Exam 4 Study Guide: Q Flashcards
which of these are ideal conditions to complete an abdominal assessment? Select all that apply
a. the client should be in a supine position
b. keep the abdomen visible while maintaining client privacy
c. a warm and well-lit environment with minimal environmental noise
d. the nurse should perform the exam prior to the client voiding for optimum bladder palpation
a. the client should be in a supine position
b. keep the abdomen visible while maintaining client privacy
c. a warm and well-lit environment with minimal environmental noise
Should the patient go to the restroom (void) before starting abdominal exam?
yes, do not want to palpate a full bladder
abdominal shape that is normal, expected
flat
abdominal shape that caves inward (concave), malnourished
scaphoid
abdominal shape that is convex and expected
rounded
abdominal shape that shows abdominal distension
protuberant
abdominal shape that is further than protuberant and firm, large protrusion of the abdomen, could be impacted, gas, ovarian cyst, ascites, bowel obstruction (pain and long period since last BM)
Distended
a history of any prior abdominal surgery puts a client at higher risk for what?
higher risk for bowel obstruction
liver
gallbladder
pylorus
duodenum
head of pancreas
right adrenal
portion of right kidney
hepatic flexion of colon
portion of transverse and ascending colon
organs in the RUQ
(right upper quandrant)
spleen
pancreas
left liver lobe
stomach
part of left kidney
left adrenal
splenic flexure of colon
part of transverse and descending colon
organs in the LUQ
(left upper quadrant)
lower section left kidney
sigmoid and descending colon
distended bladder
ovaries
salpinx
organs in the LLQ
(left lower quadrant)
appendix
cecum
lower portion of right kidney
portion of ascending colon
bladder
ovaries
salpinx
organs in the RLQ
(right lower quadrant)
what is a positive Blumberg’s sign and what disease does it indicate?
rebound tenderness which signals appendicitis
is tenderness on palpation subjective or objective?
subjective
what is the typical cause of ascites?
usually caused by liver malfunction
- sodium retention
- fluid retention
- decreased albumin production
when are colorectal screenings recommended?
- regular screening
- beginning at age 45
- is the key to preventing colorectal cancer and finding it early
- the U.S. preventive services task force (USPTF) recommends that adults aged 45 - 75 be screened for colon cancer
T or F:
decreased ambulation causes constipation
True
- encourage fluids
- high fiber diet and exercise
when a client is experiencing constipation, what are some questions to ask? (essay question)
Are you passing gas?
When was your last BM?
How active have you been lately?
When is the last time you ate or drank anything?
What is your regular diet like?
Have you had any previous abdominal surgery?
what are some questions to ask when a client comes in with abdominal pain? (essay question)
PQRST
Ask about nausea, vomiting, diarrhea?
When was last BM?
Any changes in appetite?
When was last PO intake and what was it?
Do they still have their appendix?
Any recent weight changes?
Belching?
Gas?
Blood in vomit or stool?
LMP?
Any previous abdominal surgeries?
what are some questions to ask when a client comes in with abdominal issues? (essay question)
When was your last BM?
What did it look like?
Are you passing gas?
Have you had any constipation or diarrhea?
What is your usual pattern?
Have you been having any nausea or vomiting?
Do you have any reflux or heartburn?
Any family history of stomach cancer?
Any unintended weight loss or gain recently?
What is your regular diet?
manifest in RLQ
also positive blumberg test (rebound tenderness)
Appendicitis
manifest in LUQ
Pancreatitis
Manifest in RUQ
GB pain can radiate to back and shoulder blades
Hepatitis & Cholecystitis
what is the correct order of techniques for an abdominal inspection?
inspection
auscultation
percussion
palpation
Why do you auscultate right after inspection?
percussion and palpation can alter bowel sounds
during an abdominal assessment, where should you inspect from?
side and foot of bed
- size, shape, symmetry of abdomen
- flat, scaphoid (concave), rounded, protuberant, distended
what do you need to do before advancing diet?
listen for bowel sounds - indicate peristalsis
- halted by anesthesia must make sure they have returned prior to any intake
what is abdominal distention?
distention
- rounded
- firm
- enlarged
- painful
- long period since recent BM
what are some causes of abdominal distention?
- adipose tissue
- flatulence
- fetus
- feces
- free fluid (ascites)
- tumor
- hernia
- ovarian cyst
what are some signs of bowel obstruction?
- pain
- abdominal distention
- prolonged period since last BM
What is purple striae?
- indication of recent stretching of the skin
- pink or bluish in color
what causes purple striae?
- pregnancy
- fluid weight gain
how long should you auscultate each quadrant before saying bowel sounds are absent?
1 minute but if abnormal listen for 5 minutes each quadrant
what is considered hyperactive bowel sounds?
- normal bowel sounds occur every 5 - 15 seconds
- hyperactive bowel sounds are usually every 3 seconds
what causes hyperactive bowel sounds?
- increased motility
- can be from diarrhea
- bowel inflammation
what causes decreased bowel sounds?
decreased motility
what is the nursing implication with decreased bowel sounds?
must delay diet advancement in post-op patient if noted
what are the functions of the stomach?
- churn food
- intrinsic factor glycoprotein necessary to absorb B12
- where digestion begins
what are the functions of the small intestine?
primary site for digestion and absorption
what are the functions of the large intestine?
sodium and water absorption
what are the functions of the pancreas?
- produces insulin and glucagon
- pancreatic enzymes
what are the functions of the liver?
- metabolism
- produces bile
- clotting factors
- detoxifies drugs and alcohol
- converts glucose to glycogen
- stores vitamins
what are the functions of the gallbladder?
stores/concentrate bile
what are the functions of the kidney?
- removes waste
- control BP
- produces erythropoietin
what are the functions of the bladder?
store urine
what is Abdominal Aortic Aneurysm (AAA)?
- can be life-threatening
- an out-pouching of the abdominal aorta
- one of the major blood vessels
how is AAA diagnosed?
- do not palpate abdomen if large
- diffuse pulsations are present
- auscultate the area for vascular sounds or bruit using the bell of the stethoscope
- notify the physician immediately
when is percussion performed during an abdominal assessment?
percussion is done before palpation and after auscultation
what is the purpose of palpation during an abdominal assessment?
- light touch to get patient used to touch to make them comfortable and note any surface changes
- abdomen should be soft and nontender with no masses
CVA (costal vertebral) tenderness indicates what disease?
kidney infection
generalized enlarged abdomen may signify what disease?
ascites (fluid in the abdominal cavity)
- resulting from liver malfunction
- results from three mechanisms
- - - abnormal movement of protein and water in the abdomen
- - - sodium and fluid retention
- - - decreased albumin production in the liver
which are nursing interventions for constipation? select all that apply
a. encourage fluids
b. high fiber diet
c. offer caffeine
d. assist with ambulation
a. encourage fluids
b. high fiber diet
d. assist with amubulation
where should you auscultate for bruits during the abdominal assessment and with what part of the stethoscope?
- auscultate over the aorta
- heard with the bell of the stethoscope
what part of the stethoscope is used for bowel sounds?
diaphragm
how do you perform percussion on the abdomen?
- only the pad of the middle finger against the client’s skin and taps with short quick motions using the tip of the finger of the other hand
- note areas of:
- tympany: in all four quadrants and dullness over organs
flexion and extension are movements that occur in what plane?
the sagittal plane
what is the movement that decreases the angle between two body parts?
flexion decreases the angle
what is the movement that increases the angle between two body parts?
extension increases the angle
the hip must flex or extend for a client to sit on a toilet?
flex
flexion of the elbow refers to the movement that brings the two proximal bones (closer or further)?
closer together
- when the elbow is flex, the angle between the two joined bones is reduced
turning the forearm so palm is down and up is called what?
pronation (down)
supination (up)
what is the term for moving the arm in a circle around the shoulder?
circumduction
inversion and eversion is moving the sole of the foot _________ and _________ at the ankle?
inward
outward
what is the action of raising the foot upwards towards the shin?
dorsiflexion
- - flexion of the foot in the dorsal, or upward direction
abduction is the movement of a limb __________ from the body.
away
- as the client lifts their leg away from their body, they are performing an abduction exercise
adduction is moving the limb of a body ________ the midline.
toward
- as the person moves their leg towards their body, they are performing an adduction exercise.
muscle strength: 5
normal full ROM against gravity and full resistance
muscle strength: 4
full ROM against gravity with some resistance
muscle strength: 3
full ROM with gravity
muscle strength: 2
full ROM without gravity
muscle strength: 1
visible or palpable contraction with no movement
which joint is the most mobile joint in the body?
the shoulder
- provides the upper extremity with tremendous ROM such as adduction, abduction, flexion, extension, internal rotation, external rotation, and 360* circumduction in the sagittal plane
concave curves
cervical and lumbar
curves are convex
thoracic and sacral
accentuated thoracic curve
Kyphosis
lateral S deviation of the spine
Scoliosis
accentuated lumbar curve
Lordosis
what clients can suffer from lordosis?
commonly occurs in pregnancy
- due to the spine adjusting itself to the center of gravity as pregnancy weight gain causes abdominal enlargement
- may shift after delivery
- can also be seen in toddlers at the lumbar spine
what clients suffer from kyphosis?
exaggerated, forward rounding of the back
- most common in older women who are postmenopausal and have a small build
- osteoporosis can also lead to kyphosis over time
what is osteoporosis?
- a loss in bone mineral density affects an estimated 10 million Americans
- increases the risk of fracture, bones become so porous that they fracture spontaneously, from bearing a person’s weight
S/S:
tender
warm
swollen joints
stiffness worse in the mornings and after inactivity
fatigue
fever
loss of appetite
also increased the risk of osteoporosis
Rheumatoid Arthritis
when does a neurological assessment begin?
- when the nurse first enters the room
- use inspection observe
- LOC
- behavior
- appearance
any weakness in an extremity would be an indicator for the nurse to do what?
a complete neurological exam
- could be a sign of stroke
S/S:
unilateral facial droop
arm drift
weakness on half of the body
expressive aphasia
confusion
loss of balance
blurred vision
stroke
damage to Broca’s area can cause what symptom?
- expressive aphasia or Broca’s aphasia
- understand what people say better than they can speak
- people will struggle to get words out
- speak in very short sentences and omit words
what are some stroke risk factors?
HTN
a-fib
smoking
diabetes
high cholesterol
obesity
CAD
ETOH abuse
African American
Hispanic
Elderly
Sleep Apnea
Sickle Cell Anemia
TIAs
what is the hypoglossal nerve responsible for?
motor nerve that is responsible for tongue movement
how can a nurse evaluate hypoglossal nerve?
ask client to stick out their tongue to inspect if it is midline and if it moves as expected
what is cranial nerve XI responsible for and how can the nurse evaluate it?
accessory nerve
- responsible for moving trapezius and sternomastoid muscles
these muscles are responsible for the shoulder shrug and shoulder movement
what is cranial nerve V responsible for and how can the nurse evaluate it?
trigeminal nerve
- responsible for sensation in the face and motor functions
- - biting and chewing
- most complex of the cranial nerves
palpate the TMJ while the patient clenches the teeth
what are the functions of CN III?
Oculomotor
- a motor nerve responsible for eye movement
what are the functions of CN VIII?
Acoustic Nerve (Vestibulocochlear)
- responsible for hearing and is only a sensory nerve
which cranial nerve is responsible for swallowing?
CN IX - Gossopharyngeal
- swallowing ability should be assessed prior to anything PO to prevent aspiration
what cranial nerve is responsible for gag reflex?
CN X - Vagus
what is CN II responsible for and how can the nurse evaluate it?
Optic Nerve
- vision
- assessed using Snellen Chart
what is CN IX responsible for?
Glossopharyngeal
- sensory and motor nerve of the tongue
- taste on the posterior 1/3 of the tongue
- swallowing
- speech sounds
- (gag reflex)
what is CN XII responsible for and how can the nurse evaluate it?
Hypoglossal
- motor nerve
- - tongue movement
have client stick out their tongue
- should be midline and without atrophy or fasciculations
- tongue deviation to the side may indicate CN XII damage
how do you assess facial weakness?
ask client:
- raise eyebrows
- close eyes tight
- smile
- frown
- show the teeth
- puff out their cheeks
assess for asymmetric features
how many hemispheres and lobes are on the cerebral cortex?
two hemispheres and four lobes
- frontal lobe
- occipital lobe
- parietal lobe
- temporal lobe
a client with traumatic brain injury with damage to the frontal lobe may present with what symptoms?
sudden behavioral, emotional, and personaility changes
Frontal lobe is responsible for?
personality
behavior
emotions
intellectual function
What is controlled by the hypothalamus?
body temp
sleep
autonomic system
what is controlled by the cerebellum?
motor coordination
equilibrium
balance
what is controlled by the cerebral cortex?
voluntary movement
which lobe is responsible for the sensation of touch?
parietal lobe
how can a nurse assess coordination?
finger-thumb opposition
running heel down the shin
finger to finger
finger to nose
toe-tapping
inspecting a client’s gait
how do you perform the Romberg test and what is it evaluating?
client to stand with their feet together
eyes closed
arms resting to their side while nurse observes for swaying or falls
tests balance
PERRLA?
P = Pupils
E = Equal
R = Round
R = Reactive to
L = Light and
A = Accommodate
how does a nurse evaluate for PERRLA?
have clients watch your finger as you bring it closer to their nose for accommodation
- use penlight to assess reactivity
unexpected findings could indicate stroke
how does the nurse test for motor function and muscle strength?
heel to toe and strength/grip assessment
- push/pull against hand
what are signs of stroke?
sudden severe headache
unilateral weakness
expressive aphasia (slurred speech)
blurred vision
what is in the LLQ?
liver
duodenum
gallbladder
sigmoid colon
what can cause hypoactive bowel sounds?
Anesthesia
what is ascites?
fluid in the abdomen
- abdominal distention
- dilated veins
what do you call bowel sounds heard every 3 seconds?
hyperactive bowel sounds
- increased motility usually from diarrhea
should a 60 yo patient get a colonoscopy?
yes
can you perform abdomen with gown covering stomach?
no
what does percussion on the abdomen check for?
fluid
masses
dullness
With stroke patients who are immobile, what could they develop?
constipation
- very common in stroke patient
- encourage fluids, fiber, and ambulation
what procedure can be performed for decompression of late phase bowel obstruction?
NG Tube
when using the bell on the abdomen and hear low-pitched swooshing sound is called what?
Bruit
what is bruit caused by and what condition?
AAA
- abdominal aortic aneurism
(fill in the blank question - can put AAA)
what should you do if AAA is noted?
call the doctor
do not palpate
what is osteoporosis?
loss of bone mineral density
are osteoporosis patients at an increased or decreased risk of fracture?
increased
how many Americans are affected by Osteoporosis?
10 million
asking patient to stick out their tongue is testing for which CN?
CII - Hypoglossal
what is the name of CN I and its functions?
Olfactory
- sensory smell
what is the name of CN II and its functions?
Optic
- sensory sight
what is the name of CN III and its functions?
Oculomotor
- Pupils
- EOM
what is the name of CN IV and its functions?
trochlear
- EOM
what is the name of CN V and its functions?
trigeminal
- facial sensations and motors
- muscles of mastication
what is the name of CN VI and its functions?
Abducens
- EOM
what is the name of CN VII and its functions?
facial
- motor
- facial muscles
- sensory
- taste (anterior tongue)
what is the name of CN VIII and its functions?
Acoustic (vestibulocochlear)
- sensory
- hearing
what is the name of CN IX and its functions?
glossopharyngeal
- quality of voice
- swallow
- cough
- “ah”
- symmetrical rise of uvula
what is the name of CN X and its functions?
Vagus
- quality of voice
- gag reflex
- cough
- symmetrical rise of uvula
- “ah”
what is the name of CN XI and its functions?
spinal accessory
- motor
- strength
- shoulder
- neck
what is the name of CN XII and its functions?
hypoglossal
- motor
- tongue
which CN are motor?
CN III
CN IV
CN VI
CN XI
CN XII
Which CN are sensory?
CN I
CN II
CN VIII
which CN are both motor and sensory? (mixed)
CN V
CN VII
CN IX
CN X
when the nurse puts their hands on patients shoulders and ask them to shrug against resistance, what CN is the nurse testing?
CN XI - Spinal Accessory
checking for sensation on forehead, cheek, and chin is t esting which CN?
CN V - Trigeminal
Snellen Chart is used to evaluate which CN?
CN II - Optic
If noting signs of stroke, what do you need to take note of?
the time
before giving oral medications, what two CNs must be intact?
Glossopharyngeal (CN IX) and Vagus (CNX)
- to swallow
when a stroke patient cant transform thoughts into words, suspect damage to which area of the brain?
Broca’s area
how do you evaluate CN V - trigeminal?
ask client to close eyes tight
- clench teeth
- smile
- raise eyebrows
what nerve is evaluated by puffing out cheeks?
CN VII - Facial
patient with Parkinson’s comes in, when checking sensory functions, what are you looking for? How do you check for sensory function?
sense sharp from dull
hot from cold
when a patient comes in with arm or leg weakness, what should you do?
complete neurological exam
CN IX is responsible for what?
Glossopharyngeal
- tongue movement
- swallowing
- (gag reflex)
- speech sounds
- taste
student nurse luring about lobes and knows cerebral cortex contains which lobes? Select all that apply
frontal
parietal
occipital
temporal
optic
frontal
parietal
occipital
temporal
