Exam 3 Flashcards

Question

Primary prevention for Colorectal Cancer (6)

Answer 1

- Consume diet high in fruits, vegetables, and whole-grain foods - Limit intake of high-fat foods - participate in moderate-to-vigorous activity for 30 minutes 5 days or more a week - Attain and maintain healthy weight - Do not smoke - Limit alcohol to no more than 2 drinks per day for men and one drink per day for women

Answer 2

- men and women of average risk screened from ages 45-75, at earlier age for individuals at higher risk - ages 76-85 should consult provider about screenings - screenings can find polyps or colorectal cancer Screening tests available o Fecal occult blood test (FOBT) annually o Flexible sigmoidoscopy every 5 years o Colonoscopy every 10 years o CT colonoscopy every 5 years

Answer 3

- Age: over 55 years. - Gender: Men> women - GERD. (M) - Barrett esophagus: condition associated with long-term esophageal reflux and results in a higher risk of esophageal cancer. (M) - Tobacco use: The longer a person uses tobacco products (cigarettes, cigars, pipes, and chewing tobacco), the greater the risk. (M) - Alcohol use (M) - Obesity: increased risk b-c obesity increases the risk of esophageal reflux. (M) - Diet: high in processed meats and low in fruits and vegetables (M) - Workplace exposures: Exposures to chemical fumes such as solvents used by dry cleaners might lead to a greater risk. (M) - Injury to the esophagus: accidently drinking lye(M)

Answer 4

- skin may be paler than other skin due to lack of exposure -surface characteristics should be smooth, sliver-white striae, scars may be present - very faint fine vascular network may be present

Answer 5

- Jaundice -> liver disease - Erythema -> inflammation - Bruises -> trauma or low platelet count - Striae -> abdominal distention - Inverted umbilicus -> increased abdominal pressure (ascites or large mass) - Dilated veins which appear to radiate from umbilicus -> portal hypertension

Answer 6

o Fat (obesity) o Fetus (pregnancy) o Fluid (ascites) o Flatulence (gas) o Feces (stool, constipation) o Fibroid tumor o Fatal tumor

Answer 7

Flat: found in muscular, athletic adults Rounded: A rounded contour is seen in adults as a result of subcutaneous fat or poor muscle tone. Scaphoid: is seen in thin adults.

Answer 8

- evaluate symmetry by viewing abdomen from two angles (standing behind patient’s head and squatting at the side to view the abdomen at eye level) - adjusting the light source to form shadows may highlight small changes in the contour - ask pt to take deep breath and hold it; this lowers diaphragm and compresses organs of abdominal cavity - ask pt to raise head which contracts rectus abdominis muscles and reveals muscle prominence in thin or athletic adults - Place measuring tape around abdomen at level of superior iliac crests to measure abdominal girth

Answer 9

- Peristalsis usually not visible - Upper midline pulsation may be visible in thin patients - Areas of bulges are expected variations in pregnancy and marked obesity o DO NOT palpate areas of pulsation b-c it may be abdominal aneurysm (weakening of abdominal aorta wall)

Answer 10

Inspection Auscultation (not necessary to listen in all four quadrants because radiate) Palpation Deep Palpation Auscultate BEFORE palpation b-c you do not want to alter presence or absence of bowel sounds or pain

Answer 11

Expected: normoactive bowel sounds (listen for 4 minutes; may be up to 30 discrete sounds per minute) abnormal: hypoactive, borborygmi (hyperactive), tinkling

Answer 12

1. warm your hands 2. ask patient to bend their knees and breathe slowly through mouth to relax abdominal muscle 3. palpate all quadrants of abdomen (if patient reports pain, palpate that spot last) 4. use pads of fingertips to depress abdomen 1 cm (0.4 inch)

Answer 13

1) sliding hands into each palpation position to maintain contact with skin 2) have pt place their hand over yours as all quadrants are palpated

Answer 14

Expected : no tenderness, abdominal muscles relaxed Abnormal - cutaneous tenderness or hypersensitivity - superficial masses - localized areas of rigidity or tension - rigidity -> peritoneal irritation and may be diffuse or localized

Answer 15

1. Warm hands 2. Palpate all quadrants (palpate area of pain last) 3. Ask the patient to breathe slowly through the mouth to facilitate muscle relaxation. 4. Use either (a or b): distal flat portions of the finger pads and press gradually and deeply (4–6 cm) into the palpation area OR bimanual technique with the lower hand resting lightly on the surface and the upper hand exerting pressure on the lower hand for deep palpation 5. Observe for facial grimaces that may indicate pain

Answer 16

Expected - no pain or masses - Aorta often palpable at epigastrium and above and slightly left of umbilicus - Borders of rectus abdominis muscles - stool in colon Abnormal -pain responses include muscle guarding (tensing abdominal muscles during palpation), facial grimaces, pulling away from nurse - Lateral pulsatile masses (abdominal aortic aneurysm)

Answer 17

- children and adolescents may resist palpation since they are ticklish - Caution when deeply palpating; toddlers may have asymmetry or Wilms tumor

Answer 18

- abdomen symmetrical, round, soft - visible pulsations in epigastric area - Lower edge of liver may be palpable in young children 1-2 cm below right costal margin - Abdominal breathers until age 7 Normal variations - Umbilical hernia is normal variation in children particularly African American and resolves spontaneously in early childhood - Diastasis recti abdominis: two rectus muscles fail to approximate one another; common in African American children but should disappear during preschool years

Answer 19

- Abdominal pain, generalized distention, liver or spleen enlargement, abdominal masses - Concave, sunken, or flat abdomen - absence of bowel sounds - Discharge around umbilicus - Pain

Answer 20

- increased fat deposits over abdominal area even with decreased subcutaneous fat over extremities - abdomen may feel soft b-c of decreased abdominal muscle tone - Decreased GI motility and lower esophageal pressure increase likelihood of regurgitation. - Bacterial flora in the intestines become less biologically active, contributing to food intolerance and impaired digestion. - Decrease in internal sphincter tone and sensation may contribute to occasional fecal incontinence. - The bladder decreases in size, shape, and muscle tone, which can cause more frequent urination and increase stress incontinence

Answer 21

- abdominal distention due to fluid or gas - asymmetry from hernias - constipation or bowel obstruction - hypoactive bowel sounds

Answer 22

Gas exchange perfusion tissue integrity nutrition pain elimination tactile perception intracranial regulation

Answer 23

Chronic diseases: osteoporosis or loss of bone density affect mobility, ADLs, reduce weight-bearing activities Medications: Calcium, magnesium, vitamin D strengthen bones and reduce risk of osteoporosis Herbals: * Aloe vera may be applied topically to reduce joint pain * Ginger or green tea may reduce joint inflammation

Answer 24

Assess surgery, accidents, or trauma that affected bones or joints (fractures, strains, sprains, dislocations) Why?: Can leave residual problems such as muscle weakness, decreased ROM, impaired mobility

Answer 25

o Vertebral disorders (curvature of spine or back problems) o Arthritis (rheumatoid arthritis, osteoarthritis, gout)

Answer 26

Drugs - Nicotine reduces blood supply to tissues -> hypoxia -> decreases bone mineral density - Excess alcohol use -> hyperuricemia -> gout Sports - Regular Exercise can strengthen bones (prevent osteoporosis), strengthen muscles, and facilitate weight loss - Protection to reduce risk of injury (wear bike helmet, wear elbow pads and waist guards for in-line skating) - stretch before running, Work and home routine - Heavy lifting and repetitive and forceful motion can cause musculoskeletal injuries; Prevent with proper body mechanics, appropriate help with lifting, use of protective equipment

Answer 27

Location - Proximal muscle weakness = myopathy - Distal weakness = neuropathy Characteristics - Swollen (edema), red (erythema), hot (warm) joints = acute inflammation from arthritis or gout - Limited movement with injury to cartilage or capsule, muscle contracture or edema - Locked joints or knees and ankles giving away with pressure = joint instability from chronic inflammation or trauma - Weakness from altered nerve innervation; muscle contraction disorder; atrophied muscles due to prolonged lack of use (i.e cast) Related symptoms - Sore throat = RA

Answer 28

* Age: >50 years. * Gender: Women > men * Race: Caucasian and Asian women are at highest risk. * Body size: Small-boned and thin women are at greater risk. * Family history * Lifestyle: Cigarette smoking, excessive alcohol intake (> 2 drinks), consuming inadequate calcium and vitamin D, and performing inadequate weight-bearing exercises increase the risk. (M) * Medications to treat chronic diseases: glucocorticoids and some anticonvulsants. (M) * Sex hormones: Estrogen deficiency from menopause or surgical removal of ovaries (oophorectomy) increases risk in women. Low levels of testosterone and estrogen increase risk in men. (M) * Eating disorder: Anorexia nervosa has an irrational fear of weight gain, which increases risk. (M)

Answer 29

* Age: older * Gender: Women over 45 > men, especially after age 50. men under 45 > women * Obesity: Extra weight puts stress on joints, especially weight-bearing joints such as hips and knees. (M) * Joint injury or overuse: such as knee bending and repetitive stress can damage the joint . (M) * Genetics: family history

Answer 30

* Eat balanced diet rich in calcium and vitamin D. Calcium intake should be between 1000 and 1300 mg/day; vitamin D intake should be between 400 and 800 IU/day. * Encourage patients to engage in weight-bearing exercise. * Encourage patients to avoid smoking and excessive alcohol use.

Answer 31

- For women age 65 and older, screening with bone measurement testing is recommended to prevent osteoporotic fractures. - Recommended for postmenopausal women younger than age 65 years who are at increased risk of osteoporosis, as determined by a formal clinical assessment tool

Answer 32

1. Inspect skeleton and muscles (for symmetry, alignment) 2. Palpate bones, joints and muscles (for number, alignment, deformity, contour, and pain) 3. Assess range of motion (ROM is full or limited; and ) 4. Assess Muscle tone via feeling resistance to passive stretch (slight tension expected) 5. Assess muscle strength (graded 0-5)

Answer 33

* 0 = No evidence of contractility * 1 = Evidence of slight contractility * 2 = Complete ROM with gravity eliminated * 3 = Complete ROM with gravity * 4 = Complete ROM against gravity with some resistance * 5 = Complete ROM against gravity with full resistance

Answer 34

- Asymmetric neck muscles = previous injury - Pain = myositis (inflammation of muscle) - Neck spasm = nerve compression or stress - Limited hyperextension and flexion = cervical vertebral disk herniation, degeneration, or osteoarthritic changes - Pain, numbness or tingling during ROM = compression of cervical spinal root nerves

Answer 35

* Flexion: Bring chin to rest on chest. * Hyperextension: Bend head back as far as possible. * Lateral flexion: Tilt head as far as possible toward each shoulder. * Rotation: Turn head as far as possible in circular movement

Answer 36

Expected: Cervical concave, thoracic convex, lumbar concave - Kyphosis: posterior curvature/convexity of thoracic spine - Lordosis: anterior curvature/concavity of spine - Scoliosis: lateral curvature of spine

Answer 37

Flexion: ask patient to bend forward and touch toes; note how close patient gets to floor by measuring from fingertips to floor (expected variation is inability to touch floor due to obesity or tight hamstrings) Hyperextension: ask patient to lend backward from waist Lateral Flexion: ask patient to bend laterally right and left; you may need to stabilize patient’s hips Rotation: ask patient to rotate the upper trunk to right and left; you may need to stabilize their pelvis

Answer 38

- pain - muscle spasm - herniated disk

Answer 39

INSPECT the shoulders and shoulder girdle for equality of height, symmetry, and smooth contour PALPATE the shoulders and upper arms for firmness, fullness, symmetry, and pain ASSESS the trapezius muscles for strength via asking patient to shrug shoulders (also tests CN XI

Answer 40

- protractor with two long arms; place the 0 setting of the goniometer over the middle of a joint that is in neutral position. - One arm of the goniometer is aligned with the extremity proximal to that joint - Other arm of goniometer is aligned with the middle of the distal joint - Keep the 0 at the middle of the joint, move the distal joint through its ROM

Answer 41

Flexion: Raise arm from side position forward to position above head. Hyperextension: Move arm behind body, keeping elbow straight Internal rotation: With elbow flexed and shoulder abducted, rotate shoulder by moving arm until thumb is turned inward and toward back. External rotation: With elbow flexed and shoulder abducted, move arm until thumb is upward and lateral to head. Adduction: brings arms down laterally toward midline Abduction: lift arms laterally away from midline

Answer 42

- Hypotonia or flaccidity: decrease in tone may be peripheral neuropathy - Hypertonia: increase in tone may be spasticity or rigidity from CNS disorders

Answer 43

ask patient to extend the arm while you resist by pushing it to flex position (triceps) then patient flex arm while you try to extend it (biceps)

Answer 44

PALPATE the elbows for pain, edema, temperature, and nodules (none expected; may be RA if present) ASSESS the elbows/forearm for ROM - Flexion: Bend elbow so lower arm moves toward its shoulder joint and hand is level with shoulder. - Extension: Straighten elbow by lowering hand. - Supination: Turn lower arm and hand so palm is up. - Pronation: Turn lower arm so palm is down.

Answer 45

Procedure: have patient grip your first two fingers on each hand (Note: nurse can cross their hands to remember better which hand person has deficits) ASSESS range of motion of wrists and hands - Flexion: move palm toward inner aspect of forearm - Hyperextension: move fingers and hand posterior to midline, bring dorsal surface of hand as far back as possible - Radial deviation: bend wrist medially toward thumb - Ulnar deviation: bend wrist laterally toward fifth finger

Answer 46

PALPATE the hips for stability and pain ASSESS range of motion of hips - Hip flexion with knee flexed Procedure: ask patient to alternately pull each knee up to the chest - Hyperextension: Move leg behind body as far as possible. - Abduction: Move leg laterally away from body. - Adduction: Move leg back toward medial position and beyond if possible.

Answer 47

Hip procedure: patient is supine; ask patient to attempt to raise one leg while you hold it down; do each leg one at a time Leg procedure: patient sitting with legs dangling - For quadriceps, patient extend legs at knee while you attempt to flex knee - For hamstrings, patient flex knee while you attempt to extend knee

Answer 48

- For knee Flexion: Bring heel back toward back of thigh. Extension: Return leg to floor. - For ankle Dorsiflexion: Move foot so toes are pointed upward. Plantar flexion: Move foot so toes are pointed downward. - For foot * Inversion: Turn sole of foot medially. * Eversion: Turn sole of foot laterally

Answer 49

* Compare children motor development to standardized tables of normal age and sequences * Observe gait for steadiness * Observe back from behind child and inspect shoulders, scapula, iliac crest for symmetry and Scoliosis

Answer 50

- Valgus/ valgum (outward) rotation of the lower extremities is normal in children 2 to 3.5 years of age and may be present up to 12 years of age-- knock kneed - Varus (inward) rotation of the lower extremities requires further evaluation for tibial torsion; it may be normal until 18 to 24 months of age-- bow-legged

Answer 51

* Bones are softer in children, making them more vulnerable to fractures. * Toddlers have wide stance and wide waddle gait that disappears by 24-36 months * By 12 to 18 months the lumbar concavity develops as the child learns to walk * lumbar lordosis in AAs under 6 (normal variation)

Answer 52

* Deviation from developmental pattern * History of falls or balance problems * Asymmetry of shoulders, scapula, iliac crest, leg length * Limited ROM, muscle tone, or muscle strength * Asymmetry/Curvature of spine (Scoliosis, kyphosis (from poor posture in adolescents), lordosis (> 6 years old)) * Hypotonia/hypertonia

Answer 53

* Muscle weakness, especially in the legs * Problems with balance or gait (THIS IS AN ABNORMAL FINDING) * Postural hypotension, dizziness * Slower reflexes * Visual problem: poor depth perception * Mental status: confusion or disorientation * Adverse effect of medications * Environment: loose rugs, clutter on floor or stairs, no stair railing or grab bars, inadequate lights, curbs (M)

Answer 54

* procedure is the same but pace may need to be changed to accommodate mobility changes * Decrease in bone mass, narrowing disc space * Posture is more flexed, center of gravity changes * Unequal bilateral muscles = muscle atrophy * Tendons and muscles decrease in tone and elasticity * Common: osteoarthritis changes in joints lead to decreased ROM in those joints

Answer 55

perfusion gas exchange motion sensory perception tactile perception nutrition functional ability elimination pain

Answer 56

- Any changes in ability to move around or participate in usual activities could be due to neurological disorder - Chronic diseases that affect brain, spine or nerves: Parkinson disease, multiple sclerosis, stroke, and seizures - Medications including OTC and herbal ( Prescriptions, street drugs, alcohol, Anticonvulsants, antitremors, antivertigo, pain medication, stimulants found in weight-loss drugs can all alter CNS)

Answer 57

* Injury to head or spinal cord (Previous injury can leave residual weakness or spasticity that you can anticipate during exam) * Previous stroke (Cerebrovascular Accident (CVA)) can have residual deficits like aphasia (affect subjective data collection) or hemiparesis

Answer 58

stroke seizures brain tumor

Answer 59

- Compression from tumors - Increased intracranial pressure - Ischemia from impaired circulation to brain - Transient headache after diagnostic tests like lumbar puncture or surgical anesthesia due to loss of CSF when patient in upright position puts tension on meninges

Answer 60

Causes: drugs, psychiatric illness, metabolic diseases (hypoxia, liver, kidney failure, or diabetes mellitus) Fast onset: may be cardiovascular problem Slow onset: neurological problem Characteristics: Blackout, faint, aware of surroundings?

Answer 61

- pain - problem with movement - problem with ADLs

Answer 62

- Headache - Seizures - Loss of Consciousness - Change in movement (tremor, weakness, or incoordination) - Change in sensations (numbness or tingling) - Difficulty swallowing/ dysphagia - Difficulty communicating/ Aphasia

Answer 63

* Counsel individuals to use lap/shoulder belts while in a car. Children should ride in an appropriate-size child safety seat in the middle of the rear seat. * Advise individuals against riding in the back of pickup trucks or in cargo areas of vehicles unless equipped with seat belts. * Distracted driving (such as using a cell phone, texting, and eating while driving) increases the chance of a motor vehicle crash. * Advise individuals against driving while under the influence of drugs or alcohol or riding as a passenger with an impaired driver. * Advise individuals to wear approved safety helmets for activities such as riding bicycles, motorcycles, all-terrain vehicles, skateboards, scooters, playing contact sports, skiing or snowboarding, or riding horses. * Review risk for falls. * Increase safety of homes and play areas for children by using safety gates at the top and bottom of stairs, installation of window guards, and placement of soft material (mulch or sand) around playground equipment

Answer 64

* Age: doubles every ten years after age 55. * Gender: women > men * Genetics and family history: Risk is greater if parent, grandparent, or sibling had a CVA. * Race: Blacks, Hispanics, American Indians, and Alaska Natives > whites or Asians.

Answer 65

* Tobacco use: damage the heart and blood vessels (M) * Alcohol: Excessive alcohol intake increases blood pressure and increases triglycerides that can harden arteries. (M) * Unhealthy Diet: high in saturated fat, trans fats, cholesterol, too much salt (sodium). (M) * Physical Inactivity: Not getting enough physical activity can lead to other health conditions (M)

Answer 66

* High blood pressure: A blood pressure (>120/80 mm Hg) (M) * High blood cholesterol: extra cholesterol can build up in arteries * Diabetes mellitus: Inadequate insulin causes an increase in blood glucose and prevents oxygen and nutrients from reaching various parts of the body, including the brain. * Obesity (M) * Previous CVA or transient ischemic attack (TIA) * Heart disease: CAD, heart valve defects, irregular heartbeats such as atrial fibrillation (heart flutters), and enlarged heart chambers. * Sickle cell disease: mainly black and Hispanic children.

Answer 67

Procedure - greet patient and note response - ask patient preferred name, location, and date to assess person, place and time - While taking history, gather more data about mental status If not alert and oriented, use Glasgow Coma Scale (score less than 8 means they need to be intubated)

Answer 68

Eye opening response Motor response Verbal response

Answer 69

- Patient’s speech coherent with sufficient volume -responses indicate understanding of what is said

Answer 70

Expected: patient maintains upright posture; walks unaided, maintains balance, and uses opposing arm swing Parkinsonian gait - Forward tilt to posture - Reduced arm swinging - Short, shuffling gait - Rigidity and tremor of extremities and head

Answer 71

- Assessing CNs are not performed routinely; they are assessed when you suspect abnormal findings - Throughout interview collect data on expected function and document as (CNII-CNXII grossly intact) - CNs innervate ipsilateral side of body

Answer 72

Type: Sensory Function: smell reception and Interpretation

Answer 73

Type: Sensory Function: Visual acuity and visual fields Intact: able to enter exam room and sit without difficulty

Answer 74

Type: motor and parasympathetic Function - Motor: Raise eyelids, most extraocular movements - Parasympathetic: Pupillary constriction, change lens shape Intact: H test and pupils reactive to light

Answer 75

Type: motor Function: downward, inward eye movement Intact: H test for Extraocular muscle movements

Answer 76

Type: motor and sensory Function -Motor: Jaw opening and clenching, chewing and mastication - Sensory: facial with ophthalmic, maxillary and mandibular divisions Intact: blinking (also with VII)

Answer 77

Type: motor Function: lateral eye movement Intact: H test for Extraocular muscle movements

Answer 78

Type: motor, sensory, parasympathetic Function - Motor: Movement of facial expression muscles except jaw when talking, close eyes, labial speech sounds (b, m, w, and rounded vowels); natural blinking - Sensory: Taste on the anterior two-thirds of tongue, sensation to pharynx - Parasympathetic: Secretion of saliva and tears

Answer 79

Type: sensory Function: hearing and equilibrium Intact: balanced gait and responding appropriately to conversation

Answer 80

Type: motor, sensory, parasympathetic Function -Motor: Voluntary muscles for swallowing and phonation (guttural speech sounds) - Sensory: Sensation of nasopharynx, gag reflex, taste on the posterior one-third of tongue - Parasympathetic: Secretion of salivary glands, carotid reflex

Answer 81

Type: motor, sensory, parasympathetic Function - Motor: Voluntary muscles of swallowing and phonation of guttural sounds (k or g) on palate, pharynx, and larynx - Sensory: Sensation behind ear and part of external ear canal - Parasympathetic: Secretion of digestive enzymes; peristalsis; carotid reflex; involuntary action of heart, lungs, and digestive tract

Answer 82

Type: motor Function: Turn head, shrug shoulders, some actions for phonation Intact: able to perform actions against resistance, smooth movements, symmetrical movements

Answer 83

Type: motor Function: Tongue movement for speech sound articulation (l, t, n) and swallowing Intact: ability to enunciate; move tongue in all directions and against resistance of nurse pressing cheek

Answer 84

Procedure 1. have patient close eyes and mouth 2. occlude one nostril while assessing other 3. assess each with different aroma 4. ask patient to identify common aromatic substances held under nose (coffee, toothpaste, orange, peppermint)

Answer 85

- Use Snellen or rosenbaum for visual acuity - Use confrontation test for peripheral vision

Answer 86

- For CN V sensory light sensation, have patient close eyes while you wipe cotton lightly over anterior scalp (ophthalmic branch), paranasal sinuses (maxillary branch), jaw (mandibular branch); do other side - For CN V sensory deep sensation, have patient close eyes while you use alternating blunt and sharp ends of a paper clip over forehead, paranasal sinuses, jaw; do other side - For CN V motor, have patient clench teeth, palpate temporal and masseter muscles for muscle mass and strength

Answer 87

- Omit if patient alert and blinking naturally - assess corneal reflex with wisp of cotton - Ask patient to remove any contact lenses and look up and away from you

Answer 88

- inspect face at rest and during conversation (symmetry) - ask patient to 1) raise eyebrows, 2) purse lips, 3) close eyes tightly, 4) show teeth, 5) smile, 6) puff out cheeks

Answer 89

- For anterior 2/3 (CN VII), ask patient to stick out tongue and leave it out; place small quantities of salt and sugar one at a time; repeat on other side - For posterior 1/3 (CN IX), repeat procedure for BITTER and SOUR with lemon

Answer 90

- For CN X, ask patient to say ah (equal upward movement of soft palate and uvula bilateral - For CN IX sensation, touch posterior pharynx with end of tongue blade (movement of posterior pharynx and presence of gag reflex (CN IX)) - For IX and X, swallowing

Answer 91

- use a cotton ball and the lightest touch possible to assess each designated area (with the patient’s eyes closed) - the patient should perceive light sensation and be able to correctly point to or name the spot touched.

Answer 92

- Test sharp (pain) and dull sensations by using the pointed tip of a paper clip (or broken tongue blade) to lightly prick each designated area (patient’s eyes are closed) - Alternate sharp and dull sensations to more accurately evaluate the patient’s response. Expected: patient able to distinguish sharp from dull and identify the area touched.

Answer 93

- Neonates and infants has age-dependent reflexes that are assessed - Children’s motor development is compared to standardized tables and normal age and sequences of motor development - Mainly assess by observation during spontaneous activity, play, interactions with parents b-c may not cooperate with requests - Making exam a game can help with data collection - Use simple numbers (such as 0, 7, 5, 3, or 1) for graphesthesia testing and X and O for younger children. - Deep tendon reflexes only tested if neurologic symptom (muscle weakness, dizziness)

Answer 94

* generally with observation * Sense of smell not usually tested; if it is use orange scent * To test visual fields and gaze (CN II, III, IV, and VI), immobilize head gently and allow child to follow with eyes * To test CN VII, approach like game and ask child to make funny faces as nurse models them

Answer 95

* Under 6, use developmental approach * Over 6, use finger-to nose test with nurse;s finger held 2.5 to 5 cm away from child’s nose

Answer 96

* Not normally tested before age 5 * Carefully explain what is being done when children are tested and use descriptions that the child can understand such as “this will feel like a tickle.”

Answer 97

normal variation of vague and minimal dysfunction in young children i.e clumsiness, language disturbances, motor overload, mirroring movement of extremities or perceptual difficulties -should disappear with maturation

Answer 98

* Asymmetry * Spasticity or paralysis * impaired vision, speech, or hearing * Identification of soft signs as child matures indicates failure to perform age-specific activities * Inattention, motor restlessness, and easy distractibility may be ADHD * Hemiparesis (decreased movement) of upper or lower extremities

Answer 99

- May have slower responses, move slowly, declined function (taste, fine motor speed) - Deviation of gait from midline - Difficulty with rapidly alternating movements - Some loss of reflexes and sensations (knee-jerk or ankle-jerk reflexes) - Short-term memory may decline with age but long-term memory is maintained

Answer 100

* Resting tremor of hand reduced with purposeful movement * Dizziness or vertigo * Hemiparesis of upper or lower extremities

Answer 101

Medications - May be associated with noncyclic breast discomfort or nipple discharge - Vitamin E supplements may reduce discomfort - Hormonal therapy (estrogen and progestin) increase breast cancer risk Changes in breast or nipple appearance or texture-lesion or inflammation? Diet high in methylxanthines (caffeine) can cause benign breast disease such as fibrocystic changes

Answer 102

- Age of Menarche or Menopause (Menarche before age 12 or menopause after age 55 increase breast cancer risk due to longer lifetime exposure to estrogen and progesterone hormones) - Pregnancy (Nulliparous (first child) after 30 increases risk of breast cancer) - Mammogram (when and the findings)- Effective for breast cancer screening b/w ages 50-74 years - Breast problems (fibrocystic changes to breast, fibroadenoma, benign breast disease (atypical hyperplasia), breast cancer)- complicate breast eval because cysts make difficult to detect new masses - History of breast cancer (including ductal carcinoma or lobular carcinoma) and benign breast diseases increase risk of breast cancer - Surgeries on breasts (biopsy, mastectomy, lumpectomy, breast reduction)-- assess why and when - Radiation (high dose radiation to chest at young age increases risk for breast cancer)

Answer 103

* Gender: Females 99% of cases. * Age: Women >45; peak incidence ages 65–84. * Race: White women * Genetic: Inherited mutations of BRCA1 or BRCA2 genes account for 5%–10% of breast cancer cases in women and 5%–20% in men. * Family history: Breast cancer in a first-degree family relative (on either maternal or paternal side) especially before age 50 increases risk; risk is highest if relative is mother or sister. Higher risk with first degree (parent, sibling, child); triples risk with 2 first degree relatives)

Answer 104

* A history of breast cancer * A history of proliferative breast disease with a biopsy-confirmed atypical hyperplasia * Exposure to ionizing radiation to the chest area as child or young adult (for treatment of other cancer such as Hodgkin disease) * Long menstrual history (menarche before age 12 and/or menopause after age 55) increases risk. * Nulliparity increases risk. * First full-term pregnancy after age 30 increases risk. * Breast density: Increased breast density is associated with a higher risk of breast cancer.

Answer 105

* Estrogen replacement: HRT >5 years after menopause (M) * Physical inactivity (M) * Alcohol intake: Increased alcohol intake (two to five drinks a day) (M) * Obesity: Obesity, especially after age 50, or increased weight gain as an adult (M)

Answer 106

* White women have the highest rate of new breast cancer, closely followed by black women * American Indian/Alaska Native have the lowest rate of new breast cancer. * Black women have the highest rates of mammography screening * Asian women have the lowest rate of mammography cancer screening of any ethnic group, closely followed by American Indian and Hispanic. * Median age at diagnosis for black women is 60 compared to age 64 for white women. * Black women have the lowest 5-year survival rate for breast cancer, compared to women of any other racial or ethnic group (Access to care and delays in follow-up may partly explain the survival gap)

Answer 107

Onset - Cyclic (bilateral edema or fullness associated with menstrual cycle due to hormonal fluctuations) - noncyclic (not related to menstrual cycle, usually unilateral and focal) Characteristics and severity - Burning or pulling with vague pain = breast cancer - Very painful = rapidly growing cyst or infection

Answer 108

- breast pain or tenderness - breast lump - nipple discharge (sign of cancer in men) - axillary pain or lump (tail of spence in axilla) - Gynecomastia (in males)

Answer 109

* Women who have family members with breast, ovarian, tubal, or peritoneal cancer should be screened for a family history associated with increased risk for genetic mutations (BRCA1 or BRCA2). * Women with positive screening for family history should receive genetic counseling and, if indicated, BRCA testing.

Answer 110

* Women aged 40–49: decision individualized based on personal value on the potential benefit as opposed to potential harm from false-positive test (women of higher risk may begin screening here) * Women aged 50–74: screening mammography every 2 years. (greatest benefit) * Women aged 75 years and older: insufficient evidence to recommend or not recommend screening mammography.

Answer 111

Expected: breast implants are normal variation Size: slightly unequal in size (symmetrical or slightly asymmetrical) Shape: smooth, convex, even

Answer 112

- Always explain procedure before beginning - get permission - patient should be sitting with gown dropped to waist and arms by sides - gently lift and inspect lower and outer aspect for dimpling, retraction, or bulging (could be malignancy

Answer 113

- Skin should be smooth, even color consistent with skin of rest of body - Skin may be lighter compared to sun-exposed skin - Venous pattern (visible veins under skin) bilaterally similar Normal variation: pronounced venous pattern in obese or pregnant females

Answer 114

Color: varies based on patient skin (pink, brown, black) Shape: round or oval and bilaterally similar Surface Characteristics - May see Montgomery glands (slightly raised bumps on areola tissue) - Hair on nipple

Answer 115

- Nipples may be protruded, flat, or inverted (all normal if unchanged throughout adult life and bilaterally symmetric) - Nipple inversion normal or abnormal (normal if not new finding and easily everted with manipulation) - Smooth and intact without bleeding, discharge, lesions, crusting Supernumerary nipples: normal variation; pink or brown mole colored nipples along embryonic milk line (under breast)

Answer 116

Procedure: patient seated with arms at side Expected - flat breast, symmetric, no rash or lesions - nipples and areolar areas intact, smooth, equal color, size, and shape bilaterally Normal variation -overweight men have thicker fatty layer of tissue on chest that may appear to be breast enlargement (ask patient if breast enlarged with weight gain or were present prior to weight gain; of enlarged with weight gain, it is normal variation)

Answer 117

* Slightly enlarged breasts in neonates due to mother’s estrogen * Some neonates may have small, watery whitish discharge (witch’s milk) during first few weeks of life due to maternal hormones * Undeveloped breast until puberty onset (precocious development prior to 8 yrs should be investigated) * Nipple flat surrounded by slightly darker pigmented areola * Nipple starts to bud in prepubertal (as young as 8)

Answer 118

Expected * By age 14, breasts often resemble those of adult female * For the adolescent, be mindful developmental stages across racial/ethnic groups—AA females may develop faster * Right and left may develop at different rate -- reassure patient that this is common * Breast tissue is firm and elastic (inspection only unless complaint) Abnormal: Lack of breast development, lesions, lumps, and nipple drainage

Answer 119

Expected - Transient unilateral or bilateral subareolar masses (firm and may be tender)-reassure adolescent these are transient and should disappear in year or so; common in obese Abnormal - gynecomastia (unexpected enlargement) due to adipose tissue of obesity or body change during puberty--very self-concious

Answer 120

- Procedure: continue regular breast exams in postmenopausal women and men due to increased risk of breast cancer Expected - Atrophic changes beginning at age 40 through menopause (Breast tissue replaced with fat and connective tissue as glandular tissue atrophies) - Breast appear flattened, elongated, pendulous secondary to relaxation of suspensory ligaments - Inframammary ridge thickness more prominent - Nipples smaller and flatter

Answer 121

Chronic illnesses - Endocrine disorders impact menstrual cycle - Diabetes, vascular insufficiency, cardiac disease, and respiratory disease cause ED Medications - Oral contraceptives and broad-spectrum antibiotics alter balance of normal vaginal flora - Diuretics and antihypertensives can cause impotence in men

Answer 122

Reproductive problems ( Endometriosis increases risk of ovarian cancer) STIs - Chronic and place partners at risk - HPV increases risk of rectal and cervical cancer - STIs can increase risk of pelvic inflammatory disease (PID) History of cancer - History of breast cancer or nonpolyposis colon cancer can increase risk of repro cancers - Testicular cancer can increase risk of occurrence in other testicle Vaccinations - HAV, HBV, HPV are all recommended during adolescence and young adulthood

Answer 123

*increased risk with 1st degree relative* -cervical -ovary -uterus -breast -colon -prostatae -testicle

Answer 124

- Well-woman visit should have pelvic exam and Pap test every 3 years if sexually active until age 65 - Men should have prostate and genitalia examined regularly based on age, history, risk factors, preexisting health conditions

Answer 125

- Men and women need to feel accepted so show genuine interest and concern - Current sexual relationship (type and type of sex had) - Frequency and satisfaction with sexual activity (satisfaction) - Number of partners (assesses risk for STI) - Protection from STI (Condoms effective for HIV, chlamydia, gonorrhea, trichomoniasis; Condoms do not fully protect against HSV or HPV) - Birth Control (what kind, frequency, perceived effectiveness and satisfaction) - Age of first intercourse and sexual abuse (choice and impact for all patients b-c Victims of sexual abuse may wait years to report or disclose especially if perpetrator is family member) - Use of drugs and alcohol with sex (Substance use associated with high-risk sexual behavior or people may use sex to gain access to their drugs of choice)

Answer 126

- Date of last Menstrual period, frequency and length of periods - Age of menopause - Amount of flow (normal is difficult to determine; Light, moderate, heavy; Number of pads or tampons used a day or an hour) - Changes in period - Age of Menarche (Typically 12-14 years; can be from 9-15)

Answer 127

- Gravida (number of pregnancies) - Para (number of pregnancies that reached 20 weeks) - Abortions, miscarriages, infants who died before birth - Possible Pregnancy (i.e symptoms include missed or abnormal periods, nausea or vomiting, breast changes or tenderness, fatigue) - Experience with infertility (how long, feelings, and if seen a HCP?)

Answer 128

Both - pain - genital lesions - vaginal or penile discharge - problems with urination - rectal bleeding. Women -problem with menstruation -problem with menopause Men -erectile dysfunction

Answer 129

- Penile discharge usually infection - Normal discharge for women is clear or cloudy with minimal odor (changes may be infection) - Unpleasant fishy odor with discharge may be bacterial vaginosis Related symptoms - Irritation from discharge causes Itching, rash or pain with intercourse - Pelvic, abdominal, or urinary pain suggest infection - If sexual partner also has discharge, probably STD

Answer 130

- Persistent infection with HPV - Sexual intercourse at an early age and a lifetime history of multiple sex partners or partners with multiple sexual partners - Suppressed immune system - Cigarette smoking (M) - Multiple childbirths - Long-term use of oral contraceptives - Obesity (M) - Family history of cervical cancer

Answer 131

- Age (highest incidence in young men ages 20–34) - Cryptorchidism (undescended testicle) - Family history (increased risk if father or brother had testicular cancer) - History of testicular cancer in other testicle - Race (highest incidence among white men)

Answer 132

- Strong family history of ovarian cancer - personal history of breast cancer - BRCA1 and BRCA2 gene mutations - PID and Lynch syndrome - Nulliparity - Obesity (M) - Estrogen use for postmenopausal hormone replacement therapy (M) - Age (increased risk with aging)

Answer 133

- Age: men over age 65. - Race: AA men - Family history: First-degree relative with prostate cancer increases risk. - Dietary: High dietary fat intake, high dairy, and calcium intake. (M) - Genetic: Lynch syndrome (a form of colorectal cancer), BRCA1, BRCA2

Answer 134

- Unprotected sex (not using a protective barrier consistently and correctly) (M) - Multiple partners (having multiple partners and/or having sex with an individual who has multiple partners) - Age (younger people, particularly women are at greater risk) - Substance use (alcohol or illicit drug use is associated with high-risk sexual behavior) (M) - Trading sex for money or drugs, having sex with a sex worker or IV drug user (M) - History of having an STD - Having sex with a partner with untreated STD (M) - Not vaccinated against HPV or hepatitis B (M) - Ethnicity (higher rates in black and hispanic)

Answer 135

* Abstinence or reduction of the number of sex partners * Use of barrier protection (male or female condoms) during sex * Preexposure vaccinations with the hepatitis B virus (HBV) vaccination, the hepatitis A virus (HAV) vaccination, and HPV vaccine

Answer 136

- all adolescents and all other individuals based on level of risk (such as M on M sex) - All pregnant women should be screened at the first prenatal visit.

Answer 137

- Annual screening is recommended for all sexually active women under age 25 and other individuals at increased risk - Pregnant women under age 25 and all other pregnant women with high-risk behaviors should be screened at the first prenatal visit and again during the third trimester.

Answer 138

- Annual screening is recommended for all sexually active women under age 25 and other individuals who are at increased risk - All pregnant women under age 25 and pregnant women with high-risk behaviors should be screened at the first prenatal visit.

Answer 139

- Routine screening is not recommended for those of average risk; all high-risk individuals should be screened. - Screen all pregnant women at the first prenatal visit and again during the third trimester or at delivery if they have high-risk behaviors.

Answer 140

All pregnant women should be tested for the presence of antigens and men who have sex with men

Answer 141

- smoking cessation - safe sex practices - maintaining healthy body weight

Answer 142

Cervical Cancer -Women ages 21-30 PAP every 3 years - women 30-65 yo every 3 years OR PAP & HPV every 5 years Endometrial, Ovarian, Prostate & Testicular Cancers: No routine screening; Genetic testing for strong family history

Answer 143

1. Prepare the room. 2. Assemble the needed equipment (ie. Foley catheter, etc) 3. Be sure that the room temperature is warm. 4. Ensure the patient’s privacy 5. Be sure to talk to the woman throughout the examination to tell her what you are doing, what you are seeing or feeling, and how long it will be until you are finished.

Answer 144

Inspecting for distribution and surface characteristics Expected - hair distribution varies but usually inverse triangle with base over mons pubis -shaved hair is matter of preference and normal variation -smooth and clear skin

Answer 145

Inspect for surface characteristics and pigmentation Expected findings - Labia majora pigmentation slightly darker than patient’s general skin tone; tissue may be shriveled or full, gaping, or closed, with smooth and dry or moist texture without drainage, lesions, sores, nodules or masses - labia minora may be symmetrical or asymmetrical with moist and dark pink inner surface - clitoris midline between labia minora; smooth, pink, moist

Answer 146

Inspect for position and surface characteristics Expected findings - Urethral meatus is midline irregular opening or slit superior to vaginal introitus - Vaginal introitus is moist, thin vertical slit or large orifice; note hymen - Perineum smooth and without lesions or discoloration Normal variation: scar (midline or mediolateral) if patient had episiotomy

Answer 147

- patient may be apprehensive about genitalia examination - be matter-of-fact and professional - use firm deliberate touch - if erection occurs, notify patient this is normal physiologic response to touch and continue with exam; do not focus on it - If patient not circumcised, ask him to retract his foreskin

Answer 148

Inspecting for distribution and surface characteristics Expected findings - Hair distribution varies but usually diamond-shaped that may extend to umbilicus - Hair coarser than scalp hair - free of parasites - Skin is intact, smooth, and clear; May be absent with grooming

Answer 149

For surface characteristics, color, tenderness, and discharge Expected findings * glans should be smooth, pink, and bulbous * Urethral meatus-located centrally at the distal tip of the glans and should appear as a slit-like opening without discharge * shaft nontender

Answer 150

-inspecting scrotum for color, texture, surface characteristics, and position. -inspecting inguinal area for bulges (should be none) Expected findings - sides may be asymmetric (left often hangs lower than right because of longer spermatic cord) -scrotum color usually more deeply pigmented than body skin but consistent coloration -scrotum has coarse-appearing surface without lesions -Scrotum may retract slightly upward in cold or hang downward in heat

Answer 151

For surface characteristics, tenderness, & pigmentation Expected Finding -smooth surface, no lesions or tenderness - perianal pigmentation increased and coarse intact skin without lesions or inflammation; anus tightly closed .

Answer 152

- no internal exam in prepubertal - Adolescents may take large active part in exam, a mirror may be used - Pelvic exam begins at age 21 OR with a complaint

Answer 153

- Until age 7, labia are thin, and clitoris is small - Hymen is intact and visible - By age 8 – 11, the labia appear thicker and pubic hair may be present - Expected findings for the adolescent are similar to those of the adult

Answer 154

- Discharge - Odor - Bruising - Pain - Findings that do not align with maturational development

Answer 155

- May be performed sitting or standing - Do not force foreskin to be retracted, examine foreskin for lesions, crusting, discharge

Answer 156

- inspection only unless symptoms are reported - Be mindful of cultural and sexual abuse considerations - Be matter of fact, use family assistance - For adolescents, if parent is present, give choice to be alone - Reassure that bodily changes are normal - Adolescents may have issue with modesty- ensure privacy, draping - Exam may be deferred to end of assessment

Answer 157

- By age 3-4 the foreskin retracts easily - Well-formed scrotum with rugae - Increase in pubic hair, - size of penis and testes occurs as male ages, skin darkens

Answer 158

Small, flat scrotum Testicular pain, masses / missing testicle Varicoceles Signs of STD/STI: discharge, odor, lesions

Answer 159

- Redness or irritation, signs of infection or pinworms - Signs of abuse: tearing, bruising, anal dilation, extreme apprehension from child (Always report signs of abuse to CPS as appropriate)

Answer 160

- Labia and clitoris are small and pale - Shortening and drying of vagina with thinning (and mucosa drying) - Skin dry with shiny appearance - Sparse, patchy, or absent pubic hair - Prolapse of vaginal walls or uterus

Answer 161

- Finer and less abundant pubic hair in men leading to pubic alopecia - Scrotal sac elongated or pendulous - Testes slightly smaller and softer than young - Smooth and rubbery prostate; median sulcus may or may not be palpable - Relaxation of perianal muscles and decreased sphincter control when bearing down

Answer 162

* injury or excoriation of scrotal sac secondary to sitting on scrotum * Prostate hyperplasia is common abnormal.

Answer 163

- toddlers have rounded (potbelly) abdomen while standing and lying down - school-age children have rounded appearance until age 13 when standing but should be flat when lying down