exam 3 Flashcards
1
Q
What is the proper technique of the abdominal exam
A
- inspection
- auscultation
- percussion
- palpitation
2
Q
When inspecting the abdomen what do you look for
A
contour
color
pulsations
3
Q
When ascultating the abdomen what do you listen for
A
bowl sounds in all 4 quadrants
vascular sounds; note any bruits
4
Q
What are the specific vascular sounds you should listen to when inspecting the abdomen
A
aortic, renal, iliac, femoral
5
Q
When percussing the abdomen, what do you do?
A
percuss all 4 quadrants
percuss the border of the liver and spleen and note any abnormalities
6
Q
When palpating the abdomen, what do you do?
A
- Lightly palpate– one hand all 4 quadrants
- Deeply palpate– two hands all four quadrants noting any tenderness, enlarged organs, guarding, or masses
7
Q
During an abdominal assessment, what position should be patient be in?
A
supine
8
Q
What are the normal abdominal assessment INSPECTION findings
A
-abdominal flat and symmetric
-no scars, striae, or varicosity
-skin is even toned with unmilizus midline
-no hernias noted
-no distention or pulsations
9
Q
What are the normal abdominal assessment AUSCULTATION findings
A
-bowl sounds are present and active in all 4 quadrants
-no bruits, venous hums, or friction rubs
10
Q
What does it mean when you don’t hear any bowl sounds
A
there could be an obstruction so you have to listen for 5 minutes in each quadrant before documenting there are no bowl sounds
11
Q
What are the normal abdominal assessment PERCUSSION findings
A
-tyranny over most of the abdomen
-dullness over the liver in the RUQ
-no pain with kidney percussion on lower flank
12
Q
light palpation normal finding
A
no pain
13
Q
deep palpation normal finding
A
no masses or tenderness
14
Q
normal spleen is located ______and is not_____?
A
LUQ and is not palpable
15
Q
is the bladder palpable?
A
no, unless it is distended
16
Q
normal bladder scan:
mL before voiding and mL after voiding
A
less than 600 mL before voiding and less than 200 mL after voiding
17
Q
normal aortic palpation and measurement
A
it is palpable and it is 2 cm
18
Q
is there a fluid wave
A
no fluid wave
19
Q
RUQ contains
A
liver and gallbladder
20
Q
RLQ contains
A
appendix, ascending colon, cecum, small intestine
21
Q
LUQ contains
A
spleen, stomach, transverse colon
22
Q
LLQ contains
A
bladder, descending colon, sigmoid colon
23
Q
flank contains
A
kidneys
24
Q
What is normal when palpating the liver
A
-the border of the liver should be just below the rib cage
-soft, smooth, and not painful to touch
25
what method should be used when palpating the liver
the hooking method
26
normal urine (2)
clear/light yellow
27
normal stool (3)
soft, light brown, formed
28
abnormal urine (3)
cloudy, bloody, dark
29
what does cloudy urine mean (4)
UTI, STI, kidney stones, dehydration
30
what does bloody urine mean (4)
UTI, kidney stones, enlarged prostate, exercise induced bleeding
31
what does dark urine mean (3)
dehydration, liver disease, kidney disease
32
abnormal emesis (3)
green, coffee grounds, bloody
33
what does green emesis mean (1)
bile; empty stomach
34
what does coffee grounds emesis mean? (1)
GI bleed
35
what does bloody emesis mean
very close; mouth, esophagus, nose bleed; anything that has not hit the stomach acid
36
abnormal stool (3)
foul smelling, very liquidy, melatonic (black/tarry)
37
what does foul smelling stool mean (4)
changes in diet (spicy/greasy foods), lactose intolerant, malabsorption, infections
38
what does very liquidy stool mean (3)
viral infection, bacterial infection
(c. diff), or IBS
39
what does black stool mean (3)
iron meds, pepto, food eaten
40
what does black, tarry (melanotic) stool mean (1)
GI bleed
41
GI bleed symptoms
nausea, vomit looks like coffee grounds, abdominal pain, dizzy, low BP
42
upper GI bleed risk factors
NSAIDS, ulcer, excessive alcohol use
43
what are the s/s of dehydration
thirst, dry mucous membranes, dark urine, delayed skin turgor
44
what are the findings associated with appendicitis
RLQ pain, abdominal pain, n/v, fever
45
what are the findings associated with constipation
distended abdomen, diarrhea, hard pellets of stool, fewer bowl movements
46
a way to help constipation
fiber and water
47
if a patient is constipated and you percuss over the colon what should you expect?
tenderness and dullness over the left colon
48
what are findings associated with gallbladder issues
heartburn, worsened pain and vomiting after eating fatty foods
49
what is Iliopsoas sign
lay on left side, pull back on right leg it will hurt if it’s appendicitis
50
iliopsoas sign is only a test for
appendicitis
51
what is rebound tenderness AKA Blumberg
press on one side and pain with release (peritonitis in general)
52
McBurney’s point
pain with RLQ palpation
53
McBurney's point is only a test for
appendicitis
54
Murphy’s Sign
think gallbladder, take in deep breath and hold palpate over right subcostal and there is pain if there is an issue with the gallbladder
55
if Murphy's sign is negative what is important to do
DOCUMENT
56
muscle strength grade: 0/5
no muscle movement
57
muscle strength grade: 1/5
visible muscle movement, but no movement at the joint
58
muscle strength grade: 2/5
movement at the joint, but not against gravity
59
muscle strength grade: 3/5
movement against gravity, but not against added resistance
60
muscle strength grade: 4/5
movement against resistance, but less than normal
61
muscle strength grade: 5/5
normal strength
62
what are the risk factors for osteoporosis
-white female (typically postmenopausal)
-low body weight or small bones
-not enough calcium or vit D
-h/o smoking
-inactivity
-family history
63
what should the nurse educate the patient about regarding osteoporosis
weight baring exercise (e.g. walking)
vit D and calcium supplements
cut back on alcohol and smoking
64
what are osteoarthritis risk factors
age, overuse, family history
65
what type of reaction is osteoarthritis NOT
no systemic reaction (throughout the body); it is localized
66
what type of pain and location is associated with osteoarthritis
distal, localized pain; may be unilateral; you can hear or feel the bones creek
67
what type of pain and location is associated with rheumatoid arthritis
systemic pain; typically proximal joints; can affect the organs
68
rheumatoid arthritis is also what disease
autoimmune disease
69
rheumatoid arthritis abnormal lab
ESR
70
examples of rheumatoid arthritis deformities
swan neck and boutonniere
71
urgent assessment for arteries
7 P's
1. pain
2. pallor
3. paresthesia
4. polar
5. pulselessness
6. paralysis
7. perfusion
72
urgent assessment for veins
DVT
73
DVT s/s
pain, edema, numbness of extremity
74
________ may result from a DVT
PE
75
urgent assessment for abdomen
acute abdominal pain which could indicate a ruptured appendix
76
urgent assessment for muscoskeletal
malalignment
77
urgent assessment for neuro
stroke, seizures, paralysis
78
how to best communicate with a patient with apasia
"yes" or "no" questions (close ended)
Ask patient to identify self and family through pictures
Ask patient about their age
Speak to their level of knowledge
79
what is the function of the cerebellum
coordination
posture
muscle tone
equilibrium
80
what are some tests to test the cerebellum function
Rhomberg- stand up, close eyes, and hold arms out
Finger to nose test
Tandem gait- sobriety walking test
81
cranial nerves (all 12)
I- Olfactory
II- Optic
III- Oculomotor
IV- Trochlear
V- Trigeminal
VI- Abducens
VII- Facial
VIII- Vestibulocochlear
IX- Glossopharyngeal
X- Vagus
IX- Accessory
XII- Hypoglossal
82
how to test for the olfactory
ask patient to identify smell
83
how to test for the optic
snellen chart
84
how to test for oculomotor
use pen light to assess pupils; pupils should constrict with light; you would document PERRLA if normal
85
how to test for trochlear
have the patient follow the pen light up, down, side to side, and diagonally
86
how to test for trigeminal
have patient look up and touch the lateral sclera to see if the patient blinks
87
how to test for abductens
ask patient to follow the pen light through the 6 cardinal fields
88
how to test for facial
ask patient to smile, frown, raise eye brows, and puff cheeks
89
how to test for vestibulocochlear
hearing
90
how to test for glossopharyngeal
-ask patient to yawn and observe for the upper movement of the soft palate
-note ability to swallow
-check gag reflex
91
how to test for vagus
ask patient to swallow and speak note any hoarseness
92
how to test for accessory
ask patient to shrug shoulders against the resistance of the nurse's hands
93
how to test for hypoglossal
ask patient to move tongue side to side
94
how are DTRs graded
0-4+
95
DTR= 0 meaning
no response
96
DTR= 1+ meaning
diminished, low normal
97
DTR= 2+ meaning
average, normal
98
DTR= 3+ meaning
brisker than normal
99
DTR= 4+ meaning
very brisk, hyperactive clonus
100
pulse locations
carotid, brachial, radial, patellor, posterior tibials, dorsalis pedis
101
what does a patient with Parkinson's look like
stooped posture
absent face
102
how often should you get a colonoscopy
every 10 years; can be done virtually
103
what does the colonoscopy look at
whole body
104
how often should you get a sigmoidoscopy
every 5 years
105
what does the sigmoidoscopy look at
one side of the body
106
how often should you get the fecal occult blood test
annually
107
how often should you get the fecal DNA test done
every 3 years
108
what will happen if you have hemorrhoids and you do the fecal occult test
you will get a false positive and will have to get a colonoscopy
109
how long does it take for a colon polyp to become cancer
10 years
110
stroke risk factors
nic use
HTN
cardiac or vascular disease
bleeding disorders (hemorrhagic or ischemic strokes)
high cholesterol (triglycerides, LDL)
obese
race
age
diabetes because sugar is pro inflammatory
111
stroke S/S
slurred speech
facial drooping
expressive or recessive aphasia
intense h/a
LOC
dysphagia
112
what 3 things do you evaluate in the Glasgow coma scale
eye, motor, verbal response
113
Glasgow coma scale measures
LOC
114
what is the lowest and highest Glasgow coma scale
3 & 15
115
any Glasgow coma score less than ____ is _____
less than 8 is considered comatose
116
migrane characteristics
severe throbbing pain
n/v
photophobia (light sensitivity)
typically one side of the head
unilateral h/a
blurry vision
could be aura only
117
what is aura
migrane without the headache
118
migrane education
avoid triggers like medications typically hormonal supplements like BC or postmenopausal hormone replacements
119
what foods trigger migranes
wines and cheeses
120
if a patient has aura what can you do to prevent the migrane from occurring
If they have aura before the h/a starts take meds, hydrate, rest, turn off lights, a small amount of caffeine
121
what are the risks for developing abdominal problems
-gastroesaphageal reflux
-infection, irritation, swelling in stomach
-smoking
-family history of IBS
122
what are the risks for developing neurological problems
-carpal tunnel syndrome
-diabetes
-autoimmune diseases like lupus or GBS
-HIV
123
what are the risks for developing muscoskeletal problems
aging
inflammation
124
frontal lobe function
complex cognition (insight), language, voluntary motor function
125
temporal lobe function
hearing, speech, behavior, memory
126
parietal-sensory lobe function
temp, touch, pressure, pain
127
Wernicke's area _______ is processed here
language is processed here
128
Broca area________ is organized here
verbal expression
129
occupational lobe function
vision
130
______controls right side of the brain
______controls left side of the brain
left controls right
right controls left
131
if there is damage to the spinal cord where else is damaged
anywhere from the injury and down
132
zoster (shingles) is what pattern
Dermatomal pattern
133
Weber & Rinne tests do what
test for hearing loss
134
how do you perform the Weber test
put at the top center of the head, they should hear vibration in both ears
135
how do you perform the Rinne test
put on mastoid and tell you when they don’t hear it anymore and when they don’t you move it to the front of the ear
136
during the Weber & Rinne _______should be twice _______
air conduction should be twice bone conduction
137
what are the age related changes related to abdominal (4)
Decreased peristalsis leading to constipation
Decreased stomach acid
Dental changes
Decreased saliva production
138
what are the age related changes related to muscoskeletal
muscle atrophy
139
what are the age related changes related to neuro
Tissue degeneration
Decreased reaction
Decreased thinking
140
what is nystagmus
Uncontrolled repetitive movements of eyes
Eyes trimble
141
how to test for nystagmus
Shine light do they both constrict and take light away do they dilate
As they follow object in the pupils constrict
