Week 2 Material + EAQ 2 Flashcards
Methods of nose, mouth, throat assessment include:
inspection
palpation
Pale lips might be seen with:
anemia
Cracked/dry lips are associated with
dehydration
exposure to wind/cold
Angular Cheilitis or cracks and redness in the corners of the mouth can occur with
Iron or vitamin B deficiency
Lesions on/around lips can be caused by:
Herpes simplex virus
skin cancer
trauma
Lip swelling can be related to
allergic reaction or injury
Hyperplasia of gums associated with
Periodontal disease
medication side effects
red/bleeding gums associated with
Gingivitis or hormonal abnormalities
Beefy red tongue associated with
Iron or vitamin B deficiency
Hairy tongue is associated with
fungal overgrowth from antibiotic therapy
A nurse is assessing a patient’s neck. Which of the following is considered an expected finding?
A. Jugular vein distention
B. Midline trachea
C. Carotid artery prominence
D. Thyroid enlargement
B. Midline trachea
Which symptom found when examining the head would be a cause for concern?
A. Symmetrical features at rest
B. Even distribution of hair
C. Bruits in the temporal arteries
D. Symmetrical features with movement
C. Bruits in the temporal arteries
What information should be included when entering documentation of an enlarged lymph node?
A. Location, size, and shape
B. Consistency and tenderness
C. Discreteness and movability
D. All of the above
D. All of the above
When assessing lymph nodes, it is important to do which of the following?
A. Compare lymph nodes bilaterally.
B. Use the thumbs to palpate.
C. Provide privacy for the patient.
D. Both comparing the lymph nodes bilaterally and providing privacy for the patient.
D. Both comparing the lymph nodes bilaterally and providing privacy for the patient.
Which lymph nodes are located in the depression above and posterior to the medial condyle of the humerus?
A. Axillary lymph nodes
B. Inguinal lymph nodes
C. Epitrochlear lymph nodes
D. Parotid lymph nodes
C. Epitrochlear lymph nodes
Which of the following indicates normal respiratory function?
A. Symmetrical chest expansion
B. Nasal flaring
C. Use of accessory muscles
D. Lip pursing
A. Symmetrical chest expansion
When palpating the thorax, which of the following would be an abnormal finding?
A. Tenderness
B. Pulsations
C. Masses
D. All of the above
D. All of the above
When percussing the thorax, which of the following would be a normal finding?
A. Dullness over the lung fields
B. Resonance over the lung fields
C. Dullness over the ribs, heart, and diaphragm
D. Both B and C
D. Both B and C
Normal breath sounds include:
A. Vesicular sounds
B. Rhonchi
C. Wheezes
D. Crackles
A. Vesicular sounds
When auscultating the lungs, it is important to:
A. Compare each side bilaterally.
B. Note abnormal sounds.
C. Ask the patient to take slow, deep breaths.
D. All of the above.
D. All of the above.
While the preoperative nurse is performing the preoperative assessment, a patient admits spending a lot of time sitting after retirement. This predisposes the patient to which factor?
A. Depression and anxiety
B. Noncompliance with discharge instructions
C. Poor postoperative wound healing
D. Development of pressure injuries
D. Development of pressure injuries
Which statement is true regarding the formation of PIs?
A. A PI develops when localized damage to the skin and underlying soft tissue occurs.
B. PIs to the skin or underlying soft tissue usually result from intermittent pressure.
C. Positioning during an operative or invasive procedure decreases the patient’s risk for skin breakdown and PI development.
D. Patients undergoing an operative or invasive procedure are at a low risk for developing PIs.
A. A PI develops when localized damage to the skin and underlying soft tissue occurs.
Which intrinsic factor increases the patient’s risk of developing a PI during an operative or invasive procedure?
A. Pressure, friction, and shear forces
B. Nutritional status, low hemoglobin level, and BMI of less than 18
C. Moisture, heat, and use of cardiopulmonary bypass
D. Age younger than 60 years, nutritional status, and high hemoglobin level
B. Nutritional status, low hemoglobin level, and BMI of less than 18
A 40-year-old biological male patient is scheduled for a procedure that is anticipated to last 3 hours or more. The patient is in the left lateral position. The patient’s history includes diabetes and decreased mobility. In addition to the patient’s history, why is there an increased risk for PIs?
A. The patient’s age
B. The patient’s biological sex
C. The procedure type
D. The procedure length
D. The procedure length
During a preoperative patient assessment, which precaution should the unscrubbed perioperative team member use to prevent a high-risk patient from developing a medical device–related PI?
A. Place multiple blankets between the patient and support surface.
B. Perform a preoperative patient skin assessment.
C. Place a barrier sleeve underneath the BP cuff.
D. Place a folded sheet under the patient’s forehead when the patient is in the prone position.
C. Place a barrier sleeve underneath the BP cuff.
The unscrubbed perioperative team member could not find any gel rolls or positioning devices for a patient that was going to be in the prone position and used rolled towels, blankets, and sheets instead. In addition to an increased risk of a PI, what other injury is the patient at increased risk to develop?
A. Burn
B. None
C. Shear
D. Friction
D. Friction
The unscrubbed perioperative team member is gathering the perioperative team to help perform a lateral transfer of a patient from the stretcher to the OR bed. Which item is an extrinsic factor that can prevent PI development?
A. Using an adequate number of perioperative team members required for the lateral transfer
B. Repositioning the patient after the lateral transfer
C. Lifting the patient’s heels during the lateral transfer
D. Verifying that the perioperative team members are ready for the transfer with a countdown
C. Lifting the patient’s heels during the lateral transfer
What are the vulnerable areas for increased risk of PI when a patient is positioned in the prone position?
A. Forehead, eyes, ears, chin, breasts, and toes
B. Occiput, hips, sacrum, coccyx, and heels
C. Occiput, elbows, lumbar area, sacrum, and coccyx
D. Dependent side of face and ear, dependent axilla, and dependent hip
A. Forehead, eyes, ears, chin, breasts, and toes
Which practice protects the nurse from infection when changing the dressing on an infected pressure injury?
A. Begin antibiotic therapy before the dressing change.
B. Use appropriate personal protective equipment.
C. Adhere to sterile technique during the intervention.
D. Complete the dressing change in an effective, efficient manner.
B. Use appropriate personal protective equipment.
The wound bed of a patient’s pressure injury is red. What does this finding indicate to the nurse?
A. Necrotic tissue
B. Presence of slough
C. Granulation tissue
D. Development of an infection
C. Granulation tissue
Which measurements would the nurse use to calculate the surface area of a patient’s pressure injury?
A. Height and weight
B. Length and width
C. Length and depth
D. Width and depth
B. Length and width
How would the nurse safely apply an enzyme debridement ointment?
A. Daub ointment on dead tissue at the wound edges.
B. Put ointment on a tongue blade, and gently spread it on the center of the wound.
C. Apply ointment to necrotic tissue in the wound while avoiding contact with surrounding skin.
D. Apply a gauze dressing to ensure contact with the ointment.
C. Apply ointment to necrotic tissue in the wound while avoiding contact with surrounding skin.
Which action can the nurse delegate to nursing assistive personnel (NAP) to help prevent the development of pressure injury in an older adult patient?
A. Reposition the patient at least every 2 hours.
B. Assess the patient’s bony prominences every shift.
C. Educate the family about the importance of healthy skin.
D. Assist the patient in the selection of high-protein foods.
A. Reposition the patient at least every 2 hours.
Physical examination [4 parts]
Inspection
Auscultation
Palpation
Percussion
Assessing signs & symptoms
Variables:
-Onset
-Location
-Duration
-Characteristics
-Aggravating factors
-Relief factors
-Treatment
Variables:
-Onset
-Location
-Duration
-Characteristics
-Aggravating factors
-Relief factors
-Treatment
_____________ Data- Health history Qs
Previous history of skin disease?
Change in mole?
Change in pigmentation?
Excessive dryness/moisture?
Pruiritus
Excessive bruising
Rash or lesion
Medications
Hair loss
Change in nails
Environmental hazards
Self-care behaviors
Subjective
__________ Data- Skin
Inspect and palpate
Color
-General pigmentation
-Widespread color change
–Pallor [pale]
–Erythema [red]
–Cyanosis [blue]
–Jaundice [yellow]
Objective
Cyanosis is usually due to low ___________
perfusion
Erytheme can happen anywhere, typically due to:
inflammation, may be associated with infection
____________ data
Temperature
-Hypothermia
-Hyperthermia
Moisure
-Diaphoresis [hot, sweaty]
-Dehydration [lack of fluid]
Objective data
Temperature
-Hypothermia
-Hyperthermia
Moisure
-Diaphoresis [hot, sweaty]
-Dehydration [lack of fluid]
_____________ data- Skin
-Texture
-Thickness
-Edema
-Mobility & turgor
-Vascularity or bruising
-Lesions
◦ Color
◦ Elevation
◦ Pattern or shape
◦ Size
◦ Location and distribution on body
◦ Exudate
Objective data- Skin
Texture
Thickness
Edema
Mobility & turgor
Vascularity or bruising
-Lesions
◦ Color
◦ Elevation
◦ Pattern or shape
◦ Size
◦ Location and distribution on body
◦ Exudate
Edema
1-4 pitting scale
Objective data- hair
Inspect and palpate
◦ Color
◦ Texture
◦ Distribution
◦ Lesions
Inspect and palpate
◦ Color
◦ Texture
◦ Distribution
◦ Lesions
Objective data- nails
Inspect and palpate
◦ Shape and contour
> Profile sign – Clubbing
◦ Consistency
◦ Color
> Capillary refill
Inspect and palpate
◦ Shape and contour
> Profile sign – Clubbing
◦ Consistency
◦ Color
> Capillary refill
Identify this
Clubbing
Teach skin self-examination, using the ABCDE rule
◦ A—asymmetry
◦ B—border
◦ C—color
◦ D—diameter
◦ E—elevation and enlargement
Lesions caused by trauma/abuse: pattern injury; what to look out for?
_____________ - pooling of blood under the skin, usually raised
Hematoma
Lymphatics
- Preauricular
- Posterior auricular (mastoid)
- Occipital
- Submental
- Submandibular
____________ data- Health history Qs
-Headache
-Head injury
- Dizziness
-Neck pain or limitation of motion
- Lumps or swelling
- History of head or neck surgery
Subjective
___________ data- head
Inspect and palpate the skull
- Size and shape
- Temporal area
Inspect the face
- Facial structures
Objective
__________ data- neck
Inspect and palpate
-Symmetry
-Range of motion
-Lymph nodes
-Trachea
-Thyroid gland
◦ Posterior approach
◦ Anterior approach
◦ Auscultate
Objective
Syncope (SINK-a-pee) is another word for for: _______________________
fainting or passing out.
You will first see changes in skin color where?
Periphery- hands/feet
Perform screening neurologic examination on ______ persons with no significant findings from history
Perform complete neurologic examination on persons with _____________ concerns, e.g., headache, weakness, loss of coordination, or who have shown signs of neurologic dysfunction
Perform neurologic recheck examination on persons with demonstrated ____________ ____________ who require periodic assessments, e.g., hospitalized persons or those in extended care or if status changes
Perform screening neurologic examination on well persons with no significant findings from history
Perform complete neurologic examination on persons with neurologic concerns, e.g., headache, weakness, loss of coordination, or who have shown signs of neurologic dysfunction
Perform neurologic recheck examination on persons with demonstrated neurologic deficits who require periodic assessments, e.g., hospitalized persons or those in extended care or if status changes
Complete neuro exam includes:
_________ Status
________ Nerves
_________ System
___________ Function
___________
Mental Status
Cranial Nerves
Motor System
Sensory Function
Reflexes
Neuro check- steps 1,2,3
1) Assess _______________________________ ◦ Patient alert, opens eyes spontaneously, answers to person, place or time ◦ Abnormal: stuporous (lack of mental function), unresponsive and
comatose
2) Assessment of _____________
◦ PERRL: pupils equal (involuntary movements), round, reactive to light
◦ Abnormal: nystagmus, constricted, dilated, unequal pupils
3) ______________ of body
◦ Smooth and symmetric
◦ Abnormal: abnormal flexion and extension, hemiplegia (paralysis) vs.
hemiparesis (weakness)
1) Assess Level of Consciousness (LOC) ◦ Patient alert, opens eyes spontaneously, answers to person, place or time ◦ Abnormal: stuporous (lack of mental function), unresponsive and
comatose
2) Assessment of pupils
◦ PERRL: pupils equal (involuntary movements), round, reactive to light
◦ Abnormal: nystagmus, constricted, dilated, unequal pupils
3) Movements of body
◦ Smooth and symmetric
◦ Abnormal: abnormal flexion and extension, hemiplegia (paralysis) vs.
hemiparesis (weakness)
Neuro check- steps 4, 5, 6
4) ___________ Nerves
5) ____________ Bulk
◦ Relaxed muscles, resistance, grips equal
◦ Abnormal: no resistance, floppy, spasticity, rigidity
6) __________
◦ Smooth without swaying
◦ Abnormal: scissoring gait, Parkinson’s gait, dystonia
◦ Test: Romberg – standing position with eyes closed
4) Cranial Nerves
5) Muscle Bulk
◦ Relaxed muscles, resistance, grips equal
◦ Abnormal: no resistance, floppy, spasticity, rigidity
6) Walking
◦ Smooth without swaying
◦ Abnormal: scissoring gait, Parkinson’s gait, dystonia
◦ Test: Romberg – standing position with eyes closed
Physical exam materials for a neuro check:
◦ Penlight
◦ Tongue blade
◦ Cotton swab
◦ Cotton ball
◦ Tuning fork
◦ Percussion hammer
◦ Occasionally need: familiar aromatic substance
◦ Penlight
◦ Tongue blade
◦ Cotton swab
◦ Cotton ball
◦ Tuning fork
◦ Percussion hammer
◦ Occasionally need: familiar aromatic substance
Cranial nerves mnemonic
Know all of the cranial nerves for head to toe assessment
On Old Olympus’ Towering Tops, A Finn And German Viewed Some Hops
or
Ooh, Ooh, Ooh To Touch And Feel Very Good Velvet. A Heaven!
I Olfactory – test one __________ at a time
nostril
II Optic – visual _________, visual ________, fundoscopic exam
visual acuity, visual fields, fundoscopic exam
III Occulomotor – _________ size, shape and reaction to light (direct and consensual) and
accommodation PERRLA – pupils equal, round, reactive to light and accomodation
pupil size, shape and reaction to light (direct and consensual) and
accommodation PERRLA – pupils equal, round, reactive to light and accomodation
IV Trochlear – downward inward movement of _______
eye
V Trigeminal Motor – temporal and masseter muscles, ______ movement
Sensory – opthalmic, maxillary and mandibular
temporal and masseter muscles, jaw movement
Sensory – opthalmic, maxillary and mandibular
VI Abducens – lateral deviation of the ______
eye
VII Facial
Sensory – _______
Motor – facial ____________, expression, closing eyes
Sensory – taste
Motor – facial movement, expression, closing eyes
VIII Acoustic – _________, air and bone conduction, _____________
hearing, air and bone conduction, balance
IX Glossopharyngeal
Motor – pharynx
Sensory – _______ - posterior tongue
Motor – pharynx
Sensory – taste - posterior tongue
X Vagus – pharynx, larynx – say _____
“ah”
XI Spinal accessory – sternocleidomastoid and ___________
sternocleidomastoid and trapezius
XII Hypoglossal - _________
tongue
Cerebellar function - __________ tests
◦ Gait
◦ Romberg Test
balance
Coordination and skilled movements
◦ Rapid Alternating _____________ (RAM)
◦ Finger-to-Finger/______Test
◦ Rapid Alternating Movements (RAM)
◦ Finger-to-Finger/Nose Test
Discrimination
Stereognosis – identify a ___________
Graphesthesia – identify a __________
Two-Point Discrimination – distance at which two points are _______
Stereognosis – identify a familiar object
Graphesthesia – identify a number
Two-Point Discrimination – distance at which two points are felt
Four types of reflexes:
______ tendon reflexes (myotatic), e.g., knee jerk
___________ , e.g., corneal reflex, abdominal reflex
__________ , e.g., pupillary response to light
___________ (abnormal), e.g., Babinski’s reflex or extensor plantar reflex - Pediatrics
Deep tendon reflexes (myotatic), e.g., knee jerk
Superficial, e.g., corneal reflex, abdominal reflex
Visceral, e.g., pupillary response to light
Pathologic (abnormal), e.g., Babinski’s reflex or extensor plantar reflex - Pediatrics
Always compare reflexes _______________
bilaterally
Reflex grading system: ?
0-4
0- no response
4- hyperactive
4+ Very brisk / Hyperactive
◦ 3+ More brisk than expected
◦ 2+ Average / expected (normal)
◦ 1+ Sluggish or diminished response
◦ 0 No response
Glasgow coma scale
Most common scoring system used to describe the _______________________ in a person following a ___________________
Basically, it is used to help gauge the __________ of an acute brain injury.
Most common scoring system used to describe the level of consciousness in a person following a traumatic brain injury.
Basically, it is used to help gauge the severity of an acute brain injury.
Musculoskeletal system - subjective data- health history Qs
__________
◦ Pain
◦ Stiffness
◦ Swelling, heat, and redness
__________
◦ Pain (cramps)
◦ Weakness
_________
◦ Pain
◦ Deformity
◦ Trauma (fractures, sprains, dislocations)
Joints
◦ Pain
◦ Stiffness
◦ Swelling, heat, and redness
Muscles
◦ Pain (cramps)
◦ Weakness
Bones
◦ Pain
◦ Deformity
◦ Trauma (fractures, sprains, dislocations)
Musculoskeletal system - subjective data- health history Qs
Functional assessment ________
◦ Bathing
◦ Toileting
◦ Dressing/Grooming
◦ Eating
◦ Mobility
◦ Communicating
Self-care behaviors
Functional assessment (ADL’s)
◦ Bathing
◦ Toileting
◦ Dressing/Grooming
◦ Eating
◦ Mobility
◦ Communicating
Self-care behaviors
Objective data- musculoskeletal system
Order of the examination
◦ ____________
Size and contour of joint
Skin and tissues over joint – color, swelling, deformities
◦ ___________
Skin temperature
Muscles, bony articulations, area of joint capsule
◦ ________________
Active
Passive
◦ ____________ testing
Apply opposing force
Grading muscle strength
◦ Inspection
Size and contour of joint
Skin and tissues over joint – color, swelling, deformities
◦ Palpation
Skin temperature
Muscles, bony articulations, area of joint capsule
◦ Range of motion
Active
Passive
◦ Muscle testing
Apply opposing force
Grading muscle strength
Range of motion (ROM)
____________ movement that is possible for that _________
Determined by genetics, disease, amt of physical activity
Maximum movement that is possible for that joint
Determined by genetics, disease, amt of physical activity
Flexion vs extension
abduction vs adduction
circumduction
Elevation vs depression
Protraction vs retraction
eversion vs inversion
Nevi are:
moles
To thoroughly inspect nevi [moles], the nurse should look for:
Size (diameter <6 mm)
Number—The healthy adult may have as many as 40 nevi throughout the body.
Color/degree of pigmentation
Location—Nevi can be found on all body surfaces but are rarely found on the scalp, breasts, and buttocks.
Shape
Surface
Symmetry
Border (regular vs. irregular)
Size (diameter <6 mm)
Number—The healthy adult may have as many as 40 nevi throughout the body.
Color/degree of pigmentation
Location—Nevi can be found on all body surfaces but are rarely found on the scalp, breasts, and buttocks.
Shape
Surface
Symmetry
Border (regular vs. irregular)
The healthy adult may have as many as ____ nevi throughout the body.
10 - 40
Which areas of the body rarely have normal nevi?
Scalp
Breasts
Buttocks
Torso
Face
Scalp
Breasts
Buttocks
the nurse will use the thumb and forefinger to assess skin ____1____, which can indicate a patient’s ______2_______ status.
1- turgor
2- hydration
Macules: _____ lesion, less than 1 cm diameter [freckles/ petechiae]
flat
Papules: ____________ , solid demarcated lesion less than 1cm [warts/ some moles]
elevated
___________ : elevated lesions, under 1 cm, filled with serous fluid [chickenpox/shingles]
Vesicles
Bullae: _________ greater than 1 cm [blister]
Vesicle
___________ : elevated lesions under 1 cm, filled with pus [impetigo/acne]
Postules
__________ : elevated, firm, coarse/scaly lesions greater than 1 cm [psoriasis]
Plaques
___________ - excess hair most often noticeable around the mouth and chin
[high androgen in women]
Hirsutism
Lack of hair on lower extremities is an abnormal finding, and can be associated with poor:
perfusion
Which elements would the nurse assess to evaluate cranial nerve XII?
Speech sounds
Which elements should be assessed to evaluate the glossopharyngeal nerve (CN IX)?
Gag reflex
Swallowing
Which olfactory element would the nurse evaluate as part of the assessment of the olfactory nerve (CN I)?
Odor identification
The nurse would inspect the face for which elements when assessing the trigeminal nerve (CN V)?
Select all that apply.
Color
Atrophy
Tremors
Fasciculation
Reaction to touch
Atrophy
Tremors
Fasciculation
The nurse would assess which elements of the jaw during assessment of trigeminal nerve (CN V)?
Tone
Strength
Which aspect of the foot should the nurse assess to evaluate the plantar reflex?
Heel > ball
Equilibrium is evaluated with the ___________ test.
Romberg
To assess _______ :
Observe as the patient walks 10 to 20 feet, turns, and returns to the starting point.
Ask the patient to walk a straight line in heel-to-toe fashion; this decreases the base of support and accentuates any problem with coordination. Test for balance by asking the patient to walk on the toes, then on the heels for a few steps.
gait
CN I is responsible for _______.
CN II is responsible for __________.
CN I is responsible for smell
CN II is responsible for vision.
Full movement of the eyes is controlled by the integrated function of cranial nerves______________________
Included in these nerves are the oculomotor, trochlear, and abducens nerves, and the six extraocular muscles.
III, IV, and VI.
CN V governs facial sensation and _________.
CN VII controls facial muscles and sense of _______.
CN V governs facial sensation and chewing.
CN VII controls facial muscles and sense of taste.
CN VIII enables ___________ .
hearing
CN IX controls _____________ movements.
CN X governs swallowing and _________.
CN IX controls swallowing movements.
CN X governs swallowing and speech.
CN XI is responsible for shoulder and head _____________ .
CN XII controls __________ movement.
CN XI is responsible for shoulder and head movement.
CN XII controls tongue movement.
Which cortical sensory function would the nurse assess by drawing a number 8 on the patient’s hand?
Graphesthesia
Graphesthesia, or the ability to identify writing on the skin, is the cortical sensory function assessed by drawing a number 8 on the patient’s hand.
Which elements of the pupils should be evaluated as part of the assessment of the cranial nerves of the eyes?
Size
The nurse should evaluate the size of the pupils as part of the assessment of the cranial nerves of the eyes.
Color
The nurse would not evaluate eye color as part of the assessment of the cranial nerves of the eyes.
Correct
Equality
The nurse should evaluate the equality of the pupils as part of the assessment of the cranial nerves of the eyes.
Response to light
The nurse should evaluate the response of the pupils to light as part of the assessment of the cranial nerves of the eyes.
When evaluating the vagus nerve (CN X), the nurse should inspect which aspect of the palate and uvula?
Symmetry
When evaluating the vagus nerve (CN X), the nurse should inspect the symmetry of the palate and uvula because the vagus nerve provides motor supply to the pharynx.
Which sensory elements should the nurse assess when evaluating the acoustic nerve (CN VIII)?
Hearing
The nurse would assess the patient’s hearing when evaluating the acoustic nerve (CN VIII).
Balance
The nurse would assess the patient’s balance when evaluating the acoustic nerve (CN VIII).
The nurse should use which tests to assess the accuracy of the patient’s movements?
Finger-to-nose test
The nurse should evaluate the ability of the patient to touch a finger to the nose to assess the accuracy of the patient’s movements.
Correct
Finger-to-finger test
The nurse should evaluate the ability of the patient to touch a finger to another finger to assess the accuracy of the patient’s movements.
Heel-to-shin test
The nurse should evaluate the ability of the patient to touch the heel to the shin to assess the accuracy of the patient’s movements.
Abnormal findings: Primary VS Secondary skin lesions
Primary
─ Macule
─ Papule
─ Patch
─ Plaque
─ Nodule
─ Wheal
─ Tumor
─ Urticaria (hives)
─ Vesicle
─ Cyst
─ Bulla
─ Pustule
Secondary
─ Crust
─ Scale
─ Fissure
─ Erosion
─ Ulcer
─ Excoriation
─ Scar
─ Atrophic scar
─ Lichenification
─ Keloid
Primary
─ Macule
─ Papule
─ Patch
─ Plaque
─ Nodule
─ Wheal
─ Tumor
─ Urticaria (hives)
─ Vesicle
─ Cyst
─ Bulla
─ Pustule
Secondary
─ Crust
─ Scale
─ Fissure
─ Erosion
─ Ulcer
─ Excoriation
─ Scar
─ Atrophic scar
─ Lichenification
─ Keloid
________ – involuntary muscle contract/relax
Clonus
Grading muscle strength
5 Full ROM/full resistance 100% Normal
4 Full ROM/some resistance 75% Good
3 Full ROM 50% Fair
2 Full ROM/passive-w/ support 25% Poor
1 Slight contraction 10% Trace
0 No contraction 0% Zero
While assessing a client’s vascular system, the nurse finds a diminished and barely papable pulse strength. Which documentation would the nurse utilize in this situation?
1+
2+
3+
4+
1+
A diminished or barely palpable pulse is documented as 1+. A normal and expected pulse strength is documented as 2+. A full, strong pulse is documented as 3+. A bounding pulse is documented as 4+.
When assessing a client who had a thyroidectomy yesterday, which cue would the nurse associate with an initial sign of hypocalcemia?
Headache
Pallor
Paresthesias
Blurred vision
Paresthesias [Tingling or prickling, “pins-and-needles” sensation]
Normally, calcium ions block the movement of sodium into cells. When calcium is low, this allows sodium to move freely into cells, creating increased excitability of the nervous system. Initial symptoms are paresthesias. This can lead to tetany if untreated. Headache, pallor, and blurred vision are not signs of hypocalcemia.
Which information, obtained during a client’s health history, would the nurse classify as biographical information? Select all that apply. One, some, or all responses may be correct.
Symptoms
Client’s age
Family structure
Type of insurance
Occupation status
Client’s age
Type of Insurance
Occupation status
Biographical information is factual demographic data about the client usually obtained by the admitting office staff. The client’s age, types of insurance, and occupation status are considered biographical information. If the client presents with an illness, the nurse gathers details about the symptoms of the illness, which is descriptive information, not biographical information. The nurse obtains information about family structure while assessing the family history of the client. It is not biographical information.
The nurse just arrived on the unit for his shift. Which action would the nurse take first to collect an initial set of data about the clients assigned to the nurse’s care?
Meet the clients’ family.
Read the clients’ medical reports.
Participate in the bedside rounds.
Visit the clients and introduce self.
Participate in the bedside rounds.
The nurse would participate in bedside rounds with the health care team from the previous shift. The nurse who is completing care for one shift prepares the change-of-shift report to communicate client details to the nurse on the next shift. These bedside rounds provide patient-centered care, because the nurse shares information about the client’s condition, status of problems, and treatment plan for the next shift. The nurse can meet the client’s family after obtaining firsthand information from the nurse completing the shift. The nurses review the client’s medical reports and discuss treatment plans for the next shift after completing bedside rounds. The nurse may meet the client during bedside rounds or after obtaining the handover report.
Which step would the nurse take first when preparing a concept map for as assigned client?
Assess the client and gather information.
Arrange cues into clusters that form patterns.
Identify patterns reflecting the client’s problem.
Identify specific nursing diagnoses for the client.
Arrange cues into clusters that form patterns.
A concept map is a visual representation of the connection between the client’s many health problems. The first step is to arrange all the cues into clusters that form patterns. This helps the nurse identify specific nursing diagnoses for the client. During the assessment stage, the nurse assesses the client and gathers information. This step is performed before preparing the concept map. After placing all cues into clusters, the nurse begins to identify patterns reflecting the client’s problem. The concept map helps the nurse obtain a holistic view of the client’s needs. The next step is to identify specific diagnoses so that appropriate nursing interventions can be provided
For a client admitted with metabolic acidosis, which two body systems would the nurse assess for compensatory changes?
Skeletal and nervous
Circulatory and urinary
Respiratory and urinary
Muscular and endocrine
Respiratory and urinary
Increased respirations blow off carbon dioxide (CO 2), which decreases the hydrogen ion concentration and the pH increases (less acidity). Decreased respirations result in CO 2 buildup, which increases hydrogen ion concentration and the pH falls (more acidity). The kidneys either conserve or excrete bicarbonate and hydrogen ions, which helps adjust the body’s pH. The buffering capacity of the renal system is greater than that of the pulmonary system, but the pulmonary system is quicker to respond. Skeletal and nervous systems do not maintain the pH, nor do muscular and endocrine systems. Although the circulatory system carries fluids and electrolytes to the kidneys, it does not interact with the urinary system to regulate plasma pH.
When providing care for a client with diarrhea, in which clinical indicator would the nurse anticipate a decrease?
Pulse rate
Tissue turgor
Specific gravity
Body temperature
Tissue turgor
Skin elasticity will decrease because of a decrease in interstitial fluid. The pulse rate will increase to oxygenate the body’s cells. Specific gravity will increase because of the greater concentration of waste particles in the decreased amount of urine. The temperature will increase, not decrease.
Which nurse’s action would help set the stage for a client-centered interview? Select all that apply. One, some, or all responses may be correct.
Close the door after entering the room.
Greet the client using his or her last name.
Open the curtains to allow plenty of light in the room.
Introduce oneself with a smile and explain the reason for the visit.
Obtain an authorization from the client after the interview.
Close the door after entering the room.
Greet the client using his or her last name.
Introduce oneself with a smile and explain the reason for the visit.
The nurse notes a client has dependent edema around the area of the feet and ankles. To characterize the severity of the edema, the nurse presses the medial malleolus area, noting an 8-mm depression after release. In which way would the nurse document the edema?
1+
2+
3+
4+
4+
Which Korotkoff sound represents the diastolic pressure for children?
First
Second
Fourth
Fifth
Fourth
The fourth Korotkoff sound represents the diastolic pressure in children. The first Korotkoff sound represents the systolic pressure. The fifth Korotkoff sound represents the diastolic pressure in adults and adolescents. A blowing or swishing sound occurs in the second Korotkoff sound.
Which factor would cause the nurse to identify an illness as chronic? Select all that apply. One, some, or all responses may be correct.
The illness is reversible and often severe.
The illness persists for longer than 6 months.
The client may develop a life-threatening relapse.
The symptoms are intense and appear abruptly.
The illness affects the functioning of one or more systems.
Confident
The illness persists for longer than 6 months.
The client may develop a life-threatening relapse.
The illness affects the functioning of one or more systems.
Which nursing intervention would the nurse use to encourage the client to verbalize their personal health problem?
The nurse takes down notes while the client is talking.
The nurse leans forward attentively during the discussion.
The nurse refrains from pausing enough after each question.
The nurse asks questions that can be answered as “yes” or “no.”
The nurse leans forward attentively during the discussion.
For an older adult client, admitted to the health care facility following a stroke, which action would the nurse take when the client’s cousin asks to see the client’s health record?
Confirm the client’s relationship first.
Ask the client’s primary health care provider.
Inform the nurse manager and show the records.
Explain medical health records are confidential.
Explain medical health records are confidential.
For a client who arrived at the health care facility for an appointment, which nurse’s action would be beneficial during the assessment interview?
Ask about the client’s current concerns
Ensure the interview follows a strict agenda
Ask questions that promote short responses by the client
Tell the client what they should expect from the visit
Ask about the client’s current concerns
Which nurse’s statement indicates the client’s interview is coming to a close?
“I have just one more question for you.”
“I hope you are comfortable and not in pain.”
“I would like to spend some time to understand your concerns.”
“I assure you that information I gather now will be confidential.”
“I have just one more question for you.”
For a client suspected of having a prostate disorder, which client position would facilitate a rectal examination by the registered nurse (RN)?
Left lateral recumbent position
Prone position
Dorsal recumbent position
Lateral recumbent position
Left lateral recumbent position
Arrange the steps of the bimanual deep palpation technique in sequence.
Apply pressure to the sensing hand
Place the sensing hand on the skin
Depress the area to be examined to 2 inches
Place the active hand on the sensing hand
Relax sensing hand
During a deep palpation, the area under the examination is depressed to 2 inches using one or both hands. When both the hands are used for palpation, the sensing hand is relaxed and placed over the client’s skin. Then the active hand is placed over the sensing hand, and pressure is applied on the sensing hand.
While assessing a client with dehydration, the nurse notices diminished skin elasticity. Which portion of the nurse’s hand would the nurse use to perform this assessment?
Fingertips
Pads of fingertips
Ulnar surface of hand
Palmer surface of finger pads
Fingertips
The nurse documents data that was gathered during an assessment in a client’s medical record. Which action would the nurse take to ensure that the data is meaningful to other health care providers?
Record subjective information in own words.
Form judgments through written communication.
Record objective information using accurate terminology.
Compare data from the physical examination with client behavior.
Record objective information using accurate terminology.
When would the nurse observe a client to assess their level of functioning? Select all that apply. One, some, or all responses may be correct.
During mealtime
When talking about pain
When preparing medication
During the assessment interview
When administering insulin injections
During mealtime
When preparing medication
When administering insulin injections
Which feature distinguishes nursing diagnoses from medical diagnoses? Select all that apply. One, some, or all responses may be correct.
Nursing diagnoses involve the client when possible.
Nursing diagnoses are based on results of diagnostic tests and procedures.
Nursing diagnoses are the identification of a disease condition in the client.
Nursing diagnoses involve the sorting of health problems within the nursing domain.
Nursing diagnoses involve clinical judgment about the client’s response to health problems.
Nursing diagnoses involve the client when possible.
Nursing diagnoses involve the sorting of health problems within the nursing domain.
Nursing diagnoses involve clinical judgment about the client’s response to health problems.
The nurse, providing care for a client whose forehead feels warm to the touch, uses a thermometer to obtain the client’s temperature. Which action is the nurse taking?
Validation
Assessment
Interpretation
Documentation
Validation
The nurse is validating the presence of fever in the client. Validation is the process of gathering more assessment data; it involves clarifying vague or unclear data. Assessment is the first step of the nursing process; it involves collecting information from the client and secondary sources. During interpretation, the nurse recognizes that further observations are needed to clarify information. Data documentation is the last part of a complete assessment. The nurse must document facts in a timely, thorough, and accurate manner to prevent information from getting lost.
When conducting a health assessment for a school-age child who is a new client to the pediatric practice, which question would the nurse ask the child and parents related to growth? Select all that apply. One, some, or all responses may be correct.
“Which grade are you currently attending?”
“At which age did your child cut their first tooth?”
“Do you have a best friend at your new school?”
“What was your child’s approximate length at 1 year of age?”
“What was your child’s approximate weight at 6 months, and 1, 2, and 5 years of age?”
“At which age did your child cut their first tooth?”
“What was your child’s approximate length at 1 year of age?”
“What was your child’s approximate weight at 6 months, and 1, 2, and 5 years of age?”
A client with a family history of diabetes mellitus has been following a diet regimen recommended by the dietitian and walking for 45 minutes daily for the past 8 months. Based on the transtheoretical model of health behavior change, which stage would the nurse document for this client?
Action
Preparation
Maintenance
Contemplation
Maintenance
The client is in the maintenance stage of human behavior change. During this stage, the client has managed to incorporate the changes into the lifestyle. This stage begins 6 months after the action has started and continues indefinitely. The action stage lasts for 6 months from the time the client has incorporated the changes into the lifestyle. During the preparation stage, the client begins to realize that the advantages of the change outweigh the disadvantages. The client starts making small changes in preparation for major changes the following month. During the contemplation stage, the client is still considering whether to incorporate changes in the next 6 months.
A client reports right ear hearing loss. When performing a Weber test with a tuning fork, the client hears the sound better with the right ear. Which condition would the nurse suspect from these results?
Normal hearing
Mixed hearing loss
Conduction hearing loss
Sensorineural hearing loss
Conduction hearing loss
During a Weber test, conduction hearing loss often causes the tuning fork to be heard better and more clearly in the impaired ear. People with sensorineural hearing loss will hear the sound better in the normal (in this case the left) ear. Mixed hearing loss is a combination of both conduction and sensorineural hearing loss and would not result in the findings observed with the Weber test. The client does not have normal hearing.
When an African American client with renal failure reports the illness is a punishment for sins, which cultural health belief is the client communicating?
Yin/Yang balance
Biomedical belief
Determinism belief
Magicoreligious belief
Magicoreligious belief
An African American client may have magicoreligious beliefs, which focuses on hexes or supernatural forces that cause illness. Such clients may believe illness is a punishment for sins. The yin/yang belief system does not consider illness as a punishment. The biomedical belief system maintains that health and illness are related to physical and biochemical processes with disease being a breakdown of the processes. The belief of determinism focuses on outcomes that are externally preordained and cannot be changed.
While assessing the eyes of a client, a health care provider notices there is an obstruction to the outflow of aqueous humor. Which additional finding would support a diagnosis of glaucoma?
Blurred central vision
Increased opacity of the lens
Elevated intraocular pressure
Changes in retinal blood vessels
Elevated intraocular pressure
In glaucoma, there is an obstruction of the outflow of aqueous humor due to intraocular structural damage, which may result from elevated intraocular pressure. Blurred central vision is seen in macular degeneration. Increased opacity of the lens may be seen in cataracts. Retinopathy may result from the changes in retinal blood vessels.
The nurse, providing care for a client who underwent cardiac catheterization, found the client’s skin was cool, tender to touch, with edema of 15.2 cm (1–6 inches) at the site of catheterization. Which condition would the nurse suspect?
Phlebitis
Infection
Infiltration
Circulatory overload
Infiltration
The client with blanched skin, edema of 15.2 cm, cool temperature, and pain at the site of catheterization has symptoms of grade 2 infiltration. Phlebitis is an inflammation of the inner layer of the vein. The findings for this include redness, tenderness, pain, and warmth along the course of the vein starting at the access site. If there is infection, there will be findings that include redness, heat, swelling at catheter-skin entry point, and possible purulent drainage. Circulatory overload can occur if intravenous solutions are infused too rapidly or in great amounts.
After performing an optical assessment on a client, a primary health care provider notices impaired near vision. Which other finding would confirm the client’s diagnosis as presbyopia?
Loss of elasticity of the lens
Increased opacity of the lens
Elevated intraocular pressure
Noninflammatory changes in eyes
Loss of elasticity of the lens
Presbyopia is defined as impaired near vision caused by a loss of elasticity of the lens. This condition is reported in middle-aged and older adults. Increased opacity of the lens is seen in cataracts. Elevated intraocular pressure is associated with glaucoma. Retinopathy causes noninflammatory eye changes.
Which skin condition would the nurse associate with a client whose skin pathophysiology involves increased visibility of oxyhemoglobin caused by an increased blood flow due to capillary dilation?
Pallor
Vitiligo
Cyanosis
Erythema
Erythema
Erythema occurs due to an increased visibility of oxyhemoglobin, which is caused by increased blood flow. Pallor is caused by a reduced amount of oxyhemoglobin or a reduced visibility of oxyhemoglobin. Vitiligo is a pigmentation disorder caused by autoimmune diseases. Cyanosis is a bluish discoloration of the skin around the lips; this occurs due to an increased amount of deoxygenated hemoglobin in the blood.
After an eye assessment, the nurse finds that the client’s eyes are not focusing on an object simultaneously and appear crossed. Which potential cause would the nurse associae with this condition?
Loss of elasticity of the lens
Impairment of the extraocular muscles
Obstruction of the aqueous humor outflow
Progressive degeneration of the center of the retina
Impairment of the extraocular muscles
Strabismus is a condition where the eyes appear crossed; this condition is caused by the impairment of the extraocular muscles. A loss of lens elasticity may lead to presbyopia, which causes impaired near vision. An obstruction of the aqueous humor outflow may lead to glaucoma. The progressive degeneration of the center of the retina indicates macular degeneration and leads to blurred central vision.
___________ is a condition where the eyes appear crossed; this condition is caused by the impairment of the extraocular muscles.
Strabismus
Of which cranial nerve does the nurse assess the function when asking the client to shrug their shoulders and to turn their head against passive resistance?
Cranial nerve II
Cranial nerve XI
Cranial nerve VI
Cranial nerve VII
Cranial nerve XI
Cranial nerve XI (the spinal accessory nerve) is the motor nerve that coordinates the movement of head and shoulders.
Cranial nerve XI (the spinal accessory nerve) is the motor nerve that coordinates the movement of ______________________
head and shoulders.
Which benefit would the nurse associate with using standard, formal, nursing diagnostic statements? Select all that apply. One, some, or all responses may be correct.
Fosters development of nursing knowledge
Allows nurses to communicate with the client
Provides precise definition of the client’s problem
Distinguishes the nurse’s role from that of other care providers
Enables the primary health care provider to deliver effective health care
Fosters development of nursing knowledge
Provides precise definition of the client’s problem
Distinguishes the nurse’s role from that of other care providers
The use of standard formal nursing diagnostic statements fosters the development of nursing knowledge, which is important to be able to assess a client’s specific risk for problems, identify them early, and take preventive action. Nursing diagnostic statements provide precise definitions of the client’s problem. They give the nurses and other members of the health care team a common language for understanding the client’s needs. Nursing is emphasized as an independent practice when the nurse formulates nursing diagnoses and individualized nursing care plans. This distinguishes the nurse’s role from that of other care providers. Nursing diagnostic statements allow nurses to communicate what they do among themselves with other health care professionals and the public. A nursing diagnosis helps the nurse focus on the scope of nursing practice and to deliver effective health care.
Which type of fever does a client have when experiencing fever spikes combined with a normal body temperature occurring at least once a day?
Sustained
Relapsing
Remittent
Intermittent
Intermittent
An intermittent fever is characterized by fever spikes interspersed with normal temperatures. In this type of fever, the body temperature returns to normal at least once in 24 hours. In the case of sustained fever, there is a constant body temperature greater than 100.4°F (38°C). In relapsing fever, there is an occurrence of periods of febrile episodes with acceptable temperature values. In remittent fever, the body temperature increases and decreases without returning to normal body temperature levels.
A registered nurse teaches a new nurse about when a client with high blood pressure would follow up with the primary health care provider. Which statement made by the new nurse indicates effective learning?
“I will advise a client with a blood pressure of 130/80 mm Hg to follow up in a year.”
“I will advise a client with a blood pressure of 110/70 mm Hg to follow up in a year.”
“I will advise a client with a blood pressure of 150/90 mm Hg to follow up in a month.”
“I will advise a client with a blood pressure of 185/115 mm Hg to follow up in a month.”
“I will advise a client with a blood pressure of 130/80 mm Hg to follow up in a year.”
A client with prehypertension tends to have a blood pressure (BP) between 120/80 and 139/89 mm Hg. These clients should be rechecked in a year. Clients with BP less than 120/80 mm Hg are considered normal. These clients should be rechecked in 2 years. Clients with stage 1 hypertension have a BP between 140/90 and 159/99 mm Hg. These clients should be rechecked in 2 months to confirm stage 1 hypertension. Clients with stage 2 hypertension have a BP greater than 160/100 mm Hg. These clients should be rechecked in 1 month. If a client’s BP is greater than 180/110 mm Hg, then the client should be treated immediately or within 1 week.
Which condition would the nurse suspect when an older adult has a thin white ring around the margin of her iris?
Cataract
Arcus senilis
Conjunctivitis
Macular degeneration
Arcus senilis
In older adults, the iris becomes faded and a thin white ring (known as arcus senilis) appears around the margin of the iris. A cataract is a condition involving increased opacity of the lens that blocks light rays from entering the eye. The presence of redness indicates allergic or infectious conjunctivitis. Macular degeneration is marked by a blurring of central vision caused by progressive degeneration of the center of the retina.
While assessing a client, the nurse finds inflammation of the skin at the bases of the client’s nails. Which event or disorder would the nurse associate with the reason behind this condition?
Trauma
Trichinosis
Pulmonary disease
Iron-deficiency anemia
Trauma
Paronychia is an abnormality of the nail bed. The condition is marked by inflammation of the skin at the base of the nail; this condition may be caused by trauma or a local infection. Trichinosis is associated with red or brown linear streaks in the nail bed. Pulmonary diseases can cause changes in the angle between nail and nail base, which is a phenomenon known as clubbing. Koilonychia, a concave curvature of the nails, may occur as a result of iron-deficiency anemia.
When teaching a health awareness class, which situation would the nurse teach as being the highest risk factor for the development of a deep vein thrombosis (DVT)?
Pregnancy
Inactivity
Aerobic exercise
Tight clothing
Inactivity
A client in the second trimester of pregnancy arrives at the clinic for a general health checkup, including a pelvic examination. For which position would the nurse prepare the client?
Left lateral recumbent position
Supine position
Lithotomy position
Dorsal recumbent position
Lithotomy position
While assessing a client who experienced an accident, the nurse found the client was unable to move her eyes laterally. Damage to which nerve led to this condition in the client?
Optic nerve
Facial nerve
Abducens nerve
Oculomotor nerve
Abducens nerve
The abducens nerve is the VI cranial nerve, which helps in lateral movement of the eyeballs. Damage to this nerve limits lateral movement of the eyeball. Injury to the optic nerve causes changes in visual acuity. Injury to the facial nerve results in loss of facial expressions and loss of taste perception from the anterior third of the tongue. Injury to the oculomotor nerve limits the extraocular movements and pupillary responses.
During a survey, the community nurse meets a client who never visited a gynecologist after the birth of a second child. The client reports the client’s mother or sister never had annual gynecologic examinations. Which factor appears to be influencing the client’s health practice?
Spiritual belief
Family practices
Emotional factors
Cultural background
Family practices
Which nurse’s action is important for establishing good communication with the client who has impaired hearing?
Speaking at a normal volume
Reducing environmental noise
Obtaining the client’s attention before speaking
Rephrasing rather than repeating if misunderstood
Obtaining the client’s attention before speaking
When conducting an assessment of a client who does not speak English and an interpreter is unavailable, which action would the nurse not utilize?
Using medical terminology
Proceeding in an unhurried manner
Speaking in a low and moderate voice
Pantomiming words and simple actions while verbalizing them
Using medical terminology
A client who does not understand English requires an interpreter. Which action by the nurse may exacerbate health disparities?
The nurse expects the interpreter to act as the client’s advocate.
The nurse expects the interpreter to have a health care background.
The nurse maintains steady eye contact with the client.
The nurse talks only to the interpreter about the client.
The nurse talks only to the interpreter about the client.
While preparing to teach a client about self-injection of insulin, which nurse’s action would increase the effectiveness of the teaching session?
Wait until a family member is also present.
Assess the client’s barriers to learning self-injection techniques.
Begin with simple written instructions describing the technique.
Wait until the client has accepted the new diagnosis of type 1 diabetes mellitus.
Assess the client’s barriers to learning self-injection techniques.
While providing postoperative care for a client, who had surgery to repair a deviated septum, the nurse would monitor for which complication associated with this type of surgery?
Occipital headache
Periorbital crepitus
Expectoration of blood
Changes in vocalization
Expectoration of blood
In which sequential order would the nurse assess the visual level of a client?
Direct the client to stand or sit 60 cm away from eye level
Close the opposite eye to superimpose the field of vision
Ask the client to close his or her left or right eye gently and look directly at the nurse’s opposite eye
Ask the client to report when he or she is able to see the finger
Move a finger equidistant between the nurse and the client outside the field of vision
The first step while assessing the visual level of the client is to direct the client to stand or sit 60 cm away at eye level.
Next, the nurse would ask the client to gently close or cover one eye and look at the nurse’s eye directly opposite.
Then, the nurse would also close his or her right eye to superimpose the field of vision.
After this, the nurse would move a finger equidistant between the nurse and the client outside the field of vision.
Finally, the nurse would ask the client to report when he or she is able to see the finger.
The palpation of the popliteal pulse is done on the popliteal artery, which is present in the posterior surface of the ________
knee
When the defining characteristics of a client’s assessment data apply to more than one diagnosis, which action would the nurse take? Select all that apply. One, some, or all responses may be correct.
Reassess the client.
Reject all diagnoses.
Gather more information.
Identify related factors.
Review all defining characteristics.
Gather more information.
Identify related factors.
Review all defining characteristics.
A registered nurse teaches a new employee about precautions taken during a client’s physical examination. Which employee’s statement indicates effective learning? Select all that apply. One, some, or all responses may be correct.
“I would examine the client in noise-free areas.”
“I would use latex gloves during the physical examination.”
“I would perform a physical examination in a cool room.”
“I would leave a combative client alone during a physical examination.”
“I would wear eye shields while examining a client with excessive drainage.”
“I would examine the client in noise-free areas.”
“I would wear eye shields while examining a client with excessive drainage.”
Pressure injuries (ulcers): _______________________________ due to unrelieved pressure
breakdown of skin integrity
Assessment of skin, hair, and nails would include: __________ and _________
Inspect and Palpate
___________ data: skin
- Previous history of skin disease
- Change in mole or skin pigmentation
- Excessive dryness or moisture
- Pruritus
- Excessive bruising, rashes, lesions
- Medications
- Hair loss
- Change in nails
- Environmental or Occupational hazards
- Self-care behaviors
Subjective
___________ data: skin
COLOR:
PALLOR, ERYTHEMA,
CYANOSIS, JAUNDICE,
FRECKLES, MOLES
TEMPERATURE:
HYPOTHERMIA,
HYPERTHERMIA
MOISTURE:
DIAPHORESIS,
DEHYDRATION
TEXTURE:
NORMAL/ABNORMAL
THICKNESS:
NORMAL/ABNORMAL
EDEMA:
NORMAL/ABNORMAL
TURGOR:
DEHYDRATION, SKIN
ELASTICITY
VASCULARITY/
BRUISING:
ANGIOMAS, LESIONS,
ABUSE
Objective
SIGNS AND SYMPTOMS Mnemonic
OLD CARTS
Onset
Location
Duration
Character
Alleviating
Radiation
Temporal patterns
Symptoms
EDEMA
___________ effect – can cover other skin signs like jaundice, cyanosis
Masking
________________ DATA: HEAD, FACE, & NECK
* Headaches (unusually frequent or severe)
* Head injury history
* Dizziness
* Neck pain or limited ROM
* Lumps or swelling
* History of head or neck cancers or surgery
SUBJECTIVE
LYMPH NODES
FUNCTION: ______________________ AND ENGULF PATHOGENS TO PREVENT HARMFUL SUBSTANCES FROM ________________________________
FILTER THE LYMPH AND ENGULF PATHOGENS TO PREVENT HARMFUL SUBSTANCES FROM ENTERING THE CIRCULATION
LYMPH NODES
PALPABLE:
HEAD AND NECK, ARMS, INGUINAL AREA, AND AXILLAE
NORMAL LYMPH NODES FEEL: _____________ , DISCRETE, SOFT, AND NONTENDER.
MOVEABLE
During an examination, the nurse finds that a patient has excessive dryness of the skin.
The best term to describe this condition is:
A. Xerosis.
B. Pruritus.
C. Alopecia.
D. Seborrhea.
A. Xerosis.
Xerosis is the term used to describe skin that is excessively _____
dry.
Pruritus refers to _________,
itching
alopecia refers to ___________
hair loss
seborrhea refers to __________
oily skin.
A patient tells the nurse that he has noticed that one of his moles has started to burn and bleed. When assessing his skin, the nurse pays special attention to the danger signs for pigmented lesions and is concerned with which additional finding?
A. Color variation
B. Border regularity
C. Symmetry of lesions
D. Diameter of less than 6 mm
A. Color variation
Abnormal characteristics of pigmented lesions are summarized in the mnemonic ABCDE:
asymmetry of pigmented lesion, border irregularity, color variation, diameter greater
than ________ , and elevation.
6 mm
An older adult woman is brought to the emergency department after being found lying on the kitchen floor for 2 days; she is extremely dehydrated. What would the nurse expect to see during the examination?
A. Smooth mucous membranes and lips
B. Dry mucous membranes and cracked lips
C. Pale mucous membranes
D. White patches on the mucous membranes
B. Dry mucous membranes and cracked lips
With _____________ , mucous membranes appear dry and the lips look parched and cracked.
dehydration
The nurse is aware that the four areas in the body where lymph nodes are accessible are the:
A. Head, breasts, groin, and abdomen.
B. Arms, breasts, inguinal area, and legs.
C. Head and neck, arms, breasts, and axillae.
D. Head and neck, arms, inguinal area, and axillae.
D. Head and neck, arms, inguinal area, and axillae.
Nodes are located throughout the body, but they are accessible to examination only in four
areas: head and neck, arms, inguinal region, and axillae.
A patient says that she has recently noticed a lump in the front of her neck below her adams apple that seems to be getting bigger. During the assessment, the finding that leads the nurse to suspect that this may not be a cancerous thyroid nodule is that the lump (nodule):
A. Is tender.
B. Is mobile and not hard.
C. Disappears when the patient smiles.
D. Is hard and fixed to the surrounding structures.
B. Is mobile and not hard.
Painless, rapidly growing nodules may be cancerous, especially the appearance of a single
nodule in a young person.
Cancerous nodules tend to be _______ and fixed to surrounding structures, not ___________.
Painless, rapidly growing nodules may be cancerous, especially the appearance of a single
nodule in a young person.
Cancerous nodules tend to be hard and fixed to surrounding structures, not mobile.
A patient comes to the clinic and tells the nurse that he has been confined to his recliner chair for approximately 3 days with his feet down and he asks the nurse to evaluate his feet. During the assessment, the nurse might expect to find:
A. Pallor
B. Coolness
C. Distended veins
D. Prolonged capillary filling time
C. Distended veins
Keeping the feet in a dependent position causes venous pooling, resulting in redness,
warmth, and _________________
distended veins.
Prolonged elevation would cause _________ and coolness.
pallor
Immobilization or prolonged inactivity would cause prolonged ___________________ time.
capillary filling
The nurse has discovered decreased skin turgor in a patient and knows that this finding is expected in which condition?
A. Severe obesity
B. Childhood growth spurts
C. Severe dehydration
D. Connective tissue disorders such as scleroderma
C. Severe dehydration
Decreased skin _________ is associated with severe dehydration or extreme weight loss.
turgor
____________ DATA: NEURO
* Headaches
* Head injury
* Dizziness or vertigo
* Seizures
* Tremors
* Weakness
* Incoordination
* Numbness or tingling
* Difficulty swallowing
* Difficulty speaking
* Significant history
* Environmental/Occupational hazards
SUBJECTIVE
NEURAL CHECKS
SCREENING NEUROLOGIC EXAMINATION –______ PEOPLE WITH NO HISTORY
COMPLETE NEUROLOGIC EXAMINATION – NEUROLOGIC CONCERNS/NEUROLOGIC
_______________
NEUROLOGIC RECHECK – NEUROLOGIC ____________ AND NEED PERIODIC SCREENING
TOOLS:
* PENLIGHT
* TONGUE BLADE
* COTTON SWAB AND BALL
* TUNING FORK
* PERCUSSION HAMMER
SCREENING NEUROLOGIC EXAMINATION –WELL PEOPLE WITH NO HISTORY
COMPLETE NEUROLOGIC EXAMINATION – NEUROLOGIC CONCERNS/NEUROLOGIC
DYSFUNCTION
NEUROLOGIC RECHECK – NEUROLOGIC DEFICITS AND NEED PERIODIC SCREENING
Cranial Nerve Mnemonics for the names & S/M/B
ROMBERG TEST
Normal: can walk tandem gait (heal to-toe) with balance, smooth, rhythmic, opposing arm swing is coordinated. Passed Romberg test, can do a shallow knee bend or hop in place
Abnormal: _________ (uncoordinated or steady gait), widened base, staggering, reeling, loss of balance, unequal rhythm of steps, slapping of foot, scraping of toe, __________ Romberg
Normal: can walk tandem gait (heal to-toe) with balance, smooth, rhythmic, opposing arm swing is coordinated. Passed Romberg test, can do a shallow knee bend or hop in place
Abnormal: ataxia (uncoordinated or steady gait), widened base, staggering, reeling, loss of balance, unequal rhythm of steps, slapping of foot, scraping of toe, positive Romberg
______________ : place a familiar object in their hand, ask if they can identify it by touch
- Classic test for Alzheimer’s
- Abnormal: astereognosis (unable to identify object, occurs in sensory cortex lesions)
Stereognosis
______________ : write a number in their hand, ask if they can identify by touch
* Classic test for assessing Alzheimer’s
Graphesthesia
__________________________
distance at which two points are felt
* More precise the closer you are to the fingertips
Two-point discrimination
______________ DATA: MUSCULAR
* Joints
* Muscles
* Bones
* Functional - ADLs
* Patient-centered care
SUBJECTIVE
RANGE OF MOTION - ROM
During ocular examinations, the nurse keeps in mind that movement of the extraocular muscles is:
A. Decreased in the older adult
B. Impaired in a patient with cataracts
C. Stimulated by cranial nerves I and II.
D. Stimulated by cranial nerves III, IV, and VI.
D. Stimulated by cranial nerves III, IV, and VI.
A patient comes to the clinic complaining of neck and shoulder pain and is unable to turn her head. The nurse suspects damage to CN ______ and proceeds with the examination by _____________.
A. XI; palpating the anterior and posterior triangles
B. XI; asking the patient to shrug her shoulders against resistance
C. XII; percussing the sternomastoid and submandibular neck muscles
D. XII; assessing for a positive Romberg sign
B. XI; asking the patient to shrug her shoulders against resistance
The nurse is checking the range of motion in a patient’s knee and knows that the knee is capable of which movement(s)?
A. Flexion and extension
B. Supination and pronation
C. Circumduction
D. Inversion and eversion
A. Flexion and extension
A patient’s thyroid gland is enlarged, and the nurse is preparing to auscultate the thyroid gland for the presence of a bruit. A bruit is a __________ sound that is heard best with the __________ of the stethoscope.
A. Low gurgling; diaphragm
B. Loud, whooshing, blowing; bell
C. Soft, whooshing, pulsatile; bell
D. High-pitched tinkling; diaphragm
C. Soft, whooshing, pulsatile; bell
If the thyroid gland is enlarged, then the nurse should auscultate it for the presence of a _______, which is a soft, pulsatile, whooshing, blowing sound, heard best with the bell of the stethoscope.
bruit
A patient states “I can hear a crunching or grating sound when I kneel”. She also states “it is very difficult to get out of bed in the morning because of stiffness and pain in my joints”. The nurse should assess for signs of what problem?
A. Crepitation
B. Bone spur
C. Loose tendon
D. Fluid in the knee joint
A. Crepitation
_______________ is an audible and palpable crunching or grating that accompanies movement and occurs when articular surfaces in the joints are roughened, as with rheumatoid
arthritis
Crepitation
When the nurse asks a 68-year-old patient to stand with his feet together and arms at his side with his eyes closed, he starts to sway and moves his feet farther apart. The nurse would document this finding as:
A. Ataxia.
B. Lack of coordination.
C. Negative Homans sign.
D. Positive Romberg sign.
D. Positive Romberg sign.
Abnormal findings for the Romberg test include swaying, falling, and a widening base of the feet to avoid falling.
A positive Romberg sign is a loss of _________ that is increased by the closing of the eyes.
balance
_________ is an uncoordinated or unsteady gait.
Ataxia
_________ sign is used to test the legs for deep-vein thrombosis.
Homans
In assessing a 70-year-old patient who has had a recent cerebrovascular accident, the nurse notices right- sided weakness. What might the nurse expect to find when testing his reflexes on the right side?
A. Lack of reflexes
B. Normal reflexes
C. Diminished reflexes
D. Hyperactive reflexes
D. Hyperactive reflexes
_________________ is the exaggerated reflex observed when the monosynaptic reflex arc is released from the influence of higher cortical levels. This response occurs with upper motor
neuron lesions
Hyperreflexia
Precentral gyrus- primary ________ area
motor
Postcentral gyrus- primary ___________ area
sensory
Parietal lobe- ___________
sensation
__________ area- speech comprehension
wernicke’s
occipital lobe- ________ reception
visual
_____________ - motor coordination, equilibrium, balance
cerebellum
___________ lobe- hearing, taste, smell
temporal
________ area- motor speech
broca’s
___________ lobe- personality, behavior, emotion, intellectual functions
frontal
A patient comes in for a physical examination and complains of freezing to death while waiting for her examination. The nurse notes that her skin is pale and cool and attributes this finding to:
a. Venous pooling.
b. Peripheral vasodilation.
c. Peripheral vasoconstriction.
d. Decreased arterial perfusion.
C A chilly or air-conditioned environment causes vasoconstriction, which results in false pallor and coolness
The findings from an assessment of a 70-year-old patient with swelling in his ankles include jugular venous pulsations 5 cm above the sternal angle when the head of his bed is elevated 45 degrees. The nurse knows that this finding indicates:
a.Decreased fluid volume.
b.Increased cardiac output.
c.Narrowing of jugular veins.
d.Elevated pressure related to heart failure.
d.Elevated pressure related to heart failure.
A patient is being assessed for range-of-joint movement. The nurse asks him to move his arm in toward the center of his body. This movement is called:
a. Flexion.
b. Abduction.
c. Adduction.
d. Extension.
c. Adduction.
A nurse assesses the left plantar reflexes of an adult client and notes the response shown in the photograph-
Which action should the nurse take next?
a. Contact the provider with this abnormal finding.
b. Assess bilateral legs for temperature and edema.
c. Ask the client about pain in the lower leg and calf.
d. Document the finding and continue the assessment.
a. Contact the provider with this abnormal finding. (correct)
The nurse notices that a patient’s palpebral fissures are not symmetrical. On examination, the nurse may find that there has been damage to cranial nerve:
VII - Facial
Facial muscles are mediated by cranial nerve (CN) VII;
asymmetry of palpebral fissures may be due to CN VII damage (______________)
(Bell’s palsy)
A patient is unable to differentiate between sharp and dull stimulation to both sides of her face. The nurse suspects damage to which nerve?
trigeminal nerve.
- Facial sensations of pain or touch are mediated by cranial nerve (CN) V trigeminal nerve.
When examining the face, the nurse is aware that the two pairs of salivary glands that are accessible to examination are the ___________________________ glands.
parotid and submandibular
- Two pairs of salivary glands accessible to examination on the face are the parotid glands, which are in the cheeks over the mandible, anterior to and below the ear; and the submandibular glands, which are beneath the mandible at the angle of the jaw. The parotid glands are not normally palpable.
A patient comes to the clinic complaining of neck and shoulder pain and is unable to turn her head. The nurse suspects damage to cranial nerve (CN) _____ and proceeds with the examination by _____.
XI; asking the patient to shrug her shoulders against resistance
- The major neck muscles are the sternomastoid and the trapezius. They are innervated by CN XI, the spinal accessory. The innervated muscles assist with head rotation and head flexion, movement of the shoulders, and extension and turning of the head.
When examining a patient’s cranial nerve (CN) function, the nurse remembers that the muscles in the neck that are innervated by CN XI are the:
sternomastoid and trapezius.
- The major neck muscles are the sternomastoid and the trapezius. They are innervated by CN XI, the spinal accessory
A patient’s laboratory data reveal an elevated thyroxine level. The nurse would proceed with an examination of the _____ gland.
thyroid
- The thyroid gland is a highly vascular endocrine gland that secretes thyroxine (T4) and tri-iodothyronine (T3). The other glands do not secrete thyroxine.
The nurse is aware that the four areas in the body where lymph nodes are accessible are the:
head and neck, arms, inguinal area, and axillae.
- Nodes are located throughout the body, but they are accessible to examination only in four areas: head and neck, arms, inguinal region, and axillae.
During an examination of a female patient, the nurse notes lymphadenopathy and suspects an acute infection. Acutely infected lymph nodes would be:
firm but freely movable.
- Acutely infected lymph nodes are bilateral, enlarged, warm, tender, and firm but freely movable. Unilaterally enlarged nodes that are firm and nontender may indicate cancer.
The inability to identify vibrations at the ankle and to identify the position of the big toe, along with a slower and more deliberate gait, and slightly impaired tactile sensation in an 80yo patient means
Sensory and motor deficits commonly associated with aging
A 70yo patient tells the nurse that every time they get up in the morning or after they’ve been sitting for a while, they get “really dizzy” and feel like they are going to fall over. What is the best response by the nurse?
“You need to get up slowly when you’ve been lying down or sitting”
Cyanosis: This is a _______ mottled color from decreased perfusion; the tissues have high levels of deoxygenated blood
bluish
Pallor: when the red-pink tones from the oxygenated hemoglobin in the blood are lost, the skin takes on the color of connective tissue (collagen), which is mostly _______.
white
Jaundice: A ____________ skin color indicates rising amounts of bilirubin in the blood
yellowish
Erythema: intense ___________ of the skin is from excess blood (hyperemia) in the dilated superficial capillaries.
redness
A 40-year-old woman reports a change in mole size, accompanied by color changes, itching, burning, and bleeding over the past month. She has a dark complexion and has no family history of skin cancer, but she has had many blistering sunburns in the past. The nurse would:
refer the patient because of the suspicion of melanoma on the basis of her symptoms.
The nurse keeps in mind that a thorough skin assessment is very important because the skin holds information about a person’s:
circulatory status.
The skin holds information about the body’s circulation, nutritional status, and signs of systemic diseases as well as topical data on the integument itself.
A 65-year-old man with emphysema and bronchitis has come to the clinic for a follow-up appointment. On assessment, the nurse might expect to see which assessment finding?
Clubbing of the nails
Clubbing of the nails occurs with cogenotal cyanotic hearty disease and neoplase and pulmonary disease. the other responses are assessment findings not assiciated with pulmonary diseases
During a skin assessment, the nurse notices that a Mexican-American patient has skin that is yellowish-brown; however, the skin on the hard and soft palate is pink and the patient’s scleras are not yellow. From this finding, the nurse could probably rule out:
jaundice
The nurse is bathing an 80-year-old man and notices that his skin is wrinkled, thin, lax, and dry. This finding would be related to which factor in the older adult?
An increased loss of elastin and a decrease in subcutaneous fat in the elderly
