Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

nu 305 > exam 3 > Flashcards

exam 3 Flashcards

1
Q

What is the proper technique of the abdominal exam

A
  1. inspection
  2. auscultation
  3. percussion
  4. palpitation
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

When inspecting the abdomen what do you look for

A

contour
color
pulsations

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

When ascultating the abdomen what do you listen for

A

bowl sounds in all 4 quadrants
vascular sounds; note any bruits

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What are the specific vascular sounds you should listen to when inspecting the abdomen

A

aortic, renal, iliac, femoral

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

When palpating the abdomen, what do you do?

A
  1. Lightly palpate– one hand all 4 quadrants
  2. Deeply palpate– two hands all four quadrants noting any tenderness, enlarged organs, guarding, or masses
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

During an abdominal assessment, what position should be patient be in?

A

supine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

light palpation normal finding

A

no pain

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

deep palpation normal finding

A

no masses or tenderness

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

normal spleen is located ______and is not_____?

A

LUQ and is not palpable

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

is the bladder palpable?

A

no, unless it is distended

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

normal aortic palpation and measurement

A

it is palpable and it is 2 cm

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

is there a fluid wave

A

no fluid wave

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

RUQ contains

A

liver and gallbladder

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

RLQ contains

A

appendix, ascending colon, cecum, small intestine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

LUQ contains

A

spleen, stomach, transverse colon

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

LLQ contains

A

bladder, descending colon, sigmoid colon

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

flank contains

A

kidneys

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

what method should be used when palpating the liver

A

the hooking method

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

normal urine (2)

A

clear/light yellow

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

normal stool (3)

A

soft, light brown, formed

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

abnormal urine (3)

A

cloudy, bloody, dark

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

what does cloudy urine mean (4)

A

UTI, STI, kidney stones, dehydration

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

what does bloody urine mean (4)

A

UTI, kidney stones, enlarged prostate, exercise induced bleeding

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

what does dark urine mean (3)

A

dehydration, liver disease, kidney disease

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

abnormal emesis (3)

A

green, coffee grounds, bloody

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

what does green emesis mean (1)

A

bile; empty stomach

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

what does coffee grounds emesis mean? (1)

A

GI bleed

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

what does bloody emesis mean

A

very close; mouth, esophagus, nose bleed; anything that has not hit the stomach acid

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

abnormal stool (3)

A

foul smelling, very liquidy, melatonic (black/tarry)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
37
Q

what does foul smelling stool mean (4)

A

changes in diet (spicy/greasy foods), lactose intolerant, malabsorption, infections

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
38
Q

what does very liquidy stool mean (3)

A

viral infection, bacterial infection
(c. diff), or IBS

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
39
Q

what does black stool mean (3)

A

iron meds, pepto, food eaten

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
40
Q

what does black, tarry (melanotic) stool mean (1)

A

GI bleed

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
41
Q

GI bleed symptoms

A

nausea, vomit looks like coffee grounds, abdominal pain, dizzy, low BP

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
42
Q

upper GI bleed risk factors

A

NSAIDS, ulcer, excessive alcohol use

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
43
Q

what are the s/s of dehydration

A

thirst, dry mucous membranes, dark urine, delayed skin turgor

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
44
Q

what are the findings associated with appendicitis

A

RLQ pain, abdominal pain, n/v, fever

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
45
Q

what are the findings associated with constipation

A

distended abdomen, diarrhea, hard pellets of stool, fewer bowl movements

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
46
Q

a way to help constipation

A

fiber and water

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
47
Q

if a patient is constipated and you percuss over the colon what should you expect?

A

tenderness and dullness over the left colon

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
48
Q

what are findings associated with gallbladder issues

A

heartburn, worsened pain and vomiting after eating fatty foods

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
49
Q

what is Iliopsoas sign

A

lay on left side, pull back on right leg it will hurt if it’s appendicitis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
50
Q

iliopsoas sign is only a test for

A

appendicitis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
51
Q

what is rebound tenderness AKA Blumberg

A

press on one side and pain with release (peritonitis in general)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
52
Q

McBurney’s point

A

pain with RLQ palpation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
53
Q

McBurney’s point is only a test for

A

appendicitis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
54
Q

Murphy’s Sign

A

think gallbladder, take in deep breath and hold palpate over right subcostal and there is pain if there is an issue with the gallbladder

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
55
Q

if Murphy’s sign is negative what is important to do

A

DOCUMENT

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
56
Q

muscle strength grade: 0/5

A

no muscle movement

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
57
Q

muscle strength grade: 1/5

A

visible muscle movement, but no movement at the joint

58
Q

muscle strength grade: 2/5

A

movement at the joint, but not against gravity

59
Q

muscle strength grade: 3/5

A

movement against gravity, but not against added resistance

60
Q

muscle strength grade: 4/5

A

movement against resistance, but less than normal

61
Q

muscle strength grade: 5/5

A

normal strength

62
Q

what are the risk factors for osteoporosis

A

-white female (typically postmenopausal)
-low body weight or small bones
-not enough calcium or vit D
-h/o smoking
-inactivity
-family history

63
Q

what should the nurse educate the patient about regarding osteoporosis

A

weight baring exercise (e.g. walking)
vit D and calcium supplements
cut back on alcohol and smoking

64
Q

what are osteoarthritis risk factors

A

age, overuse, family history

65
Q

what type of reaction is osteoarthritis NOT

A

no systemic reaction (throughout the body); it is localized

66
Q

what type of pain and location is associated with osteoarthritis

A

distal, localized pain; may be unilateral; you can hear or feel the bones creek

67
Q

what type of pain and location is associated with rheumatoid arthritis

A

systemic pain; typically proximal joints; can affect the organs

68
Q

rheumatoid arthritis is also what disease

A

autoimmune disease

69
Q

rheumatoid arthritis abnormal lab

A

ESR

70
Q

examples of rheumatoid arthritis deformities

A

swan neck and boutonniere

71
Q

urgent assessment for arteries

A

7 P’s
1. pain
2. pallor
3. paresthesia
4. polar
5. pulselessness
6. paralysis
7. perfusion

72
Q

urgent assessment for veins

A

DVT

73
Q

DVT s/s

A

pain, edema, numbness of extremity

74
Q

________ may result from a DVT

A

PE

75
Q

urgent assessment for abdomen

A

acute abdominal pain which could indicate a ruptured appendix

76
Q

urgent assessment for muscoskeletal

A

malalignment

77
Q

urgent assessment for neuro

A

stroke, seizures, paralysis

78
Q

how to best communicate with a patient with apasia

A

“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
Q

what is the function of the cerebellum

A

coordination
posture
muscle tone
equilibrium

80
Q

what are some tests to test the cerebellum function

A

Rhomberg- stand up, close eyes, and hold arms out
Finger to nose test
Tandem gait- sobriety walking test

81
Q

cranial nerves (all 12)

A

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
Q

how to test for the olfactory

A

ask patient to identify smell

83
Q

how to test for the optic

A

snellen chart

84
Q

how to test for oculomotor

A

use pen light to assess pupils; pupils should constrict with light; you would document PERRLA if normal

85
Q

how to test for trochlear

A

have the patient follow the pen light up, down, side to side, and diagonally

86
Q

how to test for trigeminal

A

have patient look up and touch the lateral sclera to see if the patient blinks

87
Q

how to test for abductens

A

ask patient to follow the pen light through the 6 cardinal fields

88
Q

how to test for facial

A

ask patient to smile, frown, raise eye brows, and puff cheeks

89
Q

how to test for vestibulocochlear

A

hearing

90
Q

how to test for glossopharyngeal

A

-ask patient to yawn and observe for the upper movement of the soft palate
-note ability to swallow
-check gag reflex

91
Q

how to test for vagus

A

ask patient to swallow and speak note any hoarseness

92
Q

how to test for accessory

A

ask patient to shrug shoulders against the resistance of the nurse’s hands

93
Q

how to test for hypoglossal

A

ask patient to move tongue side to side

94
Q

how are DTRs graded

A

0-4+

95
Q

DTR= 0 meaning

A

no response

96
Q

DTR= 1+ meaning

A

diminished, low normal

97
Q

DTR= 2+ meaning

A

average, normal

98
Q

DTR= 3+ meaning

A

brisker than normal

99
Q

DTR= 4+ meaning

A

very brisk, hyperactive clonus

100
Q

pulse locations

A

carotid, brachial, radial, patellor, posterior tibials, dorsalis pedis

101
Q

what does a patient with Parkinson’s look like

A

stooped posture
absent face

102
Q

how often should you get a colonoscopy

A

every 10 years; can be done virtually

103
Q

what does the colonoscopy look at

A

whole body

104
Q

how often should you get a sigmoidoscopy

A

every 5 years

105
Q

what does the sigmoidoscopy look at

A

one side of the body

106
Q

how often should you get the fecal occult blood test

A

annually

107
Q

how often should you get the fecal DNA test done

A

every 3 years

108
Q

what will happen if you have hemorrhoids and you do the fecal occult test

A

you will get a false positive and will have to get a colonoscopy

109
Q

how long does it take for a colon polyp to become cancer

A

10 years

110
Q

stroke risk factors

A

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
Q

stroke S/S

A

slurred speech
facial drooping
expressive or recessive aphasia
intense h/a
LOC
dysphagia

112
Q

what 3 things do you evaluate in the Glasgow coma scale

A

eye, motor, verbal response

113
Q

Glasgow coma scale measures

A

LOC

114
Q

what is the lowest and highest Glasgow coma scale

A

3 & 15

115
Q

any Glasgow coma score less than ____ is _____

A

less than 8 is considered comatose

116
Q

migrane characteristics

A

severe throbbing pain
n/v
photophobia (light sensitivity)
typically one side of the head
unilateral h/a
blurry vision
could be aura only

117
Q

what is aura

A

migrane without the headache

118
Q

migrane education

A

avoid triggers like medications typically hormonal supplements like BC or postmenopausal hormone replacements

119
Q

what foods trigger migranes

A

wines and cheeses

120
Q

if a patient has aura what can you do to prevent the migrane from occurring

A

If they have aura before the h/a starts take meds, hydrate, rest, turn off lights, a small amount of caffeine

121
Q

what are the risks for developing abdominal problems

A

-gastroesaphageal reflux
-infection, irritation, swelling in stomach
-smoking
-family history of IBS

122
Q

what are the risks for developing neurological problems

A

-carpal tunnel syndrome
-diabetes
-autoimmune diseases like lupus or GBS
-HIV

123
Q

what are the risks for developing muscoskeletal problems

A

aging
inflammation

124
Q

frontal lobe function

A

complex cognition (insight), language, voluntary motor function

125
Q

temporal lobe function

A

hearing, speech, behavior, memory

126
Q

parietal-sensory lobe function

A

temp, touch, pressure, pain

127
Q

Wernicke’s area _______ is processed here

A

language is processed here

128
Q

Broca area________ is organized here

A

verbal expression

129
Q

occupational lobe function

A

vision

130
Q

______controls right side of the brain
______controls left side of the brain

A

left controls right
right controls left

131
Q

if there is damage to the spinal cord where else is damaged

A

anywhere from the injury and down

132
Q

zoster (shingles) is what pattern

A

Dermatomal pattern

133
Q

Weber & Rinne tests do what

A

test for hearing loss

134
Q

how do you perform the Weber test

A

put at the top center of the head, they should hear vibration in both ears

135
Q

how do you perform the Rinne test

A

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
Q

during the Weber & Rinne _______should be twice _______

A

air conduction should be twice bone conduction

137
Q

what are the age related changes related to abdominal (4)

A

Decreased peristalsis leading to constipation
Decreased stomach acid
Dental changes
Decreased saliva production

138
Q

what are the age related changes related to muscoskeletal

A

muscle atrophy

139
Q

what are the age related changes related to neuro

A

Tissue degeneration
Decreased reaction
Decreased thinking

140
Q

what is nystagmus

A

Uncontrolled repetitive movements of eyes
Eyes trimble

141
Q

how to test for nystagmus

A

Shine light do they both constrict and take light away do they dilate
As they follow object in the pupils constrict

nu 305 (2 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions