exam 3

Question 1

stage 1 pressure ulcer

Answer 1

intact skin, non blanchable redness over bony prominence

Question 2

stage 2 pressure ulcer

Answer 2

partial thickness tissue of dermis presenting as a shallow open ulcer with reddish pink would bed

Question 3

stage 3 pressure ulcer

Answer 3

full thickness tissue loss with visible sub q fat, no muscle or bone exposure

Question 4

stage 4 pressure ulcer

Answer 4

full thickness loss with exposed muscle or bone

Question 5

ABCDEs of skin lesions

Answer 5

asymmetry
border
color
diameter
evolution

Question 6

signs and symptoms of dehydrated individual

Answer 6

decreased turgor
dry mouth, kips, eyes
dark urine
dizzy
sunket eyes and cheeks

Question 7

confluent lesions

Answer 7

smaller lesions run together to form a larger lesion

Question 8

what assessment findings indicate jaundice?

Answer 8

yellow skin tones, sclera, oral mucosa, palms, and soles

Question 9

1+ edema

Answer 9

mild pitting, 2 mm depression

Question 10

2+ edema

Answer 10

moderate pitting, 4 mm depression disappears in 10-15 seconds

Question 11

3+ edema

Answer 11

moderately severe pitting, 6 mm depression may last more than a minute

Question 12

4+ edema

Answer 12

severe pitting, 8 mm depression can last more than 2 minutes

Question 13

skin functions

Answer 13

protection
fluid & electrolyte balance
sensation
excretion
vitamin D
repair
external view of internal system
temperatuer regulation
youth and appearance

Question 14

how to interpret a Braden scale score

Answer 14

lower Braden score= higher risk
< 18 indicates risk status

Question 15

otitis media symptoms

Answer 15

red, bulging eardrum and diminished or absent light reflex

Question 16

how are the tonsils graded

Answer 16

1+ normal size or no tonsils
2+ tonsils a little enlarged
3+ tonsil touching uvula; tonsils beyond pillars
4+ tonsils expand to midline

Question 17

how should pupils react to penlight?

Answer 17

pupils constrict to direct and indirect light

Question 18

what does PERRLA stand for

Answer 18

pupils
equal
round
reactive to
light and
accommodation

Question 19

how to place otoscope in an adult ear

Answer 19

up & back

Question 20

how to place otoscope in a child ear

Answer 20

down & back

Question 21

where to you assess a dark-skinned person for pallor

Answer 21

eye & mouth lining

Question 22

weber test

Answer 22

strike the tuning fork on top of the head

Question 23

normal weber test

Answer 23

sound heard equally in both ears

Question 24

abnormal weber test

Answer 24

hear louder in one ear than the other

Question 25

conductive hearing loss

Answer 25

sound lateralizes to defective ear; something impairing passage of vibrations

Question 26

sensorineural hearing loss

Answer 26

sound lateralizes to the better ear; damage to inner ear

Question 27

rinne test

Answer 27

tuning fork at opening of the ear canal and patient states how long they hear the sound. once they can not hear it anymore, move tuning fork to the mastoid bone

Question 28

what does rinne test

Answer 28

air and bone conduction

Question 29

normal rinne test

Answer 29

AC > BC

Question 30

abnormal rinne test

Answer 30

BC > AC

Question 31

OD

Answer 31

ocular dexter (right eye)

Question 32

OS

Answer 32

ocular sinister (left eye)

Question 33

glaucoma

Answer 33

crescent shaped shadow in the iris, blurred vision, severe eye & head pain, nausea or vomiting, sudden sight loss

Question 34

normal snellen chart reading

Answer 34

20/20 in both eyes a patient can see at 20 feet what people normally see at 20 feet

Question 35

what type of vision loss is glaucoma

Answer 35

gradual peripheral vision loss

Question 36

macular degeneration

Answer 36

slow, progressive loss of central vision "you let the blinds down halfway"

Question 37

retinal detachment

Answer 37

sudden appearance of floaters, flashes of light in one or both eyes, blurred vision

Question 38

what type of vision loss is retinal detachment

Answer 38

gradual reduced peripheral vision; emergency!!

Question 39

cataracts

Answer 39

blurry/cloudy vision, cannot see well at night, halo around lights

Question 40

hypothyroidism

Answer 40

decreased metabolism; sensitive to cold, weight gain, constipation, muscle aches and weakness, fatigue, hair loss

Question 41

hyperthyroidism

Answer 41

increased metabolism; sensitive to hear, hyperactivity, difficulty sleeping, feeling tired all the time, unintentional weight loss, rapid heartbeat

Question 42

hirsutism

Answer 42

excessive facial hair on females, characteristic of Cushing disease

Question 43

macule

Answer 43

small, flat, non-palpable skin color change less than 1 cm; ex. freckles, flat moles, port wine stains

Question 44

papule

Answer 44

elevated, palpable, solid mass with border less than 0.5; ex. elevated nevi, warts

Question 45

vesicle

Answer 45

circumscribed elevated, palpable mass containing serous fluid less than 0.5 cm; ex. herpes simplex/zoster, varicella, poison ivy

Question 46

strabismus

Answer 46

constant misalighment of the eye

Question 47

nystagmus

Answer 47

an oscillating movement of the eye, may be associated with an inner ear disorder, multiple sclerosis, brain lesions, or narcotics use

Question 48

dysphagia

Answer 48

difficulty swallowing

Question 49

entropion

Answer 49

inverted lower eye lid

Question 50

ectropion

Answer 50

everted lower eye lid

Question 51

exophthalmos

Answer 51

protruding eyeballs and retracting eye lids

Question 52

presbycusis

Answer 52

gradual loss of hearing due to age, especially high-pitched sounds

Question 53

adenopathy

Answer 53

large or swollen lymph nodes

Question 54

lymph nodes to know

Answer 54

preauricular postauricular occipital submental submandibular tonsillar posterior cervical chain

Question 55

posterior cervical chain location

Answer 55

behind ear and dow both sides

Question 56

how do you palpate the thyroid gland?

Answer 56

stand behind patient, make sure their chin is lowered, ask patient to swallow and with one hand press and feel the thyroid move with the other

Question 57

what documentation is important regarding skin lesions?

Answer 57

COLDSPA type, color, shape, pattern, location, size, configuration

Question 58

confrontation test

Answer 58

tests visual fields; you are sitting across from pt and hold your fingers out and have pt tell you when they can see your fingers

Question 59

who is the control in the confrontation test

Answer 59

nurse

Question 60

cardinals field of gaze

Answer 60

make sure eye movement is clean and smooth

Question 61

ptosis

Answer 61

dropping of the lid

Question 62

what are the visual abnormalities associated with age

Answer 62

glaucoma macular degeneration cataracts

Question 63

acute angle glaucoma

Answer 63

sudden onset eye pain

Question 64

risk factors for oral cancer

Answer 64

smoking, alcohol, exposure to HDV, male gender, older than 55, poor oral hygiene

Question 65

temporal artery

Answer 65

palpate; tenderness and inflammation can lead to blindness

Question 66

purpose of the cochlea

Answer 66

helps with balance

Question 67

romberg test

Answer 67

tests for equilibrium

Question 68

tragus

Answer 68

inner ear