Test 2 Flashcards
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. corneal light reflex
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
B. Constriction
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
B. Pupils dilate when looking at an object far away
PERRLA
A= accommodations of eyes contstrict (close), dilate (far)
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. Interpret this as a normal finding
Hypothyroidism
-Weight gained
-Constipation
-Increased sleep
-Bradycardic
-Hair loss
-Elevated TSH
-Apathy (lack interest/concern)
Hyperthyroidism
-Weight lost
-Increased stool
-Anxiety
-Tachycardic/abnormal
-Decreased TSH
-Thin Skin
-Hypertension
True or False
A large percentage of clients who develop oral cancer consume excessive amounts of alcohol
True
True or False
Incidence of oral cancer increases after age 80.
False
True or False
Thyroid cancer typically does not cause symptoms.
True
PERRLA
Pupils are Equal, Round and Reactive to Light & Accommodations
Pupils ______ when focusing on close objects
Constrict
Pupils_______ when focusing on object in distance
Dilate
Lab Values: ABGs
measures the oxygen and carbon dioxide levels in your blood as well your blood’s pH balance.
Lab Values: BUN (assess kidney filtering capabilities)
10-20 minutes to easily take out waste from your body
Normal: 10-20
Increased- dehydration, GI bleed, sepsis, renal disease
Decreased- liver failure, overhydration, pregnancy
Lab Values: Cholesterol type of lipid
> 200mg
Lab Values: Glucose (sugar)(glycemia)/HgBA1C (avg. bs)(energy source)
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)
Lab Values: Hemoglobin(o2 transport from lungs to tissues)
13-18 young blood high energy
Normal: 13-18(M) & 12-16(F) Usually mirrors RBCs
Increased=COPD, CHF
Decreased= Anemia, blood loss, Hodgkin disease, cirrhosis, lymphoma
Lab Values: Platelets- thrombocytes (to prevent and stop bleeding)
Small but high values
Normal: 150,000-400,000/mm3
Too high=Thrombocytosis (Prolong bleed, strenuous exercise)
Too low= Thrombopenia (Menstruation, hemorrhage)
Lab Values: Potassium/kalemia (maintains normal levels of fluid in body)
3.5 bananas to make 5 smoothies
Adult: 3.5-5.0 mEq/L
Too high- Hyperkalemia (renal failure, crush injuries, infection, dehydration)
Too low= Hypokalemia ( Burns, GI disorders, diuretics, insulin)
Lab Values: Sodium/Natremia (conducts nerve impulses, muscle contract/relax, balance of water/minerals)
i-495 salty drivers
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
Lab Values: WBC
Protects body from infections
5,000-10,000 warriors
Normal: 5,000-10,000
Too high= leukocytosis (infections)
Too low= Leukopenia (autoimmune diseases)
Lab Values: Creatinine (supply energy to muscle)
1 TBSP is more than enough
Normal: 0.6-1.2(M) & 0.5-1.1 (F)
Increased- renal disease, Rhabdomyolysis
Decreased- debilitation, decreased muscle mass
Lab Values: PT, PTT, APTT
Blood clot timing quicky
PT (Prothrombin time)- 11-12.5
PTT (Partial thromboplastin time)- 60-70 seconds
Lab Values: INR (International normalized ratio) blood clot time
0.8-1.1
Lab Values: RBCs- Erythrocytes
5mill
Delivers O2 to the body
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)
Lab Values: Hematocrit
Measures volume proportion of RBCs in blood
Just about half crit
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
BMP ( Basic Metabolic Panel)
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)
Lab Values: CO2/Bicarbonate
(respiratory, blood pH)
More than 23 RR
Normal: 23-30mEq/L
Lab Values: Chloride (balance body fluids)
Older ppl more fluids
Adult: 98-106
Increased- acute renal failure, dehydration
Decreased- burns, sweating, GI loss (vomiting, diarrhea)
Calcium- Calcemia
blood clotting, helping muscles to contract, and regulating normal heart rhythms and nerve functions.
Adult: 9-10.5
Too high- Hypercalcemia (hyperparathyroidism, paget/addison disease, lymphoma)
Too low- Hypocalcemia (hypoparathyroidism, renal failure, Vitamin D, pancreatitis
Magnesium- building proteins and strong bones, and regulating blood sugar, blood pressure, and muscle and nerve functions
Double miralax
Adult: 1.3-2.1
Fluoroscopy- Higher exposure to radiation, coated with calcium tungstate
Fluorescent viewing screen, can see organs and their motions
upper gi
Nuclear Scanning
Diagnoses cancer, cholecystitis, pulmonary embolism
Endoscopy- Inspect internal organs using an endoscope
View and biopsy sus tissues, removes polyps, inject varices, perform surgical procedures
Clubbing of nails
Clubbing
Beau’s Lines
Beau’s Lines
Vascular Spider
Vascular Spider
Stage 1 pressure injury
Stage 1
Bulla
Bulla
Papule
Papule
How would you describe this lesion? (Herpes Varicella)
A. grouped
B. linear
C. discrete
D. gyrate
Grouped
What is displayed?
A. lichenification
B. Hirsutism
C. telangiectasia
D. onychomycosis
Hirsutism
What is this named?
A. impetigo
B. ecchymosis
C.furuncle
D. petechiae
Petechiae
Macule
Macule
Excoriation
Excoriation
Stage 2 pressure injury
Stage II
Patch
Patch
Fissure
Atrophic Scar
Stretch marks
Keloid
Ecchymosis
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
C. Diabetes and hypertension increase risk
What is an expected finding when palpating lymph nodes?
a. mobile
b. tender
c. fixed
d. hard
A. Mobile
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
B. 2 mm brown macule on the face
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
C. Under the chin
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. the client has an increased risk of clotting
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
b. pull the pinna back and down
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
c. exophthalmos (eye bulging)
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
b. constriction
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
c. Pull pinna up & back before inserting speculum
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
d. this is a normal finding
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
c. ask what medications the client is taking
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
c. pearly gray and slightly concave
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
b. the purpose is to lubricate the ear
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. convergence (eyes follow close object)
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. small brown macules
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. consider this a normal finding
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
c. client can read at 20 ft what a normal eye can read at 30 ft
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. corneal light reflex
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. high tone frequency loss
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
d. use the Snellen chart
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. loss of lens elasticity
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
d. constriction of both pupils in response to light
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. increased INR (clotting factors slowed)
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. taking immune suppression medications
What describes a wound that has opened along suture lines?
a. primary intention
b. secondary intention
c. dehiscence
d. evisceration
c. dehiscence (spittling or bursing open of wound)
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. 3 cm sebaceous cyst
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. maxillary
Hypothyroidism
Elevated Tsh
Muscle weakness, apathy, weight gain, more sleep, coarse, dry skin/hair
Hyperthyroidism
Lowered Tsh
Muscle weakness, manic behavior, decreased weight, lost sleep, flushed skin, fine hair
Types of exudate:
Serous
Sanguineous
Serosanguinous
Purulent
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
Annular/circular
Gyrate (swirls or s shape)
Discrete (looks like pimples)
Grouped (little dots together)
Polycyclic (bigger watery looking dots)
Confluent (hivesX10)
Linear
Zosteriform
Primary Skin Lesions
Direct result from disease
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
Secondary Skin Lesions
evolve from primary lesions or develop as a consequence of the patient’s activities.
Crust
Scale
Fissure
Erosion
Ulcer
Excoriation
Scar
Atrophic scar
Lichenification
Keloid
Normal Results for different ethnicity
Dark skinned nails- yellow or brown/ vertical bands
Eyes: light yellow
Pressure injury stages
Ear abnormalities
lesion that is pink, smooth, and rubbery and has increased in size long after healing
Keloid
