HA LECTURIO Flashcards
The nurse is assessing a client’s scalp and notices patches of hair that are missing. What does the nurse suspect may be causing? Select all that apply
Trichotillomania & Alopecia
The student nurse is assessing a client. which student nurse statement causes the nurse instructor to intervene?
“You’re talking normally, so that means I do not need to check your mouth or throat” , “The white patches on your tongue are called thrush, a bacterial infection, “It is normal for you to have some pain when I touch your outer ear”
What is considered a medical emergency?
Tracheal deviation
The nurse is admitting a new client with parotitis. What clinical findings does the nurse expect to find when assessing the client?
Bulging cheeks
The nurse notices that the new client is presenting with proptosis. The nurse should ask the client if they have a history of which disease?
Hyperthyroidism
The client complains of ear pain is exacerbated when the nurse palpates the tragus and tugs on the helix of the client’s ear. Which condition does the nurse suspect the client is experiencing?
Otitis externa
A dry tongue with fissures may indicate what condition?
Hypovolemia
Which sinus areas may be percussed on physical exam?
Frontal and Maxillary
A patient with bulging cheeks often described as ‘chipmunk’ facies likely has which of the following diseases?
Mumps
On the physical examination, a patient’s sclerae can clearly be seen above their irides. What condition does this patient most likely have?
Hyperthyroidism
Palatal petechiae suggest a diagnosis of what condition?
Measles
What does a hairy tongue with increased hyperkeratinization suggest?
The patient is a smoker
Ludwig’s angina indicates?
Submandibular infection
When using an otoscope what does the green line represent?
The appropriate setting for a user with 20/20 vision
What physical exam finding is most suggestive of otitis externa?
Pain when pulling on the ear
What physical examination findings suggests hypovolemia?
Sunken eyes
What is pterygium?
A wing of conjunctival tissue that extends toward the cornea
What internal cause of eye pain is an ophthalmological emergency?
Closed angle glaucoma
What is the best way to position a patient for examination with handheld ophthalmoscope?
Face to face with the patient’s eyes close to the height of the examiner
What is the purpose of the green filter on a direct ophthalmoscope?
To better visualize retinal blood vessels
A diffusely enlarged and firm thyroid is most suggestive of what diagnosis?
Hashimoto’s disease
What does a bruit heard on auscultation over the thyroid suggest?
Graves disease
What is one of the signs of hypothyroidism found on physical examination?
Diffuse hair loss
What sign associated with hyperthyroidism is found on physical examination?
Lid lag
What condition may interfere with visualization of the red reflex?
cataracts
What is a normal cup to disc ratio when examining the optic nerve on a fundoscopic exam
1:3
What is a characteristic finding in a patient with Graves’ disease?
Pretibial myxedema
What is a characteristic of a concerning breast nodules?
Asymmetric
What is the Tail of Spence?
Glandular tissue lateral to the upper outer quadrant of the breast
What findings may indicate breast cancer?
Peau d’orange & Retracted nipple
Which anatomical piece of the stethoscope is placed on the client?
Chest piece
What are the names of the two components on the chest piece of the stethoscope that are used for auscultating different sounds?
Diaphragm & bell
What is the scientific term for listening to a client’s respiratory sounds?
Auscultation
What visual observations can a nurse make about a client’s respiratory status while talking with a client?
Respiratory rhythm, respiratory rate, symmetrical rise and fall of the chest, respiratory effort
What is a normal adult respiratory pattern indicating comfortable breathing?
12-20 breaths per minute
What are some common factors that influence the character/quality of respirations?
Pain, Anxiety/panic attacks, Exercise/exertion, body positioning
What are the signs and symptoms of respiratory impairment?
Abnormal breath sounds, Paradoxical chest wall movement, Use of accessory muscles, shortness of breath with normal activity
What are less visual signs of respiratory impairment that the nurse understands should be addressed immediately?
restlessness, changes in personality such as confusion, decreased level of consciousness, irritability
What are late signs of respiratory impairment?
use of accessory muscles, paradoxical chest wall movement, stridor sounds, the inability to talk without becoming short of breath
Which type of sounds can be heard through the diaphragm side of the stethoscope?
High pitched sounds
Which type of sounds can be heard through the bell of the stethoscope?
Low pitched sounds
Which breath sounds are considered adventitious?
wheezes, crackles, stridor, rhonchi
What is dyspnea?
Difficulty breathing
What are the common causes of dyspnea?
COPD, Thromboembolic disease, Interstitial lung disease, Congestive heart failure
What is the medical term for abnormal widening and thickening of the bronchi?
Bronchiectasis
What is an infectious disease that can cause dyspnea?
Tuberculosis
Which elements are required for an appropriate respiratory assessment?
Visual evaluation & Lung auscultation
What are pulse oximeters used to measure?
Hemoglobin in the blood (oxygen saturation)
What oxygen saturation levels are considered normal/
96 - 100%
What is the gold standard invasive method to determine an accurate oxygen saturation level?
Arterial Blood Gases (ABG)
What is the scientific term for the movement of air in and out of the lungs?
Ventilation
What does the infrared light measure when the nurse is using a pulse oximeter?
Oxyhemoglobin
What conditions can cause poor peripheral perfusion or inaccurate low pulse oximeter oxygen saturation readings?
Finger nail polish/ artificial nails, Methylene blue dye, Cold extremities (Raynaud’s disease), Significant movement of the hands
What is a dangerous gas that binds with hemoglobin and gives false normal pulse oximeter readings?
Carbon monoxide