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► Nursing Notes > Exam 3: NR414 Rev > Flashcards

Exam 3: NR414 Rev Flashcards

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1
Q

The extraocular muscles consist of four straight or ________ muscles and two slanting or ______ muscles.

A

rectus; oblique

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2
Q

A slight protrusion of the eyeballs may be noticed when examining individuals who come from which ethnic/cultural group?

A

African American

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3
Q

The location in the brain where optic nerve fibers from the temporal fields of vision cross over is identified as the:

A

optic chiasm

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4
Q

Which of the following groups of individuals need to be tested for the presence of color blindness (deficiency)?

A

White males between the ages of 4 and 8 years

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5
Q

Which of the following statements is true in regard to the results obtained from use of the Snellen chart?

A

The larger the denominator the poorer the vision

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6
Q

The lens of the eye functions as a:

A
  • Refracting medium keeping a viewed object in continual focus on the retina.
  • think cover test
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7
Q

When inspecting the eyeballs of an African American individual, which of the following might the examiner expect to observe?

A

Small brown macules on the sclera

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8
Q

The normal color of the optic disc is:

A

creamy yellow-orange to pink.

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9
Q

Which of the following is an expected response on the cover test?

A

The covered eye maintains its position when uncovered.

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10
Q

The covered eye maintains its position when uncovered.

A

A unilateral small regular pupil that reacts to light and accommodation

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11
Q

Decreased vision in the elderly may be due to which of the following conditions?

A

cataracts, glaucoma, or macular degeneration

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12
Q

Narrow palpebral fissures, epicanthal folds, and midfacial hypoplasia are characteristic of:

A

fetal alcohol syndrome

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13
Q

Kyphosis of the spine is common with aging. To compensate, older adults will:

A

extend their heads and jaws forward.

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14
Q

Most facial bones articulate at a suture. Which facial bone articulates at a joint?

A

mandible

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15
Q

What disease is characterized by a flat, expressionless, or mask-like face, a staring gaze, oily skin, and elevated eyebrows?

A

Parkinson disease

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16
Q

Facial characteristics include a plethoric, rounded, “moonlike” face, prominent jowls, red cheeks, and hirsutism on the upper lip, lower cheeks, and chin.

A

Cushings Syndrome

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17
Q

Binaural interaction at the level of the brain stem permits:

A

identification of the direction of the sound.

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18
Q

What behavior may be indicative of
hearing loss?

A

Frequently asking for the question to be repeated

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19
Q

Which of the following children is at risk of recurrent otitis media?

A

An 18-month-old infant who has had three episodes of ear infections in a 5-month period.

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20
Q

The external structure of the ear is identified as the:

A

auricle or pinna

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21
Q

The labyrinth of the inner ear is responsible for maintaining the body’s:

A

equilibrium

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22
Q

The normal pathway of hearing is

A

air conduction

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23
Q

The eustachian tube allows

A

equalization of air pressure on each side of the tympanic membrane.

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24
Q

When an otoscope examination is performed on an older adult client, the tympanic membrane may be:

A

whiter than that of a younger adult, or opaque and dull

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25
Q

assesses the ability of the vestibular apparatus in the inner ear to help maintain standing balance.

A

Romberg Test

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26
Q

gives a precise quantitative measure of hearing by assessing the person’s ability to hear sounds of varying frequency.

A

An audiometer test

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27
Q

The position of the tympanic membrane in the neonate is more ________________, making it more difficult to visualize with the otoscope.

A

horizontal

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28
Q

What color is a normal tympanic membrane

A

shiny and translucent, with a pearly gray color.

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29
Q

If the tympanic membrane has white dense areas, the examiner suspects:

A

scarring from recurrent ear infections.

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30
Q

This documentation statements indicates a normal assessment of the perianal area?

A

“Anus moist, color darker than adjacent tissues. No lesions or discharge. Opening tightly closed.”

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31
Q

Upon palpation the prostate gland is enlarged, nontender, firm and smooth with a palpable central groove. This assessment finding indicates:

A

benign prostatic hypertrophy.

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32
Q

Long-term use of laxatives frequently leads to:

A

dependence

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33
Q

Voluntary control of the external anal sphincter cannot occur until

A

the nerves supplying the area have become fully myelinated, usually around 1½ to 2 years of age.

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34
Q

Which continent has the lowest prevalence rate of prostate cancer?

A

Asia

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35
Q

tears that occur in the superficial mucosa and often result from trauma

A

fissure

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36
Q

An anorectal fistula is usually caused by:

A

a chronically inflamed gastrointestinal tract.

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37
Q

A patient is taking iron supplements. The patient should expect the stools to be:

A

nontarry and black.

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38
Q

blood in the stools that is not visible.

A

occult

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39
Q

Hematuria is a term used for:

A

blood in the urine

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40
Q

The most common sexually transmitted infection in the United States is:

A

chlamydia

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41
Q

Cessation of menses is known as:

A

menopause

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42
Q

inflammation of the fallopian tube.

A

salpingitis.

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43
Q

refers to the structures most closely related structurally and functionally to the uterus; these structures include the ovaries, fallopian tubes, and ligaments

A

Adnexa

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44
Q

The cervical mucosa during the second month of pregnancy is blue which is termed

A

the Chadwick sign

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45
Q

small, red mass protruding from the urethral meatus

A

A caruncle

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46
Q

Adnexa is/are:

A

uterine accessory organs

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47
Q

Dyspareunia is the term to describe

A

painful intercourse

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48
Q

a thin, circular or crescent shaped fold that may cover part of the vaginal orifice or may be absent completely.

A

hymen

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49
Q

Dysmenorrhea is:

A

pain associated with menstruation

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50
Q

The first sign of puberty in girls is:

A

breast and pubic hair development

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51
Q

Decreased estrogen levels during menopause cause:

A

the ovaries to atrophy

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52
Q

The sequence of techniques used during an examination of the abdomen

A
  1. Inspect
  2. Auscultate
  3. Percuss
  4. Palpate
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53
Q

What may be noted through inspection of the abdomen

A

venous patterm peristaltic waves, and ab contour

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54
Q

Right upper quadrant tenderness may indicate pathology in the?

A

liver, pancreas, or ascending colon

55
Q

Hyperactive bowel sound characteristics x3

A
  1. high pitched
  2. rushing
  3. tinkling
56
Q

The absence of bowel sounds is established after listening for how long?

A

5 full minutes

57
Q

Auscultation of the abdomen may reveal bruits of the _____arteries.

A
  • aortic
  • renal
  • iliac
  • femoral
58
Q

The range of normal liver span in the right midclavicular line in the adult is:

A

6-12 cm

59
Q

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?

A

silvery white

60
Q

Auscultation of the abdomen is begun in the right lower quadrant because?

A

bowel sounds are always normally present here

61
Q

A dull percussion note forward ot the left midaxillary line is:

A

indicative of spleen enlargement

62
Q

Shifting dullness is a test for?

A

ascites

63
Q

Tenderness during abdominal palpation is expected when palpating in this area?

A

sigmoid colon

64
Q

this is pain felt when taking a deep breath when the examiner’s fingers are on the location of the inflamed gallbladder?

A

Murphy sign

65
Q

This indicates the presence of occult blood from bleeding higher in the GI tract. Blood has been broken down during the digestive process.

A

Black tarry stools

66
Q

This occurs with localized bleeding in the lower GI tract around the anus (hemorroids)

A

Red Blood in stools

67
Q

The examiner is inspecting and palpating for a hernia. The man is instructed to?

A

bear down when the examiner’s fingersi at the inguinal canal

68
Q

Normal finding of a scrotum assessment?

A

the left testicle hangs lower than the right

69
Q

Symptoms of prostatic hypertrophy

A
  • straining
  • loss of force
  • sense of residual urine
70
Q

a 64 year old man has come for a health examination. A normal age-related change in scrotum would be?

A

pendulous scrotum

71
Q

A normal finding during palaption of the testes?

A

firm, rubbery and smooth

72
Q

Age range for testicular cancer

A

15-34

73
Q

During examination of a full term newborn male, a finding requiring investigation would be

A

absent testes

74
Q

How sensitive to pressure are normal testes?

A

somewhat

75
Q

The first physical sign associated with puberty in boys is:

A

testes enlargement

76
Q

In the aging male, when does infertility occur?

A

there is no specific age, men may be fertile into their 80s and 90s

77
Q

A patient has soft, moist fleshy painless papules around the anus. The examiner suspects this condition is:

A

HPV

78
Q

Vaginal lubrication is provided during intercourse by this gland

A

bartholin’s glands

79
Q

How does the cervix appear on a woman who has not had any children?

A

smooth and circular

80
Q

Examination of the genitalia of a 70 year old woman, normal finding?

A

thin and sparse pubic hair

81
Q

A woman has come for health care complaining of a thick, white discharge with intense itching. These symptoms are:

A

Candidiasis

82
Q

How do you prepare the vaginal speculum for insertion?

A

lubricate with warm water

83
Q

How do you insert a speculum so patient remains comfortable?

A
  • press introitus down with one hand
  • insert the blades obliquely with the other hand
84
Q

Before withdrawing the speculu, the examiner swabs the cervix with a swab soaked in acetic acid. This examination is done to asses for?

A

Human papillomavirus

85
Q

Describe the uterus

A
  • Pear shaped
  • thick walled organ
  • flattened anteroposteriorly
86
Q

When placing a finger on either side of the cervix and moving it side to side you are assessing for?

A

cervical motion tenderness

87
Q

Normal findings on inspection/palpation of the vulva and perineum?

A
  • labia majora that are wide apart and gaping
88
Q

The notation in a health record indicated G2 P3 Ab0

A

Pregnant 2x with 3 children and all children are living

89
Q

Problems with smoking and oral contraceptives?

A
  • thrombophlebitis
  • pulmonary emboli
90
Q

When preparing to insert an indwelling urinary catheter in a male patient, it is important for the nurse to do what?

A

lubricate the first 5-7 inches of the catheter

91
Q

This decreases the patients’ risk for injury during inserting of an indwelling urinary catheter?

A

assessing the patiient for allergies related to latex, antiseptic tape, or iodine based substances

92
Q

Instruction given to the NAP caring for the patient with an indwelling catheter has been effective, in this scenario?

A

the excess catheter tubing has been coiled beside the patients inner thigh

93
Q

What should you do if you do not see urine flow after inserting the urinary catheter in a female patient?

A

inspect the catheter location as it may be in the vagina

94
Q

Mr M’s hearing has gotten much worse in a short amount of time, which test should you use to assess?

A

Whispered Voice Test

95
Q

What is a safety issue with ambulation related to ears?

A

Vertigo

96
Q

perceptive hearing loss indicates a pathologic condition of cranial nerve 8

A

Sensorineural

97
Q

what might be the cause of sensorineural hearing loss

A

presbycusis- an age-related gradual degeneration of the nerve

98
Q

hearing loss involves a mechanical dysfunction of the external or middle ear. If the sound amplitude is increased enough, the person can hear.

A

Conductive

99
Q

What might be the cause of conductive hearing loss

A

Cerumen buildup and otosclerosis

100
Q

What technique do you use to palpate the cervical lymph nodes?

A
  • Gentle Pressure
  • use both hands
  • compare both sides
101
Q

Normal Findings Nursing Inspection/Palpation of the Head:

A
  • Normocephalic appropriate to body size
  • No deformities or lumps, tenderness
  • Symmetry of Movement (CN VII)
  • No involuntary movements or edema
102
Q

Inspection of the Neck Normal Findings

A
  • Active ROM
  • No enlargements of the salivary glands
  • No tenderness at lymph
  • Lymph nodes should be freely moveable
103
Q

PERRLA Stands for

A
  • Pupils
  • Equal
  • Round
  • Reactive
  • Light
  • Accomodation
104
Q

How do you inspect the ear w/ an otoscope for an adult

A

up and back

105
Q

How do you inspect the ear with a child under 3 years

A

down and back

106
Q

What are you looking for with the otoscope

A
  1. Cerumen discharge
  2. redness or swelling of canal wall
  3. external canal
107
Q

What are you looking for in the tympanic membrane?

A
  • Color/characteristics
  • position (flat, bulging, retracted)
  • integrity of membrane
108
Q

Note response to conversational speech

A
109
Q
A
  • CVA Tenderness
  • if they have an infection of the kidneys will be very painful when you do this
110
Q

Right Upper Quadrant

A
  • Liver
  • Kidney
  • Gallbladder
  • Pancreas
  • lg/sm intestine
111
Q

Left Upper Quadrant

A
  • Liver
  • Kidney
  • Stomach
  • Spleen
  • lg/sm intestine
112
Q

Left Lower Quadrant

A
  • lg/sm intestine
  • bladder
113
Q

Right Lower Quadrant

A
  • lg/sm intestine
  • bladder
  • APPENDIX
114
Q

this describes the nutritional state and normally ranges from flat to rounded

A

contour of the abdomen

115
Q
A
116
Q

What does a bruit in the thyroid gland indicate

A

hyperplasia- enlargement of an organ or tissue

117
Q

a condition in which part of an organ is displaced and protrudes through the wall of the cavity containing it

A

Hernia

118
Q

Can be brought on by heavy lifting, muscle atrophy, obesity, chronic cough, or ascites?

A
  • Hernia
119
Q

Where can a testicular self exam take place

A

in the shower where it is warm and relaxed

120
Q

What technique to do a testicular self exam>

A

roll testicle between fingers feel for any lumps

121
Q

When you percuss the abdomen what are you listening for?

A

tympany vs dullness

122
Q

Describe Retinal Detachment

A
  • lacks oxygen
  • Risk for permanent blindness
123
Q

You may feel as though you are off balance, spinning, whirling, falling, or tilting

A

Vertigo

124
Q

a feeling that you are about to faint or “pass out.” Often goes away or improves when you lie down

A

Lightheadedness

125
Q

Changes associated with menopause

A
  • Vagina shrinks
  • Itchiness, dryness
  • Risk for pain during intercourse (dyspanunia)
  • Becomes more alkaline
126
Q

This measures the five stages of pubic hair development. Helpful in teaching girls sequence of sexual development.

A

Tanner Stages

127
Q

measured by the ability to discern letters or numbers at a given distance according to a fixed standard.

A

Visual Acuity

128
Q

An increase in abdominal pressure – such as when you exercise, laugh, sneeze, or cough. Urine leaks due to weakened pelvic floor muscles and tissues.

A

Stress Incontinence

129
Q

overactive bladder: You have an urgent need to go to the bathroom and may not get there in time, leaking urine.

A

Urge Incontinence

130
Q

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.

A

Overflow

131
Q

physical problems such as arthritis, or cognitive problems such as dementia, prevent you from getting to the bathroom in time.

A

Functional Incontinence

132
Q

How do we detect Prostate Cancer early?

A
  • Blood for prostate specific antigen (PSA)
  • Digital Rectal Examination (DRE)
133
Q

What is Menoconium

A

stool

► Nursing Notes (33 decks)

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