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NUR 326 > Exam 3 > Flashcards

Exam 3 Flashcards

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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
Why would we measure the ankle-brachial index?
If the pt has arterial occlusion
26
What is a pulse deficit?
Difference b/w the apical and peripheral/radial pulses
27
How do you assess for a pulse deficit?
Palpate the radial pulse while auscultating the apical pulse for one full minute, they should be identical
28
What would indicate the need to assess for a pulse deficit?
An irregular rhythm
29
What are common causes of a pulse deficit?
A-fib, atrial flutter, premature ventricular contractions, heart block
30
Describe pallor
Loss of color Tone may go from pale to ashen Seen in arterial insufficiency, decr blood supply, and anemia
31
Describe the color of cyanosis in light and dark skinned people
Blue tinge of skin for light skin | Darker skin may appear blue, dull, or lifeless
32
Central cyanosis is seen where? | Caused most frequently by what?
Seen around the mouth - assess mucous membrane/oral mucosa | Usually d/t resp prob or cardiopulmonary prob
33
Peripheral cyanosis is seen where? | Caused most frequently by what?
Seen in the nail bed or conjunctiva and extremities | D/t circulatory prob (vasoconstriction)
34
Where is jaundice most commonly noticed for light and dark skinned people?
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
What is erythema commonly seen with?
Inflammation, allergic reactions, trauma
36
How to assess skin? | What is the normal finding?
Dorsal side of hand (back of hand) | Warm skin, not hot; usually mobile w elasticity
37
What does turgor refer to?
Skin elasticity and how quickly it returns to its original shape
38
What skin finding might be associated with extreme weight loss and dehydration?
Poor skin turgor
39
What might a half white, half pink nail indicate?
Kidney disease
40
What might the nail of someone with iron deficiency anemia look like?
Thin or concave nail
41
What is nail clubbing a result of?
Low O2, can be a sign of various types of lung diseases
42
Papule vs vesicle
Papule is an elevated, solid mass | Vesicle is fluid filled, not solid
43
What type of skin lesion is a freckle, flat mole, ecchymosis, or rubella?
Macule
44
What type of skin lesion is poison ivy, herpes, varicella, or second-degree burns?
Vesicle
45
Urticaria and insect bites are what type of skin lesion?
Wheal
46
What is a wheal caused by?
movement of serous fluid into the dermis, it does not contain free fluid in a cavity like a vesicle does
47
What does ABCDE stand for when assessing a skin lesion?
Asymmetry, Boarder (irregular or uneven), Color changes, Diameter ( > 1/4 in or 6mm), Elevated/Evolution (how it changes over time)
48
What is the scratch test for? How is it done?
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
Where do you palpate the spleen?
ULQ
50
Normal finding for palpating the spleen
Not firm, won't feel it
51
When assessing the spleen you find dullness, what does this mean and what should you do?
Stop palpating bc it can rupture Dullness = enlarged spleen Prepare for splenectomy
52
What is the Blumberg sign?
When you press the abdomen there is no pain but when you release the pressure there is pain This indicates appendicitis
53
What is the psoas sign?
Tests for appendicitis | Have client lay on left side, flex the hip (hyperextend) Pain in the RLQ = positive psoas = appendicitis
54
What would fluid or ascites in the peritoneal cavity look and sound like?
Abnormal distension | Hyperresonance
55
What is the term for difficulty swallowing?
DysphaGia (remember g for gustatory)
56
What is the term for difficulty speaking?
DysphaSia (remember s for speak)
57
What is the term for heartburn?
Pyrosis (pyro = fire)
58
What is the term for black, tarry stool?
Melena
59
What can you use to measure ROM in degrees?
Goniometer
60
ROM scale: 5
Normal | Active motion against full resistance
61
ROM scale: 4
Slight weakness | Active motion against some resistance
62
ROM scale: 3
Average weakness | Active motion against gravity
63
ROM scale: 2
``` Poor ROM Passive ROM (assisted) ```
64
ROM scale: 1
Severe weakness | Slight flicker of contraction
65
ROM scale: 0
Paralysis | No muscular contraction
66
What is the bulge sign?
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
What test confirms sciatica? | How do you test it?
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
Osteoarthritis vs RA
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
Swelling from excessive fluid in the joint capsule is called what?
Joint diffusion
70
Romberg test tests for what and how?
Balance | Pt should stand erect w minimal swaying w eyes both open and closed
71
What is the name for the ability to tell what an object is with your eyes closed?
Stereognosis
72
Reflex grading scale: 4+
Hyperreflexia Brisk/hyperactive w clonus Indicative of neurologic disease, swelling, or edema
73
Reflex grading scale: 3+
Increased/brisker than normal but not pathologic
74
Reflex grading scale: 2+
Normal
75
Reflex grading scale: 1+
Present but diminished/decreased
76
Reflex grading scale: 0
Hyporeflexia | No response at all
77
What is orchitis? What is it associated with?
Inflammation of the testes Associated w mumps Genital pain, swollen, tender, heaviness, fever
78
What does epididymitis present with?
Sudden pain with enlarged, red, swollen scrotum
79
Where are skene glands located and what is their purpose?
On either side of the urethral opening of a female | Secrete mucus to lubricate and maintain a moist environment
80
Where are bartholin glands located and what is their purpose?
B/w the vaginal opening and the labia minora | Secrete mucus to lubricate area during sexual intercourse
81
What abnormal finding presents w genital warts and a yellow-green, frothy, and foul smelling discharge?
Trichomonas
82
What abnormal finding presents with a painless, silvery/white papule on the genitalia?
Syphilis
83
What is candidiasis? | How does it present?
Overgrowth of yeast | Thick, white, cheesy discharge w intense itching

NUR 326 (1 decks)

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