Exam 2 Flashcards

Question 1

Q

7 Concepts related to Oxygenation

Answer

A

perfusion
sleep
nutrition
tissue integrity
motion
metabolism
intracranial regulation

Question 2

Q

9 commonly reported CV symptoms

Answer

A

chest pain
shortness of breath
cough
urinating during the night (nocturia)
fatigue
fainting (syncope)
swelling of the extremities
leg pain
enlarged lymph nodes

Question 3

Q

CV chest pain

Origin (3)
What if aggravated by arm movements?

Answer

A

Origin: pulmonary, musculoskeletal, gastrointestinal

Aggravated by arm movements may mean muscle strain

Question 4

Q

Women vs Men Myocardial Infarction (4)

Answer

A

Women report milder pain than men
-Men report viselike and tightness
Women have vague symptoms which are often missed by patients and HCPs which often include pain in neck, jaw, shoulder, arms, or upper back
-Women may have difficulty sleeping, shortness of breath, indigestion, anxiety, and chest pressure up to one year before myocardial infraction

Question 5

Q

Angina

Answer

A

symptoms of coronary artery disease indicating myocardial ischemia due to lack of oxygen to meet demand of myocardium

Question 6

Q

Stable Angina

Onset
Location (2)
Duration (2)
Characteristics (4)
Severity
Related Symptoms (5)
Aggravating factors (4)
Treatments (5)

Answer

A

Onset: Gradual onset

Location: Usually located substernal, can radiate to left arm, neck, jaw, shoulders

Duration: Constant, sharp, stabbing pain; lasts less than 10 minutes

Characteristics: Pressure/squeezing, burning, heaviness/fullness, crushing,

Severity: variable

Related Symptoms: Dyspnea, diaphoresis, palpitations, nausea, weakness

Aggravating factors: Physical exertion, stress, cold, stimulants, e.g., cocaine

Treatments: Rest, nitroglycerin, beta-blocker, calcium channel blocker, aspirin

Question 7

Q

Myocardial Infraction

Onset
Location
Duration
Characteristics (3)
Severity
Related Symptoms (6)
Aggravating factors (3)
Treatments (4)

Answer

A

Onset: Sudden (unstable angina) or gradual onset (stable angina),

Location: Substernal, radiates to arms, neck, jaw

Duration: constant pain, lasts 20 minutes or longer

Characteristics: Heavy pressure, squeezing, crushing; burning, not relieved with rest, position change or nitrates

Severity: 10 of 10 on pain scale

Related Symptoms: Dyspnea, diaphoresis, palpitations, nausea, weakness, fever

Aggravating factors: Physical exertion, stress, excitement

Treatments: Beta-blocker, aspirin, heparin, oxygen.

Question 8

Q

Acute pericarditis

Onset and Duration
Location
Characteristics (2)
Severity
Related Symptoms (4)
Aggravating factors (3)
Treatments (2)

Answer

A

Onset and Duration: constant

Location: Substernal, radiates to left shoulder, neck, or arms

Characteristics: sharp, stabbing pain

Severity: Moderate, 4 to 6 of 10 on pain scale

Related Symptoms: Fever, dyspnea, orthopnea, anxiety

Aggravating factors: Deep inspiration, coughing, lying down

Treatments: Sitting up and leaning forward; shallow breathing to relieve pain

Question 9

Q

Esophageal Reflux

Onset
Location
Characteristics (4)
Severity
Related Symptoms (4)
Aggravating factors (2)
Treatments (4)

Answer

A

Onset: Spontaneous onset, often associated with eating

Location: Midepigastric to xiphoid; radiates to neck, ear, or jaw

Characteristics: Burning, tight sensation, squeezing

Severity: Moderate to severe

Related Symptoms: Dysphagia, dyspnea, coughing, disturbed sleep patterns

Aggravating factors: Spicy or acidic meal, alcohol

Treatments: Weight loss, antacids, H2 blocker, proton pump inhibitors

Question 10

Q

Costochondritis

Onset
Location
Duration
Characteristics
Severity
Related Symptoms
Aggravating factors (3)
Treatments (3)

Answer

A

Onset: Sudden onset

Location: Rib cage or sternum, confined to one area

Duration: intermittent

Characteristics, Severity, Related symptoms: varied, varied, none

Aggravating factors: Coughing, deep breathing, sneezing

Treatments: Localized heat, analgesics, inflammatory

Question 11

Q

Shortness of breath

Origin
Onset (gradual vs sudden)
Assess Impact on ADL
Related symptoms (2)

Answer

A

Origin: Dyspnea may be respiratory or cardiac problem

Onset: Gradual onset may mean heart failure which develops slowly from backup of fluid from left heart into alveoli causing limited oxygen; sudden onset may be pneumonia

Impact of ADL: Level blocks able to walk; if this is decreasing condition may be worsening and/or they need supplemental O2

Related symptoms: SOB may be symptom of severe heart murmur or heart failure; SOB with dependent edema in ankles or feet may be right-sided heart failure

Question 12

Q

Shortness of breath and CV and RS

Aggravating factors (5 and what to note)

Answer

A

Aggravating factors
- talking (note how many words they can say before dypnea)
-Activity (dyspnea on exertion; stairs increase workload of heart, note how many level blocks)
- orthopnea (Due to abdominal contents pushing against diaphragm; seen in pulmonary disease, note how many pillows or recliner relieves)
- Paroxysmal nocturnal dyspnea: shortness of breath that awakens person in middle of night due to feeling of suffocation
- Allergens such as pets, stress, or emotions may trigger Asthma attacks

Question 13

Q

Cough and CV: What are these a sign of?

Hemoptysis (2)
White, frothy sputum (2)
Increased coughing when lying down

Answer

A

Cough
–Hemoptysis: coughing up blood is symptoms of mitral stenosis and pulmonary disorders
–White, frothy sputum may be sign of pulmonary edema and left-sided heart failure
—Coughing more when lying down may mean heart failure

Question 14

Q

Nocturia and CV

When seen?
Causes (2)

Answer

A

Seen in heart failure for those ambulatory during the day

Causes
- Lying down creates fluid shift and increases need to urinate
- Diuretic may also contribute so stop taking before bed and limit fluid intake before bed to prevent

Question 15

Q

Fatigue and CV

Onset (gradual (2) vs rapid)
Duration (2)
Aggravating factors
What nutrition to ask about?

Answer

A

Onset: Gradual onset with anemia and heart disease; rapid onset if from acute blood loss

o Duration
- May be all day or worse in the morning if from anxiety or depression
- All day if from anemia

Aggravating factors
- May happen with ADLs if heart cannot pump enough blood to meet body tissue need

Nutrition: Ask about iron deficiencies and supplements (iron pills, green leafy vegetables, heavy menstrual flow)

Question 16

Q

Fatigue and CV

What are related Symptoms for following conditions related to fatigue?

Mild anemia and heart failure
Moderate-to-severe anemia (7)

-Anemia due to B12 Deficiency

Answer

A

Related Symptoms
- Mild anemia and heart failure: exertional dyspnea

-Moderate-to-severe anemia: tachycardia, headache, pallor, brittle, spoon-shaped nails, glossitis, and cheilitis

-Anemia due to B12 Deficiency: Neurological symptoms (muscle weakness, difficulty thinking, unusual feeling in hands) aka peripheral neuropathy

Question 17

Q

CV and Fainting (syncope)—brief lapse of consciousness

Preceding factors for the following causes:
Hypotension (3)
Other Cardiovascular (2)
Neurologic/stroke (3)
Ear (2)

Answer

A

Hypotension or inadequate blood flow to brain if occurs with activity, position changes or causes dizziness

CV: Small emboli in cerebral circulation due to atrial fibrillation, valvular disease, or cardiac dysrhythmias -> rapid heart rate, chest pain

Neuro: May cause stroke -> headache, confusion, numbness

Ear: Fluid or infection in ear may cause vertigo or ringing in ear which may be described as fainting

Question 18

Q

Leg pain and CV

Intermittent claudication (2)
-Calf vs butt/thigh claudication

Rest pain

Answer

A

Intermittent claudication: leg pain during walking and relieved within 10 minutes of rest; this is due to artery being occluded
- Calf claudication=femoral or popliteal artery involvement
- Butt and thighs claudication= iliac artery involvement

Rest pain: arterial insufficiency pain that worsens with walking which worsens and is no longer relieved with rest

Question 19

Q

Arterial insufficiency (2) vs venous insufficiency (2)

Answer

A

Arterial insufficiency: worse when legs elevated; improved with legs dependent
Coldness, pallor, hair loss, sores, redness or warmth over veins; visible veins
Venous insufficiency: worse with prolonged standing or sitting in one position; worse in dependent position and relieved with elevation
Often worse at end of day

Question 20

Q

Swelling of Extremities and CV

What may be the cause if:

Edema:
-bilateral
-unilateral (2)
-localized (2)

Women and menstrual cycle
-Thrombophlebitis
-Dependent edema

Treatments
Increase in day, decreases at night or with elevation
Compression garments (2)

Answer

A

Edema
- Bilateral may be fluid overload from systemic disease i.e., heart, renal, or liver failures
- Unilateral may be lymphedema due to occlusion of lymph channels (elephantiasis or trauma) or surgical removal of lymph channels (mastectomy)
- Localized of one leg may be venous insufficiency from varicosities or thrombophlebitis

Women
- Thrombophlebitis may be Associated with hormonal contraceptives
- Dependent edema may be causes by increase in estrogen and progesterone blood levels

Treatments
- If increases during the day and decreases at night or with elevation may be venous stasis
- Compression garments may reduce lymphedema or venous insufficiency

Question 21

Q

Related symptoms for Edema related to

Heart failure
Weight gain
Warmth and redness
Discoloration and ulceration

Answer

A

Heart failure= may have dyspnea
Weight gain from fluid retention
Warmth and redness= inflammation
-Discoloration and ulceration=ischemia

Question 22

Q

Primary prevention for Cardiovascular disease (5)

Answer

A

Smoking cessation and limit alcohol
Nutrition: Plant-based or Mediterranean-like diet high in vegetables, fruits, nuts, whole grains, lean vegetable or animal protein (preferably fish) and vegetable fiber
Blood lipid management: Total cholesterol less than 190 mg/dL
Weight: Achieve and maintain a desirable body weight (BMI between 18.5 and 24.9)
Physical activity: At least 150 min a week of at least moderate-intensity physical activity such as brisk walking

Question 23

Q

Blood pressure screening and CV

Who should be screened?
Who should be screened every 3-5 yrs?
Who should be screened annually?

3 groups at increased risk

Answer

A

Screening for high blood pressure is recommended for all adults aged 18 and older

Adults aged 18–39 years with normal blood pressure (<120/<80 mm Hg) who do not have other risk factors should be rescreened every 3–5 years

Annual screening is recommended for adults aged 40 and older and for those who are at increased risk for high blood pressure.

Persons at increased risk: those with elevated blood pressure (120 to 129/>80 mm Hg), those overweight or obese (M), and African Americans.

Question 24

Q

Lipid-level screening and CV

General age recommendation (men and women)

Age Recommendation for younger adults with risk factors

5 risk factors for heart disease

Answer

A

Screening for lipid disorders is strongly recommended for men >35 and women > 45
Screening for lipid disorders is recommended for younger adults (men ages 20–35 and women ages 20–45)
Risk factors: family hx of cardiovascular disease before age 50 in male relatives or age 60 in female relatives, family history of hyperlipidemia, diabetes mellitus, hypertension or tobacco use

Question 25

Q

Older Adults and CV

Expected variations (3) and abnormal finding

What are they?
What may they indicate?

Answer

A

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

Question 26

Q

Children and CV

3 Procedure differences

Answer

A

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

Question 27

Q

Venous hum

Answer

A

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

Question 28

Q

Toddlers and CV

Expected Finding (2)

Abnormal Findings
Squatting during ADLs
Cyanosis or Pallor
Labored respirations
Weak/absent femoral pulse

Other things to note (2 re: Cyanosis and feeding)

Answer

A

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

Question 29

Q

MEASURE each leg circumference to assess for symmetry

When done?
Procedure:
Expected findings

Abnormal
3 things size increase may mean
Other signs to assess

Answer

A

-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

Question 30

Q

PALPATE femoral, popliteal, posterior tibial, and dorsalis pedis pulses for amplitude bilaterally

Procedure for each
Expected finding
Abnormal Finding (and what it means)

Answer

A

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

Question 31

Q

PALPATE the lower extremities for temperature, skin turgor, capillary refill, pain, numbness, edema, and angle of nail beds

Abnormal Findings (3)

Answer

A

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

Question 32

Q

INSPECT the lower extremities for symmetry, skin integrity, color, hair distribution, and superficial veins

Expected
Abnormal (4)

Answer

A

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

Question 33

Q

PALPATE brachial and radial pulses for rate, rhythm, amplitude, and contour. When indicated, palpate ulnar pulses

Procedure
Expected finding
Abnormal findings (plus medication that may make abnormal)

Answer

A

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

Question 34

Q

PALPATE the upper extremities for temperature, turgor, and capillary refill

Expected
Abnormal (and notes)
Cold
Edema (2)
Tenting
Capillary refill > 2 sec
Clubbing

Answer

A

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

Question 35

Q

MEASURE the blood pressure

Procedure (normal and with hx of dizziness or certain meds)
Expected finding (4)
Abnormal (2)
- For Orthostatic Hypotension, what is decrease in systolic and diastolic; what are three causes?

Answer

A

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

Question 36

Q

INSPECT the jugular veins for pulsations

What it reflects
Procedure (plus angle)
Expected finding
Abnormal (and what it may mean)

Answer

A

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

Question 37

Q

4 tips on palpating pulses

Answer

A

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

Question 38

Q

Contour (Outline or shape of the pulse that is felt)

Expected vs Abnormal

Answer

A

Expected: Smooth and rounded, a series of unvaried, symmetric pulse strokes

Abnormal: Varied strokes or asymmetry between left and right extremities suggest impaired circulation

Question 39

Q

Amplitude (Force) of pulses

Expected

Abnormal (3 to notice)
Pulsus alternans
Paradoxical pulse
Amplitude ratings

Answer

A

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

Question 40

Q

Rhythm of pulses

Expected
Abnormal (3 and when seen)

Answer

A

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

Question 41

Q

PALPATE temporal and carotid pulses for amplitude and rhythm

Procedure
Expected
Abnormal (for temporal and carotid)

Answer

A

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

Question 42

Q

Difference in S1 and S2 at each valve

Answer

A

S1 =S2 at ERB
S1>S2 at mitral and tricuspid; apex
S1<S2 at Aortic and pulmonic; base

Question 43

Q

5 heart valves and location

Answer

A

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

Question 44

Q

Difference between S1 and S2
(3 notes for each)

Answer

A

-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

Question 45

Q

AUSCULTATE the heart for sounds, pitch, and splitting

Where are the sounds from?
Procedure (what if difficult to hear?)
Expected finding (2)

Answer

A

-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

Question 46

Q

Abnormal Heart sounds and what they may mean

Splitting
S3 and S4 sounds
Pericardial friction rub
Murmurs (and how to describe (4))

Answer

A

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

Question 47

Q

INSPECT the anterior chest wall for contour and retractions

Procedure
Expected finding (2)
Abnormal (2)

Answer

A

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

Question 48

Q

Purpose of palpating and auscultating apical pulse

Answer

A

You palpate for location and size

You auscultate for rate and rhythm

Question 49

Q

PALPATE the apical pulse for location and size

Procedure (what to do if not palpable?)

Expected finding

Abnormal findings (and what they mean?)
Lateral PMI
Downward PMI
Large heart

Answer

A

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

Question 50

Q

AUSCULTATE the apical pulse for rate and rhythm

Procedure
Expected findings (2)
Abnormal findings(5)

Answer

A

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

Question 51

Q

Pruritus and Skin

Onset
Location
Common factors (7)
Systemic Causes (2)

Answer

A

Onset: sudden or gradual
Location: spreading?

Common factors: allergies, dry skin, sensitive skin, chemicals, lices, scabies, insect bites

Systemic Causes: biliary cirrhosis, lymphoma

Question 52

Q

Rash

Duration
Characteristics (2 sets)
Common factors (3)
What else to as about

Answer

A

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

Question 53

Q

Skin color changes

Common factors for general Changes (4)

Localized changes (4)
Potential factors for localized changes (4)

Answer

A

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

Question 54

Q

5 common symptoms of skin changes

Answer

A

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

Question 55

Q

Lesions

Characteristics to note (6)
Common factors (6)

Answer

A

Characteristics: color, shape, texture, bleeding, itching, drainage

Common factors: acne, trauma, infections, exposure to chemicals, tumors, systemic disease

Question 56

Q

Wounds and Skins

2 notes on causes
History of impaired wound healing may mean (3)

Answer

A

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

Question 57

Q

Skin texture changes (what they may indicate)

thinning, dryness, fragile (2)
Xerosis (3)

Answer

A

—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

Question 58

Q

8 risk factors for skin cancer

Answer

A

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)

Question 59

Q

3 notes on skin cancer

Answer

A

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

Question 60

Q

Nail Symptoms (potential indications?)

nail separating from nail bed
pitting brittle, crumbling, color changes (3)

What does stress lead to related to nails?

Answer

A

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

Question 61

Q

Hair Changes

Factors (6)
Unique factors for:
- dry or brittle (2)
- dullness or easily plucked
- decreased on lower extremity (4)
- increased hair growth

Answer

A

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

Question 62

Q

Coining (3)

Answer

A

-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

Question 63

Q

Secondary prevention for skin cancer (2)

Answer

A

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

Question 64

Q

ABCDE mneumonic

Answer

A

-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 65

A

-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 66

A

-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 67

A

-Expected: nail smooth and intact

Abnormalities:
- nail biting
-cyanosis of nail or nail clubbing may indicate respiratory or cardiac disease

Answer 68

A

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

Answer 69

A

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 70

A

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 71

A

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 72

A

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 73

A

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 74

A

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 75

A

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 76

A

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 77

A

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 78

A

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 79

A

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 80

A

-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 81

A

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 82

A

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 83

A

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 84

A

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 85

A

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 86

A

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 87

A

Light: May be visualized and felt with light palpation

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

Answer 88

A

Light: narrow scar line

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

Answer 89

A

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 90

A

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 91

A

Definition: Elevated, firm, circumscribed area less than 1 cm in diameter

Example: Wart (verruca), elevated moles, lichen planus, cherry angioma, neurofibroma, skin tag

Answer 92

A

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 93

A

Definition: Elevated, firm, and rough lesion with flat top surface greater than 1 cm in diameter

Example: Psoriasis, seborrheic and actinic keratoses, eczema

Answer 94

A

Definition: Elevated irregular-shaped area of cutaneous edema; solid, transient; variable diameter

Example: Insect bites, urticaria, allergic reaction, SLE

Answer 95

A

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 96

A

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 97

A

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 98

A

Definition: Vesicle greater than 1cm in diameter

Example: Blister, pemphigus vulgaris, SLE, impetigo, drug reaction

Answer 99

A

Definition: Elevated, superficial lesion; similar to a vesicle but filled with purulent fluid

Example: Impetigo, acne, folliculitis, herpes simplex

Answer 100

A

Definition: Elevated, circumscribed, encapsulated lesion; in dermis or subcutaneous layer; filled with liquid or semisolid material

Example: Sebaceous cyst, cystic acne

Answer 101

A

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 102

A

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 103

A

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 104

A

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 105

A

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 106

A

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 107

A

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 108

A

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 109

A

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 110

A

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 111

A

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 112

A

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 113

A

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 114

A

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 115

A

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

Answer 116

A

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 117

A

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 118

A

-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 119

A

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 120

A

ability to assess and interpret information, adapt communication style, establish relationships

-communicate respectfully with appropriate language and behaviors

Answer 121

A

-the interaction with individuals from cultural backgrounds

-use knowledge of health beliefs, practices, and communication patterns with interacting

Answer 122

A

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

Answer 123

A

-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 124

A

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

Answer 125

A

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 126

A

-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 127

A

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 128

A

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 129

A

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 130

A

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 131

A

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

Answer 132

A

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 133

A

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 134

A

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 135

A

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

Answer 136

A

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 137

A

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 138

A

-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 139

A

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 140

A

-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 141

A

-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 142

A

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 143

A

-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 144

A

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 145

A

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 146

A

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 147

A

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 148

A

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 149

A

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 150

A

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 151

A

-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 152

A

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 153

A

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 154

A

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 155

A

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 156

A

-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 157

A

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 158

A

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

Answer 159

A

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 160

A

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

Answer 161

A

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 162

A

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 163

A

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 164

A

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 165

A

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 166

A

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 167

A

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 168

A

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

Answer 169

A

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 170

A

Pattern: periodic intervals, last few hrs to 1-3 days

Location: unilateral

Characteristics: throbbing pain

Related Symptoms: visual disturbances, nausea, vomiting

Treatments: rest

Answer 171

A

Sinus headache: tenderness over frontal or maxillary sinuses

Tension headache: viselike over front or back of head

Answer 172

A

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 173

A

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 174

A

-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 175

A

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 176

A

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 177

A

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

Answer 178

A

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 179

A

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 180

A

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 181

A

-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 182

A

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 183

A

-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 184

A

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 185

A

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 186

A

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 187

A

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 188

A

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 189

A

-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 190

A

-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 191

A

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 192

A

-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 193

A

-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 194

A

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 195

A

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 196

A

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 197

A

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 198

A

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 199

A

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 200

A

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 201

A

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 202

A

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 203

A

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 204

A

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 205

A

-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 206

A

-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 207

A

-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 208

A

-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 209

A

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 210

A

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 211

A

-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 212

A

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 213

A

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 214

A

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 215

A

-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 216

A

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 217

A

-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 218

A

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 219

A

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 220

A

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 221

A

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 222

A

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 223

A

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

Answer 224

A

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 225

A

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 226

A

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 227

A

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 228

A

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 229

A

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 230

A

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 231

A

-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 232

A

preauricular
postauricular
occipital
retropharyngeal (tonsillar)
submandibular
submental
anterior cervical
posterior cervical
supraclavicular nodes

Answer 233

A

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

Answer 234

A

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 235

A

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 236

A

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 237

A

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

Answer 238

A

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 239

A

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

Spoon shaped nails may be iron deficiency

Answer 240

A

-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 241

A

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 242

A

-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 243

A

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 244

A

o Insufficient income
o Reduced Transportation Options
o Social Isolation

Answer 245

A

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 246

A

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

Answer 247

A

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

Answer 248

A

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 249

A

*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 250

A

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 251

A

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 252

A

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

Answer 253

A

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 254

A

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 255

A

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 256

A

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 257

A

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 258

A

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 259

A

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 260

A

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 261

A

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 262

A

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 263

A

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 264

A

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 265

A

Expected: flexion, hyperextension, lateral bending, rotation of neck same as younger adult with less range

Abnormal: Stiff neck may mean cervical arthritis

Answer 266

A

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 267

A

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 268

A

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 269

A

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 270

A

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

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