Exam 5 Flashcards
Rosenbaum eye chart
Tests near vision
Vesicles
Tiny to small fluid filed blisters
Papules
Papules are small, raised bumps on the skin that are typically less than 1 centimeter in diameter. These skin lesions can have various causes, including inflammation, infections, or allergic reactions. Acne lesions, for example, often start as papules. The appearance and characteristics of papules can help dermatologists determine the underlying skin condition and guide appropriate treatment. If you have concerns about skin lesions, consulting with a healthcare professional is recommended for an accurate diagnosis and tailored advice.
Wheals
Wheals, also known as hives or welts, are raised, red, and often itchy skin lesions with defined borders. They are typically caused by an allergic reaction, but other factors such as stress, medications, or infections can also trigger them. Wheals can vary in size and shape and may come and go over a short period. If you’re experiencing wheals or have concerns about your skin, it’s advisable to consult with a healthcare professional for a proper evaluation and guidance on management.
Pleural friction rub
Dry, grating ,or rubbing sound as the inflamed visceral and parietal rub against during inspiration and expiration
Ronchi
Coarse , loud low pitched rumbling sounds resulting from fluid or mucus , can clear with coughing
Wheezing
High pitched whistling , musical sounds as air passes through narrow or obstructed airways
Crackles
Fine to coarse bubbly sounds
S1
Systole ( contraction ) lub sound
Place diaphragm of the stethoscope at the apex
S2
Closure of the Aortic and pulmonic valves
Diastole relaxation dub sound
Place stethoscope at the aortic area
S3 and s4
Unexpected finding using the bell of the stethoscope
Thrills
Palpable vibrations
Bruits
Blowing or swooshing sounds
Left sided heart failure
About 75% of patients with left sided heart failure complain of exertional dyspnea (Camm & Camm, 2016). Patients who feel short of breath while sleeping in the supine position may be more comfortable if they use two pillows to elevate their upper body.
Edema
Cardiovascular assessment
Supine , head of bed at 30 degrees
A. P. E. T. M.
the five landmarks
Scoliosis
Abnormal sideways curvature of the spine
Kyphosis
Outward curvature of the spine
Lordosis
Inward curvature of the spine
Ankylosis
Stiffening or immobility of a joint due to fusion of bones
Normal abnormal lymph nodes
Normal:
1. Size: Normal lymph nodes are usually small, soft, and not easily palpable. 2. Mobility: They are typically mobile and can move easily beneath the skin. 3. Tenderness: Healthy lymph nodes are usually non-tender or only mildly tender when palpated. 4. Consistency: Normal nodes are usually soft and rubbery.
Not Normal (Potential Signs of Concern):
1. Enlargement: Significant enlargement of lymph nodes may indicate infection, inflammation, or other underlying issues. 2. Hardness: Hard or fixed lymph nodes may be a cause for concern and could be associated with more serious conditions, such as cancer. 3. Pain: Persistent or severe pain in the lymph nodes might be indicative of an underlying issue. 4. Warmth and Redness: Inflammation of the lymph nodes may lead to warmth and redness in the surrounding area.
Resonance for lungs
Normal Lung Resonance:
1. Loudness: Resonant sounds are relatively loud and low-pitched. 2. Duration: The sound is prolonged, continuing for a longer duration. 3. Quality: It has a hollow, drum-like quality.
Abnormal Findings:
1. Dullness: If an area of the lung is not filled with air, such as in pneumonia or lung consolidation, the sound may be dull. 2. Hyperresonance: In conditions like pneumothorax, where there is an abnormal accumulation of air in the pleural space, the resonance may be hyperresonant.
Tuning fork
Medical Uses:
1. Rinne Test: Compares air and bone conduction of sound to evaluate hearing loss. 2. Weber Test: Assesses hearing by determining if sound lateralizes to one ear or the other. 3. Vibratory Sensation Test: Evaluates vibratory sensation in neurological exams, such as testing for peripheral neuropathy.
Tuning forks are struck against a surface to produce vibrations, and the vibrating fork is then applied to specific points on the body or near the ears to assess various aspects of hearing and sensation. These tests are often part of a comprehensive examination conducted by healthcare professionals.
ABCDE for melanoma
The ABCDE rule is a helpful guide for assessing potential signs of melanoma, a type of skin cancer. It stands for:
- A - Asymmetry: One half of the mole or lesion doesn’t match the other half.
- B - Border Irregularity: The edges of the mole are notched, irregular, or blurred.
- C - Color: The color is not uniform; there may be different shades of brown or black, or even red, white, or blue.
- D - Diameter: The size of the mole is larger than 6 millimeters (about the size of a pencil eraser).
- E - Evolution: Changes in the mole over time, such as growth, changes in color, or changes in shape.
Regular self-exams and periodic skin checks by a healthcare professional are crucial for early detection of melanoma and other skin cancers. If you notice any concerning changes in your moles or skin, it’s important to consult with a dermatologist for further evaluation.
When performing an abdominal assessment and percussing the abdomen, the nurse should instruct the client to:
Empty the Bladder:
• A full bladder can interfere with the accuracy of abdominal assessment, especially during percussion. Therefore, the nurse may ask the client to empty their bladder before the examination.
2. Assume a Supine Position:
• Instruct the client to lie down on their back with knees bent. This position relaxes the abdominal muscles, making it easier to assess for distension, masses, or tenderness.
3. Remain Relaxed:
• Advise the client to keep their abdominal muscles relaxed during the examination. Tensing the muscles can make it challenging to assess for tenderness or palpate organs properly.
4. Breathe Normally:
• Instruct the client to breathe normally throughout the assessment. This helps in assessing diaphragmatic movement during percussion and palpation.
5. Avoid Sudden Movements:
• Ask the client to avoid sudden movements or deep breathing during palpation or percussion to enhance accuracy.
6. Provide Clear Instructions:
• Clearly explain the purpose of the assessment and any steps the client needs to follow. This helps alleviate anxiety and promotes cooperation.
Chancre sore
Painless sore primary stage of syphilis
Anal fissure
Small tear or cut
Anal fissure
Small tear or cut
Cranial nerve II optic
Sight from the eyes to the brain
Cranial nerve III oculomotor
Movement of eyes eyelids pupils
Cranial nerve IV four trochlear
Moving eyeBALLS
Cranial nerve 5 V trigeminal
Moving facial muscles , jaw
Glossyopharngeal IX Nine
Swallowing , taste
Cranial nerve 10 X vagus
Peripheral nervous system
Rhonchi
Mucus moving in the larger airways
Snoring , low quality
Left lung
Consist of two lobes
Eye movement cranial nerve
IV trochlear nerve
Vesicular breath sounds are
Normal !
Blood pressure is the highest at
Systole
Crackles
Abnormal wet sounds
Orthopnea
SOB occurs while laying down
Murphys test
Abdomen gallbladder inflammation
Pallor
Mucous membranes