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Assessments Across the Lifespan > Exam 1 > Flashcards

Exam 1 Flashcards

1
Q

Outermost skin layer

A

Epidermis

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2
Q

Innermost skin layer

A

Subcutaneous layer

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3
Q

Second layer of skin

A

Dermis

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4
Q

Yellow discoloration of skin and sclerae

A

Jaundice

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5
Q

Paleness

A

Pallor

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6
Q

Bluish discoloration

A

Cyanosis

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7
Q

Dependent redness

A

Rubor

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8
Q

Redness

A

Flushing, erythema

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9
Q

Dark, leathery appearance

A

Brawny

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10
Q

T/F: A would is assessed for location, size, color, texture, drainage, wound margins, surrounding skin, and healing status

A

True

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11
Q

T/F: Skin changes related to aging include melasma, linea nigra, increased sebaceous and cutaneous gland function, and hair loss

A

False

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12
Q

The older adult has _________ skin texture and prolonged time for _________ healing, and the thermoregulation changes increase the risk for hypothermia and hyperthermia.

A

rougher, wound

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13
Q

Skin ________ -examination assists patients to identify problematic lesions.

A

self

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14
Q

The depth of a burn can be superficial, superficial-dermal, dermal, or ________ thickness.

A

total

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15
Q

Tenting of the skin indicates __________

A

dehydration

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16
Q

What are the 6 categories of the Braden scale?

A
  1. Sensory perception
  2. Moisture
  3. Activity
  4. Mobility
  5. Nutrition
  6. Friction
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17
Q

What are the ABCDEs for assessing of Melanoma?

A

Asymmetry
Border irregularity
Color variety
Diameter of more than 6mm
Evolution of lesion over time

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18
Q

This tests extraocular muscles for symmetrical movements of the eyes in nine fields

A

Cardinal Fields of Gaze

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19
Q

This tests for visual field defects

A

Confrontation Test

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20
Q

Eye test that assesses near vision

A

Jaeger Test

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21
Q

This eye test tests for presence and amount of ocular deviation.

A

Cover Test

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22
Q

This eye test assesses distance visual acuity

A

Snellen Test

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23
Q

T/F: Patients older than 40 years of age often have an increased ability to accommodate, moving the object further away to read

A

False

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24
Q

T/F: A patient with 20/20 vision can read at 20ft what the normal person can read at 20ft.

A

True

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25
Q

T/F: Cranial nerves involved with the eyes include II, III, IV, and V.

A

False

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26
Q

Cloudiness in the lens can indicate a ______

A

cataract

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27
Q

________ is documented when the pupils are equal, round, and reactive to light and accommodation.

A

PERRLA

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28
Q

__________ is the leading cause of blindness in middle and older adults.

A

Diabetic retinopathy

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29
Q

Name two Nursing Diagnoses associated with the eyes

A
  1. Impaired vision: assess for safety risks in their environment - fall risk for individuals with low vision and mobility.
  2. Eye care: Ensure the patient is wearing clean eyeglasses and refer those who need corrective lenses.
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30
Q

T/F: The Weber test differentiates bilateral hearing loss.

A

False

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31
Q

T/F: Nonverbal cues of hearing loss include leaning forward, concentrating on lip reading, or giving incorrect answers to questions asked

A

True

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32
Q

T/F: The inner ear contains the malleus, incus, and stapes that conduct sound waves to the middle ear.

A

False

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33
Q

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.

A

True

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34
Q

The _________ membrane is the barrier between the external auditory canal and the middle ear.

A

tympanic

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35
Q

The semicircular canals and vestibule provide the body with ______ and equilibrium.

A

proprioception

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36
Q

Color and consistency of _______ differs according to cultural background

A

cerumen

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37
Q

_________ hearing loss is caused by either blockage or the external auditory canal by cerumen or fluid in the middle ear`

A

Conductive

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38
Q

How should the nurse hold the ear of an adult patient when performing an otoscopic examination?

A

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.

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39
Q

What is the Rinne test testing for?

A

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.

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40
Q

Shortness of breath

A

dyspnea

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41
Q

Gray or blue skin - indicating lack of oxygen

A

Cyanosis

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42
Q

Coughing up frank blood

A

Hemoptysis

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43
Q

Breathing more than 24 breaths/minute

A

Tachypnea

44
Q

Difficulty breathing when lying flat

A

Orthopnea

45
Q

Airway collapse

A

Atelectasis

46
Q

Unusual paleness of the skin

A

Pallor

47
Q

Continuous, high-pitched, musical sounds caused by air squeezing through narrowed airways. Associated with emphysema, asthma, and bronchitis

A

Wheezing

48
Q

A high-pitched crowing sound from the upper airway; results from tracheal or laryngeal spasm or constriction. Can indicate an emergency

A

Stridor

49
Q

Normal breath sound, heard at larynx and trachea, inspiration less than expiration

A

Bronchial

50
Q

Continuous, low-pitched, snoring sounds resulting from secretions moving around in airways. May clear with coughing. Associated with pneumonia

A

Rhonchi

51
Q

Normal breath sound, heard anteriorly between 1st and 2nd ICSs; between scapula, inspiration equal to expiration

A

Bronchovesicular

52
Q

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.

A

Fine Crackles

53
Q

Low-pitched, moist, longer sounds similar to Velcro slowly being separated. Associated with respiratory edema, COPD, and respiratory fibrosis.

A

Coarse Crackles

54
Q

Normal breath sound, heard over most of the lung field, inspiration greater than expiration.

A

Vesicular

55
Q

T/F: The right lung has two lobes, whereas the left lung has three.

A

False

56
Q

T/F: Lungs should be auscultated from the base to the apex.

A

False

57
Q

T/F: The only trigger for breathing is increased carbon dioxide in the blood.

A

False

58
Q

T/F: In an emergency respiration situation, it is important to stay with and calm the patient to reduce anxiety.

A

True

59
Q

T/F: Midclavicular line runs vertically down the center of the sternum.

A

False

60
Q

The ________ contains the heart, lungs, thymus, distal part of the trachea, and most of the esophagus.

A

mediastinum

61
Q

The ______ refers to the very bottom of the lung fields; the _______ is the very top (opposite of the labeling of the heart).

A

base, apex

62
Q

The _____ are the primary units in the lungs that absorb oxygen and excrete carbon dioxide.

A

alveoli

63
Q

________ is considered the leading cause of preventable death.

A

Smoking

64
Q

__________ are abnormal breath sounds, such as crackles, wheezes, or rhonchi.

A

Adventitious breath sounds

65
Q

An angle of 180 degrees or more is called ______ of the fingers, which indicates chronic hypoxia.

A

clubbing

66
Q

_________ is the AP to transverse ratio in patients with a barrel chest. ________ is normal AP to transverse ratio.

A

1:1, 1:2

67
Q

_______ respiration pattern is usually seen in patients at end of life.

A

Cheyne-Stokes

68
Q

_______ respiration pattern is a regular irregular rhythm that cycles from deep and fast to shallow and slow with some periods of apnea.

A

Biot breathing

69
Q

T/F: Breast cancer is the leading cause of cancer in females.

A

True

70
Q

T/F: Breasts often feel full, sore, or heavy just prior to menstruation.

A

True

71
Q

T/F: The most common breast concerns that cause women to seek medical evaluation area a newly discovered lump, pain, and nipple discharge.

A

True

72
Q

________ is when one or both male breasts temporarily enlarge as a result of changing hormone levels.

A

Gynecomastia

73
Q

______ is the beginning of menstruation and occurs during late puberty or Tanner stage 3 or 4.

A

Menarche

74
Q

A well-defined, usually single, nontender, firm or rubbery, round or lobular mass that is freely movable is called a ______

A

fibroadenoma

75
Q

What seven signs/symptoms require further investigation to rule out cancer?

A
  • 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)
76
Q

The nurse should have the patient sit/stand in five different positions when inspecting breasts. What are these five positions?

A
  • 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.
77
Q

When palpating the breasts there are three different techniques that can be performed. What are these three techniques?

A
  • Vertical pattern
  • Circular pattern
  • Wedge pattern
78
Q

Valve that separates the left atrium and left ventricle

A

Mitral valve

79
Q

Valve that separates the right atrium and right ventricle

A

Tricuspid valve

80
Q

Valve that lies between the left ventricle and aorta

A

Aortic valve

81
Q

Valve that lies between the right ventricle and pulmonary artery

A

Pulmonic valve

82
Q

Volume in the right atrium at the end of diastole

A

Preload

83
Q

Contraction of the ventricles

A

Systole

84
Q

Amount of blood ejected from the left ventricle each minute

A

Cardiac output

85
Q

Common name for the extra heart sounds S3 and S4

A

Gallop

86
Q

How much blood is ejected with each beat or stroke

A

Stroke volume

87
Q

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.

A

Bruits

88
Q

Swishing auscultatory sound that indicates turbulent blood flow or narrowing from constriction or dilation of a tortuous vessel.

A

Murmur

89
Q

Ventricular relaxation

A

Diastole

90
Q

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.

A

False

91
Q

T/F: The coronary veins may develop atherosclerotic plaques that narrow them, leading to a myocardial infarction (heart attack) or angina.

A

False

92
Q

T/F: The pulmonary artery carries deoxygenated blood to the lungs, whereas the pulmonary vein delivers oxygenated blood to the left atrium.

A

True

93
Q

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.

A

False

94
Q

T/F: African American men are 40% more likely to have high blood pressure than Caucasians.

A

False

95
Q

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.

A

mediastinum

96
Q

The parts of the heart that pump blood to the lungs and out of the body are called __________

A

arteries

97
Q

The cells in the SA node are unique because they possess ___________ (property that enables the heart to generate its own impulses).

A

automaticity

98
Q

__________ are abnormal heart rhythms with early (premature), delayed, or irregular beats.

A

Arrhythmias

99
Q

If a patient is experiencing chest pain, dyspnea, cyanosis, diaphoresis, or dizziness, focus assessment on data to __________ the discomfort while simultaneously providing treatments.

A

alleviate

100
Q

Heart Rate x Stroke Volume =

A

Cardiac output

101
Q

_______ _________ is one cause of reduced cardiac output. It is a medical diagnosis that reduces contractility, causing preload to increase.

A

Heart failure

102
Q

What is the term used to describe the area where the apical pulsation can be seen or palpated?

A

Point of maximal impulse (PMI)

103
Q

Where would you locate the point of maximal impulse?

A

In most adults, it is commonly found at the intersection of the 5th ICS mitral area and the left MCL.

104
Q

Indicate the number and a description of the Grading of Pulse Scale

A

0: Nonpalpable or absent
1+: Weak and thready
2+: Normal, expected
3+: Full, increased
4+: Bounding

105
Q
A

Assessments Across the Lifespan (2 decks)

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