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CNUR 107 > MIDTERM #1 > Flashcards

MIDTERM #1 Flashcards

1
Q

What is subjective data?

A

What the person says about themselves, their feelings, sensations, health history, verbal descriptions created by care giver, symptoms

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2
Q

What is objective data?

A

What the health care provider observes during the assessment, what is measurable, seen and heard.

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3
Q

What are the 5 parts of the nursing process

A 
Assessment
Nursing Diagnosis
Planning
Implementation
Evaluation
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4
Q

Explain “Assessment” in the nursing process

A

Collecting, organizing, validating, and documenting Data.

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5
Q

Explain “Nursing Diagnosis” in the nursing process

A

Analyze data, Identify health problems risks and strengths, formulate diagnostic statements.

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6
Q

Explain “Nursing Planning” in the nursing process

A

Prioritize problems and diagnoses, formulate goals, design health outcomes, identify nursing intervention

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7
Q

Explain “Nursing Implementation” in the nursing process

A

Reassess the patient, determine the nurse’s need for assistance, implement nursing interventions, supervise delegated care, document nursing activities.

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8
Q

Explain “Nursing Evaluation” in the nursing process

A

Collect data related to outcomes, complete data with outcomes, relate nursing actions to patient goals/outcomes, draw conclusions about problem status, continue to modify or end the patient’s care plan.

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9
Q

Nursing Assessment

A

Collection of data about an individual health state

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10
Q

Inspection

A

Concentrated/purposeful watching, always performed first

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11
Q

Palpation

A

Assessment of texture, temperature, moisture, size, swelling vibration etc.

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12
Q

What are your fingertips best at assessing?

A

Best for determining, texture, swelling, pulsation, and lumps.

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13
Q

What are grasping action between fingers best for assessing?

A

Best for detecting the position, shape, and consistency of an organ or mass.

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14
Q

What are the back of the hands best for assessing?

A

Temperature

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15
Q

What are the base of fingers best for assessing?

A

Vibration

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16
Q

What is percussion

A

Tapping the person skin and assessing the sound

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17
Q

What is resonant?

A

medium in sound low pitch and hollow

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18
Q

What is hyper resonant?

A

Very Loud in sound very deep, booming

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19
Q

What is Tymphany?

A

Loud in sound, high pitch sounds musical like

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20
Q

What is Dull?

A

Soft, high pitched muffled thud

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21
Q

What is flat?

A

Very soft, high pitched instant stop of dull sound

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22
Q

What is ausculation

A

Listening to sounds

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23
Q

What is the bell for

A

Low sounds

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24
Q

What is the diaphragm for?

A

For high sounds

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25
Q

What are signs?

A

An objective abnormality that you as the examiner detect on a physical examination, or report

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26
Q

What are Symptoms?

A

Subjective statements that patient feels from the disorder

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27
Q

Iliac is AKA?

A

Inguinal

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28
Q

Hypo-gastric is AKA?

A

Suprapubic

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29
Q

I fell off my bike 2 hours ago.

A

Subjective

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30
Q

Client is slumped over in the chair.

A

Objective

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31
Q

I took 2 Tylenol for my broken arm.

A

Subjective

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32
Q

BP 120/80 Respiratory Rate 12 Pulse 80

A

Objective

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33
Q

The client is 52 years old.

A

Objective

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34
Q

The client’s hair is brown.

A

Objective

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35
Q

My hair started falling out about a month ago.

A

Subjective

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36
Q

Bruising on left forearm that is purple and blue in color.

A

Objective

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37
Q

It feels like I have bugs crawling on my skin.

A

Subjective

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38
Q

The client’s room smells like alcohol.

A

Objective

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39
Q

The client is wearing clothes inappropriate for the weather.

A

Sign

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40
Q

The client’s temperature was 37 C.

A

Sign

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41
Q

The client stated he expected to have more pain than he is.

A

Symptom

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42
Q

“It is very hot in this room.”

A

Symptom

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43
Q

The length of the client’s leg is 31 inches

A

Sign

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44
Q

“I feel like I am going to throw up.”

A

Symptom

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45
Q

The client stated that she has had this feeling before.

A

Symptom

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46
Q

Bowel Sounds present in all 4 abdominal quadrants.

A

Sign

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47
Q

The client stated her husband hit her in the head.

A

Symptom

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48
Q

The nurse heard the client crying.

A

Sign

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49
Q

What is the 60 second assessment

A 
ABC’s
Tubes and Lines
Respiratory Equipment
Patient Safety Survey
Environmental Survey
Sensory
Additional Assessments
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50
Q

What is the 60 second assessment

A 
ABC’s
Tubes and Lines
Respiratory Equipment
Patient Safety Survey
Environmental Survey
Sensory
Additional Assessments
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51
Q
  1. You are teaching an adolescent girls’ group about safer sexual practices. This is an example of which level of disease prevention?
    a. primary prevention
    b. secondary prevention
    c. tertiary prevention
    d. disease screening
A

A

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52
Q
  1. An example of a “looking upstream” approach would be:
    a. starting up an early-childhood development program. b. ensuring that adolescents have access to sexually transmitted infection screening.
    c. initiating a school lunch program.
    d. providing foot care to diabetic seniors.
A

A

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53
Q
  1. You are providing nutritional counselling to a diabetic woman living in a remote First Nations community. You advise her to include more fresh vegetables in her diet, but she tells you that vegetables are very expensive in the community and she can’t afford to buy them. This is an example of:
    a. secondary prevention.
    b. the Ottawa Charter for Health Promotion
    c. tertiary prevention.
    d. a social determinant of health.
A

D

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54
Q

Describe the 5 principles of culturally competent care?

A

Resist the practice of “othering”
Everyone has a unique cultural identity
There is as much diversity within culture as across them
There is a difference between self-identity and being identified
Beware the dangers of stereotyping

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55
Q

State the purpose of the complete health history.

A

The purpose of the complete health history is to collect subjective data. The history is combined with the objective data that are obtained from the
physical examination and laboratory studies, to form the database. The database is used to make a
judgement or diagnosis about the health status of a person.

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56
Q

List and define the critical characteristics used to explore each symptom the patient identifies

A

O – onset (When did the pain start?)
P – provocative/palliative (Does anything make it feel worse)
Q – quality of pain (What does it feel like?)
R – region of body/radiation (Where is located? is it going anywhere?)
S – severity (How would you rate the intensity?)
T - treatment/timing ( Have you done anything to help, is the pain constant or a cycle?)
U – understanding of the pain ( What does patient think this is?)
V – values (What is your acceptable level?)

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57
Q
  1. When reading a medical record, you see the following notation: “Patient states, ‘I have had a cold for about a week, and now I am having difficulty breathing.’” This is an example of:
    a. past history.
    b. a review of systems.
    c. a functional assessment.
    d. a reason for seeking care.
A

D

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58
Q

You have reason to question the reliability of the information being provided by a patient. One way to verify the reliability within the context of the interview is to:

a. rephrase the same questions later in the interview.
b. review the patient’s previous medical records.
c. call the person identified as emergency contact to verify data provided.
d. provide the patient with a printed history to complete and then compare the data provided.

A

A

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59
Q

The statement “reason for seeking care” has replaced the “chief complaint.” This change is significant because: a. “chief complaint” is really a diagnostic statement.

b. the newer term allows another individual to supply the necessary information.
c. the newer term incorporates wellness needs.
d. “reason for seeking care” can incorporate the history of present illness.

A

C

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60
Q

During an initial interview, the examiner says, “Mrs. J., tell me what you do when your headaches occur.” With this question, the examiner is seeking information about: a. the patient’s perception of the problem.

b. aggravating or relieving factors.
c. the frequency of the problem.
d. the severity of the problem.

A

B

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61
Q

Which of the following is an appropriate recording of a patient’s reason for seeking health care?

a. angina pectoris, duration two hours
b. substernal pain radiating to left axilla, one hour duration
c. “grabbing” chest pain for two hours
d. pleurisy, two days’ duration

A

C

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62
Q
  1. Select the best description of “review of systems” as part of the health history.
    a. the evaluation of the past and present health state of each body system
    b. a documentation of the problem as described by the patient
    c. the recording of the objective findings of the practitioner
    d. a statement that describes the overall health state of the patient
A

A

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63
Q

Which of the following is considered to be subjective?

a. temperature of 38.5°C
b. pulse rate of 96 beats/min
c. measured weight loss of 10 kg since the previous measurement
d. pain lasting two hours

A

D

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64
Q

Functional assessment measures how a person manages day-to-day activities. The impact of a disease on the daily activities of older adults is referred to as:

a. interpersonal relationship assessment.
b. instrumental activities of daily living.
c. reason for seeking care.
d. disease burden.

A

D

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65
Q

Functional assessment measures how a person manages day-to-day activities. The impact of a disease on the daily activities of older adults is referred to as:

a. interpersonal relationship assessment.
b. instrumental activities of daily living.
c. reason for seeking care.
d. disease burden.

A

D

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66
Q

Distinguish between direct percussion and indirect percussion

A

Direct percussion involves the striking hand directly contacting the body wall. Indirect percussion is
used more often, and uses both hands. A hand is placed over the area, the stationary hand, which
remains fixed, while the striking hand contacts the stationary hand to produce a sound.

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67
Q

Describe the environmental conditions to consider in preparing the examination setting.

A

Ensure that the examination room is warm, comfortable, quiet, private, and well lit. Be sure to have
all equipment available. Before starting any assessment, do an environmental scan to ensure the
environment is safe.

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68
Q
  1. Various parts of the hands are used during palpation. The part of the hand used for the assessment of vibration is (are) the:
    a. fingertips.
    b. index finger and thumb in opposition.
    c. dorsum of the hand.
    d. ulnar surface of the hand.
A

D

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69
Q
  1. When performing indirect percussion, the stationary finger is struck:
    a. at the ulnar surface.
    b. at the middle joint.
    c. at the distal interphalangeal joint.
    d. wherever it is in contact with the skin.
A

C

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70
Q
  1. The best description of the pitch of a sound wave obtained by percussion is:
    a. the intensity of the sound.
    b. the number of vibrations per second.
    c. the length of time the note lingers.
    d. the overtones of the note.
A

B

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71
Q
  1. The bell of the stethoscope:
    a. is used for soft, low-pitched sounds.
    b. is used for high-pitched sounds.
    c. is held firmly against the skin.
    d. magnifies sound.
A

A

72
Q
  1. At the conclusion of the examination, the examiner should:
    a. document findings before leaving the examining room.
    b. have findings confirmed by another practitioner.
    c. relate objective findings to the subjective findings for accuracy.
    d. summarize findings to the patient.
A

D

73
Q
  1. A nosocomial infection is one that is acquired:
    a. in a hospital setting.
    b. in a public facility.
    c. by the fecal–oral route.
    d. through airborne contaminants.
A

A

74
Q

Symmetrical

A

Client’s left side and right side looks the same

75
Q

Alert

A

Awake, readily aroused, aware of stimuli & able to respond appropriately to that stimuli

76
Q

Lethargic

A

not fully alert, look drowsy or inattentive; thinking seems slow or fuzzy; drift off to sleep but can be aroused when name called

77
Q

Oriented

A

get a sense if the person if fully oriented to these 4 domains:
TIME - day of the week, date, year, season
PLACE – present location, name of city, where they live
PERSON – who the examiner is
SELF – what is their own name, age

78
Q

Define Pallor

A

When client is pale in skin tone

79
Q

Define Stupor (semicoma)

A

respond only to vigorous shake or painful stimulus; not really verbal but groans or mumbles

80
Q

Coma

A

completely unconscious; no response to pain or any other stimulus

81
Q

Hyper vs hypothermia

A

Hyperthermia: Very hot
Hypothermia: Very cold

82
Q

Febrile / afebrile

A

Febrile: Fever
Aferbrile: No fever

83
Q

Hyper vs hypotension

A

Hypertension: High BP
Hypotension: Low BP

84
Q

Systolic blood pressure

A

The maximum pressure on the artery during left ventricular contraction

85
Q

Diastolic blood pressure

A

The elastic recoil or resting pressure that the blood exerts during each contraction

86
Q

Bradycardia

A

Slow heart reat

87
Q

Tachycardia

A

Fast heart rate

88
Q

Tachypnea

A

Slow breathing

89
Q

What are the parts of a general survey?

A 
Age
Sex
Level of Consciousness
Skin Colour
Facial Features
90
Q

What is the normal temperature range of a person

A

35.8 - 37.3

91
Q

What is a healthy person’s heart rate

A

50 to 95 beats/min

92
Q

What is a healthy person’s respiration

A

10-20 breaths/min

93
Q

What is a healthy person blood pressure

A

120/80

94
Q

What is a healthy person’s SP02

A

97-99%

95
Q

Why are vitals signs important

A

They determine which treatment protocols to follow, provide critical information needed to make life-saving decisions, and confirm feedback on treatments performed.

96
Q

Nociceptive Pain

A

Caused by tissue injury, well localized

97
Q

Somatic

A

Superficial derived from skin surface or subcutaneous; or deep structures (i.e., tendon, bone)

98
Q

Visceral

A

Arises from larger interior organs, often poorly localized, constant or intermittent (i.e. appendicitis)

99
Q

Neuropathic Pain

A

Results from damage to nerve pathway/or directly from a lesion or a disease. Burning, shooting sensations; may be decreased pain sensation

100
Q

Referred Pain

A

Originates in one location and is felt somewhere else

101
Q

Acute Pain

A

Short term; self-limiting; goes away after injury heals

Follows a predictable trajectory (i.e. after surgery)

102
Q

Persistent (or chronic)

A

Present for 6 months or longer that the time expected for healing to occur
May be experienced differently by different clients
Malignant (related to cancer)
Non-malignant (i.e. arthritis)

103
Q

What nervous system is pain detected in

A

Central nervous system

104
Q 
List the significant information considered in each of the four areas of a general survey: 
physical appearance, 
body structure, 
mobility,
behaviour.
A

Physical appearance: age, sex, level of consciousness, skin colour, facial features
Body structure: stature, nutrition, symmetry, posture, position, body build, contour
Mobility: gait, range of motion
Behaviour: facial expression, mood and affect, speech, dress, personal hygiene

105
Q

Describe the normal posture and body build.

A

Normal posture: The person stands comfortably erect, as appropriate for his or her age. Note
the normal “plumb line” that would cross through the anterior ear, shoulder, hip, patella, and ankle. The
toddler may have “toddler lordosis” because of a normally protuberant abdomen, and the aging person
may have kyphosis.
Body build, contour proportions are:
 Arm span (fingertip to fingertip) equals height
 Body length from crown to pubis roughly equals the length from pubis to sole

106
Q

For Pounds to Kg what is the formula

For Cm to inches what is the formla

A

Divide by 2.2 to get KG

Divide by 30 for Feet

107
Q

What changes in height and in weight distribution would you expect for an adult in his or her 70s and 80s?

A

In the older adult, body weight decreases as a result of muscle shrinkage. Subcutaneous fat is lost
from the face and periphery, and additional fat is deposited on the abdomen and hips. Height may also
decrease because of shortening of the spinal column secondary to thinning of the vertebral disks and
shortening of the individual vertebrae, as well as the postural changes of kyphosis, and slight flexion in the hip and knees

108
Q

Factors that affect bp

A

BP taken when patient is moody, when arm is above or below heart, patient supports own are, deflating too quickly or slowly, halting and restarting, time of day, cardiac output, viscosity, elasticity, resistance, volume

109
Q

Explain the significance of phase I, phase IV, and phase V Korotkoff’s sounds during blood pressure measurement.

A

Phase 1 Systolic
Phase 5 diastolic
Phase 4 Recorded on separate occasions

110
Q

Describe the tympanic membrane thermometer, and compare its use to other forms of temperature measurement.

A
  1. The tympanic membrane thermometer (TMT) senses the infrared emissions of the tympanic
    membrane, which shares the same vascular supply that perfuses the hypothalamus (the internal carotid
    artery). Compared with other forms of temperature measurement, the TMT is noninvasive,
    nontraumatic, quick, and efficient. It is useful with toddlers, who need restraint if the rectal route is
    used, and is also useful for preschoolers, who are unable to cooperate for an oral temperature and fear
    the invasion of a rectal temperature. Conflicting evidence has led to a move away from the use of
    tympanic thermometry in critical patients and has fallen out of favour in many acute hospital
    environments.
111
Q

Describe four qualities to consider when assessing the pulse.

A

(1) Rate
(2) Rhythm
(3) Force
(4) Elasticity

112
Q

Define and describe the relationships among the terms pulse pressure, and mean arterial pressure

A

Pulse pressure is the difference between the systolic and diastolic and reflects the stroke volume, mean arterial pressure is pressure-forcing blood into the tissues, averaged over the cardiac cycle. Close to diastolic pressure plus one-third of pulse pressure

113
Q

Note aspects of normal gait

A

Base is as wide as the shoulder width. Foot placement is accurate, walk is booth, coordinated, even and well balanced, symmetrical arm swing present

114
Q

Stage 1 hypertensoin

Stage 2 Hypertension

A

S more than 120 D more than 80
S more than 140 D more than 90
S: more than 160 D: more than 100

115
Q

The four areas to consider during the general survey are:

a. ethnicity, sex, age, and socioeconomic status.
b. physical appearance, sex, ethnicity, and affect.
c. dress, affect, nonverbal behaviour, and mobility.
d. physical appearance, body structure, mobility, and behaviour.

A

D`

116
Q

During the general survey part of the examination, gait is assessed. When walking, the base is usually:

a. varied, depending upon the height of the person.
b. equal to the length of the arm.
c. as wide as the shoulder width.
d. half of the height of the person

A

C

117
Q

During the eighth and ninth decades of life, what changes occur in height and weight?

a. both increase
b. weight increases, height decreases
c. both decrease
d. both remain the same as during the 70s

A

C

118
Q

During an initial home visit, the patient’s temperature is noted to be 36.3°C. This temperature: a. cannot be evaluated without a knowledge of the person’s age. b. is below normal. The person should be assessed for possible hypothermia. c. should be retaken by the rectal route because this best reflects core body temperature. d. should be reevaluated at the next visit before a decision is made.

A

A

119
Q

Select the best description of an accurate assessment of a patient’s pulse.

a. count for 15 seconds if pulse is regular
b. begin counting with 0; count for 30 seconds
c. count for 30 seconds, and multiply by 2 for all cases
d. count for 1 full minute; begin counting with 0

A

B

120
Q

After assessing the patient’s pulse, the practitioner determines the pulse force to be “normal.” This would be recorded as:

a. 31
b. 21
c. 11
d. 0

A

B

121
Q

Select the best description of an accurate assessment of a patient’s respirations.

a. count for a full minute before taking the pulse
b. count for 15 seconds, and multiply by four
c. count after informing the patient where you are in the assessment process
d. count for 30 seconds following pulse assessment

A

D

122
Q

Pulse pressure is:

a. the difference between the systolic and diastolic pressure.
b. a reflection of the viscosity of the blood.
c. another way to express the systolic pressure.
d. a measure of vasoconstriction.

A

A

123
Q

Mean arterial pressure is:

a. the arithmetic average of systolic and diastolic pressures.
b. the driving force of blood during systole.
c. diastolic pressure plus one-third pulse pressure.
d. corresponding to phase III Korotkoff’s

A

C

124
Q

Explain how acute and persistent pain differs in terms of nonverbal behaviours.

A

Acute pain nonverbal behaviours: guarding; grimacing; vocalizations, such as moaning, agitation,
restlessness, stillness, and diaphoresis, or changes in vital signs.
Persistent pain nonverbal behaviours: there will be more variability of behaviours with chronic pain
because the person adapts to it over time. Some examples include bracing, rubbing, diminished activity,
sighing, and change in appetite.

125
Q

How would you assess for pain in an individual with dementia?

A

Use observations and chart with smiley faces

126
Q

What would you say to a colleague who remarks that the individual with Alzheimer’s disease does not feel pain and therefore does not require an analgesic?

A

They can still feel pain so they need it. Alzheimer’s isn’t painful but it can cause pain.

127
Q

While you are taking a history, the patient describes a burning, painful sensation that moves around his toes and bottoms of his feet. These symptoms are suggestive of:

a. nociceptive pain.
b. neuropathic pain.

A

B

128
Q

The most reliable indicator of pain in the adult is:

a. degree of physical functioning.
b. nonverbal behaviours.
c. magnetic resonance imaging findings.
d. the patient’s self-report.

A

C

129
Q

When a person presents with acute pain of the abdomen, following the initial examination, it is best to withhold analgesia until diagnostic testing is completed and a diagnosis is made.

a. true
b. false

A

B

130
Q

A pain problem should be anticipated in a cognitively impaired older adult with a history of:

a. diabetes.
b. peripheral vascular disease.
c. chronic obstructive pulmonary disease (COPD).
d. Parkinson’s disease.

A

B

131
Q

During the physical examination, your patient is diaphoretic and pale, and complains of pain directly over the left upper quadrant (LUQ) of the abdomen. This would be categorized as:

a. cutaneous pain.
b. somatic pain.
c. visceral pain.
d. psychogenic pain

A

C

132
Q

For older adult postoperative patients, poorly controlled acute pain places them at higher risk for:

a. atelectasis.
b. increased myocardial oxygen demand.
c. impaired wound healing.
d. all of the above.

A

D

133
Q

A 30-year-old female reports having persistent intense pain in her right arm related to trauma sustained from a car accident 5 months ago. She states that the slightest touch or clothing can exacerbate the pain. This report is suggestive of:

a. referred pain.
b. psychogenic pain.
c. complex regional pain syndrome.
d. cutaneous pain.

A

C

134
Q

What does GU mean

A

Genitourinary

135
Q

Dysuria

A

Painful or difficult urination, burning

136
Q

Hematuria

A

Presence of blood in a person’s urine

137
Q

HPV

A

Common sexually transmitted disease that can lead o genital warts

138
Q

TSE

A

Testicular self-examination

139
Q

What stores sperm

A

Epididymis

140
Q

Nocturia

A

Excessive peeing during the night

141
Q

What are the efffects of prostate englargement

A

Trouble urinating

142
Q

What are the objective data for a penis

A

Inspect and palpate the penis
Inspect and palpate the scrotum
Inspect and palpate for hernia
Palpate the inguinal lymph nodes

143
Q

What happens to womens vagina when they age

A 
Rapid decrease in hormones 
Stages of menopause
Shrinkage of uterus and ovaries
More fragile vaginal surfaces
Physiological changes in sexual response cycle 
Decreased natural lubrication
144
Q

Vagina objective data

A 
External genitalia—Inspection
Skin colour
Hair distribution
Labia majora
Any lesions
Clitoris
Labia minora
Urethral opening
Vaginal opening 
Perineum
Anus
145
Q

Comparison of Female and Male Genitourinary Anatomy

A

Urethra is 5x longer in males than in females
Divided into 3 segments in males but is only one short tube in females

Females are more prone to urinary tract infections

A common duct for the urinary and reproductive systems in males.

Two separate systems in females

146
Q

What screening are older women reccomend to get

A

Cervical screening

147
Q

Describe the function of the cremaster muscle

A

The cremaster muscle controls the size of the scrotum by responding to the temperature around the scrotal area. This action keeps the testes at a temperature 3°C below the abdominal temperature, which is the ideal temperature for producing sperm.

148
Q

Identify the structures that provide transport of sperm

A

Sperm are transported along a series of ducts. First, the testis is capped by the epididymis, which is the main storage site for sperm. The lower part of the epididymis is continuous with a muscular duct, the vas deferens, which then approximates with other vessels to form the spermatic cord. The spermatic cord eventually joins the duct of the seminal vesicle to form the ejaculatory duct, which empties into the urethra.

149
Q

Describe the significance of the inguinal canal and the femoral canal.

A

Knowledge of these anatomical areas in the groin is useful because they are potential sites for a hernia, which is a portion of bowel protruding through a weak area in the musculature.

150
Q

Identify the normal bladder capacity, daily total volume of urine output, and the average bladder volume that typically initiates the urge to void.

A

Normal adult urine output is 1500 mL per day but varies with food and fluid intake, and normal bladder capacity ranges from 600 to 1000 mL. On average, 200 to 250 mL of urine in the bladder causes moderate distention and urge to urinate. (See p. 763, “Assessment of Urine Output.”)

151
Q

During examination of the scrotum, a normal finding would be that:

a. the left testicle is firmer to palpation than the right.
b. the left testicle is larger than the right.
c. the left testicle hangs lower than the right.
d. the left testicle is more tender to palpation than the right.

A

C

152
Q

A 64-year-old man has come for a health examination. A normal, age-related change in the scrotum would be:

a. testicular atrophy.
b. testicular hypertrophy.
c. pendulous scrotum.
d. increase in scrotal rugae

A

C

153
Q

During palpation of the testes, the normal finding would be:

a. firm to hard, and rough.
b. nodular.
c. 2 to 3 cm long by 2 cm wide and firm.
d. firm, rubbery, and smooth.

A

D

154
Q

A 20-year-old man has indicated that he does not perform testicular self-examination. One of the facts that should be shared with him is that testicular cancer, though rare, does occur most commonly in men aged:

a. under 15.
b. 15 to 49.
c. 50 to 65.
d. 65 and older

A

B

155
Q

How sensitive to pressure are normal testes?

a. somewhat
b. not at all
c. left more sensitive than right.
d. only when inflammation is present

A

A

156
Q

List the external structures of the female genitalia.

A

Vulva, mons pubis, labia majora, labia minora, frenulum, clitoris, vestibule, urethral meatus, paraurethral glands, vaginal orifice, hymen, vestibular glands

157
Q

Outline the changes observed during the perimenopausal period.

A

During the perimenopausal period, decline in ovarian function causes irregular menses that gradually become farther apart and produce a lighter flow than usual. The ovaries stop producing progesterone and estrogen, causing the dramatic physical changes of menopause. The uterus shrinks in size, and the ovaries atrophy. The sacral ligaments relax, and pelvic musculature weakens, causing the uterus to droop. The cervix shrinks and looks paler with a thick, glistening epithelium. The vagina becomes shorter, narrower, and less elastic; the vaginal epithelium atrophies, becoming thinner, drier, and itchy. Externally, the mons pubis looks smaller as a result of atrophy of the fat pad. The labia and the clitoris gradually decrease in size, and pubic hair becomes thin and sparse.

158
Q

Discuss infection control precautions taken during examination of female genitalia and procuring of specimens.

A
  1. The examiner should first wash the hands and then put on gloves and protective clothing. The examiner will perform a visual inspection and palpation of the external genitalia, and then insert the speculum to examine the internal structures. Once the speculum examination is completed, cervical smears and culture specimens are obtained, and then the speculum is removed. The metal speculum should be placed in a basin for later sterilizing and disinfection; use of plastic types should be avoided. At this point, gloves should be discarded and the hands washed. With fresh gloves, the bimanual examination is performed, followed by the rectovaginal examination. Gloves should be changed again before the rectovaginal examination to prevent spreading any possible infection. When obtaining specimens, the nurse must be ensure that the sterile swabs and culture media are not contaminated.
159
Q
  1. Vaginal lubrication is provided during intercourse by: a. the labia minora.
    b. sebaceous follicles.
    c. Skene’s glands.
    d. Bartholin’s glands.
A

D

160
Q

During the examination of the genitalia of a 70-year-old woman, a normal finding would be:

a. hypertrophy of the mons pubis.
b. increase in vaginal secretions.
c. thin and sparse pubic hair.
d. bladder prolapse.

A

C

161
Q

Which of the following is (are) normal, common finding(s) on inspection and palpation of the vulva and perineum?

a. labia majora that are wide apart
b. palpable Bartholin’s glands
c. clear, thin discharge from paraurethral glands
d. bulging at introitus during Valsalva manoeuvre

A

A

162
Q

What is the name of all auscultation valves of the heart

A

Aortic, Pulmonary, Erb’s point, tricuspid Mitral

163
Q

Apical Pulse

A

Heard on the apex of the heart, Seen when patient rolls on their side, can be seen in children

164
Q

What is S1 and S2

A

S1 is lub S2 is dub
S1 is the start of systole, caused by the closure of AV Valves
S2 closure of semilunar valves

165
Q

What are bruits

A

They are vascular murmers that are generated by turbulent blood flow

166
Q

What is a pulse deficit?

A

Weak contraction of the ventricles

167
Q

What are the layers of the heart wall

A

Perocardium, Myocardium, Endocardium

168
Q

What are the four changbers of the heart seperated byq

A

Valves

169
Q

Right AV valve is AKA

A

Tricuspid

170
Q

Left AV valve is AKa

A

Bicuspid/Mitralq

171
Q

right semilunar valve is aka

A

Pulmonic Valve

172
Q

Left semilunar valve is aka

A

Aortic Valve

173
Q

In diastol ventricles are __________________ valves

_______ __________ are ______ so the ventricles can fill with blood

A

Relaxd
Tricuspd
Bicuspid
Open

174
Q

SYSTOLE
↑ pressure in _____(from blood) causes _____ & ____- valve closure
Ventricles _________, semilunar valves open & blood pumped to body or lungs

A

Ventricles
Tricuspid
Mitral

175
Q

Preload

A

Preload = amount of blood in atria at the end of diastole

176
Q

Afterload

A

Afterload = pressure the ventricles must contract against (resistance

CNUR 107 (2 decks)

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