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NUR 326 > Exam 3 > Flashcards

Exam 3 Flashcards

1
Q

Location of the apical pulse

A

5th ICS at the MCL

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2
Q

How to palpate apical pulse

A

Remain on pt right side, have pt supine, use finger pads

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3
Q

When auscultating the heart what do you listen for first?

A

HR and rhythm

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4
Q

When auscultating the heart what do you listen for after identifying the HR and rhythm?

A

S1 and S2

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5
Q

What is S1? Where is it the loudest?

A

“lub” starts systole
Closure of AV valves (bi and tricuspid)
Loudest at apex of heart

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6
Q

What is S2? Where is it the loudest?

A

“dub” starts diastole
Closure of semilunar valves (aortic and pulmonary)
Loudest at the base of the heart

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7
Q

What is a thrill?

A

Palpable vibration/pulsation over precordium or artery

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8
Q

What is a bruit?

A

Swishing sound caused by turbulent blood flow through a narrowed vessel

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9
Q

What is the main difference b/w a bruit and a thrill?

A

Bruit you hear, thrill you palpate/feel

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10
Q

How do you assess the size of the aorta?

A

Palpate deep in the epigastrium left of the midline.

Width can be measured by placing both palms on the abdomen with 1 index finger extended on either side of the aorta

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11
Q

What is a weak pulse indicative of?

A

Hypovolemia, shock, decreased cardiac output

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12
Q

What is a strong and bounding pulse typically caused by?

A

Hypervolemia

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13
Q

Pulse amplitude scale: 1+

A

weak, diminished (easy to obliterate)

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14
Q

Pulse amplitude scale: 2+

A

Normal (obliterate w moderate pressure)

This is what we want the pulse to be

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15
Q

Pulse amplitude scale: 3+

A

Strong (obliterate w firm pressure)

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16
Q

Pulse amplitude scale: 4+

A

Bounding (unable to obliterate)

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17
Q

Pulse amplitude scale: 0

A

Pulse is absent

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18
Q

Where is the radial artery?

A

Extends down the thumb side of the arm

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19
Q

Where is the ulnar artery?

A

Extends down the pinky side of the arm

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20
Q

Where can you palpate the femoral artery?

A

Just under the inguinal ligament

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21
Q

Where is the posterior tibial artery?

A

B/w the medial malleolus and achilles tendon

Palpated behind the medial malleolus of the ankle

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22
Q

Where is the dorsalis pedis artery palpated?

A

On top of the foot by the big toe side

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23
Q

What is a doppler used for?

A

To find a pulse you cannot palpate

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24
Q

How do you measure the ankle-brachial index?

A

Systolic BP of ankle divided by systolic BP of arm

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25
Q

Why would we measure the ankle-brachial index?

A

If the pt has arterial occlusion

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26
Q

What is a pulse deficit?

A

Difference b/w the apical and peripheral/radial pulses

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27
Q

How do you assess for a pulse deficit?

A

Palpate the radial pulse while auscultating the apical pulse for one full minute, they should be identical

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28
Q

What would indicate the need to assess for a pulse deficit?

A

An irregular rhythm

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29
Q

What are common causes of a pulse deficit?

A

A-fib, atrial flutter, premature ventricular contractions, heart block

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30
Q

Describe pallor

A

Loss of color
Tone may go from pale to ashen
Seen in arterial insufficiency, decr blood supply, and anemia

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31
Q

Describe the color of cyanosis in light and dark skinned people

A

Blue tinge of skin for light skin

Darker skin may appear blue, dull, or lifeless

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32
Q

Central cyanosis is seen where?

Caused most frequently by what?

A

Seen around the mouth - assess mucous membrane/oral mucosa

Usually d/t resp prob or cardiopulmonary prob

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33
Q

Peripheral cyanosis is seen where?

Caused most frequently by what?

A

Seen in the nail bed or conjunctiva and extremities

D/t circulatory prob (vasoconstriction)

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34
Q

Where is jaundice most commonly noticed for light and dark skinned people?

A

Yellow tone noticed in sclera and oral mucosa

Dark skinned people it is seen best in oral mucosal membrane where soft and hard palate meet

35
Q

What is erythema commonly seen with?

A

Inflammation, allergic reactions, trauma

36
Q

How to assess skin?

What is the normal finding?

A

Dorsal side of hand (back of hand)

Warm skin, not hot; usually mobile w elasticity

37
Q

What does turgor refer to?

A

Skin elasticity and how quickly it returns to its original shape

38
Q

What skin finding might be associated with extreme weight loss and dehydration?

A

Poor skin turgor

39
Q

What might a half white, half pink nail indicate?

A

Kidney disease

40
Q

What might the nail of someone with iron deficiency anemia look like?

A

Thin or concave nail

41
Q

What is nail clubbing a result of?

A

Low O2, can be a sign of various types of lung diseases

42
Q

Papule vs vesicle

A

Papule is an elevated, solid mass

Vesicle is fluid filled, not solid

43
Q

What type of skin lesion is a freckle, flat mole, ecchymosis, or rubella?

A

Macule

44
Q

What type of skin lesion is poison ivy, herpes, varicella, or second-degree burns?

A

Vesicle

45
Q

Urticaria and insect bites are what type of skin lesion?

A

Wheal

46
Q

What is a wheal caused by?

A

movement of serous fluid into the dermis, it does not contain free fluid in a cavity like a vesicle does

47
Q

What does ABCDE stand for when assessing a skin lesion?

A

Asymmetry, Boarder (irregular or uneven), Color changes, Diameter ( > 1/4 in or 6mm), Elevated/Evolution (how it changes over time)

48
Q

What is the scratch test for? How is it done?

A

Used when palpating the liver suggests enlargement, also useful if the abdomen is tense, distended, obese, or too tender to palpate
Auscultate and palpate
When you reach the liver’s edge the sound will be magnified if it’s enlarged

49
Q

Where do you palpate the spleen?

A

ULQ

50
Q

Normal finding for palpating the spleen

A

Not firm, won’t feel it

51
Q

When assessing the spleen you find dullness, what does this mean and what should you do?

A

Stop palpating bc it can rupture
Dullness = enlarged spleen
Prepare for splenectomy

52
Q

What is the Blumberg sign?

A

When you press the abdomen there is no pain but when you release the pressure there is pain
This indicates appendicitis

53
Q

What is the psoas sign?

A

Tests for appendicitis

Have client lay on left side, flex the hip (hyperextend) Pain in the RLQ = positive psoas = appendicitis

54
Q

What would fluid or ascites in the peritoneal cavity look and sound like?

A

Abnormal distension

Hyperresonance

55
Q

What is the term for difficulty swallowing?

A

DysphaGia (remember g for gustatory)

56
Q

What is the term for difficulty speaking?

A

DysphaSia (remember s for speak)

57
Q

What is the term for heartburn?

A

Pyrosis (pyro = fire)

58
Q

What is the term for black, tarry stool?

A

Melena

59
Q

What can you use to measure ROM in degrees?

A

Goniometer

60
Q

ROM scale: 5

A

Normal

Active motion against full resistance

61
Q

ROM scale: 4

A

Slight weakness

Active motion against some resistance

62
Q

ROM scale: 3

A

Average weakness

Active motion against gravity

63
Q

ROM scale: 2

A 
Poor ROM
Passive ROM (assisted)
64
Q

ROM scale: 1

A

Severe weakness

Slight flicker of contraction

65
Q

ROM scale: 0

A

Paralysis

No muscular contraction

66
Q

What is the bulge sign?

A

Confirms presence of small amt of fluid across joint (often in knee)
Firmly stroke up the medial aspect of the knee 2-3 times and you will see fluid displaced, this confirms a positive bulge sign

67
Q

What test confirms sciatica?

How do you test it?

A

Straight leg test

Pt lay on back and extend leg bent at knee if it causes pain it is positive, should not cause pain normally

68
Q

Osteoarthritis vs RA

A

Osteo: not inflammatory, localized disorder, hard nontender nodules on sides of interphalangeal joints (heberden nodes), usually painless
RA: chronic inflammatory process w swelling of joints leads to fibrosis and bone destruction, limited ROM, deformities; painful, swollen and tender
stiffness, esp in the morning

69
Q

Swelling from excessive fluid in the joint capsule is called what?

A

Joint diffusion

70
Q

Romberg test tests for what and how?

A

Balance

Pt should stand erect w minimal swaying w eyes both open and closed

71
Q

What is the name for the ability to tell what an object is with your eyes closed?

A

Stereognosis

72
Q

Reflex grading scale: 4+

A

Hyperreflexia
Brisk/hyperactive w clonus
Indicative of neurologic disease, swelling, or edema

73
Q

Reflex grading scale: 3+

A

Increased/brisker than normal but not pathologic

74
Q

Reflex grading scale: 2+

A

Normal

75
Q

Reflex grading scale: 1+

A

Present but diminished/decreased

76
Q

Reflex grading scale: 0

A

Hyporeflexia

No response at all

77
Q

What is orchitis? What is it associated with?

A

Inflammation of the testes
Associated w mumps
Genital pain, swollen, tender, heaviness, fever

78
Q

What does epididymitis present with?

A

Sudden pain with enlarged, red, swollen scrotum

79
Q

Where are skene glands located and what is their purpose?

A

On either side of the urethral opening of a female

Secrete mucus to lubricate and maintain a moist environment

80
Q

Where are bartholin glands located and what is their purpose?

A

B/w the vaginal opening and the labia minora

Secrete mucus to lubricate area during sexual intercourse

81
Q

What abnormal finding presents w genital warts and a yellow-green, frothy, and foul smelling discharge?

A

Trichomonas

82
Q

What abnormal finding presents with a painless, silvery/white papule on the genitalia?

A

Syphilis

83
Q

What is candidiasis?

How does it present?

A

Overgrowth of yeast

Thick, white, cheesy discharge w intense itching

NUR 326 (1 decks)

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