more palpable * feel firm and stringy b/c of fibrosis and calcification.
84
What does a “normal” tympanic membrane look like?
Shiny, translucent, pearly grey
85
An Area not commonly associated with pain
intramuscular
86
* Nodule * tumor larger than 3 cm
87
What is the Frontal Lobe concerned with?
* Personality * Behavior * Emotions * Intellectual Function * **Broca's Area- Motor Speech**
88
Pronation and supination of the hand and forearm are hte result of the articulation of the
* Radius * Ulna
89
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
90
Jarvis: What is the difference between S2 & S3?
S3 is lower pitched and is heard at the apex
91
Jarvis: Where is a split S2 heard most clearly?
pulmonic
92
Characteristics of S1
* First heart sound * Closure of the AV valves * "Lub" * heard best at the *apex* * Beginning of systole
93
Characteristics of S2
* Second heart sound * closure of semilunar valves * "Dub" * End of Systole * heart at Base of heart
94
Characteristics of S3
* Vibrations from filling ventricles * "lub-dubba" "kentucky" * Early diastole, after S2 * At apex with **bell** * left lateral position
95
Characteristics of S4
* Blood being pushed into a noncompliant ventricle * "da-lub-dub" "Tennessee" * End of diastole, presystole, before S1 * Heard at apex with **bell**
96
*During removal of a fecal impaction, which of the following could occur Because of vaginal stimulation?* A) Bradycardia B)Atelectasid C) Tachycardia D) Cardiac tamponade
A) Bradycardia Removing a fecal impaction manually may result in stimulation of the vaginal nerve and resulting bradycardia
97
Pathological Reasons for Listening for S3
Anemia, sign of HF Volume overload hyperthyroidism pregnancy renal failure persists when sitting up
98
Reasons for listenting for S4
decreased compliance of ventricle systolic overload aortic stenosis systemic hypertension
99
What are reasons for having a murmur
During menstrual cycle (benign) During Exercise Thyroid level too high Anemia (low blood)-less rbcs, less oxygen expected for infants structural defects in valve unusual openings in chambers
100
Where can a right heave be seen
sternal border
101
Where is a left heave seen?
at the apex
102
Characteristics of Split S2
* happens during inspiration but NOT while holding breath * in the pulmonic area
103
What is the difference for children vs adults with lymph nodes?
* enlarge in children * atrophy in adults
104
What is this representative of?
Emphysema
105
This is chronic productive cough, hypersecretion of mucous and v/q mismath
* **Chronic Bronchitis** * obstruction during expiration * narrowing of arrows
106
Describe Emphysema
* Enlargement of the alveoli * Loss of elastic recoil * Air gets trapped in the lungs * hyperexpansion of the chest
107
Nursing School Pt 1
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