When assessing risk factors for eye and vision problems, the nurse knows that genetics can play a role. What major eye problem are patients most likely at increased risk for if a first-degree relative has it?
Glaucoma
Emergency medical technicians bring a 17-year old boy to the ED after a diving accident. The patient is alert and coherent. He tells the nurse, "i think i hit a rock and now i can't feel my arms or legs." A rapid physical assessment shows no other apparen
Immobilize the spine until it is cleared of injury.
A normal assessment of the neck would include palpation of the thyroid isthmus. Where would the nurse find the isthmus?
just below the cricoid cartilage
A light is pointed at the patient's pupil, which contracts. It is also noted that the other pupil contracts as well, though it is not exposed to bright light. What term is used to describe this latter phenomenon?
consensual reaction
You feel a small mass that you think is a lymph node. It is mobile in both the up-and-down and side-to-side directions. What is this mass?
a lymph node
A sudden, painless unilateral vision loss may be caused by ____.
retinal detachment
The open space between the eyelids is called ______.
the palpebral fissure
A clinic patient complains of recurring headaches that are worse when first waking up and with coughing or sneezing. What would be the nurse's most appropriate action?
perform a focused asessment
A patient is assigned a visual acuity of 20/100 in her left eye. What does that mean?
she can see at 20 feet what a normal person could see at 100 feet.
A 64-year old patient is admitted to the hospital with severe diarrhea. When assessing the patient the nurse notes a round "moon" face, a buffalo hump, and a velvety discoloration around the neck. What are these signs indicative of?
Cushing's syndrome
The nurse is admitting a new patient to the floor and asks if the patient has any dizziness. Why does the nurse do this?
to check for possible dehydration.
Modifiable risk factors for breast cancer include, what?
obesity
A nurse is providing patient teaching related to SBE to a 67 year old woman. When would be the best time during the month for this patient to perform a SBE?
a convenient day of each month.
A 37-year old woman is 2 days p.o. after a right breast mastectomy included in the discharge teaching is care of the surgical incision. What would be the most appropriate intervention for this patient?
provide a mirror to visualize the incision.
A patient asks what can be done to reduce the risk of developing breast cancer. What should the nurse instruct this patient?
maintain a healthy weight, limit alcohol use
When palpating a patient's liver, the nurse feels a firm edge. What would this indicate?
cirrhosis
When assessing the breast and lymphatics of the axillae, where would the nurse locate the central axillary nodes?
high in the axillae at the top of the ribs.
While ascultating a patient's abdomen, the student notes abnormal bowel sounds. The nurse preceptor asks the student to describe the sounds. The student describes a high-pitched, rushing sound. The preceptor, an experienced nurse would know that these sou
partial intestinal obstruction
The nurse is caring for a patient who is vomiting. When inspecting the vomit, the nurse notes that it appears to contain coffee grounds. This would indicate what to the nurse?
digested blood
A 26-year old comes in complaining of severe right-sided abd pain for the last 12 hours. He began having a stomach ache yesterday, with a decreased appetite, but today the pain is just on the lower right side. He has had some N/V but no constipation or di
acute appendicitis
An obese 55-year old woman went through menarche at age 16 and menopause 2 years ago. She is concerned because her aunt had osteoporosis. Which of the above is a risk factor for osteoporosis?
delayed menarche
Mrs. Fletcher complains of numbness of her right hand. On examination, sensation of the volar aspect of the web of the thumb and index finger and pulp of the middle finger are normal. The pulp of the index finger has decreased sensation. What nerve is aff
median nerve
You are assessing a patient with joint pain and are trying to decide whether it is inflammatory or noninflammatory in nature. Which of the following symptoms is consistent with an inflammatory process?
nodules, ecchymosis, cool temperature, tenderness
tenderness
You are assessing a patient with diffuse joint pains and want to make sure that only the joints are the problem. What disease is a systemic cause of joint pain?
Lupus
An 85-year old woman comes in with her daughter to establish care. Her daughter is concerned because her mother has started to fall more. As part of her physical exam, you ask her to walk across the room. Which of the following is not part of the stance p
foot arched
A 19-year old comes into the clinic for evaluation of joint pains. She has been back from spring break for 2 weeks and went camping during that time. She notes that she had a red spot, shaped like a target but then it started spreading, and then the joint
Lyme disease
A 50-year old comes into the office for evaluation of neck pain. She was in a motor vehicle collision 2 days ago but didn't think she needed to go to the ER. Now, she has severe neck pain and stiffness. On examination you note pain and spasm over the para
cervical sprain (whiplash)
Mark is a contractor who recently injured his back. He was told he had a "bulging disc" to account for the burning pain down his right leg and slight foot drop. The vertebral bodies of the spine involve which type of joint?
cartilaginous
Which of the following synovial joints would be an example of a condylar joint?
temporomandibular joint
Pain, swelling, loss of both active and passive motion, locking, and deformity would be consistent with what?
articular joint pain.
T/F: the thyroid gland is usually larger in women than in men.
True
When the nurse feels an enlarged thyroid gland, she may also hear a _____ when a stethoscope is placed over the lateral lobes.
bruit
The nurse is examining the head and neck and knows the patient can feel his ______ gland when bowing and pressing his tongue against the lower incisors.
submandibular
When doing an exam of the thyroid suggest the sequence of the exam for a posterior approach.
flex the neck forward, place the fingers of both hands on either side of the thyroid, have the patient sip and swallow water, displace the trachea right and then left evaluating the margins of the lobe.
True/False: Primary headaches are more worrisome than secondary headaches.
False
The nurse is performing a physical exam and notes an enlarged left supraclavicular lymph node, the nurse understands that this could indicate ______.
metastasis
The nurse would expect to assess which symptoms in a patient complaining of migraine headaches.
photophobia, throbbing, recurrent
The nurse should ask about or assess which associated factors when a patient complains of cluster headaches?
miosis, lacrimation, ptosis, rhinorrhea
A patient with hypothyroidism is admitted to the medical unit. The nurse would expect to assess which signs/symptoms?
cool skin, constipation, lower systolic blood pressure, and lethargy
The nurse does a health history. The patient states she has lost 30lbs in the last couple of months, without trying. The patient also states that he feels warm all the time and sometimes feels like he has heart palpitations. The nurse would anticipate ord
hyperthyroidism
The nurse understands that conjunctivitis differs from conjunctival hemorrhage in that conjunctivitis ________
has a watery, mucoid discharge
A patient complains of feeling like he is slowly losing his central vision. The nurse knows this symptom could represent ____.
macular degeneration
When looking through an opthalmoscope, the nurse knows that the posterior part of the eye is called the _____.
fundus
The patient asks the nurse about the "blind spot" that someone said everyone has in his or her eye. The nurse bases the answer on the fact that the blind spot is created because there are not retinal receptors at the ______ ______.
optic disc
The nurse observes an inward turning of the lower lid in a 77-year old patient. The nurse documents _____.
entropion
When looking into the eye, the nurse would expect to see what color if the disc is dead?
white
The nurse using the opthalmoscope to examine the patient's eyes, she holds the scope ____
in the right hand for the right eye and in the left hand for the left eye.
True/False: the nurse tests the six cardinal directions to test extra ocular movement of the eye.
true
The nurse is performing a light reaction test and shines the light in the retina of the right eye. The right eye constrictions is called _____ reaction and the reaction that occurs in the opposite eye is called ____ reaction.
direct, consensual
True/False: A parent is very upset because she is told that her child has a refractive error. The nurse reassures the parent that refractive errors are the most common visual change in children.
True
During an assessment, the patient describes vomiting moderate amounts that "smell like poop". The nurse might suspect ____
small bowel obstruction.
Visceral pain is associated with a hollow abdominal organ such as the intestine. Visceral pain is ________.
usually difficult to localize.
When palpating the abdomen, the nurse may be able to feel the lower edge of the liver in which quadrant?
right upper
A female patient presents with right lower quadrant pain that radiates from the periumbilical area. The abdomen is rigid on palpation. The nurse would prepare for physician follow-up for possible ____.
pelvic inflammatory disease.
The nurse notes guarding while palpating the abdomen of a newly admitted patient despite asking the patient to relax. The nurse should ______
assess relaxation of abdominal muscle after the patient exhales, have the patient mouth breathe with the jaw dropped open, distract the patient with conversation.
A patient has COPD, on examination the nurse would expect the liver dullness to be ______
displaced downward
True/False: When the spleen enlarges, the nurse would not be surprised to percuss dullness over the stomach.
true
___________ is a test of referred rebound tenderness in appendicitis.
Rovsing sign
When teaching a class about hepatitis C, the nurse should include the fact that hepatitis is transmitted through blood in all but hepatitis ___
A
The nurse is teaching a patient about prevention of uriniary incontinence. Included in the teaching would be pelvic muscle training and exercises and ______
biofeedback
How often should women 20-40 years old have a clinical breast exam?
every 3 years
What are some risk factors for developing breast cancer?
early menarche (<12), late menopause (>55), late pregnancies (>30), obesity, alcohol, long-term use of hormone therapy, high bone density, first-degree relatives with breast cancer, and age
The nurse suspects carpal tunnel syndrome after examining a patient at the clinic. A test result that would suggest this diagnosis would be ____
weak opposition of the thumb, positive Tinel's sign, or positive phalen's sign
The nurse is evaluating the bone density of a patient diagnosed with osteopenia. What bone density result would the nurse expect?
1.0-2.5 standard deviation below the mean
What would the bone density result be for a patient with osteoporosis?
2.5 or above standard deviation below the mean.
What are the muscles that make up the rotator cuff?
remember "SITS" supraspinatus, infraspinatus, teres minor, and subscapularis.
_______ are rope-like bundles that connect bone to bone.
ligaments
The skull is an example of a ____ joint.
fibrous
On inspection of the spine of a 79 year old man the nurse might expect to find an ____
increased thoracic curve
In _________ incontinence there is weakness of the pelvic floor with inadequate muscular support of the bladder and proximal urethra. This is commonly caused by surgery or childbirth and prostatic surgery in men. It is characterized by momentary leakage o
stress incontinence
What organs are in the RUQ?
ascending colon, duodenum, gallbladder, kidney, liver, pancreas (head), transverse colon, ureter.
What organs are in the LUQ?
descending colon, kidney, pancreas (body), spleen, stomach, transverse colon, ureter
what organs are in the RLQ?
appendix, ascending colon, bladder, cecum rectum, ovary, uterus, fallopian tube, prostate, small intestine, and ureter
What organs are in the LLQ?
bladder, descending colon, ovary, uterus, fallopian tube, prostate, small intestine, and ureter, sigmoid colon
Visceral pain in the RUQ may be ______
alcoholic hepatitis
Pain of duodenal or pancreatic origin may be referred to ______.
the back
________ pain can go to the right shoulder or posterior chest.
biliary tree
Pain from ______ or _____ may be referred to the epigastric area.
pleurisy, acute myocardial infarction
What conditions cause epigastric pain?
gastritis or gastroesphageal reflux disease or GERD
Doubling over with cramping colicky pain indicates, what?
renal stone
Sudden knife-like pain occurs in _______
gallstone pancreatitis
______ may occur with inflammatory bowel disease.
bloating
Upper abdominal discomfort from multifactorial causes include ______, _____, ______.
gastritis from H. pylori, peptic ulcer disease, and psychological factors.
What are the symptoms and signs of GERD?
chronic abd discomfort, heartburn, acid reflux, mucosal damage on endoscopy
What are some risk factors for GERD?
reduced salivary flow, delayed gastric emptying, certain medications, and hiatal hernias.
How can you tell the difference between angina and heartburn?
angina gets worse with exertion and better with rest.
What are "alarm symptoms" for gastric cancer?
difficulty swallowing (dysphasia), pain with swallowing, recurrent vomiting, evidence of gastrointestinal bleeding, weight loss, anemia, or other risk factors for gastric cancer.
RLQ pain or pain that migrates from the periumbilical region, combined with abdominal wall rigidity on palpation is most likely caused by one of which 4 conditions.
appendicitis, pelvic inflammatory disease, ruptured ovarian follicle, or ectopic pregnancy
LLQ pain with a palpable mass may be _____
diverticulitis
Diffuse abd pain with absent bowel sounds and firmness, guarding or rebound on palpation indicates ______
small or large bowel obstruction
Sudden vomiting without nausea may be indicative of ______
increased intracranial pressure
________ occurs in GERD, esophageal stricture, and esophageal cancer
regurgitation
vomiting that smells like feces, and pain indicates ______
small bowel obstruction
When a patient with dysphasia points to below the sternoclavicular notch indicates ________ dysphagia.
esophageal
What are some possible causes of excessive gas, flatus?
aerophagia, legumes or other gas-producing foods, intestinal lactose deficiency, or IBS
_____ diarrhea is usually caused by infection, ______ diarrhea is typically non-infectious in origin, as in Crohn disease and ulcerative collitis.
acute, chronic
A patient with oily residue, frothy or floating stools, or fatty diarrheal stools probably suffers from _____
pancreatic insufficiency, cystic fibrosis, or small bowel bacterial overgrowth.
Thin, pencil-like stool occurs in an obstructing "apple core" lesion of the _______
sigmoid colon
Pain, with urgency suggests ____
bladder infection or irritation.
In men, painful urination without frequency or urgency suggests ______
urethritis
What are the symptoms of acute pyelonephritis?
kidney pain, fever, and chills
A patient with cushing syndrome may have ______ colored stria.
pink-purple
Which headaches can be more worrisome, primary or secondary?
secondary.
If a patient with a headache and complains that coughing, sneezing, or changing position makes it worse what could the headache be caused from?
brain tumor or acute sinusitis.
Tender nodes suggest _________; hard fixed nodes suggest ______.
inflammation, malignancy
How could you distinguish between a lymph node and muscle or artery?
you should be able to roll a node in two directions: up and down and side to side
They thyroid gland will feel ______ in Graves disease and _____ in Hashimoto thyroiditis or malignancy.
soft, firm
What type of headaches are characterized by unilateral throbbing or aching; that come on quickly and peaks within 1-2 hours, last anywhere from 4-72 hours, have N/V, photophobia, visual auras, and phonophobia?
migraines
Which type of headaches are characterized by a mild-mod. pressing or tightening pain usually at the back of the head and upper neck or to the frontotemporal area bilaterally, have a gradual onset and can last for minutes to days, they sometimes include ph
tension headaches
Headaches that are unilateral, usually behind or around the eye with a severe deep, continuous pain that comes on abruptly and lasts for up to 3 hrs with associated factors such as lacrimation, rhinorrhea, miosis, ptosis, & eyelid edema is most likely a _
cluster
A patient comes in and during assessment the nurse notices that she has a round "moon" face with red cheeks. She also has excessive hair growth on her face what condition could she have?
Cushing syndrome
Patients with ________ often have an edematous pale face. The swelling usually appears first around the eyes and in the morning.
nephrotic syndrome
How might a patient with myxedema or severe hypothyroidism appear?
dull, puffy face, pronounced edema around the eyes, hair and eyebrows are dry, course and thinned; the skin is also dry.
A patient with ______ would have a blunted expression due to decreased facial mobility. decreased blinking and characteristic stare, neck and upper trunk are flexed forward. The facial skin becomes oily, and drooling may occur.
Parkinson disease
____________ includes the isthmus and lateral lobes; there are no discretely palpable nodules. Causes include Graves disease, Hashimoto thyroiditis, and endemic goiter.
diffuse enlargement
A single nodule on the thyroid may be
a cyst, benign tumor, or malignant tumor.
A ____________ is an enlarged thyroid gland with two or more nodules and suggests a metabolic rather than neoplastic process.
multinodular goiter
What is scotoma?
an area of lost or depressed vision within the visual field and is surrounded by an area of normal vision.
Vision difficulty with close work suggests ____
hyperopia which is called farsightedness or presbyopia which is aging vision
Vision difficulty with distances is called _____
myopia or nearsightedness
Unilateral visual loss that is painless could be due to
vitreous hemorrhage, macular degeneration, retinal detachment, retinal vein occlusion, or central retinal artery occlusion.
If a patient has unilateral vision loss that is painful it could be from _____
the cornea or anterior chamber such as corneal ulcer, uveitis, traumatic hyphema, and acute glaucoma.
Bilateral and painless vision changes is probably caused from _____
a medication
What could be some possible causes of black tarry stools?
peptic ulcer, gastritis, stress ulcer, esophageal varices, reflux esophagitis, a tear in the esophagus.
What would cause a patient to have black, nonsticky stools?
ingestion of iron, Pepto-bismol, licorice, or even chocolate cookies.
If a patient has red blood in their stools what could be the problem?
cancer of colon, polyps, diverticula, ulcerative colitis, crohns disease, proctitis, ischemic colitis, hemorrhoids, anal fissure
If a patient eats beets what would their stool look like?
reddish but nonbloody, usually preceded with pink urine.
________ produces bulging flanks that are dull to percussion. Turn the patient onto their side to detect the shift in position of the fluid level.
ascitic fluid
Bowel sounds may be _______ in diarrhea and early intestinal obstruction.
increased
Decreased or absent bowel sounds could indicate what?
adynamic ileus or peritonitis
How long should you listen for bowel sounds before determining they are absent?
5 min
Where would the pain be in a patient with acute cholecystitis?
right upper quadrant
Where would the patient experience pain in appendicitis?
right lower quadrant - may radiate from umbilicus
A patient with acute diverticulitis which is most often in the sigmoid colon and is felt in the ______
left lower quadrant
What are some risk factors for breast cancer?
previous breast cancer, an affected mother or sister, increasing age, early menarche, late menopause, late or no pregnancies, previous radiation to chest wall.
While examining a patient's breast tissue what should you be noting?
consistency of the tissue, tenderness, nodules
A patient comes in for a breast exam and while palpating the nurse feels a hard, irregular, poorly circumscribed nodule that is fixed to the skin or underlying tissues, what could this indicate?
breast cancer
What would cause enlarged axillary nodes?
an infection of the hand or arm, recent immunizations or skin tests in the arm, or part of generalized lymphadenopathy.
While examining a post mastectomy patient the nurse notes masses, modularity, and change in color or inflammation, especially in the incision line suggests, what?
recurrence of breast cancer.
How often should women age 50-74 get mammograms?
every two years
How often should women 20-40 years of age get a clinical breast exam?
every 3 years
______ are collagen fibers connecting muscle to bone.
tendons
_____ overlies bony surfaces
cartilage
What are bursae?
pouches of synovial fluid that cushion the movement of tendons and muscles over bone or other joint structures.
What are the three types of joint articulation?
synovial, cartilaginous, and fibrous
A joint that is freely movable like the knee or shoulder is a ____________
synovial joint
A slightly movable joint like the vertebral bodies of the spine are called ______
cartilaginous
Describe a Fibrous joint and give an example of one.
immovable, skull sutures
Describe the movement and give an example of a spheroidal synovial joint.
wide-ranging flexion, extension, abduction, adduction, rotation, and circumduction; shoulder and hip
A hinge synovial joint has which type of movement and what are some examples.
flexion and extension; finger, hands, feet, and elbow.
What type of joints are the knee and temporomandibular joints and how can they move?
condylar synovial joints; movement of two articulating surfaces
What are some possible causes of extra-articular joint pain?
sprains from stretching or tearing ligaments, muscle or tendon strain, bursitis, or tendonitis
Acute pain of only one joint suggests, what?
trauma, septic arthritis, gout
______________ arthritis typically involves several joints, systemically distributed. The patient would also likely have muscle weakness and atrophy.
Rheumatoid
What is pseudohypertrophy?
an increase in muscle bulk with diminished strength
Marked floppiness indicated muscle _______ or ______, usually from a disorder of the peripheral motor system.
hypotonia, flaccidity
Describe the scale for grading muscle strength.
0: no muscular contraction, 1: barely detectable flicker or trace of contraction, 2: active movement of body part with gravity eliminated, 3: active movement against gravity, 4: active movement against gravity with some resistance, 5: normal muscle streng
Telling the patient to "raise your arms in front of you and overhead" would demonstrate which type of movement?
flexion of shoulder
Raise your arms behind you" is which type of movement?
extension of shoulder
place one hand behind your back and touch your shoulder blade" is which type of movement?
internal rotation of shoulder
place one hand behind your head as if your brushing your hair" demonstrates which movement?
external rotation of shoulder
Tenderness distal to the epicondyle in ________ and medially in _______
lateral epicondylitis (tennis elbow), medial epicondylitis (golfers elbow)
bend your elbow
flexion
straighten your elbow
extension
turn your palms up as if carrying soup
supination
turn your palms down
pronation
A patient with osteoarthritis could have ________ nodes at the DIP joint and _____ nodes at the PIP joint.
Heberden, Bouchard
Symmetrical deformity in the PIP, MCP, and wrist joints with ulnar deviation indicates ___
Rheumatoid arthritis
Tenderness over the ______ in scaphoid fractures.
snuffbox
What are some possible causes of a weak grip?
cervical radiculopathy, de Quervain tenosynovitis, CTS, arthritis, epicondylitis
The thumb abduction, tinel's sign, and phalen's sign all test for ____
median nerve CTS
What are the phases of gait?
Stance phase: when the foot is on the ground and bears weight. includes heelstrike, foot flat, midstance, and push off.
Swing phase: wthen the foot moves forward and does not bear weight
What is kyphosis? When is it commonly seen?
increased thoracic curvature, with elderly
What is lordosis? When is it commonly seen?
increased lumbar curvature, in pregnant women
What does sciatic nerve tenderness suggest?
herniated disc, mass lesion impinging on the contributing nerve roots.
What could tenderness in the costovertebral angles signify other than a musculoskeletal problem?
a kidney infection
List the movements of the neck & back.
flexion, extension, rotation, and lateral bending
What does a wide base gait suggest?
cerebellar disease or foot problems
What conditions would produce a waddling gait?
hip dislocation, arthritis, abductor weakness
What are the movements of the hip?
flexion: bend knee to chest, extension: lie face down and bend knee and lift up, abduction: lying flat move your lower leg away from your midline, adduction: lying flat bend knee and move lower leg toward midline, external rotation: lying flat bend knee a
In ______________ of the hip, as the opposite hip is flexed the affected hip does not allow full leg extension and the affected thigh appears flexed.
flexion deformity of the hip
What is the medical term for bowlegs?
genu varum
What is the medical term for knock-knees?
genu valgum
What are some indications of achilles tendon rupture?
absence of plantar flexion, sudden severe pain "like a gunshot wound", ecchymosis from the calf into the heal, and a flat-footed gait.
What movements can the knee do?
flexion, extension, internal and external rotation
What are the movements of the ankle and foot?
ankle flexion aka plantar flexion, ankle extension aka dorsiflexion, inversion, and eversion
What are some risk factors for osteoporosis?
postmenopausal, older than 50, low weight, hx of fractures, alcohol, delayed menarche, early menopause, smokers, low levels of Vit. D, sedentary lifestyle
Differentiate between osteoporosis and osteopenia.
osteopenia: bone density 1.0-2.5 below the mean
osteoporosis: bone density 2.5 or more below the mean
A musculoligamental sprain or strain from forced hyperflexion-hyerextension injury to the neck characterized by localized paracervical tenderness, decreased neck ROM, weakness of upper extremities is known as ______
whiplash a type of mechanical neck pain
What is the difference between RA and OA?
RA: chronic inflammation of synovial membranes, symmetrical spread pattern
OA: degeneration and progressive loss of cartilage, additive spread pattern
Painful, tender, hot, dusky red swelling that extends beyond the margin of the joint of the great toe suggests _____
acute gouty arthritis
In ______ the great toe is abnormally abducted in relationship to the first metatarsal. A bursa may form at the pressure point and it may become inflammed.
Hallux Valgus
What is a Morton Neuroma?
tenderness over the plantar surface of 3rd and 4th metatarsal heads due to a neuroma
________ most commonly involves the second toe, and is characterized by hyperextension at the metatarsophalangeal joint with flexion at the proximal interphalangeal joint.
Hammer toe
What is a corn?
a painful conical thickening of skin that results from recurrent pressure on normally thin skin.