NUR 352 ASU LECTURE NOTES 216 Final Exam 2023.pdf

216 Final Exam Review Guide

Module 1- Introduction to Health Assessment

1. What are the steps in the nursing process? Be able to identify examples of each step.

Assessment: Obtaining subjective and objective data

Diagnosis: Nursing diagnosis analyzes the data collected, identifying actual and

potential problems.

Planning: Using SMART to create a plan based off data and diagnosis

Implementation: Use skills to implement appropriate therapeutic interventions.

Evaluation: Monitor the effectiveness and achievability of goals and the need for

intervention or adjustment

2. What are the components of the general survey?

Physical Appearance

Body structure

Mobility/Gait

Behavior

Speech

Dress, hygiene, grooming, and odors (body, breath)

Vital signs with asking about Pain

3. What types of questions may be asked in the review of systems?



Start with the head all the way down to toes and ask relevant questions that are

age-appropriate for each system

oIntegumentary

oHead, neck, cognitive

oEyes, ears, nose, mouth

oRespiratory

oCardiovascular

oGI

oGU

oMSK

oNeuro

oEndocrine

oMental

4. What are the four techniques used in physical assessment?



Inspection



Palpation



Auscultation



Percussion

5. What are the techniques used when assessing the abdomen?

Inspection

Auscultation

Palpation

6. How do you properly palpate for temperature?



With the dorsal side of the hand

7. What is each side of the stethoscope called and used for?

Diaphragm: used for high pitched

Bell: Low pitched (heart murmur)

Module 2- General Survey

1. What are the vital signs you typically need to collect from every patient?



Temperature 96.8-100.4F



Pulse 60-100 bpm



Respiration rate 12-20 bpm



Pulse Ox 95-100%

Blood pressure <120 / <80

oHypotension <90 / <60

oHypertension >130-140 / 80-90

2. Be able to identify the most common pulse points.

Radial (or thumb side of the wrist)



3. What are the different ways to take a temperature? What is the technique for each one?

Oral

Rectal -- sims position with upper leg flexed. 2.5-3.5 cm (1-1.5 inches) for adult.

Axillary

Tympanic -- Pull the ear up and back (for adults) or down and back (for a child)

Temporal

4. Which sources are considered core and surface temperatures?

CORE = Oral and Rectal

SURFACE = Axillary, Tympanic, and Temporal

5. What are some causes of out-of-range vital signs?

Exercise, Medication, smoking, lifestyle habits, drinking a cold drink, food,

diseases, conditions, hormonal changes, stress, ect.

6. How do you perform a two-step blood pressure?

Palpate brachial pulse, wait 30 secs, place diaphragm and up 20 above, let out

pressure

7. What are the stages of hypertension?

Hypotension: <90 systolic, <60 diastolic

HTN 1: 130 - 139 sys, 80-90 diastolic

HTN 2: >140 sys, > 90 diastolic

8. How do you describe the behavior and effect of a patient?



AOX4



Questions you ask --> Name, DOB, Location, Situation

oOrientation needs to know where they are, who they are and time

9. Be able to differentiate between mobility, posture and body structure.



Mobility: ability to move



Posture: the position in which someone holds their body when they are sitting or

standing



Body structure: a particular complex anatomical part of a living thing

10. What does each BMI range represent?

Less than 18.5 is underweight

18.5-24.9 Normal BMI

25-29.9 overweight

Obese 30 or greater

11. When is a focused assessment appropriate? A full physical examination?



Focused assessment: focuses on a particular topic, body part, or functional ability

rather than an overall health status



Physical exam: uses techniques of inspection, palpation, percussion, auscultation

(head to toe assessment)

Module 3- Health History

1. What questions would you ask to obtain a complete health history from a patient?



Childhood illnesses, chronic illness, hospitalizations, surgeries, immunizations,

examinations, screenings, allergies

2. What is the difference between subjective and objective data? How do you collect each?

Subjective = symptoms (only what the pt an tell you how they feel)

oPain scale, Feelings, Symptoms

Objective = what you can see (5 senses) and observe

oVital signs, Bruises/cuts, Assessment

3. What is an open-ended question? When is it most appropriate to use them?



Open-ended questions are not yes or no questions

oTell me more about...



Useful when you need to probe but respectfully for more information

4. What question types would you want to avoid?



Close ended questions/Yes or no

5. What is a functional assessment?

Determines the pt’s ability to care for themselves

oAre they able to do things for themselves (physically, mentally)

oADL’s

6. How does culture influence a patient’s health?

FICA

oF = Faith

oI = Influence

oC = Community

oA = Address preferences

7. What is the history of present illness (HPI) assessment?

Description of the development of the pt’s present illness --> S/S

oOLD CART

O = Onset

L = Location

D = Duration

C = Characteristics

A = Aggravating and Alleviating Factors

R = Related symptoms

T = Treatment

S = Severity

Health Assessment Modules 4-5 Review

1. What findings would lead a nurse to suspect abuse?

Examine all body surfaces for signs of physical abuse

Bruises, burns

Assess for injuries of abuse

Black eyes, facial injuries

2. What areas are at highest risk for pressure related skin breakdown?

Bony prominences - areas where bones are close to the surface

3. What categories are assessed in the Braden Scale?

For predicting pressure sore risk

Sensory Perception 1-4

oAbility to respond meaningfully to pressure related discomfort

Moisture 1-4

oDegree to which skin is exposed to moisture

Activity 1-4

oDegree to physical activity

Mobility 1-4

oAbility to change and control body position

Nutrition 1-4

oUsual food intake pattern

Friction and Shear 1-4

oMovement in bed/sheets

SEVERE RISK: Total score 9

MILD RISK: Total score 15-18

4. What assessment findings would indicate dehydration?

Poor indicates possible dehydration, increased risk for skin breakdownturgor

oPoorly hydrated skin retains the tent shape of the pinched skin

Weak and rapid pulse

Hypotension

5. Who should perform foot care on a diabetic?

Podiatrist

6. What are age-related changes associated with the integumentary system?

Skin -- Thinning, drier

Loss of elasticity

Slow wound healing

Decline in glandular structure and function (less oil, moisture, sweat)

7. What should a diabetic patient be educated on regarding foot care?

Inspect feet daily

Use lukewarm water/dry thoroughly

Clean cotton socks daily

Comfortable shoes that don’t restrict circulation

8. What are the functions of the skin?

Protect the inner body parts and organs

Body temperatures regulation through shivering and sweating

Sensory perception of temperature, touch and pain

Produce vitamin D

First line of defense

9. What assessment findings would a nurse expect with a patient with liver failure?

Jaundice- yellow to orange color

oA slight yellow tinge can be an expected finding for client who have dark

skin

oCan be found in

Skin, sclera, mucous membranes

10. What patients are at an increased risk for developing a pressure ulcer?

Thinner skin (due to age)

Poor nutritional state, which affects healing

Presence of moisture due to incontinence, wound drainage or perspiration

Immobility

11. What is herpes zoster (shingles)? What findings would you expect with a patient with

herpes zoster?

Herpes zoster – shingles

oCommon viral infection that erupts years after exposure to chickenpox and

invades a specific nerve tract

Findings

oPain, Itching, Tingling, Burning along the involved dermatome

12. What is the ABCDE skin assessment? What is it used to assess?

Check lesions system tousing the ABCDE detect possible skin cancer

A – A symmetry of shape

B – B order irregularity

C – C olor variation within one lesion

D – D iameter greater than 6mm

E - E volving or changing in color, elevation, shape, size, itching, crusting or

bleeding

13. What are the signs and symptoms of anemia?

Anemia: Reduced hemoglobin and poor circulation

oS/S

RR increased and depth

Pallor – loss of pink or yellow skin

Weakness

SOB

Cold hands and feet

Tachycardia (increased heart rate)

14. What is the best way to assess jaundice in a dark-skinned patient?

Jaundice -- A slight yellow tinge

oYellow coloring of the sclera

On the palms and soles

15. What would you describe pallor in a patient with dark skin?

In black skin tones

oA change to gray, particularly in the mucous membranes

In brown skin tones

oA change to yellow brown

Observe by inspecting the color of the lips, mucus membranes, nailbeds

16. How do you assess a patient for pitting edema?

 Pitting edema is present when pressure on the affected area leaves a visible

indentation in the skin.

4 points scale is used to document the degree of pitting edema

o1+ = Trace, 2mm, rapid skin response

o2+ = Mild, 4mm, 10 to 15 second skin response

o3+ = Moderate, 6mm, prolonged skin response

o4+ = Severe, 8mm, prolonged skin response

17. What is purulent, serous, serosanguineous, and sanguineous fluid?

Serous – Clear

Serosanguineous – Both blood and liquid part of blood (serum)

Purulent – Contains leukocytes and bacteria

oIndicate infection

Sanguineous – Contains red blood cells, red and bloody

18. What patients would be at the highest risk for developing malignant melanoma?

“Ugly ducklings” skin – client who has many nevi (moles)

The risk of melanoma increases with each additional sunburn

19. What are some interventions to prevent pressure ulcers?

Inspect the skin daily for signs of breakdown

Reposition every 2 hours

Elevate the head of the bed no more than 30 degrees to prevent a shearing injury

Remove sources of excessive moisture due to incontinence, drainage, diaphoresis

Keep skin clean, dry and intact

20. How would you describe vesicles, bullas, papules, and wheals?

Vesicles: Raised, fluid filled

oSmall superficial, filled with serous fluid

oEx: Blister, herpes simples, varicella (chicken pox), shingles, acute

eczema

Bullas: small superficial, filled with serous fluid

oEx: blister, medication reaction

Papules: Primary lesion, raised lesion – small < 1cm area

oPalpable, circumscribed, solid elevation of the skin

oEx: Elevated mole, wart, skin tag

Wheals: Irregular area of edema on the skin

oRaised solid area, Palpable, irregular borders, edematous

oEx: Insect bite, allergic reactions, hives

21. What would you expect to see on assessment in a patient who has a wound infection?

Erythema and swelling around the wound

Fever, warmth of the surrounding soft tissue

Foul odor

22. How would you describe a stage 1, 2, 3, and 4 pressure ulcers?



 Stage 1: Reddened area that does not blanch with pressure

oNon-blanchable erythema of intact skin:



 Stage 2: Partial loss of dermis

oInvolves epidermis and dermis

oThe wound bed is viable with reddish-pinkish bed without slough, eschar,

granulation tissue, or adipose tissue



 Stage 3: Full thickness skin loss with damage or necrosis to subcutaneous

tissue

oVisible adipose tissue with possible granulation tissue and epibole (wound

edges appear rolled under), some slough, eschar present.

Possible undermining or tunneling.

Stage 4: Full thickness of skin loss resulting in exposed bones, tendons /

muscles

oSkin and tissue loss with cartilage, bone, fascia, muscle, ligaments, or

tendon exposed in the wound or easily palpable

Epibole, tunneling, and undermining are common

23. How do you perform a whisper test?



 Whisper test (CN VIII)

oTechnique- occlude one ear and test the other to see if the client can hear

whispered sounds without seeing your mouth move

24. What is a Snellen chart used for? What does the top and bottom number indicate?

Snellen chart:

oUse to screen for myopia (impaired for vision)

oTop number: The distance (in feet) the client stands from the chart

oBottom number: The distance at which a visually impaired eye can see

the same line clearly

For clients who can’t read

25. What is the Weber test?

Weber test: Auditory screening test (ears)

oTechnique: Place a vibrating turning fork on top of the client’s head.

oThey should be able to equally hear sound with both ears

26. When assessing lymph nodes on a healthy patient, what would you expect?

There should be no lumps or swelling visible or palpate in the neck, no

tenderness, no enlargement nodes

27. How do you assess accommodation on a patient?

Accommodation of the pupils when they dilate to look at an object far away and

then converge and constrict to focus on a near object

oFollow pen light to nose

28. When performing an otoscopic examination, what are some expected and unexpected

findings?

Expected findings:

oThe auricle, or outer ear, should appear symmetric in size placement

oThe color of the client’s ear should be the same as the client's face, should

be intact, with no lumps, edema, or lesions

o Cerumen can be wide variety of colors and textures from grey, yellow to

tan to black moist and waxy to dry and flaky.

Unexpected findings:

o Redness of the client’s ears is a sign of inflammation / fever

o Redness, edema, and purulent, or crusty drainage of the ear canal can

indicate an infection

o Bright red blood or watery discharge following a trauma can indicate a

fracture to the base of the skull

29. What tool would be used when performing an examination of the tympanic membrane?

Otoscope

30. What teaching should be done for a patient who is at risk for falls due to vision

impairment?

Maintaining adequate lightning

Keeping the call light within reach

Ensuring that the path to chair and bathroom are clear

31. When caring for a patient with hearing loss, what should the nurse assess first?

Assess client's ability to hear various frequencies (high vs low pitch) at various

decibels (soft vs loud tones)

32. What are the expected findings for a head and neck examination for the older adult

patient?

ROM in the head and neck may be limited because musculoskeletal changes or

osteoarthritis

33. How should the nurse palpate for lymph nodes of the neck?

Use the pads of the index and middle fingers and move the skin over the

underlying tissue in a circular motion to try to detect enlarged nodes.

o Compare from side to side, one at a time

34. How should an otoscopic examination be performed on an adult patient?

Pull up and back adults down and back for childrenon the auricle of adults ( )

oUsing the otoscope, slightly down and forward 1 to 1.5 cm, following but

not touching the ear canal to visualize

35. When assessing a patient’s pupils with a penlight, what would the nurse expect to find?

Pupils should be black, round, regular, and equal in size with the iris clearly

visible.

oPERRLA

36. When assessing pupil size, what size of pupils are expected?

Normal adult pupil size

o3-5 mm

PERRLA- uses CN II, CN III

oP - Pupils clear

oE - Equal

oR - Round

oRL - Reactive to Light

Both directly and consensually when you direct light into one pupil

and then the other

oA - Accommodation

Of the pupils when they dilate to look at an object far away and

then converge and constrict to focus on a near object

37. What vision tests for central vision acuity?

Snellen chart

Rosenbaum chart

38. How is the Rosenbaum vision test performed?

Hold chart 14 inches from the client’s face to screen for presbyopia (impaired

near vision or farsightedness). Visual Acuity

39. What are the causes of conductive hearing loss?

Ear infections, Obstruction, Wax Accumulation ( ), Cerumen Tympanic

Membrane Perforation (Ear drum damage), Otosclerosis (Abnormal bone growth

in ear)

40. How should the nurse perform an assessment of the thyroid?

Inspecting: Inspect the lower half of the neck. Have the pt hyperextend the neck.

Instructing: Instruct pt to take a sip of water and feel the thyroid gland as it

moves up with the trachea.

Palpating: Palpate thyroid gland on both sides

Auscultation: If the thyroid is enlarged, auscultate it.

oA indicates an increase in blood flow to the area, possibly due to bruit

hyperthyroidism

41. *A patient should be instructed to sleep with an artificial eye in place to keep the

socket stable and healthy. *

42. Which cranial nerves are associated with HEENT and how do you test their function?

CN I Olfactory -- – Sense of smell

oHave patient smell a scent

CN V Trigeminal – –

oHave patient bite down

oTouch - rub the side of the jaw to see if they detect the sensation.

CN VII Facial – –

oPuff up their cheeks and raise their eyebrows.

oAsk patients to use different facial expressions

CN XI Accessory Spinal- -

oPress down the pt shoulders while they are shrugging to test their

resistance

oTurning head from side to side

Examination Test Terms:

Rinne - Hearing/Place in front of ear and mastoid process

Diplopia – Double vision

Myopia - Near sided

Carinal Nerves



 CN I Olfactory

oSmell



 CN II Optic

oVision --> Snellen chart



 CN III Oculomotor

oEye movement

oControl of pupil diameter



 CN IV Trochlear

oEye gaze down and up



 CN V Trigeminal

oBiting down

oClose eyes for touch to face



 CN VI Abducens

oGaze laterally (side to side)



 CN VII Facial

oDifferent facial expressions

oStick out tongue



 CN VIII Vestibulocochlear

oHearing --> Weber's test



 CN IX Glossopharyngeal

oMouth movement of soft palate and gag reflex

oSwallowing and speech quality

oTaste



 CN X Vagus

oMouth movement of soft palate and gag reflex

oSwallowing and speech quality



 CN XI Accessory

oResistance to shoulder shrug (sternocleidomastoid)



 CN XII Hypoglossal

oAssess tongue for movement and strength

CN Acronym

▫Oliver = lfactory o

▫Often = optic

▫Orbits = oculomotor

▫Through = trochlear

▫The = trigeminal

▫Atmosphere = abducens

▫For = acial f

▫Very = vestibulocochlear

▫General = glossopharyngeal

▫Vape = vagus

▫And = accessory spinal

▫Herion = hypoglossal

Module 6 - Respiratory

1. What breath sounds would you expect to hear with an asthma attack?





Wheezes: are whistling, high-pitched musical sounds

2. What are r? What do they sound like?





Popping: when alveoli are not opening enough. Popping sound at the end of the

breath

3. What are bronchovesicular, bronchial, and vesicular breath sounds? Where would they

be heard?





Bronchovesicular breath sounds: Heard over right and left major bronchi





Bronchial breath sounds: Heard to the right and left of trachea and larynx





Vesicular breath sounds: Auscultated over anterior and posterior chest wall

oHeard from clavicle to lower rib change

oSounding like wind blowing through trees

4. What is central cyanosis? Where would we assess for this?





Central cyanosis --> associated with Hypoxia

oA blue-gray coloration

oCentral = found on head, neck, trunk

Assess: Lips, tongue, mucous membranes, facial features, nail beds, Extremities,

hands, feet

5. What are Cheyne-Stokes respirations?





Cheyne-Strokes Breathing: appears to have a “start-stop” pattern, become faster

and deeper than normal, then slower, progress of apnea

oSeen at end of life

6. What assessment findings would you expect in a patient with COPD?





S/S of COPD

oCoughing

oBarrel chest

Rounded, bulging chest that resembles the shape of a barrel

oWheezing

oPursed-lip breathing

oClubbed fingers

oCyanosis

oHypoxia

oDyspnea



7. What is the most common cause of COPD?

Long-term smoking

8. What lung sounds would you expect to hear with pneumonia?





Crackles: rattling, crackling, popping or bubbling sound

9. What lung sounds would you expect to hear with croup?





Stridor: High-pitched crowing or animal (screeching) sound

oResult of upper airway obstruction

oSeen in kids or adults with Croup

10. What factors could interfere with your ability to assess lung sounds?

Clothing, Body hair, Your own hand, Your own breathing

11. What are Kussmaul’s respirations?





Kussmaul respirations: Increased RR, Regular pattern, abnormally deep

12. What would you expect to hear when auscultating a plural friction rub?





Pleural Friction Rub: coarse, grating tone like rubbing two pieces of leather

together

13. What respiratory tool should be used for post-op patients to prevent atelectasis and

pneumonia?

Reposition every 2 hours. Deep breath and cough exercises. Incentive Spirometers



 Atelectasis: collapse of alveoli due to hyperventilation, airways blocked by

mucous plugs, immobility



 Pneumonia: inflammation of the alveoli due to infection with bacteria or viruses,

toxins, or irritants

14. What is pursed lip breathing? What patients would this type of breathing benefit?





Pursed Lip Breathing: mechanism used to prolong expiration, help expel trapped

air and keep alveoli open longer for maximum oxygenation of pulmonary blood.

(COPD, Asthma)

15. When preparing to do a respiratory assessment, what should the nurse do first?

Inspect / observe first

oThen palpate / percuss and auscultate

16. What are rhonchi? How does it sound like?





Rhonchi: continuous snoring-type sound

oCause by fluid, mucus, or a growth in larger airways

17. What is the first thing we should do when a patient is experiencing shortness of breath?

Rise the head of the bed to a Semi-Fowlers position

18. What can we encourage the patient to do to thin respiratory secretions?

Encourage fluid intake, Humidifier, IS, deep breathing exercise

19. How can we prevent respiratory post-surgical complications?





ICOUGH

oI = S Incentive Spirometer I

oC = ough & Deep Breathe C

oO = Oral Care

oU = nderstanding (patient education)U

oG = et out of bedG

oH = ead of bed elevated 90 degrees (High Fowler's) when eating H





Deep breathing treatments

Module 7 – Cardiovascular

1. Where should you access the apical pulse?

Medial to the left midclavicular line at the 5th ICS

2. Where should the nurse assess for the dorsalis pedis pulse?

On the top of the foot, along a line with the groove between the extensor tendons

of the first and second toes.



3. What is the order of blood flow through the heart?



 Superior/Inferior Vena Cava (from the body) --> Right Atria --> Tricuspid

Valve --> Right Ven --> Pulmonic Valve --> Left Atria --> Mitral Valve -> Left

Ventricle -->Aortic Valve --> Aorta (to the body)



4. What do we worry about when a patient has orthostatic hypotension?

Decreased blood pressure when changing position from standing, sitting, or lying.

oFall risk due to dizzy spells

5. What are the S&S of right-sided heart failure?





If not pumping well, blood backs up in the body

6. What are the S&S of left-sided heart failure?





If not pumping well, blood backs up in the left lung

7. What are risk factors for cardiovascular disease?

Family History

High BP

Cholesterol Levels

Lifestyle Habits

8. Where are the aortic, pulmonic, tricuspid, and mitral valves heard? Know the landmarks.





Aortic: Just right of the sternum at the 2nd ICS (Intercostal space)





Pulmonic: Just left of the sternum at the 2nd ICS





Tricuspid: Left 4 ICS just lateral to the sternum





Mitral: Left midclavicular line at the 5th ICS

9. What is sinus tachycardia?

An SA node that is sending electrical impulses greater than 100/min

10. What is the primary pacemaker of the heart called?

The SA node (1 node), Located in the right atrium,

st 60-100 bpm

11. What are the S&S of inadequate circulation?

Long capillary refill

Cold hands

Pale skin

12. What tool can the nurse use if they are unable to palpate peripheral pulses?





Doppler

13. What is a peripheral venous ulcer? What is a peripheral arterial ulcer?





Peripheral Venous Ulcer: Insufficient blood returns to the heart, damage to the

veins

Peripheral Arterial Ulcer: Lack of blood flow to the arteries. Damage to the

arteries

14. How would a nurse document a normal pulse in the medical record?

+1 weak pulse

+2 normal pulse

+3 strong pulse

+4 bounding pulse

15. How should the nurse assess JVD?

Elevate head of bed to 30- to 45-degree angle, turn neck to the side. Shin a light at

vein to see if it is distended

16. What order does the blood flow through the valves of the heart?





Toilet Paper My Ass

oT T = ricuspid valve

oP = Pulmonary valve

oM = Mitral valve

oA A = ortic valve

17. What does a murmur sound like?

Murmur = Blowing or swishing

18. Where is the best place to assess S1 ? S2 ? (lub) (dub)

S1 Lub -- Is valve (4 intercostal) and valve (5 intercostal)tricuspid th mitral th

S2 Dub -- Is valve (2 intercostal) and valve (3 intercostal)aortic nd pulmonic rd

19. Where is the apical pulse located?

5 th

intercostal space at the left midclavicular line.

20. What are the early signs of hypoxia?

RAT = early hypoxia

oR = Restless

oA = Anxiety

oT = Tachypnea/Tachycardia

Hypertension

21. What are chronic signs of hypoxia?

Bed = late hypoxia

oB = Bradypnea/Bradycardia

oE = Extreme Restlessness

oD = Dyspnea (severe)

Clubbing

Hypotension

22. What is the heart’s conduction system?

Save A Bunny Rabbit Please

oS S = inoatrial (SA) node. 60-100 bpm

oA = Atrioventricular (AV) node. 40-60 bpm

oB B = undle of His

oR R = ight and Left bundle branches

oP P = urkinje fibers. 20-40 bpm

Last resort to keep going

23. Heart Sounds?

S1 = Lub = closing of tricuspid/ mitral valves

S2 = Dub = aortic/ pulmonic valve closure

S3 = may be heard in adolescents

24. Know circulation?

Arteries – blood from heartery

Vein – bring back in for oxygen

Module 8 – Abdomen

1. What organs are in the left lower quadrant, left upper quadrant, right lower quadrant,

right upper quadrant?



2. What are the different abdominal shapes?



Flatus: The protrusion is mainly midline, No change in the flank

3. When is it normal to see abdominal aortic pulsations?

(Consensus: in thin adults it’s normal)

oPeristalsis: wavelike motions visible in thin adults or in patients with

intestinal blockages.

oPulsations: Regular beats of movement midline above umbilicus (belly

button) expected in thin adults, pulsating mass is unexpected.

4. What are the causes of hypoactive and hyperactive bowel sounds?

Hypoactive: Decreased bowel sounds

oAbsent bowel sounds, diminished, soft sounds that occur less than 1 min





Hyperactive: Increased bowel sounds, Loud growling sounds (borborygmi)

5. What is an umbilical hernia, incisional hernia, and inguinal hernia?

Hernia: Is when the abdominal viscera protrude through the muscle wall of the

abdomen

Umbilical Hernia: Is an outward bulging due to delayed closure around a small

muscle around the umbilicus (belly button)

Incisional Hernia: Is an protrusion of tissue, intestine, organ that forms at the site

of a healing surgical scar

Inguinal Herina: It is a bulge that occurs in the groin region, with weakening of

muscles in the lower abdomen

6. What are expected variations and unexpected findings during inspection of the abdomen?

What causes them?

Expected Findings: Eye level with abdomen helps.

oSmooth and even skin. Silver striae aka stretch marks (rude). Healed

scares. Moles ( )nevi





Unexpected:

oDilated veins, Jaundice, Cyanosis, Redness, Ascites, Scars, lesions,

7. What assessment findings would we see in a patient with pancreatitis? Cholecystitis?

Appendicitis? Ascites?

Pancreatitis: Inflammation of the pancreas. LUQ

Cholecystitis: Gallbladder infection. RUQ

Appendicitis: Inflammation of the appendix. RLQ

Ascites: Distended stomach due to fluid retention, possible reflect cirrhosis

8. What symptoms are consistent with duodenal ulcer?

Duodenal Ulcer: Is a peptic ulcer that develops in the first part of the small

intestine (duodenum)

Peptic Ulcers: Are open sores that develop on the inside lining of the stomach and

upper portion of small intestine

9. What is an early sign of a paralytic ileus?

Paralytic Ileus: ---> intestinal obstruction. A cessation of bowel peristalsis

S/S:

oDistended abdomen, Fullness, Gas, Abdominal spasms, Constipation or

diarrhea, Nausea, Foul smelling breath

10. What is the priority for a patient who has just had a GI endoscopy?





GI Endoscopy: Esophageal to stomach endoscopic imaging technique

oAssessing chest pain, bleeding, fever, abdominal pain, vomiting

Module 9 – Musculoskeletal & Neurological

1. Know anatomical positions and joint movement terminology.





Fibrous joint: Immovable, no joint cavity





Cartilaginous: Not highly movable, no joint cavity





Synovial: Moveable, all limb joints and most joints of the body





Joint Movement Synovial Joints / with example & movement ( )

oPivot

oHinge

oCondyloid

oSaddle

oBall and Socket





Body Movements:



2. What is osteoporosis?





Osteoporosis: A loss in bone mineral density that increases the risk of fracture

3. How do we document muscle strength?





Muscle Testing- Push/Pulls

oGrade 5- Full ROM against gravity and full resistance

oGrade 4- Full ROM against gravity and some resistance

oGrade 3- Full ROM against gravity

oGrade 2- Full ROM with gravity eliminated (passive motion) can't do

against gravity on

oGrade 1- Slight contraction when they push against you

oGrade 0- No contraction

Grade 3 through 0 is unexpected

4. What joint has the greatest mobility?

Synovial -- Ball in socket

5. What are unexpected findings in the spinal column?



 Scoliosis - Curvature Lateral of the spine



 Lordosis - Lower back coming inward (Curvature of lumbar spine)



 Kyphosis- Hunch back (Curvature of thoracic spine)



 Flat back - No curve in back



 Ankylosis - Fusing of a joint

6. Know the cranial nerves I-XII and how to assess them.



 I – Olfactory: Smell

oSensory

Ask pt to close their eyes and see if they can smell the cotton ball



 II – Optic: Vision

oSensory

Use Snellen chart to test for vision fields



 III – Oculomotor: Eye movement

oMotor

Evaluate pt pupils with light



 IV – Trochlear: Controls downward and inward eye movement

oMotor

Light, EOMs, PERRLA



 V – Trigeminal: Biting / chewing, facial sensation

oBoth

Clench teeth, sensation on forehead check and chin



 VI – Abducens: Controls parallel eye movement

oMotor

Light, EOMs, PERRLA



 VII – Facial: Facial expression, taste

oBoth

Do different facial expressions, puff cheeks, raise eyebrows, close

eyes



 VIII – Vestibulocochlear / Acoustic: Balance and hearing

oSensory

Check hearing, Weber tests (tuning fork)



 IX – Glossopharyngeal: Tonge movement, swallowing, taste

oBoth

Gag reflex, taste



 X – Vagus: Swallowing, speaking, cough, facial sensation

oBoth

Check uvula, sensation coming from skin to ear, swallow test



 XI – Spinal Accessory: Controls strength of neck and shoulder muscles

oMotor

Shrugs shoulders against resistance, turn head laterally



 XII – Hypoglossal: Tongue movement

oMotor

Tongue movement, stick out tongue

7. What are the signs and symptoms of a stroke?



8. How do we assess balance?



 Romberg Test: Stand with eyes closed for 30 seconds



 Heel to toe walk: (tandem walking)

9. What does the frontal lobe control?

Personality, intellect, expressive aphasia (knowing what to say, but can’t)

10. What does the hypothalamus control?



 Temperature and sleep control bodily functions including release of hormones

from pituitary gland.

11. What is rheumatoid arthritis?





Rheumatoid Arthritis: Chronic inflammation affecting many joints.

oBody’s immune system attacks it’s own tissue and joints in body

What does it look like?

oUlnar deviation -- Fingers curve under

12. What is nystagmus? What cranial nerves are involved?

Nystagmus - shaking of the eyes

oCN III, IV, VI

13. What is accommodation in PERRLA? How do we assess it?



 PERRLA:

oP- Pupils: Clear

oE – Equal: between 3 to 7 mm in diameter

oR - Round

oRL – Reactive: to Light both directly and consensually when you direct

light into one pupil and then the other

oA – Accommodation: of the pupils when they dilate to look at an object

far away and then converge and constrict to focus on a near object.



 Extraocular Movement - cat whiskers



 Ptosis - drooping eye lids (ABNORMAL)



 Pseudoptosis: relaxation of the upper eyelid causing the lid to rest on the

eyelashes is an expected variation for an older adult client (NORMAL)



 Exophthalmos - bulging eyes (relating to hyperthyroid)



 Strabismus - eyes do not look in the same direction



 Entropion - the bottom eyelid turns (in)



 Extropian - the bottom eyelid turns (out)

14. What is the normal finding for pupil size?

Equal and between 3-7 mm in diameter

15. Know the levels of consciousness from alert to comatose.



 Levels of consciousness

oAlert - spontaneous responsive and able to open eyes/answer questions

right away and correctly.

oLethargic- opens eyes but drowsy, responds but falls asleep readily

oObtunded- responds to light touch, confused, slow to respond

oStuporous - painful stimuli to arouse client (pen into nail bed). May not

verbally respond.

oComatose- no response to painful stimuli. Abnormal rigidity present.



16. What is the Broca’s area? What is Wernicke’s area?





Broca’s Area: Region in the frontal lobe (dominant hemisphere) of the brain with

functions linked to speech production



 Broca’s Aphasia or Dysphasia - Have extreme difficulty forming words and

sentences, may speak with difficulty or not at all





Wernicke’s Area: Region of the brain that contains motor neurons involved in the

comprehension of speech



 Wernicke’s Aphasia or Receptive Aphasia - (jumbled, word salad)

oCan't understand words. Speak with regular rhythm / grammar



17. What is a GCS score?





Glasgow Coma Scale (GCS Score):

oEvaluates eye opening, motor responses, verbal responses



oHighest 15, lowest 3, NEVER 0, 1 across the board = comatose/no

reaction

Best score: 15

Comatose: 8 or less

Totally unresponsive 3

18. What is atrophy?





Atrophy: Decreases in muscle size due to disuse



 Hypertrophy: Enlargement of muscle due to strengthening

19. What does it mean if your voice changes while swallowing?





Indicates aspiration

20. What are the expected findings for the deep tendon reflexes?

2 is expected on the 0-4 scale

o0 no response, 1 diminished, 2 expected, 3 above average, 4 clonus



 Triceps Reflex: Extension of the elbow



 Achilles Reflex: Plantar flexion of the foot



 Bicep Reflex: Flexion of the elbow



 Brachioradialis: Pronation of the forearm and flexion of the elbow



 Patellar: Extension of the lower leg

Module 10 – Adult Health Assessment

1. What intervention can we take to reduce extraneous noise when auscultating lung

sounds?

Close the door, Skin contact, go underneath clothes, turn off noises in room – TV,

music, phone, Remove extra people in room – family

2. What is clubbing? Cyanosis? Signs of respiratory distress?

Clubbing: an angle of the nail greater than 160 degrees, and the nail and base can

eventually exceed 180 degrees.

o Can result from chronic low oxygen saturation, chronic or long-term

hypoxia

Cyanosis: bluish color

oLocation: Nail beds, lips mouth mucosa, skin, palms

oIndication: Hypoxia or impaired venous return

Signs of Respiratory Distress

o Possible breath sound heard

Stridor: crowing/animal sound

o Confusion

o Circumoral (around the mouth) cyanosis

o Use of accessory muscles, nasal flaring

o Neck vein distension

o Pale, diaphoretic

3. As a person ages, which orientation is first to go (person, place, or time)?

Orientation to time usually the first to be lost

4. Where do we take the patient’s posterior tibial pulse?



5. What area do we listen to each of the heart valves?

Aortic Valve: Just right of the sternum at the second ICS

Pulmonic Valve: Just left of the sternum at the second ICS

Erb’s Point: Just left of the sternum at the third ICS

Tricuspid Valve: Just left of the sternum at the fourth ICS

Apical/Mitral Valve: Left midclavicular line at the fifth ICS

Heart Sounds:

oS1 “Lub” -- Closing of the mitral and tricuspid valves

oS2: “Dub” -- Closing of the aortic and pulmonic valves

6. What is included in the general appearance?

 Overall assessment of the pt.'s general appearance

oPhysical Appearance

oBody Structure

oMobility

oBehavior

oVital Signs

Module 11 – Breast & Lymph

1. What is the best time for a female to perform a breast self-examination?

4-7 days after the start of their menstrual cycle or right after menstruation

ends

2. How do we perform a breast self-examination?

Inspect -- Inspect breast for any changes

Palpate -- palpate lumps

o Should palpate each breast using pads of three middle fingers

Apply light, medium, and then form pressure to each area

o Beginning at outer edge near the axilla

 Move across the breast tissue in a top to bottom fashion

o Palpate area in axilla



3. What are expected and unexpected findings?

Expected Findings:

obreast should be approximately the same size and shape with a smooth

contour

o Should be NO Dimpling, Rashes, Edema, Palpable lumps, Localized areas

of tenderness in the breast or axillae

oShould be no rash or drainage on the nipple or areola

Unexpected Findings: should notify provider if any changes in

o Breast tissue appearance or texture

oAbnormal findings

Significant breast size differences, Asymmetry of breast contour or

shape, Inflammation, Warmth, Localized tenderness, Changes in

skin texture or appearance, Lumps, Drainage

4. What is the purpose of the lymphatic system?

Lymphatic system: is a network of nodes, vessels, and organs that transport thin,

clear lymphatic fluid from the interstitial spaces in the body tissues to the blood

circulation

oLymph nodes: are small oval-shaped lymphatic glands arranged in chain-

like groupings along the lymphatic vessels

Lymphatic System three main functions

oDetecting and eliminating microorganisms

Such as bacteria, and viruses from the body

oAbsorbing lipids from the small intestines during digestion

oReabsorbing fluid from interstitial tissues

5. What is lymphedema?

Lymphedema: Who has a history of mastectomy may have this

o Due to the surgical procedure disrupting the normal pathways of lymph

drainage from the breast area

oEdema in the axillae or arm can be related to an infection in the breast,

arm or hand

6. What is the purpose of a mammogram?

 A is to screen breast cancer mammogram

oX-ray picture of the breast

Mammogram screening every 1 to 2 years for females aged 45 and

above who have a low risk of breast cancer

40 if present in immediate family

Continue screening till 75 or longer

7. Where would you take blood pressure on a patient who has double mastectomy?

DO NOT place a BP cuff on the same side as the site of a mastectomy

o Can be but need to have a big cuffplaced on thigh

8. What is Peau d’Orange? What does it look like?

Peau d’Orange: When the breast tissue resembles the skin of an orange

 Looks like an orange



9. What are some signs and symptoms of breast cancer?

Thickened rough skin

Edema

Inflammation

Unilateral rash

Peau d’Orange

Significant difference in breast sizes

10. Where is the tail of Spence located?

 Breast are located over the anterior pectoralis muscle on the chest wall

Each breast is divided into quadrants:

oUpper outer

oLower outer

oUpper inner

oLower inner

 In females an additional triangular area of breast tissue called the Tail Of Spence,

extends up and into the axillae lateral to the upper outer quadrant



11. What is a supernumerary nipple?



Supernumerary nipple: extra nipple

o Supernumerary = extra

12. What is gynecomastia?

Gynecomastia: enlargement of the male breast tissue



Module 12

1. When should a bladder scan be performed? How do we perform a bladder scan?

Should be performed when pt. reports

oAny problems with urinating, especially bladder distention

Bladder Scanner:

oWill measure the urinary volume within the bladder

o To measure Post-Void Bladder Residual Urine Volume, perform

the scan within 10 mins of pt. emptying their bladder

o Expected findings are post-void residual urine 50 to 100 mL

volume

Unexpected if greater than 100 mL notify provider

2. What location would the bladder be palpated?

 If bladder distention is suspected the bladder will be palpable

oBladder distention: related to urine retention is caused by an inability to

empty the bladder during urination

o Could be related to obstruction, weak bladder muscles,

medications, or a neurological condition

oLocation -

oAbove the symphysis pubis along the midline of the abdomen

3. At what age should patients start getting screened for colorectal cancer?

Recommended for every pt. beginning at the age of 50

4. What is epispadias? Hypospadias? Phimosis? Priapism?

Unexpected findings in the urethral meatus

o Is the opening at the center of the glans (tip of the penis) for urine to exit

the penis is the urethral meatus

o Should be located midline in the center if the glans (Normal)

oEpispadias: Occurs when the meatus is located on the dorsal side of the

glans or penis shaft

oHypospadias: The meatus is located on the ventral side of the glans or

penis shaft

Phimosis: Condition in which the prepuce (foreskin) is not able to be retracted

Priapism: Painful, sustained erection without sexual desire that can last a long

period of time

5. What teaching should be done for a patient with genital herpes?

Genital Herpes: Groups of small painful fluid filled vesicles that break and

become superficial ulcers

oS/S in both male and female

o Small painful blisters on genitals

o Herpes (L), Warts (R)

6. What education should be provided to prevent HPV? STIs in general?

Genital Human Papillomavirus or Human Papilloma Virus = AKA HPV = most

common STI

o There is a vaccine

oSeries of 3 immunizations over a 6-month period

Sexually Transmitted Infections = STIs

o May be caused by bacteria, viruses, fungi, or parasites

oTo determine if someone has an STI you must obtain a culture, swab of

secretions from the genitals

oFor oral or anal sex culture of throat or rectum is obtained

oIncreased Risk for an STI:

o Unprotected sex

o More than one sexual partner

o Alcohol and drug use

o Sharing needles

o Nonadherence to the STI Tx regimen

7. What position should a woman be placed in for a vaginal examination? Perianal exam?

Position placed for a vaginal examination

o Lie in supine position with knees bent and feet placed on the bed

 OR

o Can position pt. in a with their feet in stirrups lithotomy position

o Used more for performing an internal examination

Perianal Exam

o Usually placed in the Lithotomy Position

o Pt on their side with hip and knee bent will allow for visualization of

perianal area

o Sim’s Position?

8. What education should be done for a woman who is scheduled to have a PAP exam?

Papanicolaou (Pap) Smear Test

oAt least every 3 years while sexually active from age 21-65

o Screenings may cease if pt. Has a hysterectomy with removal of the cervix

OR is older than 65 years

9. What are some age-related changes for the perianal region?

Decreased control of the anal opening is an expected variation in older adults due

to weakened perineal muscles

Decline in estrogen or testosterone production

Enlarged prostate

Bladder problems

10. What can we do to promote urination for a patient who is having difficulty?

Maintain hydration (at least 2,000 mL/day unless restricted)

Provide perineal care

Teach bladder training

11. What condition can cause difficult urination in men?

Enlarged Prostate: Can obstruct the bladder outlet and cause urinary retention

and urgency which can lead to incontinence and UTIs

Benign Prostatic Hyperplasia

oAKA enlarged prostate

12. What education should be done for a patient who is preparing to have a PSA test done?

Prostate Specific Antigen (PSA)

oScreening for prostate cancer

oInstruct the patient to abstain from ejaculation for 2 days prior to

PSA blood test.

oShould be done starting at age 50 until 70, high risk start at 40 or 45.

13. What are hemorrhoids? What are the signs and symptoms?

External Hemorrhoids: Are dilated veins on the exposed portion of the anus

o S/S:

o Appear as tissue flaps that are painless. Irritated or thrombosed

(lack blood flow due to a blood clot)

Thrombosed Hemorrhoids: Appear bluish-purple, shiny, and full

o S/S:

o Local pain. Itchiness. Bleeding during BM

14. What is syphilis? Gonorrhea? What are the signs and symptoms? What do these look

like?

Syphilis: Caused by a bacterium that is transmitted from person to person by

direct contact with the syphilis sore

o Can be seen on

 External genitalia, Vagina, Lips, Mouth, Anus, Rectum

oS/S

Chancre (painless, ulcer-like sore at site of contact)

Generalized Non itchy, painless rash

Sore throat

Low-grade fever

Aches and pains

Gonorrhea: Caused by a bacterium. Yellow/Green discharge

oS/S-

Dysuria

May be asymptomatic

Burning

15. When and how should males perform testicular examinations?

Once a month, While standing, After a warm shower

oGently roll each testicle between the fingers and thumb

16. What are the expected findings in a testicular examination?

Bumps on the skin of scrotum (could be from shaving). Ingrown hairs. Rash

Soft ropy cord, which is a normal part of the scrotum called the epididymis. Leads

upward from the top of the back part of each testicle.

17. What are the signs and symptoms of an upper GI bleed?

Tarry black stool

bright red blood in vomit

vomit that looks like coffee grounds

18. What causes post-menopausal vaginal dryness?

Decreased hormone levels after menopause cause atrophy and dryness of the

genitalia structures

oEstrogen Helps maintain the vagina’s lubrication, elasticity, and thickness

19. What are Bartholin’s glands?

Bartholin’s glands Surrounding the vaginal orifice are these glands

oThey secrete a lubricating mucus into the vaginal opening

Bartholin’s gland abscess – Unexpected finding

o It is a fluid-filled pocket with overlying red and shiny skin that is painful

and causes the labia to swell

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