Exam 1 Flashcards
(105 cards)
1
Q
Outermost skin layer
A
Epidermis
2
Q
Innermost skin layer
A
Subcutaneous layer
3
Q
Second layer of skin
A
Dermis
4
Q
Yellow discoloration of skin and sclerae
A
Jaundice
5
Q
Paleness
A
Pallor
6
Q
Bluish discoloration
A
Cyanosis
7
Q
Dependent redness
A
Rubor
8
Q
Redness
A
Flushing, erythema
9
Q
Dark, leathery appearance
A
Brawny
10
Q
T/F: A would is assessed for location, size, color, texture, drainage, wound margins, surrounding skin, and healing status
A
True
11
Q
T/F: Skin changes related to aging include melasma, linea nigra, increased sebaceous and cutaneous gland function, and hair loss
A
False
12
Q
The older adult has _________ skin texture and prolonged time for _________ healing, and the thermoregulation changes increase the risk for hypothermia and hyperthermia.
A
rougher, wound
13
Q
Skin ________ -examination assists patients to identify problematic lesions.
A
self
14
Q
The depth of a burn can be superficial, superficial-dermal, dermal, or ________ thickness.
A
total
15
Q
Tenting of the skin indicates __________
A
dehydration
16
Q
What are the 6 categories of the Braden scale?
A
- Sensory perception
- Moisture
- Activity
- Mobility
- Nutrition
- Friction
17
Q
What are the ABCDEs for assessing of Melanoma?
A
Asymmetry
Border irregularity
Color variety
Diameter of more than 6mm
Evolution of lesion over time
18
Q
This tests extraocular muscles for symmetrical movements of the eyes in nine fields
A
Cardinal Fields of Gaze
19
Q
This tests for visual field defects
A
Confrontation Test
20
Q
Eye test that assesses near vision
A
Jaeger Test
21
Q
This eye test tests for presence and amount of ocular deviation.
A
Cover Test
22
Q
This eye test assesses distance visual acuity
A
Snellen Test
23
Q
T/F: Patients older than 40 years of age often have an increased ability to accommodate, moving the object further away to read
A
False
24
Q
T/F: A patient with 20/20 vision can read at 20ft what the normal person can read at 20ft.
A
True
25
T/F: Cranial nerves involved with the eyes include II, III, IV, and V.
False
26
Cloudiness in the lens can indicate a ______
cataract
27
________ is documented when the pupils are equal, round, and reactive to light and accommodation.
PERRLA
28
__________ is the leading cause of blindness in middle and older adults.
Diabetic retinopathy
29
Name two Nursing Diagnoses associated with the eyes
1. Impaired vision: assess for safety risks in their environment - fall risk for individuals with low vision and mobility.
2. Eye care: Ensure the patient is wearing clean eyeglasses and refer those who need corrective lenses.
30
T/F: The Weber test differentiates bilateral hearing loss.
False
31
T/F: Nonverbal cues of hearing loss include leaning forward, concentrating on lip reading, or giving incorrect answers to questions asked
True
32
T/F: The inner ear contains the malleus, incus, and stapes that conduct sound waves to the middle ear.
False
33
T/F: Environmental factors that increase the risk for otitis media include secondhand smoke, propping bottles for babies to feed, and bottle feeding in the supine position.
True
34
The _________ membrane is the barrier between the external auditory canal and the middle ear.
tympanic
35
The semicircular canals and vestibule provide the body with ______ and equilibrium.
proprioception
36
Color and consistency of _______ differs according to cultural background
cerumen
37
_________ hearing loss is caused by either blockage or the external auditory canal by cerumen or fluid in the middle ear`
Conductive
38
How should the nurse hold the ear of an adult patient when performing an otoscopic examination?
Hold the ear at the helix (top) and lift up and back so that the canal is aligned for the best visualization of the tympanic membrane.
39
What is the Rinne test testing for?
To determine if hearing is equal in both ears and if conductive hearing loss or SNHL is present. This test compares the difference between air conduction and bone conduction.
40
Shortness of breath
dyspnea
41
Gray or blue skin - indicating lack of oxygen
Cyanosis
42
Coughing up frank blood
Hemoptysis
43
Breathing more than 24 breaths/minute
Tachypnea
44
Difficulty breathing when lying flat
Orthopnea
45
Airway collapse
Atelectasis
46
Unusual paleness of the skin
Pallor
47
Continuous, high-pitched, musical sounds caused by air squeezing through narrowed airways. Associated with emphysema, asthma, and bronchitis
Wheezing
48
A high-pitched crowing sound from the upper airway; results from tracheal or laryngeal spasm or constriction. Can indicate an emergency
Stridor
49
Normal breath sound, heard at larynx and trachea, inspiration less than expiration
Bronchial
50
Continuous, low-pitched, snoring sounds resulting from secretions moving around in airways. May clear with coughing. Associated with pneumonia
Rhonchi
51
Normal breath sound, heard anteriorly between 1st and 2nd ICSs; between scapula, inspiration equal to expiration
Bronchovesicular
52
High-pitched, soft, brief sounds that can be simulated by rolling a strand of hair near the ear. Associated with heart failure, asthma, or COPD.
Fine Crackles
53
Low-pitched, moist, longer sounds similar to Velcro slowly being separated. Associated with respiratory edema, COPD, and respiratory fibrosis.
Coarse Crackles
54
Normal breath sound, heard over most of the lung field, inspiration greater than expiration.
Vesicular
55
T/F: The right lung has two lobes, whereas the left lung has three.
False
56
T/F: Lungs should be auscultated from the base to the apex.
False
57
T/F: The only trigger for breathing is increased carbon dioxide in the blood.
False
58
T/F: In an emergency respiration situation, it is important to stay with and calm the patient to reduce anxiety.
True
59
T/F: Midclavicular line runs vertically down the center of the sternum.
False
60
The ________ contains the heart, lungs, thymus, distal part of the trachea, and most of the esophagus.
mediastinum
61
The ______ refers to the very bottom of the lung fields; the _______ is the very top (opposite of the labeling of the heart).
base, apex
62
The _____ are the primary units in the lungs that absorb oxygen and excrete carbon dioxide.
alveoli
63
________ is considered the leading cause of preventable death.
Smoking
64
__________ are abnormal breath sounds, such as crackles, wheezes, or rhonchi.
Adventitious breath sounds
65
An angle of 180 degrees or more is called ______ of the fingers, which indicates chronic hypoxia.
clubbing
66
_________ is the AP to transverse ratio in patients with a barrel chest. ________ is normal AP to transverse ratio.
1:1, 1:2
67
_______ respiration pattern is usually seen in patients at end of life.
Cheyne-Stokes
68
_______ respiration pattern is a regular irregular rhythm that cycles from deep and fast to shallow and slow with some periods of apnea.
Biot breathing
69
T/F: Breast cancer is the leading cause of cancer in females.
True
70
T/F: Breasts often feel full, sore, or heavy just prior to menstruation.
True
71
T/F: The most common breast concerns that cause women to seek medical evaluation area a newly discovered lump, pain, and nipple discharge.
True
72
________ is when one or both male breasts temporarily enlarge as a result of changing hormone levels.
Gynecomastia
73
______ is the beginning of menstruation and occurs during late puberty or Tanner stage 3 or 4.
Menarche
74
A well-defined, usually single, nontender, firm or rubbery, round or lobular mass that is freely movable is called a ______
fibroadenoma
75
What seven signs/symptoms require further investigation to rule out cancer?
- A new breast lump or mass
- Swelling of all or part of a breast (even if no distinct lump is felt)
- Skin irritation or dimpling
- Breast or nipple pain
- Nipple retraction (turning inward)
- Redness, scaliness, or thickening of the nipple or breast skin
- Nipple discharge (other than breast milk)
76
The nurse should have the patient sit/stand in five different positions when inspecting breasts. What are these five positions?
- Patient sitting with their arms at the sides.
- Lifting their arms over their head.
- Patient's hands pressed firmly on the hips.
- Patient standing and leaning forward from the waist.
- Lying supine.
77
When palpating the breasts there are three different techniques that can be performed. What are these three techniques?
- Vertical pattern
- Circular pattern
- Wedge pattern
78
Valve that separates the left atrium and left ventricle
Mitral valve
79
Valve that separates the right atrium and right ventricle
Tricuspid valve
80
Valve that lies between the left ventricle and aorta
Aortic valve
81
Valve that lies between the right ventricle and pulmonary artery
Pulmonic valve
82
Volume in the right atrium at the end of diastole
Preload
83
Contraction of the ventricles
Systole
84
Amount of blood ejected from the left ventricle each minute
Cardiac output
85
Common name for the extra heart sounds S3 and S4
Gallop
86
How much blood is ejected with each beat or stroke
Stroke volume
87
Abnormal heart sound that may result from intrinsic cardiovascular disease or circulatory disturbance. Usually indicates disease of the heart valves, either from stenosis or regurgitation.
Bruits
88
Swishing auscultatory sound that indicates turbulent blood flow or narrowing from constriction or dilation of a tortuous vessel.
Murmur
89
Ventricular relaxation
Diastole
90
T/F: The top of the heart is referred to as the apex because it is broad; the bottom of the heart is referred to as the base.
False
91
T/F: The coronary veins may develop atherosclerotic plaques that narrow them, leading to a myocardial infarction (heart attack) or angina.
False
92
T/F: The pulmonary artery carries deoxygenated blood to the lungs, whereas the pulmonary vein delivers oxygenated blood to the left atrium.
True
93
T/F: S1, or "lub", the beginning of systole, results from closure of the aortic and pulmonic valves, ans S2, or "dub", the end of systole and beginning of diastole, results from closure of the mitral and tricuspid valves.
False
94
T/F: African American men are 40% more likely to have high blood pressure than Caucasians.
False
95
The heart and great vessels are located in the _________ between the lungs and above the diaphragm from the center to the left of the thorax.
mediastinum
96
The parts of the heart that pump blood to the lungs and out of the body are called __________
arteries
97
The cells in the SA node are unique because they possess ___________ (property that enables the heart to generate its own impulses).
automaticity
98
__________ are abnormal heart rhythms with early (premature), delayed, or irregular beats.
Arrhythmias
99
If a patient is experiencing chest pain, dyspnea, cyanosis, diaphoresis, or dizziness, focus assessment on data to __________ the discomfort while simultaneously providing treatments.
alleviate
100
Heart Rate x Stroke Volume =
Cardiac output
101
_______ _________ is one cause of reduced cardiac output. It is a medical diagnosis that reduces contractility, causing preload to increase.
Heart failure
102
What is the term used to describe the area where the apical pulsation can be seen or palpated?
Point of maximal impulse (PMI)
103
Where would you locate the point of maximal impulse?
In most adults, it is commonly found at the intersection of the 5th ICS mitral area and the left MCL.
104
Indicate the number and a description of the Grading of Pulse Scale
0: Nonpalpable or absent
1+: Weak and thready
2+: Normal, expected
3+: Full, increased
4+: Bounding
105
