Final Exam Cumulative Flashcards
(207 cards)
1
Q
subjective data + examples; also known as what?
A
patients’ feelings and statements (“I feel…”) + pain
AKA symptoms
2
Q
objective data + examples; also known as what?
A
observable, measurable (VS, labs, assessments)
AKA signs
3
Q
this type of communication technique can be helpful for changes in patient status, communicating needs, updating providers or other healthcare team members about situation
A
SBAR
4
Q
components of SBAR
A
situation
background
assessment
recommendation
5
Q
normal adult BP value
A
systolic <120 / diastolic <80
6
Q
what is hypertension defined as?
A
> or = 140/90
7
Q
normal adult HR
A
60-100 bpm
8
Q
normal adult RR
A
12-20 RR
9
Q
normal adult temperature
A
97-99°F
10
Q
normal adult O2 saturation
A
> 90%
11
Q
fever is defined as what value?
A
> 100.4°F
12
Q
is rectal temp usually higher or lower than oral?
A
slightly HIGHER
13
Q
normal pulse quality value
A
2+
14
Q
describe location for apical pulse
A
5th IC space, midclavicular line
15
Q
when should you check apical pulse?
A
irregular HR, cardiac hx, infant + children, BP meds
16
Q
word to describe absence of breath sounds for 15 seconds
A
apnea
17
Q
HYPOtension value
A
<100/60 or 30 mmHg below patient baseline
18
Q
name 5 ways to prepare for taking a BP to ensure accurate reading
A
- no nicotine or caffeine for 30 mins before
- choose correct cuff size
- rest for 5 minutes before taking
- don’t cross legs
- arm supported @ heart level
19
Q
orthostatic hypotension defined as drop of ___ mmHg in systolic and ___ mmHg drop in diastolic
A
20 mmHg drop Systolic
10 mmHg drop diastolic
20
Q
thorough method to assess pain or new condition (reason for seeking care)
A
OLDCARTS
21
Q
describe components of OLDCARTS
A
Onset Location Duration Characteristics Aggravating/Alleviating Related symptoms Treatment Severity
22
Q
information in a review of systems (ROS) is obtained how?
A
through PATIENT - subjective !!
23
Q
the _____ ______ gives us a global impression of the person we’re assessing
A
general survery
24
Q
the general survey includes which 4 components?
A
- physical appearance
- body structure
- mobility
- behavior
“Physical Bodies Move Bashfully”
25
mood is defined as
a person's emotional state
26
affect is defined as
the expression of that emotion
27
ataxia
defective muscular coordination; walking all over the place; staggering (can resemble ETOH intoxication)
28
ataxia is cause by dysfunction of what area of the brain?
cerebellum
29
describe decerebrate posture
-deep tendon reflexes -exaggerated
-pronated palms
-clenched teeth
=MORE SERIOUS
30
describe decorticate posure
- clenched fists
- legs adducted
- hands come to core
31
people lose which type of memory last?
remote (months or years ago) - think about how a person with dementia can sometimes still remember stories from their childhood...
32
paresis
partial or complete paralysis
33
paresthesia
burning or tingling (r/t nerve injury)
34
proprioception
being aware of where we are and our body movements
35
orientation is assesing what?
level of awareness of reality
36
what questions would you ask for orientation?
1. person: who are you? DOB?
2. time: what is the day of the week? --> what season is it? (adjust these questions based on their orientation level)
3. place: where are you right now?
4. situation: what brought you in?
37
level of consciousness is assessing what?
responsiveness (overlaps with orientation)
38
re: LOC, fully conscious =
awake/alert
39
re: LOC, lethargy =
drowsy + sluggish but awakens; needs engagement
40
re: LOC, obtunded =
fades in and out; confused when awake; needs CONSTANT stimulation to stay awake
41
re: LOC, stupor =
arouses to vigorous stimulation (usually pain); cannot verbalize or follow commands
42
re: LOC, coma =
no purposeful response to anything you do to them
43
re: reflex responses, what is a normal/average score?
2+
44
re: reflex responses, what is the score for hyperactive w/clonus and ABNORMAL
4+
45
re: Morse Fall Scale, what is a low risk score?
moderate risk score?
high risk score?
0-24
25-45/50?
>45-50
46
re: Morse Fall scale, what is a low risk score?
0-24
47
re: Morse Fall Scale, what is a high risk score?
>45/50
48
describe Romberg Test and what a positive result would be?
patient stands with feet together, eyes closed + arms at side
provider gently pushes patient
positive result: patient sways, widens stance or loses balance
49
term for recognizing an object by touching it with eyes closed
stereognosis
50
term for the ability to recognize numbers or letters written on palm with eyes closed
graphesthesia
51
the glascow coma scale assesses which 3 things?
1. eye opening
2. verbal response
3. motor response
= can you open your eyes? can you talk? can you move?
52
re: Glasgow Coma Scale, which score usually indicates coma?
less than 8
**the higher the number the better - 15 is highest**
53
Purpose of functional assessment
function r/t ADLs - what can you do and how well?
54
ROM assessment should show what?
smooth, painless, movement through motion
55
describe passive ROM (PROM)
nurse anchors joint with one hand and uses other to move body part
56
two of the most important things to remember with ROM
- keep eyes on patient to indicate pain (nonverbals)
| - STOP if resistance or pain is felt!
57
joint exam findings - snap, crackle, pop =
crepitation
58
ankylosis =
stiffness or fixation of joint
59
subluxation =
partial dislocation of joint
60
atonic =
no tone or movement
61
spasticity =
sudden muscle contractions
62
flaccidity =
weakness
63
atrophy =
wasting
64
hypertrophy =
increased muscle mass
65
contracture =
shortened muscle
66
fasciculation =
muscle twitch
67
re: muscle testing, what score would you give for someone who can move joint with passive ROM
2
68
re: muscle testing, what score would you give for someone who can move against gravity
3
69
re: muscle testing, what score would you give for someone who can move against some resistance
4
70
re: muscle testing, what score would you give for someone who can move against FULL resistance
5
71
difficulty breathing while lying down
orthopnea
72
what valves are closing during S1 ("lub")?
mitral and tricuspid
73
what valves are closing during S2 ("dub")?
aortic and pulmonic
74
where can we hear S1 the best?
apex
75
where can we hear S2 the best?
base of heart (up top)
76
what mneumonic can you use for landmarks of the heart?
2245 APT M
2nd IC space R of sternum (aortic)
2nd IC space L of sternum (pulmonic)
4th IC space L of sternum (tricuspid)
5th IC space L of sternum (mitral = apex)
77
what are the AV valves?
mitral + tricuspid
78
what are the semilunar valves?
aortic + pulmonic
79
where can the PMI be felt?
5th IC space midclavicular line = apex
80
where can you find Erb's Point? why is it a helpful landmark?
3rd IC space L sternal border = can hear everything about the same!
81
term for a high-pitched scratchy/grated sound + what causes it?
friction rub r/t pericardial inflammation
82
describe differences between MI in male + female
```
men = chest pressure
women = more likely to report N/V, sweating, pain in neck, jaw, abdomen, back; unusual fatigue; sleep disturbance; SOB; impending doom :(
```
83
blowing or swishing sound (using bell)
bruit
84
what is a normal capillary refill?
< 2-3 ish seconds
85
pitting edema
leaves indention
86
1+ pitting edema =
```
depresses 2mm (x2)
disappears rapidly
```
87
2+ pitting edema =
depresses 4mm (x2)
88
3+ pitting edema =
```
depresses 6mm (x2)
lasts a minute or so
```
*edema becoming visibly obvious at this stage*
89
4+ pitting edema =
```
depresses 8mm (x2)
lasts 2 mins or more
```
90
S+S of DVT
UNILATERAL edema
erythema
warmth
pain, ache, cramps
**DON'T MOVE**
91
which peripheral disorder is worse with activity?
arterial disorder (blood not getting where it needs to go)
92
which peripheral disorder improves with activity?
venous disorder (blood can move from pool and get back to heart)
93
what peripheral disorder is characterized by intermittent claudication?
arterial (pain after exercise)
94
re: arterial disorder, what movement with feet will reduce pain?
lowering feet
95
re: venous disorder, what movement with feet will reduce pain?
elevating feet (sends blood back to heart)
96
what will the skin look like with arterial disorder?
cool, cold, shiny, hairless, pallor (w/elevation), NO edema
97
what will the skin look like with venous disorder?
mottled, warm, edematous
98
pulses present in arterial or venous disorder?
venous
99
S+S of acute arterial disorder
6 P's
1. pain
2. poikilothermic
3. pallor
4. paresthesia
5. paralysis
6. pulselessness
100
pallor
pale/greyness
101
cyanosis
blue-ish purple-ish
can be pale in people with more melanin
102
what could pallor indicate?
anemia; reduced blood flow
103
where is a good location to assess for pallor (regardless of melanin levels in skin)
conjunctival sacs
104
what can cyanosis indicate?
hypoxia
105
acrocyanosis is found where?
extremities
106
circumoral cyanosis is found where?
around the mouth
107
where does jaundice initially occur before it spreads?
mouth + palates + mucous membranes
108
hypopigmentaton is also called what?
VITILIGO
109
macule
flat, small
110
papule
solid, small, elevated
111
pustule
raised, pus-filled
112
vesicle
elevated, small, serous filled
113
loss of outer layers from itching/rubbing
excoriation
114
cleft into the skin, often from drying
fissure
115
large, dark, palpable scar w/increased collagen
keloid
116
confluent skin issues
run together - think confluence of a river
117
arciform skin lesions
with arcs, rings; circle within a circle
ex: annular lesion
118
re: skin lesions what is diffuse distribution
widespread, generalized, over entire body
119
re: skin lesions, what is localized
limited + discrete
120
re: skin lesions, what is one lesion in each area called? (separated from each other)
discrete
121
cherry red proliferation of blood vessels
hemangioma
122
petechiae
tiny, pinpoint hemorrhages
123
purpura
flat hemorrhage, larger area
124
hematoma
elevated bruise; can be palpated
125
ecchymosis
capillary bleeding into tissue; not palpated; will see color progression
126
what method do we use for assessing moles/skin lesions? (skin cx)
```
ABCDE
asymmetry
border
color
diameter
elevation/enlargement
```
127
hirsutism
excessive hair growth in unusual places
128
paronychia
inflammation/ infection of nail bed
129
clubbing can indicate what?
chronic hypoxia
130
define approximated
pulled together, matched up, closed wound
131
stage 1 pressure injury
non-blanchable redness
132
stage 2 pressure injury
epidermis removed; partial thickness
133
stage 3 pressure injury
full thickness; into subcutaneous tissue; may see eschar + slough; could see undermining + tunneling
134
stage 4 pressure injury
full thickness; into the bone, tendon, muscle
135
unstageable pressure injury
cannot visualize bottom of wound bed - don't know what's under there
136
6 components of Braden Scale (to predict pressure injury risk)
- sensory perception
- moisture
- mobility
- friction/shear
- activity
- nutrition
137
how is Right lung different from left lung?
right has 3 lobes (middle lobe), left has 2
138
when auscultating posterior lung fields, which landmark do you start at?
C7 - work in ladder-like fashion down
139
what signs might you see with dyspnea?
- nasal flaring
- retraction
- pursed lips
- labored breathing
140
re: thoracic assessment, describe pectus excavatum
caved in
141
re: thoracic assessment, describe pectus carinatum
bird beak
| CARINatum = CANARY bird
142
re: thoracic assessment, describe barrel chest
bulging and rounded; AP diameter is equal
143
hyperventilation is what RR?
>24
144
hypoventilation is what RR?
<10
145
which type of breathing pattern is this: rate + depth are variable w/periods of apnea; aka "end of life breathing" or "death rattles"
cheyne-stokes
146
which type of breathing pattern is this: increased depth + rate with abrupt pauses; associated with head trauma
Biot's
147
which type of breathing pattern is this: abnormally deep w/increased rate; associated with DKA
kussmaul
148
what could cause increased tactile fremitus?
pneumonia, phlegm, tumor (sound + vibration travels much quicker / easier through liquid)
149
what could decrease tactile fremitus?
COPD, emphysema, pleural effusion, pneumothorax
150
what sounds do you hear over lung fields; the majority of the sounds heard?
vesicular
151
what sounds do you hear over the trachea?
bronchial
152
what sounds do you hear near sternum?
broncho-vesicular
153
# define this abnormal breath sound:
crackles or popping
crackles
154
can crackles be cleared by coughing?
no (fluid is too deep)
155
# define this abnormal breath sound:
moaning, snoring, gurgles
rhonchi
156
can rhonchi be cleared by coughing?
yes
157
# define this abnormal breath sound:
whistling, musical sound
wheezes
158
# define this abnormal breath sound:
squeaking or grating sound
pleural friction rub
159
# define this abnormal breath sound:
crowing (can usually hear w/o a stethoscope)
stridor
MEDICAL EMERGENCY!
160
constipation is defined as what?
BM < 3 x / week
161
what is the unique order of assessment with the GI system?
auscultate before palpation or percussion
162
re: abdomen, describe a scaphoid shape
concave
163
re: abdomen, describe a protuberant shape
PROTRUDING out
obesity, pregnancy, ascites
164
what should you do if you find a bulging mass on the abdomen during your GI assessment?
DON'T PALPATE + GET HELP!
165
for a GI assessment, which quadrant should you start at? and how should you move?
RLQ (ileocecal valve)
clockwise direction
166
what conditions could cause hyperactive bowel sounds?
diarrhea, just ate (increased peristalsis)
167
what conditions could cause hypoactive bowel sounds?
post-op, constipation, decreased peristalsis
168
definition of ABSENT bowel sounds
no sounds for 5 minutes TOTAL
169
re: stool assessment, frank red color could indicate what?
bleeding close to source (hemorrhoids)
170
re: stool assessment, maroon/dark red color could indicate what?
bleeding in upper GI tract (time to hemolyze) - small intestine is possibility?
frank red would be lower GI bleeding
171
re: stool assessment, black/not sticky stool could indicate what?
- iron supps
| - Pepto Bismol (bismuth) use
172
re: stool assessment, brown, clay-colored could indicate what?
little to no bile
173
re: stool assessment, yellow/greasy could indicate what?
increased fat content in diet
174
re: emesis, frank blood could indicate what?
esophageal bleeding or bleeding close to source
175
re: emesis, "coffee grounds" could indicate what?
GI bleed (blood clots in emesis)
176
describe expected stool consistency from a COLOSTOMY
resembling expected/usual stool - more formed since ostomy is lower down in GI tract
177
describe expected stool consistency from an ILEOSTOMY
loose stool (ostomy is in small intestine so not as much H2O absorption)
178
what are the assessment findings of a healthy stoma
beefy red, healthy periostomal area
NOT retracted, NO edema, NO bleeding
179
at what level of fullness should you empty an ostomy bag?
1/3; NO MORE than 1/2!
180
describe the "Fluid Wave" assessment for ascites
- Place ulnar surface of hand firmly on midline of abdomen
| - Strike one side of abdomen with fingers and feel impulse of fluid with other hand
181
describe "Shifting Dullness" assessment for ascites
- 1st Patient lying supine
- find tympany in center of abdomen
- percuss outward in several directions to denote dullness
- ask patient to turn to one side then percuss for tympany to dullness (fluid sinks to lowest point)
182
describe rebound tenderness assessment for peritoneal irritation (possible ruptured appendix)
- applies pressure to an area of abdomen
| - More painful when pressure is released
183
describe kidney tenderness assessment
o Find costovertebral angle
o Place left hand flat in this area on one side; hit hand sharply with fist of other
o If tenderness present, patient will indicate!!!
184
what is minimum volume for voiding per hour?
30mL/hr
185
oliguria is defined as what?
<20mL/hr or <400mL/day
186
what is anuria?
NO URINE
187
polyuria is defined as what? and what condition might we see this in?
increased volume; DM
188
what is a bladder scanner assessing for?
urinary retention
| post void residual
189
at what age do mammograms usually begin?
40 yrs old; earlier with risk factors
190
re: breast exam, describe describe Peau D'Orange
dimpling, puckering r/t breast cx; resembles skin of an orange
191
describe some abnormal findings in a breast and lymph node exam?
hard, non-mobile, cannot feel edges, asymmetrical, not cyclic, located in tal of spence
(expected findings are opposite of this)
192
epistaxis =
nose bleeds
193
edentulous =
without teeth
194
leukoplakia
thick white patches that cannot be scraped off
195
describe the different grades of enlarged tonsils
* 1+ less than 25% (visible tonsils)
* 2+ less than 50% (enlarged halfway)
* 3+ less than 75% (tonsils almost touching uvula)
* 4+ kissing tonsils (tonsils almost touching each other)
196
what is PERRLA assessing?
2 things to look for
Pupils Equal Round and Reactive to Light + Accommodation
- direct pupil rxn
- consensual pupil rxn
197
what is the expected finding for accomodation w/PERRLA?
bilateral pupil contraction as you near nose
198
anisocoria
uneven eyes/different size pupils
199
miosis
small, tiny, constricted pupils
200
myadrasis
dilated, fixed pupils
201
visual acuity is tested with what?
```
Snellen chart
(20/20) - describe this
```
202
amblyopia
"lazy eye"
203
ptosis
droopy eyelid
lacking symmetry
204
where do you place tuning fork with Weber test?
on top of head
can they hear equally with both ears?
205
where do you place tuning fork with Rinne test?
on mastoid bone
is AC>BC?
206
what tests would we use for depression screening?
Patient Health Questionnaire (PHQ) 2 --> PHQ 9 if they are positive for the other 2 questions
207
S+S of agitation
- repetitive motor activity
- foot tapping
- hair pulling
- fiddling
- repetitive vocalizations
- irritability
- heightened response to stimuli
- aggression
