Exam 1 Flashcards
Outermost skin layer
Epidermis
Innermost skin layer
Subcutaneous layer
Second layer of skin
Dermis
Yellow discoloration of skin and sclerae
Jaundice
Paleness
Pallor
Bluish discoloration
Cyanosis
Dependent redness
Rubor
Redness
Flushing, erythema
Dark, leathery appearance
Brawny
T/F: A would is assessed for location, size, color, texture, drainage, wound margins, surrounding skin, and healing status
True
T/F: Skin changes related to aging include melasma, linea nigra, increased sebaceous and cutaneous gland function, and hair loss
False
The older adult has _________ skin texture and prolonged time for _________ healing, and the thermoregulation changes increase the risk for hypothermia and hyperthermia.
rougher, wound
Skin ________ -examination assists patients to identify problematic lesions.
self
The depth of a burn can be superficial, superficial-dermal, dermal, or ________ thickness.
total
Tenting of the skin indicates __________
dehydration
What are the 6 categories of the Braden scale?
- Sensory perception
- Moisture
- Activity
- Mobility
- Nutrition
- Friction
What are the ABCDEs for assessing of Melanoma?
Asymmetry
Border irregularity
Color variety
Diameter of more than 6mm
Evolution of lesion over time
This tests extraocular muscles for symmetrical movements of the eyes in nine fields
Cardinal Fields of Gaze
This tests for visual field defects
Confrontation Test
Eye test that assesses near vision
Jaeger Test
This eye test tests for presence and amount of ocular deviation.
Cover Test
This eye test assesses distance visual acuity
Snellen Test
T/F: Patients older than 40 years of age often have an increased ability to accommodate, moving the object further away to read
False
T/F: A patient with 20/20 vision can read at 20ft what the normal person can read at 20ft.
True
T/F: Cranial nerves involved with the eyes include II, III, IV, and V.
False
Cloudiness in the lens can indicate a ______
cataract
________ is documented when the pupils are equal, round, and reactive to light and accommodation.
PERRLA
__________ is the leading cause of blindness in middle and older adults.
Diabetic retinopathy
Name two Nursing Diagnoses associated with the eyes
- Impaired vision: assess for safety risks in their environment - fall risk for individuals with low vision and mobility.
- Eye care: Ensure the patient is wearing clean eyeglasses and refer those who need corrective lenses.
T/F: The Weber test differentiates bilateral hearing loss.
False
T/F: Nonverbal cues of hearing loss include leaning forward, concentrating on lip reading, or giving incorrect answers to questions asked
True
T/F: The inner ear contains the malleus, incus, and stapes that conduct sound waves to the middle ear.
False
T/F: Environmental factors that increase the risk for otitis media include secondhand smoke, propping bottles for babies to feed, and bottle feeding in the supine position.
True
The _________ membrane is the barrier between the external auditory canal and the middle ear.
tympanic
The semicircular canals and vestibule provide the body with ______ and equilibrium.
proprioception
Color and consistency of _______ differs according to cultural background
cerumen
_________ hearing loss is caused by either blockage or the external auditory canal by cerumen or fluid in the middle ear`
Conductive
How should the nurse hold the ear of an adult patient when performing an otoscopic examination?
Hold the ear at the helix (top) and lift up and back so that the canal is aligned for the best visualization of the tympanic membrane.
What is the Rinne test testing for?
To determine if hearing is equal in both ears and if conductive hearing loss or SNHL is present. This test compares the difference between air conduction and bone conduction.
Shortness of breath
dyspnea
Gray or blue skin - indicating lack of oxygen
Cyanosis
Coughing up frank blood
Hemoptysis
Breathing more than 24 breaths/minute
Tachypnea
Difficulty breathing when lying flat
Orthopnea
Airway collapse
Atelectasis
Unusual paleness of the skin
Pallor
Continuous, high-pitched, musical sounds caused by air squeezing through narrowed airways. Associated with emphysema, asthma, and bronchitis
Wheezing
A high-pitched crowing sound from the upper airway; results from tracheal or laryngeal spasm or constriction. Can indicate an emergency
Stridor
Normal breath sound, heard at larynx and trachea, inspiration less than expiration
Bronchial
Continuous, low-pitched, snoring sounds resulting from secretions moving around in airways. May clear with coughing. Associated with pneumonia
Rhonchi
Normal breath sound, heard anteriorly between 1st and 2nd ICSs; between scapula, inspiration equal to expiration
Bronchovesicular
High-pitched, soft, brief sounds that can be simulated by rolling a strand of hair near the ear. Associated with heart failure, asthma, or COPD.
Fine Crackles
Low-pitched, moist, longer sounds similar to Velcro slowly being separated. Associated with respiratory edema, COPD, and respiratory fibrosis.
Coarse Crackles
Normal breath sound, heard over most of the lung field, inspiration greater than expiration.
Vesicular
T/F: The right lung has two lobes, whereas the left lung has three.
False
T/F: Lungs should be auscultated from the base to the apex.
False
T/F: The only trigger for breathing is increased carbon dioxide in the blood.
False
T/F: In an emergency respiration situation, it is important to stay with and calm the patient to reduce anxiety.
True
T/F: Midclavicular line runs vertically down the center of the sternum.
False
The ________ contains the heart, lungs, thymus, distal part of the trachea, and most of the esophagus.
mediastinum
The ______ refers to the very bottom of the lung fields; the _______ is the very top (opposite of the labeling of the heart).
base, apex
The _____ are the primary units in the lungs that absorb oxygen and excrete carbon dioxide.
alveoli
________ is considered the leading cause of preventable death.
Smoking
__________ are abnormal breath sounds, such as crackles, wheezes, or rhonchi.
Adventitious breath sounds
An angle of 180 degrees or more is called ______ of the fingers, which indicates chronic hypoxia.
clubbing
_________ is the AP to transverse ratio in patients with a barrel chest. ________ is normal AP to transverse ratio.
1:1, 1:2
_______ respiration pattern is usually seen in patients at end of life.
Cheyne-Stokes
_______ respiration pattern is a regular irregular rhythm that cycles from deep and fast to shallow and slow with some periods of apnea.
Biot breathing
T/F: Breast cancer is the leading cause of cancer in females.
True
T/F: Breasts often feel full, sore, or heavy just prior to menstruation.
True
T/F: The most common breast concerns that cause women to seek medical evaluation area a newly discovered lump, pain, and nipple discharge.
True
________ is when one or both male breasts temporarily enlarge as a result of changing hormone levels.
Gynecomastia
______ is the beginning of menstruation and occurs during late puberty or Tanner stage 3 or 4.
Menarche
A well-defined, usually single, nontender, firm or rubbery, round or lobular mass that is freely movable is called a ______
fibroadenoma
What seven signs/symptoms require further investigation to rule out cancer?
- A new breast lump or mass
- Swelling of all or part of a breast (even if no distinct lump is felt)
- Skin irritation or dimpling
- Breast or nipple pain
- Nipple retraction (turning inward)
- Redness, scaliness, or thickening of the nipple or breast skin
- Nipple discharge (other than breast milk)
The nurse should have the patient sit/stand in five different positions when inspecting breasts. What are these five positions?
- Patient sitting with their arms at the sides.
- Lifting their arms over their head.
- Patient’s hands pressed firmly on the hips.
- Patient standing and leaning forward from the waist.
- Lying supine.
When palpating the breasts there are three different techniques that can be performed. What are these three techniques?
- Vertical pattern
- Circular pattern
- Wedge pattern
Valve that separates the left atrium and left ventricle
Mitral valve
Valve that separates the right atrium and right ventricle
Tricuspid valve
Valve that lies between the left ventricle and aorta
Aortic valve
Valve that lies between the right ventricle and pulmonary artery
Pulmonic valve
Volume in the right atrium at the end of diastole
Preload
Contraction of the ventricles
Systole
Amount of blood ejected from the left ventricle each minute
Cardiac output
Common name for the extra heart sounds S3 and S4
Gallop
How much blood is ejected with each beat or stroke
Stroke volume
Abnormal heart sound that may result from intrinsic cardiovascular disease or circulatory disturbance. Usually indicates disease of the heart valves, either from stenosis or regurgitation.
Bruits
Swishing auscultatory sound that indicates turbulent blood flow or narrowing from constriction or dilation of a tortuous vessel.
Murmur
Ventricular relaxation
Diastole
T/F: The top of the heart is referred to as the apex because it is broad; the bottom of the heart is referred to as the base.
False
T/F: The coronary veins may develop atherosclerotic plaques that narrow them, leading to a myocardial infarction (heart attack) or angina.
False
T/F: The pulmonary artery carries deoxygenated blood to the lungs, whereas the pulmonary vein delivers oxygenated blood to the left atrium.
True
T/F: S1, or “lub”, the beginning of systole, results from closure of the aortic and pulmonic valves, ans S2, or “dub”, the end of systole and beginning of diastole, results from closure of the mitral and tricuspid valves.
False
T/F: African American men are 40% more likely to have high blood pressure than Caucasians.
False
The heart and great vessels are located in the _________ between the lungs and above the diaphragm from the center to the left of the thorax.
mediastinum
The parts of the heart that pump blood to the lungs and out of the body are called __________
arteries
The cells in the SA node are unique because they possess ___________ (property that enables the heart to generate its own impulses).
automaticity
__________ are abnormal heart rhythms with early (premature), delayed, or irregular beats.
Arrhythmias
If a patient is experiencing chest pain, dyspnea, cyanosis, diaphoresis, or dizziness, focus assessment on data to __________ the discomfort while simultaneously providing treatments.
alleviate
Heart Rate x Stroke Volume =
Cardiac output
_______ _________ is one cause of reduced cardiac output. It is a medical diagnosis that reduces contractility, causing preload to increase.
Heart failure
What is the term used to describe the area where the apical pulsation can be seen or palpated?
Point of maximal impulse (PMI)
Where would you locate the point of maximal impulse?
In most adults, it is commonly found at the intersection of the 5th ICS mitral area and the left MCL.
Indicate the number and a description of the Grading of Pulse Scale
0: Nonpalpable or absent
1+: Weak and thready
2+: Normal, expected
3+: Full, increased
4+: Bounding
