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Physical assessment > Exam #3 > Flashcards

Exam #3 Flashcards

1
Q

What is the equation for cardiac output?

A

Cardiac output= HR x SV (stroke volume)

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2
Q

What is known as the “pacemaker” ?

A

SA node
Rate: 60-100 bpm
generates impulses

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3
Q

What are the 5 areas for listening to the heat and where they are located?

A

All People Enjoy Time Magazine
- Aortic: right 2nd intercostal space
- Pulmonic: left 2nd intercostal space
- Erbs Point: left 3rd intercostal space
- Tricuspid: lower left eternal border; 4th intercostal space
- Mitral: left 5th intercostal, medial to midclavicular line

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4
Q

What is happening in the heart during systole and diastole?

A
  • Systole: contraction and emptying; lub; S1 (closing of AV valves)
  • Diastole: relaxation and filling; dub; S2 (closing of semilunar valves)
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5
Q

What are older client considerations for the heart?

A
  • Be cautions with older clients because atherosclerosis may have caused obstruction, and compression may easily block circulation
  • The apical impulse may be difficult to palpate because of increased anteroposterior chest diameter
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6
Q

When do you use the bell and diaphragm of the stethoscope?

A

Bruit: use the bell
Murmur: use diaphragm then bell

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7
Q

What carries deoxygenated, nutrient-depleted, waste-laden blood from the tissues back to the heart?

A

Veins

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8
Q

What is an ABI test?

A

Tests for peripheral artery disease
- compares ankle and arm blood pressure measurement

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9
Q

What are the characteristics of Arterial insufficiency?

A

Pain: intermittent claudication to sharp (very painful)
Pulse: diminished or absent
Skin: Dry, shiny skin
Ulcer: Deep
Edema: minimal

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10
Q

What are characteristics of Venous Insufficiency?

A

Pain: cramping, aching (minimal pain)
Pulse: present
Skin: reddish, blue in color
Ulcer: superficial
Edema: moderate to sever

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11
Q

What are older clients findings of the peripheral vascular system?

A
  • Hair loss on lower extremities (occurs with aging)
  • lymphatic tissue is lost, resulting in smaller and fewer lymph nodes
  • Varicosities are common in older clients
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12
Q

While examining a patient the nurse observes abdominal pulsations between the xyphoid process and umbilicus. The nurse would suspect these are?

A

Normal abdominal aortic pulsations

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13
Q

How often should normal bowel sounds be heard?

A

5 - 30 times per minute

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14
Q

If a patient is suspected of having cholecystitis (inflamation of gallbladder) what test should the nurse do?

A

Murphy sign

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15
Q

What are the abdominal quadrants? And where should you start your assessment?

A

Start in Right Lower Quadrant
RUQ: right upper quadrant
RLQ: right lower quadrant
LUQ: left upper quadrant
LLQ: left lower quadrant

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16
Q

What is located in the Right lower quadrant?

A
  • Appendix
  • Colon/ large intestine
  • Right kidney
  • Right ovary and tube
  • Right ureter
  • Right spermatic cord
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17
Q

What is located in the right upper Quadrant?

A
  • liver
  • gallbladder
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18
Q

What is the structure and function of the liver?

A

Largest solid organ in the body
- stores glucose, iron, vitamins, has clotting factors, deconstruction of RBCs

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19
Q

What is GERD? signs and symptoms

A

When stomach acid or contents flow back into esophagus
*raise head of bed and have patient sleep on left side
- hoarseness
- laryngitis
- chronic dry cough
- asthma
- feeling of lump in throat

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20
Q

What are the steps of assessing the Abdomen?

A
  • Insect
  • Auscultation: so you can listen to bowel sounds before you disrupt them with percussion
  • Percussion
  • Palpation
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21
Q

What are the 5 F’s of abdomen distention?

A
  • Fat
  • Fluid
  • Feces
  • Flatus
  • Fetus
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22
Q

How do you grade bowel sounds?

A

Absent:
- no BS for 5 minutes (have to check for 5 min if absent)
Hypoactive:
- less than 5 per minute
Active:
- 5 - 30 per minute
Hyperactive:
- > 30 per minute
Borborygmus: more than hyperactive

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23
Q

How to test for appendicitis

A
  • Rebound tenderness
  • Rovsing’s sign (left side)
  • Referred rebound tenderness
  • Psoas sign (push down on right leg)
  • Obturator sign (External rotation of right heal)
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24
Q

How to test for cholecystitis?

A

Murphy sign

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25
Q

Older client considerations for abdomen

A
  • Dilated superficial capillaries
  • increased risk of peptic ulcer disease
  • increased lactose intolerance
  • increased likelihood of constipation (decreased GI movement)
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26
Q

What are the muscle movements?

A
  • Abduction: away from midline
  • Adduction: toward midline
  • Circumduction: circular motion
  • Inversion: soles of feet inward
  • Eversion: soles of feet facing out
  • Extension: increasing degree
  • Flexion: degreasing degree
  • Pronation: face down
  • Supination: face up
  • Protraction: pushing jaw out
  • Retraction: pushing jaw back
  • Rotation
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27
Q

What are the parts of the brain and their function?

A
  • Brain stem and pons: posture, heart rate
  • Frontal: communication, emotion, judgement (fully develops by 25)
  • Parietal: tactile
  • Occipital: primary visual; reading
  • Temporal: hearing
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28
Q

What are the cranial nerves and their function?

A
  • I (olfactory): smell
  • II (optic): visual acuity (Snellen chart)
  • III (oculomotor): PERRLA
  • IV (trochlear): PERRLA
  • V (trigeminal): clench jaw
  • VI (abducens): PERRLA
  • VII (facial): smile, frown
  • VIII (acoustic, vestibulochlear): whisper test
  • IX (glossopharyngeal): say “ah” swallow
  • X (vagus): tested the same as glossopharyngeal
  • XI (spinal/accessory): shoulder shrug
  • XII (hypoglossal): stick out and move tongue
29
Q

When does a cerebrovascular Accident happen (stroke)?
risk factors and signs and symptoms

A

When blood flow to portion of brain is interrupted or stopped; deprives brain of oxygen; cells die resulting in permanent brain damage
- Hemorrhagic: rupture or leakage of blood vessels
- ischemic: blood clot blocks blood vessel
Risk factors:
- hypertension
- diabetes
- heart disease
- oral contraceptives
- smoking and exposure
- personal or family history
- age, gender, race, ethnicity

30
Q

What does BEFAST stand for?

A

Balance
Eyes
Face
Arms
Speech
Time

31
Q

What are the different abnormal Gaits to check for?

A
  • Cerebellar ataxia: wide-based staggering (cerebellar disease or intoxication)
  • Parkinsons gait: shuffling, turns in stiff manner (might also see “masked face” known as hypomimia)
  • Cerebral palsy: flexed arms held close to body, drags toe of left foot stiffly in circles or outward and forward
  • footdrop: foot and knee lifted high with each step, slaps foot down. cannot walk on heels
32
Q

How to test ROM of the cervical, thoracic, and lumbar spine

A
  • Cervical: chin to chest look up to ceiling
  • Thoracic: ear to shoulder
  • Lumbar: bend and touch toes, lean backward
33
Q

How to test for Carpal Tunnel

A
  • Phalen test: pace backs of both hands together
  • Tinel test: percussion lightly over the median nerve in wrist
34
Q

How to grade joints and muscles

A

5 : active motion against full resistance (normal)
4 : active motion against some resistance (slight weakness)
3 : active motion against gravity (average weakness)
2 : passive ROM (poor ROM)
1: slight flicker of contraction (severe weakness)
0 : No muscular contraction (paralysis)

35
Q

How do you grade reflexes?

A

4+ very brisk; hyperactive
3+ brisker than average
2+ average; normal
1+ somewhat diminished
0 no response

36
Q

What is Decorticate posturing

A

Arms flexed and adducted
Wrists flexed
Legs are internally rotated and plantar feet

37
Q

Decerebrate posturing

A

Arms extended and adducted
Wrists flexed
Feet are plantar flexed

38
Q

Are veins or arteriole walls thicker?

A

Arteriole because there is more pressure

39
Q

What are the major arteries of the arm and leg?

A

Arm: brachial, radial, ulnar
Leg: femoral, popliteal, dorsalis pedis, posterior tibial

40
Q

How do you grade a pulse?

A

0 = absent
1+ = weak thready
2+ = normal
3+ = bounding

41
Q

What are major veins of the leg

A

femoral, popliteal, saphenous veins

42
Q

When assessing lymph nodes

A

Should be moveable and elastic

43
Q

Where are Epitrochlear and Superficial Inguinal nodes found

A
  • Epitrochlear: front inner side of elbow
  • Inguinal: upper femoral crease
44
Q

What is DVT and risk factors

A

Deep vein thrombosis: blood clot
- reduced mobility
- dehydration
- increased viscosity of the blood
- venous stasis

45
Q

What are the signs, symptoms, and risk factor of PAD

A

Peripheral artery disease
- pain with exertion
- ischemic rest pain
Risk factors:
- smoking
- diabetes
- obesity
- high blood pressure
- high cholesterol
- family history of PAD
- excess levels of homocysteine
- african american

46
Q

How do you do the Allen test and what does it identify?

A

Evaluates patency primarily of the ulnar arteries to ensure adequate collateral blood supply.
- have patient rest hand palm side up on table and make a fist. apply pressure using your hands to the radial and ulnar arteries.
continue pressure and have client open fist. release pressure on the ulnar artery and watch for color return.
— It is important to know if the ulnar artery would be capable of perfusing the entire hand if the radial artery was compromised.

47
Q

When palpating the legs what do you want to look for?

A
  • Temperature
  • Superficial Inguinal nodes
  • Femoral pulse (bruits)
    and other leg pulses
48
Q

How do you elicit the homans sign?

A

inspect client for variscosities and thrombophlebitis by asking client to stand

49
Q

When palpating the abdomen the nurse notices the presence of tenderness in the left upper quadrant with deep palpation. which structure is most likely involved?

A

Spleen

50
Q

a student nurse hears that a patient has hepatomegaly and recognizes that this term refers to

A

Enlarged liver

51
Q

What is located in the left Upper quadrant?

A

pancreas, spleen, stomach

52
Q

What are the stomach regions commonly used and location

A
  • Epigastric: upper central region of abdomen; below sternal area
  • Umbilical: belly button
  • Suprapubic: above pubic bone
53
Q

What is the function of the spleen?

A

filters blood, digest microorganisms, return breakdown product to liver

54
Q

What are the signs, symptoms, and risk factors for Peptic Ulcer Disease

A
  • Burning stomach pain
  • feeling of fullness, bloating
  • Fatty food intolerance
  • Heartburn
  • Nausea or vomiting
  • dark blood in stool stools black tarry.
  • trouble breathing
  • faint and dizzy if blood loss occurs look at hemaglobin and hematocrit
55
Q

What are the 4 abdominal shapes?

A
  • Flat
  • Scaphoid (concave)
  • Rounded
  • Protuberant (due to a mass)
56
Q

What are striae and when can you see this?

A

stretch marks
Cushing’s Disease

57
Q

What side of the heart is the largest?

A

left ventricle due to more pumping

58
Q

What valve comes first tricuspid or bicuspid?

A

Tricuspid: opens from right atrium into right ventricle
and then
Bicuspid: opens from left atrium to left ventricle

59
Q

What are signs and symptoms of Coronary Artery disease

A
  • arrhythmias
  • heart infections
  • congenital heart defects
  • narrow or blocked blood vessels that lead to heart attack
60
Q

What is Pulse Rate Deficit?

A

assess peripheral pulse rate and apical pulse rate and compare the two.
the difference between the two is the pulse deficit
this reflects the number of ineffective cardiac contractions in 1 min

61
Q

What is Jugular venous distension

A

when your jugular vein visibly bulges
this is seen with CHF

62
Q

What should you not do when palpating the Carotid arteries?

A

Do not apply pressure to both sides at the same time
- can cause someone to pass out

63
Q

What are all the pulse points and where are they located?

A
  • Temporal (side of head)
  • Carotid (neck)
  • Brachial (front side of elbow)
  • Ulnar
  • Radial
  • Femoral (in femoral crease)
  • Popliteal (back of Knee)
  • Dorsalis pedis (top of foot)
  • Posterior tibial (back of ankle)
64
Q

What are cultural considerations for the heart and vessels?

A
  • Black males have a lower resting heart rate than white males
  • Black females and Mexican American females have a slower resting pulse rate than white females
  • heart disease is the leading cause in all groups; highest in southern states
65
Q

What are signs, symptoms, risk factors and preventions of Osteoporosis?

A

Risk factors:
- lack of exercise, low calcium, anorexia nervosa, low estrogen levels, smoking, caffeine, alcohol, medication intake
Prevention:
- nutritious diet with adequate calcium
- adequate protein
- adequate vitamin D
- regular physical activity
- avoid second hand smoke

66
Q

Difference between skeletal, smooth, and cardiac muscle?

A
  • Skeletal: only voluntary muscle you have
  • Smooth: found in organs
  • Cardiac: found in your heart
67
Q

What is the sympathetic nervous system known for?

A

fight or flight response

68
Q

What are older adult considerations for Neuroskeletal and muscular systems

A
  • Bones lose density
  • joint stiffening
  • Osteoporosis is more common
  • impaired sense of position
  • decrease in hearing, seeing, taste, smell,
  • tremors
  • reduced muscle mass
  • uncertain gait

Physical assessment (3 decks)

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