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
2
Q
Glandular tissue in the breast are lobules that contain clusters of…
A
alveoli that produce milk
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
4
Q
crusting on the nipple relates to what?
A
Paget’s disease
5
Q
What type of nerve is in the anal canal?
A
the somatic sensory nerve (sensitive to pain)
6
Q
What is the lowest portion of the large intestine
A
rectum
7
Q
Rectum contains what 3 things
A
- columns of morgagni
- visceral nerves
- anal crypts
8
Q
what issues can a female patient feel or find in the vagina?
A
- pain
- itching
- lesions
- discharge
- lumps, swelling, masses
9
Q
vascular lesions in the anal region are…
A
hemorrhoids
10
Q
low stream or difficulty urinating can be a sign of…
A
blockage
11
Q
when patient starts to urinate more frequently, that can be a sign of what?
A
infection
12
Q
pain with urination is called
A
dysuria
13
Q
urge incontinence is what?
A
cant hold urine beyond a certain point aka sister Ann)
14
Q
what is stress incontinence
A
when patient sneezes and coughs and urin comes out
15
Q
an overuse of laxatives can contribute to what?
A
constipation!!!
16
Q
fecal incontinence is usually associated with what?
A
GI infection
17
Q
black stools can a sign of what 2 things?
A
GI bleed or IRON SUPPLEMENTS
18
Q
FRANK BLOOD MEANS
A
red blood
19
Q
clay stool means
A
low bile pigment, related to cholecystitis
20
Q
mucus in stool related to diarrhea can be what?
A
GI infection
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
22
Q
when do you diagnose Menopause?
A
absense of menses for 12 mnths; between ages of 40-58
23
Q
menopause before age 30 is called
A
premature menopause
24
Q
menopause between the ages of 31-40 is called
A
early menopause
25
stopping menopause due to surgery removal of ovaries is called
artifical menopause
26
increased incidence in vaginal yeast infections happen to people with
diabetes
27
what supplement does not replace screen for a colonoscopy?
calcium supplements
28
what is lithotomy?
female patient gets into position with legs open on the table before looking into vagina
29
When palpating the external genitalia of the female, what are we palpating? (PUBI)
- perineum
- urethra
- bartholin's glands
- inguinal lymph nodes
30
Internal female genitalia:
- color?
- position?
- Size?
-
color - pink, even
after pregnancy - blue
position -
31
how does cervix look before and after birth?
Whatis the SPECIFIC term for after?
before: open hole, like a donut
after: closed hole (KAGEL)
32
A blue cervix is called what sign?
chadwicks sign
33
blue cervix is a sign of what?
venous congestion
34
slight pale cervix is a for patients who are...
post menopause
35
red cervix or patches of white or strawberry spots is a sign of
infection or inflammation
36
what is goodall sign
when cervix feels soft at 5-6 weeks; shows that patient is pregnant
37
what does pap smear screen for?
cervical cancer
38
what does pap smear not scan for
endometrial or ovarian cancer
39
taking iron supplemtns can contribute to what type of stools? and what type of bowel movment difficulty?
tarry stool; constipation
40
lower part of uterus will begin to soften DURING pregnancy which is called?
Hagar sign
41
bulbourethral glands also know as...
Cowper's glands
42
swelling in the scrotum can be a sign of...
scrotal hernia or testicular tumor
43
what is not expected in kids when it comes to rectal area
hemorrhoids
44
kidney inflammation may also cause what to be in urine?
blood (hematuria)
45
colonoscopy is done every...
10 years after 50 yrs old
46
flex sig is done every...
5 years after 50
47
we ask patients about how many sexual partners they have because they are at risk for...
getting STI's
48
fiber can decrease the risk of what cancer?
colon cancer
49
how often do we perform a testicular self examination?
once a month; in the shower
50
erection during an exam is normal or not
normal when penis is touched
51
what is hipospadius
birth defect where opening of the urethra is not located at the tip of the penis: just below the end of the penis
52
What is epispadius
urethra opening of the penis is slightly above; on the dorsal surface
53
when foreskin cannot be pulled all the way back
phimosis
54
when foreskin cannot return to its resting position?
paraphimosis
55
yellow discharge is
gonorrhea
56
clear white discharge is
urethritis
57
wrinkles on scrotum is called
ruggae
58
when scrotal sac appears large
hydro seal
59
anything felt on the testes without pain is an indicator of what?
cancer
60
translumination is...
see something in your scrotum when you shine a light through your sack in the dark
61
"bear down" is when we check for a...
hernia
62
if testes are not descended that is called
cryptorchidsm
63
know the tanner stagers for genital and pubic hair changes in boys (ON EXAM)
find in the pearson etextbook
64
when planning assessment of genital area, make sure it is ...
right after abdominal exam
65
what type of patients can experience urethral strictures?
phalloplasty patients
66
what action in transgender women may result in acute or chronic complications?
TUCKING the penis between the legs
67
transgender women are at risk for...
Prostate and testicular cancer
68
what is elimination
the excretion of waste products
this includes waste through:
- skin, kidney, lungs, and intestines
69
what is bowel elimination?
the passage of stool through the intestinal tract and the dispelling of the stools through intestinal muscle contraction
70
function of GI tract
move, breakdown, and absorbs nutrients
- synthesize nutrients
- collects waste
71
higher physical movement equals...
faster GI motility
72
what impacts bowel elimination
- Fiber diet
- Fluid intake
- Physical movement
- Defecation habits: do they go right away or hold it
- Laxatives
73
What is metabolism?
the sum of all the physical and chemical processes by which living organized substance is produced and maintained then used by organs.
74
When doing abdominal assessment, what Data related to history do we look for?
- Appetite: change, wt loss/ gain, anorexia
- Dysphagia: solids, liquids
- Food intolerance: lactase deficiency, pyrosis, eructation
- Pain: point to it!
- NV: color, amount, hematemesis
75
What is visceral pain?
internal organ - dull, poorly localized
76
What is parietal pain?
inflammation peritoneum - sharp, localized, increased with movement
77
what is referred pain?
disorder in another site
78
we want to know patients family diet bc
that diet will directly reflect the patient's diet
79
smoking and alcohol can increase the risk of developing what disease in the stomach?
peptic ulcer disease
80
black and tarry stool typically shows....
typically stickier if its from a...
iron supplements or GI bleed
- GI bleed
81
non tarry black stool is typically from
iron medication
82
an issue with bile can show what color stool?
Gray stool
83
what is an ulcer a break down of?
a break down of tissues
84
What increases risk of a peptic ulcer?
loss of...
excessive secretion of...
what type of drugs?
what bacteria?
loss of mucous membrane in stomach
- excessive secretion of gastric acid
- NSAIDS
- H. Pylori
85
NSAIDS stand for...
non steroidal anti-inflammatory drugs
86
what are some risk factors for PUD (what they do or have that increases risk?)
H. Pylori presence
- excessive alcohol intake
- regular use of NSAIDs
87
risk factors for GERD
- obesity
- hiatal hernia
- pregnancy
- smoking
- dry mouth
- asthma
- diabetes
- delayed stomach emptying
- alcohol consumption
88
purpleish discoloration at the flanks is called what sign?
gray turner sign
89
bluish-purpleish discoloration of the belly button shows what?
whatis this sign called?
intraabdominal bleeding aka the colon sign
90
if you see a sign of an abdominal aortic aneurysm, do you keep palpating
NO! Stop and get a consultant immediately
91
borborygmus
increased gi motility
92
avg bowel sounds per minute
5-30 per minute
93
if you here absent bowel sounds, how long do you listen for?
5 minutes
94
tympany, what is it
predominates - air rises to surface when supine
95
dullness in abdominal quadrants may be what?
distended bladder, adipose, mass or fluid
96
hyper resonance means
excessive gas
97
when we palpate, when do we palpate tenderness?
at the end of the assessment
98
What are the tests for appendicitis?
- rebound tenderness
- psoas sign - hyperextend the leg
- obturator sign- flexing the leg
- perform hypersensitivity test: stroke abdomen with a sharp object
99
what are the 4 tests for cholecystitis?
- RUQ pain/tenderness
- Murphy sign: pain when pressure is put on liver border and pain upon inhalation
100
Rovsing sign
pain in the RLQ during pressure in the LLQ
100
Blumberg sign
rebound tenderness test halfway between the umbilicus an the anterior iliac crest
101
Symptoms of hypoglycemia
trembling
- dizziness
- sweating
- mood changes
- hunger
- headaches
102
symptoms of hyperglycemia
- extreme thirst
- dry mouth
- frequent urination
- drowsiness
- bed wetting
- stomach pain
103
babies get introduced solid foods at...
6 months old
104
What is gravida
total # of confirmed pregnancies
105
What is Para
total # of pregnancies carried past 20 weeks
106
is ibuprofen an NSAID
YES!
107
expected sounds with percussion of the abdomen
Tympany - a loud, hollow sound
Dullness - heard over organs
+ if in LLQ, can be stool
108
Hyperreactive bowel sounds occur when patient...
has an infection or diarrhea
109
Hypoactive bowel sounds occur when a patient
after abdominal surgery or a bowel obstruction
110
Absent bowel sounds indicates...
paralytic ileus and should be listened to for 3-5 min
111
how does an abdominal aortic aneurysm present
check pulsations or lifts
112
reasons for abdominal distention
reasons for lower midline abdominal distention?
- gas
- obesity
- bladder distention or ovarian mass
113
What type of ab distention is seen with ascites and/or tumors?
General distention + inverted umbilicus
114
Bloating may occur with what?
- bowel obstruction
- Diverticulitis
115
reason pregnant women have abdominal distention and what else comes with it?
fetus growing and then have striae and linea nigra
116
do infants and toddlers have normally distended abs?
YES
117
What is Striae
- white or silver-colored stretch marks seen in obesity
118
spider angiomas are seen correlated with what disease
liver disease
119
cullen sign?
sing of bleeding through bruising around the umbilicus
120
what is the order of assessment for the abdominal
inspection, palpation, percussion, and auscultation
121
if patient is too ticklish for abdomen assessment then you should...
place pillow under patients knees
122
bowel sounds in a newborn should be audible every....
10-30 seconds
123
how to know how many weeks a fundus has been present in a pregnant lady?
distance of funds from the pubic symphysis correlates with the number of weeks that the pt is pregnant
124
holding in urine can contribute to developing a
UTI
125
risk factors for cervical cancer
- Smoking
- STI (HPV, chlamydia)
- Sexual Hx
126
what is pseudomenorrhea
first week infant born has blood-tinged mucus coming from vagina - normal!!
127
Orchitis
inflamed 1 or both testicles
128
GU and rectal exams are done at what point in the assessment
at the end of the exam
129
how do you assess retraction and dimpling in a female patient?
Raise the arms above the head.
Push the hands together, with elbows flexed (2).
Press the hands down on the hips
130
risk factors for breast cancer
- family hx of it
- genetics
- age
- obesity
- never pregnant
- alcohol
- hormonal therapy
131
the 5 stages of breast development
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
if popliteal pulse cannot be pulsated, what do we do?
pulsate dorsal to get better idea of circulation
133
symptoms of menopause
- dyspareunia - less vaginal lubrication
- fractures
- hot flashes
- mood swings
- UTI
- yeast infections
134
if pediatric patient has hemorrhoids, thats a sign of
Chronic Liver Disease
135
What does CVA stand for and what is it checked for?
- costovertebral angle
- kidney inflammation, tenderness, or kidney stones
136
mastoiditis, what is it and what can it be a result from?
inflammation of the mastoid (behind the ear)
- results from an acute otitis media infection
137
what is tinnitus
hearing sounds/noises not made from outside environment
138
why are children more susceptible to ear infections?
shorter and horizontal ear drainage
139
what changes in hearing can occur with age?
- gradual loss of hearing
- cerebrum build up
- high frequency hearing loss
- tinnitus
140
what causes nasal congestion in pregnancy?
what hormone?
- Inc. blood flow and dilation of nasal veins
- Human Growth Hormone (HGH)
141
stridor
high-pitched sound within the trachea and larynx
- this suggests narrowing of tracheal passage
142
crackles
high-pitched popping sound during inhalation
- (milk poured over cereal)
143
atelectasis
collapsed lung
144
rhonchi
coarse low-pitched that continues throughout inspiration
- indicates blockage of large airway passage
145
pleural friction rub
pleural inflammation
- low-pitched, crackling sound is typically present during both ins/expiration
146
if you hear adventitious sounds, waht do you have the patient do?
cough and re-evaluate
147
Vaccines related to respiratory
- pneumonia
- flu
148
chest pain coldspa questions
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
otalgia means what
earache
150
presbycusis
age-related hearing loss
- happens gradually
151
what are the changes that occur as we age for seeing
decrease in visual activities
- higher chance of glaucoma
- Decreased tear production: eyes feel dry; burning
- loss of peripheral vision, aching pain
152
presbyopia
near vision loss bc of lens hardening
153
3 main causes of decreased visual functioning
- cataract formation - lens opacity
- glaucoma - inc. ocular pressure
- macular degeneration- loss of central vision
154
what type of issue is acrocyanosis
a thermoregulation issue
155
what suggests sinusitis during examination?
pain or tenderness upon palpitation
- can be with symptoms of fever or rhinorrhea
156
HEALTH PROMOTION OPPORTUNITY:
Ways to reduce risk of pressure ulcers
- 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
ASSESS FOR PRESSURE ULCER
RISK FACTORS: Braden scale assess for what 6 things?
- perception
- mobility
- moisture
- nutrition
- friction or shear aginst surfaces
- Tissue tolerance decreased
158
the braden scale: Sensory 1-4
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
when do you assess the patients gait?
when patient walks into the room
160
Muscle test grading 0-5 Rating
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
what the test called that tests for carpal tunnel syndrome?
what makes the test positive?
Phalen test
tingling or numbness when back of both hands are touching
162
What are the 7 musculoskeletal movements of the body?
Flexion
Extension
Abduction
Adduction
Pronation
Supination
Inversion
Eversion
Protraction
Retraction
Elevation
Depression
Circumduction
Rotation
163
what is general survey?
the first impression of the patient that you obtain from observing them
164
difference between nursing and medical assessment
medical: focuses on the disease process; done by a physician
nurse: holistic in approach, includes signs and symptoms
165
what is holistic assessment?
(it encompasses...)
it encompasses mind body and spirit
166
how may a client appear anxious?
- Fidgeting
- Sweating
- shaking
- Pacing
- Blushing
- Biting fingernails
167
how to adjust nursing interview to a client with various emotional states
- express empathy
- dont judge
- reflective listening
- rephrase client comments to convey active listening
168
who is the family of a patient?
whoever the patient says they are?
- can be bloodline or friends
169
if there is a discrepancy in the family assessment, what does the nurse do?
document it!!!!
170
FLACC pain scale is used for what ages and what does it stand for?
face, legs, activity, cry, and consolability
ages 2 months - 7 yrs old
171
The face pain scale is used at what ages?
3-18 years old
172
what do we need to assess first before we assess a patients mental status?
the individual's sensory abilities
173
componentsof ROS (subjective data
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
when interviewing older adults, what do we have to remember when considering developmental stages
older adults may take longer to process information
175
what are the 9 components of health history
- 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
