Download NUR-634 Advanced Physical Assessment Midterm Study Guide with correct answers and more Exams Nursing in PDF only on Docsity!
NUR-634 Advanced Physical Assessment
Midterm Study Guide with correct answers
Subjective Data - CORRECT ANSWERS โโ -symptoms from the client's point of view and include: feelings, perceptions, and concerns -what the patient tells you Objective Data - CORRECT ANSWERS โโ -what the health professional observes by inspecting, palpating, percussing, and auscultating during the physical examination -observed signs Assessment - CORRECT ANSWERS โโ -the clinical reasoning process that interprets the patient's history and physical examination, singles out identified problems, and movement from each problems to its action plan Plan - CORRECT ANSWERS โโ -incorporates patient education, changes in medications, needed tests, referrals to other clinicians, and return visits for counseling and support -requires good interpersonal skills and sensitivity to the patients goals, economic means, competing responsibilities, and family struggles/dynamics Percussion - CORRECT ANSWERS โโ -a diagnostic procedure designed to determine the density of a body part by the sound produced by tapping the surface with the fingers
-use of the striking or plexor finger (usually the 3rd) to deliver a rapid tap or blow against the distal pleximeter finger (usually the distal 3rd finger of the left hand laid against the surface) to evoke a sound wave -the 5 sounds are resonant, flat, dull, hyper resonant, and tympanic -Resonant sounds are low pitched, hollow sounds heard over normal lung tissue. -Flat are normally heard over solid areas such as bones. thigh -Dull or thudlike sounds are normally heard over dense areas such as the heart or liver. Dullness replaces resonance when fluid or solid tissue replaces air-containing lung tissues, such as occurs with pneumonia, pleural effusions, or tumors. -Hyperresonant sounds that are louder and lower pitched than resonant sounds are normally heard when percussing the chests of children and very thin adults. Hyperresonant sounds may also be heard when percussing lungs hyperinflated with air, such as may occur in patients with COPD, or patients having an acute asthmatic attack. An area of hyperresonance on one side of the chest may indicate a pneumothorax. -Tympanic sounds are hollow, high, drumlike sounds. Tympany is normally heard over the stomach, but is not a normal chest sound. Tympanic sounds heard over the chest indicate excessive air in the chest, such as may occur with pneumothorax. Attributes of a Symptom - CORRECT ANSWERS โโ -seven attributes -OPQRST & Associated manifestations (anything else accompanying it) -onset, provocative/palliative, quality, region/radiation, severity, timing Talkative Challenging Patient Intervention - CORRECT ANSWERS โโ - give 5-10 minutes uninterrupted
-consider delirium or intoxication -conduct a mental status examination focusing on LOC. orientation, memory, and capacity to understand -ask for permission to speak with family members to obtain their perspectives Hearing Impaired Challenging Patient Intervention - CORRECT ANSWERS โโ -determine patients preferred method of communication -do they belong to the deaf/hearing culture -when did the hearing loss occur relative to the development of speech and language -kinds of schools patient attended -use an interpreter -hand written questions (timely) -do they use hearing devices -unilateral hearing loss sit on good side -remove background noise -face lip readers -speak normal volume and rate -ask for teach back and give written instructions to take home ABCDE-EFG - CORRECT ANSWERS โโ -method used to screen moles for melanomas -if >2 present risk of melanoma increases and biopsy should be considered
-Assymetry, Border irregularity, Color Variations, Diameter >6mm, Evolving -EFG added to help detect aggressive nodular melanomas (Elevated, Firm to palpation, growing progressively) New Patient Documentation - CORRECT ANSWERS โโ -should consist of a comprehensive health history consisting of identifying data and source of hx, chief complaint, HPI, PMH, Family history, personal/social hx, ROS Established Patient Documentation - CORRECT ANSWERS โโ -should consist of a focused assessment consisting of chief complaint, assessment of symptoms restricted to a specific body system, examination relevant to thorough assessment of problem area Stages of Skin (Pressure) Ulcers - CORRECT ANSWERS โโ -Stage 1: presence of a reddened area that fails to blanch with pressure and changes in temperature, consistency, sensation, or color -Stage 2: Skin forms a blister/sore, partial thickness skin loss or ulceration involving the epidermis, dermis, or both -Stage 3: a crater appears in the skin with full thickness skin loss and damage to or necrosis of subcutaneous tissue that may extend to but not through underlying muscle -Stage 4: the pressure ulcer deepens, there is full thickness skin loss with destruction, tissue necrosis, or damage to underlying muscle, bone, and sometimes tendons/joints
-verrucous texture, may bleed or crumble if picked, may be erythematous if inflamed, may have milia like cysts or comedones like openings Basal Cell Carcinoma - CORRECT ANSWERS โโ -Most common and least severe type of skin cancer; often characterized by light or pearly nodules. -superficial has a pink patch that does not heal and may have focal scaling -nodular has a pink papule, pearly appearance overlying telangiectasis, focal pigmentation, central depression -ulcerated is non healing resulting in a rolled border Squamous Cell Carcinoma - CORRECT ANSWERS โโ -Type of skin cancer more serious than basal cell carcinoma; often characterized by scaly red papules or nodules. -Keratoacanthomas are SCCs that arise rapidly and have a crateriform center -have a smooth but firm border -can become quite large if left untreated -can metastasize to scalp, lips, and ears Optic Neuritis - CORRECT ANSWERS โโ -an inflammation that damages the optic nerve, a bundle of nerve fibers that transmits visual information from your eye to your brain. -Pain and temporary vision loss in one eye are common symptoms of optic neuritis
Subconjunctival Hemorrhage - CORRECT ANSWERS โโ -Leakage of blood outside vessels producing a homogeneous, sharply demarcated, red area that fades over days to yellow and then disappears* (red slide) Otitis Externa - CORRECT ANSWERS โโ -inflammation of the external ear canal; commonly called swimmer's ear Otitis Media - CORRECT ANSWERS โโ -Infection of the middle ear with or without purulent effusion often caused by bacterial infection -symptoms include earache, fever, and hearing loss, reddened eardrum, loss of landmarks, lateral bulging Presbyopia - CORRECT ANSWERS โโ -farsightedness caused by loss of elasticity of the lens of the eye, occurring typically in middle and old age. Glaucoma - CORRECT ANSWERS โโ -a group of eye diseases characterized by increased intraocular pressure -Primary Open angle glaucoma (POAG) is a gradual loss in vision in the peripheral visual fields resulting from loss of retinal ganglion cell axons -IOP > 21mmHg -Narrow angle caused by a rapid or sudden increase in pressure inside the eye Conjunctivitis - CORRECT ANSWERS โโ -diffuse dilatation of conjunctival vessels with redness that tends to be maximal peripherally -can be bacterial, viral, highly contagious
Asthma - CORRECT ANSWERS โโ -A chronic allergic disorder characterized by episodes of severe breathing difficulty, coughing, and wheezing. -s/s: cough at times with thick mucoid sputum esp. near end of attack, episodic wheezing and dyspnea, cough may occur alone, often with a hx of allergies, resonant to diffusely hyper resonant percussion, decreased tactile fremitus, crackles/wheezes chronic obstructive pulmonary disease (COPD) - CORRECT ANSWERS โโ -A slow process of dilation and disruption of the airways and alveoli caused by chronic bronchial obstruction. -s/s: slow progressive dyspnea, relatively mild cough later with scant mucoid sputum, diffuse hyperresonant percussion, decreased tactile femitus, decreased or absent breath sounds Pneumonia - CORRECT ANSWERS โโ -An inflammation of lung tissue, wherer the alveoli in the affected areas fill w/fluid, fro lung parenchyma of the respiratory bronchioles to the alveoli -s/s: pleuritic pain, cough (mucoid/purulent), sputum, fever, malaise, headache, poss dyspnea, chills, chest pain, dullness on percussion, bronchial breath sounds, late inspiratory crackles over involved area, tactile fremitus increased with ego phony, bronchophony, and whispered pectoriloquy Pleural Pain - CORRECT ANSWERS โโ -inflammation of the parietal pleura, as in pleurisy, pneumonia,pulmonary infarction, or neoplasm -s/s: sharp/knifelike persistent pain on deep inspiration/coughing/movement of the trunk
Stages of Hypertension (JNC 8) - CORRECT ANSWERS โโ -Normal BP: <120 systolic/<80 diastolic -Pre HTN: systolic 120-139/80-89 diastolic -Stage 1 HTN: systolic 140-159/ 90-99 diastolic -Stage 2 HTN: systolic >160/ >100 diastolic -using the mean of two or more properly measured pressure readings taken on two or more office visits verified on the contralateral arm. Stages of Hypertension (American Academy of Cardiologists) - CORRECT ANSWERS โโ Normal: Less than 120/80 mm Hg; Elevated: Systolic between 120-129 and diastolic less than 80; Stage 1: Systolic between 130-139 or diastolic between 80-89; Stage 2: Systolic at least 140 or diastolic at least 90 mm Hg; Hypertensive crisis: Systolic over 180 and/or diastolic over 120, with patients needing prompt changes in medication if there are no other indications of problems, or immediate hospitalization if there are signs of organ damage. Dissecting Aortic Aneurysm - CORRECT ANSWERS โโ -A splitting within the layers of the aortic wall, allowing passage of blood to dissect a channel -severe tearing knifelike pain, radiatinq from chest through to back, unequal pulses/BP (putsating abdominal mass) -s/s: anterior chest pain, often tearing or ripping and radiating into the back/neck/abdomen, abrupt onset with early peak and persistent -if thoracic can have hoarseness, dysphagia, syncope, semi/paraplegia
-a condition marked by a tear in the mucous membrane, or inner lining, where the esophagus meets the stomach. Most tears heal within 7 to 10 days without treatment, but Mallory-Weiss tears can cause significant bleeding -s/s: abdominal pain, vomiting up blood (coffee grounds) which is called hematemesis, involuntary retching, bloody or black stools Esophageal Varices - CORRECT ANSWERS โโ -swollen, twisted veins in the esophagus that are especially susceptible to ulceration and hemorrhage -This condition occurs most often in people with serious liver diseases -Esophageal varices develop when normal blood flow to the liver is blocked by a clot or scar tissue in the liver. To go around the blockages, blood flows into smaller blood vessels that aren't designed to carry large volumes of blood. The vessels can leak blood or even rupture, causing life-threatening bleeding -s/s: Vomiting large amounts of blood, black/tarry/bloody stools, lightheadedness, loss of consciousness in severe cases, yellow coloration of your skin and eyes (jaundice), easy bleeding or bruising, fluid buildup in your abdomen (ascites) Gastric Ulcer - CORRECT ANSWERS โโ -painful sores in the stomach lining. Stomach ulcers are a type of peptic ulcer disease. Peptic ulcers are any ulcers that affect both the stomach and small intestines. -stomach ulcers occur when the thick layer of mucus that protects your stomach from digestive juices is reduced. This allows the digestive acids to eat away at the tissues that line the stomach, causing an ulcer. -s/s: burning sensation or pain in the middle of your abdomen between your chest and belly button, dull pain in the stomach, weight loss, not wanting to eat because of pain, nausea or vomiting, bloating, feeling easily
full, burping or acid reflux, heartburn that may improve when you eat/drink/antacids, anemia (whose symptoms can include tiredness, shortness of breath, or paler skin), dark/tarry stools, vomit that's bloody or looks like coffee grounds Irritable Bowel Syndrome - CORRECT ANSWERS โโ -Irritable bowel syndrome (IBS) is a group of symptoms that occur together, including repeated pain in your abdomen and changes in your bowel movements, which may be diarrhea, constipation, or both. With IBS, you have these symptoms without any visible signs of damage or disease in your digestive tract. -s/s: Abdominal pain/cramping/bloating that is typically relieved or partially relieved by passing a bowel movement, excess gas, diarrhea or constipation โ sometimes alternating bouts of diarrhea and constipation, mucus in the stool Inflammatory Bowel Disease - CORRECT ANSWERS โโ -a term for two conditions (Crohn's disease and ulcerative colitis) that are characterized by chronic inflammation of the gastrointestinal (GI) tract.1 Prolonged inflammation results in damage to the GI tract -s/s Crohn's Dx: small/soft/watery stool, melena, cramps periumbilical, RLQ (enteritis) or diffuse (colitis) pain, anorexia, fever, weight loss, perianal/rectal abscesses/fistulas, may cause small or large bowel obstruction, dehydration -s/s ulcerative colitis: frequent watery/ bloody stools, cramping, tenesmus, fever, fatigue, weakness, abdominal pain if complicated by toxic megacolon, spiscleritis, uveitis, arthritis, erythema nodosum, abdominal distention, flatulence
CN II - CORRECT ANSWERS โโ -Optic nerve: sensory, located in and behind the eyes, controls central and peripheral vision CN III - CORRECT ANSWERS โโ -Oculomotor nerve: motor, in and behind the eyes controls pupillary constriction CN IV - CORRECT ANSWERS โโ -Tochlear nerve: motor, moves eyes down and toward tip of the nose CN V - CORRECT ANSWERS โโ -Trigeminal nerve: motor/sensory, covers most of the face involving forehead, cheek, jaw, check for sensation with soft and dull object, assess jaw opening and closing strength CN VI - CORRECT ANSWERS โโ -Abducens nerve: motor, controls eye movement to the sides, six cardinal fields of gaze CN VII - CORRECT ANSWERS โโ -Facial nerve: sensory/motor, controls facial movements and expression CN VIII - CORRECT ANSWERS โโ -Auditory nerve (vestibulocochlear): sensory, located in the ears controls hearing CN IX - CORRECT ANSWERS โโ -Glossopharyngeal nerve: sensory/motor, innervate tongue and throat (pharynx/larynx) check together with CN X
CN X - CORRECT ANSWERS โโ -Vagus nerve: sensory/motor, innervate tongue and throat (pharynx/larynx) check together with CN X CN XI - CORRECT ANSWERS โโ -Spinal Accessory nerve: motor, control neck and shoulder movement CN XII - CORRECT ANSWERS โโ -Hypoglossal nerve: motor, innervates the tongue, stick out tongue, dysphagia
