A Papanicolaou specimen is used to:

1a

A Papanicolaou specimen is used to test for cervical and vaginal cancer

1b

A(n) ________ is the blowing sound caused by turbulence in a narrowed section of a blood vessel.
2a

A bruit is the blowing sound caused by turbulence in a narrowed section of a blood vessel
2b

An occlusion is _______.

3a

An occlusion is a blockage of a vessel (Artery or vein)

3b

Assessment of the skin reveals the patient's health status related to: (5)

4a

a. Oxygenation b. Circulation c. Nutrition d. Local tissue damage e. Hydration

4b

Atherosclerosis is indicated by ________.

5a

Atherosclerosis in indicated by diminished or unequal carotid pulsations

5b

Benign (fibrocystic) breast disease is characterized by:

6a

Benign (fibrocystic) breast disease is characterized by bilateral lumpy, painful breast, sometimes with nipple discharge
6b

Briefly describe the following abnormalities of the nail bed. Beau lines
7a

Beau lines are transverse depressions in the nails

7b

Briefly describe the following abnormalities of the nail bed. Clubbing

8a

Clubbing is a change in the angle between the nail and nail base, including softening, flattening, and enlargement of the fingertips
8b

Briefly describe the following abnormalities of the nail bed. Koilonychia

9a

Koilonychia are concave curves

9b

Briefly describe the following abnormalities of the nail bed. Paronychia

10a

Paronychia is inflammation of the skin at the base of the nail

10b

Briefly describe the following abnormalities of the nail bed. Splinter hemorrhages
11a

Splinter hemorrhages are red or brown linear streaks in nail beds

11b

Briefly describe the following primary skin lesions and give an example of each. Atrophy
12a

Thinning of skin with loss of normal skin furrow, with skin appearing shiny and translucent; varies in size (e.g. arterial insufficiency)
12b

Briefly describe the following primary skin lesions and give an example of each. Macule
13a

Flat, non palpable change in skin color; smaller than 1 cm (e.g. freckle, petechiae)
13b

Briefly describe the following primary skin lesions and give an example of each. Nodule
14a

Elevated solid mass, deeper and firmer than papule; 1-2 cm (e.g. wart)
14b

Briefly describe the following primary skin lesions and give an example of each. Papule
15a

Palpable, circumscribed, solid elevation in skin; smaller than 1 cm (e.g. elevated nevus)
15b

Briefly describe the following primary skin lesions and give an example of each. Pustule
16a

Circumscribed elevation of skin similar to vesicle but filled with pus; varies in size (e.g. acne, staphylococcal infection)
16b

Briefly describe the following primary skin lesions and give an example of each. Tumor
17a

Solid mass that extends deep through subcutaneous tissue; larger than 1-2 cm (e.g. epithelium)
17b

Briefly describe the following primary skin lesions and give an example of each. Ulcer
18a

Deep loss of skin surface that extends to dermis and frequently bleeds and scars; varies in size (e.g. venous stasis ulcer)
18b

Briefly describe the following primary skin lesions and give an example of each. Vesicle
19a

Circumscribed elevation of skin filled with serous fluid, smaller tha 1 cm (e.g. herpes simplex, chickenpox)
19b

Briefly describe the following primary skin lesions and give an example of each. Wheal
20a

Irregularly shaped, elevated are or superficial localized edema; varies in size (e.g. hive, mosquito bite)
20b

Briefly explain the two types of aphasia. Expressive

21a

A person understands written and verbal speech but cannot write or speak appropriately when attempting to communicate
21b

Briefly explain the two types of aphasia. Receptive

22a

A person cannot understand written or verbal speech

22b

Chancres are:

23a

Chancres are syphilitic lesions, which appear as small, open ulcers that drain serous material
23b

Chest excursion is normally ________ Reduced chest excursion may be caused by _______.
24a

Symmetrical, separating thumbs 3 to 5 cm; reduced chest excursion may be caused by pain, postural deformity or fatigue
24b

Complete the following table by listing the signs of venous and arterial insufficiency. Assessment Criterion: Color Venous: ? Arterial: ?
25a

Venous: Normal or cyanotic Arterial: Pale; worsened by elevation of extremity; dusky red when extremity is lowered
25b

Complete the following table by listing the signs of venous and arterial insufficiency. Assessment Criterion: Edema Venous: ? Arterial: ?
26a

Venous: Often marked Arterial: Absent or mild

26b

Complete the following table by listing the signs of venous and arterial insufficiency. Assessment Criterion: Pulse Venous: ? Arterial: ?
27a

Venous: Normal Arterial: Decreased or absent

27b

Complete the following table by listing the signs of venous and arterial insufficiency. Assessment Criterion: Skin changes Venous: ? Arterial: ?
28a

Venous: Brown pigmentation around ankles Arterial: Thin, shiny skin; decreased hair growth; thickened nails
28b

Complete the following table by listing the signs of venous and arterial insufficiency. Assessment Criterion: Temperature Venous: ? Arterial: ?
29a

Venous: Normal Arterial: Cool (blood flow blocked to extremity)

29b

Define acromegaly

30a

Acromegaly is a condition that causes enlarges jaws and facial bones in adults
30b

Define auscultation

31a

Auscultation is listening to the internal sounds the body makes.

31b

Define hydrocephalus

32a

Hydrocephalus is the buildup of cerebrospinal fluid in the ventricles

32b

Define inspection.

33a

Inspection is looking, listening, and smelling to distinguish normal from abnormal findings
33b

Define murmur

34a

A murmur is a sustained swishing or blowing sound heard at the beginning, middle, or end of the systolic or diastolic phase
34b

Define palpation

35a

Palpation involves using the hands to touch body parts.

35b

Define pigmentation.

36a

Pigmentation is skin color. It is usually unifrom over the body

36b

Define the following common eye and visual abnormalities. Cataract

37a

A cataract is an increased opacity of the lens

37b

Define the following common eye and visual abnormalities. Glaucoma

38a

Glaucoma is intraocular structural damage resulting from increased intraocular pressure

38b

Define the following common eye and visual abnormalities. Hyperopia

39a

Hyperopia is a refractive error causing farsightedness

39b

Define the following common eye and visual abnormalities. Macular degeneration
40a

Macular degeneration is blurred central vision often occurring suddenly caused by progressive degeneration of the center of the retina
40b

Define the following common eye and visual abnormalities. Myopia

41a

Myopia is a refractive error causing nearsightedness

41b

Define the following common eye and visual abnormalities. Presbyopia

42a

Presbyopia is impaired near vision in middle-age and older adults caused by loss of elasticity of the lens
42b

Define the following common eye and visual abnormalities. Retinopathy

43a

Retinopathy is a noninflammatory eye disorder resulting from changes in retinal blood vessels
43b

Define the following common eye and visual abnormalities. Strabismus

44a

Strabismus is a congenital condition in which both eyes do not focus on an object simultaneously
44b

Define the following normal breath sounds heard over the posterior thorax. Bronchial
45a

Bronchial sounds are loud and high pitched with a hollow quality that are related by air moving through trachea close to chest wall
45b

Define the following normal breath sounds heard over the posterior thorax. Bronchovesicular
46a

Bronchovesivular sounds are blowing sounds that are medium pitched and of medium intensity that are created by air moving through large airways
46b

Define the following normal breath sounds heard over the posterior thorax. Vesicular
47a

Vesicular sounds are soft, breezy and low pitched that are created by air moving through smaller airways
47b

Define the following terms related to muscle tone and strength. Atrophied
48a

Atrophied muscled are reduced in size; they feel soft and boggy

48b

Define the following terms related to muscle tone and strength. Hypertonicity
49a

Hypertonicity is increased muscle tone

49b

Define the following terms related to muscle tone and strength. Hypotonicity
50a

Hypotonicity is a muscle with little tone

50b

Define the following terms related to the abdomen. Aneurysm

51a

An aneurysm is a localized dialation of a vessel wall

51b

Define the following terms related to the abdomen. Borborygmi

52a

Borborygmi is growling sounds, which are hyperactive bowel sounds

52b

Define the following terms related to the abdomen. Distention

53a

Distention is swelling by intestinal gas, tumor, or fluid in the abdominal cavity

53b

Define the following terms related to the abdomen. Hernias

54a

A hernia is a protrusion of abdominal organs through the muscle wall

54b

Define the following terms related to the abdomen. Peristalsis

55a

Peristalsis is movement of contents through the intestines, which is a normal function of the small and large intestine
55b

Define the following terms related to the abdomen. Rebound tenderness

56a

Rebound tenderness is the pain a patient may experience when the nurse quickly lifts up his or her hand away after pressing it deeply into the involved area.
56b

Define the following terms related to the abdomen. Striae

57a

Striae are stretch marks

57b

Define the following terms related to the external eye. Conjunctivitis

58a

Conjunctivitis is the presence of redness, which indicates an allergy or an infection

58b

Define the following terms related to the external eye. Ectropion

59a

An ectropion is an eyelid margin that turns out

59b

Define the following terms related to the external eye. Entropion

60a

An entropion is an eyelid margins that turn in

60b

Define the following terms related to the external eye. Exophthalmos

61a

Exophthalmos is a bulging of the eye

61b

Define the following terms related to the external eye. PERRLA

62a

Pupils equal, round, and reactive to light and accommodation

62b

Define the following terms related to the external eye. Ptosis

63a

a ptosis is an abnormal drooping of the eyelid over the pupil

63b

Define the following terms that relate to the nose. Excoriation

64a

Excoriation is skin breakdown characterized by redness and skin sloughing

64b

Define the following terms that relate to the nose. Polyps

65a

Polyps are tumor-like growths

65b

Define the following terms that relate to the oral cavity. Exostosis
66a

Exostosis is extra bony growth between the two palates

66b

Define the following terms that relate to the oral cavity. Leukoplakia
67a

Leukoplakia are thick white patches that are often precancerous lesions seen in heavy smokers and people with alcoholism.
67b

Define the following terms that relate to the oral cavity. Varicosities
68a

Varicosities are swollen, tortuous veins thay are common in older adults
68b

Define the following terms. Cherry angiomas

69a

Cherry angiomas are ruby-red papules

69b

Define the following terms. Edema

70a

Edema means areas of the skin that are swollen or edematous from a buildup of fluid in the tissues
70b

Define the following terms. Goniometer

71a

A goniometer is an instrument that measures the precise degree of motion in a particular joint
71b

Define the following terms. Indurated

72a

Indurated means hardened

72b

Define the following terms. Kyphosis

73a

A kyphosis is a hunchback, and exaggeration of the posterior curvature of the thoracic spine
73b

Define the following terms. Lordosis

74a

Lordosis is a swayback, an increased lumbar curvature

74b

Define the following terms. Osteoporosis

75a

Osteoporosis is a metabolic bone disease that causes a decrease in quality and quantity of bone
75b

Define the following terms. Scoliosis

76a

Scoliosis is a lateral spinal curvature

76b

Define the following terms. Senile keratosis

77a

Senile keratosis is a thickening of the skin

77b

Define the following terms. Turgor

78a

Turgor is the skin's elasticity

78b

Define vocal or tactile fremitus

79a

Vocal or tactile fremitus are vibrations that you can palpate externally caused by sound waves
79b

Delirium is characterized by:

80a

Delirium is characterized by confusion, disorientation, and restlessness

80b

Describe how you would assess for phlebitis.

81a

Inspect the calves for localized redness, tenderness, and swelling over vein sites.
81b

Describe the sounds auscultated by the following murmurs. Grade 1

82a

barely audible in a quiet room

82b

Describe the sounds auscultated by the following murmurs. Grade 2

83a

clearly audible but quiet

83b

Describe the sounds auscultated by the following murmurs. Grade 3

84a

moderately loud

84b

Describe the sounds auscultated by the following murmurs. Grade 4

85a

loud with associated thrill

85b

Describe the sounds auscultated by the following murmurs. Grade 5

86a

very loud thrill easily palpable

86b

Describe the sounds auscultated by the following murmurs. Grade 6

87a

louder; heard without stethoscope

87b

Examination of the eye includes assessment of five areas. Name them (5)
88a

a. Visual acuity b. Visual fields c. Extraocular movements d. External eye structures e. Internal eye structures
88b

Explain how to perform the Rinne test. (6)

89a

1. Place the stem of the vibrating tuning fork against the patient's mastoid process 2. Begin counting the interval with your watch 3. Ask the patient to tell you when he or she no longer hears the sound; not the number of seconds 4. Quickly pace still0vibrating tines 1 to 2 cm from ear canal and ask the patient to tell you when he or she no longer hears the sound 5. Continue counting time the sound is heard by air conduction 6. Compare the number of seconds the sound is heard by bone conduction versus air conduction
89b

Explain how to perform the Weber test. (3)

90a

1. Hold the fork at its base and tap it lightly against the heel of the palm 2. Place the base of the vibrating fork on the middle vertex of the patient's head or middle of forehead 3. Ask the patient if he or she hears the sound equally in both ears or better in one ear

90b

Explain the difference between: Deep palpation

91a

Deep palpation involves depressing the area 4 cm to assess the conditions of organs.
91b

Explain the difference between: Light palpation

92a

Light palpation involves pressing inward 1 cm (surperficial)

92b

Explain the following skin malignancies. Basal cell carcinoma

93a

0.5- to 1-cm crusted lesion that is flat or raised and has a rolled, somewhat scaly border Frequently appearance of underlying, widely dilated blood vessels within the lesion
93b

Explain the following skin malignancies. Melanoma

94a

0.5- to 1-cm brown, flat lesion; appears on sun-exposed or nonexposed skin; variegated pigmentation, irregular borders, and indistinct margins Ulceration, recent growth, or recent changes in long-standing mole are ominous signs

94b

Explain the following skin malignancies. Squamous cell carcinoma

95a

Occurs more often on mucosal surfaces and nonexposed areas of skin than basal cell 0.5- to 1.5-cm scaly lesion sometimes ulcerated or crusted; appears frequently and grows more rapidly than basal cell
95b

Explain the following terms related to assessment of the heart. Point of maximal impulse
96a

The point of maximal impulse is where the apex of the heart is touching the anterior chest wall at approximately the fourth to fifth intercostal space just medial to the left midclavicular line
96b

Explain the following terms related to assessment of the heart. S1

97a

Mitral and tricuspid calve closure cause the first heart sound (S1)

97b

Explain the following terms related to assessment of the heart. S2

98a

Aortic and pulmonic valve closure causes the second heart sound (S2)

98b

Explain the following terms related to assessment of the heart. S3

99a

When the heart attempts to fill already distended ventricle, a third heart sound (S3) can be heard
99b

Explain the following terms related to assessment of the heart. S4

100a

When the atria contract to enhance ventricular filling, a fourth sound is heard (S4)
100b

Explain the steps the nurse would use to assess venous pressure. (5)

101a

1. Place the patient in semi-Fowler position 2. Expose the neck; align the head 3. Lean the patient back into a supine position; the level of venous pulsations begins to rise as the patient reaches 45-degree angle 4. Use two rulers to measure 5. Repeat the same measurement on the other side
101b

For each skin color variation, identify the mechanism that produces color change, common causes of the variation, and the optimal sites for assessment: Color: Cyanosis Condition: ? Causes: ? Assessment Locations: ?

102a

Condition: Increased amount of deoxygenated hemoglobin (associated with hypoxia) Causes: Heart or lung disease, cold environment Assessment Locations: Nail beds, lips, mouth, skin (severe cases)
102b

For each skin color variation, identify the mechanism that produces color change, common causes of the variation, and the optimal sites for assessment: Color: Erythema Condition: ? Causes: ? Assessment Locations: ?

103a

Condition: Increased visibility of oxyhemoglobin caused by dilation or increased blood flow Causes: Fever, direct trauma, blushing, alcohol intake Assessment Locations: Face, area of trauma, sacrum, shoulders, other common sites for pressure ulcers

103b

For each skin color variation, identify the mechanism that produces color change, common causes of the variation, and the optimal sites for assessment: Color: Jaundice Condition: ? Causes: ? Assessment Locations: ?

104a

Condition: Increased deposit of bilirubin in tissues Causes: Liver disease, destruction of red blood cells Assessment Locations: sclera, mucous membranes, skin
104b

For each skin color variation, identify the mechanism that produces color change, common causes of the variation, and the optimal sites for assessment: Color: Loss of pigmentation Condition: ? Causes: ? Assessment Locations: ?

105a

Condition: Vitiligo Causes: Congenital or autoimmune condition causing lack of pigment Assessment Locations: Patchy areas on skin over face, hands, arms
105b

For each skin color variation, identify the mechanism that produces color change, common causes of the variation, and the optimal sites for assessment: Color: Pallor Condition: ? Causes: ? Assessment Locations: ?

106a

Condition: Reduced amount of oxyhemoglobin Causes: Anemia Assessment Locations: Face, conjunctivae, nail beds, palms of hands Condition: Reduced visibility of oxyhemoglobin resulting from decreased blood flow Causes: Shock Assessment Locations: Skin, nail beds, conjunctivae, lips
106b

For each skin color variation, identify the mechanism that produces color change, common causes of the variation, and the optimal sites for assessment: Color: Tan-brown Condition: ? Causes: ? Assessment Locations: ?

107a

Condition: Increased amount of melanin Causes: Suntan, pregnancy Assessment Locations: Areas exposed to sun: face, arms, areolae, nipples
107b

Identify some signs of patient abuse.

108a

Physical injury or neglect are signs of possible abuse (evidence of malnutrition or presence of bruising). Also watch for fear of the spouse or partner, caregiver, or parent.
108b

Identify the 12 cranial nerves. (12)

109a

a. Olfactory b. Optic c. Oculomotor d. Trochlear e. Trigeminal f. Abducens g. Facial h. Auditory i. Glossopharyngeal j. Vagus k. Spinal accessory l. Hypoglossal
109b

Identify the appropriate sites for inspection and palpation of the following. Angle of Louis
110a

Lies between the sternal body and manubrium and feels the ridge in the sternum approximately 5 cm below the sternal notch
110b

Identify the appropriate sites for inspection and palpation of the following. Aortic area
111a

Second intercostal space on the right

111b

Identify the appropriate sites for inspection and palpation of the following. Epigastric area
112a

Tip of the sternum

112b

Identify the appropriate sites for inspection and palpation of the following. Mitral area
113a

Fifth intercostal space just to the left of the sternum; left midclavicular line
113b

Identify the appropriate sites for inspection and palpation of the following. Pulmonic area
114a

Left second intercostal space

114b

Identify the appropriate sites for inspection and palpation of the following. Second pulmonic area
115a

Left third intercostal space

115b

Identify the appropriate sites for inspection and palpation of the following. Tricuspid area
116a

Fourth or fifth intercostal space along the sternum

116b

Identify the common symptoms of testicular cancer.

117a

Common symptoms include a painless enlargement of one testis and the appearance of a palpable, small, hard lump on the side of the testicle
117b

Identify the correct range of motion for the following terms. Abduction
118a

away from the midline

118b

Identify the correct range of motion for the following terms. Adduction
119a

toward the midline

119b

Identify the correct range of motion for the following terms. Dorsiflexion
120a

flexion of the toes and foot upward

120b

Identify the correct range of motion for the following terms. Eversion
121a

turning of the body part away from the midline

121b

Identify the correct range of motion for the following terms. Extension
122a

increasing angle between two adjoining bones

122b

Identify the correct range of motion for the following terms. External rotation
123a

rotation of the joint outward

123b

Identify the correct range of motion for the following terms. Flexion
124a

movement decreasing angle between two adjoining bones

124b

Identify the correct range of motion for the following terms. Hyperextension
125a

beyond its normal resting extended position

125b

Identify the correct range of motion for the following terms. Internal rotation
126a

rotation of the joint inward

126b

Identify the correct range of motion for the following terms. Inversion
127a

turning the body part toward the midline

127b

Identify the correct range of motion for the following terms. Plantar flexion
128a

bending of toes and foot downward

128b

Identify the correct range of motion for the following terms. Pronation
129a

that the frontal or ventral surfaces face downward

129b

Identify the correct range of motion for the following terms. Supination
130a

front or ventral surfaces face upward

130b

Identify the functions of the cerebellum.

131a

The cerebellum controls muscular activity, maintains balance and equilibrium, and helps to control posture
131b

Identify the guidelines to achieve the best results during inspection. (6)
132a

a. Adequate lighting is available b. Use direct light source c. Inspect each area for size, shape, color, symmetry, position, and abnormality d. Position and expose body parts as needed, maintaining privacy e. Check for side-to-side symmetry f. Validate findings with the patient

132b

Identify the internal eye structures that you would examine with an ophthalmoscope. (6)
133a

a. Retina b. Choroids c. Optic nerve disc d. Macula e. Fovea centralis f. Retinal vessels
133b

Identify the key landmarks of the chest. (6)

134a

a. Patient's nipples b. Angle of Louis c. Suprasternal notch d. Costal angle e. Clavicles f. Vertebrae
134b

Identify the physical findings of the skin that are indicative of substance abuse. (8)
135a

a. Diaphoresis b. Spider angiomas c. Burns (especially on fingers) d. Needle marks e. Contusions, abrasions, cuts, scars f. "Homemade" tattoos g. Vasculitis h. Red, dry skin

135b

Identify the principles to follow to keep an examination well organized. (7)

136a

a. Compare both sides for symmetry b. If a patient is ill, first assess the systems of the body part most at risk c. Offer rest periods if the patient becomes fatigued d. Perform painful procedures near the end of the examination e. Record assessments in specific terms in the record f. Use common and accepted medical terms and abbreviations g. Record quick notes during the examination to avoid delays
136b

Identify the questions related to the following acronym. CAGE

137a

C: Have you ever felt the need to cut down on your use? A: Have people annoyed you by criticizing your use? G: Have you ever felt bad or guilty about your use? E: Have you ever used or had a drink first thing in the morning as an "eye opener" to steady your nerves or feel normal?
137b

Identify the structures of the external eye that you would inspect. (7)
138a

a. Position and alignment b. Eyebrows c. Eyelids d. Lacrimal apparatus e. Conjunctivae and sclera f. Corneas g. Pupils and irises
138b

Identify the three parts of the ear canal and list the structures within each. (3)
139a

a. External ear (auricle, outer ear canal, and tympanic membrane) b. Middle ear (three bony ossicles) c. Inner ear (cochlea, vestibule, and semicircular canals)

139b

Identify the three systematic approaches to palpation of the breast. (3)

140a

a. Clockwise or counterclockwise b. Vertical technique c. Center of the breast in radial fashion

140b

Identify the three types of hearing loss. (3)

141a

a. Conduction b. Sensorineural c. Mixed

141b

Identify the two types of normal reflexes and provide an example of each. (2)
142a

a. Deep tendon reflexes (biceps, triceps, patellar, Achilles) b. Cutaneous reflexes (plantar, gluteal, abdominal)
142b

In a patient with pneumonia, the nurse hears high-pitched, continuous musical sounds over the bronchi on expiration. These sounds are called: 1. Rhonchi 2. Crackles 3. Wheezes 4. Friction rubs

143a

3. High-velocity airflow through severely narrowed or obstructed airway

143b

List at least 12 specific observations of the patient's general appearance and behavior that should be reviewed. (12)
144a

a. Gender and race b. Age c. Signs of distress d. Body type e. Posture f. Gait g. Body movements h. Hygiene and grooming i. Dress j. Body odor k. Affect and mood l. Speech
144b

List seven variations in the nurse's individual style that are appropriate wen examining older adults. (7)
145a

a. Do not stereotype about aging patients's level of cognition b. Be sensitive to sensory or physical limitations (more time) c. Adequate space is needed d. use patience, allow for pauses, and observe for details e. Certain types of information may be stressful to give f. Perform the examination near bathroom facilities g. Be alert for signs of increasing fatigue

145b

List seven variations in the nurse's individual style that are appropriate when examining children. (7)
146a

a. Gather all or part of the histories of infants and children from parents b. Perform the examination in a nonthreatening are and provide time for play c. Offer support to the parents during the examination and do not pass judgment d. Call children by their first names and address their parents as Mr. and Mrs. e. Use open-ended questions to allow parents to share more information f. Treat adolescents as adults g. Provide confidentiality for adolescents; speak alone with them
146b

List the five nursing purposes for performing a physical assessment. (5)
147a

a. Gather baseline data about the patient's health status b. Support or refute subjective data obtained in the nursing history c. Confirm and identify nursing diagnoses d. Make clinical judgments about a patient's changing health status and management e. Evaluate the outcomes of care
147b

List the principles related to the nurse performing daily physical examinations. (4)
148a

a. A head-to-toe assessment is required daily b. Reassessment is performed when the patient's condition changes as it improves or worsens c. The environment, equipment, and patient are properly prepared d. Safety for confused patients should be a priority
148b

List the risks for skin lesions in hospitalized patients. (9)

149a

A. Exposure to pressure during immobilization b. Various medications c. Neurologic impairment d. Chronic illness e. Orthopedic injury f. Diminished mental status g. Poor tissue oxygenation h. Low cardiac output i. Inadequate nutrition
149b

List the sequence for assessing the nodes of the neck (6)

150a

1. Occipital nodes ar the base of the skull 2. Postauricular nodes over the mastoid 3. Preauricular nodes at the base of the skull 4. Retropharyngeal nodes at the angle of the mandible 5. Submandibular nodes 6. Submental nodes

150b

List the six factors to consider when assessing a murmur. (6)

151a

a. Auscultate all valve areas for placement in the cardiac cycle (timing), where best heard (location), radiation, loudness, pitch, and quality b. Distinguish between systolic and diastolic murmurs by determining if they occur between S1 and S2 (systolic) and S2 and S1 (diastolic) c. The location is not necessarily over the valves d. listen over areas besides where the murmur is heard best to assess for radiation e. Feel for thrust or intermittent palpable sensation at the auscultation site in serious murmurs and rate the intensity f. Low-pitched murmur best heard with the bell of the stethoscope; a high-pitched murmur is best heard with the diaphragm

151b

List three actions that should be taken to ensure accurate weight measurement of a hospitalized patient. (3)
152a

a. Weigh patients at the same time of day b. Weigh patients on the same scale c. Weigh patients in the same clothes
152b

Name the three types of lice. (3)

153a

a. Pediculus humanus capitis (head lice) b. Pediculus humanus corporis (body lice) c. Pediculus pubis (crab lice)
153b

Proper preparation for examination should include: (5)

154a

a. Infection control b. Environment c. Equipment d. Physical preparation of the patient e. Psychological preparation of the patient
154b

Sound: Crackles Site Auscultated: ? Cause: ? Character: ?

155a

Site Auscultated: Are most common in dependent lobes: right and left lung bases Cause: Random, sudden reinflation of groups of alveoli; disruptive passage of air through small airways Character: Fine crackles are high-pitched fine, short; interrupted crackling sounds heard during end of inspiration; usually not cleared with coughing. Medium crackles are lower; moister sounds heard during middle of inspiration; not cleared with coughing. Coarse crackles are loud, bubbly sounds heard during inspiration; not cleared with coughing.

155b

Sound: Pleural friction rub Site Auscultated: ? Cause: ? Character: ?

156a

Site Auscultated: Heard over anterior lateral lung field (if patient is sitting upright) Cause: Inflamed pleura; parietal pleura rubbing against visceral pleura Character: Dry, rubbing, or grating quality is heard during inspiration or expiration; does not clear with coughing; heard loudest over lower lateral anterior surface.
156b

Sound: Rhonchi (sonorous wheeze) Site Auscultated: ? Cause: ? Character: ?

157a

Site Auscultated: Are primarily heard over trachea and bronchi; if loud enough, able to be heard over most lung fields Cause:Muscular spasm, fluid, or mucus in larger airways; new growth or external pressure causing turbulence Character: Loud, low-pitched, rumbling coarse sounds are heard either during inspiration or expiration; sometimes cleared by coughing.
157b

Sound: Wheezes (sibilant wheeze) Site Auscultated: ? Cause: ? Character: ?

158a

Site Auscultated: Heard over all lung fields Cause: High-velocity airflow through severely narrowed or obstructed airway Character: High-pitched, continuous musical sounds are like a squeak heard continuously during inspiration or expiration; usually louder on expiration.
158b

Structures examined during assessment of the neck include: (6)

159a

a. Neck muscles b. Lymph nodes of the head and neck c. Carotid arteries d. Jugular veins e. Thyroid gland f. Trachea
159b

Syncope is caused by _______.

160a

Syncope is caused by a drop in heart rate and blood pressure

160b

The American Cancer Society (2010) recommends the following guidelines for early detection of breast cancer. (6)
161a

a. Monthly BSE for women in their 20s b. Women ages 20 years and older need to report any breast changes c. Women need to have a clinical breast examination every 3 years (ages 20-40 years) and yearly after the age of 40 years d.Women with a family history need a yearly examination e. Asymptomatic women need a screening mammogram by age 40 years. Women older than age 40 years need an annual mammogram f. For women with increased risk, additional testing should be discussed with the health care provider
161b

The component that should receive the highest priority before a physical examination is: 1. Preparation of the equipment 2. Preparation of the environment 3. Physical preparation of the patient 4. Psychological preparation of the patient
162a

4. A thorough explanation of the purpose and steps of each assessment lets patients know what to expect and what to do so they can cooperate.
162b

The following are sounds that are described when auscultating. Please explain each one. Amplitude
163a

Amplitude describes the loudness, soft to loud

163b

The following are sounds that are described when auscultating. Please explain each one. Duration
164a

Duration describes length of time that sound vibrations last

164b

The following are sounds that are described when auscultating. Please explain each one. Frequency
165a

Frequency indicates the number of sound wave cycles generated per second by a vibrating object
165b

The following are sounds that are described when auscultating. Please explain each one. Quality
166a

Quality describes sounds of similar frequency and loudness

166b

The normal tympanic membrane appears:

167a

The normal tympanic membrane appears translucent, shiny, and pearly gray
167b

The nurse assesses the skin turgor of the patient by: 1. Inspecting the buccal mucosa with a penlight 2. Palpating the skin with the dorsum of the hand 3. Grasping a fold of skin on the back of the forearm and releasing 4. Pressing the skin for 5 seconds, releasing, and noting each centimeter of depth
168a

3. Normally, the skin lifts easily and snaps back immediately to its resting position; the back of the hand is not the best place to test for turgor
168b

The purpose of digital examination is:

169a

Digital examination is used to detect colorectal cancer in the early stages and prostatic tumors
169b

The purpose of the Glasgow Coma Scale is to:

170a

The Glasgow Coma Scale provides an objective measurement of consciousness on a numerical scale over time
170b

The purpose of the Mini-Mental State Examination is to measure:

171a

The Mini-Mental State Examination measures orientation and cognitive function

171b

The second heart sound (S2) occurs when: 1. Systole begins 2. There is rapid ventricular filling 3. The mitral and tricuspid valves close 4. The aortic and pulmonic calves close
172a

4. After the ventricle empty, ventricular pressure falls below that in the aorta and pulmonary artery, allowing the valves to close and causing the second heart sound
172b

The sensory pathways of the central nervous system conduct what type of sensations? (5)
173a

a. Pain b. Temperature c. Position d. Vibration e. Crude and finely localized touch

173b

When assessing the patient's thorax, the nurse should: 1. Complete the left side and then the right side 2. Compare symmetrical areas from side to side 3. Begin with the posterior lobes on the right side. 4. Change the position of the stethoscope between inspiration and expiration.
174a

2. Use systematic pattern when comparing the right and left sides. You need to compare lung sounds in one region on one side of the body with sounds in the same region on the opposite side of the body
174b

When palpating abnormal masses in the breast, you should note: (7)

175a

a. Location in relation to the quadrant b. Diameter c. Shape d. Consistency e. Tenderness f. Mobility g. Discreteness
175b

While examining Mr. Parker, the nurse notes a circumscribed elevation of skin filled with serous fluid on his upper lip. The lesion is 0.4 cm in diameter. This type of lesion is called a: 1. Macule 2. Nodule 3. Vesicle 4. Pustule
176a

3. Circumscribed elevation of skin filled with serous fluid, smaller than 1 cm

176b