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NURS 190-Physical Assessment > Final Exam Concepts > Flashcards

Final Exam Concepts Flashcards

1
Q

Inspection

A

Assessment technique done initially in Physical Assessment

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2
Q

Palpation

A

Assessment technique that should be used to elicit crepitus in a patient who sustained chest injury

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3
Q

Auscultation

A

Assessment technique that should be used when listening to the heart sound

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4
Q

Percussion

A

*Use the non-dominant middle finger on the area of the body to be percussed and use the tip of the middle finger as tapper
*Assessment technique that should be used to elicit diaphragmatic excursion.

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5
Q

Indirect Percussion

A

Assessment technique that should be used to assess lung tissues or lobes of the lungs or client with full or distended bladder.

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6
Q

Direct Percussion

A

Assessment technique that should be used to assess sinus infection

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7
Q

Goniometer

A

Instrument used to assess the degree of joint flexion and extension

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8
Q

Doppler

A

Used to assess non palpable pulses

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9
Q

Wood Lamp

A

Used to assess presence of fungal infection of the skin

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10
Q

Skinfold Caliper

A

Used to assess subcutaneous thickness

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11
Q

Transilluminator

A

Used to detect blood, fluid, or masses in the body cavities

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12
Q

How do you grade pulses (0-4+)

A

0-no pulse
1+ weak and thready
2+ normal
3+ brisk
4+ bounding

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13
Q

What is the difference between a target and angular lesion?

A

Target lesions have a concentric circles of color. Erythema and Anular has just one circle lesion, like ringworm

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14
Q

What is the difference between discreet lesions and confluent lesions

A

Discreet lesions are separate and confluent lesions run together

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15
Q

What is the difference between linear lesions and grouped lesions

A

Linear lesions form a line and grouped lesions have several lesions that appear in clusters/ lesions that are together

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16
Q

Describe a wheal lesion

A

A lesion that is caused by insect bites or hives that are reddened with an irregular border

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17
Q

Describe Lichenification

A

Lesions that are rough, thickened, hardened epidermis due to constant scratching and rubbing.

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18
Q

Describe Vesicles

A

Palpable round or oval lesions with a translucent wall filled with fluids

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19
Q

Describe Atrophy

A

Translucent, dry, paper-like wrinkled skin due to loss of collagen & elastin. Common in the elderly.

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20
Q

What are the normal findings in adults regarding the lymph nodes and what assess technique is used?

A

*Adults- non-palpable
*Assessment technique-gentle, circular motions using 2-3 finger pads.

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21
Q

CNs #1

A

Olfactory-sense of smell of both nostrils

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22
Q

CNs #2

A

Optic- Snellen Test (distance) & Rosenbaum (Close)

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23
Q

CNs #3

A

Oculomotor

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24
Q

CNs #4

A

Trochlear- PERRLA & 6 Cardinal Field of Gaze

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25
Q

CNs #6

A

Abducens

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26
Q

CN #5

A

Trigeminal-Clenching of teeth, Move jaw Right to left, open and close mouth, protrude and retract jaw

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27
Q

CNs#7

A

Facial-movement of face, puff cheeks, smile, frown, raise eyebrows up & down

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28
Q

CNs #8

A

Vestibulocochlear- whisper test and Romberg’s test

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29
Q

CNs #9

A

Glossopharyngeal- swallowing and gag reflex

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30
Q

CNs #10

A

Vagus- Swallowing and phonation

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31
Q

CNs #11

A

Accessory- shoulders up and down with- without resistance

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32
Q

CNs #12

A

Hypoglossal- movement of tongue, up and down, right to left

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33
Q

What is a venous lake

A

Soft lesion on the lips or neck that is elevated, dark blue and compressible. Common seen in the elderly.

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34
Q

What is a port wine stain?

A

*Flat, irregularly shaped, pale red to deep purple red.
* Color deepens in response to exertion, crying, emotional response or exposure to extreme temperature.
* Present at birth and typically does not fade.

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35
Q

What is hemangioma

A

A bright red raised lesion, does not blanch with pressure, present at birth or few months after birth, typically disappear at age 10.

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36
Q

What is spider angioma

A

A flat bright red dot with tiny radiating blood vessels ranging from pinpoint to 2 cm, will blanche with pressure.

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37
Q

Differentiate the 3 types of abdominal palpation

A
  • Light palpation-use finger pads of one hand-1/2 to 1 cm use for patient with abdominal pain, assess skin texture, & inflamed area
  • Moderate palpation finger pads 2-3 cm- use to determine the depth, size, shape, consistency and mobility of organs as well as pain, tenderness or pulsation
    *Deep Palpation- use palmar surface of the hands bimanually - 4- 5 cm- caution must be used. It is used to assess organs that lie deep within the body such as liver, spleen or kidneys
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38
Q

When a client suddenly refused your examination. What should you do as a nurse?

A

Document what was done and what was refused

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39
Q

What question should you ask a client when you suspect Lyme DIsease?

A

Have you been hiking recently?

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40
Q

What is the indication of an open sore in the has that has not healed for several months?

A

The indication is the client may have malignancy or skin cancer.

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41
Q

A client with nystagmus will demonstrate?

A

Jerky eye movements during the 6 cardinal field of gaze

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42
Q

Normal Consensual response?

A

Illuminated eye, pupil will constrict faster than the other eye but the other eye pupil will constrict sluggishly

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43
Q

Describe the Weber Test

A

*Normal findings- equal lateralization of vibration to the right and left ear
*Patient with impacted cerumen of the right ear- sounds lateralization will go to the right ear with cerumen

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44
Q

Normal Rinne test findings

A

Air conduction is 2X greater than bone conduction

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45
Q

When sinuses are filled with fluid…?

A

They will not transilluminate, red glow is absent.

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46
Q

What is craniosynostosis?

A

A condition when infants have elongated head and face and orbits of eyes are altered

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47
Q

What is hydrocephalus

A

A condition when infants have enlarged head with visible scalp veins due to accumulation of on non-draining (cerebrospinal fluid).

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48
Q

What is presbyopia?

A

Older adult clients (>45 Y/O), report difficulty with near vision

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49
Q

What is hyperopia?

A

Young adults with difficulty with near vision

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50
Q

What is myopia

A

Difficulty with far vision

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51
Q

When a nurse is triaging patients in Ophthalmology clinic the patient that requires immediate attention will be the client with…

A

… acute Glaucoma because increase pressure in the eyes that can lead to blindness

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52
Q

Describe Otitis Externa

A

An infection of the outer part of the ear but tympanic membrane is still normal pearly gray

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53
Q

Describe Otitis media

A

An infection of external part of the ears and ossicles

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54
Q

Describe Otitis Interna or Labyrinthitis

A

An infection goes into the inner ear affecting the semicircular canal, cochlea, and vestibule
S/S-severe vertigo and dizziness

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55
Q

Describe a normal tympanic membrane

A

Shiny pearly grey

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56
Q

It is appropriate for the nurse to use an otoscope in the physical assessment…

A

When funneling light into the ear canal

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57
Q

The manifestation of patient with retinal detachment will be…

A

Diminished vision of the affected eye

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58
Q

The technique that a nurse will use to assess the eom (extra ocular muscle movements) will be…

A

Assessment 6-cardinal field of gaze using the wheel wagon method or the H method

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59
Q

Describe diabetic retinopathy

A

The leading cause if blindness in the USA

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60
Q

Enlarged lymph nodes may indicate what?

A

Infection, normal findings are non-palpable lymph nodes for adults. Children may or may not have enlarged lymph nodes & this can still be normal, however, refer to MD if palpable

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61
Q

When testing the integrity of CN III, the nurse must advise the patient…

A

to look up and down without moving the head

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62
Q

White patches on the tympanic membrane indicate what?

A

Scarring from a previous infection

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63
Q

When testing for Romberg test…

A

The nurse must advise the client to stand erect with feet together, hands on the sides and close eyes for 20-seconds

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64
Q

What are the normal findings the Romberg Test and what should be done for a patient with abnormal findings?

A

*Normal findings -no swaying
*Swaying more than 2 inches is abnormal
*For abnormal Romberg test to meet the elimination needs of the client provide a bedside commode

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65
Q

How do you interpret a Snellen test of a patient with 20/50 reading?

A

This patient sees at 50 feet what a person with normal vision sees at 20 feet.

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66
Q

Describe a sinus headache

A

headache from a sinus infection

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67
Q

Describe a classic migraine

A

headache preceded by aura, seeing spots, flashes of light, feeling nauseated, or experience numbness and tingling of the face and extremities

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68
Q

Describe a cluster headache

A

numerous headaches occur over a period of days or months. No aura, onset is sudden and may last for a few minutes or a few hours

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69
Q

Describe a tension headache

A

Also known as muscle contraction headache. Onset is gradual, pain is steady. Usually associated with stress and being overworked. May be unilateral or bilateral, ranges from cervical region to the top of the head.

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70
Q

Differentiate Entropion and Ectropion:

A

*Entropion- upper lid inverted into the eyes causing the eyes to be irritated.
*Ectropion- lower lid is everted downward exposing the conjunctiva.

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71
Q

What is the most common type of Hyperthyroidism?

A

Graves’ Disease

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72
Q

What are the cues or signs and symptoms of Gingivitis?

A

(1) Red gums
(2) Bleeding gums
(3) Receding gums

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73
Q

Expected findings for client with Bell’s Palsy?

A

(1) Muscle distortion
(2) Pain behind the ear
(3) Impaired Taste

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74
Q

If sinuses are not filled with fluid, you will…

A

…elicit red glow on transillumination of the sinuses using your penlight. If sinuses are filled with fluid, it will not transilluminate, you will not elicit red glow or red glow is absent.

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75
Q

For elderly client when is the best time of the month to perform SBE?

A
  • Preferably the same day every month.
  • For a client that is still menstruating, 3- 5 days after the menstrual period when the hormones are more stable.
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76
Q

Describe Intraductal Papilloma

A

The most common cause benign nipple discharge of post-menopausal client complaining of leakage of serum or bloody discharge of the breasts.

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77
Q

Describe Benign Breast or Fibrocystic Breast

A

*common in the 20’s
*S/S: tenderness, nipple discharge, & thickening of the breast tissues

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78
Q

Describe fibroadenoma

A

*A defined breast tumor like with no tenderness or discharge.
* Common in adolescent girls 15 to 35 years old.

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79
Q

A client with an orange-peel or Peau D’Orange skin appearance on the breast is an indication of?

A

Malignancy

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80
Q

Any change in consistency of a breast lump must be?

A

Evaluated by the physician

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81
Q

Describe an early sign of hypoxia

A

Altered level of consciousness

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82
Q

Use whispered pectoriloquy or bronchophony on auscultations when…

A

Assessing a client with bilateral pneumonia and both lungs are filled with fluid, the sounds you will hear are sounds that are loud and clear bilaterally.

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83
Q

What are the normal lung sounds with no fluids during whispered pectoriloquy and bronchophony

A

You will hear sounds that are soft & almost indistinguishable for Whispered Pectoriloquy & Muffled sounds for Bronchophony.

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84
Q

The most appropriate technique in assessing the respiratory system is?

A

Assessing from side to side

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85
Q

Describe tracheal breath sounds on auscultation

A

over the trachea- Inspiration is < than expiration (harsh, high pitched)

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86
Q

Describe bronchial breath sounds on auscultation

A

superior to each clavicle & in the 1st ICS, E>I (loud high pitched)

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87
Q

Describe bronchovesicular breath sounds on auscultation

A

over major Bronchi in the 2nd and 3rd ICS between Scapula I=E (medium loudness, medium pitched)

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88
Q

Describe vesicular breath sounds on auscultation

A

remainder of the lungs I>E (soft, low pitched)

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89
Q

Describe bradypnea

A

slow regular rate <10 per minute (DM Coma, Drug Induced, > intracranial pressure)

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90
Q

Describe hypoventilation

A

irregular, shallow rate <10 (narcotic OD, anesthetic, prolonged bedrest, chest splinting)

91
Q

Describe hyperventilation

A

rapid deep rate>24/minute (extreme exertion, fear, DM ketoacidosis, hypoxia, salicylate OD hypoglycemia)

92
Q

Describe tachypnea

A

rapid, shallow rate >24 (fever, fear, exercise, respiratory insufficiency, pleuritic pain, alkalosis, pneumonia)

93
Q

Describe Cheyne-Stokes

A

regular pattern with period of deep breathing alternating with apnea (Normal children and aging, heart failure, uremia brain damage, drug induced respiratory depression, common in elderly dying patient)

94
Q

Describe Biot’s/ Ataxic

A

Irregular pattern respiration- Shallow deep respiration with periods of apnea (respiratory depression and brain damage)

95
Q

Describe normal breathing

A

(1) Eupnea even, regular I=E
(2) Eupnea w/ occasional sigh

96
Q

Describe coarse rales/ crackles

A

low pitched, bubbling, loud & moist (collapsed or fluid filled alveoli). Example: Lobar Pneumonia

97
Q

Describe Ronchi Sibilant

A

high pitched continuous (blocked airflow as in Asthma, infection)

98
Q

Describe Ronchi Sonorous

A

low pitched continuous, snoring & rattling (Fluid Blocked airway) Example: COPD

99
Q

Describe Stridor

A

loud, high pitched, crowing heard w/o stethoscope (obstructive upper airway)

100
Q

Describe Friction Rub

A

low pitched grating rubbing Example: Pleural inflammation

101
Q

What is Elliptical Chest Configuration

A

Normal chest configuration wherein the lateral diameter of the chest is 2:1 with the anteroposterior diameter
*By age 6, with normal child development & growth the child will have elliptical chest configuration.

102
Q

Infant chest configuration is…

A

barrel chest which is rounded with equal lateral and anteroposterior diameter

103
Q

Barrel chest is common in what patients?

A

COPD and elderly

104
Q

Describe Pectus Carinatum or pigeon chest

A

Forward displacement of the sternum with depression of the adjacent cartilage. No treatment is required.

105
Q

Describe Pectus Excavatum or Funnel Chest

A

*Depression of the sternum and adjacent cartilage
*Murmur maybe present with cardiac compression
*Surgical intervention maybe required in severe cases

106
Q

Describe Scoliosis

A

*Common in females- lateral curvature of the spinous process (thoracic & lumbar curvature or rotation)
May result in elevation of the shoulder and pelvis Deviation greater than 45
*May cause distortion of the lungs resulting in lung volume

107
Q

Describe kyphosis

A

Exaggerated posterior curvature of the thoracic spina, associated with aging It may, lung expansion and > cardiac problem

108
Q

Describe lordosis

A

Exaggerated curvature of the lumbar vertebrae during pregnancy

109
Q

Air trapped in the lungs is the indication of…?

A

Hyperresonance sound on percussion of client lung area

110
Q

In assessing a patient with pleural effusion on auscultation…

A

The breath sounds that you will expect will be absent breath sounds on the affected lung or lobes of the lungs.

111
Q

Fluid filled alveoli adventitious sounds that are…

A

low-pitched, loud, moist, and bubbling quality on auscultation

112
Q

Describe a fluid blocked airway

A

Adventitious sounds on auscultations when the lung sounds are low pitched, continuous & rattling quality

113
Q

Describe precordium

A

Part of the chest where you perform cardiac assessment

114
Q

Landmark of the Aortic area?

A

2nd ICS right sternal border

115
Q

Landmark of the Pulmonic area?

A

2nd ICS left sternal border

116
Q

Landmark of the ERB’S Point?

A

3rd ICS left sternal border

117
Q

Landmark of the Tricuspid area?

A

4th ICS left sternal border

118
Q

Landmark for Mitral or PMI in adult?

A

5th ICS, left mid-clavicular line. Location of PMI in Children- 4th ICS, LMCL

119
Q

Landmark of the angle of Louis?

A

Articulation of the manubrium and the body of the sternum

120
Q

Pathologic cardiac murmurs are associated with the following:

A

(1)Tricuspid stenosis
(2) Mitral regurgitations
(3) Aortic regurgitation

121
Q

Differentiate b/w Arterial insufficiency and Venous insufficiency:

A
  • Arterial Insufficiency- affected leg is cold and no more growing hair.
  • Venous Insufficiency- affected leg skin temperature is still normal- warm.
  • Both anomalies the patient experiences pain and other symptoms
122
Q

Describe ECG

A

Electrical representation of the cardiac cycles documented by deflections on recording paper

123
Q

Describe depolarization or contraction

A

Happens after stimulation by the electrical current wherein the cardiac cells are positively charged

124
Q

Describe repolarization

A

Happens after contraction wherein the inside of the cardiac cell returns to negatively charged. P Wave- represents part of Atrial depolarization. PR Interval- time needed for electrical current to travel across both atria & arrive at AV node. Atrial Repolarization is hidden behind the QRS.

125
Q

P wave

A

Is known as atrial depolarization

126
Q

Atrial Repolarization

A

Is hidden behind the QRS

127
Q

QRS Complex

A

Is known as ventricular depolarization

128
Q

T wave

A

ventricular repolarization

129
Q

QT interval

A

Represents the beginning of ventricular depolarization to the moment of repolarization which represents ventricular contraction

130
Q

Describe Allen’s test

A

The test is performed to determine the patency of the radial or ulnar arteries

131
Q

Describe Raynaud’s Disease

A

The findings that a Nurse will anticipate will be spasm and tingling sensation of hands and fingertips. Hands turn whitish, cyanotic and then reddish or presence of rubor. Common in young healthy female secondary to connective tissue disease, drug intoxication, pulmonary HTN or trauma

132
Q

Describe DVT

A

*occlusion of deep veins such as the femoral or pelvic circulation by blood clot
*Subjective findings: sudden intense sharp pain along iliac, popliteal or calf muscles. Increase pain w/ dorsiflexion of the foot. *Objective symptoms- unilateral edema, low grade fever & tachycardia
*DVT- can migrate to the lungs resulting in PE (Pulmonary Embolism)

133
Q

Thin red lines or splinter hemorrhages in the nail beds are present in client with

A

Infective Endocarditis

134
Q

A pathologic cardiac murmur during cardiac assessment is

A
  • Related to structural abnormalities of the heart
    *Examples: Mitral regurgitation, Tricuspid Stenosis, Aortic regurgitation
135
Q

How should a nurse explain to the patient the S2 heart sound or (dub)

A

Closure of the semilunar valve. Heard loudest at the base of the heart. S1(lub) closure of the Tricuspid and Mitral valves. Heard loudest at the apex of the heart

136
Q

Describe the SA Node

A

*known as the pacemaker of the heart where the initial electrical pulses occur
*It fires 60-100 joules/minute. AV node fires 60 joules/minute and Bundle branches fire 40-60 joules/minute

137
Q

S4 Atrial Gallop is….

A

heard before S1 & S3 ventricular gallop is heard after S2

138
Q

5 major risk factors of heart disease are:

A

1) Smoking
(2) HTN
(3) Obesity
(4) DM
(5) high Cholesterol

139
Q

Patent Foramen Ovale

A
  • Is a passageway for blood between the right and left atria
  • Should close shortly after birth
140
Q

Describe Patent Ductus Arteriosus

A

The opening between the pulmonary artery & descending aorta, closes 24-48 hours after birth

141
Q

Describe Tetralogy of Fallot

A

A cardiac condition where there are 4 cardiac defects in a baby that is life-threatening, surgery must be performed immediately

142
Q

Describe the 2 cardiac nerves of the heart

A

(1) Sympathetic-stimulates the heart, increase HR & Increase dilatation of the coronary arteries (2) Parasympathetic- decrease stimulation of the HR, decrease HR & decrease dilatation of the coronary arteries

143
Q

What are the manifestations of heart failure?

A

(1) fatigue
(2) dyspnea
(3) tachycardia
(4) weak peripheral pulses
(5) ankle edema

144
Q

Describe the grading of pulses

A

0 no pulse
1+ weak & thready
2+ normal
3+ Brisk
4+ Bounding

145
Q

For patients with new arteriovenous graft (AV) graft, which technique should the nurse perform to assess the potency of the graft?

A

Palpate the site for a thrill

146
Q

Dorsalis Pedis location

A

top of the feet, lateral to the big toe

147
Q

Popliteal Pulses location

A

Behind the knees medially

148
Q

Femoral Pulse location

A

Inguinal areas

149
Q

Posterior Tibialis location

A

At the grooves behind the medial malleolus and Achilles tendon

150
Q

Radial Pulse location

A

Lateral wrist, in line with the thumb

151
Q

Ulnar pulses location

A

Medial wrist, in line with the small fingers

152
Q

What are the two types of abdominal mappings or reference points?

A
  • 4 Quadrants
  • 9 Region
153
Q

When the intake of the client is more than the output?

A

The client is retaining fluid

154
Q

What is the landmark for assessing CVAT?

A

Costovertebral Angle using Blunt Percussion

155
Q

What does it mean when the output is more than the intake?

A
  • The client is secreting more fluid
    *Observed in patients with: DM, Kidney Failure, or access intake of fluids
156
Q

What are the sounds heard when percussing the lower border of the liver at the Right Upper Quadrant at the midclavicular line?

A

Dullness

157
Q

Describe a + Blumberg Sign

A

A sharp stabbing pain as the compressed abdomen returns to non-compressed state indication of positive to appendicitis, peritonitis or peritoneal irritation “emergency.”

158
Q

Describe a + Rovsing Sign

A

A sharp pain on the right lower quadrant of the abdomen when the nurse palpates the left lower quadrant- sign of acute appendicitis or peritoneal irritation.

159
Q

Describe a + Psoas Sign

A

Right lower quadrant pain when right leg is raised up with resistance- + positive to appendicitis

160
Q

Describe a + Murphy’s Sign

A

Upper right quadrant pain when client is asked to deep breath, while nurse is palpating the lower border of the liver - positive to Cholecystitis

161
Q

Describe a + Cullen’s Sign

A

Ecchymosis or bluish discoloration of the abdomen-indication of
possible Ruptured ectopic pregnancy or bleeding in the abdomen

162
Q

Describe the meaning of pain at McBurney’s Point

A

+ to Acute Appendicitis. Location Of McBurney’s point middle third of the imaginary line from the umbilicus to the right inguinal area

163
Q

Normally, all 4 quadrants of the abdomen will have…?

A

Tympanic Sound
*Except for the lower border of the liver on the upper right quadrant wherein the sound is dullness because the liver is a solid organ

164
Q

Types of Abdominal Palpations

A

(1) Light- ½ to 1 cm depth, one hand use to assess tender abdomen
(2) Moderate- 2-3 cm depth one hand
(3) Deep- 4-5 cm depth, bimanual – MD & NPC

165
Q

Flat Contour of the Abdomen

A

Normal for a skinny person

166
Q

Scaphoid or concave abdomen

A

normal for a very skinny person

167
Q

Rounded contour of the abdomen

A

Normal for obese, toddler, or early pregnant

168
Q

Protuberant contour of the abdomen

A

Normal for some toddler, late stage of pregnancy, and abnormal in case of client with ascites

169
Q

During inspection which of the abdominal findings should the nurse report immediately

A

Strong abdominal pulsation to r/o AAA

170
Q

the main organs that a nurse will assess at the left upper quadrant of the abdomen

A

stomach and spleen

171
Q

the main organs that a Nurse will assess at the right upper quadrant

A

liver and gallbladder

172
Q

When client has diverticulitis which quadrant of the abdomen will the Nurse assess?

A

Left lower quadrant

173
Q

What is the correct sequence for assessing the abdomen?

A

(1) Inspection
(2) Auscultation
(3) Percussion
(4) Palpation

174
Q

Describe Hepatitis

A

Hepatitis is the inflammation of the liver caused by viruses, bacteria, chemicals or drugs or parasite

175
Q

What are the types of Hepatitis and how are they transmitted

A

Types are:
*Hepatitis B (HBV)- transmitted by blood, sexually, perinatally & parenterally.
*Hepatitis C (HCV)- transmitted by blood & blood products & parenterally- more common in clients with tattoos.
*Hepatitis D - the same as (HBV)
*Hepatitis A- (HAV)- transmitted by fecal or oral route- more common in children.
*Hepatitis E (HEV)- transmitted by drinking dirty water supply. Common for travelers in underdeveloped countries.

176
Q

Anuria

A

Below 100 cc urine output in 24 hours

177
Q

Oliguria

A

Between 100 cc to 400 cc urine output in 24 hours

178
Q

Polyuria

A

Frequent Urination

179
Q

Hematuria

A

Blood in the urine

180
Q

Dysuria

A

Difficulty of urination

181
Q

Nocturia

A

Frequent urination at night

182
Q

Glycosuria

A

Sugar in the urine

183
Q

Enuresis

A

Involuntary urination at night, common in 5 years old or younger (has familial tendency)

184
Q

Normal bowel sounds on auscultation are…

A

5-30 times per minute in each quadrant which are irregular, high pitched & gurgling

185
Q

Borborygmi

A

*Frequent loud gurgling bowel sounds when a person has not eaten for 5-7 hours.
*Normally when there are no other S/S
*Can be abnormal when accompanied by other GI S/S

186
Q

Hyperactive Bowel Sounds

A

Due to diarrhea or gastritis

187
Q

Hypoactive bowel sounds

A

Due to post op patient or bowel obstruction

188
Q

Absent bowel sounds

A

Due to paralytic ileum

189
Q

Friction Rub Bowel Sounds

A

Grating rubbing together or inflamed organs

190
Q

Describe Colitis

A

*Inflammation of the colon
*S/S: Abd pain, diarrhea & Bloody stool
*May require medical interventions

191
Q

Describe Crohn Disease

A

*chronic inflammation of the GI, can involve any part of the lower intestine
*S/S: diarrhea, abdominal pain & Wt. loss
*No medical interventions required

192
Q

Risk for PUD

A

(1) Smoking
(2) NSAID
(3) Helicobacter Pylori

193
Q

Describe Glomeruli

A

Clusters of capillaries of the kidneys that filter 1 liter of fluid per minute to get rid of toxins, waste & foreign matter from the blood

194
Q

Describe Uremia

A

*Hallmark of Chronic Renal Failure * Urine products built up in the blood
*S/S: N/V, anorexia, altered mentation, uremic frost on the skin. edema, fatigue & weight loss

195
Q

Exposure to extreme environmental temperature will subject a person to…?

A

Hypernatremia (too much sodium in the blood)

196
Q

Manifestations of a client with Hypernatremia include:

A

(1) Hypotension
(2) weakness
(3) Tachycardia
(4) dry mucus membrane
(5) oliguria

197
Q

What are the part of the Diencephalon?

A

Thalamus
Hypothalamus
Epithalamus

198
Q

What are the 2 parts of the Nervous System?

A

Central & Peripheral

199
Q

Which clinical manifestation does the nurse anticipate when assessing tremors associated with Parkinson’s Disease?

A

Rhythmic Shaking

200
Q

What concept should a nurse use to explain why decreased in height occurs with aging?

A

Shortening of the vertebral column

201
Q

What is the main difference between Osteoarthritis & Rheumatoid Arthritis?

A

Osteoarthritis pain is aggravated by activities whereas Rheumatoid Arthritis pain is improved while doing activities

202
Q

What symptom should a nurse detect for the risk of developing osteomyelitis with a patient with an open metacarpal fracture?

A

Fever

203
Q

When assessing the range of motion of the finger or feet, when nurse ask the client to move the finger or foot outward away from the center of the body it is known as…

A

Abduction

204
Q

Moving toward the center of the body is…?

A

Adduction

205
Q

What are the risk factors for Osteoporosis?

A

Sedentary Lifestyle or no exercise

206
Q

The findings of clients with Positive Carpal Tunnel Syndrome when conducting Phalen’s test are…

A

Tingling sensation and numbness over median nerve, palmar surface of the thumb, the index finger, middle finger, and part of the ring finger with pain in the upper arms, shoulders, neck & chest when client is asked to hold the wrist at 90* flexion for 60 seconds or 1 minute

207
Q

Describe Tinel Test

A

Direct percussion on median nerve- Normal, no pain or tingling sensation on the arm surrounding the median nerve

208
Q

When assessing a client with shoulder pain, what findings will indicate rotator cuff injury?

A

Inability to abduct the arm at the shoulder

209
Q

What reflex is elicited when tapping directly with the flat end of the DTR hammer 2-3 inches above the wrist with palm in semi- prone position?

A

Brachioradialis Reflex

210
Q

What reflex is elicited when tapping indirectly with the pointed end of the DTR hammer at the antecubital area of the arm, with palm in semi- prone position?

A

Bicep Reflex

211
Q

Describe Plantar Reflex

A

Trace the sole of the foot with a tongue depressor upward to toes in an inverted “J”- Normal findings- downward response of hallux & toes

212
Q

What findings will the nurse document when a patient is having difficulty of ambulation due to unsteady gait with wide base, slapping & swaying which is common in Multiple Sclerosis, Drug/Alcohol Intoxication?

A

Ataxia

213
Q

What is the nurse assessing when drawing a letter with the use of Q-Tips on the client’s hands with eyes closed and client is ask to identify the letter?

A

Graphesthesia. Inability to identify may indicate Cortical Disease (CBD- Corticobasal Degenerative Disease- involves the pathology of the cerebral cortex & basal ganglia. S/S: Marked disorder in movements: cognition is classified as one of the Parkinson’s Plus Syndrome that occurs at age 5-=70. Duration of the Disease is 6 years) Definitive DX is through Neuropathology Exam

214
Q

What is the nurse assessing when a client with closed eyes is asked to identify a familiar object placed on her hand?

A

Stereognosis- Inability to identify may indicate Cortical Disease

215
Q

What is the test that a nurse should perform when assessing for sensory functions?

A

Touch the patient with eyes closed with soft, sharp or dull object & client is asked she can feel & identify the sensation.

216
Q

What would the nurse expect normally when assessing for the normal Achilles Tendon Reflex?

A

Plantar Flexion of the foot & heel jump

217
Q

When caring for a client with T-4 spinal injury what is the indication that the client is at risk for experiencing autonomic dysreflexia?

A

The client’s bladder becomes distended.

218
Q

Describe the Babinski Sign reflex

A

dorsiflexion of the big toe & fanning of the rest toes, is normal in children up to 2 years old

219
Q

Babinski Sign is abnormal after 2 years old which will indicate…

A

CNS pathology- upper neuron disease

220
Q

Describe Plantar Reflex (Adult(

A

With the use of tongue depressor trace from heel of foot toward the toes to the big toe in an inverted “J”. Normal response: downward response of hallux or big toe & toes

221
Q

Describe Romberg’s Test

A

Test for balance, feet together, hands to the sides, closed eyes for 20 seconds, while nurse is supporting client front & back. Provide “Bedside Commode” to meet the elimination needs of client.

222
Q

Describe Crepitation

A

Pain, stiffness, crunching, and grating sounds of joints

223
Q

Describe objective findings when assessing a client with Meningitis.

A

(1) Fever
(2) Irritability
(3) Vomiting
(4) Seizures
(5) Coma

NURS 190-Physical Assessment (7 decks)

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