NURS MISC PA Final Review 2 Completed A

NURS MISC PA Final Review 2  Four Techniques of Assessment o Inspection (Least intense) o Auscultation o Percussion o Palpation (Most intense)  Most common type of assessment equipment o Woods Lamp: assesses fu ...

NURS MISC PA Final Review 2  Four Techniques of Assessment o Inspection (Least intense) o Auscultation o Percussion o Palpation (Most intense)  Most common type of assessment equipment o Woods Lamp: assesses fungal infection o Stethoscope  Bell: Low pitch, Bruit auscultation  Diaphragm: High pitch o Goniometer: Measures degree of flexion or extension of a joint o Stadiometer: Measures height o Skin fold caliper: Measures subcutaneous thickness o Doppler: Used when pulses cannot be palpated o Transilluminator: detects blood, fluid, or mass in body cavity  Primary Lesions o Macule: Flat non palpable change in skin color, <1cm o Papule: Elevated solid palpable mas with circumscribed border <.5cm o Vesicle/Bulla: Elevated, fluid filled round or oval shaped palpable with thin translucent walls, circumscribed border <.5cm o Wheal: Elevated, often reddish area with irregular border caused by diffuse of fluid in tissue, ex) hives, insect bites o Nodule: Elevated, solid, hard or soft palpable mass that may extend deeper into dermis, circumscribed border <2cm o Pustule: Elevated pus-filled vesicle/bulla with circumscribed border ex) acne  Secondary Lesions o Keloid: elevated irregular darkened area of excess scar tissue o Fissure: linear crack with sharp edges extending into dermis o Lichenification: rough, thickened hardened area of epidermis resulting from chronic irritation o Atrophy: translucent dry paperlike, sometime wrinkled skin surface resulting from thinning or wasting of the loss of collagen and elastin o Erosion: wearing away of epidermis causing moist shallow depression o Crust: dry blood, serum, or pus on skin from burst vesicles or pustules o Scales: shedding flakes of greasy keratinized skin tissue o Scar: flat irregular area of connective tissue left after a lesion or wound has healed o Ulcer: deep irregular area of skin loss extending into dermis or subcutaneous layer  Vascular Lesions o Hemangioma o Port-wine stain o Ecchymosiso Hematoma o Purpura o Petechiae o Spider angioma o Venous Lake purplish/blue lesion  Malignant Skin Lesions o Basal cell carcinoma o Squamous cell carcinoma o Malignant melanoma o Kaposi’s sarcoma  Lesions according to configuration o Annular: Lesions with circular shape o Confluent: Lesions that run together o Discrete: Lesions that are separate and discrete o Target: Lesions with concentric circles of color o Group: Appear in a cluster o Linear: Appear in a line o Polycyclic: Circular but united lesions o Zosteriform: Arranged in a linear manner along a nerve route (Herpes)  Pulse Locations o Brachial: Antecubital area of arm o Radial: Lateral aspect of wrist o Ulnar: Medial aspect of wrist o Femoral: Inguinal area o Popliteal: Behind knee o Dorsalis Pedis: Top of foot  Areas of hand used in assessment o Dorsal: Skin temperature o Finger tips: Percussion o Finger pads: Assess pulses, edema, lymph nodes, light palpation o Metacarpophalangeal: Moderate to deep palpation  Grading Edema o 0: No edema o 1+: 2mm o 2+: 4mm o 3+: 6mm o 4+: 8mm  Pulse Grading o 1+: Weak, Thready o 2+: Normal o 3+: Brisk o 4+: Bounding  Abdominal Palpation o Light: 0.5cm - 1cm o Moderate 1-2cm o Deep Bimanual palpation (Used in obese patients) 2-4cm Indication of nonhealing wound on head during assessment o Malignancy, overexposure to UV  If patient is suspect to have Lyme disease, what is most valuable assessment question o Have you been hiking or camping (Result of deer tick bite) o Extremity of tick can still be embedded in scalp or back  If patient suddenly refuses your exam, what would be appropriate documentation o Document what was done and what was refused by patient  Skin composition o Epidermis o Dermis o Subcutaneous tissue o Muscles and bone  Stages of decubitus o Stage 1: epidermis affected, usually reddened o Stage 2: Epidermis and dermis affected o Stage 3: Epidermis, Dermis, Subcutaneous layer affected o Stage 4: All layer affected  Sweat Glands o Eccrine  Water and Salt, found all over body o Apocrine  Water, Salt, Fatty acids, Protein  Usually present in groin, axillary region, and genital region  Produces musky odor when mixed with bacteria  Hair Types o Terminal  Long hair found on scalp, chest, face, legs, pubic hair, eyebrow o Vellus  Fine hair that covers body  Lymph Nodes o Pre-auricular: In front of ears o Post-auricular: behind ears o Occipital: base of skull o Submandibular: below mandible lateral aspect o Submental: Below head anterior aspect o Tonsillar: along tonsils o Posterior cervical o Anterior cervical o Deep cervical chain: embedded with sternocleidomastoid muscles o Supraclavicular: Along top of clavicle  Technique for assessing lymph nodes o Gentle circular motions with three fingers  Skin Conditions o Milia: Tiny white papules on nose of baby o Vernix caseosa: white cheese like substance found on face and back of baby made from sebum and epidermal cellso Mongolian spots: bluish spots found on sacral area on most dark-skinned babies o Vitiligo: Patchy pigmented areas over face, hands, and skin folds of children or adult o Lanugo: Fine downy hair of newborn common on shoulder and chest of newborns  Normal findings of lymph node palpation in adult o Non-palpable  Criteria to rule out malignant lesion o A: asymmetry o B: border irregularity o C: color that is not uniform o D: diameter greater than 6mm o E: evolving size shape or color  Headache Types o Classic Migraine o Tension-due to stress o Cluster o Sinus  Assessment of clubbing o Mirroring of dorsal aspect of hand o Normal is diamond shape, 160 degrees  Best technique for assessing skin turgor o Pinching below clavicle or wrist  Head and Neck abnormalities o Craniosynostosis: Premature closure of coronal suture and sagittal suture o Fetal Alcohol Syndrome: deformed upper lip below septum, intellectual disability o Acromegaly: enlargement of the bones, facial features, hands, and feet due to increased amount of growth hormone o Down syndrome: Slanted eyes, flat nasal bridge, flat nose, protruding tongue, broad neck o Hydrocephalus: Enlargement of the head by inadequate draining of CSF(vein showing) o Bell’s Palsy: Sudden temporary disorder affecting CN VII, produces unilateral paralysis  Where to assess jaundice on dark skinned client o Oral mucosa, sclera, palm of hand, soles of feet, lips  Scalp conditions o Pediculosis capitis (Head lice): white particles (Eggs) attached to hair shaft  Nursing intervention: advise client to wash all clothing, disinfect combs, wash anything client uses in warm water with detergent o Dandruff: dead scaly flakes of epidermal cells  Protection of examiner during assessment against infection o Handwashing, before and after every patient interaction  Percussion sounds o Bone: Flat short sound o Solid Organ (Liver): Denseo Abdomen: Tympany  Normal rate per minute of abdominal sounds, 5-30 sounds per minute  Over 30 may indicate gastritis or diarrhea  Under 30 may indicate obstruction  None may indicate complete intestinal obstruction o Lungs: Resonance  Hyperresonance: Lungs full of air  For an anxious patient prior to an exam, an appropriate action of nurse to reduce anxiety will be o Provide warm comfortable and private environment  Normal capillary refill o Under 2 seconds o If patient has nail polish, pinch sides of fingers  Albinism o Absence of color o Patient may have pale skin, blonde hair pink iris of eye  Which part of the eye is the most sensitive to pain? o Cornea  Is the Snellen chart for short distance vision or far distance vision? o Far distance vision  What is normal vision? o 20/20, also called emmetropia  What is the numerator in a vision reading? o Distance from the chart  What is the denominator in a vision reading? o Line/grade that the patient is able to read  What is the test you use for close vision? o Rosenbaum test  What is the normal for the Rosenbaum test? o 14/14  If patient cannot read half of line when performing Snellen test, what is the grade? o The line above  If the patient can read more the half the line when performing Snellen test, what is the grade? o That line  What is the term for farsightedness in elderly? o Presbyopia  What is the term for farsightedness in adult? o Hyperopia  What is the term for nearsightedness? o Myopia  What do adults with farsightedness have difficulty in? o Seeing near  What do adults with nearsightedness have difficulty in? o Seeing far What is the test for peripheral vision? o Confrontation  How do you test for consensual response? o You apply the light of the penlight to the side of the eye and visualize that the closest pupil will constrict, and the farther eyes pupil will have a sluggish constriction since the light is farther away o Result will be normal, illuminated eye pupil constrict faster than non-illuminated eye, however non-illuminated eye could still constrict  What is known as the drooping of the eyelid/defect in cranial nerve 3 o Ptosis  What do you call the cholesterol deposit, soft jello plaques on the inner canthus of the eye, usually in patients with high cholesterol or elderly patients (also associated with normal aging)? o Xanthelasma  What is the yellow thick and dense lens that’s causing blurred vision? o Cataract (due to over exposure to the sun or over exposure to dust)  What is the light grey or white thinning surrounding the iris due to deposit of lipids? o Arcus senilis o Doesn’t usually affect vision o Usually occurs in elderly  What are the yellowish nodules that is the thickened area of the vulvar conjunctiva of the pupil? o Pinguecula o Occurs in elderly o Due to long exposure to sun, wind, and dust  The deposit of vulvar conjunctiva that can grow over the cornea and block the vision of an elderly patient? o Pterygium  If you are in a clinic and the elderly patient is saying, “I think I’m getting blind, because I always feel graining in my eyes, reddening in my eyes, I have a burning sensation in my eyes” what is your response? o Dry eyes normally occur in aging, advise patient to apply artificial tears and follow instructions on the bottle  How do you test for accommodation? o Ask patient to follow object in your hand and place it really close to their eyes and check pupil constriction and convergence of the eyes.  What is the test that you do for pediatric patient to rule out strabismus? o Cover uncover  What are you testing when you are asking the patient to follow the gesture of an H or wheel wagon? o Integrity of the EOM (extra ocular movement) or 6 cardinal field of gaze  What are the normal findings when testing the 6 cardinal fields of gaze? o No nystagmus or jerky movement of the eye  What is nystagmus? o Jerking movement of the eye  What is the difference between entropion and ectropion?o Entropion=inner eyelid inverted into the eye creating eye irritation and redness of the eyes o Ectropion=conjunctiva is drooping down, exposing the conjunctiva (could be unilateral or bilateral)  What is the normal response of the patient when the nurse touches the eye with a sterile cotton swab? o Blink reflex  What is macular degeneration? o Loss of central vision o Loss of central vision/peripheral vision intact o Ex: when driving on freeway you cannot see car in front of you but can see the cars in your peripheral  What is the leading cause of blindness in the US? o Diabetic retinopathy  How would interpret a Snellen score of 20/70? o The patient can read the line at 20/70 at 20 feet and also step back to 70 feet and read the same letters  What is a legally blind reading? o 20/200  If you are in an ophthalmologist clinic, which patient do you need to refer to the doctors right away? o Patient with acute glaucoma  Why do you advise the patient not to use cotton swab into the ears? o Patient can puncture tympanic membrane  If your patient is presenting with swollen oricle, redness, ear canal drainage, itching, fever, but looking at tympanic membrane and it is pearly grey, what is it? o Infection of the external ear (otitis externa)  When ossicles are involved and outer ear of the infection, what is it? o Otitis media  If the cochlear and vestibule are involved in infection, what is it? o Labyrinthitis (otitis internal)  What do you called the test when you use the tuning fork to assess hearing by comparing air conduction with bone conduction? o Rinne test o Air conduction is greater than bone conduction o Normal is air conduction is 2x longer than bone conduction  After you activate the top of tunning fork for the rinne test what do you do? o Place on mastoid process, time it, then when they cannot hear it anymore put it one inch from ear  What does the normal tympanic membrane look like? o Pearly grey  When looking at the ear and you see white patches on the tympanic membrane, what does it mean? o Previous ear infection  When your tympanic membrane is busted, what is the manifestations of the patient? o Diminished hearing How do you perform the weber test? o Activate top of tuning fork by hitting it on your hand then placing the base of the tuning fork on the middle of the skull o Normal finding is bilateral equal sound  If patient has infected ear where does the vibration go during weber test? o To the defected ear (right ear affected=lateralization to right ear)  When you’re using the otoscope and cannot see anything, what do you do? o Pull out and reposition  The otoscope can also be used for inspection of? o The nose by using shorter tip  If you have a patient that says, “oh my god I think I’m loosing my hearing” what would be the most valuable question to ask? o Does anyone in your family have any similar hearing problems? o Because hearing problems are hereditary o Hearing loss is familia  When you are assessing the ear of the patient, what is the finding that is alert/concern to you? o Tenderness of the mastoid process because infection can go to the brain  When you are testing for cranial nerve 8 (vestibulocochlear), what tests are you doing? o Whisper test and Romberg test  If your patients Romberg test is positive and your patient is in inpatient care, what would you do so that the patient wouldn’t fall? o Order a bedside commode  What kind of percussion would the nurse imply with a patient with a sinus headache? o Direct percussion  What are the normal findings of transillumination of the sinuses? o Red glow present  Is red reflex normally present in newborns? o Yes, because with red reflex you are ruling out cancer of the eye or congenital cataract  When you are trans illuminating the sinuses and you cannot illicit the red glow, what does that mean? o Patient is congested  If patient has rhinitis, what is the most important question you should ask? o Do you have allergies?  What is the technique that you do to measure the contraction of the diaphragm (diaphragmatic excursion)? o Percussion o Start below the scapula, going down from resonance to dullness and mark it o Do both right and left lungs o Patient exhales then holds, and you percuss  What is a normal diaphragmatic excursion? o 3-5cm  For a well fit individual what is the normal diaphragmatic excursion be? o 7-8cm If diaphragmatic excursion is below 3cm, what is the confirming diagnostic test that the doctor is supposed to order? o Chest x-ray  What is the function unit of the lungs? o Alveoli  When you are percussing the lungs, what kind of sound is the normal sound? o Resonance  What kind of percussion do you do when percussing the lungs and where at? o Indirect in the ICS  What kind of sound will you hear when air is trapped in the lungs when percussing? o Hyperresonance  What is the other name for thorax? o Chest  What are the three sections of the respiratory system? o Mediastinum: left, middle, and right  What is in the mediastinum? o Trachea, esophagus, heart, major blood vessels  The left lung has how many lobes? o 2  The right lung has how many lobes? o 3  What is known as an external respiration? o Exchange of O2 and CO2 at the alveoli level  What is known as internal respiration? o Exchange of O2 and CO2 at the cellular level  What is the anomaly in newborns that you have to inspect right away because it can cause respiratory failure? o Choanal atresia o Which is a soft membrane that is obstructing the nasal passages  What is the normal respiratory rate for adults? o 12-20 per minute  What is the normal respiratory rate for newborns? o 40-80 per minute, irregular  When does the respiratory rate go down to 35 per minute? o The age of 5  What are the terms that are used interchangeably when you are describing the function of the respiratory system? o Respiratory cycle o Respiration o Breathing  The two phases of respiration are? o Inspiration: active phase o Expiration: passive phase  On lung auscultation when you are listening to the sternum border, and you hear medium pitch sound with equal inspiration and expiration, what kind of breathing is that?o Bronchovesicular  What kind of breathing is it when you hear the loudest sound when auscultating the sternum border? o Tracheal  What is the initial step in respiratory assessment? o Inspection  What is bradypnea? o Slow regular breathing  What is hypoventilation? o Irregular, low/shallow breathing  What is Tachypnea? o Rapid, shallow breathing  What is Hyperventilation? o Rapid, deep breathing  Cheyne-strokes vs Biot’s (ataxic) breathing o Cheyne-strokes: periods of deep breathing alternating with periods of apnea, regular o Biot’s (ataxic): shallow, deep respiration with period of apnea, irregular  Which kind of breathing is usually observed when an elderly is dying? o Cheyne-strokes  When there is a lump in the breast of a women with a change in consistently, what is your next step as a nurse? o Refer the patient to a doctor for further examination  Where is the breast tumor usually located? o Upper outer quadrant of the breast  What is the type of bronchi that is present in patients with asthma? o Bronchi sibilant (high pitched, wheezing)  If patient has bilateral pneumonia and both lungs are filled with fluid and you auscultate using bronchophony, what sound will you hear? o Loud and clear sound o Because normal is muffled  What sound is bronchi soronous? o Low pitched, snoring and rattling  How do you characterize blocked air flow? o High pitched and continuous on auscultation  A patient with lobar pneumonia, what kind of advantageous sound will you hear? o Crackles  When alveoli are filled with fluid, what kind of advantageous sound will you hear? o Moist and bubbling  What kind of congenital anomality is it when there is forward misplacement of the sternum with depression of adjacent cartilage? o Pectus carinatum or pigeon chest  What is the chest configuration of a COPD patient? o Barrel chest  What is the normal configuration of the chest?o Elliptical o When the lateral diameter is 2:1 compared to anterior and posterior diameter  What is the congenital deformity when the chest is concaved? o Pectus excavatum or funnel chest  What is the lateral deviation of the spinal process? o Scoliosis  What is the exaggerated curvature of the thoracic vertebrae present in elderly and patients with osteoporosis? o Kyphosis  What is the exaggerated curvature of the lumbar vertebrae that is common in pregnant women? o Lordosis  What structure of the breast is responsible for milk production? o Acini cells  When do you advise an elderly patient to do SBE? o Same time, same day, every month  When do we advise a person that is still menstruating to do SBE? o 3-5 days after menstruation  What is normal breath sounds on auscultation? o Tracheal, bronchial, bronchovesicular, and vesicular  What is the indication of Peau D’ Orange? o Sign of malignancy or cancer  What kind of technique do you use when assessing a patient for tactile fremitus when patient is coughing or talking? o Palpation  What is the most common cause of benign nipple discharge on a patient that is not menstruating anymore? o Intraductal papilloma o Discharges is usually serous (clear) or serosanguinous (clear, bloody)  When a patient is post-op and is not ambulating what can happen? o Atelectasis (collapse of lungs)  What is the characteristic of Biot’s breathing? o It is shallow, deep respiration with periods of apnea o It is irregular compared to Cheyne-strokes breathing  How do you define obstructive breathing? o Prolonged expiration o Common in patient with asthma, COPD, and chronic bronchitis  What is normal breathing called? o Eupnea  What is the heart size? o 5in long o 3.5in diameter o 2.5in thickness o The female heart is slightly smaller and less in weight compared to male heart  The heart rate can easily be palpated or auscultated where?o 5th ICS midclavicular line left of chest  What is the flow of the blood in a healthy person? o One way/unidirectional  When the cardiac valves are diseased, how does it affect the blood flow? o Backs up/back flow which results in regurgitation  What does regurgitation create when auscultating? o Heart murmur  S1 is also known as? o LUB o First heartbeat o Closure of the tricuspid and mitral valve  S2 is also known as? o DUB o The second heartbeat o closure of the semilunar values (aortic and pulmonic valves) o S2 heard loudest at base of heart  The area of the chest where you auscultate and assess the heart sound is known as? o Precordium  What is the heart sound grading? o 1+: faint (weak thready) o 2+: normal o 3+: brisk o 4+: bounding  The opening between the pulmonary artery and descending aorta is known as? o Patent ductus arteriosus  What is the electrical representation of the cardiac cycle that are documented by the deflection on the recording paper? o ECG (electrocardiogram)  When you are assessing the fingers of a cardiac patient and you notice red lines or splinter hemorrhages on the nail beds of the patient, what do you call that? o Infective endocarditis  S3 usually follows what? o S2 o Also known as the ventricular gallop  The P wave in the EKG reading represents what? o Atrial depolarization  What is hidden behind the QRS? o Atrial repolarization  What does the QRS wave represent? o Ventricular depolarization  What does depolarization mean? o Contraction  What does repolarization mean? o Relaxation  The T wave in the EKG represents what?o Ventricular repolarization  What is the total absence of regular heart rhythm in the EKG? o Ventricular fibrillation  You are assessing the legs of your patient and they are feeling cold and no more hair is growing on them, what do you call that? o Arterial insufficiency  You are assessing the legs of your patient and they are warm and have pain for prolonged sitting or standing, what is it known as? o Venous insufficiency  Where is the aortic landmark located? o 2nd ICS right of the sternum boarder o Where S2 is louder than S1  Where is the pulmonic landmark located? o 2nd ICS left of the sternum boarder o Where S2 is louder than S1  Where is the ERBs point landmark located? o 3rd ICS left of the sternum boarder o Where S1=S2  Where is the tricuspid landmark located? o 4th ICS left of sternum boarder o Where S1 is louder than S2  Where is the mitral landmark located? o 5th midclavicular line on the left side o Where S1 is louder than S2 o This is where you will hear point of maximal impulse  What are cardiac murmurs associated with? (SATA) o Regurgitation o Such as mitral regurgitation, tricuspid stenosis, tricuspid regurgitation, aortic regurgitation, or mitral stenosis  What are the major risk factors for cardiac diseases? o Smoking o Hypertension o High cholesterol o Diabetes o Obesity  Where does the electrical initiation of the cardiac current start? o SA node o Also known as pacemaker o Requires 60-100 Jules/min  The heart sounds are interpreted according to what? o Pitch and duration o Intensity and phase  Where is your angle of louis located? o In line with second rib  What are the two cardiac nerves? o Sympathetico Parasympathetic  What is the sympathetic responsible for? o The stimulation of the heart o Increases heart rate  What is the parasympathetic responsible for? o Decreases heart rate o Relaxation of heart  The PMI of an adult patient is located where? o 5th ICS midclavicular line  Where is the PMI located in an infant? o 4th ICS midclavicular line o Because an infant’s heart is more horizontally positioned  What is the heart rate of a newborn? o 160-180 bpm  When does it reduce to 112 from 120? o Age 5  What are the symptoms of severe aortic regurgitation? o Bobbing of the head o In sync with the heart rate  What are the signs and symptoms of heart failure? o Fluid overload o JVD over 3cm o Low blood pressure o High heart rate o Ankle edema o Shortness of breath o Presents of S3  How do you check for JVD? o Adjust patient to 45 degrees o 3cm is normal  Where are pedal pulses located? o Lateral to the big toe  Where are popliteal pulses located? o Behind the knee, medially  Where are femoral pulses located? o Inguinal area  Where are the posterior tibialis pulses located? o The groove behind the malleolus bone and Achilles tendon, medially  Where are the brachial pulses located? o Antecubital area of the arms  Where are the radial pulses located? o Medial wrist o Landmark: thumb  Where are the ulnar pulses located? o Lateral part of wristo Landmark: pinky  What is the test for the patency of the radial artery or ulnar artery? o Allen’s test  How do you perform the Allen’s test? o Ask patient to pump the hand then check for patency of the ulnar artery by excluding the radial artery then check radial artery by excluding the ulnar artery o Normal result is blood flow returning to hand right away  On expectation of the fingers and hands of the patient who has Raynaud’s syndrome, what will you see? o Rubber and skin pallor  On percussion of the heart, what sound should you anticipate? o Dullness  When you are inspecting for varicosities and you ask patient to elevate the legs, does the varicosities disappear? o No  When the intake of the patient is more than the output, what will the client look like? o Swollen o Edema o Anasarca (generalized edema)  What is the rhythm for ventricular tachycardia? o Rapid, regular heartbeat o As high as 200 bpm  When is it common to have tetralogy of Fallot? o Children with 4 cardiac defects o Dextroposition of the aorta, pulmonary stenosis, right ventricular hypertrophy, and ventricular septal defect  What is the normal blood pressure? o Less than 120/80  What is a prehypertension reading? o 120/80-139/89  What is a hypertension reading? o 140/90 and above  Patent ductus arteriosus, which is the opening between the pulmonary artery and descending aorta is supposed to close when? o 24-48 hrs after birth o If it doesn’t close, then surgical intervention is required o You will hear cardiac murmur if it is not repaired  What is passage of blood between the right and left atrium? o Foramen ovale o Suppose to close right after birth/shortly after birth o If it doesn’t close you with hear a murmur  When does cardiac depolarization occur? o When the current of the SA node spreads across the atrium and causes cardiac contraction o Cardiac cell is positively charged  How are the cardiac cells charged during repolarization?o Negatively charged o Cardiac muscles are relaxed  What is the electrolyte that is helpful in the electrical conduction of the heart? o Calcium o Potassium o Salt  When you are working in ICU or CCU you usually look at the lab work of your patient to make sure that? o There is no electrolyte imbalance o Because if there is an imbalance it can interfere with the conduction system of the heart  S3 and S4 are usually common in patients with? o Cardiac conditions such as MI or ventricular hypertrophy  What instances is it normal to have S3? o Healthy children (some children outgrow it) o Healthy adults o Last trimester of pregnancy (usually disappears after pregnancy)  What instances is it normal to have S4? o Healthy children o Athletes o Healthy elderly  What separates the left and right atrium? o Interatrial septum  What separates the left and right ventricles? o Interventricular septum  What usually causes a JVD of greater than 3cm? o Increased intravenous pressure o Fluid overload o Pressure at the superior vena cava  True or false: African American have a higher incidence of hypertension? o True  True or false: Caucasian females 65-74 years old have a higher chance of cardiovascular disease? o True  What is smoking attributed to? o Cardiovascular diseases  What is cocaine attributed to? o Hypertension o MI o Ruptured aorta  70% of children will have what? o Innocent murmur o Aggravated when they have high temperature and anemia  How do you grade cardiac murmur? o 1-6 o 1/6 is barely audibleo 6/6 is the loudest  What does the abdominal cavity include? o Digestive system o Urinary system o Reproductive system  What is the alimentary canal? o Hollow tube from the mouth to the anus  How long is the esophagus? o 10 inches  How big is the stomach? o It depends on how much you eat  How long is the small intestines? o 18-21 feet  How long is the large intestines? o 5-5.5 feet  What is the largest gland of the body? o Liver  What is the largest organ of the body? o Skin  What does the liver produce? o Antibodies o Bile o Spore for coagulation of blood o Egg and protein and carbohydrate metabolism o Detoxifies harmful stuff in the body o Stores vitamins  What does the gull bladder do? o Releases stores bile for fat emulsification  What kind of gland is the pancreas? o Exocrine and endocrine o Endocrine creates insulin for the metabolism of sugar and carbs o Exocrine secretes pancreatic juice to assist in digestion of protein fat and carbs  What is the largest lymphoid organ? o The spleen  What does the spleen do? o Graveyard for RBC o Site for lymphocytic proliferation o Immune surveillance o Filters blood o Destroys and returns warn out products to the liver  What does the urinary system consist of? o Kidneys o Ureters o Bladder o Urethra  What are the glomeruli?o Clusters of capillaries in the kidneys that filters at least 1L of fluid per minute  What is the landmark of the urinary system? o The CVA o Rectus abdominus o Symphysis pubis  What are the abdominal landmarks/reference points? o Division of abdomen in quadrants o Division of abdomen in 9 regions  What is the major concern for an individual who is getting old? o Urinary elimination  At what age is there a loss of nephron leading to less glomeruli filtration, which leads to susceptibility to drug toxicity? o 75 years and above  What age does BPH (benign prostatic hypertrophy) usually occur? o 85 years and above o 95% of men will have it at this time  What is known as renal calculi? o Kidney stone or urolithiasis o Urolithiasis is most common in Caucasians  What is the most important question to ask if patient has urolithiasis? o Whether there is anyone in the family with urolithiasis because it is familial  What do you advise the patient when they have urolithiasis? o Drink at least 3L of fluid in 24 hours o The purpose for drinking water is to pass the stone o Main responsibility as a nurse is to strain urine to see if there are any stones, if there are, save stones and call the doctor  What are the main organs in the right upper quadrant? o Liver and gull bladder  What are the main organs in the left upper quadrant? o Spleen and stomach  What are the main organs in the right lower quadrant? o Appendix  What are the main organs in the left lower quadrant? o Large intestines where you find any diverticulosis or diverticular diseases  On percussion of solid organs, such as liver, pregnancy, ascites, the heart, and tumor, what should you hear? o Dullness  You’re palpating the right midclavicular and go towards the rib and it changes from tympani to dullness, what did you hit? o Boarder of the liver  What is the strict sequence of abdominal assessment? o 1. Inspection o 2. Auscultation o 3. Percussion o 4. Palpation On inspection of the abdomen what’s the most important findings that you should be alerted on and call the doctor? o Strong abdominal pulsation due to possible AAA (aortic abdominal aneurism)  Why do you start your auscultation of the abdomen on the right lower quadrant? o Because bowel sounds are usually present in that area  What is the best position when assessing the abdomen for distention or blood? o Supine with small pillow behind the head  What kind of assessment technique will the nurse do when assessing for bladder distention? o Supine with small pillow behind head o Technique would be indirect percussion  The abdominal contour of a slightly skinny person is? o Flat  The abdominal contour of a VERY skinny person is? o Scaphoid  What would the abdominal contour look like with a person with ascites? o Protuberant  What do infants abdomens usually look like? o Rounded or protuberant  What do women on third trimester of pregnancy abdominal contour usually look like? o Protuberant  A patient involved in major accident and has hematoma located on CVA, what would you inspect? o Injury of the kidney  When assessing the kidney, what do you have to ask the patient? o If they still have both kidneys  What kind of percussion do you do when assessing the CVA? o Blunt percussion  When there is pain for the patient when doing blunt percussion on the CVA, what does that mean? o Kidney disease  Are kidneys palpable? o no o only when there is cancer or polycystic disease  What is bladder cancer usually linked to? o Smoking o Usually common in men  If acute renal failure does not become chronic, what are the 3 stages? o 1. Oliguria: urine output less than 400 cc o 2. Diuresis: urinating a lot o 3. Recovery phase  What is the hallmark for chronic renal failure? o Uremia: urine product build in the blood  What does incontinence mean? o Inability to retain urineo 5 types: functional, reflex, stress, urge, and total incontinence  What is the inability to empty the bladder? o Urinary retention  When the output in less than the intake what is happening? o The patient is retaining fluid  What is it called when the patient is having painful urination? o Dysuria  What is it called when patient is having frequent urination at night? o Nocturia  What is it called when there is sugar in the urine? o Glycosuria  What does is it called when your urine output is less than 100cc in 24 hours? o Anuria  What is it called when urine output is less than 400cc in 24 hours? o Oliguria  What is it called when there is blood in the urine? o Hematuria  When blood pressure suddenly drops, what is the major roll of the kidneys in this situation? o Release of renin  Different type hepatitis o Hep A  Fecal oral route, most common in children o Hep B  Parentally, sexually, perinatally o Hep C  Blood, parentally o Hep D  Same as B o Hep E  Fecal oral route. Common with those who travel to India, Africa, Asia, and Central America  What is the difference between Crohn’s and ulcerative colitis? o Crohn’s disease is chronic inflammation of the intestine and can involve any part of the lower intestines. Signs would be abdominal pain, diarrhea, then remission. No medical or surgical intervention is needed. o Ulcerative colitis signs and symptoms is abdominal pain, diarrhea, and bloody stool. Patient may require long term medical intervention.  What does splenomegaly mean? o Inflammation of the spleen usually cause by mononucleosis or kissing disease, caused by herpes virus 4  What is known as AGE and what are the signs and symptoms? o Acute gastro enteritis o Diarrhea with and without fever and hyperactive bowel and with or without nausea and vomiting o Watch for dehydration What are the most accurate signs of dehydration in children? o ALOC o Weight loss o Low urine output  What could be the indication of widened aorta? o Aneurism o Normal is 3cm and below  Where is your McBurney’s point? o Right lower quadrant, imaginary line, middle third  What is the sign that you are trying to illicit when you compress the abdomen then return to not compressing and the patient has a stabbing pain? o Positive to Blumberg sign/rebound tenderness o Could be peritoneal irritation  How do you test for murphy sign? o Palpate the boarder of the liver and ask patient to deep breathe then release and if patient has pain then it is positive to cholecystitis/murphy’s sign  How do you test for Rovsing’s sign? o When you palpate the left lower quadrant and the pain is felt on the right lower quadrant o Positive is peritoneal irritation or appendicitis o when patient has pain in right lower quadrant when patient is raising the legs up with resistance and has pain in right lower quadrant also indicative to peritoneal irritation and appendicitis  What is Collins sign? o Ecchymosis or hematoma surrounding the periumbilical area which can be a sign of ruptured ectopic pregnancy or internal bleeding  What is the lab work that is usually ordered when patient has an acute kidney injury? o BUN  When an elderly female client has a sudden onset of urinary incontinence, what would you expect? o Cystitis  Malignancy of the kidney in an infant is known as? o Wilms tumor o When you palpate and feel a mass stop right away because you can disseminate the seeds into the abdomen  If the tumor of the infant is located in the cigar light of the left lower quadrant you suspect what? o Constipation o Ask mother whether the baby is constipated  Umbilical hernia in children can usually be resolved before what age? o Age 5 so they don’t usually do any intervention before then o But after age 5 the intervention is surgical intervention  What is a normal bowel sound per minute? o 5-30 per min o Irregular, high pitched, and gurgling