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Nursing Exam 2


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copy deck
what is the TMJ?
temporomandibular joint
cracking/grating sound of jaw
large head; disorder associated with excess growth hormone
small head size; seen in some cases of mental retardation
accumulation of excessive of cerebrospinal fluid
enlarged thyroid
are palpable lymph nodes normal?
not in adults
what are swollen lymph nodes an indication for?
infection, cancer
if palpable, what should the lymph nodes feel like?
small (0.5-1 cm), mobile, firm, nontender
name the ten lymph nodes of the head and neck (OPPTSSSPDS)
1. occipital 2. pre-auricular 3. post-auricular 4. tonsillar 5. sub-maxillary 6. sub-mental 7. superficial cervical chain 8. posterior cervical chain 9. deep cervical chain 10. supraclavicular
what do OD, OS, and OU stand for?
OD - right eye OS - left eye OU - both eyes
what are sunken eyes an indication for?
bulging eyes
growth or thickening of conjunctiva from the inner canthus toward the iris
everted eyelid
inverted eyelid
drooping of the eyelid
what color should the sclera be?
smooth, glistening, blue-white in color
what color might the sclera be in a dark-skinned patient?
yellowish or small brown spots
blood visible in the sclera is known as:
subconjunctival hemmorhage
what is the outermost layer of the eyeball?
what color should the cornea be?
transparent, smooth, moist
a white ring circling the outer rim of the cornea is known as:
acrus senilis
what does a cataract do to the eye?
impairs vision by making the lens opague
what is a pupil's direct response to light?
it constricts
what is a pupil's consenual response to light?
both eyes with constrict even though light is only being shone into one of them
what is pupil accomodation?
the pupils constrict and the eyes cross as a person attempts to focus on an object moving toward them
what does PERRLA stand for?
pupils equal, round, reactive to light and accomodation
enlarged pupils
constricted pupils
unequal pupils
dimished distant vision (near-sighted)
diminished near vision (far-sighted)
What do we use to test color vision?
Ishihara chart
red-green color blindness affects about what percent of males?
how is color-blindness usually passed down?
usually from mother to son
visual field:
area observable with the eye
what do we use to test visual acuity?
snellen chart
what is the extraoccular muscle function?
control the movement of the eye and eyelids that allow you to track movement
what are diseases that commonly limit the visual field?
poorly-controlled diabetes, cataracts, macular degeneration, and advanced glaucoma
where should you use an ophthalmoscope?
in a darkened room
how far away should you hold the ophthalmoscope to the eye?
12-14 inches
the area commonly known as the 'blind spot' with no photoreceptors is:
the optic disk
what is otosclerosis?
hardening of the inner ear; more common in women
the inner ear is responsible for:
hearing and equilibrium
otis externa:
outer ear infection
otis media:
inner ear infection
ear wax
area behind the ear
how far do you put in the otoscope into an adult ear?
1/2 inch
the malleus and umbo are where?
middle ear
what color should the tympanic membrane be?
pearly gray, shiny, translucent
what is the voice test?
whispered statement 1-2 feet away
weber test:
tuning for on the center of the client's head, they should be able to sense vibrations equally in both ears (POSITIVE if vibration is louder in one ear over the other)
Rinne test:
tuning fork used to compare bone vs air conduction (air normally 2x longer than bone)
romberg test:
test for equilibrium; client stands with eyes closed and feet together - they should be able to maintain balance)
watery discharge from the nose could be what?
allergies or CSF
purulent and malodorous discharge from the nose may indicate what?
a foreign body
inflammation of the tongue
a dry, furry tongue is associated with
inflammation of oral mucosa
white, curdy patches that scrape off and bleed are:
thrush (fungal infection)
mons pubis:
pad of fatty tissue over the symphysis pubis
the 3 phases of the menstrual cycle are:
menstrual phase, follicular phase, luteal phase
people whose gender identity differs in some way from their apparent biological gender
feels trapped in the body of the opposite gender
hermaphrodite; born with ambiguous sexual organs
beginning of menstruation
what is sexual health?
state of mental, physical, emotional and social well-being related to sexuality
what are the 4 stages of sexual response?
excitement, plateau, orgasm, and resolution
an individual's typical level of desire
what is a refractory period (in men)?
stage immediately following orgasm when men cannot achieve an erection
painful menstruation
painful intercourse
intense involuntary contractions of the perineal muscles which close the vaginal opening and prevent prenile penetration
foreskin of the penis is too tight
inflammation of the penis
retrograde ejaculation:
when semen empties into the bladder instead of through the urethra (results in sterility)
tiny, pinpoint red or reddish-purple spots
tapping on the skin with short strokes of fingers
sound hear over a gastric air bubble
a focused assessment focuses on what?
topic, body part, functional ability
the position for a female pelvic exam is
position of lying on your stomach is
hair loss
turgor refers to:
elasticity of your skin
auscultation is:
reddened areas:
bruised area:
when skin takes more than 3 seconds to return to normal position
the bladder usually can hold how much urine?
200-450 mL
a well-hydrated infant produces how many wet diapers a day?
nocturnal enuresis:
nighttime bed wetting
frquent urination
renal calculi:
kidney stones
what are the 2 common urine tests
creatnine and BUN
if you are collecting a 24-hour urine specimen, what do you do with the first one?
throw it out to start with an empty bladder
what are the 5 types of incontinence?
urge, stress, overflow, functional, transient, unconscious
which catheter stays in for periods of time?
indwelling or foleys
which catheter is used to get a urine sample or to see how much urine is retained in the bladder?
straight cath
what is the catheter used only in males over 45?
coude catheter (hook around the end to keep it in place around the prostate)
absense of urine
painful or difficult urination
blood in the urine
urine output of less than 400 mL in 24 hours
excessive urination
pus in the urine
specific gravity is:
indicator or urine concentration
what does a refractometer do?
measures extent of light beam passing through the urine (the higher the concentration of solids in the urine, the more the light is refracted)
what does BUN stand for?
blood urea nitrogen
infection of the urethra
when bacteria travels up into the bladder causing infection
what are the risk factors for a UTI?
sexually active women, women who use spermacidal contraceptive gel, older women, enlarged prostate, kidney stones, indwelling catheters, diabetes, history of UTI
what is transient incontinence?
short-term incontinence that's expected to resolve spontaneously
what is a urostomy?
surgically created opening for elimination of urine
how much water should you drink a day?
2-3 L
Crede's maneuver:
applying manual pressure over the bladder to promote emptying
what position should men and women be in to insert a catheter?
dorsal recumbant
the wave of contractions and relaxation in digestion is:
what is peristalsis?
the wave of contraction and relxation to push a bolus
the process of eliminating waste
a semisolid mass of fiber, undigested food, inorganic material, etc is:
which is voluntary: your internal or external sphincter?
what are some factors that affect bowel elimination?
developmental stage, personal factors, nutrition/hydration, medications, procedures, pregnancy, bowel diversions
fiber and vitamin C tend to: soften/harden stool?
a colonoscopy is:
a direct look at the colon
an occult blood test looks for:
hidden blood
to get an adequate sample of liquid stool, how much should you collect?
20-30 mL
what is the amount of formed stool you should collect for a specimin?
2.5 cm/1 inch
what is the best position to place a patient in to promote regular defecation?
seated upright
diarrhea can be caused by:
contaminated food, infection, dietary change, medication side effect
acute diarrhea is 0 to ? months
0-6 months
what is the BRAT diet for diarrhea?
bananas, rice, applesauce, toast
should you take antidiarrheal medications for acute diarrhea?
NO - your body is trying to quickly get something OUT
if you have constipation, do you want to limit or increase high-fiber foods?
what is the best treatment for fecal impaction?
what are 4 things to do to establish a bowel training program?
1. plan with the client 2. increase fiber in diet gradually 3. increased fluid intake to 8 glasses water per day 4. establish a designated time for defecation
what is an FMS?
fecal management system
which intestine is sterile?
small intestine
which intestine is bacteria often found in?
large intestine
what is a paralytic ileus?
cessation of bowel peristalsis
what is lavage?
therapeutic cleansing
what is primary prevention?
prevention of problems before they occur and health promotion and protection
secondary prevention is:
early detection and intervention; early diagnosis and treatment
tertiary prevention is:
when a permanent, irreversible conditions exists; correction and prevention of further deterioration; limitation of disability
what level of prevention is a mammogram or colonoscopy?
secondary prevention
a vaccine, adequate diet, vitamins are all what kind of prevention?
what are the main health goals for the community by 2010?
increase quality and years of healthy life and eliminate health disparities
WIC is:
women, infant, children (nutritional)
CHIP is:
children's health insurance program
what is medicare?
entitlement program to provide health care to the growing population of those 65 or older, permanently disabled (you have EARNED this by putting money towards it)
what is medicaid?
universal health care coverage for poor older adults, the blind, disabled and families with children (you are income dependent)
this organ receives 1/3 of the cardiac output
the skin
what is the normal pH of our skin?
how often does the skin regenerate?
30 days
what are the functions of the skin?
protection, sensation, water retention, thermoregulation, synthesis of vitamin D, expression of emotion
a chronic wound is any wound that has not shown significant progress towards healing in:
30 days
a non-functioning or inadequate calf muscle pump and incompetent valves in the leg veins is:
venous stasis ulcer
what happens to a person with a venous stasis ulcer?
venous blood pools in the lower extremity and food and eventually it bursts and imbeds in tissues, then turn them blue/brown and the tissue begins to die
what is an arterial ulcer?
caused by insufficient arterial blood supply to the lower limb - the arteries narrow, blood clots cause full or partial obstruction of the artery - results in ischemia and necrosis
what is a pressure ulcer?
localized area of cellular necrosis due to vascular insufficiency in an area under pressure
where do you usually find a pressure ulcer?
over a bony prominence
95% of pressure ulcers occur where?
lower part of the body - sacrum is the most common site, then heels
what is friction?
2 surfaces moving against each other - usually seen as an abrasion on the skin's surface
what is shearing?
separation of the tissue layers - usually can't be seen - skin can look rippled
where does shearing most often occur?
the sacral area of an immobile patient who spends long periods with the head of the bed elevated more than 30 degrees
what factors can contribute to pressure ulcers?
immobility, spinal cord injury, moisture/incontinence, inadequate nutrition, diabetes, age, fever
most wounds are described as being:
partial or full-thickness
a stage 1 pressure ulcer is:
non-blanchable erythema of intact skin, changes in skin temperature, tissue consistency, may appear as blue or purple
a stage 2 pressure ulcer:
skin loss involving the epidermis and/or dermis, ulcer is superficial and presents as an abrasion, blister, or shallow crater
a stage 3 pressure ulcer:
skin loss involving damage or necrosis of subcutaneous tissue, ulcer is a deep crater
a stage 4 pressure ulcer:
full thickness skin loss with extensive destruction, tissue necrosis, damage to muscle, bone or tendon, undermining and tunneling also present
are most pressure ulcers infected?
NO - they are contaminated, not infected
to obtain a wound culture, you clean with:
normal saline
if a patient scores ____ or less, they should be on a skin care immobility protocol
16 or less
patients should be turned every:
2 hours
what is the rule of 30?
bed bound patients should not be elevated more than 30 degrees, side-lying patients should be placed at a 30 degree laterally inclined position
if you notice very shiny, smooth and thin skin on a patient, what is likely happening?
an arterial issue with poor circulation
why does a fever affect your skin?
it affects moisture and metabolic rate
digestive enzymes in feces breaks down skin
what is a colonized infection?
immune system is able to control it, you may not show signs of infection
what is an open wound?
skin has a break in it
what is a closed wound?
the skin is closed and intact
what is an acute wound?
recent wound
what is a chronic wound?
takes a long time to heal
what is a penetrating wound?
hitting organs, very deep
what is serum?
plasma without clotting
serous exudate:
straw-colored; thin and yellow
bloody drainage
serosanguineous: mix of bloody and straw-colored
purulent: yellow, contains pus, thick
what is regeneration?
epithelial healing without a scar
what is primary intention in wound healing?
a clean surgical incision with edges approximated (closed), minimal scarring
what is secondary intention in wound healing?
wound edges are not approximated, there is some tissue loss; the wound heals from inner layer to surface
what does granulating tissue look like?
red, beefy, grainy!
what is tertiary intention in wound healing?
granulating tissue is brought together and there is a delayed closure of wound edges (they will only close it once they are sure there isn't infection)
the braden scale measures what?
skin integrity
what is a hemorrhage?
blood bursting
where should you check a patient for bleeding?
underneath them!
rupture of layers of a wound
when an organ pops out from the wound
what should you do if your patient eviscerates?
cover with a WET dressing, bend the knees to relieve pressure
what is a fistula?
a passageway between 2 cavities
how many risk factors does the braden scale have?
what can you use to find the depth of a wound?
a q-tip
what should you look for in your wound assessment?
location, size, appearance, drainage
what is slough?
yellow and stringy drainage from a wound
what is a jackson-pratt?
a drainage system (ones that look like little grenades)
enzymatic breakdown:
topical enzyme on the bad tissue to break it down
autolysis breakdown:
using your body to break it down
when applying heat and cold, use the ___ minutes on, ____ minutes off rule
15 minutes on, 15 minutes off
when referring to wound color code systems, what do red, yellow and black mean?
red-good, yellow-infection, black-dead
pressure ulcers affect what percent of hospital patients?
the cost of treatment for pressure ulcers, per year:
5-8.5 billion
where would you find the angle of louis?
2nd intercostal space
what is pectus excavatum?
funnel chest
barrel chest is a common sign of:
COPD, heavy smoking
what is the normal ratio of a normal chest shape?
what does the diaphragm do during respiration?
it expands to create a negative pressure so we can inhale
movement of air into and out of the lungs is:
respiration is the exchange of:
gases - oxygen and carbon dioxide in the lungs
what is oxygenation?
how well cells, tissues, and organs are supplied with oxygen
the circulation of blood to body systems
what does a blood gas check?
how much oxygen is in your hemoglobin
what side should a person be positioned on for breathing?
left side
what areas for respiration should you palpate?
tracheal position, chest tenderness, crepitus, chest excursion, tactile fremitus
the 3 normal breath sounds are:
vesicular, brochovesicular, bronchial
this sound is soft, low pitched with a long inspiratory phase and short expiratory phase that's heard over most lung fields
these breath sounds are moderate with a medium pitch, equal inspiration and expiration. It is normally heard over the 1st and 2nd IC spaces
these are loud, high pitched sounds that are hollow with a short inspiration phase and a long expiration phase, normally heard in neck
where are vesicular sounds heard?
over most lung fields
where are bronchovesicular sounds heard?
1st and 2nd IC spaces anteriorly and between the scapula posteriorly
where are bronchial sounds heard?
the anterior neck and nape of neck posteriorly
if you hear a normal sound in an abnormal position, what does that mean?
what are adventitious breath sounds?
abnormal sounds over normal ones
what are common adventitious breath sounds?
crackles, rhonchi, wheezes, friction rub, stridor, grunting
what is friction rub?
the pleural lining inflames and rubs together
what abnormal breath sound is never affected by coughing?
friction rub
what is stridor?
a high pitched snoring sound
what are 3 abnormal voice sounds?
bronchophony, whispered pectoriloquy, egophony
an increased tone or clarity of a spoken word is:
to test for egophony, have your patient:
say "eee" - if it sounds like "ay," egophony is present
normal patterns of breathing:
slow respirations:
fast respirations:
Kussmaul's pattern of breathing is:
regular but abnormally deep and increased in rate
this pattern of breathing has equal depth, alternating with periods of apnea
this pattern of breathing has a gradual increase in depth, followed by gradual decrease and then a period of apnea
the absense of breathing
what is surfactant?
a lipoprotein that lubricates the alveoli
if a patient smokes 1 pack a day for ten years, what is he?
10 pack year smoker
what is a normal co2 level?
what are factors that influence oxygenation?
hypoxemia, hypoexia, hypercarbia, hypocarbia
hypoxemia is:
a low arterial blood oxygen level
poor oxygenation of tissues/organs
hypercarbia is:
high level of dissolved co2
hypocarbia is:
low level of dissolved co2
to help a patient mobilize their secretions, what can you have them do?
deep breath 3x, then cough upon the exhalation of the 3rd breath
a simple oxygen mask gives how much oxygen?
5-10 L
a nasal cannula will give how much oxygen?
1-6 L
a venturi mask gives what percentage of oxygen?
a nonrebreather mask gives how many liters of oxygen and what percentage?
6-15 L, 70-100%
a partial rebreather gives how many liters and percentage of oxygen?
6-15 L, 50-90%
in the elderly, ____ is a more common characteristic of infection than an elevated temperature
what are the 3 kinds of stimuli to test arousal?
auditory, tactile, painful
to look at cerebral functioning, what behaviors should you look at?
facial expression, posture, affect, grooming
LOC stands for
level of consciousness
someone who is sluggish and appears half asleep is
what is an obtunded LOC?
opens eyes, responds slowly to questions, somewhat confused and has decreased interest in their environment; they fall asleep quickly
what is a stuporous LOC:
near unconsciousness with apparent mental inactivity and reduced ability to respond to stimulation
a person who does not respond to verbal or painful stimuli is
What do you ask to check a patient's orientation?
person, place and time
an orientation to person question would be
what is your name?
an orientation to time question would be
what is today's date?
an orientation to place question would be
where are you now?
a remote memory question would be
where were you born?
a recent memory question would be
what did you have for breakfast?
a general knowledge question is
who is the US president?
an attention and calculation skills questions is:
can you count backwards from 20 to 1?
a judgement question to ask a patient would be:
why are you here?
a score of less than 24 on the mini mental exam indicates:
a score of 24 or higher on a mini mental exam indicates:
a normal range
CN I is:
olfactory nerve
CN II is:
optic nerve
CN III is:
occulomotor nerve
CN IV is:
CN VI is:
abducens nerves
CN V is:
trigeminal nerve
CN VII is:
facial nerve
acoustic (auditory)
CN IX is:
glossopharyngeal nerve
CN X is:
vagus nerve
CN XI is:
CN XII is:
anosmia means:
loss of smell
what do you do to test CN 1?
have the client hold a nostril and smell
what do you do to test CN 2?
test the visual acuity and visual fields
how do you test CN 3, 4 & 6?
six cardinal positions of gaze, PERRLA
what are the 6 cardinal positions of gaze?
up, side, down, down, side, up
what is PERRLA?
pupils equal, round, reactive, light and accomodation
how do you test CN 5?
test motor and sensory function and corneal reflex
how do you test for motor function in CN 5?
bite down hard on something
how do you test sensory function in CN 5?
touch face with cotton ball and then with toothpick
how do you test the corneal reflex?
gently touch cornea with cotton or a puff of air
how do you test motor function of CN 7?
smile, frown, raise eye brows, shower upper teeth, shower lower teeth, puff out cheeks, purse lips, close eyes against resistance
how do you test sensory function for CN 7?
test taste on tongue for sweet, sour, salty
what should you check for hearing for CN 8?
watch tick test, weber and rinne test (testing sound on the bone and then the air)
what is the romberg test?
test for balance
how do you test the CN 9 and 10?
"say ah," stimulate gag reflex, swallow and cough
how do you test CN 11?
motor function of neck and shoulder muscles against resistance; turn head; shrug shoulders
how do you test CN 12?
say "d, l, n, t," protrude tongue and move from side to side
if a person has superficial sensation, do you use temperature sensation?
To test for sensory function, what do you do?
superficial sensations, deep sensations, discriminatory sensations
recognition of familiar object by touch is:
graphesthesia is:
identifying a number or letter traced in the hand
what is the 2-point discrimination test?
smallest distance of discrimination of 2 points
what is point localization?
ability to sense and locate area being stimulated
what is sensory extinction?
simultaneous touch of both sides and identifications of where they were touched
what does a 0 mean on a tendon reflex?
no response detected
what does a 1 mean on a deep tendon reflex?
response present but diminished
what does a 2 mean on a deep tendon reflex?
normal response
what does a 3 mean on a deep tendon reflex?
response somewhat stronger than normal
what does a 4 on a deep tendon reflex mean?
response hyperactive with clonus
what is clonus?
the presence of rhythmic involuntary contractions
how do you test the biceps contraction with flexion of forearm?
rest elbow in non-dominant hand, with thumb over biceps tendon and strike your thumbnail
how do you test the triceps reflex?
abduct patient's arm and flex it at the elbow. strike the tendon 1-2 inches above olecranon process approaching is from directly behind
how do you test the brachioradialis reflex?
support patient's hand and palpate brachioradialis tendon 3-5 cm above wrist, simultaneously strike styloid process of radius
how do you test the achilles reflex?
hold the foot dorsiflexed and strike the achilles tendon - should have plantarflexion of foot
if you get +4 reflexes while supporting leg and foot, what do you do?
quickly dorsiflex foot
what are 3 superficial reflexes
plantar, abdominal, anal
what are protective reflexes?
cough, gag, swallow, blink, corneal
what are 6 primitive reflexes?
babinski, sucking, grasp, rooting, snout, glabellar
how do you test for rooting reflex?
stroke side of face and client turns face toward stroked side
how do you test snout reflex?
gently tap oral area and lips pucker
how do you test the glabellar reflex?
tap client's forehead and client blinks
what is the best position for examining the lungs, heart, pulses and abdomen?
sitting up
what are the 5 physical assessment skills?
inspection, palpation, percussion, auscultation, olfaction
what is the normal order of skills performed?
impaction, palpation, percussion, auscultation
what is the order of skills performed in an abdominal assessment?
inspection, auscultation, percussion, palpation
what aspects of the skin should you assess?
color, odor, temperature, texture, turgor, edema, lesions
what should you look at if you find a lesion?
size, shape, color, distribution, texture, exudate, pain, tenderness
what are the major components of an eye assessment?
inspection of external eye and lids, snellen exam, near vision assessment with newsprint, color vision check, visual field exam, internal eye exam with an ophthalmoscope
your client has a negative Weber test. now what?
nothing - a negative test is normal.
dyspareunia is:
painful intercourse
a false negative reading of a heme cult test could be related to:
taking vitamin C
a false positive reading of a heme cult test could be related to:
iron supplements or eating red meat
what would a chronically elevated BUN and creatinine level suggest?
chronic renal disease
what is the recommended daily intake of fiber?
25-30 grams per day
what medication increases urine output?
what quantity of urine in the bladder will stimulate the urge the void?
200-450 mL in adults, 50-200 mL in kids
an properly hydrated infant has how many wet diapers each day?
8-10 per day
what is the instrument used to measure the specific gravity of urine?
the gentle, manual pressure over the bladder to promote emptying is:
crede's maneuver
involuntary urination after the age of 5 or 6 is:
an abnormal passage between 2 body cavities is
a fistula
tapes used for dressings that require frequent changins are
montgomery straps
a type of surgical drain we use
softening of the skin is
true or false: a venous hum will go away with pressure
what is a parasystolic murmer?
no pause between s1 and s2 sounds
what does the ankle-brachial index do?
accesses circulatory impairment of the feet
how do you perform the ankle-brachial index?
compare blood pressure at the posterior tibialis vs. brachial artery, then divide the systolic pressure at the ankle by the systolic pressure at the brachial site
what is a normal score on the ankle-brachial test?
1 or greater - should be close to the same
anything less than a 1 on the ankle-brachial scale means what?
minimal to severe disease
what are the 4 lymph node sites?
cervical, axillary, epitrochlear, inguinal
the manual compression test is used for:
assessing valve competence
PMI stands for
point of maximum impulse
where would you find the PMI?
5th ICS mid-clavicular
your PMI should be visible where?
at the apex
an adults, a bruit suggest:
carotid stenosis
petechaie is:
red/purple dots on the skin
the aortic sounds are found:
2nd ICS lateral to sternum
the pulmonic sounds are found:
2nd ICS lateral to sternum
the tricuspid sounds are found:
4th ICS near sternum
the mitral/apical sounds are found: 5th ICS
5th ICS
a normal pulse amplitute is:
what is the Allen's test?
make a tight fist, compress both radial and ulnar arteries and release. pallor should resolve in 3-5 seconds
pallor in elevated legs and a red/purple color are signs of:
arterial insufficiency
varicosities are:
painful veins
destruction of cells or tissues by their own enzymes
what can antacids do to a bowel pattern?
slow down peristalsis
is meconium stool in a 1-day old infant normal?
what is the difference between hypotonic/isotonic enemas and hypertonic enemas?
hypo/iso are usually large volume and promote rapid evacuation; hypertonic is a small volume and attracts water to the colon and stimulates peristalsis - it's more irritating
what part of the respiratory system is most prone to aspiration?
the larynx - it's the narrowest part
which lung is more susceptible to aspiration?
the right bronchus is shorter and fatter than the left and leaves the trachea at a more verticle angle, so inhaled objects can enter more easily
dyspnea is:
heavy or labored breathing
which is a better reading: arterial blood gas or pulse oximetry?
signs of a wound infection include:
swelling/inflammation, erythema (redness), purulent drainage
bright red drainage is:
a watery, bloody drainage is
when assessing LOC, the nurse checks:
arousal, orientation
an abnormally shaped head:
TRUE/FALSE: bronchial breath sounds are soft and low-pitched with a long inspiratory phase and short expiratory phase
when assesessing the client's lungs over the 1st and 2nd intercostal spaces, it is noted that inspiratory and expiratory phases are equal:
a sound produced by turbulent flow in the heart is a
what position is NOT recommended for cardiac examination?
right lateral recumbent
an s4 heart sound may be associated with
when assessing the carotid arteries, you will assess for _____, but not ______
bruits, not thrills
a thrill is palpated over the 2nd ICS right sternal border. this finding indicates a possible:
the s2 sound is when the heart valves open or close?
excess facial and trunk hair
edema of 2 mm with a rapid return is:
+1 edema
what is +2 edema?
4mm depression that disappears in 10-15 seconds
edema of 6mm, a return within 1-2 minutes and skin the appears swollen is
+3 edema
what is +4 edema characteristics?
8mm, takes 2-3 minutes to return, looks grossly edematious
concave nails are associated with:
iron deficiency
capillary refill should occur in
3 seconds or less
Ishihara cards test:
color blindness
what is the normal angle of ear attachment?
< 10 degrees
normal ears are how long?
4-10 cm in length
otitis media:
inflammation of the middle ear
how do you perform the weber test?
use the tuning fork on top of the head, patient should hear sounds equally
what is the Rinne test?
tuning fork on the mastoid process, then air in front of ear: air sound transmission should be 2x longer than bone transmission
nasal flaring is a sign of
respiratory distress
clear nasal drainage suggests
yellow/green nasal drainage suggests
upper respiratory infection
how many teeth do adults half?
28-32, kids have 20
enlarged, palpable lymph nodes
yellow/green drainage suggests
upper respiratory infection
most adults have how many teeth?
28-32, kids have 20
is your thyroid usually palpable?
excessive thoracic curvature
normal A:P ratio is
a normal costal angle should be
< 90 degrees
scoliosis is:
curvature of the spine
tactile fremitus should be felt:
bilaterally on both anterior and posterior chest wall
rhonchi results from:
mucous secretions in the large airways
wheezing is caused by:
narrowing of the airways by spasm and inflammation
bronchophony is present if:
words are heard over the lungs
egophony is present if
instead of "eee" you hear "ay"
whispered pectoriloque is if you hear
the whispered "one, two, three" over the lungs
crackles/rales are when:
air is bubbling through moisture in the alveoili
stridor is caused by
upper airway obstruction or tracheal/laryngeal spasm
friction rub sounds are:
high pitched grating or squeaking from pleural layers rubbing together
grunting is caused by:
retention of air in the lungs, high pitched sounds heard on expiration
wounds are considered infection when bacteria counts in the would tissues are above _____ organisms per gram of tissue
a wound that heals from inner layer to the surface is healing by
secondary intention
a wound with approximated edges is healing by:
primary and tertiary intention
a wound that heals by approximating 2 surfaces of granulating tissue is
tertiary intention
a wound that is sutured and has minimal or no tissue loss is
primary intention
these are used to close superficial, low-tension wounds, like skin tears or lacerations or to give support to a wound after sutures or staples have been used
this is the most traditional would closure technique
a light-weight titanium to be used as a wound closure technique
surgical staples
a piece of open-cell foam in the wound attached to a tube for a negative pressure pump to remove wound drainage
VAC dressing
these are used with venous stasis ulcers on the lower extremities to apply continuous pressure to the veins, which facilitates venous return
compression stockings
dehiscence is:
when a wound pops open
what are signs of internal hemorrhage?
swelling, pain, changes in vitals, a hematoma
what is the preferred method for a wound culture?
needle aspiration
what is the effect of adding moisture to heat or cold treatments?
moisture amplifies the intensity of the treatment
hypoxemia is a problem with
oxygenation - oxygen getting to cells, tissues, organs
hypoxia is a problem with
perfusion, the circulation of blood to all body areas
which gas is more diffusible through capillary membranes?
carbon dioxide
which gas is the primary stimulant for breathing?
carbon dioxide
during diastole, what are the only arteries in the body that fill?
coronary arteries
hypoventilation/hypercarbia is
excess of carbon dioxide, not enough oxygen
hyperventilation/hypocarbia is
a low level of carbon dioxide in the blood
what will a very high CO2 level do?
cause an anesthetic effect on the nervous system
what will a very low CO2 level do?
stimulating effect on the nervous system and lead to muscle twitching or spasm, numbness and tingling
a pulse oximetry reading tells you what?
the percentage of hemoglobin carrying oxygen
systemic circulation is blood to the
pulmonary circulation is blood to the
which should be higher: HDL or LDL?
systolic pressure is when
the heart is contracting and pushing blood OUT - hard part
diastolic pressure is when
the heart is filling back up with blood - resting stage
which is longer, systole or diastole?
this happens when the ventricles are at rest
ventricular diastole
which side of the heart has to work harder?
left side - right only pumps to the lungs
when atria are at work, what is resting?
when does the atrial kick occur?
end of diastole
this makes 25% of the cardiac output
atrial kick
what is a normal stroke volume?
60-100 mL
what is the cardiac output?
the amount of blood ejected each minute
preload volume in the cardiac cycle is:
the volume of blood in ventricles at the end of diastole just before it fills up
afterload volume in the cardiac cycle is:
last pressure push
if you are losing blood, what will happen?
your heart rate will increase to try and keep the same amount of blood flowing
a murmur is always heard in:
a normal murmur in a pregnant client is called
mammary souffle murmur
what culture has the highest incidence of CAD?
white people
more than 3 cm when measuring a jugular venous pressure means what?
it's abnormal
you will hear an s3 when?
right after s2
you will hear an s4 when?
right before s1
where is erb's point?
3rd ICS left sternal border
abnormal heart sounds are always heard in
community based nursing is
people who are ill
public health nursing is for
the general population, run by the state, wellness focus
community-oriented nursing is
public health and community health nursing; a broader scope - nurse provides health care after a community diagnosis
community health nursing is
nursing practice in the community with the primary focus on the health care of individuals, familes - maintain, promote, preserve health
the primary goal of public health is
prevention of disease and disability
the way public health practice makes sure that essential community-wide health services are available:
HMO is
health maintenance organization - method for delivering healthcare whereby people pay a fixed fee for primary care, ER care, and hospital care provided by a certain group
this refers to personal health care that provides first contact and continuous, comprehensive and coordinated care
primary care - your own doctor
this type of care includes a comprehensive range of services including public health, prevention, diagnostic, therapeutic, and rehab services made universally assessible to individuals and families in a community
primary health care
the agency most involved in government health care functions is
USDHHS - united states department of health and human services
what are some of the important parts of healthy people 2010
increase quality and years of healthy life, eliminate health disparities

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