Assessment Final UPDATE Flashcards
Which cranial nerves control the extraocular muscles (EOM)?
- Oculomotor (II),
- Abducens (VI),
- Trochlear (IV)
Documenting Heart Sounds x4
- Frequency/Pitch
- Intensity/Loudness
- Duration
- Timing: systole/diastole
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?
Silvery White
- Keloid
- hypertrophic scar
- elevetated skin by excess scar tisue
All Patients Take Meds..
- Aortic (2nd Rt, ICS)
- Pulmonary (2nd Left, ICS)
- Tricuspid (Lt lower sternum)
- Mitral (5th ICS midclavical)
Cranial Nerve Mneumonic Sensory, Motor or Both
- Some Say Marry Money But My Brother Says Bad Business Marry Money
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.
Osteoarthritis
- Keloid
- hypertrophic scar
- elevetated skin by excess scar tisue
- Polycyclic
- i.e. psoriasis
- anular lesions grow together
Define a Lymph Node
- Small oval clumps of lymphatic tissue located at intervals along the vessels.
- Filter fluid before returned to bloodstream
- remove harmful organisms.
Compound Nevus
Which of the following options is not a change that comes with menopause?
- The vaginal pH becomes more alkalotic
- The vagina becomes shorter and narrower
- The cervix shrinks
- The ovaries hypertrophy
junctional nevus
- Scale
- compact flakes of skin
- Scale
- compact flakes of skin
During assessment of the spine, what do you ask the patient?
- Flex
- Extend
- Abduct
- Rotate
Characteristics of Osteoarthritis?
- 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
- Meta-tarso-phangeal joint
- Redness, swelling, heat, tenderness
- metabolic disorder, elevated serum uric acid
- More predominant in men older than 40 yrs
What 4 areas do you auscultate when listening to the heart?
- Aortic, Pulmonic, Tricuspid, Mitral
Describe the Cervical Node
- Drains the head and neck
A murmur heard after S1 and before S2 is classified as
systolic (possibly benign)
- zosteriform
- linear around unilateral nerve
- ex: herpes
Describe the Epitrochlear Node
- In the Antecubital fossa
3 Common types of birthmarks
- freckles
- junctional nevus
- compound nevus
moving the sole of the foot outward at the ankle
eversion
3 Common types of birthmarks
- freckles
- junctional nevus
- compound nevus
- Confluent Lesion
- ex hives//uriticaria
The nurse assess a patient with osteoarthritis, what would be an expected sign/symptom?
- stiff knees, hips, fingers, and vertebrae
Describe the Left Lung
- narrower than the right w/ 2 lobes
moving the arm in a circle around the shoulder
circumduction
Melena
really dark stools b/c of blood
- Discrete lesion
- Skin tags//acne
3 areas of the Glasgow Coma Scale
- eye opening
- motor response to stimuli
- verbal response
Swan-neck, boutonnière deformity, and ulnar deviation are conditions associated with
rheumatoid arthritis
Cerebellar function is assesed by which of the following tests?
coordination, hop on one foot
Often seen with history of trauma or obesity, and can be genetic
osteoarthritis
junctional nevus
Arterial Insufficiency Characteristics
- coolness/pallor
- Diminished pulses
- shiny, thin skin
- well defined edges NO bleeding
- pale ischemic base
- occur at toes, heels, lateral ankle
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
What is the parietal lobe concerned with?
- post-central gyrus
- primary center for sensation
The group of axillary lymph nodes that drains the other three groups of nodes is the:
Central Nodes
An area of the body that is supplied mainly from one spinal segment through a particular spinal nerve is identified as a:
dermatone
Why are children more at risk for ear infections?
They have shorter, wider, more horizontal Eustachian tubes
Each half of the cerebrum is a
hemisphere
characterized by hard, nontender nodules, 2 to 3 mm or more
Osteoarthritis
-
Wheal
- Urticaria-hives
- raised irregular shape due to edema
- mosquito bites, allergies
control of body temperature
hypothalamus
- Discrete lesion
- Skin tags//acne
Describe the inguinal nodes
- in the groin
- Macule
- Patch larger than 1 cm
- flat not raised
Where is S1 louder than S2
at the apex
Gyrate Lesion
Where do arteries carry blood from?
from the heart
Temporal Lobe Function?
- Auditory reception center
- Hearing, taste, and smell
- Wernicke’s Area= language comprehension
Gyrate Lesion
- Polycyclic
- i.e. psoriasis
- anular lesions grow together
This occurs when the pulmonic valve stays open a little bit longer during inspiration.
Split S2 (lub-T-dub)
Objective Findings for Osteoarthritis
- Limited ROM in the affected joint
- fluid is easily moved around the joint space
Turning the forearm so the palm is out
Pronation
-
Vesicle
- Bulla- larger than 1cm
- a blister, herpes chicken pox, shingles
Subjective Data for Osteoarthritis
- Pain (worse later in the day)
- stiffness
- reported limited ROM
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.
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
Moving the body part forward and parallel to the ground
protraction
A newborn’s nail beds may be blue (cyanotic) for the first few hours of life, then they turn what color?
pink
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
-
Vesicle
- Bulla- larger than 1cm
- a blister, herpes chicken pox, shingles
Turning the forearm so the palm is up
supination
What is the function of the occipital lobe?
Visual Receptor Center
Describe the Axillary Nodes
- drain the breast and upper arm
What is the best position for inspecting the breasts for retraction?
Sitting with hand pushing onto hips
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
Venous Insufficiency Characteristics
- Brawny edema
- brown pigment deposits
- pulses are normal
- Bleeding uneven edges
What do veins do?
drain deoxygenation blood from the tissues and return it to the heart
Straightening a limb at a joint
extension
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,
During neurologic examination the tendon reflex fails to appear. Before striking the tendon again, the examiner might use what type of technique?
reinforcement
Bending a limb at a joint
flexion
- zosteriform
- linear around unilateral nerve
- ex: herpes
- Confluent Lesion
- ex hives//uriticaria
When is the best time to perform a breast self examination?
on the 4th - 7th day of the cycle
-
Papule
- Plaque larger than 1 cm
- can feel, slightly elevated
- mole wart
Influences Body Temperature
Diurnal Cycle
Where is the most common site for breast tumors
upper outer quadrant
moving a body part backward and parallel to the ground
retraction
Compound Nevus
Dehydration Assessment
- Dry mucous membranes
- lips cracked
- Skin is fissured
- Tenting w/ turgor
skin normal findings seen mostly in infants? x3
- Cafe Au Lait Spot
- Mongolian Spot
- Lanugo
Which of the following vital signs are characteristic of an aging adult?
- Decreased temperature
- Decreased sweating
- Increased risk of orthostatic hypotension
What are the 4 main lymph nodes accessible to inspection and palpation?
- Cervical Node
- Axillary Node
- Epitrochlear Node
- Inguinal Node
How often should males 15 y/o+ do a testicular self exam?
Once a month
What is genu valgum?
Knocked Knees
-
Papule
- Plaque larger than 1 cm
- can feel, slightly elevated
- mole wart
- Macule
- Patch larger than 1 cm
- flat not raised
Older Adult Expected Finding During Breast Exam
- lactiferous ducts are more palpable
- feel firm and stringy b/c of fibrosis and calcification.
What does a “normal” tympanic membrane look like?
Shiny, translucent, pearly grey
An Area not commonly associated with pain
inramuscular
- Nodule
- tumor larger than 3 cm
What is the Frontal Lobe concerned with?
- Personality
- Behavior
- Emotions
- Intellectual Function
- Broca’s Area- Motor Speech
-
Wheal
- Urticaria-hives
- raised irregular shape due to edema
- mosquito bites, allergies
Pronation and supination of the hand and forearm are hte result of the articulation of the
- Radius
- Ulna
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
- Nodule
- tumor larger than 3 cm
