Final Review Flashcards
(177 cards)
1
Q
what technique to elicit crepitus on chest injury?
A
palpation
2
Q
what technique for diaphragmatic excursion?
A
percussion
3
Q
what technique for full/distended bladder?
A
indirect percussion
4
Q
what technique for the sinuses?
A
direct percussion
5
Q
what technique for the lungs?
A
indirect percussion
6
Q
transilluminator
A
detect blood, fluid, or masses in body cavity
7
Q
wheal
A
reddend, irreg border
- ie/ insect bite, hives
8
Q
lichenification
A
rough, thick, hardened epidermis due to constant scratching/rubbing
9
Q
venous lake
vascular lesion
A
elevated, dark blue, compressible soft lesion on the lip or neck
- common in elderly
10
Q
port wine stain
vascular lesion
A
falt, irreg, pale-deep purple red;
color deepens in response to emotion or high temp
11
Q
hemengioma
vascular lesion
A
bright red, raised, nonblanch
- present @ birth - few months after
- disappears at age 10
12
Q
spider angioma
vascular lesion
A
flat red dot w/ tiny radiating vessels; pinpoint - 2 cm; blanchable
13
Q
light palpation
A
fingerpads of 1 hand
- 0.5-1 cm
14
Q
moderate palpation
A
fingerpads
- 2-3 cm
15
Q
deep palpation
A
palmar surface; bimanual
- 4-5 cm
- liver, spleen, kidneys
16
Q
indication:
open sore on hand; not healed for several months
A
malignancy/skin cancer
17
Q
nystagmus
A
jerky eye movement during 6 cardinal field of gaze
18
Q
weber test
A
normal: equal lateralization to right and left ears
- abnormal: impacted cerumen; lateralization towards the ear w/ cerumen
19
Q
rhine test
A
normal: air conduction 2x greater than bone conduction
20
Q
craniosynostosis
A
infant w/ elongated head; altered face and orbit of eyes
21
Q
presbyopia
A
difficulty with near vision
- common in ages 45+
22
Q
hyperopia
A
difficulty w/ near vision
23
Q
myopia
A
difficulty w/ far vision
24
Q
acute glaucoma
A
increase pressure in the eyes
- S/Sx: sudden pain; ↓ vision; halos around light; dilated, oval pupil; cloudy cornea w/ curcumcorneal redness
- Outcome: may lose vision in 1-2 hours
- Tx: surgery
- EMERGENCY; IMMEDIATE ATTENTION
25
otitis externa
infection of outer ear; tympanic normal, pearly grey
26
otitis media
infection external & ossicles
27
otitis interna
| (labyrinthitis)
infection in the semicircular canal, cochlea, & vestibule
- **S/Sx**: severe vertigo, dizziness
28
otoscope
funnels light into ear canal
29
retinal detachment
- **S/Sx:** diminished vision; floaters; sudden flash; shadow in vision
- **Outcome:** lose vision withing days of diagnosis
- **Tx:** laser surgery (photocoagulation); freezing (cryopexy)
30
how to assess EOM
6 cardinal fields of gaze
- H or wheel wagon method
31
leading cause of blindness in US?
diabetic retinopathy
32
how to test integrity of cranial nerve III?
look up and down without moving head
33
# indication:
white patches of tympanic membrane
scarring from previous infection
34
# nursing care:
positive rombergs test
provide bedside comode
35
sinus headache
from sinus infection
36
classic migraine
preceded by aura; spots and flashes; numbness/tingling of face and extremities
37
cluster headache
numerous headaches over days-months; no aura; sudden onset
- associated w/ alcohol, stress, or emotional distress
- may last for a few minutes-hours
38
tension headache
| (muscle contraction headache)
gradual onset; steady pain; starts from cervical to top of head; unilateral or bilateral
- associated with stress, overwork, dental problem
39
intropion
inverted upper lid
- irritation of eyes
40
ectropian
lower lid everted
- exposes conjunctiva
41
most common hyperthyroidism
graves' disease
42
gingivitis
- **S/Sx:** red, bleeding, receeding gums
43
# expected finding:
bell's palsy
- muscle distortion
- pain behind ears
- impaired taste
44
# expected finding:
1) no fluid in sinus
2) fluid in sinus
1) red glow
2) no red glow
45
SBE for elderly client
the same day every month
46
SBE for mensturating client
3-5 days after cycle
- hormones are more stable
47
common cause of benign nipple discharge
intraductal papilloma
- postmenopausal client
- serous/bloody discharge
48
benign breast
| (fibrocystic disease)
- **S/Sx:** lumps, pain/tenderness, and nipple discharge due to thickening of breast tissure
- common in womens 20's
49
fibroadenoma
defined breast tumor w/ NO tenderness/discharge
- common in ages 15-35
50
Peau D' Orange
orange peel appearance
- indicates malignancy
51
most reliable indicator of central cyanosis in asthma client
oral mucosa
52
early signs of hypoxia
- altered LOC
53
# abnormal findings:
whispered pectriloguy w/ bilateral PNA
| (both lungs filled w/ fluid)
loud, clear bilaterally
54
# expected findings:
whispered pectriloguy
## Footnote
auscultate technique
soft, indistinguishable
55
technique to assess respiratory system
assessing from side to side
56
tracheal
## Footnote
normal lung sounds
harsh, high-pitch
- I < E
- over trachea
57
bronchial
## Footnote
normal lung sounds
loud, high-pitch
- E > I
- next to trachea, above each clavical, 1st ICS
58
broncho-vesicular
## Footnote
normal lung sounds
medium, medium-pitch
- I = E
- over major bronchi in 2nd & 3rd ICS; between scapulae
59
vesicular
## Footnote
normal lung sounds
soft, low-pitch
- I > E
- remainder of the lungs
60
bradypnea vs hypoventilation
## Footnote
abnormal breathing patterns
< 10 breaths/min; slow
- **bradypnea:** regular
- **hypoventilation:** irregular
61
tachypnea vs hyperventilation
## Footnote
abnormal breathing patterns
> 20 breaths/min; rapid
- **tachypnea:** shallow
- **hyperventilation:** deep
62
cheyne-stokes vs biot's (ataxic)
## Footnote
abnormal breathing patterns
periods of apnea
- **cheyne-stokes:** regular; in dying patients
- **biot's (ataxic):** irregular; brain damage
63
crackles
## Footnote
adventitious sounds
low-pitched, bubbling, loud
- due to collapsed, fluid filled lungs
- *ie/ lobar pnuemonia
64
rhonchi
| (sibilant)
## Footnote
adventitious sounds
high-pitched, continuous
- due to blocked airflow
- *ie/ asthma*
65
rhonchi
| (sonorous)
## Footnote
adventitious sounds
low-pitched, continuous, snoring, rattling
- *ie/ COPD*
66
stridor
## Footnote
adventitious sounds
loud, high-pitched, crowing heard W/O stethoscope
- common in obstructive upper airway
67
friction rub
## Footnote
adventitious sounds
low-pitched, grating, rubbing
- *ie/ pleural inflammation
68
# expected findings:
normal chest
## Footnote
chest configuration
elliptical with lateral diameter 2:1 with anteroposterior diameter
- usually by age 6
69
# expected findings:
infant chest
## Footnote
chest configuration
rounded; equilateral in anteroposterior diameter; barrel chest
- COPD = barrel chest
70
# abnormal findings:
pectus carinatum
| (pigeon chest)
## Footnote
congenital chest deformities
forward displacement of sternum w/ depression of adjacent cartilage
- no tx required
71
# abnormal findings:
pectus excavatum
| (funnel chest)
## Footnote
congenital chest deformities
depression of sternum & adjacent cartilage
- cradiac murmur
- surgery required in severe cases
72
# abnormal findings:
scoliosis
## Footnote
chest configurations
lateral curve of spinal process
- common in female
73
# abnormal findings:
kyphosis
## Footnote
chest configurations
exaggerated posterior curve of thoracic spine
- associated w/ aging
74
# abnormal findings:
lordosis
## Footnote
chest configurations
exaggerated curve of lumbar spine
- during last term of pregnancy
75
# indication:
hyperesonant sound on percussion of lungs
## Footnote
breath sounds
air trapped in lungs
76
# abnormal findings:
pleural effusion
## Footnote
auscultation of breath sounds
absent breath sounds of affected lung
77
# indication:
low-pitched, loud, moist, bubbling on auscultation
## Footnote
adventitious lung sounds
fluid filled alveoli
78
what part of the chest do you perform cardiac assessment?
precordium
79
location of PMI
| (point of maximal impact)
left midclavicular line; 5th ICS
80
erb's point
## Footnote
cardiac landmark
3rd ICS; LSB
81
angle of louis
## Footnote
cardiac landmark
articulation of manubrium & body of sternum in line w/ 2nd rib
82
# abnormal findings:
arterial insufficiency
## Footnote
peripheral vascular
- cold, no hair
- deep muscle pain from activity/elevation of limb
83
# abnormal finding:
venous insufficiency
## Footnote
peripheral vascular
- temp is normal, edema
- pain from prolonged standing/sitting
84
ECG
| (electrocardiogram)
electrical representation of cardiac cycles, documented by a deflection on a recording paper
85
depolarization
| (contraction)
## Footnote
ECG
after stimulation by electrical current
- inside cardiac cells: **+** charge
86
repolarization
| (relaxation)
## Footnote
ECG
after contraction
- inside cardiac cells: **-** charge
87
P wave
## Footnote
ECG
atrial depolarization
- ~ 0.08 secs
88
PR interval
## Footnote
ECG
time needed for electrical current to travel across both atrium & arrive at AV node
- 0.12 - 0.20 secs
89
where is atrial polarization hidden in?
## Footnote
ECG
QRS interval
90
QRS interval
## Footnote
ECG
ventricular depolarization
- .08 - 0.11 secs
91
T wave
## Footnote
ECG
ventricular repolarization
92
QT interval
## Footnote
ECG
beginning of ventricular depolarization to moment of repolarization
| (ventricular contraction)
93
allen's test
determines the patency of radial and ulnar ateries
94
# abnormal findings:
raynaud's disease
## Footnote
peripheral vascular
spasm/tingling of hands & fingertips turn whitish → cyanotic → reddish
- common in young, healthy females 2/2 connective tissue disease, drug intoxication, pulmonary HTN, or trauma
95
deep vein thrombosis
| (DVT)
## Footnote
peripheral vascular
occulsions of deep veins by blood clot
- sudden swelling on one leg
- dependent edema
- ***IMMEDIATE REFERRAL; can become VTE → lung = PE***
96
# subjective findings:
DVT
## Footnote
peripheral vascular
- intense, sharp pain along the iliac, popliteal, or calf muscle
- intense pain w/ dorsiflexion of foot
97
# objective findings:
DVT
## Footnote
peripheral vascular
- unilateral edema
- low grade fever
- tachycardia
98
# abnormal findings:
infective endocarditis
thin red lines or splinter hemorrhages on nail beds
99
pathological cardiac murmurs
structural abnormalities of the heart
- mitral regurgitation
- tricuspid stenosis
- aortic regurgitation
100
aortic area
## Footnote
cardiac landmark
2nd ICS, RSB
101
S2
| (dub)
## Footnote
heart sounds
closure of the semilunar valves
- loudest at the base of the heart
102
S1
| (lub)
## Footnote
heart sounds
closure of the tricuspid and mitral valves
- loudest at the apex of the heart
103
SA node
pacemaker of the heart; where the initial electrical impulse occurs
- 60 - 100 joules/min
104
AV node
60 joules/min
105
bundle branches
40 - 60 joules/min
106
S4
| (atrial gallop)
## Footnote
heart sounds
before S1
107
S3
| (ventricular gallop)
## Footnote
heart sounds
after S2
108
what are the major risk factor for diseases?
smoking, HTN, DM, obesity, & high cholesterol
109
foramen ovlale
## Footnote
congenital heart diseases
passage way for blood between the atriums
- should close shortly after birth
110
ductus arteriosus
## Footnote
congenital heart diseases
opening between the pulmonary artery and the descending aorta
- should close 24 - 48 hours after birth
111
tetralogy of fallot
## Footnote
congenital heart diseases
- 4 cardiac defects
- ***life threatening; sx right away***
112
sympathetic
## Footnote
cardiac nerves
stimulates the heart
- ↑HR, ↑ dilation of coronary arteries
113
parasympathetic
## Footnote
cardiac nerves
↓ stimulation of the heart
- ↓HR, ↓ contraction of heart, and ↓ dilation of coronary the coronary arteries
114
# manifestations:
heart failure
## Footnote
cardiac diseases
- fatigue
- tachycardia
- SOB/dyspnea
- weak paripheral pulses
- S3
- ankle edema
115
what technique to assess patency of arterious venous graft?
| (AV graft)
palpate the side for thrill
116
2 types of abdominal mapping
- 4 quadrants
- 9 regions
117
costovertebral angle tenderness
| (CVAT)
## Footnote
abdominal landmark
costovertebral angle using blunt percussion
118
# indication:
input > output
retaining fluid
- CHF
119
# indication:
output > input
secreting more fluid that intaking
- DM, kidney failure, excess intake of fluids
120
positive blumberg sign
## Footnote
abdominal abnormal findings
sharp, stabbing rebound pain
- positive peritonitis/peritoneal irritation
- ***EMERGENCY***
121
positive rovsing sign
## Footnote
abdominal abnormal findings
sharp pain in RLQ when palpating LLQ
- acute appendicitis/peritoneal irritation
122
positive psoas sign
## Footnote
abdominal abnormal findings
RLQ pain when R leg is raised up w/ resistance
- appendicitis
123
positive murphy's sign
## Footnote
abdominal abnormal findings
RUQ pain when deep breathing while palpation of lower border of liver
- cholecystitis
124
positive cullen's sign
## Footnote
abdominal abnormal findings
ecchymosis/blueish discoloration of abdomen
- ruptured ectopic pregnancy
- internal bleeding in abd
125
location of mcburney's point
middle 1/3 of the imaginary line from the umbillicus to the right inguinal area
126
# normal findings
thin person
## Footnote
abdominal contours
flat
127
# normal findings:
very thin person
## Footnote
abdominal contours
scaphoid
128
# normal findings:
obese; toddler; early pregnancy
## Footnote
abdominal contours
rounded
129
# normal findings:
some toddlers; late stage pregnancy; ascites
## Footnote
abdominal contours
protuberant
130
abdominal aortic aneurysm
| (AAA)
strong abdominal pulsation
- ***EMERGENCY***
131
LUQ organs
stomach; spleen
132
RUQ organs
liver; gallbladder
133
what quardant to assess for diverticulitis
LLQ
134
sequence of assessing the abdomen
1) inspect
2) auscultate
3) percuss
4) palpate
135
hepatitis
inflam. of liver caused by:
- virus, bacteria, chemicals, drugs, parasite
136
hepatitis B & D
transmitted by:
- blood
- sexually
- perinatally
- parenterally
137
hepatitis C
transmitted by:
- blood
- parenterally
138
hepatitis A
transmitted by:
- fecal/oral
- common in children
139
hepatitis E
transmitted by:
- drinking dirty water
- common in travelers
140
anuria
## Footnote
urinary conditions
< 100cc in 24 hrs
141
oliguria
## Footnote
urinary conditions
100 - 400cc in 24 hrs
142
enuresis
## Footnote
urinary conditions
involuntary urination at night
- common in ages 5 and younger
- familial tendency
143
normal bowel sounds in each quadrant
irregular, high-pitched, gurgling
- 5 - 30/min
144
borborygmi
- **normal:** frequent, loud bowel sounds when a person has not eaten in 5-7 hours
- **abnormal:** when accompanied by other GI symptoms (bleeding, IBD)
145
# indication:
hyperactive
## Footnote
bowel sounds
diarrhea; gastritis
146
# indication:
hypoactive
## Footnote
bowel sounds
post-op; bowel obstruction; constipation
147
# indication:
absent
## Footnote
bowel sounds
paralytic ileus; complete bowel obstruction
148
collitis
## Footnote
abdominal disorder
inflam. of colon
- **S/S:** abd pain, diarrhea, bloody stool
- may require medical intervs.
149
crohn's
## Footnote
abdominal disorder
chronic inflam. of the GI; any part of lower intestines
- **S/S:** abd pain, diarrhea, weight loss
- no medical interv
150
glomeruli
clusters of capillaries in kidneys
- filter 1L/min
151
# manifestations:
chronic renal failure
- ***UREMIA***
- **S/S:** N/V, anorexia, altered mentation, uremic frost on skin, edema, fatigue, weight loss
152
# cause & manifestations:
HYPERnatremia
- **Cause:** exposure to extreme environmental temp
- **S/S:** hypotension, weakness, tachycardia, dry mucosa, oliguria
153
diencephalon
thalamus, hypothalamus, epithalamus
154
tremors of parkinson's
rhymic shaking
155
why do you get shorter when you age?
shortening of vertebral column
156
osteoarthritis
pain aggravated by activities
157
rheumatoid arthritis
pain improve with activites
158
risk of osteomyelitis for open metacarpal fracture
fever
159
**AB**duction
move outward/away from center of body
160
**AD**duction
move inward/toward center of body
161
risk factors for osteoporosis
sedentary lifestyle; no exercise
162
# abnormal findings:
positive carpal tunnel syndrome
| (phalen's test)
tingling/numbness over media nerve, palmar of thumb, index, middle, ring; pain of upper arm, shoulders, neck, chest
| (hold wrist @ 90° flexion for 60 secs)
163
tinel's sign
direct percussion on median nerve
- **normal:** no pain/tingling on arm along median nerve
164
# indication:
rotator cuff injury
inability to ABduct arm at shoulder
165
brachioradialis
tap flat of DTR hammer 2-3in above wrist when palm in semi-prone w/ elbows aligned w/ waist
166
bicep reflex
tap indirectly point of DTR hammer @ antecubital of arm when palm in semi-prone w/ elbows aligned w/ waist
167
ataxia
diff. w/ ambu D/T unsteady gait; wide base; swaying
- common in multiple sclerosis, drug/alcohol intox
168
graphesthesia
| (two point discrimination)
draw letter on clients hand w/ eyes closed
- inability may indicate cortical diseases
169
stereognosis
identify familiar object place on hand w/ eyes closed
- inability may indicate cortical diseases
170
how to assess for sensory function
sharp or dull touch w/ eyes closed
171
normal achilles tendon reflex
plantar flexion of foot and heel jump
172
risk for autonomic dysreflexia in T4 spinal injury patient
clients bladder becomes distended
173
bell's palsy
one-sided inflam. of CN VII
- **S/S:** pain behind ears w/ tinnitus; no headache; impaired taste; diff w/ speech & eating; muscle distortion
174
babinski reflex
extend and fan toes & flex foot
- normal up to 24 months
- in >24 months indicates: CNS pathology; upper neuron disease
175
plantar reflex
stim sole of foot, from heel across ball of foot to big toe in an inverted 'J'
- normal adults: plantar felxion, toes curl towards sole of foot
176
# expected and unexpected findings:
when assessing CN 12
- **Expected:** ease and eqaulity of movement
- **Unexpected:** tremor, paralysis, diff. w/ speech or swallowing
177
# objective findings:
meningitis
- fever, irritability, vomit, seizure, coma
