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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
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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26
Q

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

A
  • Aortic, Pulmonic, Tricuspid, Mitral
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27
Q

Describe the Cervical Node

A
  • Drains the head and neck
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28
Q
A
  • zosteriform
  • linear around unilateral nerve
  • ex: herpes
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29
Q

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:

A

Arcus Senillis

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30
Q

Describe the Epitrochlear Node

A
  • In the Antecubital fossa
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31
Q

Cerebellar function is assesed by which of the following tests?

A

coordination, hop on one foot

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32
Q

3 Common types of birthmarks

A
  1. freckles
  2. junctional nevus
  3. compound nevus
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33
Q

moving the sole of the foot outward at the ankle

A

eversion

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34
Q

3 areas of the Glasgow Coma Scale

A
  1. eye opening
  2. motor response to stimuli
  3. verbal response
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35
Q

The nurse assess a patient with osteoarthritis, what would be an expected sign/symptom?

A
  • stiff knees, hips, fingers, and vertebrae
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36
Q
A
  • Confluent Lesion
  • ex hives//uriticaria
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37
Q

Describe the Left Lung

A
  • narrower than the right w/ 2 lobes
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38
Q

moving the arm in a circle around the shoulder

A

circumduction

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39
Q

Melena

A

really dark stools b/c of blood

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40
Q
A
  • Discrete lesion
  • Skin tags//acne
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41
Q

Swan-neck, boutonnière deformity, and ulnar deviation are conditions associated with

A

rheumatoid arthritis

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42
Q

An area of the body that is supplied mainly from one spinal segment through a particular spinal nerve is identified as a:

A

dermatone

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43
Q

Often seen with history of trauma or obesity, and can be genetic

A

osteoarthritis

44
Q

Arterial Insufficiency Characteristics

A
  • coolness/pallor
  • Diminished pulses
  • shiny, thin skin
  • well defined edges NO bleeding
  • pale ischemic base
  • occur at toes, heels, lateral ankle
45
Q

What is the parietal lobe concerned with?

A
  • post-central gyrus
  • primary center for sensation
46
Q

Cranial Nerve Mneumonic

Oh Oh Oh To Touch And Feel Very Good Velvet AH!

A
  • Olfactory
  • optic
  • Oculomotor
  • Trochlear
  • Trigeminal
  • Abducens
  • Facial
  • Vestibulocochlear
  • Glossopharyngeal
  • Vagus
  • Accessory
  • Hypoglossal
47
Q

The group of axillary lymph nodes that drains the other three groups of nodes is the:

A

Central Nodes

48
Q

Why are children more at risk for ear infections?

A

They have shorter, wider, more horizontal Eustachian tubes

49
Q

Each half of the cerebrum is a

A

hemisphere

50
Q

characterized by hard, nontender nodules, 2 to 3 mm or more

A

Osteoarthritis

51
Q
A
  • Wheal
    • Urticaria-hives
  • raised irregular shape due to edema
  • mosquito bites, allergies
52
Q

control of body temperature

A

hypothalamus

53
Q

Where do arteries carry blood from?

A

from the heart

54
Q

Subjective Data for Osteoarthritis

A
  • Pain (worse later in the day)
  • stiffness
  • reported limited ROM
55
Q

Describe the inguinal nodes

A
  • in the groin
56
Q
A
  • Macule
    • Patch larger than 1 cm
  • flat not raised
57
Q

Where is S1 louder than S2

A

at the apex

58
Q
A

Gyrate Lesion

59
Q

Temporal Lobe Function?

A
  • Auditory reception center
  • Hearing, taste, and smell
  • Wernicke’s Area= language comprehension
60
Q

Objective Findings for Osteoarthritis

A
  • Limited ROM in the affected joint
  • fluid is easily moved around the joint space
61
Q

This occurs when the pulmonic valve stays open a little bit longer during inspiration.

A

Split S2 (lub-T-dub)

62
Q

Turning the forearm so the palm is out

A

Pronation

63
Q
A
  • Vesicle
    • Bulla- larger than 1cm
  • a blister, herpes chicken pox, shingles
64
Q

Signs/Symptoms of Hemorrhoids

A
  • 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
Q

Moving the body part forward and parallel to the ground

A

protraction

66
Q

Neurological Changes in the Older Adult

A
  • 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
Q

What is the function of the occipital lobe?

A

Visual Receptor Center

68
Q

Describe the Axillary Nodes

A
  • drain the breast and upper arm
69
Q

Signs/Symptoms of Fecal Impaction

A
  • 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
Q

Venous Insufficiency Characteristics

A
  • Brawny edema
  • brown pigment deposits
  • pulses are normal
  • Bleeding uneven edges
71
Q

What do veins do?

A

drain deoxygenation blood from the tissues and return it to the heart

72
Q

RAM

A
  • 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
Q

During neurologic examination the tendon reflex fails to appear. Before striking the tendon again, the examiner might use what type of technique?

A
  • reinforcement
  • perform a muscle group away from the one being tested, if patient cannot relax
74
Q

Bending a limb at a joint

A

flexion

75
Q

When is the best time to perform a breast self examination?

A

on the 4th - 7th day of the cycle

76
Q
A
  • Papule
    • Plaque larger than 1 cm
  • can feel, slightly elevated
  • mole wart
77
Q

Influences Body Temperature

A

Diurnal Cycle

78
Q

moving a body part backward and parallel to the ground

A

retraction

79
Q

Dehydration Assessment

A
  • Dry mucous membranes
  • lips cracked
  • Skin is fissured
  • Tenting w/ turgor
80
Q

Which of the following vital signs are characteristic of an aging adult?

A
  1. Decreased temperature
  2. Decreased sweating
  3. Increased risk of orthostatic hypotension
81
Q

What are the 4 main lymph nodes accessible to inspection and palpation?

A
  1. Cervical Node
  2. Axillary Node
  3. Epitrochlear Node
  4. Inguinal Node
82
Q

What is genu valgum?

A

Knocked Knees

83
Q

Older Adult Expected Finding During Breast Exam

A
  • lactiferous ducts are more palpable
  • feel firm and stringy b/c of fibrosis and calcification.
84
Q

What does a “normal” tympanic membrane look like?

A

Shiny, translucent, pearly grey

85
Q

An Area not commonly associated with pain

A

intramuscular

86
Q
A
  • Nodule
    • tumor larger than 3 cm
87
Q

What is the Frontal Lobe concerned with?

A
  • Personality
  • Behavior
  • Emotions
  • Intellectual Function
  • Broca’s Area- Motor Speech
88
Q

Pronation and supination of the hand and forearm are hte result of the articulation of the

A
  • Radius
  • Ulna
89
Q

Characteristics of rheumatoid arthritis?

A
  • 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
Q

Jarvis:

What is the difference between S2 & S3?

A

S3 is lower pitched and is heard at the apex

91
Q

Jarvis:

Where is a split S2 heard most clearly?

A

pulmonic

92
Q

Characteristics of S1

A
  • First heart sound
  • Closure of the AV valves
  • “Lub”
  • heard best at the apex
  • Beginning of systole
93
Q

Characteristics of S2

A
  • Second heart sound
  • closure of semilunar valves
  • “Dub”
  • End of Systole
  • heart at Base of heart
94
Q

Characteristics of S3

A
  • Vibrations from filling ventricles
  • “lub-dubba” “kentucky”
  • Early diastole, after S2
  • At apex with bell
  • left lateral position
95
Q

Characteristics of S4

A
  • Blood being pushed into a noncompliant ventricle
  • “da-lub-dub” “Tennessee”
  • End of diastole, presystole, before S1
  • Heard at apex with bell
96
Q

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

A) Bradycardia

Removing a fecal impaction manually may result in stimulation of the vaginal nerve and resulting bradycardia

97
Q

Pathological Reasons for Listening for S3

A

Anemia,
sign of HF
Volume overload
hyperthyroidism
pregnancy
renal failure
persists when sitting up

98
Q

Reasons for listenting for S4

A

decreased compliance of ventricle
systolic overload
aortic stenosis
systemic hypertension

99
Q

What are reasons for having a murmur

A

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
Q

Where can a right heave be seen

A

sternal border

101
Q

Where is a left heave seen?

A

at the apex

102
Q

Characteristics of Split S2

A
  • happens during inspiration but NOT while holding breath
  • in the pulmonic area
103
Q

What is the difference for children vs adults with lymph nodes?

A
  • enlarge in children
  • atrophy in adults
104
Q

What is this representative of?

A

Emphysema

105
Q

This is chronic productive cough, hypersecretion of mucous and v/q mismath

A
  • Chronic Bronchitis
  • obstruction during expiration
  • narrowing of arrows
106
Q

Describe Emphysema

A
  • Enlargement of the alveoli
  • Loss of elastic recoil
  • Air gets trapped in the lungs
  • hyperexpansion of the chest
107
Q
A

Nursing School Pt 1 (4 decks)

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