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NUR 2102 > Test 2 > Flashcards

Test 2 Flashcards

1
Q

The nurse is assessing the client’s extraocular muscles (EOM). What test would be best to assess these muscles?

a. corneal light reflex

b. confrontation test

c. pupillary reaction

d. Snellen chart

A

a. corneal light reflex

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2
Q

When testing pupillary response to light, what is the expected reaction in the right eye when light is shone in the left eye?

a. no reaction

b. constriction

c. dilation

d. convergence

A

B. Constriction

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3
Q

The nurse is assessing the patient’s accommodation response. The expected response would be:

a. Peripheral vision intact

b. Pupils dilate when looking at an object far away

c. Can read 20/20 line without errors or squinting

d. Can follow object in 6 different places

A

B. Pupils dilate when looking at an object far away

PERRLA
A= accommodations of eyes contstrict (close), dilate (far)

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4
Q

The nurse is performing the corneal light reflex and notices the light reflects at 2 o’clock on both eyes. The nurse would:

a. Interpret this as a normal finding

b. Refer the client for further evaluation

c. Perform the cover/uncover test

d. Perform the confrontation test

A

A. Interpret this as a normal finding

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5
Q

Hypothyroidism

A

-Weight gained
-Constipation
-Increased sleep
-Bradycardic
-Hair loss
-Elevated TSH
-Apathy (lack interest/concern)

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6
Q

Hyperthyroidism

A

-Weight lost
-Increased stool
-Anxiety
-Tachycardic/abnormal
-Decreased TSH
-Thin Skin
-Hypertension

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7
Q

True or False

A large percentage of clients who develop oral cancer consume excessive amounts of alcohol

A

True

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8
Q

True or False

Incidence of oral cancer increases after age 80.

A

False

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9
Q

True or False

Thyroid cancer typically does not cause symptoms.

A

True

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10
Q

PERRLA

A

Pupils are Equal, Round and Reactive to Light & Accommodations

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11
Q

Pupils ______ when focusing on close objects

A

Constrict

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12
Q

Pupils_______ when focusing on object in distance

A

Dilate

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13
Q

Lab Values: ABGs

A

measures the oxygen and carbon dioxide levels in your blood as well your blood’s pH balance.

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14
Q

Lab Values: BUN (assess kidney filtering capabilities)
10-20 minutes to easily take out waste from your body

A

Normal: 10-20
Increased- dehydration, GI bleed, sepsis, renal disease
Decreased- liver failure, overhydration, pregnancy

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15
Q

Lab Values: Cholesterol type of lipid

A

> 200mg

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16
Q

Lab Values: Glucose (sugar)(glycemia)/HgBA1C (avg. bs)(energy source)

A

Levels vary throughout the day
Non fasting-200
Fasting- 70-110mg/dL
Too high= hyperglycemia(stress, cortisol, crushing, renal failure)
Too low=hypoglycemia (hypothyroidism, liver disease, insulin overdose, starvation)

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17
Q

Lab Values: Hemoglobin(o2 transport from lungs to tissues)
13-18 young blood high energy

A

Normal: 13-18(M) & 12-16(F) Usually mirrors RBCs
Increased=COPD, CHF
Decreased= Anemia, blood loss, Hodgkin disease, cirrhosis, lymphoma

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18
Q

Lab Values: Platelets- thrombocytes (to prevent and stop bleeding)
Small but high values

A

Normal: 150,000-400,000/mm3
Too high=Thrombocytosis (Prolong bleed, strenuous exercise)
Too low= Thrombopenia (Menstruation, hemorrhage)

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19
Q

Lab Values: Potassium/kalemia (maintains normal levels of fluid in body)
3.5 bananas to make 5 smoothies

A

Adult: 3.5-5.0 mEq/L
Too high- Hyperkalemia (renal failure, crush injuries, infection, dehydration)
Too low= Hypokalemia ( Burns, GI disorders, diuretics, insulin)

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20
Q

Lab Values: Sodium/Natremia (conducts nerve impulses, muscle contract/relax, balance of water/minerals)
i-495 salty drivers

A

Adult: 135-145 mEq/L
Too high=Hypernatremia (increased sodium intake, sweating, burns, GI loss w/ no hydration)
Too low= hyponatremia ( decreased sodium intake, Addison’s disease, diarrhea, vomiting, and nasogastric aspiration

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21
Q

Lab Values: WBC
Protects body from infections
5,000-10,000 warriors

A

Normal: 5,000-10,000
Too high= leukocytosis (infections)
Too low= Leukopenia (autoimmune diseases)

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22
Q

Lab Values: Creatinine (supply energy to muscle)
1 TBSP is more than enough

A

Normal: 0.6-1.2(M) & 0.5-1.1 (F)
Increased- renal disease, Rhabdomyolysis
Decreased- debilitation, decreased muscle mass

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23
Q

Lab Values: PT, PTT, APTT
Blood clot timing quicky

A

PT (Prothrombin time)- 11-12.5
PTT (Partial thromboplastin time)- 60-70 seconds

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24
Q

Lab Values: INR (International normalized ratio) blood clot time

A

0.8-1.1

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25
Q

Lab Values: RBCs- Erythrocytes
5mill
Delivers O2 to the body

A

Normal: 4.7-6.1 mill (M) & 4.2 -5.4 (F)
Too High=Erythrocytosis (low o2, dehydration)
Too Low=Erythropenia (Blood loss, hemolysis, malnutrition)

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26
Q

Lab Values: Hematocrit
Measures volume proportion of RBCs in blood
Just about half crit

A

Normal: 42-52%(M), 37-47%(F)
Usually 3X amount of Hgb if RBC is normal
Increased- dehydrated, low o2
Decreased- Anemia, blood loss, hemolysis, malnutrition

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27
Q

BMP ( Basic Metabolic Panel)

A

Glucose (70-110)
Calcium (9-10.5)
Sodium (135-145)
Potassium(3.5-5.0)
CO2 (23-30)
Chloride(98-106)
BUN (blood urea nitrogen) (10-20)
Creatinine (0.6-1.2)

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28
Q

Lab Values: CO2/Bicarbonate
(respiratory, blood pH)
More than 23 RR

A

Normal: 23-30mEq/L

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29
Q

Lab Values: Chloride (balance body fluids)
Older ppl more fluids

A

Adult: 98-106
Increased- acute renal failure, dehydration
Decreased- burns, sweating, GI loss (vomiting, diarrhea)

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30
Q

Calcium- Calcemia
blood clotting, helping muscles to contract, and regulating normal heart rhythms and nerve functions.

A

Adult: 9-10.5
Too high- Hypercalcemia (hyperparathyroidism, paget/addison disease, lymphoma)
Too low- Hypocalcemia (hypoparathyroidism, renal failure, Vitamin D, pancreatitis

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31
Q

Magnesium- building proteins and strong bones, and regulating blood sugar, blood pressure, and muscle and nerve functions
Double miralax

A

Adult: 1.3-2.1

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32
Q

Fluoroscopy- Higher exposure to radiation, coated with calcium tungstate

A

Fluorescent viewing screen, can see organs and their motions
upper gi

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33
Q

Nuclear Scanning

A

Diagnoses cancer, cholecystitis, pulmonary embolism

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34
Q

Endoscopy- Inspect internal organs using an endoscope

A

View and biopsy sus tissues, removes polyps, inject varices, perform surgical procedures

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35
Q

Clubbing of nails

A

Clubbing

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36
Q

Beau’s Lines

A

Beau’s Lines

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37
Q

Vascular Spider

A

Vascular Spider

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38
Q

Stage 1 pressure injury

A

Stage 1

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39
Q

Bulla

A

Bulla

40
Q

Papule

A

Papule

41
Q

How would you describe this lesion? (Herpes Varicella)
A. grouped
B. linear
C. discrete
D. gyrate

A

Grouped

42
Q

What is displayed?
A. lichenification
B. Hirsutism
C. telangiectasia
D. onychomycosis

A

Hirsutism

43
Q

What is this named?
A. impetigo
B. ecchymosis
C.furuncle
D. petechiae

A

Petechiae

44
Q

Macule

A

Macule

45
Q

Excoriation

A

Excoriation

46
Q

Stage 2 pressure injury

A

Stage II

47
Q

Patch

A

Patch

48
Q

Fissure

A
49
Q

Atrophic Scar

A

Stretch marks

50
Q

Keloid

A
51
Q

Ecchymosis

A
52
Q

Which of the following is true regarding glaucoma?

a. Risk increases after age 35
b. Caucasians are at highest risk
c. Diabetes and hypertension increase risk
d. Family history is not a risk factor

A

C. Diabetes and hypertension increase risk

53
Q

What is an expected finding when palpating lymph nodes?

a. mobile
b. tender
c. fixed
d. hard

A

A. Mobile

54
Q

When completing a skin assessment on a 19 yo female, the nurse notes which as an acceptable findings?

a. A black mole on the shoulder with an uneven border
b. 2 mm brown macule on the face
c. Mild bilateral ankle edema
d. Small amount of coarse hair on chin

A

B. 2 mm brown macule on the face

55
Q

When assessing the submental nodes, where are they located?

a. under the jaw
b. behind the ears
c. under the chin
d. at the angle of the jaw

A

C. Under the chin

56
Q

The client’s platelets are 600,000 mm3. How would the nurse interpret that value?

a. the client has an increased risk of clotting
b. the client needs a blood transfusion
c. this level is normal
d. the client may be overhydrated

A

a. the client has an increased risk of clotting

57
Q

The nurse is performing an otoscopic exam on a 2 year old. What technique should be used?

a. pull the helix up and forward
b. pull the pinna back and down
c. pull the helix forward and down
d. pull the pinna up and forward

A

b. pull the pinna back and down

58
Q

18 yo reports her heart racing & diagnosed with hyperthyroidism . On PE of the eyes, what may the nurse notice?

a. enophthalmos
b. clouding of the cornea
c. exophthalmos
d. recession

A

c. exophthalmos (eye bulging)

59
Q

Testing pupillary response, the right pupil constricts with light. What is the expected reaction in the left eye?
a. dilatation
b. constriction
c. no reaction
d. convergence

A

b. constriction

60
Q

When performing an otoscope examination on an adult, which of the following is true?

a. Tilt the client’s head forward
b. Release traction after the speculum is in the ear
c. Pull pinna up & back before inserting speculum
d. Use the smallest speculum

A

c. Pull pinna up & back before inserting speculum

61
Q

On PE of a 20 yo Asian client ,the nurse see dry, flaky cerumen in his canal. What is the significance of this?

a. this likely from eczema
b. poor hygiene and the nurse should do teaching
c. possibly from change in cilia- assess for hearing loss
d. this is a normal finding

A

d. this is a normal finding

62
Q

The client has been shown to have a sensorineural (lesion or disease caused) hearing loss. What is important during assessment?

a. speak loudly so he can hear the questions
b. assess for middle ear infection
c. ask what medications the client is taking
d. look for the source of obstruction

A

c. ask what medications the client is taking

63
Q

The tympanic membrane should appear:

a. light pink with a slight bulge
b. pulled in at the cone of light
c. pearly gray and slightly concave
d. whitish with a small speck of light in the superior portion

A

c. pearly gray and slightly concave

64
Q

Which of the following statements about cerumen is correct?

a. sticky, honey colored is a sign of infection
b. the purpose is to lubricate the ear
c. it is indicative of poor hygiene
d. it is necessary for transmitting sound

A

b. the purpose is to lubricate the ear

65
Q

The nurse is assessing a client’s eyes for accommodation. What is expected?

a. convergence
b. nystagmus
c. parallel extra ocular movements
d. pupil constriction when focusing on distant object

A

a. convergence (eyes follow close object)

66
Q

What is an expected finding when assessing the sclera of a dark skinned, African American client?

a. small brown macules
b. yellow color
c. white fatty deposits
d. pallor

A

a. small brown macules

67
Q

The nurse notes light reflected at 2:00 in both eyes during the corneal light reflex. What is the significance?

a. consider this a normal finding
b. document asymmetrical light reflex
c. refer for further evaluation
d. perform confrontation test to confirm findings

A

a. consider this a normal finding

68
Q

A patient’s vision is recorded as 20/30 using the Snellen eye chart. What does this mean?

a. client can read the whole chart at 30 feet
b. client can read at 30 ft what a normal eye can read at 20 ft
c. client can read at 20 ft what a normal eye can read at 30 ft
d. client can read 20 ft in right eye and 30 ft in left eye

A

c. client can read at 20 ft what a normal eye can read at 30 ft

69
Q

The nurse is testing the client’s EOMs (extraocular muscles). Which of the below is the best for assessing these muscles?

a. corneal light reflex
b. pupillary reaction
c. fundus color
d. red light reflex

A

a. corneal light reflex

70
Q

Which of the following would be a normal finding in an 80-year-old client?

a. high tone frequency loss
b. increased production of cerumen
c. a shiny, pink tympanic membrane
d. large nodule on the lobe

A

a. high tone frequency loss

71
Q

The nurse is preparing to assess the visual acuity of a 16 yo. What is the best method?

a. perform the confrontation test
b. ask the client to read the Jaeger card
c. ask the client to read the newspaper
d. use the Snellen chart

A

d. use the Snellen chart

72
Q

Which of the following physiological changes is responsible for presbyopia? (lose ability to focus on near objects)

a. loss of lens elasticity
b. decreased distance vision
c. degeneration of the cornea
d. arcus senilis

A

a. loss of lens elasticity

73
Q

What is the meaning of a client has a normal pupillary light reflex?

a. the eyes converge to focus on the light
b. light is reflected in the same spot on both eyes
c. the eyes follow in parallel movement through the cardinal gazes
d. constriction of both pupils in response to light

A

d. constriction of both pupils in response to light

74
Q

The client took twice the prescribed amount of oral anticoagulants for 8 weeks. What may the nurse see?

a. increased INR
b. increased hemoglobin
c. increased RBCs
d. decreased hematocrit

A

a. increased INR (clotting factors slowed)

75
Q

Which of the following put the client at an increased risk of skin cancer?

a. taking immune suppression medications
b. African race
c. being a plumber
d. brown eyes

A

a. taking immune suppression medications

76
Q

What describes a wound that has opened along suture lines?

a. primary intention
b. secondary intention
c. dehiscence
d. evisceration

A

c. dehiscence (spittling or bursing open of wound)

77
Q

The nurse is examining an African American’s right ear. What would be an unexpected finding?

a. 3 cm sebaceous cyst
b. sticky brown cerumen
c. cone of light at 5:00
d. small painless nodule on the helix

A

a. 3 cm sebaceous cyst

78
Q

The client report “sinus pain.” The nurse can examine which of the following sinuses using palpation?

a. maxillary
b. sphenoid
c. ethmoid
d. sublingual

A

a. maxillary

79
Q

Hypothyroidism

A

Elevated Tsh
Muscle weakness, apathy, weight gain, more sleep, coarse, dry skin/hair

80
Q

Hyperthyroidism

A

Lowered Tsh
Muscle weakness, manic behavior, decreased weight, lost sleep, flushed skin, fine hair

81
Q

Types of exudate:
Serous
Sanguineous
Serosanguinous
Purulent

A

Serous-clear, thin, and watery (inflammation healing stage)
Sanguineous-Bright red trauma
Serosanguinous- most common type, thin, pink, and watery in presentation.
Purulent- yellow, thick, build up from infection

82
Q

Annular/circular

A
83
Q

Gyrate (swirls or s shape)

A
84
Q

Discrete (looks like pimples)

A
85
Q

Grouped (little dots together)

A
86
Q

Polycyclic (bigger watery looking dots)

A
87
Q

Confluent (hivesX10)

A
88
Q

Linear

A
89
Q

Zosteriform

A
90
Q

Primary Skin Lesions
Direct result from disease

A

Macule- freckle
Papule- palpable slightly elevated (mole)
Patch
Plaque
Nodule- elevated solid firmer than papule
Wheal
Tumor
Urticaria (hives)
Vesicle- elevated w/fluid
Cyst
Bulla
Pustule

91
Q

Secondary Skin Lesions
evolve from primary lesions or develop as a consequence of the patient’s activities.

A

Crust
Scale
Fissure
Erosion
Ulcer
Excoriation
Scar
Atrophic scar
Lichenification
Keloid

92
Q

Normal Results for different ethnicity

A

Dark skinned nails- yellow or brown/ vertical bands
Eyes: light yellow

93
Q

Pressure injury stages

A
94
Q

Ear abnormalities

A
95
Q

lesion that is pink, smooth, and rubbery and has increased in size long after healing

A

Keloid

NUR 2102 (3 decks)

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