Exam 5

Question 1

Rosenbaum eye chart

Answer 1

Tests near vision

Question 2

Vesicles

Answer 2

Tiny to small fluid filed blisters

Question 3

Papules

Answer 3

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.

Question 4

Wheals

Answer 4

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.

Question 5

Pleural friction rub

Answer 5

Dry, grating ,or rubbing sound as the inflamed visceral and parietal rub against during inspiration and expiration

Question 6

Ronchi

Answer 6

Coarse , loud low pitched rumbling sounds resulting from fluid or mucus , can clear with coughing

Question 7

Wheezing

Answer 7

High pitched whistling , musical sounds as air passes through narrow or obstructed airways

Question 8

Crackles

Answer 8

Fine to coarse bubbly sounds

Question 9

S1

Answer 9

Systole ( contraction ) lub sound
Place diaphragm of the stethoscope at the apex

Question 10

S2

Answer 10

Closure of the Aortic and pulmonic valves
Diastole relaxation dub sound
Place stethoscope at the aortic area

Question 11

S3 and s4

Answer 11

Unexpected finding using the bell of the stethoscope

Question 12

Thrills

Answer 12

Palpable vibrations

Question 13

Bruits

Answer 13

Blowing or swooshing sounds

Question 14

Left sided heart failure

Answer 14

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

Question 15

Cardiovascular assessment

Answer 15

Supine , head of bed at 30 degrees

A. P. E. T. M.
the five landmarks

Question 16

Scoliosis

Answer 16

Abnormal sideways curvature of the spine

Question 17

Kyphosis

Answer 17

Outward curvature of the spine

Question 18

Lordosis

Answer 18

Inward curvature of the spine

Question 19

Ankylosis

Answer 19

Stiffening or immobility of a joint due to fusion of bones

Question 20

Normal abnormal lymph nodes

Answer 20

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.

Question 21

Resonance for lungs

Answer 21

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.

Question 22

Tuning fork

Answer 22

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.

Question 23

ABCDE for melanoma

Answer 23

The ABCDE rule is a helpful guide for assessing potential signs of melanoma, a type of skin cancer. It stands for:

1. A - Asymmetry: One half of the mole or lesion doesn’t match the other half.
2. B - Border Irregularity: The edges of the mole are notched, irregular, or blurred.
3. C - Color: The color is not uniform; there may be different shades of brown or black, or even red, white, or blue.
4. D - Diameter: The size of the mole is larger than 6 millimeters (about the size of a pencil eraser).
5. 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.

Question 24

When performing an abdominal assessment and percussing the abdomen, the nurse should instruct the client to:

Answer 24

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.

Question 25

Chancre sore

Answer 25

Painless sore primary stage of syphilis

Question 26

Anal fissure

Answer 26

Small tear or cut

Question 27

Anal fissure

Answer 27

Small tear or cut

Question 28

Cranial nerve II optic

Answer 28

Sight from the eyes to the brain

Question 29

Cranial nerve III oculomotor

Answer 29

Movement of eyes eyelids pupils

Question 30

Cranial nerve IV four trochlear

Answer 30

Moving eyeBALLS

Question 31

Cranial nerve 5 V trigeminal

Answer 31

Moving facial muscles , jaw

Question 32

Glossyopharngeal IX Nine

Answer 32

Swallowing , taste

Question 33

Cranial nerve 10 X vagus

Answer 33

Peripheral nervous system

Question 34

Rhonchi

Answer 34

Mucus moving in the larger airways
Snoring , low quality

Question 35

Left lung

Answer 35

Consist of two lobes

Question 36

Eye movement cranial nerve

Answer 36

IV trochlear nerve

Question 37

Vesicular breath sounds are

Answer 37

Normal !

Question 38

Blood pressure is the highest at

Answer 38

Systole

Question 39

Crackles

Answer 39

Abnormal wet sounds

Question 40

Orthopnea

Answer 40

SOB occurs while laying down

Question 41

Murphys test

Answer 41

Abdomen gallbladder inflammation

Question 42

Pallor

Answer 42

Mucous membranes