Week 3 Flashcards
Where is the apical impulse located?
A. In the fifth intercostal space at the midclavicular line
B. In the third intercostal space at the left sternal border
C. In the second intercostal space at the left sternal border
D. In the second intercostal space at the right sternal border
A. In the fifth intercostal space at the midclavicular line
Auscultatory sites of the heart include:
A. Systolic and diastolic murmurs
B. Bruits and thrills
C. Aortic, pulmonic, tricuspid, and mitral areas
D. Extra heart sounds and splitting
C. Aortic, pulmonic, tricuspid, and mitral areas
Which of the following findings during a cardiac assessment of an adult patient are considered normal?
A. Ejection or systolic clicks
B. Pericardial friction rubs
C. Murmurs
D. S1 and S2 sounds
D. S1 and S2 sounds
The S1 heart sound:
A. Is louder at the apex of the heart
B. Results from closure of the mitral and tricuspid valves
C. Marks the start of systole
D. All of the above
D. All of the above
When palpating the carotid arteries:
A. Palpate one artery at a time.
B. Feel for thrills.
C. Use the thumb to palpate.
D. Both A and B
D. Both A and B
What is the correct order for abdominal assessment?
A. Inspection, palpation, auscultation, percussion
B. Inspection, auscultation, percussion, palpation
C. Auscultation, inspection, palpation, percussion
D. Palpation, inspection, auscultation, percussion
B. Inspection, auscultation, percussion, palpation
How often should normal bowel sounds be heard in each quadrant of the abdomen?
A. 5–35 times per minute
B. Less than 5 times per minute
C. 15–20 times per minute
D. 20–40 times per minute
A. 5–35 times per minute
Which of the following is an important part of performing an abdominal assessment?
A. Completing the assessment as quickly as possible
B. Stopping the assessment if the patient has any tenderness
C. Explaining each step of the assessment to the patient
D. Having the patient talk when auscultating for bowel sounds
C. Explaining each step of the assessment to the patient
What should you do if a patient is ticklish when you are palpating the abdomen?
A. Distract the patient by talking to him or her.
B. Do not palpate the abdomen in the upper quadrants.
C. Do only deep palpation of all four quadrants.
D. Place your hand over the patient’s hand during palpation.
D. Place your hand over the patient’s hand during palpation.
Moderate and deep palpation of the abdomen:
A. May cause tenderness
B. Should not detect masses
C. Should never be done over a surgical incision
D. All of the above
D. All of the above
What is included in the preparation for an assessment of the female genitalia?
A. Having the patient empty the bladder
B. Explaining the exam thoroughly if it is the patient’s first exam
C. Laying the head of the table flat
D. Both A and B
D. Both A and B
When should gloves be changed or discarded?
A. After touching the genital skin
B. After completing the internal vaginal exam
C. After completing the rectal exam
D. All of the above
D. All of the above
Which description is consistent with normal vaginal secretions?
A. Clear, thick, and with a fishy odor
B. Clear or cloudy, and odorless or with a slight odor
C. Yellow, thin, and with a strong odor
D. Green, thick, and with a foul odor
B. Clear or cloudy, and odorless or with a slight odor
What is a Pap smear?
A. A screening test for cervical cancer
B. A screening test for colon cancer
C. A screening test for sexually transmitted diseases
D. None of the above
A. A screening test for cervical cancer
Screening for endometrial cancer consists of reinforcing the need to report:
A. Bloody stools
B. Painful bowel movements
C. Unexpected vaginal bleeding or spotting
D. Green or yellow vaginal discharge
C. Unexpected vaginal bleeding or spotting
Symptoms of prostate enlargement (NUTS)
Nocturia
Urine dribbles
Tries to void but can’t
Small urine stream
Which of the following should be included in a male genital exam?
A. Teaching the patient how to do self-exams
B. Palpating for abnormalities
C. Retracting and replacing the foreskin in an uncircumcised patient
D. All of the above
D. All of the above
Nocturia, urine dribbles, difficulty voiding, and a small urine stream are common symptoms of which of the following conditions?
A. Colorectal cancer
B. Benign prostatic hypertrophy
C. Testicular cancer
D. Hernias
B. Benign prostatic hypertrophy
In which patient population does benign prostatic hypertrophy occur most commonly?
A. Males over 50 years of age
B. Adolescent males
C. Males between 20 and 35 years of age
D. Males between 35 and 50 years of age
A. Males over 50 years of age
Which of the following patients are considered at increased risk for colon cancer?
A. Patients with a history of chronic inflammatory bowel disease
B. Patients with a family history of adenomatous polyposis
C. Patients with a history of appendicitis
D. Both A and B
D. Both A and B
Which possible signs and symptoms of testicular cancer should be reported to a physician?
A. A lump, tenderness, or swelling in the scrotum or testicles
B. Unexplained weight loss
C. Breast development
D. All of the above
D. All of the above
Which of the following techniques is used to assess muscle strength in a patient?
A. Apply an opposing force or resistance.
B. Observe the patient at rest.
C. Percuss the muscle.
D. Palpate the muscle.
A. Apply an opposing force or resistance.
Neck flexion and extension should be:
A. 90 degrees
B. 70 degrees
C. 30 degrees
D. 45 degrees
D. 45 degrees
What is an increased thoracic curvature, common in older adults, called?
A. Scoliosis
B. Lordosis
C. Kyphosis
D. Swayback
C. Kyphosis
Which of the following cranial nerves is assessed by holding a scented object under the patient’s nose?
A. Facial nerve
B. Oculomotor nerve
C. Olfactory nerve
D. Acoustic nerve
C. Olfactory nerve
What are the Snellen and Rosenbaum charts used to assess?
A. Optic nerve
B. Trigeminal nerve
C. Abducens nerve
D. Facial nerve
A. Optic nerve
What does a goniometer measure?
A. Muscle strength
B. Joint stability
C. Cranial nerve function
D. Angles of extension and flexion
D. Angles of extension and flexion
Which of the following findings in a musculoskeletal assessment would be considered abnormal?
A. Nodules
B. Bogginess
C. Symmetry
D. Both A and B
D. Both A and B
What questions can you ask a patient to assess his or her state of consciousness?
A. Ask the patient about his or her thoughts, feelings, and emotions.
B. Ask for the date, his or her name, and the location.
C. Ask the patient to repeat a series of five numbers.
D. Ask the patient to write his or her name and address.
B. Ask for the date, his or her name, and the location.
Which of the following are included in the assessment of mental status?
A. Speech and language
B. Emotional stability
C. Physical appearance and behavior
D. All of the above
D. All of the above
Which of the following actions are part of the assessment of the glossopharyngeal and vagus nerves?
A. Testing the gag reflex
B. Having the patient swallow
C. Touching the patient’s face with dull and sharp objects
D. Both A and B
D. Both A and B
Which test or tests assess accuracy of movement?
A. Finger-to-finger test
B. Finger-to-nose test
C. Heel-to-shin test
D. All of the above
D. All of the above
What should the nurse do if a patient displays staggering or loss of balance during the Romberg test?
A. Give the patient a gentle push to further assess balance.
B. Delay other balance tests.
C. Have the patient stand on one foot with the eyes closed.
D. Have the patient hop on one foot.
B. Delay other balance tests.
How would you assess sensitivity to superficial pain?
A. Touch the patient with the sharp side of a broken tongue blade.
B. Have the patient keep his or her eyes open.
C. Allow 2 seconds between stimuli.
D. Both A and C.
D. Both A and C.
A deep tendon reflex with a normal response is scored as:
A. 0
B. 1+
C. 2+
D. 3+
C. 2+
Which of the following tips will assist with eliciting the patellar and Achilles deep tendon reflexes?
A. Have the patient sit with his or her feet flat on the floor.
B. Have the patient focus on pulling his or her clasped hands apart.
C. Have the patient flex his or her knees at a 45-degree angle.
D. Strike the knee above the patella.
B. Have the patient focus on pulling his or her clasped hands apart.
The nurse is preparing to use a slide board to transfer a patient from the bed to a stretcher. How many additional people will the nurse need to help with this transfer?
A. Four
B. Two
C. One
D. None
B. Two
The nurse is preparing to move a patient from the bed to a stretcher. What will the nurse do first?
A. Cross the patient’s arms over his or her chest.
B. Lower the side rails of the bed.
C. Make sure the bed brakes are locked.
D. Fanfold the draw sheet.
C. Make sure the bed brakes are locked.
When turning a patient to place a slide board, where do the assistants stand?
A. At the side of the bed to which the patient will be turned
B. At the side of the bed from which the patient will be turned
C. At the head and foot of the bed
D. At the foot of the bed only
A. At the side of the bed to which the patient will be turned
The nurse and his or her assistants are using a slide board to move a patient from the bed to a stretcher. The nurse, standing alone on the side of the bed opposite the stretcher, will perform which action during this move?
A. Hold the slide board.
B. Pull the draw sheet.
C. Hold the patient’s head stationary.
D. Lock the brakes on the stretcher.
A. Hold the slide board.
After moving a patient from the bed to a stretcher, what will the nurse do next?
A. Lock the wheels on the stretcher.
B. Cover the patient with a blanket.
C. Raise the head of the stretcher if doing so is not contraindicated.
D. Unlock the wheels of the bed.
C. Raise the head of the stretcher if doing so is not contraindicated.
When positioning a hemiplegic patient in the supported Fowler’s position, what is the primary reason a trochanter roll is placed alongside the patient’s legs?
A. To reduce the risk of a fall while the side rails are down
B. To reduce the risk of contracture
C. To control pain
D. To cushion the legs
B. To reduce the risk of contracture
When repositioning a patient, what can the nurse do to prevent the patient’s hips from rolling outward?
A. Apply therapeutic boots to the feet.
B. Place sandbags along the legs.
C. Place a small pillow at the lumbar region of the back.
D. Place a pillow under the calves.
B. Place sandbags along the legs.
To which position would the nurse assist the patient who is experiencing difficulty with breathing?
A. Left lateral recumbent position
B. 30-degree lateral position
C. Fowler’s position
D. Prone position
C. Fowler’s position
The nurse is preparing to move a patient with hemiplegia into the prone position. What action should the nurse take when rolling the patient onto her side?
A. Place a small pillow under the shoulder.
B. Use the affected arm as a guide during rolling.
C. Place a pillow on the abdomen.
D. Place rolled bath blankets along the dependent leg.
C. Place a pillow on the abdomen.
The nurse is preparing to logroll a patient in bed. Why are two assistants needed on the side toward which the patient is being turned?
A. To position the pillows
B. To keep the spine in alignment
C. To roll the patient as a unit
D. To ease the patient back onto the support pillows
C. To roll the patient as a unit
Inspection of the Chest: Respiration
During inspection, the nurse evaluates the patient’s respirations for rate and rhythm by inspecting the chest wall.
Chest movement should be observed during breathing for _____________________________________________________. The nurse should also note any audible sounds with respiration.
symmetry and use of accessory muscles
Which elements are important for the nurse to assess on inspection of a patient’s chest?
Select all that apply.
Color
Symmetry
Tenderness
Venous patterns
Prominence of ribs
Color
Symmetry
Venous patterns
Prominence of ribs
[The nurse would assess tenderness of the chest on palpation, not inspection.]
During physical assessment, which elements are part of a chest and lung inspection?
Select all that apply.
Symmetry
Temperature
Muscle tone
Use of accessory muscles
Resistance to pressure
Symmetry
Use of accessory muscles
Which structure or landmark should the nurse inspect while assessing the quality of respirations?
Neck
Upper abdomen
Chest wall
Posterior axillary line
Chest wall
To assess tactile fremitus, the nurse asks the patient to :
recite numbers or words.
While the patient does this, the nurse systematically palpates the chest with the palmar surfaces of fingers or the ulnar aspect of a clenched fist, using a firm, light touch. The nurse assesses the area from front to back and side to side and then compares the sides. Tactile fremitus can be best palpated posteriorly and laterally at the level of the bronchial bifurcation.
When palpating the chest, which elements should the nurse note?
Select all that apply.
Sensations
Symmetry
Tactile fremitus
Thoracic expansion
Use of accessory muscles
Sensations
Symmetry
Tactile fremitus
Thoracic expansion
When palpating the chest, which sensations should the nurse note?
Select all that apply.
Crepitus
Color
Grating vibrations
Tactile fremitus
Superficial venous patterns
Crepitus
Grating vibrations
Tactile fremitus
What is being assessed when the nurse asks the patient to recite numbers or words during palpation of the chest?
Symmetry
Tactile fremitus
Thoracic expansion
Tenderness
Tactile fremitus
In which position should the patient be for the nurse to assess the lateral and anterior chest?
Arms at sides
Lying supine
Arms raised overhead
Arm crossed
Arms raised overhead
The nurse percusses the anterior chest to obtain information about which elements of the internal organs?
Select all that apply.
Size
Condition
Function
Location
Developmental state
Size
Condition
Location
When percussing the chest, how should the nurse compare tones?
Bilaterally
Anterior-posterior
Lateral-anterior
Caudal-cranial
Bilaterally
When auscultating the chest, which elements are important for the nurse to note?
Select all that apply.
Symmetry
Tactile fremitus
Vocal resonance
Duration of breath sounds
Unexpected breath sounds
Vocal resonance
Duration of breath sounds
Unexpected breath sounds
In which ways should the nurse characterize the breath sounds heard on auscultation of the chest and lungs?
Select all that apply.
Pitch
Intensity
Tone
Quality
Duration
Pitch
Intensity
Quality
Duration
For which elements of vocal resonance should the nurse auscultate?
Select all that apply.
Nasal quality to spoken words
Change in accent of spoken words
Increased loudness of spoken words
Increased loudness of whispered words
Absence of the ability to hear spoken words
Nasal quality to spoken words
Increased loudness of spoken words
Increased loudness of whispered words
During inspection, which peripheral structures provide clues about the patient’s cardiac health?
Select all that apply.
Lips
Nails
Hair
Fingers
Alae nasi
Lips
Nails
Fingers
Alae nasi
In which position should a patient be when the nurse is percussing the back?
Lying supine with arms at sides
Prone position with arms at sides
Standing erect with arms raised above head
Leaning forward with arms crossed and neck flexed
Leaning forward with arms crossed and neck flexed
Which element is being assessed when the nurse auscultates the chest?
Rib location
Liver location
Diaphragm size
Lung condition
Lung condition
On inspection of the chest and lungs, the nurse should evaluate which features of the patient’s respirations?
Tone
Rate
Rhythm
Amplitude
Audible sounds
Rate
Rhythm
Audible sounds
What is a nurse assessing in relation to the trachea when he/she uses palpation during a thorough chest and lung examination?
Resonance
Location
Symmetry
Tactile fremitus
Location
During examination of the chest and lungs, the nurse would palpate posteriorly and laterally at the level of the bronchial bifurcation to assess the quality of __________________.
tactile fremitus
The Point of Maximal Impulse PMI is located at the ______ of the heart, which is at the fifth intercostal at the midclavicular line
apex
Some basic equipment is required to assess the ______. Necessary equipment includes:
Stethoscope with bell and diaphragm
Marking pencil
Centimeter ruler
heart
What initial step should be performed when assessing the heart?
Auscultation
Inspection
Palpation
Percussion
Inspection
Inspection is the initial step in the examination process and is used to identify the contour of the anterior chest wall and the location of the point of maximal impulse (PMI).
The nurse is performing a cardiac assessment on a patient and is attempting to inspect the apical pulse. The nurse understands that the best location to visualize the apical pulse is:
Second intercostal space to the left of the sternum
Second intercostal space to the right of the sternum
Fifth intercostal space at the midclavicular line
Fifth intercostal space to the left of the sternum
Fifth intercostal space at the midclavicular line
The nurse is assessing a patient with jugular venous distention in the supine position. The nurse knows that the best way to assess jugular venous distention is to:
Measure the pressure in centimeters
Locate the internal jugular vein
Identify the highest point of pulsation
Raise the head of the bed
Raise the head of the bed
Raising the head of the bed helps to identify the external jugular vein, which leads to a better visualization of the internal jugular vein
When palpating the base of the heart, the hand of the nurse will be placed at which location?
Second intercostal space to the right of the sternum
Second intercostal space to the left of the sternum
Fifth intercostal space to the left of the midclavicular line
Fifth intercostal space to the left of the sternal border
Second intercostal space to the left of the sternum
The nurse is attempting to palpate the apical pulse of a patient with heart-related symptoms. The nurse understands that the apical pulse is most easily palpated during which part of the cardiac cycle?
Contraction of the left ventricle
Stimulation of the sinoatrial (SA) node
Relaxation of the left ventricle
Contraction of the tricuspid valve
Contraction of the left ventricle
Why has the chest x-ray made the technique of percussion optional?
The patient can be in any position to have a chest x-ray.
A chest x-ray can offer more precise information.
A chest x-ray is preferred by women.
A chest x-ray is less time consuming.
A chest x-ray can offer more precise information.
For which patients would the nurse expect distorted findings while percussing the heart?
Select all that apply.
A body builder
An overweight patient
A patient with leukemia
A malnourished patient
A patient with pericardial effusion
A body builder
An overweight patient
A patient with pericardial effusion
_____________ _________, an extra systolic sound heard best when the patient leans forward and the heart is closer to the chest wall.
Ejection click
_______________, a scraping sound heard when there is inflammation in the heart tissue.
Friction rub
Mitral _______ , heard when a thickened, diseased mitral valve opens.
snaps
____________, extra, low-pitched heart sounds that can be defined as either S3 (rapid filling of ventricle with blood at the beginning of diastole) or S4 (atrial contraction resulting in ejection of blood into a ventricle that cannot expand), depending on when during the cardiac cycle it is heard.
Gallops
Select the location for auscultation of the aortic area.
Second right intercostal space to the right of the sternal border
Second left intercostal space to the left of the sternal border
Fourth left intercostal space along the lower left sternal border
Fifth intercostal space at the midclavicular line
Second right intercostal space to the right of the sternal border
Using the diaphragm of the stethoscope, the nurse will begin auscultating the heart in which anatomical area of a typical patient?
Aortic
Pulmonic
Tricuspid
Mitral
Mitral
The point of maximal impulse (PMI) is located in the mitral area, which is the apex of the heart, and can be easily identified in most patients. This is the usual location at which to begin auscultation of the heart. From the apex, the nurse would follow a systematic sequence.
The second heart sound (S2) should be assessed at which location?
Aortic area
Mitral area
Tricuspid area
Second pulmonic area
Aortic area
Atrial contraction resulting in ejection of blood into a ventricle that cannot expand
S4
Closure of the pulmonic and aortic valves
S2
Early, rapid filling of the ventricle with blood at the very beginning of diastole
S3
Blood flow across an incompetent valve
murmurs
What term identifies a split sound heard during auscultation of the heart?
Fixed
Gallop
Murmur
Regurgitation
fixed (splitting)
While inspecting the chest, the nurse observes unusual chest movements. Which assessment technique should the nurse perform next?
Auscultation
Inspection
Palpation
Percussion
Palpation
Identify the area of the body where the nurse observes for lifts and heaves.
Precordium
Right internal jugular vein
Epigastric region
Carotid artery
Precordium
Describe how the nurse uses palpation to ensure the identification of the first heart sound (S1).
Using two fingers over the popliteal artery
Using two fingers over the aortic and pulmonic valves
Counting the beats from the popliteal artery and radial artery
Placing the hand over the carotid artery and point of maximal impulse (PMI)
Placing the hand over the carotid artery and point of maximal impulse (PMI)
Describe how the nurse uses palpation to identify dextrocardia.
Locate the point of maximal impulse (PMI)
Observe for presence of cyanosis
Locate the borders of the heart
Identify the direction of the thrill
Locate the point of maximal impulse (PMI)
The nurse is palpating the base of the heart and identifies a fine rushing vibration. The nurse correctly documents this symptom as what?
Pericardial friction rub
Murmur
Gallop
Opening snap
Murmur
Which statement describes the limitations of using the percussion technique in physical examination?
Select all that apply.
Percussion is difficult to learn.
The percussion technique is not sensitive enough to detect changes in heart size.
The heart conforms to the chest’s shape, making it difficult to assess heart size.
Fluid or air can distort findings.
Enlargement of the right ventricle occurs laterally.
The heart conforms to the chest’s shape, making it difficult to assess heart size.
Fluid or air can distort findings.
Using percussion, the nurse identifies the cardiac border by a change from a _____ to a _____ note.
Flat; dull
Resonant; dull
Hyperresonant; tympanic
Split; fixed
Resonant; dull
The nurse is having trouble auscultating the apical impulse of an obese patient. Which action by the nurse would improve this assessment?
Have the patient lie supine.
Have the patient lean forward.
Tell the patient to take a deep breath and hold it.
Place the stethoscope over the epigastrum.
Have the patient lean forward.
Identify the area where the mitral valve should be auscultated.
Second intercostal space to the left of the sternum
Second intercostal space to the right of the sternum
Fourth intercostal space along the lower left sternum
Fifth intercostal space at the midclavicular line
Fifth intercostal space at the midclavicular line
The nurse is auscultating heart sounds of a patient with heart-related symptoms. The nurse understands that the bell of the stethoscope is best used for auscultating what heart sounds?
High-pitched heart sounds
Low-pitched heart sounds
High-pitched heart murmurs
Closure of the tricuspid and mitral valves
Low-pitched heart sounds
The nurse assesses a patient with abnormal heart sounds. This symptom is correctly documented as the third heart sound (S3) because it is low-pitched and located at which area of the heart?
Apex
Entire pericardium
Second right intercostal space
Second left intercostal space
Apex
When auscultating the heart sounds, the nurse makes note of what qualities of the auscultated sounds?
Select all that apply.
Pitch
Rhythm
Location
Timing
Frequency
Pitch
Rhythm
Location
Timing
Why is it vital to identify the baseline rate and rhythm of the heart?
Select all that apply.
To identify tachycardia or bradycardia
To measure cardiac output
To identify the first heart sound (S1)
To identify dysrhythmias
To identify tachycardia or bradycardia
To identify dysrhythmias
During assessment of the peripheral vascular system, it is important for the nurse to assess temperature and sensation, as well as the 3 Ps:
_________
First symptom of peripheral arterial disease
Referred to as claudication
Dull ache in the leg(s) with muscle fatigue and cramps
Usually appears during exercise (walking longer distances, climbing stairs)
Typically relieved by rest
________
Color change of the skin
Note if skin is pale or cyanotic
_________
Strong, weak, or absent
Pain
Pallor
Pulse
What characteristic of the pulse can be described as smooth, rounded, or dome-shaped?
Contour
Amplitude
Symmetry
Rate and rhythm
Contour
Which sound, auscultated over the neck, is heard at the medial end of the clavicle and anterior border of sternocleidomastoid muscle?
Venous hum
Cardiac bruit
Temporal bruit
Femoral bruit
Venous hum
When assessing for peripheral arterial disease, the nurse should assess for signs and symptoms related to which aspects of decreased blood flow?
Select all that apply.
Pain
Pallor
Poor movement
Muscle cramps
Pain at rest
Pain
Pallor
Muscle cramps
When assessing for peripheral arterial disease, what should the nurse note about the condition of the patient’s skin?
Select all that apply.
Color
Temperature
Hair growth
Atrophy
Cyanosis
Color
Temperature
Atrophy
Cyanosis
Which characteristics suggest deep vein thrombosis (DVT)?
Select all that apply.
Leg lesion
Constant calf pain
Tenderness over a vein
Swelling to one extremity
Calf pain with dorsiflexion of the foot
Tenderness over a vein
Swelling to one extremity
Calf pain with dorsiflexion of the foot
The amplitude of a pulse can be described on a scale of 0-4. Which number represents a bounding, aneurysmal pulse?
4
Which pulse characteristic can be assessed by comparing the strength of the upper extremity pulses with the strength of the lower extremity pulses?
Heart rate
Symmetry
Waveform
Amplitude
Symmetry
Which pulse characteristic should the nurse assess when looking for evidence of local obstruction?
Rate
Rhythm
Bruits
Contour
Bruits
When assessing for peripheral arterial disease, which pulse characteristics should the nurse evaluate after assessing the patient’s pain?
Pulse rate
Pulse rhythm
Pulse strength
Loss of core body warmth
Pulse strength
The nurse is using capillary refill time to assess the severity of arterial insufficiency. After blanching the nail bed and releasing the pressure, what is the next step the nurse performs?
Assessing jugular vein distention
Recording the patient’s pulse
Taking the patient’s blood pressure
Counting the time for the skin to return to normal
Counting the time for the skin to return to normal
What action should the nurse take to help distinguish jugular pulsations from carotid pulsations?
Palpate the carotid pulse
Have the patient stand up during the assessment
Ask the patient to hold his or her breath during the assessment
Hold pressure for 10 seconds while the patient is lying at 45 degrees
Palpate the carotid pulse
On assessment of a patient’s leg for edema, the nurse observes deep pitting lasting 2-5 minutes and gross distortion of the affected leg. Which grade of edema should the nurse document?
1+
2+
3+
4+
4+
For which signs of venous obstruction leading to insufficiency should the nurse expect to assess?
Select all that apply.
Fatigue
Hair loss
Homans’ sign
Swelling and tenderness
Engorgement of superficial veins
Hair loss
Homans’ sign
Swelling and tenderness
Engorgement of superficial veins
Which characteristics of the lymph nodes would be assessed on palpation?
Select all that apply.
Size
Color
Warmth
Mobility
Tenderness
Size
Warmth
Mobility
Tenderness
Liver
Kidney
Duration of breath sounds:
Bronchial
Bronchiovesicular
Vesicular
Auscultation sites for the heart - mnemonic
APE TO MAN
Aortic point
Pulmonic point
Erb’s point
Tricuspid point
Mitral valve point.
Identify A, B, C
A- Pericardium
B- Base
C- Apex
Identify A, B, C, D, E
A- Aorta
B- Left atrium
C- Aortic valve
D- Mitral (AV) valve
E- Left ventricle
Identify F, G, H, I, J, K
F- Right ventricle
G- Tricuspid (AV) Valve
H- Right atrium
I- Pulmonic valve
J- Pulmonary artery
K- Superior vena cava
Identify A, B, C, D, E, F
A- clavicle
B- 2nd intercostal space
C- Suprasternal notch
D- Body of sternum
E- Xiphoid process
F- Costal angle
identify
scoliosis
identify
Kyphosis
identify all parts
know lung anatomy
identify all
A- spleen
B- Stomach
C- small intestine
D- Bladder
E- appendix
F- Gallbladder
G- Liver
Review deep internal anatomy of abdomen
identify all
what is this?
Striae
Describe signs and symptoms of heart failure
Review blood flow of the heart
