Jen ch 30 Part I

Question 0

Alopecia

Answer 0

Partial or complete loss of hair; baldness

Question 1

Adventitious sounds

Answer 1

Abnormal lung sounds heard with auscultation

Question 2

Aphasia

Answer 2

Abnormal neurological condition in which language function is defective or absent; related to injury to speech center in cerebral cortex, causing receptive or expressive aphasia.

Question 3

arcus senilis

Answer 3

Opaque ring, gray to white in color, that surrounds the periphery of the cornea. The condition is caused by deposits of fat granules in the cornea. Occurs primarily in older adults.

Question 4

atrophied.

Answer 4

Wasted or reduced size or physiological activity of a part of the body caused by disease or other influences.

Question 5

Borborygmi

Answer 5

Audible abdominal sounds produced by hyperactive intestinal peristalsis.

Question 6

Bruit (pronounced “brewee”)

Answer 6

Abnormal sound or murmur heard while auscultating an organ, gland, or artery.

Question 7

cerumen

Answer 7

Yellowish or brownish waxy secretion produced by sweat glands in the external ear.

Question 8

clubbing

Answer 8

Bulging of the tissues at the nail base caused by insufficient oxygenation at the periphery, resulting from conditions such as chronic emphysema and congenital heart disease.

Question 9

Conjunctivitis

Answer 9

Highly contagious eye infection. The crusty drainage that collects on eyelid margins can easily spread from one eye to the other.

Question 10

Distention

Answer 10

the state of being stretched beyond normal dimensions

Question 11

Ectropion

Answer 11

Eversion of the eyelid that exposes the conjunctival membrane and part of the eyeball.

Question 12

Entropion

Answer 12

Condition in which the eyelid turns inward toward the eye.

Question 13

Edema

Answer 13

Abnormal accumulation of fluid in interstitial spaces of tissues.

Question 14

Erythema

Answer 14

Redness or inflammation of the skin or mucous membranes that is a result of dilation and congestion of superficial capillaries; sunburn is an example.

Question 15

Excoriation

Answer 15

Injury to the surface of the skin caused by abrasion.

Question 16

Goniometer

Answer 16

an instrument used to measure angles, particularly range-of-motion angles of a joint.

Question 17

Hypertonicity

Answer 17

Excessive tension of the arterial walls or muscles.

Question 18

Hypotonicity

Answer 18

Reduced tension of the arterial walls or muscles.

Question 19

Indurated

Answer 19

Hardened, usually used with reference to soft tissues becoming extremely firm but not as hard as bone.

Question 20

Inspection

Answer 20

Method of physical examination by which the patient is visually systematically examined for appearance, structure, function, and behavior.

Question 21

Integumentary system

Answer 21

The bodily system consisting of the skin and its associated structures, such as the hair, nails, sweat glands, and sebaceous glands.

Question 22

jaundice

Answer 22

Yellow discoloration of the skin, mucous membranes, and sclera caused by greater-than-normal amounts of bilirubin in the blood.

Question 23

Kyphosis

Answer 23

Exaggeration of the posterior curvature of the thoracic spine.

Question 24

Lordosis

Answer 24

Increased lumbar curvature.

Question 25

Murmurs

Answer 25

Blowing or whooshing sounds created by changes in blood flow through the heart or abnormalities in valve closure.

Question 26

nystagmus

Answer 26

Rhythmic, oscillating motions of the eyes are called nystagmus. The to-and-fro motion is generally involuntary. Vertical nystagmus occurs much less frequently than horizontal nystagmus and is often, but not necessarily, a sign of serious brain damage. Nystagmus can be a normal physiological response or a result of a pathologic problem.

Question 27

olfaction

Answer 27

The sense of smell.

Question 28

orthopnea

Answer 28

Abnormal condition in which a person must sit or stand to breathe comfortably.

Question 29

osteoporosis

Answer 29

Disorder characterized by abnormal rarefaction of bone, occurring most frequently in postmenopausal women, sedentary or immobilized individuals, and patients on long-term steroid therapy.

Question 30

ototoxicity

Answer 30

Ototoxicity is damage to the hearing or balance functions of the ear by drugs or chemicals.

Question 31

palpation

Answer 31

Method of physical examination whereby the fingers or hands of the examiner are applied to the patient's body to feel body parts underlying the skin.

Question 32

percussion

Answer 32

Method of physical examination whereby the location, size, and density of a body part is determined by the tone obtained from the striking of short, sharp taps of the fingers.

Question 33

peristalsis

Answer 33

Rhythmical contractions of the intestine that propel gastric contents through the length of the gastrointestinal tract.

Question 34

PERRLA

Answer 34

Acronym for “pupils equal, round, reactive to light, accommodation”; the acronym is recorded in the physical examination if eye and pupil assessments are normal.

Question 35

petechiae

Answer 35

Tiny purple or red spots that appear on skin as minute hemorrhages within dermal layers.

Question 36

polyps

Answer 36

A tumor with a small flap that attaches itself to the wall of various vascular organs such as the nose, uterus and rectum. Polyps bleed easily, and if they are suspected to be cancerous they should be surgically removed.

Question 37

ptosis

Answer 37

Abnormal condition of one or both upper eyelids in which the eyelid droops; caused by weakness of the levator muscle or paralysis of the third cranial nerve.

Question 38

scoliosis

Answer 38

Lateral spinal curvature.

Question 39

stenosis

Answer 39

Abnormal condition characterized by the constriction or narrowing of an opening or passageway in a body structure.

Question 40

striae

Answer 40

Streaks or linear scars that result from rapid development of tension in the skin.

Question 41

syncope

Answer 41

Brief lapse in consciousness caused by transient cerebral hypoxia.

Question 42

thrill

Answer 42

Continuous palpable sensation like the purring of a cat.

Question 43

ventricular gallop

Answer 43

S3 gallop an accentuated third heart sound in patients with cardiac disease characterized by pathological alterations in ventricular filling in early diastole.

Question 44

vocal or tactile fremitus

Answer 44

fremitus: a vibration felt on palpation. vocal fremitus: (VF) one caused by speaking, perceived on auscultation. tactile fremitus: vocal fremitus felt on the chest wall.

Question 45

Use physical examination to:

Answer 45

* Gather baseline data about the patient's health status. * Support or refute subjective data obtained in the nursing history. * Identify and confirm nursing diagnoses. * Make clinical decisions about a patient's changing health status and management. * Evaluate the outcomes of care.

Question 46

Items to factor in when prepping for examination:

Answer 46

~Infection Control (good hygiene, be mindful of latex allergies) ~Environment (Private, good lighting, climate control, etc) ~Equipment (cleaned/sterilized? works?) ~physical prep of patient (gown, position, etc) ~psychological prep of patient (what is about to happen and when) ~age and how to assess for that age

Question 47

techniques of physical assessment:

Answer 47

~Inspection (and olfaction) - look for symmetry ~palpation - start with light end with deep ~percussion - tap to produce vibration, sound det. location, size, density ~auscultation - recognize normal form abnormal sounds

Question 48

What falls under "general survey?"

Answer 48

assessing: gender and race, age, signs of distress, body type, posture, gait, body movements, hygiene and grooming, dress, body odor, affect and mood, speech, signs of abuse, signs of substance abuse, vital signs, height and weight

Question 49

When assessing skin look at:

Answer 49

color, moisture, temp., texture, turgor, vascularity, edema, lesions

Question 50

When looking at lesions what is ABCD

Answer 50

~Asymmetry (not symmetrical) - uneven shape ~Border Irregularity - edges blurred, notched, ragged ~Color - not uniform, blue, black, brown, pink, white, gray, red ~Diameter - look for bigger than a pencil eraser

Question 51

When assessing hair and scalp look at:

Answer 51

Color, distribution, quantity, thickness, texture, lubrication

Question 52

Signs of hypothyroidism

Answer 52

wide part in hair, eyebrows don't go to the end of eye towards ear

Question 53

When assessing nails:

Answer 53

Inspect the nail bed for color, length, symmetry, cleanliness, and configuration. Palpate for abnormalities like swelling and erythema

Question 54

When assessing head and neck look at:

Answer 54

head, eyes, ears, nose, mouth, pharynx, and neck (lymph nodes, carotid arteries, thyroid gland, and trachea).

Question 56

When assessing eyes look at

Answer 56

size, shape, structure, visual acuity, visual fields, conjunctiva, sclera, cornea, pupil and iris (PERRLA), position and alignment, eyebrows, eyelids, lacrimal apparatus,

Question 57

When assessing auricles look at:

Answer 57

texture, tenderness, lesions, color, pain, cerumen

Question 58

Infants vs. adults using otoscope:

Answer 58

For infants the auricle should be pulled down and back. Insert the scope while pulling the auricle upward and backward in the adult and older child

Question 59

three types of hearing loss

Answer 59

conduction, sensorineural, mixed

Question 60

conduction hearing loss

Answer 60

interrupts sound waves as they travel from the outer ear to the cochlea of the inner ear because the sound waves are not transmitted through the outer and middle ear structures

Question 61

sensorineural hearing loss

Answer 61

loss involves the inner ear, auditory nerve, or hearing center of the brain. Sound is conducted through the outer and middle ear structures, but the continued transmission of sound becomes interrupted at some point beyond the bony ossicles

Question 62

mixed hearing loss

Answer 62

combination of conduction and sensorineural loss

Question 63

Tuning fork tests (2)

Answer 63

Weber's, Rinne

Question 64

Weber's test

Answer 64

top of head; Patient with normal hearing hears sound equally in both ears. In conduction deafness sound is heard best in impaired ear. In sensorineural hearing loss, sound is heard better in normal ear.

Question 65

Rinne test

Answer 65

against mastoid process then next to ear canal;Patient should hear air-conducted sound twice as long as bone-conducted sound

Question 66

When assessing nose look at:

Answer 66

shape, size, skin, color, and the presence of deformity or inflammation

Question 67

nasal discharge

Answer 67

Pale mucosa with clear discharge indicates allergy. A mucoid discharge indicates rhinitis. A sinus infection results in yellowish or greenish discharge

Question 68

When assessing lips look at:

Answer 68

color, texture, hydration, contour, and lesions

Question 69

discolorations in lips and causes

Answer 69

Anemia causes pallor of the lips, cyanosis caused by respiratory or cardiovascular problems. Cherry-colored carbon monoxide poisoning, lesions should be evaluated for potential of infection, irritation, or skin cancer

Question 70

When assessing mouth look at:

Answer 70

buccal mucosa, gums, teeth, tongue, floor of mouth, palate, pharynx

Question 71

When assessing neck look at:

Answer 71

neck muscles, lymph nodes of the head and neck, carotid arteries, jugular veins, thyroid gland, and trachea

Question 72

To palpate supraclavicular nodes:

Answer 72

sk the patient to bend the head forward and relax the shoulders. Palpate these nodes by hooking the index and third finger over the clavicle lateral to the sternocleidomastoid muscle. Palpate the deep cervical nodes only with the fingers hooked around the sternocleidomastoid muscle.

Question 73

Trachea inspection:

Answer 73

Determine the position of the trachea by palpating at the suprasternal notch, slipping the thumb and index fingers to each side. Note if the finger and thumb shift laterally