Lab Quiz 2

Question 1

Cataracts

Answer 1

Increased opacity of the lens

One of the most common eye disorders

Cloudy pupils indicate cataracts

Question 2

Hyperopia

Answer 2

Farsightedness

Rays of light enter the eye and focus behind the retina

People are able to see distant objects but not close ones

Question 3

Myopia

Answer 3

Nearsightedness

Rays of light enter the eye and focus in front of the retina

People are able to see close objects but not distant objects

Question 4

Strabismus

Answer 4

Condition in which both eyes do not focus on an object simultaneously

Question 5

Glaucoma

Answer 5

Increased intraocular pressure

Obstruction of the outflow of aqueous humor causes this

With out treatment this leads to blindness

Question 6

Retinopathy

Answer 6

Non inflammatory eye disorder resulting from changes in retinal blood vessels

Question 7

Presbyopia

Answer 7

Impaired near vision in middle age and older adults

Caused by loss of elasticity of the lens

Question 8

Normal size of the pupil

Answer 8

3 to 7 mm in diameter

Question 9

How to test pupillary reflexes (light and accommodation)

Answer 9

Ask the patient to look straight ahead bring the penlight from the side of his or her face directing the light into their pupil. It should constrict and the opposite pupil constrict con sensually

Accommodation the patient gazes at a distant object (far wall) and then at a test object (finger or pencil) held 4 inches from the bridge of their nose the pupils should converge and accommodate by constricting when looking at close objects

Question 10

PERRLA

Use if assessment of pupillary reaction is normal in all test

Answer 10

Pupils equal, round, reactive to light, and accommodation

Question 11

Normal responses that determine a patients level of consciousness

Answer 11

Responds to questions quickly and expresses ideas logically

Question 12

Glasgows coma scale

Answer 12

Use when a patient has a lower consciousness. Check to see if the patient has any sensory losses before starting. The higher the score the better the persons neurological function.

Question 13

Delirium

Answer 13

Is an acute mental disorder that occurs among hospitalized patients most often presents itself within the first 48 to 72 hours of hospital admission. Characterized by Confusion disorientation and restlessness. Often labeled with “sundown syndrome” because patients get worse at night. Condition often reverses when it’s correctly assessed and treated.

Question 14

Jaundice

Answer 14

Increased deposits of bilirubin in tissues

Yellow orange discoloration

Question 15

Erythema

Answer 15

Red discoloration can indicate circulatory changes

Often accompanies an increase in temp

Question 16

Pallor

Answer 16

Decrease in color of skin. Often accompanies a decrease in skin temp and reflects a decrease in blood flow

Question 17

You can identify stage one of a pressure ulcer by?

Answer 17

Noting warmth over an area of erythema

Question 18

Turgor

Answer 18

Degree of elasticity of skin

Question 19

What do edema and dehydration do to turgor?

Answer 19

Diminishes turgor. Skin stays pinched and shows tenting. The person with poor skin turgor does not have resilience to normal wear and tear. Which predisposes the patient to skin breakdown

Question 20

Petechiae

Answer 20

Non blanching pin point size red or purple spots on skin caused by small hemorrhages in the skin layers.

Question 21

Edema

Answer 21

Area of skin becomes swollen or edematous from a build up of fluid in the tissues. Skin appears stretched and shiny

Question 22

Pitting edema

Answer 22

When pressure from an examiners fingers leaves an indentation in the edematous area.

Question 23

Skin lesions

Answer 23

Refers broadly to any unusual findings of the skins surface

Question 24

Papule

Answer 24

Circumscribed solid elevation in skin

Question 25

Atrophy

Answer 25

Thinning of skin with loss of normal skin furrow appears shiny and translucent

Question 26

Cyanosis

Answer 26

A slightly bluish or grayish discoloration in skin

Question 27

Vesicle

Answer 27

Circumscribed elevation of skin filled with serous fluid

Question 28

Pustule

Answer 28

Circumscribed elevation of skin similar to Vesicle but filled with pus

Question 29

Macule

Answer 29

Flat non palpable change in skin color smaller than 1 cm

Freckle Petechiae

Question 30

What location should the nurse use to listen for clients apical pulse?

Answer 30

The fifth intercostal at left midclaviular line

Question 31

The second heart sound (s2) occurs when?

Answer 31

The aortic and pulmonic valves close

Question 32

The first heart sound (s1) is heard when?

Answer 32

There is rapid ventricular filling

Question 33

Macular degeneration

Answer 33

Blurred central vision caused by progressive degeneration of the center of the retina

Most common vision impairment of individuals over 50. Most common cause of blindness in older adults there is no cure

Question 34

Stage 4 pressure ulcer

Answer 34

Ulcer is full thickness tissue loss with exposed bone tendon or muscle. Slough or Eschar may be present. It often includes undermining and tunneling

Question 35

Stage 3 pressure ulcer

Answer 35

Full thickness skin loss (fat visible) ulcer is full thickness tissue loss subcutaneous fat may be visible but bone or tendon or muscle are not visible. Some slough may be present

Question 36

Stage 2 pressure ulcer

Answer 36

Partial thickness skin loss or blister. Partial thickness loss of dermis presents as a shallow open ulcer with a red pink wound bed without slough. It may also present as intact or open ruptured serum filled or serosangineous filled blister. Presents shiny or dry shallow ulcer with out slough or bruising

Question 37

Stage 1 pressure ulcer

Answer 37

Intact skin presents with non blanchable erythema of localized area discoloration of the skin warmth edema hardness or pain may be present. May be difficult to detect in patients with darker skin tones

Question 38

Braden scale

Answer 38

Is a valid tool used for pressure ulcer risk assessment. Lower total score indicates a higher risk for pressure ulcer development

Question 39

When assessing pulse strength 2+

Answer 39

Expected normal

Question 40

Capillary refill is normal if less than

Answer 40

2 seconds