Exam 2 Flashcards
(101 cards)
1
Q
What is an expected finding of the neck?
A
Trachea midline
2
Q
What is JVD?
A
Jugular Vein Distention
3
Q
The nurse should assess a client’s ears when they are wearing a nasal canula. True or false?
A
True
4
Q
How long does the battery in hearing aids typically last?
A
1 Week
5
Q
Wipe eyes from the outer to inner canthus. True or false?
A
False (wipe inner to outer)
6
Q
A client’s teeth should be brushed how many times a day?
A
2 times
7
Q
Should your client’s head be normocephalic?
A
True
8
Q
Which tool is used to test visual acuity?
A
Snellen chart
9
Q
What means nearsightedness?
A
Myopia
10
Q
How many times should you brush an unconscious persons teeth?
A
Provided oral care up to every 2 hours
11
Q
Artificial eyes should be cleaned how often?
A
As needed
12
Q
What does PERRLA stand for?
A
Pupils are equal round and reactive to light and accommodation
13
Q
How will the nurse best assess a client’s ability to brush their teeth?
A
observe the client brushing their teeth
14
Q
Which reduces risk for aspiration when providing care for an unconscious client?
A
Suction secretions
15
Q
What is true for denture care?
A
Place a towel below while cleaning
16
Q
Denture care should be performed after meals and at bedtime. True or False?
A
True
17
Q
There are no contraindications for ear irrigation. True or False?
A
False
18
Q
What color should the tympanic membrane (in the ear) be in a healthy client?
A
Pearly Grey
19
Q
The Rinne test compares air and bone conduction. True or False?
A
True
20
Q
What can cause a false low blood pressure reading?
A
Arm above the heart
21
Q
What can cause high blood pressure reading?
A
Legs crossed, cuff too narrow, and smoking
22
Q
Where is the apical impulse located?
A
5th ICS MCL
23
Q
What is measured when assessing a radial pulse?
A
Rate, rhythm, amplitude
24
Q
The nurse osculating over the 5th intercostal space left midclavicular will hear?
A
Mitral Valve
25
A pulse deficit is found by adding the apical rate to the radial pulse rate. True or False?
False
26
What action should the nurse take to ausculate heart sounds?
Identify S1 and S2
27
The nurse knows that S2 is the sound of?
The closure of the semi-lunar valves
28
What is an extra heart sound heard at the beginning of diastole?
S3
29
De-oxygenated blood is pumped from the right ventricle to the?
Lung
30
The nurse suspect right sided heart failure based on which assessment finding?
+4 pitting edema
31
What is a blowing or swishing sound found in the carotid artery?
Bruit (found in the artery)
32
What is a blowing or swishing sound found in the heart?
Murmur (in the heart)
33
What is correct when assessing the carotid arteries?
Palpate one at a time
34
A Doppler ultrasound is used to detect a peripheral pulse undetectable through palpation. True or False?
True
35
A client with acute vasoconstriction may have which skin color change?
Pallor
36
A client with atherosclerosis are at risk for tissue ischemia. True or False?
True
37
What finding indicated Arterial Disease?
+1 Pedal Pulses bilaterally
38
What is atherosclerosis?
Plan build up on the arteries
39
Capillary refill time will increase with arterial disease. True or False?
True
40
What BEST increases venous blood return?
Ambulation
41
What assessment finding indicates venous insufficiency?
Leg aching relieved by elevation
42
What assessment finding indicate a DVT?
Redness, warmth, swelling, pain in 1 leg
43
The nurse documents a client's respirations by collecting?
Rate, depth, and rhythm
44
A respiratory rate of 8bpm that is regular is called?
Bradypnea
45
Which respiratory pattern is marked by waxing and waning with periods of apnea?
Cheyenne-Strokes Respirations
46
What term means shortness of breath while lying down?
Orthopnea
47
Where will the nurse osculate the anterior apex of the lungs?
Above the clavical
48
What is correct when osculating lung sounds?
Use a side to side comparison
49
What technique will the nurse use to assess to resonance?
Percussion
50
Soft, low rustling breath sounds are called?
Vesicular
51
How do you check distant vision?
Snellen eye chart
52
Myopia
Nearsightedness
53
How do you check near vision?
Handheld card
54
Presbyopia
Gradual loss of your eyes' ability to focus on nearby objects (Occurs with aging)
55
Nystagmus
Involuntary, rapid, rhythmic movement of the eyeball (extraocular movements)
56
PERRLA
pupils are equal, round and reactive to light and accommodation
57
What is included in a physical assessment of the head?
Inspect and palpate the skull, inspect the face
58
What is an expected finding of the tongue?
protrudes in midline
59
what is included in an assessment of the neck?
Inspect and palpate lymph nodes, symmetry, range of motion, trachea and thyroid gland
60
What are expected findings of the Head?
Normocephalic, no lumps, no lesions, no tenderness
61
What are expected findings of the face?
Symmetric, no weakness or drooping, no involuntary movements
62
What are expected findings of the neck?
Supple with full ROM, no pain, symmetric, no lymphadenopathy or masses, trachea midline, thyroid not palpable, no bruits
63
Artifical eye care
leave a towel below in case the eye is dropped
64
How do you test for hearing?
Weber test and rinne test (tuning fork tests), whispered voice test, and conversational speech
65
What is used for an internal ear examination?
Otoscope
66
Denture care
leave a towel below while cleaning, store in a container with water, brush teeth thoroughly
67
Ear irrigation
pull the ear up then down then take a syringe and flush warm water gently through the ear
68
Eye irrigation
Lay supine and gently put saline in it while holding the eye open
69
Dysphagia
Difficulty swallowing
70
What is an expected finding of the throat?
Uvula rises in midline on phonation
71
Unconscious oral hygiene
Have suction available, do not put fingers in the patients mouth, have the patient in semi fowlers or supine position with head turned to the side
72
What are expected findings of the mouth for an aging adult?
Pale gums and decreased production of saliva
73
What will increase in an elderly adult client?
Cerumen (ear wax)
74
What are equal pitched with medium duration lung sounds heard over the major bronchi called?
Bronchovesicular
75
The nurse ausculates high pitched, loud, and tumbular sounds over the trachea and documents?
Normal bronchial breath sounds
76
What are high pitched popping lung sounds on inspiration called?
Fine Crackles
77
The nurse hears high pitched, musical squeaking on auscultation of the lungs and documents?
Wheezing
78
What will the nurse note on a client with COPD?
AP diameter equal to transverse diameter
79
What finding is expected on a focused assessment of the lung and thorax?
Symmetrical tactile fremitus
80
What is the greatest risk factor for impaired gas exchange?
Smoking
81
What is an unexpected finding of the neck?
Enlarged thyroid
82
What is true when cleaning the eyes?
Wipe inner cantos to outer canthus
83
Direct and consensual light reflexes are confirmed with pupillary dilation. True or false?
False
84
Artificial eyes should be cleaned as needed with mild soap and water and rinsed with saline. True or False?
True
85
Dentures should be stored in a clean moist container at night. True or False?
True
86
The person who sees 20/30 sees better than the person who sees 20/20. True or False?
False
87
De- oxygenated blood is pumped from the right ventricle to the
Pulmonary artery
88
The nurses osculating over the 2nd intercostal space left sternal border will hear?
The pulmonary valve
89
The nurse knows that S1 is the sound of?
The closing of the atrial ventricular valves
90
The nurse may suspect right sided heart failure based on what assessment finding?
Jugular Vein Distention
91
The nurse may suspect right sided heart failure based on which assessment finding?
+4 pitting edema
92
What is a blowing or swishing sound found in the carotid artery?
Bruit
93
What is an extra heart sound heard at the end of diastole?
S4
94
The nurse documents a client's respiration when collecting?
Rate, depth, rhythm
95
Soft, low breath sounds are called?
Vesicular
96
The nurse ausculates high pitched, loud, and tubular sounds over the trachea and documents?
Bronchial breath sounds
97
The nurse hears high pitched, popping on auscultation of the lungs and documents?
Crackles
98
The nurse hears high pitched, musical squeaking on auscultation of the lungs and documents?
Wheezing
99
The client with COPD may present with which sign or symptoms due to their chronic illness?
Nail bed angle of 180 degrees
100
What finding is expected on a focused assessment of the lung and thorax?
Symmetrical tactile fremitus
101
