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193 Cards in this Set
- Front
- Back
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A waist to hip ratio of greater than 1 in men and .8 in women = |
Andriod (upper body) obesity |
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Andriod (upper body) obesity |
A waist to hip ratio of greater than 1 in men and .8 in women = |
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A waist circumference of __ in women and __ in men increases risk for what? |
>35, >40 Heart disease DM Metabolic Syndrome |
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Best place to do a skin fold test? |
Triceps |
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for skin fold, values more than/less than 10% of normal = |
under/over nutrition |
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___ may produce falsely high skin fold readings |
Edema |
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Mid arm circumfrance estimates what? |
Muscle mass and fat stores |
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Prediabetes = |
Fasting plasma glucose levels of 110-125 |
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Hemoglobin test |
Iron deficient anemia |
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Hematocrit Test |
cell colume and iron status |
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Cholesterol Test |
Fat metabolism/risk for CVD |
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Triglyceride Test |
Hyperlipidemia or CAD |
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Good Cholesterol vs bad |
HDL LDL |
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Serum protein test |
Test for serum albumin - visceral protein status |
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C-reactive protein |
Used by liver - monitors metabolic stress |
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Detectable levels of CRP are indicative of |
Increased risk of atherosclerosis
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Cardinal features of successful weight loss plan |
Exercise 30 mins 4-5x/week Low cal Low fat Monitoring food intake |
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Obesity = |
20% above ideal body weight or 30-40 BMI |
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Maramus |
Protein calorie malnutrition Starvation |
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Kwashiorkor |
Protein malnutrition - lack of protein in diet appears well nourished but with edema |
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Maramus/Kwashiorkor mix = |
Prolonged inadequate intke of protein and calories Emaciated |
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Pigmented keratotic scaling from niacin deficient |
Pellagra |
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Dry bumpy skin associated with vita A or linoleic acid deficeincy |
Follicular hyperkeratosis |
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Deficiency of vita C - shows in swollen gums |
Scorbutic gums |
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Riboflavin deficiency |
Magenta Tongue (tongue turns red) |
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Vita D and Ca deficeincy in children |
Rickets |
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Foamy plaques of the cornea - sign of vita A def. |
Bitots Spots |
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What sound appears over a distended bladder, fat tissue, fluid or mass? |
Dullness |
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Hyperresonance is present with |
Gaseous distention |
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Large liver span indicates |
Hepatomegaly (liver enlargement) |
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Accumulation of fluid in the gastrointestinal area |
Ascites |
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Ascites occurs with which diseases? |
CHF, protal hypertension, cirrhosis, hepatitis, pancreatitis, cancer |
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Should you palpate an enlarged/tender spleen? |
No |
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Order for GI assessment |
Inspect Auscultate Palpate/Percuss |
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Blumberg Sign |
Rebound tenderness |
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Murphy Sign |
Inspiratory Arrest Pain w/ inspiration |
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Iliopsoas muscle test |
Leg at 45 degree angle If lots of pain = appendix |
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What test is used for appendix |
Iliopsoas test |
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Enlarged liver occurs with |
Fatty infiltration Portal obstrucion of cirrhosis Obstruction of inferior vena cava Lymphocytic leukemia |
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Enlarged nodular liver occurs with |
Late potral cirrhosis Metastic cancer Syphillis |
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Enlarged Gall occurs with |
Cholecystitis Stones |
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Enlarged Spleen occurs with |
Mono |
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Enlarged kidney occurs with |
Hydrophrosis cyst neoplasm |
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Aortic aneurysm hints |
Bruit Decreased femoral pulse |
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Names of lymphs on head/neck (10) |
Preauricular Posterior Auricular Occipital Submental Submandibular Jugulodigastric Superficial Cervical Deep Cervical Posterior Cervical Supraclavicular |
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Round and symmetric skull |
Normocephalic |
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Abnormally small/large head |
Microcephaly Macrocephaly |
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Obstruction of drainage of cerebral spinal fluid - enlargement of head |
Hydrocephalus |
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Askeletal disease of increased bone resorption and formation which softens, thickens and defomrs bone |
Pagets Disease of Bone |
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Excessive secretion of growth hormone from the pituitary land - enlarged skull and thickened cranial bones |
Acromegaly |
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A hemotoma in one sternomastoid muscle - tilt to one side and limited ROM |
Torticollis (wryneck) |
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Chronic enlargement of thyroid |
Goiter |
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Smooth, firm fluctuant swelling on the scalp that contain sebum and keratin |
Pilar cyst |
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Rapid painful inflammation of the parotid occurs with mumps |
Parotid gland enlargement |
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Thyroid deficiency at early age - impaired growth and neurologic deficit |
Congenital Hypothyroidism |
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Chromosomal aberration - unslanting eyes, flat nasal bridge, small board and flat nose, protruding thick tongue, low ears, broad neck, |
Down syndrome |
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Children with choronic allergies develop |
Atopic Facies Blue eye shaddows, open mouth breath, pallor |
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Transverse line on the nose from allergies |
Allergic salute and crease |
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Deficiency of the neurotransmitter dopamine and degeneration of the basal ganglia in the brain |
parkinson's |
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Excessive secretion of corticotropin hormone ACTH Round face/moonlike |
Cushing syndroms |
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Most common cause of hyperthyroidism |
Grave's diseas - bulging eyeballs |
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Thyroid hormone deficeincy |
Myxedema - puffy eyes |
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Nerve 7 paralysis disease |
Bells Palsy Assymetrical face |
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Cachectic appearance = |
Chronic wasting disease (skinny0 |
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Hard skin - rare connective tissue disease - hardening and shrinking of skin |
Scleroderma |
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Grey and white area around limbus of eye |
Arcus senilis |
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Soft raised yellow plaques of the eye |
xanthelasma |
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Lids are swollen and puffy |
Periorbital edema |
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Protruding eyes |
exophthalmos |
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Drooping upper lid |
Ptosis |
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Upward eye slant |
Upward palpebral slant |
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Lower lid is loose and rolling out |
Ectropin |
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Lower lid rolls in |
Entropion |
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Inflammation of eyelid |
Blepharitis |
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Beady module prodruding in lid (cystlike) |
Chalazion |
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Sty |
Hordeolum |
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Inflammation of lacrimal sac |
Dacrocystitis |
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Papule with ulcerated center (in the eye) |
Basal cell carcinoma |
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Unequal pupil size |
Anisocoria CNS disease |
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Dilated and fixed pupils |
Mydriasis CNS, circularoty arrest or recent trauma |
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no rxn to light in pupils |
Argyll Robertson pupil Brain tumor alcoholism |
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Unilateral small regular pupil |
Horners syndrome |
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Constricted and fixed pupils |
Miosis Use of drops, narcotics, damage to pons |
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Sluggish rxn to light |
Tonic pupil unilateral and large pupil |
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What does cranial nerve damage 3 look like |
Unilateral dilated pupil with no rxn to light |
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Pink eye |
Conjuctivitis |
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Red patch on sclera |
Subconjunctival hemorrhage - broken blood vessels (stress) |
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Deep red halo around cornea |
Iritis Immediate referral needed |
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Triangular opaque wing of bulbar conjuctiva overgrows towards eye center |
Pterygium Chronic exposre to hot/dry/sandy |
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Blood in anterior eye chamber |
Hyphema - from herpes zoster or blunt trauma |
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reddish blue discoloration and swelling of auricle after exposure to extreme cold |
Frostbite |
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Infection of outer ear |
Otitis externa aka swimmers ear |
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Skin tag of cartilage |
Branchial remnant and ear deformity |
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Inflammation of loose, subcutaneous connective tissue - thickening of auricle |
Cellulitis |
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Location behind lobule of ear - blacking and filled with sebacous fluid |
sebaceous cyst |
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small whitish yellow nontender nodule on ear |
Tophi |
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Painful nodules on rim of ear |
Nodularis helicus |
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overgrowth of scar tissue |
keloid |
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Ulcerated crusted nodule with indurated base that fails to heal |
Carcinoma (ear) |
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Which of these statements is true regarding the vertebra prominens? The vertebra prominens is:
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D. the spinous process of C7. D. the spinous process of C7. |
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The nurse is percussing the seventh right intercostal space at the midclavicular line over the liver. Which sound should the nurse expect to hear?
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D. Dullness |
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Which structure is located in the left lower quadrant of the abdomen?
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A. Sigmoid colon |
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The nurse suspects that a patient has a distended bladder. How should the nurse assess for this condition?
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C. Percuss and palpate the midline area above the suprapubic bone. |
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A 22-year-old man comes to the clinic for an examination after falling off his motorcycle and landing on his left side on the handlebars. The nurse suspects that he may have injured his spleen. Which of these statements is true regarding assessment of the spleen in this situation?
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C. An enlarged spleen should not be palpated because it can rupture easily. |
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A patient's abdomen is bulging and stretched in appearance. The nurse should describe this finding as:
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B. protuberant. |
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The nurse is describing a scaphoid abdomen. To the horizontal plane, a scaphoid contour of the abdomen depicts a _____ profile.
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C. concave |
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The nurse is watching a new graduate nurse perform auscultation of a patient's abdomen. Which statement by the new graduate shows a correct understanding of the reason auscultation precedes percussion and palpation of the abdomen?
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B. "It prevents distortion of bowel sounds that might occur after percussion and palpation." |
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The nurse is assessing the abdomen of a pregnant woman who is complaining of having "acid indigestion" all the time. The nurse knows that esophageal reflux during pregnancy can cause:
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B. pyrosis. |
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The nurse is performing percussion during an abdominal assessment. Percussion notes heard during the abdominal assessment may include:
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D. tympany, hyperresonance, and dullness. |
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An older patient has been diagnosed with pernicious anemia. The nurse knows that this condition could be related to:
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C. decreased gastric acid secretion. |
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During an abdominal assessment, the nurse elicits tenderness on light palpation in the right lower quadrant. The nurse interprets that this finding could indicate a disorder of which of these structures?
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D. Appendix |
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A mother brings her 2-month-old daughter in for an examination and says, "My daughter rolled over against the wall and now I have noticed that she has this spot that is soft on the top of her head. Is there something terribly wrong?" The nurse's best response would be:
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B. "That 'soft spot' is normal, and actually allows for growth of the brain during the first year of your baby's life." |
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C. sternomastoid and trapezius. |
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B. cluster headaches |
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A patient has come in for an examination and states, "I have this spot in front of my ear lobe here on my cheek that seems to be getting bigger and is tender. What do you think it is?" The nurse notes swelling below the angle of the jaw and suspects that it could be an inflammation of his:
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A. parotid gland |
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The nurse notices that an infant has a large, soft lump on the side of his head and that his mother is very concerned. She tells the nurse that she noticed the lump about 8 hours after her baby's birth, and that it seems to be getting bigger. One possible explanation for this is:
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C. cephalhematoma |
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The nurse has just completed a lymph node assessment on a 60-year-old healthy female patient. The nurse knows that most lymph nodes in healthy adults are normally:
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B. not palpable |
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The nurse is performing an external eye examination. Which statement regarding the outer layer of the eye is true?
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A. The outer layer of the eye is very sensitive to touch. |
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The nurse is reviewing causes of increased intraocular pressure. Which of these factors determines intraocular pressure?
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A. Amount of aqueous produced and resistance to its outflow at the angle of the anterior chamber |
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Which of these assessment findings would the nurse expect to see when examining the eyes of a black patient?
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A. A dark retinal background |
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When performing the corneal light reflex assessment, the nurse notes that the light is reflected at 2 o'clock in each eye. The nurse should:
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A. consider this a normal finding. |
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When assessing the pupillary light reflex, the nurse should use which technique?
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D. Shine a light across the pupil from the side and observe for direct and consensual pupillary constriction. |
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In a patient who has anisocoria, the nurse would expect to observe: |
B. pupils of unequal size. |
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The nurse is examining a patient's ears and notices cerumen in the external canal. Which of these statements about cerumen is correct?
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B. The purpose of cerumen is to protect and lubricate the ear. |
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During an interview, the patient states he has the sensation that "everything around him is spinning." The nurse recognizes that the portion of the ear responsible for this sensation is:
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C. the labyrinth. |
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A 31-year-old patient tells the nurse that he has noticed pain in his left ear when people speak loudly to him. The nurse knows that this finding:
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A. is a characteristic of recruitment. |
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A colleague is assessing an 80-year-old patient who has ear pain and asks him to hold his nose and swallow. The nurse knows that which of the following is true concerning this technique?
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B. This should not be used in an 80-year-old patient. |
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While performing the otoscopic examination of a 3-year-old boy who has been pulling on his left ear, the nurse finds that his left tympanic membrane is bright red and that the light reflex is not visible. The nurse interprets these findings to indicate:
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A. acute otitis media. |
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The nurse is performing a middle ear assessment on a 15-year-old patient who has a history of chronic ear infections. When examining the right tympanic membrane, the nurse sees the presence of dense white patches. The tympanic membrane is otherwise unremarkable. It is pearly, with the light reflex at 5 o'clock and landmarks visible. The nurse should:
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B. know that these are scars caused from frequent ear infections. |
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The projections in the nasal cavity that increase the surface area are called the:
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D. turbinates. |
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The nurse is obtaining a history on a 3-month-old infant. During the interview, the mother states, "I think she is getting her first tooth because she has started drooling a lot." The nurse's best response would be:
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B. "She is just starting to salivate and hasn't learned to swallow the saliva." |
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The nurse is doing an assessment on a 21-year-old patient and notices that his nasal mucosa appears pale, gray, and swollen. What would be the most appropriate question to ask the patient?
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D. "Are you aware of having any allegies?" |
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Which of these techniques best describes the test the nurse should use to assess the function of cranial nerve X?
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B. Ask the patient to say "ahhh" and watch for movement of the soft palate and uvula. |
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While performing an assessment of the mouth, the nurse notices that the patient has a 1-cm ulceration that is crusted with an elevated border. It is located on the outer third of the lower lip. What other information would be most important for the nurse to assess?
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C. When the patient first noticed the lesion |
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When assessing the tongue of an adult, the nurse knows that an abnormal finding would be:
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C. a smooth glossy dorsal surface. |
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The wife of a 65-year-old man tells the nurse that she is concerned because she has noticed a change in her husband's personality and ability to understand. He also cries and becomes angry very easily. The nurse recalls that the cerebral lobe responsible for these behaviors is the _____ lobe.
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A. frontal |
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While gathering equipment after an injection, a nurse accidentally received a prick from an improperly capped needle. To interpret this sensation, which of these areas must be intact?
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B. Lateral spinothalamic tract, thalamus, and sensory cortex |
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The ability that humans have to perform very skilled movements such as writing is controlled by the:
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D. corticospinal tract. |
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During an assessment of an 80-year-old patient, the nurse notices the following: inability to identify vibrations at the ankle and to identify position of big toe, slower and more deliberate gait, and slightly impaired tactile sensation. All other neurologic findings are normal. The nurse should interpret that these findings indicate:
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A. normal changes due to aging |
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The nurse is testing the function of cranial nerve XI. Which of these best describes the response the nurse should expect if the nerve is intact? The patient:
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C. moves the head and shoulders against resistance with equal strength. |
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The nurse places a key in the hand of a patient and he identifies it as a penny. What term would the nurse use to describe this finding?
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B. Astereognosis |
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Warms, humidifies, and filters inhaled air |
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To increase surface area available to warm, humidify and filter inhaled air |
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What is a deviated septum?
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When the septum of the nose is not completely straight and it deviates to one side or the other |
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What cranial nerve relates to the nose? |
Cranial nerve I, the olfactory nerve. It transmits smell to the temporal lobe of the brain |
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How do you test cranial nerve I? |
Test for scent identification with each nare separately. |
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Nasal mucosa should appear: |
moist and intact |
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Describe what the nasal mucosa will look like with a respiratory infection or rhinitis. |
Swollen and bright red in appearance |
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How do you test to see if there is a perforation in the septum? |
Shine a light up one nare. Insert a scope into the opposite nare and observe for the light to shine through. Generally, this will not be present and the septum will just glow. |
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What is epistaxis? |
Bloody nose |
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What is the treatment for epistaxis? |
Apply pressure to the bridge of the nose, lean forward.` Cauterization in severe cases. |
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What sinuses are accessible for examination?
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Frontal and maxillary |
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When palpating the sinuses, the patient should feel: |
Firm pressure, but no tenderness or pain. |
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Functions of the mouth: |
First segment of the digestive system |
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What does pallor of the lips possibly indicate? |
Shock or anemia |
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What does cyanosis of the lips possibly indicate? |
Hypoxemia or chilling |
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Cherry bright red lips are noted with what condition(s)? |
Carbon monoxide poisoning |
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What are fluid filled lesions on the lip-skin junction?
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Cold sores Herpes simplex 1 virus |
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What cranial nerves are associated with the mouth? |
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What does cranial nerve IX do? |
Allows for swallowing |
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How can you simultaneously test cranial nerves IX and X? |
Have the patient say "ahh" and observe as the palate and uvula rise with speaking. |
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What does cranial nerve X do? |
Allows for talking and phonation |
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What should the buccal mucosa look like? |
Pink |
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What is xerostomia?
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Dry mouth |
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What is the number 1 cause of dry mouth in the older population? |
Taking anticholinergic medications |
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What are the functions of the tongue? |
Mastication--chewing |
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A white, cheesy, curd-like patch on the tongue or buccal mucosa is: |
a yeast infection, often called candidiasis or thrush |
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How many teeth do children have? Adults? |
Children: 20 |
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What cranial nerve innervates the tongue? |
cranial nerve XII, the hypoglossal nerve. |
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How do you test the function of cranial nerve XII?
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Have the patient stick their tongue out. It should be midline and still. |
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What kind of breath would you expect to smell in a patient with diabetic ketoacidosis? |
a sweet, fruity scent |
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When assessing the tonsils, they are graded on what kind of scale? |
+1 to +4 |
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What do a "+3" grading of tonsils indicate? |
The tonsils are each touching the uvula |
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What is dysphagia?
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Difficulty swallowing |
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What interventions can be done to help with dysphagia? |
Thickened diet Sit upright while eating |
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Brown teeth |
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choanal atresia
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bony or membranous septum between the nasal cavity and pharynx of a new born |
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epistaxis |
bleeding from the nose |
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foreign body |
a blockage up the nose; like a toy |
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perforated septum |
a hole in the septum (usually cartilage part) caused from snorting cocaine, chronic infection, trauma of picking crusts or nasal surgery |
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furnuncle l |
a small biol located in the skin or mucous membrane; red and swollen and painfu |
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allergic rhinitis
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itching of the nose and eyes, lacrimation, nasal congestion. Serous edema and swelling of turbinates to fill air space; turbinates are usually pale |
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acute rhinitis |
clear, watery discharge, rhinorrhea, later becomes purlent. |
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sinusitis |
facial pain after upper respiratory infection. Red swollen nas mucosa, swollen turnbinates |
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nasal polyps |
smooth, pale gray nodules (overgrowth of mucosa) from chronic allergic rhinitis |
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cleft lip |
most common congenital deformities of head and neck |
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angular cheilitis |
erythema, scaling and painful fissures at corn of mouth |
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carcinoma |
lesion is round and indurated and becomes crusted with an elevated border |
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retention "cyst" |
a round translucent nodule that may be very small or up to 1-2 cm |
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turbinates
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Bones that protrude into the nasal cavity- they increase surface area for filtering dust and dirt particles by the mucous membrane. |
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nares |
nose opening |
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rhinorrhea |
persistent watery mucus discharge from the nose (as in the common cold) |
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things to focus on for nose |
discharge, frequent colds, sinus pain, trauma, epistaxis, allergies, altered smell |
