Exam 2 Flashcards

Question

Older Adults and CV Expected variations (3) and abnormal finding What are they? What may they indicate?

Answer 1

- Expected Finding o Occasional ectopic beats are common and may or may not be significant o S4 heart sound is common in older adult and may be due to decreased ventricular compliance o Cold feet and weak pedal pulses may be peripheral arterial disease due to higher risk in elderly - Abnormal Findings o Carotid bruits may be arteriosclerosis

Answer 2

- Note differences in rate, amplitude b/w pulses particularly radial and femoral - use pediatric stethoscope - Use bell of stethoscope over right supraclavicular space at medial end of clavicle along anterior border of sternocleidomastoid muscle to hear venous hum

Answer 3

vibration over jugular vein due to turbulent blood flow; continuous, low-pitched sound which is louder during diastole and can be stopped by applying gentle pressure b/w trachea and sternocleidomastoid muscle at level of thyroid cartilage -heard in children

Answer 4

* Expected Finding o Venous hum in jugular vein is normal variation o Pulse may increase on inspiration and decrease on expiration * Abnormal Finding - Squatting during ADLs may be compensatory position for child with congenital heart defect - Cyanosis or pallor may be poor perfusion - labored respirations may be heart problem - weak or absent femoral pulses may be coarctation of aorta Other things to note - Note if increased cyanosis with crying, facial edema (particularly periorbital edema) or ankle edema - Note signs of poor feeding and reports of caregiver that child stops eating to take breath b-c may mean heart problem

Answer 5

-done when one thigh or calve looks bigger than the other or patient complains of pain in these areas Procedure: place patient supine; measure circumference of each thigh or calf; note distance from patella to affected area to measure same place on both legs Expected finding: circumference of both legs is the same Abnormal finding - usually silent and early sign of Venous thromboses - increase in thigh or calf circumference (>1.5cm) may mean edema - chronic venous stasis may show increase bilaterally Color and temp differences are other signs

Answer 6

Procedure - For the femoral pulses, palpate below the inguinal ligament, midway between the symphysis pubis and anterior superior iliac crest, and move your fingers inward toward the pubic hair. * NAVEL: N, nerve; A, artery; V, vein; E, empty space; L, lymph * Firm compression may be required for obese patients - For the popliteal pulses, palpate the popliteal artery behind the knee in the popliteal fossa. This pulse may be difficult to find, so place patient in prone position and flex the leg slightly to help locate it. - For posterior tibial pulses, palpate on medial aspect of the ankle below and slightly behind the medial malleolus (ankle bone) - For dorsalis pedis pulse, palpate lightly over the dorsum of the foot between the extension tendons of the first and second toes; palpate both at same time for comparison Expected finding: regular rhythm, smooth contour with 2+ amplitude Abnormal finding: Irregular rhythm; weak or bounding upstroke which may mean arterial insufficiency

Answer 7

- pitting edema: when indent of thumb or finger remains in skin and indicates excess fluid in interstitial space seen in venous thromboembolism and venous insufficiency - pain on palpation - stocking anesthesia: sensation where legs feel numb in pattern resembling stockings

Answer 8

Expected finding: symmetrical, skin intact with color appropriate for race; evenly distributed hair if present; superficial veins are not presents Abnormal - Thickened skin, skin tears - Marked pallor or mottling (discolorations) when extremity elevated or ulceration of toes - Arterial insufficiency may decrease hair peripherally or make skin appear thin, shiny, and taut - Varicose veins: appear dilated or tortuous veins when legs in dependent position

Answer 9

Procedure: palpate firmly with index and 2nd finger; - For brachial artery, palpate in grooves between biceps and triceps medial to biceps tendon at antecubital fossa - For radial pulses, palpate at the thumb side of the forearm at the wrist - If radial pulse difficult to pulsate or injured, palpate the ulnar pulses located on the medial side of the forearm Expected finding: HR b/w 60-100 beats/minutes; spacing/rhythm should be equal/regular; smooth contour with 2+ amplitude Abnormal: Irregular rhythm, weak or bounding upstroke; Beta blockers or digoxin may slow pulse rates

Answer 10

Expected finding: warm bilaterally, elastic turgor, capillary refill <2 sec Abnormal: - Cold extremities in warm environment may be Arterial insufficiency - Edema (unilateral or bilateral; soft, firm, or hard; pain or no pain; lymphedema if one arm larger than other - Tenting when skin does not fall back in place indicated reduced fluid in interstitial space from fluid volume deficit - Capillary refill > 2 seconds indicates poor perfusion - Clubbing (angle of nails greater than 160 degrees) indicated chronic hypoxia

Answer 11

Procedure: take in both arms during initial visit; varies by age, gender, body weight, time of day - If patient has history of dizziness or antihypertensive medications, measure while supine, sitting, and standing Expected finding - pulse pressure b/w 30-40 mm Hg - BP <120/80 mm Hg - may vary 5-10 mmHg b/w arms - BP usually lower in supine than sitting and may be lower by 10-15 mmHg for systolic and 5 mmHg for diastolic when standing Abnormal - hyper or hypotension - Orthostatic hypotension: decrease in systolic BP of 20 mm Hg and/or diastolic BP of 10 mm Hg within 3 minutes of standing -> due to ECV deficit, drugs (antihypertensives), prolonged bed rest

Answer 12

- Reflect right atrial pressure Procedure: patient is supine, elevate head of bed until venous pulsations in external jugular vein is seen above clavicle close to insertion of sternocleidomastoid muscles. Elevate chin and tilt head away from side being examined. Use tangential light across jugular veins and observe for pulsations. Examine the other side. - Angle may be 30-45 degrees to 90 degrees if venous pressure elevated Expected finding: pulsations of veins are visible but not the veins themselves Abnormale: Note fluttering or oscillating of pulsation and irregular rhythms or unusually prominent waves which may indicate right sided heart failure

Answer 13

- Notice the rate, rhythm, amplitude, and contour of each pulse. - Compare strength of upper and lower extremities - Comparing pulses on each side of the body is customary - When you are unable to palpate a pulse, use a Doppler to amplify the sounds of the pulse

Answer 14

Expected: Smooth and rounded, a series of unvaried, symmetric pulse strokes Abnormal: Varied strokes or asymmetry between left and right extremities suggest impaired circulation

Answer 15

Expected: Easily palpable, smooth upstroke; 2+ normal Abnormal - Notice any exaggerated or bounding upstroke OR weak, small, or thready OR prolonged - Pulsus alternans: Upstrokes should not vary - Paradoxical pulse: force of beat reduced during inspiration - Ratings of amplitude 0+ Absent 1+ Diminished, barely palpable 3+ Full volume 4+ Full volume, bounding hyperkinetic

Answer 16

Expected: Regular, equal spacing b/w beats Abnormal - Coupled beats (two beats that occur closely together) - Regular irregularity: Irregular rhythms with pattern; an extra beat every third heartbeat seen in pulses of patients who have premature ventricular contractions. - Irregular irregularity: Irregular rhythms without a pattern seen in pulses of patients who have atrial fibrillation

Answer 17

Procedure: palpate temporal bone on each side of head lateral to eyebrows to assess amplitude and pain; palpate carotid along medial edge of sternocleidomastoid in lower third of neck to assess amplitude (one carotid artery at a time) Expected finding: regular rhythm, smooth contour (outline of pulse) with 2+ amplitude Abnormal - Pain, edema of temporal arteries - Irregular rhythm, weak, bounding upstroke of carotid arteries

Answer 18

S1 =S2 at ERB S1>S2 at mitral and tricuspid; apex S1

Answer 19

Aortic- 2nd RICS Pulmonic- 2nd LICS Erb's point- 3rd LICS Tricuspid- 4th LICS Mitral- 5th LICS

Answer 20

-S1 (lubb) from simultaneous closing of mitral and tricuspid valves indicating start of systole; louder at apex; slightly higher pitch than S2 S2 (dub) from simultaneous closing of aortic and pulmonic valves indicating beginning of diastole; louder at base

Answer 21

-sounds generated by closing of heart valves and are heard best where blood flows away from valves instead of on valves themselves; auscultate in 5 areas corresponding to projection of sound (APE To Man or backward) Procedure: patient upright leaning slightly forward to bring heart closer to chest wall - Use diaphragm (high-pitch sounds) and place firmly over chest to listen for heart sounds over aortic valve area on 2nd ICS - Use bell secondly and use light pressure on same 5 areas - If difficult to hear, ask patient to hold their breath to eliminate lung sounds and close your eyes to concentrate Expected finding: two distinct heart sounds should be heard; low pitched and low intensity

Answer 22

- Splitting: when S1 split (mitral and tricuspid valves do not close at the same time) or S2 split (pulmonic and aortic values do not close at the same time); these create two sounds instead of one. - S3 and S4 heart sounds (represent S1->systole -> S2 -> diastole)-sounds during systole or diastole o S3--normal in children and young adults; for adults, >30 years of age heart failure o S4-- uncontrolled hypertension - Pericardial friction rub: low-pitched coarse rubbing or grating sound caused by fluid accumulation in the pericardial sac. - Murmurs: due to turbulent blood flow producing prolonged extra sounds heard during systole or diastole; Described by timing the cardiac cycle, pitch, quality, intensity, and location

Answer 23

Procedure: modesty for females; use penlight to create tangential light to inspect chest at eye level; look for slight retraction of apical pulse at fourth or fifth intercostal space (ICS), medial to left midclavicular line (LMCL) Expected finding: round chest; no retractions Abnormal: Marked retraction of apical space may mean pericardial disease or right ventricular hypertrophy; increased size may mean large heart

Answer 24

You palpate for location and size You auscultate for rate and rhythm

Answer 25

Procedure: use fingertips at 5th ICS LMCL which is point of maximal impulse (PMI) corresponding to left ventricular apex - If not palpable, place patient in lying position, turned to left side which places left ventricle closer to the chest wall Expected finding: apical pulse or PMI is expected in 5th ICS, LMCL which tells us the heart is good size Abnormal - Lateral PMI--Myocardium is enlarged and may have more lateral PMI in left ventricular hypertrophy - Downward PMI--Overinflated lungs in COPD - Large heart may be seen in heart failure

Answer 26

Procedure: clean bell and diaphragm of stethoscope; place diaphragm on anterior chest and listen carefully for two distinct sounds; count for 1 minute and note rhythm Expected finding: HR b/w 60-100 beats/minutes; spacing/rhythm should be equal/regular Abnormal: Rate >100 or <60 beats/minute; Irregular rhythm, sporadic, extra beats, occasional slight pauses b/w heartbeats may need further evaluation

Answer 27

Onset: sudden or gradual Location: spreading? Common factors: allergies, dry skin, sensitive skin, chemicals, lices, scabies, insect bites Systemic Causes: biliary cirrhosis, lymphoma

Answer 28

Duration: constant or intermittent Characteristics (2 sets): flat or raised; itching or burning Common factors: allergies, skin disorder, systemic illness What else to ask about: family history

Answer 29

Common factors for general Changes: medications, anemia, poor circulation, systemic disease Localized changes: redness, discoloration, bruises, patches Potential factors for localized changes: perfusion, cyanosis, hematologic condition, vitiligo

Answer 30

- pruritus - rashes - pain - lesions and wounds - changes in skin color and texture

Answer 31

Characteristics: color, shape, texture, bleeding, itching, drainage Common factors: acne, trauma, infections, exposure to chemicals, tumors, systemic disease

Answer 32

Causes -chronic on leg = poor peripheral perfusion -if reported cause is incongruent it may be IPV (unexplainable welts, cuts, bruises, scratches) Hx of impaired healing may mean: nutritional /metabolic issue, infection, poor circulation

Answer 33

---thinning, dryness, fragile may be expected w/ aging or indicate a metabolic/nutrition issue -Seborrhea or xerosis may be seasonal, intermittent, or continuous; dry skin related to thyroid disease, low humidity, or poor skin lubrication

Answer 34

* Personal history of skin cancer * Family history of skin cancer * Older age * Exposure to UV radiation: Lifetime sun exposure; severe, blistering sunburns (early age) * Indoor tanning (including through occupation) * Fair skin; blond or red hair * Blue or green eyes * Moles (large numbers of common moles or a dysplastic nevus)

Answer 35

- Skin Cancer (most common cancer) - non melanoma(basal o r squamous) not required to be reported - melanoma(100k case in 2020) - diagnosed at later stages in elderly and more likely to be lethal

Answer 36

* nail separating from nail bed = hyperthyroidism * pitting brittle, crumbling, color changes = nutrient deficiency, systemic disease, localized fungal symptoms * stress and nail biting → local or fungal infection

Answer 37

Factors: stress, fever, illness, itching, nutritional deficiency, hair care products (may change texture and condition) * dry or brittle = stress or systemic disease * dullness or easily plucked = protein deficiency * ↓ hair growth on lower extremity = aging , hypothyroidism, immune disorder, ↓ peripheral circulation * ↑hair growth= ovarian or adrenal tumor

Answer 38

-southeastern Asia practice -body is rubbed vigorously with coin or scraped with spoon while exerting pressure until red marks appear over rib cage on back and chest -may be mistaken for abuse

Answer 39

-adults should examine skin periodically -new or unusual lesions should be evaluated by healthcare provider

Answer 40

-for melanoma lesion screening A—Asymmetry (not round or oval) B—Border (poorly defined or irregular border) C—Color (uneven, variegated) D—Diameter (usually greater than 6 mm) E—Evolving (looks different from others or is changing in size, shape, or color)

Answer 41

-used in latin america or russia - alternative medicine for arthritis, stomach aches, bruises, paralysis -glass cup or rubber pump to create negative pressure is attached to the skin and leaves a reddened area or mark

Answer 42

-seek shade whenever possible esp at midday -avoid sunbathing and indoor tanning -protect skin from sun exposure via wide brimmed hat, sunglasses, tightly woven clothes, sunscreen with SPF >15 even if cloudy -counsel parents about minimizing UV exposure from 6 months to 24 years

Answer 43

-Expected: nail smooth and intact Abnormalities: - nail biting -cyanosis of nail or nail clubbing may indicate respiratory or cardiac disease

Answer 44

- Expected: very little body or facial hair - Common abnormalities: alopecia due to hair pulling, twisting, head rubbing; lice, nits, scabies

Answer 45

- Hair changes significantly and by the end of adolescent there is as adult hair distribution pattern Common abnormality of nails: Persistent nail biting may be habit, coping mechanism for stress; evaluate reason

Answer 46

Hair - Thin, gray, coarse - Decreased body, pubic and axillary hair in men and women - Men have increase in amount and coarseness of nasal and eyebrow hair; symmetric balding in men - Women develop coarse facial hair Nails: thick and brittle especially toenails

Answer 47

Precaution: provide adequate privacy and be sensitive to patient concerns Expected finding: increased perspiration, oiliness, and acne due to sebaceous gland activity Common abnormality: - acne from 7-16 yrs on face, chest, back, or shoulder -includes blackheads, whiteheads, pustules, and cysts -may be painful, mild to severe, and impact appearance

Answer 48

Expected -Smooth, consistent color, no lesions -bruising is common on legs as toddler becomes mobile (ask caregiver about bruising) -Skin turgor should be easy and quick Common - Eczema in toddler and preschool due to chronic or intermittent disorder - lesions due to communicable diseases (roseola, fifth disease, tinea corporis (ringworm), scabies, impetigo, pediculosis corporis (body lice)) Uncommon -varicella (chickenpox), rubella, and rubeola (measles) due to lack of immunity Things to investigate -bruising inconsistent with developmental level, in unusual area (upper arms, back, butt, abdomen), multiple, or large -If skin turgor is tented, it can mean severe dehydration

Answer 49

Expected -thin and parchment-like appearance especially over bony prominences (dorsal surfaces of hands and feet, forearms, lower legs) - skin hangs loosely on frame due to loss of adipose tissue and elasticity (tenting and skin tears are common) -skin may be cool due to impaired circulation Abnormal - lesions -> may be from sun exposure - dry skin-> dehydration or malnutrition (tenting unreliable indicator due to loss of subcutaneous tissue) - Edema -> fluid retention from cardiovascular or renal diseases - inconsistent fractures, bruising, laceration, and pressure ulcers -> abuse

Answer 50

- Solar lentigo (liver spots): irregularly shaped, flat, deeply pigmented macules on BSAs with repeated exposure to sun - Seborrheic keratoses: pigmented, raised, warty- appearing lesions on skin of face or trunk (differentiate from premalignant lesions- actinic keratoses) - Acrochordon (skin tag): Small, soft tag of skin that generally appears on the neck and upper chest; may or may not be pigmented

Answer 51

- Not necessary at every exam, but it should be done if person has new lesion or lesion has changed - Use strong Light source to determine exact color, elevation, and borders - Use centimeter ruler to measure size of lesion

Answer 52

Location and distribution of the lesion.: Generalized over body OR localized to a specific area such as waist, under jewelry, or in the hair? Color and how it differs in color from other lesions on the body (e.g., a mole or freckle). Any changes in color noticed by patient? Pattern and pattern development Shape Edge of lesion (regular or irregular, and has the patient noticed a change in the shape of the lesion?) Depth of lesion(flat,raised,or sunken) Current size of the lesion ( Has the patient noticed any change in size?) Characteristics (hard, soft, fluid-filled); any exudate (what is the color, odor); has the patient noticed any change in either the characteristics or drainage of the lesion? If so, how and when?

Answer 53

Round/ oval: solid appearance; no central clearing Annular: round with central clearing; tinea corporis Iris: pink macule with purple concentric ring (erythema multiforme) Gyrate: snakelike appearance

Answer 54

Singular: demarcated lesions that remain separate; insect bite Grouped/clustered: lesions that bunch together in little groups (herpes simplex, impetigo) Polycyclic: annular lesions that come in contact with one another as they spread; tinea corporis Confluent: lesions that merge and run together over large areas; pityriasis rosea Linear: lesions that form a line; poison ivy, contact dermatitis Zosteriform: lesions that follow a nerve; herpes zoster Generalized: lesions that are scattered all over the body; herpes varicella

Answer 55

Common: freckles, patches, comedones/acne Wood's lamp: darken room, shine light on area to be assessed; fluorescent light is soft violet if not fungal infection and yellow-green or blue green if fungal infection present

Answer 56

-lesion due to trauma or change in primary lesion -Scars expected but may indicate abuse if excessive or on skin surfaces that are usually protected -Scars may indicate IV drug usage if track marks

Answer 57

Normal Variations - Ecchymosis (bruising) on bony prominence due to ADLs - Telangiectasia: fine, irregular, red line due to permanent dilation of group of superficial BVs - Cherry angioma: small, slightly raised, bright red area typically on face, neck, and trunk of body; increased size and number with age Abnormal -Hematoma: leakage of blood in confined space due to break in blood vessel - bruising over soft tissue in absence of injury OR multiple bruises in varying stages of healing may indicate physical abuse or bleeding disorder

Answer 58

Light: Grayish-blue tone, especially in nail beds, earlobes, lips, mucous membranes, palms, and soles of feet Dark: Ashen-gray color most easily seen in the conjunctiva of the eye, oral mucous membranes, and nail beds

Answer 59

Light: Reddish tone with evidence of increased skin temperature secondary to inflammation Dark: Deeper brown or purple skin tone with evidence of increased skin temperature secondary to inflammation

Answer 60

Light: Yellowish color of skin, sclera of eyes, fingernails, palms of hands, and oral mucosa Dark: Yellowish-green color most obviously seen in sclera of eye (do not confuse with yellow eye pigmentation, which may be evident in dark- skinned patients), palms of hands, and soles of feet

Answer 61

Light: Pale skin color that may appear white Dark: Skin tone appears lighter than normal; light- skinned African Americans may have yellowish-brown skin; dark-skinned African Americans may appear ashen; specifically evident is a loss of the underlying healthy red tones of the skin

Answer 62

Light: Lesions appear as small, reddish- purple pinpoints Dark: Difficult to see; may be evident in the buccal mucosa of the mouth or sclera of the eye

Answer 63

Light: May be visualized and felt with light palpation Dark: Not easily visualized but may be felt with light palpation

Answer 64

Light: narrow scar line Dark: Frequently has keloid development, resulting in a thickened, raised scar

Answer 65

Light: Dark red, purple, yellow, or green color, depending on age of bruise Dark: Deeper bluish or black tone; difficult to see unless it occurs in an area of light pigmentation

Answer 66

Definition: Flat, circumscribed area that is a change in the color of the skin; less than 1 cm in diameter Example: Freckles, flat moles (nevi), petechiae, measles, scarlet fever

Answer 67

Definition: Elevated, firm, circumscribed area less than 1 cm in diameter Example: Wart (verruca), elevated moles, lichen planus, cherry angioma, neurofibroma, skin tag

Answer 68

Definition: A flat, nonpalpable, irregular- shaped macule more than 1 cm in diameter Example: Vitiligo, port wine stains, Mongolian spots, café-au- lait spots

Answer 69

Definition: Elevated, firm, and rough lesion with flat top surface greater than 1 cm in diameter Example: Psoriasis, seborrheic and actinic keratoses, eczema

Answer 70

Definition: Elevated irregular-shaped area of cutaneous edema; solid, transient; variable diameter Example: Insect bites, urticaria, allergic reaction, SLE

Answer 71

Definition: Elevated, firm, circumscribed lesion; deeper in dermis than a papule; 1 to 2 cm in diameter Example: Dermatofibroma erythema nodosum, lipomas, melanoma, hemangioma, neurofibroma

Answer 72

Definition: Elevated and solid lesion; may or may not be clearly demarcated; deeper in dermis; greater than 2 cm in diameter Example: Neoplasms, lipoma, hemangioma

Answer 73

Definition: Elevated, circumscribed, superficial, not into dermis; filled with serous fluid; less than 1cm in diameter Example: Varicella (chickenpox), herpes zoster (shingles), impetigo, acute eczema

Answer 74

Definition: Vesicle greater than 1cm in diameter Example: Blister, pemphigus vulgaris, SLE, impetigo, drug reaction

Answer 75

Definition: Elevated, superficial lesion; similar to a vesicle but filled with purulent fluid Example: Impetigo, acne, folliculitis, herpes simplex

Answer 76

Definition: Elevated, circumscribed, encapsulated lesion; in dermis or subcutaneous layer; filled with liquid or semisolid material Example: Sebaceous cyst, cystic acne

Answer 77

Expected - Color should be consistent over BSA with exception of vascular areas (cheeks, upper chest, genitalia) which may appear pink to reddish-purple - Skin tone: whitish pink -> olive -> deep brown - Sun exposed skin may have slightly darker pigmentation Abnormalities Common: cyanosis, pallor, jaundice Uncommon: Hypopigmentation (albinism) or hyperpigmentation (increased melanin deposits which may indicate endocrine or liver disorder)

Answer 78

- natural variations in pigmentation is normal as well as tattoos - Pigmented nevi (moles): common on above waist on sun- exposed areas; uniformly tan to dark brown; <5 mm; raised or flat - Freckles: small, flat, hyperpigmented macules commonly seen on face, arms, back, sun exposed areas - Patch: area of darker skin pigmentation; present at birth and may or may not fade over time

Answer 79

- make note of discoloration, rashes, or maceration under skinfolds - Melanoma: moles below waist, on scalp, on breast are rarely “normal” moles - Vitiligo: acquired condition with unpigmented patch or patches; more common in dark-skinned races; may be autoimmune disorder - Localized hyperpigmentation: endocrine or autoimmune disorders - Striae: silver or pink “stretch marks” secondary to weight gain or pregnancy

Answer 80

- nail edge should be smooth and rounded - nail surface should be smooth and flat in center and slightly curved downward at edges; should be firm and adhere to nail beds; nail polish and artificial nails may limit direct evaluation of nail surface - Nail skin: intact, no edema or color variation Nail Bed color - In light-skinned, nail beds are pink - In dark-skinned, nail beds usually yellow or brown with vertical bands - Nail bed angle (angle of proximal nail fold and nail plate)—should be 160 degrees - Thickness: uniform -capillary refill tells strength of nails and perfusion; should be < 2 seconds

Answer 81

- Pitting: minor often but may be associated with psoriasis - Beau’s lines: groove or transverse depression running across nail; appears first at cuticle and grows with nail; due to stressor, trauma - Koilonychia: spoon nail; thin depressed nail with lateral edges turned upward; due to anemia or congenital factors - Leukonychia: white spots on nail plate; due to minor trauma or manipulation of cuticle - Inflammation/edema, or erythema of finger tissue may indication infection - Clubbing: angle of nail base>180 degrees; due to proliferation of connective tissues enlarging distal fingers; due to chronic respiratory or cardiovascular disease such as cystic fibrosis or COPD; poor perfusion - Thin or brittle nails due to poor peripheral circulation or nutrient deficiency -Yellow nails may be due to cigarette smoking unless dark skinned

Answer 82

- Fine vellus hair covers body - Coarse hair on eyebrows and lashes, pubic region, axillary, male beards, sometimes arms and legs - Men: noticeable hair on lower face, neck, nares, ears, chest, axilla, back, shoulders, arms, legs, and pubic; Pubic hair in upright triangle from midline to umbilicus - Women: noticeable hair on arms, legs, axillae, pubic, nipples (some cultures may have facial or chin hair); Pubic hair in inverse triangle from midline to umbilicus - Transgender women may remove hair from face, chest, back, abdomen

Answer 83

- Hair loss on legs due to poor peripheral perfusion - Eyebrow thinning due to hypothyroidism - Pubic hair deviation from typical gender pattern may be due to hormonal imbalance - Hirsutism: increased hair growth on face, body, pubic area of women may be due to endocrine disorder

Answer 84

Expected: -Scale: Smooth, no flaking, scaling, redness or open lesions - Hair: shiny, soft; fine or coarse; Men have genetic and elevated androgen level related gradual, symmetric hair loss abnormal -For isolated areas of hair loss; note if hair broken off or absent -Dull, coarse, and brittle hair due to nutrient deficiency, hypothyroidism, chemical exposure - Fine hair due to hyperthyroidism - Parasitic infection: lice eggs in scalp on hair shaft - Alopecia: hair loss due to autoimmune disorders, anemia, nutrient deficiency, radiation, antineoplastic agents

Answer 85

Expected - smooth, soft, intact, even surface - Calluses: normal variation; excessive thickening of skin usually on hands, feet, elbows, knees (usually due to friction or pressure) - Excess dryness, flaking, cracking, or scaling of skin may be secondary to environmental conditions or may be signs of systemic disease or nutritional deficiency

Answer 86

Temperature - Warm and consistent; feet and hands may be cooler - Cool skin o Generalized may indicate shock or hypothermia o Localized may indicate poor peripheral perfusion - Hot Skin o Generalized may reflect hyperthermia due to fever, high metabolic rate (hyperthyroidism, exercise) o Localized may reflect inflammation, infection, trauma, thermal injury

Answer 87

Expected - Normally dry; minimal perspiration or oiliness - Perspiration expected with heat, exercise, anxiety Abnormal - Excessive moisture -> metabolic condition - Diaphoresis – abnormal in absence of strenuous activity; may indicate hyperthermia, extreme anxiety, pain, shock

Answer 88

Procedure: Assess by picking up and slightly pinching skin on forearm or clavicle Expected: Skin should be elastic and bounce back; elasticity is mobility; mobility is the ability to pinch the skin (unable with edema), Turgor is if tenting or not, the resiliency abnormal - Tenting of the skin=poor skin turgor -> Result of dehydration, extreme weight loss - Poor skin mobility -> Edema, excess scarring, connective tissue disorders

Answer 89

Expected Varies by age and area of body o Thickens until adulthood; decreased after age 20 o Thickest over palms of hands and soles of feet (calluses common) o Thinnest over eyelids Abnormal - Increased thickness due to diabetes from hyperglycemia causing abnormal collagen - Excessively thin (shiny, transparent) due to hyperthyroidism, arterial insufficiency, aging

Answer 90

- Preferred name - Place of birth - Important cultural practices - Language (primary, english proficiency) - Communication styles (eye contact, touch, silence, personal space) - Personal beliefs on health ( locus of control/ health practices, rituals, taboo topics) - Beliefs on sickness (cause, severity, preferred treatment, fears, problems due to sickness) - Religion and spiritual influences (beliefs, practices, effect on health practices, importance)

Answer 91

- nurse lack of knowledge - nurse uncomfortable - nurse embarrassed to ask about things and seeing it as a private matter

Answer 92

1.Develop cultural competence thru sensitivity to differences 2. Avoid stereotypes and assumptions (cultures may share values and beliefs but every individual is unique) 3. incorporate cultural questions in personal psychosocial history to form foundation of care

Answer 93

- 1st step -an internal motivation to develop skills interacting with people from other backgrounds - begins when nurse gives up prejudices and biases and respects and cares for everyone regardless of culture

Answer 94

-process of self-reflection of one's own culture and their reactions to people from other backgrounds - important because our cultural lens influences what we notice -enhanced by cultural humility -more realistic goal than cultural competence for nursing

Answer 95

- process to intentionally learn about beliefs, customs, traditions of people from other backgrounds; life-long - includes similarities and differences, disease incidence, prevalence, ethnic pharmacology

Answer 96

- ability to assess and interpret information, adapt communication style, establish relationships -communicate respectfully with appropriate language and behaviors

Answer 97

-the interaction with individuals from cultural backgrounds -use knowledge of health beliefs, practices, and communication patterns with interacting

Answer 98

- life- long, process of openness, self-awareness, being egoless, and incorporating self-reflection and critique after interactions w/ diverse

Answer 99

-one question at a time -allow ample time for a response -use active voice -avoid medical jargon -be aware of patient behaviors during interview that offer clues about preferred communication practices

Answer 100

- Nurse is not responsible for knowing about every culture - Nurse is responsible for asking about cultural identification

Answer 101

- Breathe Diaphragmatically; count for 1 minute because infant’s RR is irregular - RR gradually slows as child ages - Increased rate and effort with crying, fever, dehydration, wheezing or noisy breathing, cough

Answer 102

-Does not differ from other adults unless lung disorder, may be more shallow or rapid - Ask about fatigue, shortness of breath, cough because older adults have higher incidence

Answer 103

- By age 2-3, child is cooperative so nurse should develop relationship to get cooperation - If palpation done, adjust fingers to a number appropriate for size of the child’s chest (2-3 fingers for small child) - Percussion not done till age 10.

Answer 104

- By 5-6, rounded thorax with 1:2 AP to lateral diameter ratio - By 6-8, breathing changes from primarily nasal and abdominal to thoracic in girls and abdominal in boys Normal Variations dependent on the size of the child and the musculature of the chest: - Small or young child with undeveloped chest musculature may include more bronchovesicular breath sounds in the peripheral lung areas and more blending of breath sounds; 1:1 AP: lateral - If the child is larger and has started to develop more, the breath sounds are equivalent to those of the adult (vesicular in the peripheral lung fields).

Answer 105

- Increased RR, retractions (may have grunting and flaring), adventitious sounds (crackles, rhonchi, wheezing) - If child’s chest proportion remains rounded, may be outward indication of asthma or cystic fibrosis

Answer 106

- Physical changes is chest wall musculature and posture - Diminished breath sounds in the bases of the lungs - may have decreased elasticity & ability to clear the air passages - Dyspnea on exertion

Answer 107

AP and lateral curvature of the spine which may increase the AP diameter, make lung expansion difficult, and result in shallow breathing.

Answer 108

Pitch: high (sounds like air source is under stethoscope) Intensity: loud Duration: Insp < Exp Expected Location: over trachea Abnormal Location: over peripheral lung fields may indicate consolidation of the lungs

Answer 109

Pitch: moderate Intensity: Medium Duration: Insp = Exp Expected Location: 1st and 2nd intercostal spaces at sternal border anteriorly; posteriorly at T4 medial to scapula Abnormal Location: peripheral lung fields

Answer 110

Characteristics: Fine, high-pitched crackling and popping noises (discontinuous sounds) - heard during inspiration and sometimes during expiration - not cleared by cough or altered by changes in body position.” Examples: in pneumonia, heart failure, restrictive pulmonary diseases

Answer 111

Pitch: low Intensity: soft Duration: Insp > Exp Expected Location: peripheral lung fields Abnormal Location: N/A

Answer 112

Characteristics: Low-pitched, coarse, loud, low snoring or moaning tone; - heard primarily during expiration but may also be heard during inspiration - coughing may clear Examples: disorders causing obstruction of the trachea or bronchus

Answer 113

Characteristics: High-pitched, musical sound similar to a squeak; ; occurs in small airways - heard more commonly during expiration but may also be heard during inspiration Examples: Heard in airway diseases when the thickness of airways increases such as asthma

Answer 114

-done when patient reports tenderness or nurse notices bulges, depressions, or unusual movements of these muscles Procedure: feel texture and consistency of skin over chest and alignment of vertebrae; identify areas that pt report as painful; simultaneously compare both sides -well developed musculature; stable, painless, firm, symmetric ribs Posterior expected finding: vertebrae straight and painless from C7-T12; scapulae symmetric Anterior expected finding: symmetrical clavicles; sternum and xiphoid relatively inflexible

Answer 115

- crepitus: crackly sensation under fingers; indicates air in subQ tissue due to leak in respiratory tree -pleural friction rub may feel like coarse, grating sensation during inspiration; second to inflammation of pleural surface -asymmetric muscular development or unstable chest indicates thoracic disorder such as fractured ribs

Answer 116

-done when asymmetry suspected Procedure: place hand around thoracic; ask pt to take several deep breaths and observe for lateral movement of both thumbs *for posterior, stand behind pt and have thumbs at T9 or T10 *for anterior, stand facing pt and have thumbs along costal margin and xiphoid process Expected Finding: both thumbs should move apart symmetrically on posterior and anterior chest walls with each breath Abnormal Finding -Unilateral or unequal movement of thumbs indicates asymmetry of expansion may mean pain or localized pulmonary disease (fractured rib, chest wall injury, pneumonia, atelectasis, collapsed lung) -barrel chest from emphysema may not have expansion due to over inflation

Answer 117

-done when congestion, obstruction, or compression of lung tissue suspected Vocal Fremitus: vibration from verbalizations; provides info about the density of underlying lung tissue and thorax Procedure: palm of hands on right and left lung fields, ask patient to say 1, 2, 3 while you palpate down lungs from apices to bases (do anterior and posterior) Expected Finding: fremitus bilaterally equal over chest walls; quality varies due to chest wall density and relative location of bronchi to chest wall

Answer 118

- Fremitus more prominent in men vs women because men have lower-pitched voices which conduct more easily through lung tissue - Fremitus may be absent in healthy person esp if high-pitch or soft voice Abnormal findings -fremitus asymmetrically diminished when fluid or tumor pushes lung away from chest wall due to unilateral pneumothorax, pleural effusion, or tumor -Fremitus asymmetrically increased when consolidation of underlying lung

Answer 119

-done when tracheal deviation suspected Procedure: face the patient; use thumbs of both hands, palpate trachea on anterior aspect of neck by placing thumbs on either side Expected Finding: trachea should be palpable, midline, and slightly movable -simple collapsed lung, pulmonary fibrosis or atelectasis pull trachea toward the affected side -Tension pneumothorax: pressure builds up on either side of collapsed lung and causes deviation away from affected side

Answer 120

Procedure: same as posterior; reach under gown for women to maintain modesty; use diaphragm to auscultate apex of lungs to base Expected Finding: - Vesicular breath sounds over anterior thorax, including the apex of the lungs above the clavicles. - Bronchovesicular breath sounds over central area of the anterior thorax around the sternal border. - Bronchial breath sounds are the expected sounds heard over the trachea and the area immediately above the manubrium. Abnormal -if pleural friction heard; determine source by asking pt to hold their breath. If no longer heard, it is the lung pleura. If still heard, it is the pericardial pleura rubbing

Answer 121

Procedure: anteroposterior (AP) diameter indirectly measured by using distance between hands while cusping sides noticing lateral diameter and compare to distance from front to back Expected Finding: AP diameter should be approximately ½ lateral diameter or 1:2 ratio of AP (front to back) to lateral diameter (one side of chest to other) Abnormal: - Barrel chest appearance (horizontal ribs and chest appears to be held in constant inspiration) due to increased AP diameter (1:1) in disorders causing hyperinflation (emphysema)

Answer 122

Expected -ribs should be sloped down with 45 degrees relative the spine; costal angle should be less than 90 degrees -thorax should be symmetric -equal muscle development Abnormal - increases costal angle = barrel chest from emphysema - scoliosis -Pectus carinatum (pigeon chest; prominent sternum) - pectus excavatum (funnel chest, sternum indented above xiphoid)

Answer 123

Procedure: instruct to sit upright and breathe slowly and deeply clean and warm diaphragm (If patient reports dizziness, wait for it to subside) 1. Move from apex (above clavicle) to base (12th rib) 2. Leave stethoscope in each location for at least one respiratory cycle Compare sounds on each side 3. Ask patient to cross arms or lift arms in front to give better access for lateral thorax Expected finding: clear vesicular breath sounds over posterior and lateral thoraxes; bronchovesicular breath sounds are expected over the upper center of posterior thorax b/w vertebrae b/w scapulae which is over main bronchi

Answer 124

- decrease in breath sounds seen due to patient not breathing deeply, airway blockage by foreign body or tumor, narrowed airway due to COPD or asthma, or CNS depression - Diminished or absent breath sounds may be heard in patients with collapsed alveoli, like emphysema, atelectasis or severe asthma attack. Stridor: harsh, high-pitched sound often due to laryngeal or tracheal obstruction.

Answer 125

- if you hear these, ask patient to cough and auscultate again - If you still hear it, note type of sound, location, phase of breathing it is heard in

Answer 126

Procedure: move behind individual; back of gown open for women and gown removed for me Expected finding: ribs slope down at 45 degree angle relative spine -thorax symmetric -spinous process in straight line -Scapulae bilaterally symmetric -equal muscle development Abnormal - Asymmetry or unequal muscle development - skeletal deformities (scoliosis) may limit expansion of chest -barrel-shaped chest seen in emphysema due to chronic trapping in alveoli

Answer 127

-Bradypnea or Tachypnea ( both shallow) -Hyperventilation (hyperpnea): deep breathing with Tachypnea -Air trapping: Increasing difficulty in getting breath out -Cheyne-Stokes: Varying periods of increasing depth interspersed with apnea -Kussmaul: Rapid, deep, labored -Biot: Irregularly interspersed periods of apnea in disorganized sequence of breaths -Ataxic: Significant disorganization with irregular and varying depths of respiration.

Answer 128

Notes -Differentiate the subjective dyspnea from objective tachypnea (rapid breathing does not always mean short of breath; do not assume tachypnea=dyspnea) -Chest retraction (intercostal muscles are drawn inward between the ribs) indicates airway obstruction seen in asthma attack or pneumonia - Frequent sighing may indicate fatigue or anxiety

Answer 129

- Adult 12-20 called eupnea - pattern should be effortless and quiet with even respiratory depth -chest wall should rise and expand symmetrically and relax without effort -men breathe diaphragmatically and women breathe thoracically -Signing: normal variation where occasional deep breaths are interspersed with an expected breathing pattern

Answer 130

Expected finding - Relaxed and upright posture - relaxed appearance - Quiet, effortless, and appropriate rate for age-- breathing effort - signs of respiratory distress include apprehension, restlessness, nasal flaring, supraclavicular or intercostal retractions, use of accessory muscles

Answer 131

Abnormal Findings -pursed-lip breathing: slow exhalation through mouth seen in COPD and asthma to reduce RR, arterial CO2, and increase O2 saturation Tripod position (leaning forward with the arms braced against the knees, a chair, or a bed) also seen in respiratory distress in patients with COPD or asthma. This enhances accessory muscle use. Paradoxical chest wall movement – seen after chest trauma when the chest wall moves in during inspiration and out during expiration

Answer 132

-routine counseling for smoking cessation and advising again smokeless tobacco -Clinicians ask all adults about tobacco use and provide tobacco cessation interventions for those who use tobacco products. -Clinicians ask all pregnant women about tobacco use and provide augmented, pregnancy-tailored counseling for those who smoke.

Answer 133

- single most preventable cause of death and disease in the United States. - cause of majority of all cancers of the lung, trachea, bronchus, larynx, pharynx, oral cavity, and esophagus - major risk factor for COPD - leading risk factor for cardiovascular diseases, including myocardial infarction, coronary artery disease, stroke, and peripheral vascular disease. -no safe tobacco alternative to cigarettes. Cigar use can cause cancer of the larynx, mouth, esophagus, and lung.

Answer 134

increase the risk for premature birth, low birth weight, stillbirth, and infant death.

Answer 135

- affects the health of nonsmokers, particularly children. - can cause heart disease and lung cancer in adults - can cause a number of health problems in infants and children, including severe asthma attacks, respiratory infections, ear infections, and SIDS

Answer 136

- causes serious oral health problems, including cancer of the mouth and gums, periodontitis, and tooth loss

Answer 137

Characteristics - rib injury causes pain with inspiration leading to shallow breathing and atelectasis - Pleuritic chest pain: sudden, sharp stabbing pain felt during inspiration may be pleural lining irritation Aggravating Factors - Prolonged coughing may cause chest pain from repeated muscle contraction of the thorax -movement -deep inspiration Treatments - Pressure, heat, pain medication - If localized to one side, and the patient may splint the affected side to try to reduce the pain. .

Answer 138

Onset: Acute (<3 wks) or Chronic (>8 wks) Causes of chronic : postnasal drip, GERD, asthma, infections (bronchitis and BP drugs); ACE inhibitors cause chronic dry cough Characteristics - Viral pneumonia=dry cough - bacterial pneumonia=productive cough Aggravating Factors: dyspnea during exercise and singing Related Symptoms - Cough with a fever, shortness of breath, and noisy breath sounds may indicate a lung infection - Tightness of the chest, SOB, nonproductive cough likely asthma. Treatments: Medications, fluids, humidifiers can all help

Answer 139

- increase in morning may mean accumulation over night as in bronchitis - Increased sputum with change in position may mean lung abscess and bronchiectasis Odor -Foul smelling (fetid) may be bacterial pneumonia, lung abscess, or bronchiectasis Consistency - Pink, frothy sputum with dyspnea may mean pulmonary edema - Thick sputum may be cystic fibrosis

Answer 140

- White or clear may be cold, viral infection or bronchitis - Yellow or green may be bacterial infection - Black may be smoke or coal dust inhalation - Rust-colored sputum may be TB or pneumococcal pneumonia

Answer 141

Home - Air pollution (near factory, on a busy street, new construction in area) - Exposure to hazards such as lead in paint, pipes, and faucets - Water leaks associated with mold growth have been shown to increase the likelihood of asthma, coughing, and wheezing - Hobbies: Woodworking, plants, metal work - Inadequately vented appliances in the home may result in increased exposure to CO Occupational (Assess usage of OSHA approved protective equipment) - Exposure to irritants (asbestos, paint fumes, vapors), dust, chemicals, known allergens Travel - explore exposure to respiratory infections through international or cross-country travel

Answer 142

Allergies -Increased frequency of allergies may indicate new allergies or ineffective treatment Herbals - ginseng, turmeric, red sage, melatonin may improve breathing Inhaler - May be for asthma, chronic bronchitis - Frequency indicated how well symptoms are controlled - Assessing purpose lets you know patient is using it correctly Oxygen at home - seen with COPD - Assess amount, frequency, situations of use and effect Exposure to infectious respiratory diseases (flu, tuberculosis, COVID-19) - Extra screening if potential exposure - USPSTF recommends screening asymptomatic adults over 18 yrs at increased risk for TB

Answer 143

- Presyncope: Feeling of faintness and impending LOC— “near faint.”; cardiovascular symptom. - Disequilibrium: Feeling of falling—often a vestibular function disorder. - Vertigo: Sensation of movement, usually rotational motion such as whirling or spinning *Subjective vertigo is the sensation that one’s body is rotating in space *Objective vertigo is the sensation that objects are spinning around the body * Vertigo is the cardinal symptom of vestibular dysfunction * Advise on fall risk, hazards of driving and operating machinary - Lightheadedness: Vague description of dizziness that does not fit any of the other classifications.

Answer 144

1. Alcohol 2. Beans (broad beans, lima beans, fava beans, snow peas) 3. Caffeine (coffee, tea, chocolate) 4. Cultured dairy products (yogurt, sour cream buttermilk) 5. Fresh fruits (citrus fruits, ripe bananas, raspberries, kiwi, pineapple, red plums, avocado) 6. Dried fruits (figs, raisins, dates) 7. MSG (soy sauce, meat tenderizers, seasoned salt) 8. Nitrates and nitrites— in processed meats (ham, hot dogs, pepperoni, bacon, sausage) 9. Nuts (peanuts, almonds, sunflower seeds) 10. Onions 11. Pizza 12. Tyramine-rich foods (strong or aged cheese, cured or smoked meats, beers on tap)

Answer 145

- May be sign of stress or chemical imbalance or serious pathology Aggravating Factors: stress, fatigue, exercise, food, alcohol Aggravating Conditions: hypertension, hypothyroidism, vasculitis Treatments: medications, massage, lying in dark room, cold cloth

Answer 146

Pattern: periodic intervals, last few hrs to 1-3 days Location: unilateral Characteristics: throbbing pain Related Symptoms: visual disturbances, nausea, vomiting Treatments: rest

Answer 147

Sinus headache: tenderness over frontal or maxillary sinuses Tension headache: viselike over front or back of head

Answer 148

Pattern: more than once a day; last less than 1 hour to 2 hours; may do this for a couple months then disappear for months or years Location: usually unilateral; produce pain over the eye, temple, forehead, and cheek. Characteristics: burning or stabbing feeling behind one eye Related Symptoms: nasal stuffiness or discharge, red teary eyes, drooping eyelids Treatment: movement

Answer 149

- Age: Prevalence increases sharply each year over age 60. - Gender: Women have a higher prevalence than men. - Ethnicity: African Americans have the highest prevalence. - Family history: 3x risk with history of glaucoma in a first-degree relative - Medication: Long-term corticosteroid use (M) - Chronic disease: Diabetes mellitus and hypertension.

Answer 150

-Involvement of both eyes may mean systemic issue while one eye may mean localized - Sudden onset may mean detached retina and emergency referral needed Related symptoms: headaches, dizziness, nausea

Answer 151

Onset - Sudden in one or both that is not associated with ear infection or upper respiratory infection needs further evaluation - Presbycusis: gradual hearing loss with advancing age; affects high frequencies Impact on daily life: May cause withdrawal and isolation due to embarrassment or lack of hearing which leads to depression, reduced interpersonal communication, exacerbates coexisting psychiatric conditions Causes:Genetics (congenital); Exposure to excessive noise (noise-induced hearing loss); Trauma; infections (especially otitis media); Certain drugs.

Answer 152

* Age: Incidence increases across life span especially after age 50 * Gender: Men have a greater risk * Environmental noise (repeated exposure to loud noise >80 dB) (M) * Ototoxic medications (aminoglycosides, salicylates, furosemide) (M) * Family history (sensorineural hearing loss) * Autoimmune disorders (sensorineural hearing loss) * History of congenital hearing loss

Answer 153

- sensation or sound heard only by affected individual - Characteristics: Ringing, hissing, crackling, or buzzing

Answer 154

- May be related to mouth, sinus, or throat infection - Ear discharge may be sign of bacterial otitis media - Pain from ear infection involves external ear or ear canal and increases with ear movement - Pain from otitis media does not change with manipulation of the ear

Answer 155

- Wear hearing protection when exposed to loud or potentially damaging noise at work, in the community, or at home. - Limit periods of exposure to noise. - Reduce volume when using stereo headsets or listening to amplified music in a confined place such as a car. - Consider noise rating when purchasing recreational equipment, children’s toys, household appliances, and power tools; look for those items with lower noise ratings.

Answer 156

- CDC recommends screening for hearing loss in all newborn infants, not later than 1 month of age. - Newborn hearing screening is required by law in many states. - If loss is identified, perform audiologic evaluation by age 3 months and enroll in appropriate intervention services by age 6 months as needed

Answer 157

-make sure to ask which teeth Causes: Tooth decay, gum disease, tooth fracture, damaged filling, abscess Related symptoms * Fever may mean abscess * Trauma to mouth may mean tooth fracture * Pain may mean tooth decay which can worsen as decay progresses

Answer 158

- biggest risk are tobacco and alcohol use* - Age: Incidence is increased after age 55, with peak incidence between ages 64 and 74. - Gender: There is a 2:1 male-to-female incidence. - Human papillomavirus (HPV) infection of the mouth - Exposure to ultraviolet (UV): increased risk for lip cancers among those with prolonged exposure to the sun. (M) - Immunosuppression increases risk

Answer 159

-anywhere in mouth, assess number and pain Causes: trauma, infection (STIs-chlamydia, gonorrhea, syphilis, herpes, HPV), nutritional deficits, immunologic problem, cancer Bleeding, lumps, enlarged lymph nodes (or infection), and thickened areas in mouth may mean oral cancer

Answer 160

Characterization: lump, burning, scratchy Causes: -Usually viral and resolve in few days - Less common causes are environmental factors (inhalation of dust, fumes, excessively dry air) - Nasal congestion which requires mouth breathing at night can cause sore throat in morning Related symptoms: edema, nasal congestion, sinus drainage, fever, fatigue, cough, painful lymph nodes, difficulty swallowing

Answer 161

Related symptoms - Itching, swelling, discharge from eyes, postnasal drip, cough = allergic rhinitis - Fatigue, fever, and pain= infection Treatment: If nasal spray other than normal saline, alert to use no more than 3-5 days to avoid rebound congestion

Answer 162

- Thick or purulent green-yellow discharge = a bacterial infection - Foul-smelling discharge (especially unilateral discharge)= foreign body or chronic sinusitis - Profuse watery discharge = typically allergies - Bloody discharge=neoplasm, trauma, or an opportunistic infection (fungal disease) - Epistaxis (nose bleed) may be secondary to trauma, chronic sinusitis, malignancy, bleeding disorder, or cocaine use

Answer 163

Procedure:look at relation of head to neck and shoulder size and shape Expected finding - head should be upright in straight position - Normocephalic: skull is symmetric and appropriately proportioned for the size of the body Abnormal Findings (2) - Microcephaly: abnormally small head - Macrocephaly: abnormally large head

Answer 164

Expected - Facial bones and features (eyes, eyebrows, palpebral fissures, nasolabial folds, sides of mouth)- appropriate proportion and symmetric - Facial movement- smooth, symmetric with calm expression - Facial skin- smooth w/o lesions or edema; even skin tone and appropriate facial hair for age and gender Abnormal - Note facial expressions associated with anxiety, stress - abnormal facial movements (tics) - abnormal skin color, uneven pigmentation or tone, lesions, coarse facial hair (in women), and edema

Answer 165

-done when suspected injury, observed irregularity or abnormality, reported pain Procedure: palpate skull from front to back with gentle rotary motion using finger pads; use gloves if scalp lesions, injury or poor hygiene Expected Finding: symmetric, intact, firm w/o tenderness skull Abnormal Findings - Lumps, marked protrusions, tenderness should be differentiated to determine if on scalp or part of skull - Depressions or unevenness may be due to skull injury

Answer 166

-done when suspected injury, observed irregularity, or reported problem such as pain or jaw clicking Procedure: place two fingers in from of each ear and ask patient to slowly open and close their mouth and move lower jaw from side to side Expected Finding: jaw moves smoothly without pain Abnormal Finding: Limited movement, pain with movement, and a jaw that clicks or catches with movement may mean TMJ

Answer 167

Procedure: use Snellen Eye Chart 1. place chart against wall in well-lighted room 2. patient may sit or stand at appropriate distance and read line of smallest letters possible 3. test each eye separately then together 4. If pt wears glasses or contact lenses, they should leave them in place (indicate on documentation) 5. Note line read completely by patient with fraction printed at end of line - For perception, pt should use both eyes to distinguish which of two horizontal lines is longer - For red and green color perception, ask pt to name color of horizontal lines Note: Tumbling E chart is for pts who cannot read letters; indicate direction E points Expected Finding: smooth pattern, 20/20

Answer 168

-note hesitancy, squinting, leaning forward, blinking, facial expressions indication person is struggling -larger the denominator, the poorer the vision i.e 20/40 means person can read at 20 ft what normal vision can read at 40 ft (if only one letter not read properly, document as 20/40-1) -refer to eye doctor if vision poorer than 20/30, person unable to see colors or line length -legally blind if best corrected acuity is 20/200

Answer 169

-Assess in people >40 yrs or who may have difficulty reading -Similar procedure to Snellen Chart but use Jaeger or Rosenbaum card 14 inches away and read smallest line Abnormal Finding Presbyopia: loss of elasticity of lens of eye with age; pt needs to move Jaeger or Rosenabum farther away to see clearly

Answer 170

Procedure: face patient, stand or sit 2-3 ft away 1. Ask pt to cover one eye and you cover your opposite eye 2. Hold pencil or your finger and extend to the farthest periphery and gradually bring object close to the midline b/w you and pt 3. Ask pt to report when they first see the object; you should see it at the same time (assumes nurse has normal peripheral visual field) 4. Slowly move object inward from periphery superiorly, inferiorly, temporally, and nasally Expected Finding: 50° superiorly, 70° inferiorly, 90° temporally, 60° nasally; temporal greater than nasal b-c position of card covering one eye Abnormal Finding: If pt cannot see pencil or finger at same time that you see it, peripheral field loss suspected so refer to eye doctor

Answer 171

- Skin intact, eyebrows thick and symmetrical; note if eyebrow extends over eye - Eyelashes should be distributed equally and curled slightly outward - Palpebral fissures should be equal bilaterally - Eyelid color should match skin color and should not be swollen - Eyelid margins should be pale pink and flush against eyeball surfaces - Upper lid should cover part of iris but not pupil - Lower lid should cover just below limbus - Lid closure should be complete with smooth, easy motion - Blinking is frequent, bilateral with involuntary movements; avg 15-20 per minute

Answer 172

- Ptosis: lid of either eye covering part of pupil -visible sclera (wide eye) b/w upper lid and iris in hyperthyroid exophthalmos -inward deformity of lid and lashes may mean enophthalmos or entropion -incomplete, difficult, or painful lid closure OR edema may mean infection

Answer 173

Procedure: use gloves, ask pt to look up, gently separate lids widely with thumb and index finger - exert pressure on bony orbit around eye - ask pt to look up, down, side to side - evert lower lid and ask pt to look up Expected findings: bulbar conjunctiva should be pink and clear; tiny red vessels noted Abnormal Findings -red conjunctiva (with purulent drainage) may mean conjunctivitis -sharply defined area of blood adjacent normal-appearing conjunctiva may indicate subconjunctival hemorrhage

Answer 174

Procedure: ask pt to stare straight ahead with both eyes open; shine penlight toward bridge of nose from 12-15 inch away Expected finding: light reflections should be symmetric with both corneas Note: if imbalance found in corneal light reflex, use cover-uncover test Abnormal -Asymmetrical light reflections at different spots in eye may indicate weak extraocular muscles

Answer 175

Expected Finding: White and clear; slight yellowing may be seen in dark skinned Abnormal Findings - Yellow sclera may mean jaundice from liver disease or obstruction of common bile duct - Redness may mean inflammation or hemorrhage - Blueness may mean osteogenesis imperfecta - Pink growth of conjunctiva over sclera is pterygium

Answer 176

Procedure: use oblique lighting and slowly move light reflection over corneal surface Expected finding: transparent quality, smooth, clear, and shiny surface Abnoramal findings -note opacities, irregularities in light reflections, lesions, abrasions, foreign bodies -white, opaque ring encircling the limbus termed corneal arcus may be seen in pts >60 or w/ hyperlipidemia

Answer 177

Expected Finding: The iris should be round with consistent coloration. Genetic factors cause differences in color Abnormal Findings - Section missing in pt with iridectomy or iridotomy to correct glaucoma - Coloboma is congenital defect of iris - Iridodialysis (tearing of iris from sclera) may happen due to blunt trauma

Answer 178

Reaction to light and consensual reaction procedure: dim lights, ask pt to hold eyes open and fix gaze on object across room; shine penlight directly in pupil of one eye Expected finding: illuminated pupil should constrict (direct response) and non illuminated should constrict too (consensual response); light reactivity is not age dependent Abnormal Findings: -Dysfunction of oculomotor nerve: Failure of one or both eyes to constrict to light in speed or magnitude - Large pupils are more sensitive to light (stimulants); small pupils are less sensitive so harder to see

Answer 179

Accommodation procedure: ask pt to fix gaze on distant object across room then ask to shift gaze to your finger placed about 6 inches from pt nose Expected finding: dilate when visualizing a distant object and constrict when focusing on near object

Answer 180

Pupil size Procedure: use pupil gauge like in Rosenbaum pocket vision screener Expected finding: pupil diameter b/w 2 and 6 mm; round and equal in size Abnormal Finding: Diameter of <2 mm or >6 mm is abnormal

Answer 181

-done as part of a neurologic exam or when the corneal light reflex is not symmetric. Procedure: While pt looking at you, position your finger 10–12 in from the pt’s nose. Ask the patient to keep the head still and use the eyes only to follow your finger or an object in your hand -move object slowly from center to upper extreme, hold, then back to center (repeat for lower extreme and temporal-nasal extremes) OR move finger slowly in circle to each of 6 directions (stop at each position to give pt time to hold gaze briefly before next position Expected finding: parallel tracking of object w/ both eyes; extraocular movements (EOM) intact; mild nystagmus at extreme lateral gaze may be noticed Abnormal Findings - Unequal movement or failure of eyes to move in parallel = weakness of the extraocular muscles or an abnormality associated with the cranial nerve. Nystagmus: involuntary movement of the eyeball in a horizontal, vertical, rotary, or mixed direction. It may be congenital or acquired from multiple causes

Answer 182

-perform if corneal light reflex is asymmetric Procedure: ask pt to stare ahead, cover one eye with opaque eye and observe uncovered eye; do same with other eye Expected finding: no deviation from steady, fixed gaze is observed Eye moves to focus after being uncovered = strabismus which is due to extraocular muscle weakness, paralysis, difficult focusing, refractive errors

Answer 183

-done when inflammation is observed or pain reported Procedure: ask pt to look down with lids closed; gently palpate upper lid over the eyeball (avoid direct pressure); palpate lower orbital rim near inner canthus which should slightly evert lower lid and show puncta as small elevations on nasal side of eyelids Expected Finding: upper lid indents with slight pressure; moist eyes w/o excessive tearing; no pain or nodules Abnormal finding -firm eyeball resistance to palpation seen in glaucoma -Dacryocystitis: Lacrimal punta clogged with mucus or particles causes inflammation -Epiphora-excessive tearing may be due to blockage of nasolacrimal duct -fluid or purulent material from puncta may be response to pressure

Answer 184

-note pt ability to hear by noticing patterns of speech; ability to engage in conversation is expected finding -subtle indications: pt asks you to repeat questions, repeatedly misunderstands questions asked, garbled speech sounds with word distortion, leans forward or tilts head, watches your lips as you speech, speaks in low monotone voice

Answer 185

Ear Alignment: top of pinna should align directly with outer canthus of eye and angled no more than 10 degrees from vertical position Ear size: ear b/w 4-10cm in length, appear same bilaterally Ear Skin: Skin should be even, intact, and match facial skin tone; note skin around piercings Darwin tubercle: small, painless nodule is normal deviation, may be on helix of ear Abnormal - low set seen in Down syndrome -Microtia: ears <4cm -Macrotia: ears >10cm -lesions and deformities (nodules, cancerous lesions, sebaceous cysts, cauliflower ear, hematoma, edema)

Answer 186

Expected Finding: No lesions or discharge (Discharge from ear is always abnormal) Abnormal Findings -blood or clear discharge w/ hx of head injury may indicate skull fracture -purulent or crusty discharge may indicate infection or presence of a foreign body

Answer 187

-Done in presence of deformity, injury, inflammation, or reported pain Expected finding: upper part of ear should be firm and flexible; earlobe is soft; all areas w/o tenderness, pain, or edema including helix Abnormal Findings -Tenderness of mastoid may indicate mastoiditis - Pain when the helix of the ear is pulled may indicate inflammation of auditory canal

Answer 188

Procedure: stand behind pt to prevent lip reading, instruct pt to occlude one ear and softly whisper several monosyllabic and disyllabic words and ask pt to repeat what is said. Repeat with other ear. - simple test, but standardization of results is difficult due to variance in loudness of whispers - Expected: pt should be able to hear and repeat at least 50% of all word whispered (whispered voice test intact) - Abnormal: pt cannot repeat at least 50% of the words spoken

Answer 189

Procedure: stand directly in front of pt with outstretched arms so hands are 3-4 inch away from pt ear; pt has eyes closed and is instructed to listen and indicate which side rubbing is heard; briskly rub your index and thumb together; repeat with other ear Expected: pt able to hear noise of fingers rubbing together Abnormal: pt with high frequency hearing loss may not be able to hear noise generated from finger rubbing

Answer 190

Nose Skin: smooth intact skin, same color as rest of face Nose position: symmetric and midline Nose Movement: nostrils not flaring or narrowed Abnormal Findings - Lesions, erythema, discoloration may mean systemic illness - Marked asymmetry of nose and septal deviation may be due to current or past injury - Edema, nasal discharge, crusting may mean infection, allergy, or injury - Watery, unilateral nasal discharge w/ hx of head injury may mean skull fracture - Unilateral, purulent, thick nasal drainage may mean foreign body

Answer 191

-done in presence of injury or reported pain or obstruction Procedure: palpate bridge and soft tissue of nose; apply pressure to occlude one nostril and ask pt to close mouth and sniff through other nostril; repeat on other side Expected Finding: nose not tender with palpation; noiseless, free exchange of air on each side Abnormal -narrowing of nostrils on inhalation may be chronic obstruction necessitating mouth breathing -noisy or obstructed breathing may be secondary to nasal congestion, trauma to nasal passage, polyps, allergies - instability or tenderness from trauma or inflammation

Answer 192

- done in presence of injury or reported pain or obstruction Procedure: use nasal speculum and light source Expected finding: Wit head erect, note floor of nose, inferior turbinate, nasal hairs, and mucosa (slightly darker red than oral mucosa) with head erect; nasal spectrum should be midline and intact With head back, inspect middle meatus and middle turbinate (should be deep pink, similar color of surrounding tissues Abnormal Findings -perforation= hole in septum wall - Erythema and edema may indicate infection or inflammation

Answer 193

-done in presence of injury or reported pain over sinuses Frontal sinuses procedure: press upward on frontal sinuses with thumbs on supraorbital ridge just below eyebrows; do not press directly over eyeballs Maxillary sinuses Procedure: press over sinus area above cheekbones Abnormal Finding Tenderness may indicate sinus congestion or infection - transilluminate sinuses if signs of congestion or sinus pain

Answer 194

Lip color and symmetry: pink and symmetric Lip texture and moisture: smooth and moist Lip border: slight vertical linear markings (vermillion border separates lips and facial skin) Abnormal Findings - Pale lips may mean anemia or shock - Cyanotic lips and circumoral cyanosis may mean hypoxemia and hypothermia - Dry, flaking, or cracked lips may be dehydration, exposure to dry air or wind - Cracks and erythema in corners of mouth may be vitamin B deficiencies - Lesions, plaques, vesicles, nodules, ulcerations may be infection, irritation, or skin cancer - Edematous may mean allergic reaction

Answer 195

Procedure: inspect condition of teeth making note of caries and broken, loose, and missing teeth; observe gum line beneath any dentures Finding: teeth white, yellow, or gray with smooth edges; gingiva around base of teeth should be pink, moist, clearly defined margin at each teeth Alignment Procedure: ask pt to clench teeth and smile Expected alignment: upper back teeth should rest directly on lower back teeth with upper incisors slightly overriding lower ones; teeth evenly spaced

Answer 196

- Missing teeth due to tooth extraction or trauma - Darkened or stained teeth due to coffee, medications, poor dental care, or frequent vomiting. - Brown spots in the crevices or b/w the teeth due to caries. - presence of debris usually occurs because of poor dental hygiene. - Excessively exposed tooth neck with receding gums due to aging or gingival disease - Malocclusion: misalignment of teeth. (Common variations: protrusion of the upper incisors (overbite), protrusion of the lower jaw (prognathism)) - Redness, edema, and bleeding of the gums due to gingivitis, systemic disease, hormonal changes, and drug therapy

Answer 197

Procedure: ask pt to stick out tongue (also tests CN XII-hypoglossal nerve) Expected finding - forward thrust should be smooth and symmetric - tongue should be symmetric, pink, moist with glistening surface dorsally and laterally - may be slightly rough due to papillae on dorsal surface of tongue Abnormal Findings - Atrophy of tongue on one side or deviation of tongue may be neurologic disorder - Smooth or beefy-red-colored edematous tongue with slick appearance may be B vitamin deficiency - Enlarged tongue in down syndrome or hypothyroidism - Hairy tongue with yellow-brown-to-black, elongated papillae may be due to antibiotic therapy, superinfection or pipe smoking - Geographic tongue: irregular patches w/ map-like appearance

Answer 198

Procedure: penlight and tongue plate, gloved hands; inspect anterior and posterior pillars Expected findings - tissue should be pale coral or pink with slight vascularity - should be smooth with transverse occlusion line adjacent to where teeth meet - clear saliva should cover surface -mouth should have slightly sweet odor or none at all Abnormal Findings - Aphthous ulcers (white, round or oval ulcerative lesions with red halo) - Leukoplakia (white patch or plaque found on oral mucosa that cannot be scrapped off) - Erhythoplakia (red patch on oral mucosa) - Excessively dry mouth or excess saliva may indicate salivary gland blockage or due to medication, dehydration or stress

Answer 199

on buccal mucosa, adjacent to upper second molar; appears as slightly elevated pinpoint red mark

Answer 200

Procedure: tongue blade and penlight; ask pt to tilt head back to inspect palate and uvula -instruct pt to say “ah” and depress tongue to test vagus nerve (CNX) - Observe if the soft palate rises symmetrically with the uvula remaining in the midline position. (tests CNIX, glossopharyngeal nerve.) Expected Findings - hard palate should be smooth, pale, and immovable with irregular transverse rugae - soft palate and uvula should be smooth and pink, with the uvula in a midline position. - tissue of pharynx should be smooth and have a glistening pink coloration. - The tonsils extend beyond the posterior pillars. They should appear slightly pink with an irregular surface. Notes -Enlarged, non inflamed tonsils are a normal variation among adolescents - touching posterior pharynx with tongue depressor may initiate gag reflex which is not part of routine exam

Answer 201

- Nodules on palate may be tumor - Failure of soft palate to rise bilaterally and uvula deviation during vocalization may indicate neurologic problem - Exudate or mucoid film on posterior pharynx if postnasal drip or infection - Grayish tinge to membrane with allergies or diphtheria - Edematous, erythematous tonsils w/ or w/o exudate may mean infection

Answer 202

Expected Findings - Neck and trachea should be centered - bilateral and symmetric trapezius and sternocleidomastoid muscles Abnormal - Note rhythmic movements or tremors of neck and head; observe for tics or spasms -tracheal deviation suggests mass in chest

Answer 203

Expected Finding: -skin should match other skin areas -thin men may have thyroid cartilage which protrudes enough to be visible (thyroid gland not usually visualized clearly) Abnormal Findings - Lesions, masses, Goiter (enlarged thyroid) may be seen as fullness in the neck

Answer 204

Procedure: ask pt to move neck forward, backward, side to side; shoulders should remain stationary; ask pt to rotate head laterally Finding: all movements painless Abnormal finding: - Limited ROM may mean systemic infection with meningeal irritation, musculoskeletal problem (muscle spasm or degenerative vertebral disk) -note weakness, tremors, pain

Answer 205

Sternocleidomastoid Procedure: ask pt to turn head sick to side against resistance of your hand placed against check and jaw Trapezius Procedure: ask pt to shrug the shoulders against resistance of your hands pressing down on their shoulders; also assesses spinal accessory nerve Expected Finding -muscles intact -palpation of neck muscles also assesses tenderness; muscles should be firm and non-tender Abnormal Findings - Unilateral or bilateral muscle weakness - Tenderness, muscle spasms, edema may suggest injury

Answer 206

Procedure: palpate above suprasternal notch for tracheal rings, cricoid cartilage, thyroid cartilage Expected Finding: midline, nontender Abnormal Findings: Tenderness, masses on palpation or location of structure away from midline

Answer 207

-done when inflammation or malignancy suspected, pt reports pain Procedure: palpate nodes using pads of 2nd, 3rd, and 4th fingers; use both hands with one on each side of head and neck to compare finding (submental may be easier to palpate with one hand; ask pt to take deep breath while you palpate supraclavicular nodes) Expected Finding: lymph nodes may or may not be palpable; if palpable, they should be soft, mobile, nontender, and bilaterally equal Abnormal Findings -Enlarged, tender, firm but freely movable may mean infection of head or throat -Hard, asymmetric, fixed, and nontender may mean malignancy

Answer 208

1. preauricular 2. postauricular 3. occipital 4. retropharyngeal (tonsillar) 5. submandibular 6. submental 7. anterior cervical 8. posterior cervical 10. supraclavicular nodes

Answer 209

- 1+, visible - 2+, halfway between tonsillar pillars and uvula - 3+, nearly touching the uvula - 4+, touching one another

Answer 210

- weight-to-height ratio that is correlated with total body fat -increases risk of developing nutrition related problems BMI = Weight (lb) x 705 / height (in2)

Answer 211

- BMI <18.5: underweight - Normal Range: 18.5 to 24.9 - BMI 25–29.9: overweight - BMI 30–34.9: obesity class I - BMI 35–39.9: obesity class II - BMI >40: obesity class III (extreme obesity)

Answer 212

- Excess obesity or generalized edema mean poor nutritional status - Prominent cheek and clavicle bones, wasted-appearing limbs (cachexia) are malnutrition - Irritability or flat affect may be insufficient caloric intake - Disorientation may be niacin deficiency

Answer 213

-Multiple bruises may be vitamin C and K deficiencies - Essential fatty acid deficiencies lead to dry flaking skin and eczema

Answer 214

- Edema may mean fluid retention and protein depletion - Dry skin and decreased skin turgor may be dehydration - Follicular hyperkeratosis (rough patches and small bumps on skin) may be vitamin A deficiency

Answer 215

-dull, easily plucked, or observable hair loss may be protein and fatty acid deficiency - Spoon shaped nails may be iron deficiency

Answer 216

-Pale conjunctivae may be anemia - Excessively red conjuntivae may be riboflavin deficiency - Bitot spots (foamy-looking areas on eyes) or excessively dry eyes due to vitamin A deficiency - Xerophthalmia (dry and hard cornea) due to excessive vitamin A deficiency

Answer 217

- Poor dentition and painful oral lesions may decrease intake - Dry mucous membranes may indicate dehydration - Bleeding gums may be sign of vitamin C or K deficiency - Cracks in corners of mouth or on lips, excessively red tongue may be Vitamin B complex deficiency - Reddish-purple tongue may be riboflavin deficiency

Answer 218

-Uncoordinated muscle movements may interfere with ability to feed oneself - Vitamin D deficiency can cause skeletal malformation - muscle weakness sign of inadequate protein intake, excess protein wasting -Thiamin (B1) deficiency causes peripheral neuropathy and paresthesia

Answer 219

o Dehydration o Poor dentition o Altered taste, smell and vision o Altered metabolism and absorption o Chronic health conditions, e.g., cardiovascular disease, diabetes, arthritis o Physical disability affecting shopping for and preparing food o Drug interactions and adverse reactions o Dementia or depression

Answer 220

o Insufficient income o Reduced Transportation Options o Social Isolation

Answer 221

1) its significant incidence found in all age groups 2) its contribution to other health conditions including hypertension, hyperlipidemia, type 2 diabetes mellitus, cardiovascular disease, gallbladder disease, sleep disturbances, respiratory disease, degenerative joint disease, and certain types of cancer. Clinical Recommendation: offer or refer adults with a BMI > 30 to intensive multicomponent behavioral interventions

Answer 222

- Compare to USDA Myplate guide; determine portion of food on typical plate for rough comparison with recommended intake

Answer 223

- appetite - food like and dislikes - food intolerances - special diets and use of dietary supplements or herbs

Answer 224

Retrospective: 24-hour recall, food frequency questionnaires - Easy but may reflect typical daily intake with underreporting common Prospective: record food as eaten during specified time; food diaries including Supertracker and Fitbit tools - Not convenient but more accurate when data recorded on two nonconsecutive days Short dietary assessment instruments (screeners) - useful when frequency of eating various categories of foods is desired rather than an assessment of the total diet - intake estimates from screeners tend to be less accurate than food diary.

Answer 225

*high incidence of underreporting * wide variation in day-to-day intake (Snapshot of intake over day or couple days may not accurately reflect long-term intake) *variations in serving portions

Answer 226

- Preoccupation with weight (M) - Perfectionist (M) - Poor self-esteem (M) - Self-image disturbances (M) - Peer pressure (M) - Athlete—drive to excel (M) - Compulsive or binge eating (M) - First-generation relative with eating disorder or alcoholism

Answer 227

- Age - Acute or chronic illness - Side effects from medications or treatments - Hospitalization for acute illness - Resident of long-term care facility (M) - Low SES (M)

Answer 228

- Sedentary lifestyle (M) - High-fat diet (M) - Genetics - Ethnicity/race - Female - Low SES (M)

Answer 229

- Ask pt what they think is the cause-medication, pregnancy, depression, chronic illness may all be possible - Duration-> appetite may fluctuate time to time; extended reduction in appetite may lead to nutritional deficiencies - May avoid entire food groups-> determine what nutrients are consumed and identify deficiencies in diet

Answer 230

- Thin liquids and food requiring forceful chewing may not be tolerated well - Soft and highly viscous foods are chewed and swallowed most easily Related Symptoms: choking, coughing, unintentional weight loss

Answer 231

- Establish total gain, time frame; sudden or gradual in last 6 month -Intentional causes: increase in calorie intake, dietary supplement; decrease in activities, change in eating habits, increased appetite, smoking cessation -Unintential Causes: fluid retention as result of medical conditions (heart failure) or side effect of medications (corticosteroids)

Answer 232

Intentional causes: Strict calorie intake, fasting, bulimia, laxative abuse or excess exercise indicate unhealthy preoccupation with body weight or possible eating disorder Unintentional causes: may be due to age, loss of appetite, vomiting, illness, stress, or medication Related Symptoms: due to inadequate energy, protein, vitamins, and minerals

Answer 233

Expected finding - acuity from 3-5 yrs is 20/40 or better; from 6-7 yrs is 20/30 or better, 8 and up should be 20/20 -normal color vision will see number or pattern in Ishihara test -symmetric corneal light reflection; clear and symmetric red reflex Referrals - if visual acuity less than expected, a two-line difference between eyes on Snellen - strabismus (eyes going in two different direction) for early recognition and treatment to restore binocular vision (diagnosis after 6 is difficult to treat and has poor long-term outcomes)

Answer 234

Visual Acuity Procedures: - 2.5-3 yrs (preliterate): Use LEA symbols or HOTV letters; show large cards with pictures up close and ask child to identify; then present at appropriate distance - 2-6 yrs: Use a Snellen “E” chart, child should point their fingers in the direction of the “arms” of the E. - 7/8 and up: Begin using the standard Snellen chart; test both eyes then each eye separately. (Screen children twice before referring them)

Answer 235

Other procedures: Color Vision Procedure - Test for color vision once between ages 4 and 8 - use red and green lines on a Snellen chart as gross screening tool for color blindness - follow with Ishihara Color Blind test if needed (Ask the child to identify each pattern seen in the cards)--color blindness if Ishiara pattern not recognized Alignment Procedure: Regularly assess ocular alignment of very young children with cover-uncover test or instrument-based photo screening assessment app -apps have high sensitivity and specificity for amblyopia (lazy eye) )

Answer 236

Small polyethylene tubes in TM of child who had myringotomy may be seen- - Surgically placed through TM to relieve middle ear pressure and allow drainage of fluid or material collected behind TM - Usually put in ears of young children with recurrent ear infections and tubes spontaneously extrude within 6-12 months after insertion

Answer 237

1 delay in verbal skills 2 speech that is monotone 3 garbled, difficult to understand, 4 inattentiveness during conversation 5 facial expressions that appear strained or puzzled 6 withdrawal or lack of interaction with others 7 frequently asks for statements to be repeated 8 frequent earaches

Answer 238

- Allergic salute: presence of transverse crease at bridge of nose due to child w/ runny nose or allergies wiping nose with upward sweep of palm - child tonsils (dark pink w/o vertical reddened lines, edema, exudate, erythema) are larger than an adults but should not interfere with swallowing or breathing - Tooth eruption is age dependent

Answer 239

- lymph nodes up 3 mm may be palpable and reach 1cm in cervical areas; mobile and nontender - Shotty: small, firm, and mobile lymph nodes; normal variation in children - cervical and submandibular nodal enlargements are more frequent in older children -occipital lymph nodes are normal but nurse should also co-palpate child’s head for inflammation or infection Abnormal Findings -tender, fixed, or > 1cm lymph nodes -Enlarged, tender nodes may be upper respiratory infection -enlarged thyroid needs more investigation

Answer 240

- dryness, flaking, or cracking corners of may mean excess lip licking, vitamin deficiency, or infection like impetigo - Koplik spots (little white spots on gingiva seen in measles) - candidiasis (thrush) may be observed - excess dry mouth may mean dehydration or fever - excess salivation may indicate gingivostomatitis or multiple dental caries - excess drooling after 12 months of age may indicate a neurologic disorder. - Bruxism: flattened edges on the teeth may indicate teeth grinding - Darkened, brown, or black teeth may indicate decay or staining from oral iron therapy - Mottled or pitted teeth may result from tetracycline therapy during tooth development or exposure in utero. - fetid or musty smell to mouth may mean investigate hygiene practices, local or systemic infections, or sinusitis

Answer 241

Expected: flexion, hyperextension, lateral bending, rotation of neck same as younger adult with less range Abnormal: Stiff neck may mean cervical arthritis

Answer 242

- examine with and without dentures in; may have edentulous crowns or bridges - surface of lips may deeply wrinkle - aging causes gum line to recede secondary to bone degeneration cause teeth to appear longer - teeth darkened or stained - gums more friable and bleed with slight pressure - worn down dental occlusion surfaces - malocclusion of teeth more common due to migration of teeth after extraction

Answer 243

- fissures at corners of mouth (perleche) may be due to overclosure of mouth or vitamin deficiency -higher risk of squamous cell carcinoma of lip (esp w/ smoking) -red, edematous tongue with erosions in corners of mouth may mean iron deficiency anemia

Answer 244

- If hearing aids, check ears for skin irritation and sores (hearing aids increase likelihood of cerumen impaction) - increased wiry hair at opening of auditory canal - tympanic membrane may be white, opaque, thickened - Presbycusis: hearing loss w/ age; ability to hear high frequency lost first such as “s” and “th” words; speech of others seems mumbled or slurred

Answer 245

- Central and peripheral vision may decrease after age 70 - 20/20 or 20/30 acuity with corrective lenses is common - Longer accommodation - Color perception of blue, violet, green may be impaired - Presbyopia: decreased near vision usually after age 40; treated with corrective lenses

Answer 246

Expected Findings -Pseudoptosis: relaxed upper eyelid with lid resting on lashes - decreased orbital fat so eyes may appear sunken or herniate (bulge from lower lid or inner third of lid to upper lid) - brown spots near limbus - bulbar conjunctiva may appear dry, clear, light pink w/o lesions or discharge -cornea is transparent, clear, often yellow; arcus senilis (gray-white circle around limbus) is common and not pathologic Abnormal Findings - Ectropion: lower lid drops away from globe - Entropion: lower lid turns inward - Macular degeneration may cause gradual loss of central vision due to changes in retina - Difficulty or inability to visualize internal structures of eyes may denote cataracts