HA LECTURIO Flashcards
1
Q
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
A
Trichotillomania & Alopecia
2
Q
The student nurse is assessing a client. which student nurse statement causes the nurse instructor to intervene?
A
“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”
3
Q
What is considered a medical emergency?
A
Tracheal deviation
4
Q
The nurse is admitting a new client with parotitis. What clinical findings does the nurse expect to find when assessing the client?
A
Bulging cheeks
5
Q
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?
A
Hyperthyroidism
6
Q
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?
A
Otitis externa
7
Q
A dry tongue with fissures may indicate what condition?
A
Hypovolemia
8
Q
Which sinus areas may be percussed on physical exam?
A
Frontal and Maxillary
9
Q
A patient with bulging cheeks often described as ‘chipmunk’ facies likely has which of the following diseases?
A
Mumps
10
Q
On the physical examination, a patient’s sclerae can clearly be seen above their irides. What condition does this patient most likely have?
A
Hyperthyroidism
11
Q
Palatal petechiae suggest a diagnosis of what condition?
A
Measles
12
Q
What does a hairy tongue with increased hyperkeratinization suggest?
A
The patient is a smoker
13
Q
Ludwig’s angina indicates?
A
Submandibular infection
14
Q
When using an otoscope what does the green line represent?
A
The appropriate setting for a user with 20/20 vision
15
Q
What physical exam finding is most suggestive of otitis externa?
A
Pain when pulling on the ear
16
Q
What physical examination findings suggests hypovolemia?
A
Sunken eyes
17
Q
What is pterygium?
A
A wing of conjunctival tissue that extends toward the cornea
18
Q
What internal cause of eye pain is an ophthalmological emergency?
A
Closed angle glaucoma
19
Q
What is the best way to position a patient for examination with handheld ophthalmoscope?
A
Face to face with the patient’s eyes close to the height of the examiner
20
Q
What is the purpose of the green filter on a direct ophthalmoscope?
A
To better visualize retinal blood vessels
21
Q
A diffusely enlarged and firm thyroid is most suggestive of what diagnosis?
A
Hashimoto’s disease
22
Q
What does a bruit heard on auscultation over the thyroid suggest?
A
Graves disease
23
Q
What is one of the signs of hypothyroidism found on physical examination?
A
Diffuse hair loss
24
Q
What sign associated with hyperthyroidism is found on physical examination?
A
Lid lag
24
What condition may interfere with visualization of the red reflex?
cataracts
25
What is a normal cup to disc ratio when examining the optic nerve on a fundoscopic exam
1:3
25
What is a characteristic finding in a patient with Graves' disease?
Pretibial myxedema
26
What is a characteristic of a concerning breast nodules?
Asymmetric
26
What is the Tail of Spence?
Glandular tissue lateral to the upper outer quadrant of the breast
27
What findings may indicate breast cancer?
Peau d'orange & Retracted nipple
28
Which anatomical piece of the stethoscope is placed on the client?
Chest piece
29
What are the names of the two components on the chest piece of the stethoscope that are used for auscultating different sounds?
Diaphragm & bell
30
What is the scientific term for listening to a client's respiratory sounds?
Auscultation
31
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
32
What is a normal adult respiratory pattern indicating comfortable breathing?
12-20 breaths per minute
33
What are some common factors that influence the character/quality of respirations?
Pain, Anxiety/panic attacks, Exercise/exertion, body positioning
34
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
35
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
36
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
37
Which type of sounds can be heard through the diaphragm side of the stethoscope?
High pitched sounds
38
Which type of sounds can be heard through the bell of the stethoscope?
Low pitched sounds
39
Which breath sounds are considered adventitious?
wheezes, crackles, stridor, rhonchi
40
What is dyspnea?
Difficulty breathing
41
What are the common causes of dyspnea?
COPD, Thromboembolic disease, Interstitial lung disease, Congestive heart failure
42
What is the medical term for abnormal widening and thickening of the bronchi?
Bronchiectasis
43
What is an infectious disease that can cause dyspnea?
Tuberculosis
44
Which elements are required for an appropriate respiratory assessment?
Visual evaluation & Lung auscultation
45
What are pulse oximeters used to measure?
Hemoglobin in the blood (oxygen saturation)
46
What oxygen saturation levels are considered normal/
96 - 100%
47
What is the gold standard invasive method to determine an accurate oxygen saturation level?
Arterial Blood Gases (ABG)
48
What is the scientific term for the movement of air in and out of the lungs?
Ventilation
49
What does the infrared light measure when the nurse is using a pulse oximeter?
Oxyhemoglobin
50
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
51
What is a dangerous gas that binds with hemoglobin and gives false normal pulse oximeter readings?
Carbon monoxide
52
Which factors can result in potential carbon monoxide poisoning?
Fuel-powered tools, Automobile exhaust, House fires
53
What is a form of hemoglobin, sometimes acquired as a genetic component, tat is incapable of carrying oxygen but gives false normal pulse oximeter readings?
Methemoglobin
54
What is a noninvasive way to measure the partial pressure of CO2 at the end of exhalation?
Capnography
55
What is the normal end tidal CO2(EtCO2) range?
35 - 45 mm Hg
56
What clinical applications does measuring end tidal CO2 have?
Verify endotracheal tube placement, Identify return of spontaneous circulation (ROSC), Adjust treatment based on EtCO2 levels
57
Why is measuring end tidal CO2 more reliable than using a pulse oximeter?
It measures exhaled air, providing instantaneous feedback on ventilation effectiveness
58
Which of following would cause an increased end tidal CO2?
Hypoventilation
59
Which of the following factors would affect the end tidal CO2, causing it to decrease below 35 mm Hg?
Hyperventilation
60
Which medication is often administered during cardiac arrest event, that in a healthy client would increase etCO2?
Bicarbonate
61
Which respiratory system factors would cause client to have an elevated EtCO2 level?
Respiratory depression, Bradypnea
62
Which circulatory system factors would cause a client to have a decreased EtCO2 level?
Pulmonary emboli, cardiac arrest, sudden hypotension
63
What measures the ratio of oxyhemoglobin to deoxyhemoglobin by calculating shining light at a specific wavelengths through tissue?
Pulse Oximetry (SaO2)
64
Which anatomical part of the lungs needs oxygenated air for effective ventilation to occur?
Alveoli
65
Which of the following is key to delivering oxygen from the alveoli to the rest of the body?
Adequate blood supply
66
What represents the amount of air that reaches your alveoli divided by the amount of blood flow in the capillaries of your lungs?
V/Q ratio
67
What is the symbol for the volume of blood flow?
Q = perfusion
68
What is a scan of the lungs that uses radioactive dye to measure how well air flows through the lungs and where blood is flowing in the lungs?
Ventilation / perfusion (VQ) scan
69
What does V/Q mismatch mean?
The gas exchange is impaired by an issue with air or blood
70
Which of the following statements are true of normal V/Q ratios?
V/Q ratio is calculated by the air (ventilation) divided by the blood supply (perfusion), Capillaries supply blood at 5 L/min,
Alveoli receive air at 4 L/min
71
Which clinical explanation is appropriate to describe the condition of a client with a high V/Q ratio and whose blood supply to the capillaries is <5 L/min?
Narrowed capillaries or dead space such as a pulmonary embolus
72
What is the terminology referring to a physical defect that allows unoxygenated blood from the right side of the heart to move through to the left side of the heart?
Shunting
73
What is a normal V/Q ratio?
0.8
74
What would the nurse expect to hear when auscultating the quadrants of the abdominal cavity of a healthy client?
Bowel sounds & Heartbeat
75
The nurse is assessing a client. which findings cause the nurse to suspect the client may have internal bleeding?
Bleeding on the flanks of the abdomen, Presence of Cullen's sign
76
What is ascites?
A build-up of fluid in the abdomen
77
What can Cullen's sign be an indicator for?
Hemorrhagic pancreatitis
78
The nurse is assessing a new client's abdomen. Which assessment findings would be most concerned for the nurse?
The nurse hears bruits when auscultating the client's abdomen, The client has ecchymosis on their flanks, The client's abdomen is distended with bulging flanks
79
The closing of which valves creates the S1 heart sound?
Tricuspid & Mitral
80
Where is Erb's point?
At the third intercostal space and the left lower sternal border
81
What is the nurse assessing for when checking a client's pulse?
Rate, Tension, Strength
82
What does jugular vein distension indicate?
Fluid volume overload, Increased central venous pressure
83
When does the cardiac exam start?
When the nurse walks into the room and first sees the client
84
What is the nurse assessing when auscultating the heart?
S1, S2, Systole, Diastole
85
What valves are heard closing in the S1 heart sound?
Tricuspid & Mitral
86
The student nurse is auscultating their client's heart. Which student nurse action causes the nurse instructor to intervene?
The student nurse uses the bell of their stethoscope to auscultate S2
87
When is the 4th heart sound audible?
Immediately before S1
88
Which position should the client be placed to hear S3 and S4 best?
Left lateral decubitus
89
How is the intensity of a murmur measured?
On a scale from 1-6, with 1 being the most subtle and 6 being the most intense
90
What is true about aortic stenosis?
It can occur early mid or late systole, It is a crescendo-decrescendo murmur
91
What might the nurse expect in a client with known aortic stenosis?
A delay between S1 occurring and the radial pulse being palpable, A bruit to the right carotid artery
92
What is true about mitral regurgitation?
It is holosystolic murmur, The grade of the murmur is a good prediction of how severe it is
93
How is the handgrip maneuver performed?
Have the client squeeze a towel with both of their hands for 5-10 seconds
94
What is true about tricuspid regurgitation?
It is high-pitched, It is best heard during inhalation
95
What is true about aortic regurgitation?
It occurs when blood regurgitates back into the left ventricle, It is best heard between the tricuspid and pulmonic areas
96
How is pulse pressure calculated?
Systolic blood pressure - diastolic blood pressure
97
The nurse is caring for a client with aortic valve regurgitation. Which assessment findings would the nurse expect to see?
An audible S3 heart sound
98
What is true about mitral stenosis?
The intensity correlates with how severe the stenosis is, It is heard at the apex of the heart
99
When is aortic regurgitation best heard?
At beginning of S2
100
where should the nurse place their hand to attempt to palpate the point of maximal impulse in a healthy client?
Just below and lateral to the left nipple
101
The Glasgow coma scale is broken down into which assessment areas?
Motor response, Eye opening, Verbal response
102
The client opens their eyes spontaneously is oriented in all spheres and can obey commands. What is their Glasgow coma scale score?
15
103
The client only opens their eyes to painful stimuli makes incomprehensible sounds and ahs no motor response. What is their Glasgow coma scale?
5
104
During the shift report, the nurse is told that their new client has had GLasgow Coma scale score of eight throughout their hospital stay. How many the nurse expect their client to present during the morning assessment?
The client only opens their eyes and withdraws in response to painful stimuli and makes incomprehensible sounds.
105
The client does not open their eyes and has no verbal or motor response. What is their glasgow coma scale score?
3
106
The client opens their eyes when the nurse calls their name when asked, tells the nurse that the pen they are holding is called a ruler, and can touch their nose with their finger when asked. What is the client's glasgow coma scale score?
12
107
The nurse wants to assess a client's coordination using the finger to nose test. How does the nurse instruct the client to complete this test?
The nurse tells the client to touch their finger to their nose and then touch their finger to the nurse's finger
108
The nurse is assigned to several clients. On which client does the nurse intend to conduct a sensation exam?
The client admitted following a hemorrhagic stroke, The client who had recent spinal surgery
109
The client has paralysis to the right side of their body following a stroke. What type of paralysis does this client have?
Hemiplegia
110
The client sustained an injury to the sacral area of their spine. The client may complain of pai or loss of sensation to which other areas of their body resulting from this injury?
Posterior lower legs
111
What does PERRLA stand for?
Pupils are equal round reactive to light and accommodation
112
The student nurse is assessing a client's pupil response. Which student nurse action causes the nurse instructor to intervene?
The student nurse turns on the room lights and the client's bedside lights
113
The nurse is assigned to a client who has overdosed on morphine. How big does the nurse expect the client's pupils to be?
1 mm
114
Which cranial nerve controls the superior oblique muscle of the eye?
Trochlear nerve
115
How can the nurse assess a Marcus Gunn pupil?
By shining a light in each eye individually and assessing for a consensual pupil response
116
Which cranial nerve is responsibl for constricting the pupils?
Oculomotor nerve
117
Asking a client to identify a specific smell tests which cranial nerve?
I
118
The nurse is assessing a client for hearing loss. Which tests could the nurse use to perform this assessment?
Rinne test & Weber test
119
The nurse rubs their fingers beside a client's ears and asks them if they can hear it. The nurse is assessing which cranial nerve?
Vestibulocochlear nerve
120
Which cranial nerve help elevate the soft palate?
Vagus & Glossopharyngeal Nerve
121
The nerve route of which vertebrae innervates the biceps and deltoid muscles?
C5
122
A client can lift their bicep against gravity but cannot keep their arm flexed when the nurse pulls their arm down. What is the clients strength scale score?
3
123
Which reflex level is considered a high normal reflex?
3
124
The brachioradialis reflex assesses the function of which nerve route?
C6
125
When should the Jendrassik maneuver be used?
When there is no evidence o reflexes in the lower extremities
126
The client's urine is brown. What does the nurse suspect may be causing this?
Excess bilirubin
127
The student nurse is caring for a client with an indwelling catheter. Which student nurse action causes the nurse instructor to intervene?
The student nurse loops the catheter tubing around the bedrail to avoid the client tripping on it
128
When should a nurse empty a catheter collection bag?
When it is no more than half full
129
What is considered an abnormal finding during a male genitourinary exam?
Lack of scrotal contraction with palpation of the inner thigh
130
What does a positive Prehn's sign suggest?
Epididymitis
131
What is hypospadias?
When the urethral orifice is underneath the glans penis
132
What materials are required to perform a female genitourinary system assessment?
Pap brush & Speculum
133
The student nurse is preparing to perform a genitourinary exam on a female client. What student nurse statement causes the nurse instructor to intervene?
"Please don't try to look while I am performing the exam, I will walk you through what I am doing"
134
The specimen collected by the pap brush is used to detect what condition?
Cervical cancer
