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Nurs 220 - Holistic Assessment > Exam 5 > Flashcards

Exam 5 Flashcards

1
Q

What is the Tail of Spence and what is it most commonly known for?

A

Superior lateral corner of breast tissue, extends into axilla.
Most commonly known for breast cancer

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2
Q

Glandular tissue in the breast are lobules that contain clusters of…

A

alveoli that produce milk

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3
Q

Fibrous tissue of the breast consists of…

A

suspensory ligaments - fibrous bands extending vertically from the surface to attach on the chest wall

  • this supports the breast
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4
Q

crusting on the nipple relates to what?

A

Paget’s disease

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5
Q

What type of nerve is in the anal canal?

A

the somatic sensory nerve (sensitive to pain)

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6
Q

What is the lowest portion of the large intestine

A

rectum

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7
Q

Rectum contains what 3 things

A
  • columns of morgagni
  • visceral nerves
  • anal crypts
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8
Q

what issues can a female patient feel or find in the vagina?

A
  • pain
  • itching
  • lesions
  • discharge
  • lumps, swelling, masses
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9
Q

vascular lesions in the anal region are…

A

hemorrhoids

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10
Q

low stream or difficulty urinating can be a sign of…

A

blockage

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11
Q

when patient starts to urinate more frequently, that can be a sign of what?

A

infection

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12
Q

pain with urination is called

A

dysuria

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13
Q

urge incontinence is what?

A

cant hold urine beyond a certain point aka sister Ann)

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14
Q

what is stress incontinence

A

when patient sneezes and coughs and urin comes out

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15
Q

an overuse of laxatives can contribute to what?

A

constipation!!!

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16
Q

fecal incontinence is usually associated with what?

A

GI infection

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17
Q

black stools can a sign of what 2 things?

A

GI bleed or IRON SUPPLEMENTS

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18
Q

FRANK BLOOD MEANS

A

red blood

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19
Q

clay stool means

A

low bile pigment, related to cholecystitis

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20
Q

mucus in stool related to diarrhea can be what?

A

GI infection

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21
Q

greasy or fatty stool that floats can be an issue with what?
and is related to what?

A

fat absoprtion; related to pancreatitis

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22
Q

when do you diagnose Menopause?

A

absense of menses for 12 mnths; between ages of 40-58

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23
Q

menopause before age 30 is called

A

premature menopause

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24
Q

menopause between the ages of 31-40 is called

A

early menopause

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25
Q

stopping menopause due to surgery removal of ovaries is called

A

artifical menopause

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26
Q

increased incidence in vaginal yeast infections happen to people with

A

diabetes

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27
Q

what supplement does not replace screen for a colonoscopy?

A

calcium supplements

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28
Q

what is lithotomy?

A

female patient gets into position with legs open on the table before looking into vagina

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29
Q

When palpating the external genitalia of the female, what are we palpating? (PUBI)

A
  • perineum
  • urethra
  • bartholin’s glands
  • inguinal lymph nodes
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30
Q

Internal female genitalia:
- color?
- position?
- Size?
-

A

color - pink, even
after pregnancy - blue
position -

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31
Q

how does cervix look before and after birth?
Whatis the SPECIFIC term for after?

A

before: open hole, like a donut
after: closed hole (KAGEL)

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32
Q

A blue cervix is called what sign?

A

chadwicks sign

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33
Q

blue cervix is a sign of what?

A

venous congestion

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34
Q

slight pale cervix is a for patients who are…

A

post menopause

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35
Q

red cervix or patches of white or strawberry spots is a sign of

A

infection or inflammation

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36
Q

what is goodall sign

A

when cervix feels soft at 5-6 weeks; shows that patient is pregnant

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37
Q

what does pap smear screen for?

A

cervical cancer

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38
Q

what does pap smear not scan for

A

endometrial or ovarian cancer

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39
Q

taking iron supplemtns can contribute to what type of stools? and what type of bowel movment difficulty?

A

tarry stool; constipation

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40
Q

lower part of uterus will begin to soften DURING pregnancy which is called?

A

Hagar sign

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41
Q

bulbourethral glands also know as…

A

Cowper’s glands

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42
Q

swelling in the scrotum can be a sign of…

A

scrotal hernia or testicular tumor

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43
Q

what is not expected in kids when it comes to rectal area

A

hemorrhoids

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44
Q

kidney inflammation may also cause what to be in urine?

A

blood (hematuria)

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45
Q

colonoscopy is done every…

A

10 years after 50 yrs old

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46
Q

flex sig is done every…

A

5 years after 50

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47
Q

we ask patients about how many sexual partners they have because they are at risk for…

A

getting STI’s

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48
Q

fiber can decrease the risk of what cancer?

A

colon cancer

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49
Q

how often do we perform a testicular self examination?

A

once a month; in the shower

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50
Q

erection during an exam is normal or not

A

normal when penis is touched

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51
Q

what is hipospadius

A

birth defect where opening of the urethra is not located at the tip of the penis: just below the end of the penis

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52
Q

What is epispadius

A

urethra opening of the penis is slightly above; on the dorsal surface

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53
Q

when foreskin cannot be pulled all the way back

A

phimosis

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54
Q

when foreskin cannot return to its resting position?

A

paraphimosis

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55
Q

yellow discharge is

A

gonorrhea

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56
Q

clear white discharge is

A

urethritis

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57
Q

wrinkles on scrotum is called

A

ruggae

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58
Q

when scrotal sac appears large

A

hydro seal

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59
Q

anything felt on the testes without pain is an indicator of what?

A

cancer

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60
Q

translumination is…

A

see something in your scrotum when you shine a light through your sack in the dark

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61
Q

“bear down” is when we check for a…

A

hernia

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62
Q

if testes are not descended that is called

A

cryptorchidsm

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63
Q

know the tanner stagers for genital and pubic hair changes in boys (ON EXAM)

A

find in the pearson etextbook

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64
Q

when planning assessment of genital area, make sure it is …

A

right after abdominal exam

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65
Q

what type of patients can experience urethral strictures?

A

phalloplasty patients

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66
Q

what action in transgender women may result in acute or chronic complications?

A

TUCKING the penis between the legs

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67
Q

transgender women are at risk for…

A

Prostate and testicular cancer

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68
Q

what is elimination

A

the excretion of waste products
this includes waste through:
- skin, kidney, lungs, and intestines

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69
Q

what is bowel elimination?

A

the passage of stool through the intestinal tract and the dispelling of the stools through intestinal muscle contraction

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70
Q

function of GI tract

A

move, breakdown, and absorbs nutrients
- synthesize nutrients
- collects waste

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71
Q

higher physical movement equals…

A

faster GI motility

72
Q

what impacts bowel elimination

A
  • Fiber diet
  • Fluid intake
  • Physical movement
  • Defecation habits: do they go right away or hold it
  • Laxatives
73
Q

What is metabolism?

A

the sum of all the physical and chemical processes by which living organized substance is produced and maintained then used by organs.

74
Q

When doing abdominal assessment, what Data related to history do we look for?

A
  • Appetite: change, wt loss/ gain, anorexia
  • Dysphagia: solids, liquids
  • Food intolerance: lactase deficiency, pyrosis, eructation
  • Pain: point to it!
  • NV: color, amount, hematemesis
75
Q

What is visceral pain?

A

internal organ - dull, poorly localized

76
Q

What is parietal pain?

A

inflammation peritoneum - sharp, localized, increased with movement

77
Q

what is referred pain?

A

disorder in another site

78
Q

we want to know patients family diet bc

A

that diet will directly reflect the patient’s diet

79
Q

smoking and alcohol can increase the risk of developing what disease in the stomach?

A

peptic ulcer disease

80
Q

black and tarry stool typically shows….

typically stickier if its from a…

A

iron supplements or GI bleed
- GI bleed

81
Q

non tarry black stool is typically from

A

iron medication

82
Q

an issue with bile can show what color stool?

A

Gray stool

83
Q

what is an ulcer a break down of?

A

a break down of tissues

84
Q

What increases risk of a peptic ulcer?
loss of…
excessive secretion of…
what type of drugs?
what bacteria?

A

loss of mucous membrane in stomach
- excessive secretion of gastric acid
- NSAIDS
- H. Pylori

85
Q

NSAIDS stand for…

A

non steroidal anti-inflammatory drugs

86
Q

what are some risk factors for PUD (what they do or have that increases risk?)

A

H. Pylori presence
- excessive alcohol intake
- regular use of NSAIDs

87
Q

risk factors for GERD

A
  • obesity
  • hiatal hernia
  • pregnancy
  • smoking
  • dry mouth
  • asthma
  • diabetes
  • delayed stomach emptying
  • alcohol consumption
88
Q

purpleish discoloration at the flanks is called what sign?

A

gray turner sign

89
Q

bluish-purpleish discoloration of the belly button shows what?
whatis this sign called?

A

intraabdominal bleeding aka the colon sign

90
Q

if you see a sign of an abdominal aortic aneurysm, do you keep palpating

A

NO! Stop and get a consultant immediately

91
Q

borborygmus

A

increased gi motility

92
Q

avg bowel sounds per minute

A

5-30 per minute

93
Q

if you here absent bowel sounds, how long do you listen for?

A

5 minutes

94
Q

tympany, what is it

A

predominates - air rises to surface when supine

95
Q

dullness in abdominal quadrants may be what?

A

distended bladder, adipose, mass or fluid

96
Q

hyper resonance means

A

excessive gas

97
Q

when we palpate, when do we palpate tenderness?

A

at the end of the assessment

98
Q

What are the tests for appendicitis?

A
  • rebound tenderness
  • psoas sign - hyperextend the leg
  • obturator sign- flexing the leg
  • perform hypersensitivity test: stroke abdomen with a sharp object
99
Q

what are the 4 tests for cholecystitis?

A
  • RUQ pain/tenderness
  • Murphy sign: pain when pressure is put on liver border and pain upon inhalation
100
Q

Rovsing sign

A

pain in the RLQ during pressure in the LLQ

100
Q

Blumberg sign

A

rebound tenderness test halfway between the umbilicus an the anterior iliac crest

101
Q

Symptoms of hypoglycemia

A

trembling
- dizziness
- sweating
- mood changes
- hunger
- headaches

102
Q

symptoms of hyperglycemia

A
  • extreme thirst
  • dry mouth
  • frequent urination
  • drowsiness
  • bed wetting
  • stomach pain
103
Q

babies get introduced solid foods at…

A

6 months old

104
Q

What is gravida

A

total # of confirmed pregnancies

105
Q

What is Para

A

total # of pregnancies carried past 20 weeks

106
Q

is ibuprofen an NSAID

A

YES!

107
Q

expected sounds with percussion of the abdomen

A

Tympany - a loud, hollow sound
Dullness - heard over organs
+ if in LLQ, can be stool

108
Q

Hyperreactive bowel sounds occur when patient…

A

has an infection or diarrhea

109
Q

Hypoactive bowel sounds occur when a patient

A

after abdominal surgery or a bowel obstruction

110
Q

Absent bowel sounds indicates…

A

paralytic ileus and should be listened to for 3-5 min

111
Q

how does an abdominal aortic aneurysm present

A

check pulsations or lifts

112
Q

reasons for abdominal distention

reasons for lower midline abdominal distention?

A
  • gas
  • obesity
  • bladder distention or ovarian mass
113
Q

What type of ab distention is seen with ascites and/or tumors?

A

General distention + inverted umbilicus

114
Q

Bloating may occur with what?

A
  • bowel obstruction
  • Diverticulitis
115
Q

reason pregnant women have abdominal distention and what else comes with it?

A

fetus growing and then have striae and linea nigra

116
Q

do infants and toddlers have normally distended abs?

A

YES

117
Q

What is Striae

A
  • white or silver-colored stretch marks seen in obesity
118
Q

spider angiomas are seen correlated with what disease

A

liver disease

119
Q

cullen sign?

A

sing of bleeding through bruising around the umbilicus

120
Q

what is the order of assessment for the abdominal

A

inspection, palpation, percussion, and auscultation

121
Q

if patient is too ticklish for abdomen assessment then you should…

A

place pillow under patients knees

122
Q

bowel sounds in a newborn should be audible every….

A

10-30 seconds

123
Q

how to know how many weeks a fundus has been present in a pregnant lady?

A

distance of funds from the pubic symphysis correlates with the number of weeks that the pt is pregnant

124
Q

holding in urine can contribute to developing a

A

UTI

125
Q

risk factors for cervical cancer

A
  • Smoking
  • STI (HPV, chlamydia)
  • Sexual Hx
126
Q

what is pseudomenorrhea

A

first week infant born has blood-tinged mucus coming from vagina - normal!!

127
Q

Orchitis

A

inflamed 1 or both testicles

128
Q

GU and rectal exams are done at what point in the assessment

A

at the end of the exam

129
Q

how do you assess retraction and dimpling in a female patient?

A

Raise the arms above the head.

Push the hands together, with elbows flexed (2).

Press the hands down on the hips

130
Q

risk factors for breast cancer

A
  • family hx of it
  • genetics
  • age
  • obesity
  • never pregnant
  • alcohol
  • hormonal therapy
131
Q

the 5 stages of breast development

A

Female breast development begins between 8 and 13 years of age and occurs in five stages (Tanner stages).

Stage 1: Prepubertal with no noticeable change

Stage 2: Breast bud with elevation of nipple and enlargement of the areola

Stage 3: Enlargement of the breast and areola with no separation of contour

Stage 4: Projection of the areola and nipple

Stage 5: Recession of the areola by about age 14 or 15, leaving only the nipple projecting.

132
Q

if popliteal pulse cannot be pulsated, what do we do?

A

pulsate dorsal to get better idea of circulation

133
Q

symptoms of menopause

A
  • dyspareunia - less vaginal lubrication
  • fractures
  • hot flashes
  • mood swings
  • UTI
  • yeast infections
134
Q

if pediatric patient has hemorrhoids, thats a sign of

A

Chronic Liver Disease

135
Q

What does CVA stand for and what is it checked for?

A
  • costovertebral angle
  • kidney inflammation, tenderness, or kidney stones
136
Q

mastoiditis, what is it and what can it be a result from?

A

inflammation of the mastoid (behind the ear)
- results from an acute otitis media infection

137
Q

what is tinnitus

A

hearing sounds/noises not made from outside environment

138
Q

why are children more susceptible to ear infections?

A

shorter and horizontal ear drainage

139
Q

what changes in hearing can occur with age?

A
  • gradual loss of hearing
  • cerebrum build up
  • high frequency hearing loss
  • tinnitus
140
Q

what causes nasal congestion in pregnancy?
what hormone?

A
  • Inc. blood flow and dilation of nasal veins
  • Human Growth Hormone (HGH)
141
Q

stridor

A

high-pitched sound within the trachea and larynx
- this suggests narrowing of tracheal passage

142
Q

crackles

A

high-pitched popping sound during inhalation
- (milk poured over cereal)

143
Q

atelectasis

A

collapsed lung

144
Q

rhonchi

A

coarse low-pitched that continues throughout inspiration
- indicates blockage of large airway passage

145
Q

pleural friction rub

A

pleural inflammation
- low-pitched, crackling sound is typically present during both ins/expiration

146
Q

if you hear adventitious sounds, waht do you have the patient do?

A

cough and re-evaluate

147
Q

Vaccines related to respiratory

A
  • pneumonia
  • flu
148
Q

chest pain coldspa questions

A

most important
C, O, and D (to see if it is musculoskeletal, resp, digestive, or cardio related)
- chest sorenes (musculoskeletal)
- burning: digestive
- dull; ache (worse when you breathe): respiratory
- vice-like: cardio

149
Q

otalgia means what

A

earache

150
Q

presbycusis

A

age-related hearing loss
- happens gradually

151
Q

what are the changes that occur as we age for seeing

A

decrease in visual activities
- higher chance of glaucoma
- Decreased tear production: eyes feel dry; burning
- loss of peripheral vision, aching pain

152
Q

presbyopia

A

near vision loss bc of lens hardening

153
Q

3 main causes of decreased visual functioning

A
  • cataract formation - lens opacity
  • glaucoma - inc. ocular pressure
  • macular degeneration- loss of central vision
154
Q

what type of issue is acrocyanosis

A

a thermoregulation issue

155
Q

what suggests sinusitis during examination?

A

pain or tenderness upon palpitation
- can be with symptoms of fever or rhinorrhea

156
Q

HEALTH PROMOTION OPPORTUNITY:
Ways to reduce risk of pressure ulcers

A
  • Inspect the skin daily and more often (Braden scale or PUSH tool)
  • Bathe with mild soap or other agent ; limit friction; use warm, not hot, water; set bath schedule that is individualized
  • Moisturize skin and maintain hydration levels
157
Q

ASSESS FOR PRESSURE ULCER
RISK FACTORS: Braden scale assess for what 6 things?

A
  • perception
  • mobility
  • moisture
  • nutrition
  • friction or shear aginst surfaces
  • Tissue tolerance decreased
158
Q

the braden scale: Sensory 1-4

A

1- completely limited: unresponsive to pain
2- very limited: responds only to painful stimuli, cannot verbalize
3- slightly limited: responds to verbal commands but cannot always communicate discomfort
4- no impairment: responds and can voice pain

159
Q

when do you assess the patients gait?

A

when patient walks into the room

160
Q

Muscle test grading 0-5 Rating

A

0 - no muscular contraction: Paralysis

1 - Slight flicker of contraction
Strength Classification: Severe weakness

2 - Passive ROM (gravity removed and assisted by the examiner)
Strength Classification: Poor ROM

3 - Active motion against gravity
Strength Classification: Average weakness

4 - Active motion against some resistance Strength Classification: Slight weakness

5 - Active motion against full resistance Strength Classification: Normal

161
Q

what the test called that tests for carpal tunnel syndrome?
what makes the test positive?

A

Phalen test
tingling or numbness when back of both hands are touching

162
Q

What are the 7 musculoskeletal movements of the body?

A

Flexion
Extension

Abduction
Adduction

Pronation
Supination

Inversion
Eversion

Protraction
Retraction

Elevation
Depression

Circumduction
Rotation

163
Q

what is general survey?

A

the first impression of the patient that you obtain from observing them

164
Q

difference between nursing and medical assessment

A

medical: focuses on the disease process; done by a physician

nurse: holistic in approach, includes signs and symptoms

165
Q

what is holistic assessment?
(it encompasses…)

A

it encompasses mind body and spirit

166
Q

how may a client appear anxious?

A
  • Fidgeting
  • Sweating
  • shaking
  • Pacing
  • Blushing
  • Biting fingernails
167
Q

how to adjust nursing interview to a client with various emotional states

A
  • express empathy
  • dont judge
  • reflective listening
  • rephrase client comments to convey active listening
168
Q

who is the family of a patient?

A

whoever the patient says they are?
- can be bloodline or friends

169
Q

if there is a discrepancy in the family assessment, what does the nurse do?

A

document it!!!!

170
Q

FLACC pain scale is used for what ages and what does it stand for?

A

face, legs, activity, cry, and consolability
ages 2 months - 7 yrs old

171
Q

The face pain scale is used at what ages?

A

3-18 years old

172
Q

what do we need to assess first before we assess a patients mental status?

A

the individual’s sensory abilities

173
Q

componentsof ROS (subjective data

A

all parts of head-to-toe
overall health
- skin
- hair
- eyes
- ears
- nose and sinuses
- mouth/throats
- neck
- breast
- axilla
- resp, cardio, urinary system
- peripheral vascular

174
Q

when interviewing older adults, what do we have to remember when considering developmental stages

A

older adults may take longer to process information

175
Q

what are the 9 components of health history

A
  • biological data
  • the source of history
  • the reason for seeking care
  • present health or history of present illness
  • Past health
  • Family history
  • ROS
  • Lifestyle and health practices
  • developmental level

Nurs 220 - Holistic Assessment (5 decks)

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