Exam 3 Study guide Flashcards
(180 cards)
1
Q
What pulse is identified by a surge of blood in the vessels
A
Arterial Pulse
2
Q
A pulse that is felt by compressing a superficial artery against an underlying bone
A
Arterial Pulse
3
Q
Blood vessels that carry oxygenated, nutrient rich blood from the heart to the capillaries
A
Arteries
4
Q
Is the arterial network a high or low pressure system ?
A
High pressure
5
Q
What is blood propelled from for the arteries?
A
Left ventricle
6
Q
What has thick and strong walls?
A
Arteries
7
Q
What vessel has walls that contain elastic fibers that stretch
A
Arteries
8
Q
What is the major artery that supplies the arm
A
Brachial Artery
9
Q
Where can the brachial pulse be palpated at ?
A
Medical to the biceps tendon
and
Above the bend of the elbow
10
Q
What does the brachial artery divide into?
A
Ulnar and radial artery
11
Q
What pulse is palpated near the medical aspect of the wrist and is a deeper pulse
A
Ulnar Pulse
12
Q
What pulse is palpated at the lateral aspect of the wrist
A
radial pulse
13
Q
What pulse is not easily palpated
A
Radial Pulse
14
Q
Where can the dorsal Pedis pulse be palpated at ?
A
The big toe on the top of the foot
15
Q
Where can the Posterior Tibial Artery be palpated at?
A
Behind the medial milieus of the ankle
16
Q
What is the purpose of the Dorsal Arch
A
To provide the feet and toes with extra protection from arterial inclusion
17
Q
How do you palpate the Popliteal Pulse?
A
It is palpated behind the knee
18
Q
Which artery is the major supplier to the legs
A
Femoral Artery
19
Q
Where is the femoral arteries pulse palpated?
A
Under the inguinal ligament
20
Q
What does the femoral artery flow into?
A
The Popliteal Artery
21
Q
Where can the Dorsal Pedis Pulse be palpated?
A
the top of the foot
22
Q
carries deoxygenated blood , nutrient depleted, waste laden blood from the tissues back to the heart
A
Veins
23
Q
What does the veins of the arms, upper trunk, head , and neck supply ?
A
Superior vena cava and the right atrium
24
Q
What does the veins of the lower trunk, and legs supply blood to?
A
Inferior Vena Cava
25
Why are vein walls much thinner then arteries?
The pressure of blood movement is lower
26
What do veins do that help reduce the hearts work flow?
Dilate in diameter and are expandable if blood volume increases
27
What are the three types of veins
Deep veins, superficial veins, and perforator ( or communicator)
28
What are the two types of deep veins
Popliteal ( knee) and femoral ( upper thigh)
29
What veins account for 90% of venous return in the lower extremities
Deep veins
30
How do skeletal muscles aid in blood propulsion back to the heart
By contracting the veins with movement, through sneezing the blood through the valves
31
Why do veins only have one way valves
this allows for blood to flow to the heart in one direction and doesn't let the deoxygenated blood mix with freshly oxygenated
32
Pressure Gradient
When inspiration increases abdominal pressure and decreases thoracic pressure at the same time producing a GRADIENT that moves blood
33
Any haltering in the three venous mechanisms produces what
Venous Stasis
34
lack of muscular activity can cause what ?
Blood to pool creating an increase in vein pressure leading to varicose veins
35
What force is created by interstitial fluid diffusing out of capillaries
Hydrostatic Force
36
Why is the capillary bed important to maintaining equilibrium
It can prevent edema from forming. Edema is caused by circulatory issues in the capillaries
37
Smoking increases the risk of what insufficiency
Arterial Insufficiency
38
Cold, Pale and clammy skin on the extremities is a sign of what insufficiency?
Arterial Insufficiency
39
Shiny skin with no hair over the lower legs is a sign of what kind of insufficiency ?
Arterial Insufficiency
40
What kind of insufficiency is associated with warm skin that is brown pigmented around the ankles
Venous Insufficiency
41
What Insufficiency is associated with dermatitis
Venous Insufficiency
42
Ulcers that are painful
Arterial
43
Ulcers that are circular, pale and black to dry
Arterial
44
Ulcers that are painless
Venous
45
Ulcers that occur in/ on the lower legal or medical ankle
Venous
46
Ulcers that's pain is identified as aching and cramping
Venous
47
Ulcers characterized by tough/ thick skin, and have no distinct borders
Venous
48
A type of insufficiency that is characterized by pallor with elevated legs
Arterial
49
What do you do when there is no palpable Dorsal Pedal Pulse
Grab a doppler
50
0 pulse
Absent
51
1+
weak, diminished, easy to obliterate
52
2+
normal, obliterate with normal pressure
53
3+
bounding, unable to obliterate with pressure
54
insufficiency characterized by diminished pulses, dependent rubor, and intermittent sharp pain
Arterial insufficiency
55
Thick and rigid nails is a sign of
arterial insufficiency
56
ulcers that are reddish- blue in color
Venous ulcers
57
Edemas
Prominent in venous insufficiency
58
What does the dorsal ped pulse tell us
It tells us if we have flow to the legs
59
If you cannot find the Doral ped pulse is it arterial or vascular
It is a vascular issue if you cannot find the pulse
60
Are clots a sign of arterial or venous insufficiency
Arterial
61
What is a major identifier of venous insufficiency in med
No hair on the shins
62
What can cause edema and vein expansion
venous insufficiency
63
True or false.... venous is gravity dependent
true
64
Thick and leathery skin, that is thick, leathery, and irregularly shaped is due to what ?
venous insufficiency
65
An ulcer that has edema only in a localized fashion in the form of inflammation
Arterial ulcers
66
An ulcer that has associated systematic edema
Venous ulcers
67
Ulcers that are circular, deep and painful
Arterial ulcers
68
Ulcers that coincide with skin pigmentation
Venous ulcers
69
pink, and red ulcers
Venous ulcers
70
What is the order of a GI assessment
```
Inspection
Auscultation
Percussion
Palpation
make sure to approach from the right side
```
71
Purple discoloration of the flanks indicates abdominal wall bleeding and is called what ?
Grey- Turners syndrome
72
Pale, taunt, skin on the abdomen is a sign of what
Ascites
73
Ascites is what ?
Fluid in the abdomen that can be a sign of severe liver disease
74
Ascites can form what ?
Striae
75
Redness on the abdomen is an indication of what
Inflammation
76
Vascularity of the umbilical above the bellybutton flows towards what
The head
77
Vascularity of the umbilical below the bellybutton flows towards what ?
The lower body
78
Distended veins on the abdomen are a sign of what
Liver cirrhosis, portal hypertension , ascites, obstruction of the inferior vena cava.
79
A spider angioma on the abdomen is a sign of what
Liver disease and portal hypertension
80
Striae are ?
Stretchmarks
81
pink and blue striae are ?
new striae
82
What is a sign of old striae
silvery, linear, and white
83
Cushing's Syndrome?
Dark blue- pink striae
84
Cullens Sign
Blue or purple discoloration around the umbilicus
85
What is Cullens sign and indicator of
intra- abdominal bleeding
86
Grey - Turner
bluish or purplish discoloration of the abdominal flanks
87
Everted umbilicus is a sign of
Abdominal distension
88
Enlarged everted umbilicus is a sign of
Umbilical hernia
89
Vigorous, wide, exaggerated pulsations may be seen with what?
An AAA ( ABDOMINAL AORTIC ANEURYSM )
90
Hearing bruits in the abdomen
AAA An AAA ( ABDOMINAL AORTIC ANEURYSM )
91
What is a AAA ( ABDOMINAL AORTIC ANEURYSM )
Weakness in the aortic was that can extend to the LUQ, it is a silent killer and you are born with it
92
What does peristaltic waves indicated
An obstruction in the intestines
93
What can absent bowl sounds be a indicator of ?
Peritonitis or a Paralytic Illeus
94
In what quadrant are peristaltic waves mostly heard
LUQ to RLQ
95
What are considered average bowl sounds
5-30 bowl sounds every 5 to 15 seconds
96
What is an indicator of hyperactive bowl sounds
rushing, tinkling, or high pitches sounds
97
When are hyperactive bowl sounds heard
bowl obstructions, gastroenteritis, diarrhea, and can be heard when laxatives are given
98
What is an indicator of hypoactive bowl sounds
diminished bowl motility
99
When are hypoactive bowl sounds heard
When there could possibly be a parasitic illeus following abdominal surgery, inflammation, or a late bowl obstruction
100
How long must you wait to declare there are no bowl sounds
5 minutes
101
How long does it take the small intestine to function properly after surgery
the first few hours post op
102
How long does it take for the stomach to resume emptying after surgery
24- 48 hours
103
How long does the colon take to resume propulsive function after surgery
3 to 5 days
104
When does a nurse suspect a hernia
when there is a profusion on the clients abdomen when she asks them to bear down
105
Besides palpation what is a second test that can be done to test for ascites
Fluid wave test
106
What is the blumberg's sign
rebound tenderness, that is the RLQ that can indicate peritoneal inflammation
107
What is a positive Rovsing sign?
Pain in the RLQ during pressure in the LLQ
108
Murphys Sign is
sharp pain that causes the client to hold there breathe, it can be a sign of cholecystitis
109
Psoas Sign
Pain in the RLQ when the leg is hyperextended
110
What does Psoas an indicator of
an inflamed appendix
111
Murphys sign is used when
pain is found under the liver boarder and is a sign of gallbladder issues
112
Pain over the CVA can be an indicator of what
A kidney infection
113
Rebound tenderness / Blumberg's sign is ?
When there is pain upon removal or pressure not when pressure is applied.
114
What is peritonitis
Inflammation of the belly or abdomen tissue that lines it
115
Papilledema
swelling of the optic nerve, occurs due to increased intercranial pressure
116
Ptosis
Drooping of the eyelid ( seen with weak eye muscles ),
117
Limited eye movement through the six cardinal fields of gaze:
increased intracranial pressure.
118
Paralytic strabismus
paralysis of the oculomotor, trochlear, or abducens nerves
119
Dilated pupil (6–7 mm)
oculomotor nerve paralysis
120
Argyll Robertson pupils:
CNS syphilis, meningitis, brain tumor, alcoholism.
121
Constricted, fixed pupils
narcotics abuse or damage to the pons.
122
Unilaterally dilated pupil unresponsive to light or accommodation
damage to cranial nerve III (oculomotor)
123
Constricted pupil unresponsive to light or accommodation:
lesions of the sympathetic nervous system.
124
Damage to cranial nerve VII (facial) results in the client’s
inability to close the eyes or wrinkle the forehead
125
Loss of visual fields and drooping of eyelids is seen
Damage to the cranial nerve II ( ocular)
126
Positive Romberg test
Swaying and moving feet apart to prevent fall is seen with disease of the posterior columns, vestibular dysfunction, or cerebellar disorders.
127
astereognosis
Inability to correctly identify objects
128
Wide base, with a staggering unsteady gait
Cerebellar Ataxia
129
A gait found when a Romberg's test is positive
Cerebellar Atacia ( client cannot stand when the feet are together )
130
Stiff, short gait, where the thighs overlap
Scissors Gait
131
A gait seen with partial leg paralysis
Scissors gait
132
A shuffling gait, where the turns are stiff
Parkinson's gait
133
A gait where the arm is flexed and held close to the body
Spastic Herniparesis
134
Client lifts foot high then slaps the foot down hard on the ground
Foot Drop ( steppage gait)
135
What is cranial nerve 1
Olfactory
136
What is cranial nerve ones function
smell
137
How do you test for cranial nerve number one olfactory
Have a patient identify a familiar scent with their eyes closed
138
What is cranial nerve ones classification?
Sensory
139
What is cranial nerve II
Optic
140
What is Cranial nerve II function
vision, and pupil reactivity to light
141
How do you assess for Cranial nerve II
Have a patient read one eye at a time , test visual fields
142
How do you assess for Cranial nerve III
Check pupillary response ( have the patient up, down, and side to side)
143
What is Cranial nerve II classification
Sensory
144
What is Cranial nerve III
Oculomotor
145
What is the function of Cranial nerve III
Pupil size and reactivity
146
What is Cranial Nerve III classification
Motor
147
What is cranial nerve IV
Trochlear
148
What is cranial nerve IV classification
Motor
149
What is cranial nerve IV's function
eye range of motion
150
How do you assess cranial nerve IV
by having the patient turn there eyes down and inward
151
What is cranial nerve V
Trigeminal
152
What is the classification of cranial nerve V
both motor and sensory
153
What is the major function of cranial nerve V
Chewing, along with facial and mouth sensation
154
What is cranial nerve VI
Abducens
155
What is cranial nerve VI's classification
motor
156
What is cranial nerve VI's major function
IF the eye can turn laterally
157
How do you assess cranial nerve VI
By having the patient move their eyes side to side
158
What is cranial nerve VII
Facial
159
What is cranial nerve VII's classification
sensory
160
what is cranial nerve VII's major function
Facial expression , posterior tongue taste buds, and eyelid and lip closure
161
What is cranial nerve VIII
Acoustic
162
What is cranial nerve VIII's function
hearing and equilibrium
163
How do you assess cranial nerve VIII
using a tuning fork rubbing fingers together, and whispering
164
What is cranial nerve IX
Glossopharyngeal
165
What is VIII's classification
sensory
166
How do you test for cranial nerve IX
gag reflex, touch the back of the throat with a tongue depressor, or have the patient swallow
167
Cranial nerve iX classification
both sensory and motor
168
Cranial nerve IX major function
gagging and swallowing
169
cranial Nerve X
Vagus
170
Cranial nerve X classification
sensory and motor
171
Cranial Nerve X function
speech
172
Cranial nerve X assessment
assess speech, gagging, and swallowing
173
Cranial nerve XI
Spinal Accessory
174
Cranial nerve XI classification
motor
175
Cranial nerve XI functions
shoulder movement and head rotation
176
How to test for cranial nerve XI
have the patient shrug shoulders
177
Cranial nerve XIII
Hypoglossial
178
Cranial nerve XIII classification
motor
179
cranial nerve XIII function
tongue movement
180
How to test for cranial nerve XIII
Have the patient stick out there tongue and move it side to side
