- indicating rising levels of bilirubin in the blood
- exhibited by yellow skin color
- yellow color of the iris extends to the sclera
Term
4 danger signs of pigmented lesions:
Definition
ABCD (Asymmetry of pigmented lesion, Border irregularity, Color variation, Diameter greater than 6 mm)
Term
What causes "liver spots" on people who like to garden?
Definition
Term
What does the top and bottom number in a blood pressure reading represent?
Definition
The systolic pressure is the maximum pressure felt on the artery during left ventricular contraction, or systole. The diastolic pressure is the elastic recoil, or resting, pressure that the blood exerts constantly in between each contraction
Term
Normal findings when palpating the sinus cavaties would report which sensation?
Definition
Firm pressure
Term
Where is the parotid gland located?
Definition
The largest, the parotid gland, lies within the cheeks in front of the ear extending from the zygomatic arch down to the angle of the jaw
Term
Important diseases or problems to ask the patient about due to genetic risk include:
Definition
Specifically ask for any family history of heart disease, high blood pressure, stroke, diabetes, blood disorders, cancer, sickle cell anemia, arthritis, allergies, obesity, alcoholism, mental illness, seizure disorder, kidney disease, and tuberculosis
Term
What does percussing assess?
Definition
Percussion yields a sound that depicts the location, size, and density of the underlying organ.
Term
The nurse is doing an assessment on a 21-year-old patient and notes that his nasal mucosa appears pale, gray, and swollen. What would be the most appropriate question to ask the patient?
Definition
Are you aware of having any allergies?
Term
What is a normal finding when examing the retina?
Definition
The optic disc is located on the nasal side of the retina. It is a creamy yellow-orange to pink color.
Term
Which cranial nerves stimulate the extraocular movements?
Definition
CN III, IV, VI
Term
In response to a question regarding use of alcohol, a patient asks the nurse why the nurse needs to know. What is the reason for needing this information?
Definition
Alcohol interacts adversely with all medications; it is a factor in many social problems such as child or sexual abuse, automobile accidents, and assaults; it contributes to many illnesses and disease processes
Term
What part of the hand should you use to assess vibration?
Definition
Ulnar surface
Term
Visual accomadation refers to what?
Definition
pupillary constriction when looking at a near object
Term
What technique is the best way to assess a patient's skin temperature?
Definition
Term
How should the tympanic membrane appear?
Definition
It is a translucent membrane with a pearly gray color and a prominent cone of light in the anteroinferior quadrant, which is the reflection of the otoscope light. The drum is oval and slightly concave, pulled in at its center by one of the middle ear ossicles, the malleus.
Term
Acutely infected lymph nodes are identified by:
Definition
Acutely infected lymph nodes are bilateral, enlarged, warm, tender, and firm but freely movable.
Term
During an interview, a woman says, “I have decided that I can no longer allow my children to live with their father’s violence. I just can’t seem to leave him though.” Using interpretation, the nurse’s best response would be:
Definition
-This statement is not based on one’s inference or conclusion. It links events, makes associations, or implies cause. Interpretation also ascribes feelings and helps the person understand his or her own feelings in relation to the verbal message
Term
decreased skin turgor = ?
Definition
Decreased skin turgor is associated with severe dehydration, aging, or extreme weight loss
Term
What is petechiae?
Definition
tiny punctate hemorrhages; 1-3 mm, round and discrete, dark red, purple, or brown in color
Term
Ecchymosis (bruising) = ?
Definition
a large patch of capillary bleeding into the tissue
Term
keloid = ?
Definition
a hypertrophic scar
Term
vesicle = ?
Definition
elevated cavity containing free fluid, up to 1 cm; clear serum flows if wall is ruptured
Term
During an examination, the nurse notes that a female patient has a round “moon” face, central trunk obesity, and a cervical hump. Her skin is fragile with bruises. The nurse notes that the patient has which condition?
Definition
Cushing's Syndrome
Term
Which technique of assessment is used to determine the presence of crepitus, swelling, and pulsations?
Definition
Palpation applies the sense of touch to assess these factors: texture, temperature, moisture, organ location and size, as well as any swelling, vibration or pulsation, rigidity or spasticity, crepitation, presence of lumps or masses, and presence of tenderness or pain.
Term
Macule = ?
Definition
flat skin lesion less than 1 cm
Term
nodule = ?
Definition
Solid, elevated, hard or soft, larger than 1 cm
Term
A patient’s vision is recorded as 20/30 when the Snellen eye chart is used. The nurse recognizes that these results indicate that:
Definition
Term
If someone is complaining of fainting episodes, what should the nurse to in her examination?
Definition
Check blood pressure in the lying, standing, and sitting positions
Term
If a 68 yr old woman is at the eye doctor complaining of having trouble reading the paper, sewing, and has central vision loss, what are her symptoms indicating?
Definition
macular degeneration; it is the most common cause of blindness
Term
What is a symptom?
Definition
A symptom is a subjective sensation that a person feels from a disorder (such as chest pain). A sign is an objective abnormality that the examiner could detect on physical examination or in laboratory reports, as illustrated by the other responses.
Term
What is the Whisper or Voice Test?
Definition
The client occludes one ear while the nurse whispers in the other ear from 30 cm (1 foot) away
Term
What is the Weber test?
Definition
A vibrating tuning fork is placed midline on top of the head and the client is asked where the sound is heard best
Term
What is the Rinne test?
Definition
A vibrating tuning fork is placed on the mastoid process and then placed near the ear when the sound is no longer heard
Term
What is tinea capitis?
Definition
Tinea capitis is rounded patchy hair loss on scale, leaving broken-off hairs, pustules, and scales on the skin. It is due to fungal infection. Lesions are fluorescent under a Wood’s light. It is usually seen in children and farmers and is highly contagious
Term
What age group would it be helpful to use games during the nurse's assessment?
Definition
preschool children
Term
What part of the ear is responsible for the feeling of vertigo?
Definition
the bony labyrinth
Term
What is a normal pupillary light reflex?
Definition
The pupillary light reflex is the normal constriction of the pupils when bright light shines on the retina
Term
If a 3 year old comes in with a bright red tympanic membrane and a light reflex that is not visible, what is the most likely cause?
Definition
acute otitis media
Term
Skin hold information about what?
Definition
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
Term
When should an examiner wash his/her hands?
Definition
The examiner should wash his or her hands at the beginning of the examination and each time he or she re-enters the room. Gloves should be worn when there is potential contact with any body fluids. Hands should be washed after gloves have been removed, even if the gloves appear to be intact
Term
“You don’t smoke, drink, or take drugs, do you?”.... This is an example of what kind of question?
Definition
biased or leading questions
Term
What is the best way to palpate the lymph nodes?
Definition
Term
What are empathetic responses?
Definition
An empathetic response recognizes the feeling and puts it into words. It names the feeling and allows the expression of it. It strengthens rapport. Other empathetic responses are, “This must be very hard for you,” “I understand,” or just placing your hand on the person’s arm
Term
What will the nurse observe in a patient with acromegaly?
Definition
Excessive secretions of growth hormone in adulthood after normal completion of body growth causes overgrowth of bones in the face, head, hands, and feet but no change in height
Term
In using the ophthalmoscope to assess a patient’s eyes, the nurse notes a red glow in the patient’s pupils. On the basis of this finding, the nurse would:
Definition
Term
Which statement is true regarding the diaphragm of the stethoscope?
Definition
The diaphragm of the stethoscope is best for listening to high-pitched sounds such as breath, bowel, and normal heart sounds. It should be held firmly against the person’s skin, firmly enough to leave a ring
Term
A patient is especially worried about an area of skin on her feet that has turned white. The health care provider has told her that her condition is vitiligo. The nurse explains to her that vitiligo is:
Definition
Vitiligo is the complete absence of melanin pigment in patchy areas of white or light skin on the face, neck, hands, feet, body folds, and around orifices—otherwise the depigmented skin is normal
Term
A 10-year-old is at the clinic for “a sore throat lasting 6 days.” The nurse is aware that which of the following would be most consistent with an acute infection?
Definition
With an acute infection, tonsils are bright red and swollen and may have exudate or large white spots. Tonsils are enlarged to 2+, 3+, or 4+ with an acute infection
Term
What are turbinates?
Definition
The projections in the nasal cavity that increase the surface area are called the:
Term
A female patient does not speak English well, and the nurse needs to choose an interpreter. Which of the following would be the most appropriate choice?
Definition
Whenever possible, use a trained interpreter, preferably one who knows medical terminology. In general, an older, more mature interpreter is preferred to a younger, less experienced one, and the same sex is preferred when possible
Term
The nurse notices that a patient has a solid, elevated, circumscribed lesion that is less than 1 cm in diameter. When documenting this finding, the nurse would report this as a:
Definition
papule
Term
When performing a physical assessment, the technique the nurse will use first is:
Definition
inspection
Term
What does it mean if lesions are confluent?
Definition
the lesions run together
Term
The nurse is conducting a visual examination. Which of the following statements regarding visual pathways and visual fields is true?
Definition
Term
A 65-year-old man with emphysema and bronchitis has come to the clinic for a follow-up appointment. On assessment of his skin, the nurse might expect to find the following:
Definition
clubbing of the nails
Term
What is the CAGE test?
Definition
The CAGE test is known as the “cut down, annoyed, guilty, and eye-opener” test. If a person answers yes to two or more of the four CAGE questions, the nurse should suspect alcohol abuse and continue with a more complete substance abuse assessment
Term
What is tinnitus?
Definition
Tinnitus is a sound that comes from within a person; it can be a ringing, crackling, or buzzing sound. It accompanies some hearing or ear disorders
Term
When performing a general survey, the examiner is:
Definition
Term
What is tactile fremitus produced by?
Definition
Fremitus is a palpable vibration. Sounds generated from the larynx are transmitted through patent bronchi and the lung parenchyma to the chest wall where they are felt as vibrations.
Term
To assess the dorsalis pedis artery, the nurse would palpate:
Definition
Term
A patient has been diagnosed with venous stasis. Which of the following would the nurse most likely observe?
Definition
A brown discoloration occurs with chronic venous stasis as a result of hemosiderin deposits (a byproduct of red blood cell degradation). Pallor, cyanosis, atrophic skin, and unilateral coolness are all signs associated with arterial problems
Term
When listening to heart sounds, the nurse knows that which of the following statements concerning S1 is true?
Definition
S1 is the start of systole, and is louder than S2 at the apex; S2 is louder than S1 at the base. S1 coincides with carotid artery pulse. Feel the carotid gently as you auscultate at the apex; the sound you hear as you feel each pulse is S1
Term
The nurse is assessing a patient with possible cardiomyopathy and assesses the hepatojugular reflux. If heart failure is present, the nurse would see which finding while pushing on the right upper quadrant of the patient’s abdomen, just below the rib cage?
Definition
Term
When listening to heart sounds, the nurse knows that the valve closures that can be heard best at the base of the heart by the second intercostal spaces are:
Definition
- The second heart sound (S2) occurs with closure of the semilunar valves and signals the end of systole. Although it is heard over all the precordium, S2 is loudest at the base.
Term
A patient is suspected of having inflammation of the gallbladder, or cholecystitis. The nurse will conduct which of the following to assess for this condition?
Definition
Murphy's Sign
Term
During an abdominal assessment, the nurse tests for a fluid wave. A positive fluid wave test occurs with:
Definition
ascites
Term
A 22-year-old man comes to the clinic for an examination after falling off his motorcycle and landing on his left side on the handlebars. The nurse suspects that he may have injured his spleen. Which of the following is true regarding assessment of the spleen in this situation?
Definition
Term
In performing a breast examination, the nurse knows that it is especially important to examine the upper outer quadrant of the breast. The reason for this is that the upper outer quadrant is:
Definition
the location of most breast tumors
Term
A 65-year-old patient is experiencing pain in his left calf when he exercises, which disappears after resting for a few minutes. The nurse recognizes that this description is most consistent with:
Definition
Term
A patient comes to the clinic complaining of a cough that is worse at night but not as bad during the day. The nurse recognizes that this may indicate:
Definition
postnasal drip or sinisitus
Term
The nurse knows that during an abdominal assessment, deep palpation is used to determine:
Definition
enlarged organs
Term
What kind of percussion note would you find in the umbilical region?
Definition
tympanic
Term
If you feel a lump or mass during a breast exam, what characteristics should you note?
Definition
If you do feel a lump or mass, note these characteristics: (1) location, (2) size—judge in centimeters in three dimensions: Width´ Length ´ Thickness, (3) shape, (4) consistency, (5) motility, (6) distinctness, (7) nipple, (8) the skin over the lump, (9) tenderness, and (10) lymphadenopathy.
Term
During an assessment of a 68-year-old man with a recent onset of right-sided weakness, the nurse hears a blowing, swishing sound with the bell of the stethoscope over the left carotid artery. This finding would indicate:
Definition
blood flow turbulence
Term
When inspecting the anterior chest of an adult, the nurse should assess for:
Definition
Term
A 45-year-old man is in the clinic for a physical. During the abdominal assessment, the nurse percusses and notes an area of dullness above the right costal margin of about 10 cm. The nurse should:
Definition
Term
When auscultating the heart, your first step is to
Definition
listen for S1 and S2
Term
When teaching the breast self-examination you would inform the woman that the best time to conduct breast self-examination is:
Definition
Term
Where do you palpate the apical pulse?
Definition
Term
During auscultation of breath sounds, the nurse will use the stethoscope correctly, as follows:
Definition
Term
What is a potential cause of hypoactive bowel sounds?
Definition
paralytic ileus
Term
What is the breast composed of?
Definition
The breast is composed of (1) glandular tissue, (2) fibrous tissue, including the suspensory ligaments, and (3) adipose tissue
Term
A 65-year-old patient with a history of heart failure comes to the clinic with complaints of “being awakened from sleep with shortness of breath.” Which action by the nurse is most appropriate?
Definition
Term
The nurse has noted unequal chest expansion and recognizes that this occurs when:
Definition
Term
During a physical examination, a 45-year-old woman states that she has had a crusty, itchy rash on her breast for about 2 weeks. In trying to find the cause of the rash, which of the following would be important for the nurse to determine?
Definition
- Paget’s disease starts with a small crust on the nipple apex and then spreads to the areola. Eczema or other dermatitis rarely starts at nipple unless it results from breast-feeding. It usually starts on the areola or surrounding skin and then spreads to the nipple
Term
Which sound is normal to elicit when percussing in the seventh right intercostal space at the midclavicular line over the liver?
Definition
Term
The manubriosternal angle is:
Definition
Term
In assessing for an S4 with a stethoscope, the nurse would listen with the:
Definition
Term
Which type of condition would produce a systolic murmur?
Definition
aortic stenosis
Term
Which statement about the apices of the lungs is true? The apices of the lungs:
Definition
The apex of the lung on the anterior chest is 3 to 4 cm above the inner third of the clavicles. On the posterior chest, the apices are at the level of C7
Term
The main reason auscultation precedes percussion and palpation of the abdomen is to:
Definition
Term
A patient complains of leg pain that wakes him at night. He states that he “has been having problems” with his legs. He has pain in his legs when they are elevated, which disappears when he dangles them. He recently noticed “a sore” on the inner aspect of the right ankle. On the basis of this history information, the patient is most likely experiencing:
Definition
Term
While examining a 75-year-old woman, the nurse notes that the skin over her right breast is thickened and the hair follicles are exaggerated. This condition is known as:
Definition
Term
While examining a patient, the nurse observes an abdominal pulsation between the xiphoid and umbilicus. The nurse would suspect that these are:
Definition
Term
What is a bruit?
Definition
A bruit occurs with turbulent blood flow, indicating partial occlusion of the artery
Term
Air passing through narrowed bronchioles would produce which of the following adventitious sounds?
Definition
wheezes
Term
After examining a patient, you make the following notation: Increased respiratory rate, chest expansion decreased on left side, dull to percussion over left lower lobe, breath sounds louder with fine crackles over left lower lobe. These findings are consistent with a diagnosis of:
Definition
left lobe pneumonia
Term
Where is the aortic valve located?
Definition
Second intercostal space; right sternal border
Term
Where is the puplmonic valve located?
Definition
Second intercostal space; left sternal border
Term
Where is the tricuspid valve?
Definition
left lower sternal border
Term
Where is the bicuspid valve located?
Definition
fifth intercostal space; midclavicular line
Term
During an abdominal assessment, the nurse is unable to hear bowel sounds in a patient’s abdomen. According to the text, before reporting this finding as “silent bowel sounds” the nurse should listen for at least:
Definition
5 minutes
Term
To the horizontal plane, a scaphoid contour of the abdomen depicts:
Definition
a concave profile
Term
Any lump found in the breast should be referred for further evaluation. A benign lesion will usually have 3 of the following characteristics. Which one of the following is a characteristic of a malignant lesion?
Definition
hard
Term
The nurse is auscultating the lungs of a patient who had been sleeping and notes short, popping, crackling sounds that stop after a few breaths. The nurse recognizes that these breath sounds are:
Definition
Term
During an examination of the anterior thorax, the nurse recalls that the trachea bifurcates anteriorly at the:
Definition
the sternal angle
Term
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:
Definition
Term
In performing auscultation of heart sounds, which sequence would the nurse use?
Definition
Aortic area—pulmonic area—Erb’s point—tricuspid area—mitral area
- Sounds produced by the valves may be heard all over the precordium. Therefore, learn to inch your stethoscope in a Z pattern, from the base of the heart across and down, and then over to the apex. Or start at the apex and work your way up
Term
The nurse knows that normal splitting of the second heart sound is associated with:
Definition
inspiration
Term
A patient is complaining of tenderness along the costovertebral angles. The nurse knows that this symptom is most often indicative of:
Definition
kidney inflammation
Term
The most important technique when progressing from one auscultatory site on the thorax to another is:
Definition
side-to-side comparison
Term
Which structure is located in the left lower quadrant of the abdomen?
Definition
sigmoid colon
Term
During percussion, the nurse knows that a dull percussion note elicited over a lung lobe most likely results from:
Definition
increased density of lung tissue
Term
Which of the following women reflect abnormal findings during the inspection phase of breast examination?
Definition
- The nipples should be symmetrically placed on the same plane on the two breasts. With deviation in pointing, an underlying cancer causes fibrosis in the mammary ducts, which pulls the nipple angle toward it
Term
Pain with palpation in the right lower quadrant could indicate a disorder of which of the following structures?
Definition
appendix
Term
When auscultating the lungs of an adult patient, the nurse notes that over the posterior lower lobes low-pitched, soft breath sounds are heard, with inspiration being longer than expiration. The nurse knows that these are:
Definition
Term
The nurse is reviewing an assessment of a patient’s peripheral pulses and notes that the documentation states that the radial pulses are “2+.” The nurse recognizes that this reading indicates what type of pulse?
Definition
normal
Term
What is the apical pulse indicative of?
Definition
heart size
Term
What is a thrill?
Definition
A thrill is a palpable vibration. It signifies turbulent blood flow and accompanies loud murmurs. The absence of a thrill does not rule out the presence of a murmur
Term
The nurse is listening to bowel sounds. Which of the following is true of bowel sounds?
Definition
Bowel sounds are high-pitched, gurgling, cascading sounds that occur irregularly from 5 to 30 times per minute. They originate from the movement of air and fluid through the small intestine
