Exam 2 Flashcards
What is an expected finding of the neck?
Trachea midline
What is JVD?
Jugular Vein Distention
The nurse should assess a client’s ears when they are wearing a nasal canula. True or false?
True
How long does the battery in hearing aids typically last?
1 Week
Wipe eyes from the outer to inner canthus. True or false?
False (wipe inner to outer)
A client’s teeth should be brushed how many times a day?
2 times
Should your client’s head be normocephalic?
True
Which tool is used to test visual acuity?
Snellen chart
What means nearsightedness?
Myopia
How many times should you brush an unconscious persons teeth?
Provided oral care up to every 2 hours
Artificial eyes should be cleaned how often?
As needed
What does PERRLA stand for?
Pupils are equal round and reactive to light and accommodation
How will the nurse best assess a client’s ability to brush their teeth?
observe the client brushing their teeth
Which reduces risk for aspiration when providing care for an unconscious client?
Suction secretions
What is true for denture care?
Place a towel below while cleaning
Denture care should be performed after meals and at bedtime. True or False?
True
There are no contraindications for ear irrigation. True or False?
False
What color should the tympanic membrane (in the ear) be in a healthy client?
Pearly Grey
The Rinne test compares air and bone conduction. True or False?
True
What can cause a false low blood pressure reading?
Arm above the heart
What can cause high blood pressure reading?
Legs crossed, cuff too narrow, and smoking
Where is the apical impulse located?
5th ICS MCL
What is measured when assessing a radial pulse?
Rate, rhythm, amplitude
The nurse osculating over the 5th intercostal space left midclavicular will hear?
Mitral Valve
A pulse deficit is found by adding the apical rate to the radial pulse rate. True or False?
False
What action should the nurse take to ausculate heart sounds?
Identify S1 and S2
The nurse knows that S2 is the sound of?
The closure of the semi-lunar valves
What is an extra heart sound heard at the beginning of diastole?
S3
De-oxygenated blood is pumped from the right ventricle to the?
Lung
The nurse suspect right sided heart failure based on which assessment finding?
+4 pitting edema
What is a blowing or swishing sound found in the carotid artery?
Bruit (found in the artery)
What is a blowing or swishing sound found in the heart?
Murmur (in the heart)
What is correct when assessing the carotid arteries?
Palpate one at a time
A Doppler ultrasound is used to detect a peripheral pulse undetectable through palpation. True or False?
True
A client with acute vasoconstriction may have which skin color change?
Pallor
A client with atherosclerosis are at risk for tissue ischemia. True or False?
True
What finding indicated Arterial Disease?
+1 Pedal Pulses bilaterally
What is atherosclerosis?
Plan build up on the arteries
Capillary refill time will increase with arterial disease. True or False?
True
What BEST increases venous blood return?
Ambulation
What assessment finding indicates venous insufficiency?
Leg aching relieved by elevation
What assessment finding indicate a DVT?
Redness, warmth, swelling, pain in 1 leg
The nurse documents a client’s respirations by collecting?
Rate, depth, and rhythm
A respiratory rate of 8bpm that is regular is called?
Bradypnea
Which respiratory pattern is marked by waxing and waning with periods of apnea?
Cheyenne-Strokes Respirations
What term means shortness of breath while lying down?
Orthopnea
Where will the nurse osculate the anterior apex of the lungs?
Above the clavical
What is correct when osculating lung sounds?
Use a side to side comparison
What technique will the nurse use to assess to resonance?
Percussion
Soft, low rustling breath sounds are called?
Vesicular
How do you check distant vision?
Snellen eye chart
Myopia
Nearsightedness
How do you check near vision?
Handheld card
Presbyopia
Gradual loss of your eyes’ ability to focus on nearby objects (Occurs with aging)
Nystagmus
Involuntary, rapid, rhythmic movement of the eyeball (extraocular movements)
PERRLA
pupils are equal, round and reactive to light and accommodation
What is included in a physical assessment of the head?
Inspect and palpate the skull, inspect the face
What is an expected finding of the tongue?
protrudes in midline
what is included in an assessment of the neck?
Inspect and palpate lymph nodes, symmetry, range of motion, trachea and thyroid gland
What are expected findings of the Head?
Normocephalic, no lumps, no lesions, no tenderness
What are expected findings of the face?
Symmetric, no weakness or drooping, no involuntary movements
What are expected findings of the neck?
Supple with full ROM, no pain, symmetric, no lymphadenopathy or masses, trachea midline, thyroid not palpable, no bruits
Artifical eye care
leave a towel below in case the eye is dropped
How do you test for hearing?
Weber test and rinne test (tuning fork tests), whispered voice test, and conversational speech
What is used for an internal ear examination?
Otoscope
Denture care
leave a towel below while cleaning, store in a container with water, brush teeth thoroughly
Ear irrigation
pull the ear up then down then take a syringe and flush warm water gently through the ear
Eye irrigation
Lay supine and gently put saline in it while holding the eye open
Dysphagia
Difficulty swallowing
What is an expected finding of the throat?
Uvula rises in midline on phonation
Unconscious oral hygiene
Have suction available, do not put fingers in the patients mouth, have the patient in semi fowlers or supine position with head turned to the side
What are expected findings of the mouth for an aging adult?
Pale gums and decreased production of saliva
What will increase in an elderly adult client?
Cerumen (ear wax)
What are equal pitched with medium duration lung sounds heard over the major bronchi called?
Bronchovesicular
The nurse ausculates high pitched, loud, and tumbular sounds over the trachea and documents?
Normal bronchial breath sounds
What are high pitched popping lung sounds on inspiration called?
Fine Crackles
The nurse hears high pitched, musical squeaking on auscultation of the lungs and documents?
Wheezing
What will the nurse note on a client with COPD?
AP diameter equal to transverse diameter
What finding is expected on a focused assessment of the lung and thorax?
Symmetrical tactile fremitus
What is the greatest risk factor for impaired gas exchange?
Smoking
What is an unexpected finding of the neck?
Enlarged thyroid
What is true when cleaning the eyes?
Wipe inner cantos to outer canthus
Direct and consensual light reflexes are confirmed with pupillary dilation. True or false?
False
Artificial eyes should be cleaned as needed with mild soap and water and rinsed with saline. True or False?
True
Dentures should be stored in a clean moist container at night. True or False?
True
The person who sees 20/30 sees better than the person who sees 20/20. True or False?
False
De- oxygenated blood is pumped from the right ventricle to the
Pulmonary artery
The nurses osculating over the 2nd intercostal space left sternal border will hear?
The pulmonary valve
The nurse knows that S1 is the sound of?
The closing of the atrial ventricular valves
The nurse may suspect right sided heart failure based on what assessment finding?
Jugular Vein Distention
The nurse may suspect right sided heart failure based on which assessment finding?
+4 pitting edema
What is a blowing or swishing sound found in the carotid artery?
Bruit
What is an extra heart sound heard at the end of diastole?
S4
The nurse documents a client’s respiration when collecting?
Rate, depth, rhythm
Soft, low breath sounds are called?
Vesicular
The nurse ausculates high pitched, loud, and tubular sounds over the trachea and documents?
Bronchial breath sounds
The nurse hears high pitched, popping on auscultation of the lungs and documents?
Crackles
The nurse hears high pitched, musical squeaking on auscultation of the lungs and documents?
Wheezing
The client with COPD may present with which sign or symptoms due to their chronic illness?
Nail bed angle of 180 degrees
What finding is expected on a focused assessment of the lung and thorax?
Symmetrical tactile fremitus