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1

Papule

Something you can feel (i.e., solid, elevated, circumscribed, less than 1 cm diameter) caused by superficial thickening in the epidermis.

Examples: elevated nevus (mole), lichen planus, molluscum, wart (verruca).

2

Elevated skin lesions that are greater than 1 cm in diameter are called:
A. bullae.
B. papules.
C. nodules.
D. furuncles.

C. nodules.

3

The nurse notices that a patient has a solid, elevated, circumscribed lesion that is less than 1 cm in diameter. When documenting this finding, the nurse would report this as a:
A. nodule.
B. bulla.
C. papule.
D. vesicle.

C. papule

4

During the examination of a patient, the nurse notices that the patient has several small, flat macules on the posterior portion of her thorax. These macules are less than 1 cm wide. Another name for these macules is:

freckles.

5

Mr. Shea is a 51-year-old patient who presents with complaints of a skin lesion. On examination, you note a linear skin lesion that runs along a nerve route. Which of the following terms best describes this lesion?
A. Zosteriform
B. Annular
C. Dermatome
D. Shingles

A. Zosteriform

6

ConfluentShapes/configurations of lesions, examples

lesions run together (e.g., urticaria [hives])

7

TargetShapes/configurations of lesions, examples

(or iris), resembles the iris of an eye, concentric rings of color in the lesions (e.g., erythema multiforme).

8

The nurse just noted from a patient’s medical record that the patient has a lesion that is confluent in nature. On examination, the nurse would expect to find:

lesions that run together.

9

List the 4 assessment techniques and know what is involved with each

Inspection – begins the moment you meet a person and develops a “general survey.” Always comes first.

Palpation – follows inspection and confirms points noted during inspection. Applies sense of touch to assess these factors: texture, temperature, moisture, organ location and size, as well as any swelling, vibration or pulsation, rigidity or spasticity, creptitation, presence of lumps or masses, and presence of tenderness or pain

Percussion – tapping the person’s skin with short, sharp strokes to assess underlying structures. Depicts the location, size, and density of an underlying organ.

Auscultation – listening to sounds produced by the body, such as heart and blood vessels and lungs and abdomen.

10

The nurse is performing a general survey. Which action is a component of the general survey?

Observing the patient’s body stature and nutritional status

The general survey is a study of the whole person that includes observation of physical appearance, body structure, mobility, and behavior.

11

When listening to heart sounds, the nurse knows that S1:

A) is louder than S2 at the apex of the heart.
B) indicates the beginning of diastole.
C) coincides with the carotid artery pulse.
D) is caused by closure of the semilunar valves.

A. is heard louder than S2 at the apex of the heart.

Although S1 and S2 are heard throughout the heart, S1 is louder than S2 at the apex of the heart.

12

Confluent

Shapes/configurations of lesions, examples

lesions run together (e.g., urticaria [hives])

13

Target

Shapes/configurations of lesions, examples

(or iris), resembles the iris of an eye, concentric rings of color in the lesions (e.g., erythema multiforme).

14

When performing a physical assessment, the technique the nurse will always use first is:
1. palpation.
2. inspection.
3. percussion.
4. auscultation.

2. inspection.

15

The nurse is planning to assess new memory with a patient. The best way for the nurse to do this would be to:

give him the Four Unrelated Words Test

16

During the history, a patient tells the nurse that “it feels like the room is spinning around me.” The nurse would document this as:

vertigo

17

During an examination, the patient states he is hearing a buzzing sound and says that it is “driving me crazy!” The nurse recognizes that this symptom indicates:
A. vertigo.
B. pruritus.
C. tinnitus.
D. cholesteatoma.

C. tinnitus.

Tinnitus is a sound that comes from within a person; it can be a ringing, crackling, or buzzing sound. It accompanies some hearing or ear disorders.

18

Syncope

Sudden loss of strength, a temporary loss of consciousness (a faint) due to lack of cerebral blood flow (e.g., low BP).

19

The inspection phase of the physical assessment:
1. yields little information.
2. takes time and reveals a surprising amount of information.
3. may be somewhat uncomfortable for the expert practitioner.
4. requires a quick glance at the patient's body systems before proceeding on with palpation.

2. takes time and reveals a surprising amount of information.

20

The nurse is examining a 3-month-old infant. While holding the thumbs on the infant’s inner mid thighs and the fingers outside on the hips, touching the greater trochanter, the nurse adducts the legs until the nurse’s thumbs touch and then abducts the legs until the infant’s knees touch the table. The nurse does not notice any “clunking” sounds and is confident to record a:
A) positive Allis test.
B) negative Allis test.
C) positive Ortolani's sign.
D) negative Ortolani's sign.

D. negative Ortolani’s sign

21

Allis test

Ortolani maneuver

- Ortolani maneuver – checks hips for congenital dislocation in infants up to 1 year old by flexing knees and adducting legs. Normally feels smooth and has no sound. Hip instability feels like a clunk as the head of the femur pops back into place – positive Ortolani sign.

- Allis test – checking hip dislocation in infants by comparing leg lengths. Place baby’s feet flat on the table and flex the knees up – scan the tops of the knees, normally they are at the same elevation.

22

The nurse places a key in the hand of a patient and he identifies it as a penny. What term would the nurse use to describe this finding?
A. Extinction
B. Astereognosis
C. Graphesthesia
D. Tactile discrimination

B. Astereognosis

23

A woman who is 8 months pregnant comments that she has noticed a change in posture and is having lower back pain. The nurse tells her that during pregnancy women have a posture shift to compensate for the enlarging fetus. This shift in posture is known as:
A) lordosis.
B) scoliosis.
C) ankylosis.
D) kyphosis.

A) lordosis.

Lordosis compensates for the enlarging fetus, which would shift the center of balance forward. This shift in balance in turn creates strain on the low back muscles, felt as low back pain during late pregnancy by some women. Scoliosis is lateral curvature of portions of the spine; ankylosis is extreme flexion of the wrist, as seen with severe rheumatoid arthritis; and kyphosis is an enhanced thoracic curvature of the spine.

24

The nurse is explaining the mechanism of the growth of long bones to a mother of a toddler. Where does lengthening of the bones occur?
A) Bursa
B) Calcaneus
C) Epiphyses
D) Tuberosities

C) Epiphyses

25

What are:

stereognosis/astereognosis

graphasthesia

- Stereognosis – ability to recognize objects by feeling their forms, sizes, and weights.

- Astereognosis – inability to identify object correctly. Occurs in sensory cortex lesions (e.g. stroke)

- Graphasthesia – ability to “read” a number by having it traced on the skin (good measure of sensory loss if person cannot make the hand movements needed for stereognosis, as occurs in arthritis)

26

lordosis

kyphosis

- Lordosis compensates for the enlarging fetus, which would shift the center of balance forward. This shift in balance in turn creates strain on the low back muscles, felt as low back pain during late pregnancy by some women.

- Kyphosis is an enhanced thoracic curvature of the spine.

27

Nodule

Solid, elevated, hard or soft, larger than 1 cm. May extend deeper into dermis than papule. Examples: xanthoma, fibroma, intradermal nevi.

28

Keloid

A hypertrophic scar. The resulting skin level is elevated by excess scar tissue, which is invasive beyond the site of original injury. May increase long after healing occurs. Looks smooth, rubbery, and “clawlike” and has a higher incidence among African Americans.

29

Macule

Solely a color change, flat and circumscribed, of less than 1 cm. Examples: freckles, flat nevi, hypopigmentation, petechiae, measles, scarlet fever.

30

Wheal

Superficial, raised, transient and erythematous; slightly irregular shape due to edema (fluid held diffusely in the tissues). Examples: mosquito bite, allergic reaction, dermographism.