Exam 3: NR414 Rev Flashcards
The extraocular muscles consist of four straight or ________ muscles and two slanting or ______ muscles.
rectus; oblique
A slight protrusion of the eyeballs may be noticed when examining individuals who come from which ethnic/cultural group?
African American
The location in the brain where optic nerve fibers from the temporal fields of vision cross over is identified as the:
optic chiasm
Which of the following groups of individuals need to be tested for the presence of color blindness (deficiency)?
White males between the ages of 4 and 8 years
Which of the following statements is true in regard to the results obtained from use of the Snellen chart?
The larger the denominator the poorer the vision
The lens of the eye functions as a:
- Refracting medium keeping a viewed object in continual focus on the retina.
- think cover test
When inspecting the eyeballs of an African American individual, which of the following might the examiner expect to observe?
Small brown macules on the sclera
The normal color of the optic disc is:
creamy yellow-orange to pink.
Which of the following is an expected response on the cover test?
The covered eye maintains its position when uncovered.
The covered eye maintains its position when uncovered.
A unilateral small regular pupil that reacts to light and accommodation
Decreased vision in the elderly may be due to which of the following conditions?
cataracts, glaucoma, or macular degeneration
Narrow palpebral fissures, epicanthal folds, and midfacial hypoplasia are characteristic of:
fetal alcohol syndrome
Kyphosis of the spine is common with aging. To compensate, older adults will:
extend their heads and jaws forward.
Most facial bones articulate at a suture. Which facial bone articulates at a joint?
mandible
What disease is characterized by a flat, expressionless, or mask-like face, a staring gaze, oily skin, and elevated eyebrows?
Parkinson disease
Facial characteristics include a plethoric, rounded, “moonlike” face, prominent jowls, red cheeks, and hirsutism on the upper lip, lower cheeks, and chin.
Cushings Syndrome
Binaural interaction at the level of the brain stem permits:
identification of the direction of the sound.
What behavior may be indicative of
hearing loss?
Frequently asking for the question to be repeated
Which of the following children is at risk of recurrent otitis media?
An 18-month-old infant who has had three episodes of ear infections in a 5-month period.
The external structure of the ear is identified as the:
auricle or pinna
The labyrinth of the inner ear is responsible for maintaining the body’s:
equilibrium
The normal pathway of hearing is
air conduction
The eustachian tube allows
equalization of air pressure on each side of the tympanic membrane.
When an otoscope examination is performed on an older adult client, the tympanic membrane may be:
whiter than that of a younger adult, or opaque and dull
assesses the ability of the vestibular apparatus in the inner ear to help maintain standing balance.
Romberg Test
gives a precise quantitative measure of hearing by assessing the person’s ability to hear sounds of varying frequency.
An audiometer test
The position of the tympanic membrane in the neonate is more ________________, making it more difficult to visualize with the otoscope.
horizontal
What color is a normal tympanic membrane
shiny and translucent, with a pearly gray color.
If the tympanic membrane has white dense areas, the examiner suspects:
scarring from recurrent ear infections.
This documentation statements indicates a normal assessment of the perianal area?
“Anus moist, color darker than adjacent tissues. No lesions or discharge. Opening tightly closed.”
Upon palpation the prostate gland is enlarged, nontender, firm and smooth with a palpable central groove. This assessment finding indicates:
benign prostatic hypertrophy.
Long-term use of laxatives frequently leads to:
dependence
Voluntary control of the external anal sphincter cannot occur until
the nerves supplying the area have become fully myelinated, usually around 1½ to 2 years of age.
Which continent has the lowest prevalence rate of prostate cancer?
Asia
tears that occur in the superficial mucosa and often result from trauma
fissure
An anorectal fistula is usually caused by:
a chronically inflamed gastrointestinal tract.
A patient is taking iron supplements. The patient should expect the stools to be:
nontarry and black.
blood in the stools that is not visible.
occult
Hematuria is a term used for:
blood in the urine
The most common sexually transmitted infection in the United States is:
chlamydia
Cessation of menses is known as:
menopause
inflammation of the fallopian tube.
salpingitis.
refers to the structures most closely related structurally and functionally to the uterus; these structures include the ovaries, fallopian tubes, and ligaments
Adnexa
The cervical mucosa during the second month of pregnancy is blue which is termed
the Chadwick sign
small, red mass protruding from the urethral meatus
A caruncle
Adnexa is/are:
uterine accessory organs
Dyspareunia is the term to describe
painful intercourse
a thin, circular or crescent shaped fold that may cover part of the vaginal orifice or may be absent completely.
hymen
Dysmenorrhea is:
pain associated with menstruation
The first sign of puberty in girls is:
breast and pubic hair development
Decreased estrogen levels during menopause cause:
the ovaries to atrophy
The sequence of techniques used during an examination of the abdomen
- Inspect
- Auscultate
- Percuss
- Palpate
What may be noted through inspection of the abdomen
venous patterm peristaltic waves, and ab contour
Right upper quadrant tenderness may indicate pathology in the?
liver, pancreas, or ascending colon
Hyperactive bowel sound characteristics x3
- high pitched
- rushing
- tinkling
The absence of bowel sounds is established after listening for how long?
5 full minutes
Auscultation of the abdomen may reveal bruits of the _____arteries.
- aortic
- renal
- iliac
- femoral
The range of normal liver span in the right midclavicular line in the adult is:
6-12 cm
Striae, which occur when the elastic fibers in the reticular layer of the skin are broken after rapid/prolonged stretching, have a distinct color when of long duration. What is the color?
silvery white
Auscultation of the abdomen is begun in the right lower quadrant because?
bowel sounds are always normally present here
A dull percussion note forward ot the left midaxillary line is:
indicative of spleen enlargement
Shifting dullness is a test for?
ascites
Tenderness during abdominal palpation is expected when palpating in this area?
sigmoid colon
this is pain felt when taking a deep breath when the examiner’s fingers are on the location of the inflamed gallbladder?
Murphy sign
This indicates the presence of occult blood from bleeding higher in the GI tract. Blood has been broken down during the digestive process.
Black tarry stools
This occurs with localized bleeding in the lower GI tract around the anus (hemorroids)
Red Blood in stools
The examiner is inspecting and palpating for a hernia. The man is instructed to?
bear down when the examiner’s fingersi at the inguinal canal
Normal finding of a scrotum assessment?
the left testicle hangs lower than the right
Symptoms of prostatic hypertrophy
- straining
- loss of force
- sense of residual urine
a 64 year old man has come for a health examination. A normal age-related change in scrotum would be?
pendulous scrotum
A normal finding during palaption of the testes?
firm, rubbery and smooth
Age range for testicular cancer
15-34
During examination of a full term newborn male, a finding requiring investigation would be
absent testes
How sensitive to pressure are normal testes?
somewhat
The first physical sign associated with puberty in boys is:
testes enlargement
In the aging male, when does infertility occur?
there is no specific age, men may be fertile into their 80s and 90s
A patient has soft, moist fleshy painless papules around the anus. The examiner suspects this condition is:
HPV
Vaginal lubrication is provided during intercourse by this gland
bartholin’s glands
How does the cervix appear on a woman who has not had any children?
smooth and circular
Examination of the genitalia of a 70 year old woman, normal finding?
thin and sparse pubic hair
A woman has come for health care complaining of a thick, white discharge with intense itching. These symptoms are:
Candidiasis
How do you prepare the vaginal speculum for insertion?
lubricate with warm water
How do you insert a speculum so patient remains comfortable?
- press introitus down with one hand
- insert the blades obliquely with the other hand
Before withdrawing the speculu, the examiner swabs the cervix with a swab soaked in acetic acid. This examination is done to asses for?
Human papillomavirus
Describe the uterus
- Pear shaped
- thick walled organ
- flattened anteroposteriorly
When placing a finger on either side of the cervix and moving it side to side you are assessing for?
cervical motion tenderness
Normal findings on inspection/palpation of the vulva and perineum?
- labia majora that are wide apart and gaping
The notation in a health record indicated G2 P3 Ab0
Pregnant 2x with 3 children and all children are living
Problems with smoking and oral contraceptives?
- thrombophlebitis
- pulmonary emboli
When preparing to insert an indwelling urinary catheter in a male patient, it is important for the nurse to do what?
lubricate the first 5-7 inches of the catheter
This decreases the patients’ risk for injury during inserting of an indwelling urinary catheter?
assessing the patiient for allergies related to latex, antiseptic tape, or iodine based substances
Instruction given to the NAP caring for the patient with an indwelling catheter has been effective, in this scenario?
the excess catheter tubing has been coiled beside the patients inner thigh
What should you do if you do not see urine flow after inserting the urinary catheter in a female patient?
inspect the catheter location as it may be in the vagina
Mr M’s hearing has gotten much worse in a short amount of time, which test should you use to assess?
Whispered Voice Test
What is a safety issue with ambulation related to ears?
Vertigo
perceptive hearing loss indicates a pathologic condition of cranial nerve 8
Sensorineural
what might be the cause of sensorineural hearing loss
presbycusis- an age-related gradual degeneration of the nerve
hearing loss involves a mechanical dysfunction of the external or middle ear. If the sound amplitude is increased enough, the person can hear.
Conductive
What might be the cause of conductive hearing loss
Cerumen buildup and otosclerosis
What technique do you use to palpate the cervical lymph nodes?
- Gentle Pressure
- use both hands
- compare both sides
Normal Findings Nursing Inspection/Palpation of the Head:
- Normocephalic appropriate to body size
- No deformities or lumps, tenderness
- Symmetry of Movement (CN VII)
- No involuntary movements or edema
Inspection of the Neck Normal Findings
- Active ROM
- No enlargements of the salivary glands
- No tenderness at lymph
- Lymph nodes should be freely moveable
PERRLA Stands for
- Pupils
- Equal
- Round
- Reactive
- Light
- Accomodation
How do you inspect the ear w/ an otoscope for an adult
up and back
How do you inspect the ear with a child under 3 years
down and back
What are you looking for with the otoscope
- Cerumen discharge
- redness or swelling of canal wall
- external canal
What are you looking for in the tympanic membrane?
- Color/characteristics
- position (flat, bulging, retracted)
- integrity of membrane
Note response to conversational speech
- CVA Tenderness
- if they have an infection of the kidneys will be very painful when you do this
Right Upper Quadrant
- Liver
- Kidney
- Gallbladder
- Pancreas
- lg/sm intestine
Left Upper Quadrant
- Liver
- Kidney
- Stomach
- Spleen
- lg/sm intestine
Left Lower Quadrant
- lg/sm intestine
- bladder
Right Lower Quadrant
- lg/sm intestine
- bladder
- APPENDIX
this describes the nutritional state and normally ranges from flat to rounded
contour of the abdomen
What does a bruit in the thyroid gland indicate
hyperplasia- enlargement of an organ or tissue
a condition in which part of an organ is displaced and protrudes through the wall of the cavity containing it
Hernia
Can be brought on by heavy lifting, muscle atrophy, obesity, chronic cough, or ascites?
- Hernia
Where can a testicular self exam take place
in the shower where it is warm and relaxed
What technique to do a testicular self exam>
roll testicle between fingers feel for any lumps
When you percuss the abdomen what are you listening for?
tympany vs dullness
Describe Retinal Detachment
- lacks oxygen
- Risk for permanent blindness
You may feel as though you are off balance, spinning, whirling, falling, or tilting
Vertigo
a feeling that you are about to faint or “pass out.” Often goes away or improves when you lie down
Lightheadedness
Changes associated with menopause
- Vagina shrinks
- Itchiness, dryness
- Risk for pain during intercourse (dyspanunia)
- Becomes more alkaline
This measures the five stages of pubic hair development. Helpful in teaching girls sequence of sexual development.
Tanner Stages
measured by the ability to discern letters or numbers at a given distance according to a fixed standard.
Visual Acuity
An increase in abdominal pressure – such as when you exercise, laugh, sneeze, or cough. Urine leaks due to weakened pelvic floor muscles and tissues.
Stress Incontinence
overactive bladder: You have an urgent need to go to the bathroom and may not get there in time, leaking urine.
Urge Incontinence
if you are not able to empty your bladder appropriately. As a result, you may have leakage once the bladder is already full. This is more common in men with symptoms of frequent dribbling of urine.
Overflow
physical problems such as arthritis, or cognitive problems such as dementia, prevent you from getting to the bathroom in time.
Functional Incontinence
How do we detect Prostate Cancer early?
- Blood for prostate specific antigen (PSA)
- Digital Rectal Examination (DRE)
What is Menoconium
stool
