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Patient Centered Care 1 > Exam 2 > Flashcards

Exam 2 Flashcards

1
Q

What is an expected finding of the neck?

A

Trachea midline

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2
Q

What is JVD?

A

Jugular Vein Distention

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3
Q

The nurse should assess a client’s ears when they are wearing a nasal canula. True or false?

A

True

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4
Q

How long does the battery in hearing aids typically last?

A

1 Week

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5
Q

Wipe eyes from the outer to inner canthus. True or false?

A

False (wipe inner to outer)

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6
Q

A client’s teeth should be brushed how many times a day?

A

2 times

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7
Q

Should your client’s head be normocephalic?

A

True

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8
Q

Which tool is used to test visual acuity?

A

Snellen chart

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9
Q

What means nearsightedness?

A

Myopia

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10
Q

How many times should you brush an unconscious persons teeth?

A

Provided oral care up to every 2 hours

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11
Q

Artificial eyes should be cleaned how often?

A

As needed

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12
Q

What does PERRLA stand for?

A

Pupils are equal round and reactive to light and accommodation

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13
Q

How will the nurse best assess a client’s ability to brush their teeth?

A

observe the client brushing their teeth

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14
Q

Which reduces risk for aspiration when providing care for an unconscious client?

A

Suction secretions

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15
Q

What is true for denture care?

A

Place a towel below while cleaning

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16
Q

Denture care should be performed after meals and at bedtime. True or False?

A

True

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17
Q

There are no contraindications for ear irrigation. True or False?

A

False

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18
Q

What color should the tympanic membrane (in the ear) be in a healthy client?

A

Pearly Grey

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19
Q

The Rinne test compares air and bone conduction. True or False?

A

True

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20
Q

What can cause a false low blood pressure reading?

A

Arm above the heart

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21
Q

What can cause high blood pressure reading?

A

Legs crossed, cuff too narrow, and smoking

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22
Q

Where is the apical impulse located?

A

5th ICS MCL

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23
Q

What is measured when assessing a radial pulse?

A

Rate, rhythm, amplitude

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24
Q

The nurse osculating over the 5th intercostal space left midclavicular will hear?

A

Mitral Valve

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25
Q

A pulse deficit is found by adding the apical rate to the radial pulse rate. True or False?

A

False

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26
Q

What action should the nurse take to ausculate heart sounds?

A

Identify S1 and S2

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27
Q

The nurse knows that S2 is the sound of?

A

The closure of the semi-lunar valves

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28
Q

What is an extra heart sound heard at the beginning of diastole?

A

S3

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29
Q

De-oxygenated blood is pumped from the right ventricle to the?

A

Lung

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30
Q

The nurse suspect right sided heart failure based on which assessment finding?

A

+4 pitting edema

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31
Q

What is a blowing or swishing sound found in the carotid artery?

A

Bruit (found in the artery)

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32
Q

What is a blowing or swishing sound found in the heart?

A

Murmur (in the heart)

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33
Q

What is correct when assessing the carotid arteries?

A

Palpate one at a time

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34
Q

A Doppler ultrasound is used to detect a peripheral pulse undetectable through palpation. True or False?

A

True

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35
Q

A client with acute vasoconstriction may have which skin color change?

A

Pallor

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36
Q

A client with atherosclerosis are at risk for tissue ischemia. True or False?

A

True

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37
Q

What finding indicated Arterial Disease?

A

+1 Pedal Pulses bilaterally

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38
Q

What is atherosclerosis?

A

Plan build up on the arteries

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39
Q

Capillary refill time will increase with arterial disease. True or False?

A

True

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40
Q

What BEST increases venous blood return?

A

Ambulation

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41
Q

What assessment finding indicates venous insufficiency?

A

Leg aching relieved by elevation

42
Q

What assessment finding indicate a DVT?

A

Redness, warmth, swelling, pain in 1 leg

43
Q

The nurse documents a client’s respirations by collecting?

A

Rate, depth, and rhythm

44
Q

A respiratory rate of 8bpm that is regular is called?

A

Bradypnea

45
Q

Which respiratory pattern is marked by waxing and waning with periods of apnea?

A

Cheyenne-Strokes Respirations

46
Q

What term means shortness of breath while lying down?

A

Orthopnea

47
Q

Where will the nurse osculate the anterior apex of the lungs?

A

Above the clavical

48
Q

What is correct when osculating lung sounds?

A

Use a side to side comparison

49
Q

What technique will the nurse use to assess to resonance?

A

Percussion

50
Q

Soft, low rustling breath sounds are called?

A

Vesicular

51
Q

How do you check distant vision?

A

Snellen eye chart

52
Q

Myopia

A

Nearsightedness

53
Q

How do you check near vision?

A

Handheld card

54
Q

Presbyopia

A

Gradual loss of your eyes’ ability to focus on nearby objects (Occurs with aging)

55
Q

Nystagmus

A

Involuntary, rapid, rhythmic movement of the eyeball (extraocular movements)

56
Q

PERRLA

A

pupils are equal, round and reactive to light and accommodation

57
Q

What is included in a physical assessment of the head?

A

Inspect and palpate the skull, inspect the face

58
Q

What is an expected finding of the tongue?

A

protrudes in midline

59
Q

what is included in an assessment of the neck?

A

Inspect and palpate lymph nodes, symmetry, range of motion, trachea and thyroid gland

60
Q

What are expected findings of the Head?

A

Normocephalic, no lumps, no lesions, no tenderness

61
Q

What are expected findings of the face?

A

Symmetric, no weakness or drooping, no involuntary movements

62
Q

What are expected findings of the neck?

A

Supple with full ROM, no pain, symmetric, no lymphadenopathy or masses, trachea midline, thyroid not palpable, no bruits

63
Q

Artifical eye care

A

leave a towel below in case the eye is dropped

64
Q

How do you test for hearing?

A

Weber test and rinne test (tuning fork tests), whispered voice test, and conversational speech

65
Q

What is used for an internal ear examination?

A

Otoscope

66
Q

Denture care

A

leave a towel below while cleaning, store in a container with water, brush teeth thoroughly

67
Q

Ear irrigation

A

pull the ear up then down then take a syringe and flush warm water gently through the ear

68
Q

Eye irrigation

A

Lay supine and gently put saline in it while holding the eye open

69
Q

Dysphagia

A

Difficulty swallowing

70
Q

What is an expected finding of the throat?

A

Uvula rises in midline on phonation

71
Q

Unconscious oral hygiene

A

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

72
Q

What are expected findings of the mouth for an aging adult?

A

Pale gums and decreased production of saliva

73
Q

What will increase in an elderly adult client?

A

Cerumen (ear wax)

74
Q

What are equal pitched with medium duration lung sounds heard over the major bronchi called?

A

Bronchovesicular

75
Q

The nurse ausculates high pitched, loud, and tumbular sounds over the trachea and documents?

A

Normal bronchial breath sounds

76
Q

What are high pitched popping lung sounds on inspiration called?

A

Fine Crackles

77
Q

The nurse hears high pitched, musical squeaking on auscultation of the lungs and documents?

A

Wheezing

78
Q

What will the nurse note on a client with COPD?

A

AP diameter equal to transverse diameter

79
Q

What finding is expected on a focused assessment of the lung and thorax?

A

Symmetrical tactile fremitus

80
Q

What is the greatest risk factor for impaired gas exchange?

A

Smoking

81
Q

What is an unexpected finding of the neck?

A

Enlarged thyroid

82
Q

What is true when cleaning the eyes?

A

Wipe inner cantos to outer canthus

83
Q

Direct and consensual light reflexes are confirmed with pupillary dilation. True or false?

A

False

84
Q

Artificial eyes should be cleaned as needed with mild soap and water and rinsed with saline. True or False?

A

True

85
Q

Dentures should be stored in a clean moist container at night. True or False?

A

True

86
Q

The person who sees 20/30 sees better than the person who sees 20/20. True or False?

A

False

87
Q

De- oxygenated blood is pumped from the right ventricle to the

A

Pulmonary artery

88
Q

The nurses osculating over the 2nd intercostal space left sternal border will hear?

A

The pulmonary valve

89
Q

The nurse knows that S1 is the sound of?

A

The closing of the atrial ventricular valves

90
Q

The nurse may suspect right sided heart failure based on what assessment finding?

A

Jugular Vein Distention

91
Q

The nurse may suspect right sided heart failure based on which assessment finding?

A

+4 pitting edema

92
Q

What is a blowing or swishing sound found in the carotid artery?

A

Bruit

93
Q

What is an extra heart sound heard at the end of diastole?

A

S4

94
Q

The nurse documents a client’s respiration when collecting?

A

Rate, depth, rhythm

95
Q

Soft, low breath sounds are called?

A

Vesicular

96
Q

The nurse ausculates high pitched, loud, and tubular sounds over the trachea and documents?

A

Bronchial breath sounds

97
Q

The nurse hears high pitched, popping on auscultation of the lungs and documents?

A

Crackles

98
Q

The nurse hears high pitched, musical squeaking on auscultation of the lungs and documents?

A

Wheezing

99
Q

The client with COPD may present with which sign or symptoms due to their chronic illness?

A

Nail bed angle of 180 degrees

100
Q

What finding is expected on a focused assessment of the lung and thorax?

A

Symmetrical tactile fremitus

101
Q
A

Patient Centered Care 1 (2 decks)

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