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70 Cards in this Set
- Front
- Back
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Visual examination: to observe, to look, to smell. The nurse observes shape, size, color, shape, position, movement, symmetry, equality, etc. |
Inspection
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using the sense of touch; to feel, to stroke the surface of an area to detect its characteristics such as temp (use dorsal surface of the hand), vibration (use the palmar surface of the hand); turgor, texture, masses, etc. |
palpation
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listening to sounds produced in the body; aided by the use of a stethoscope which focuses and amplifies sound. |
auscultation
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a systematic, orderly process by which the nurse collects objective data about the client's body, mind, and spirit. It is a critical investigation and evaluation of client's present status. |
physical examination
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What is the student nurse responsibility?
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-collecting data in a professional manner using proper techniques
-validating and analyzing the data -recognizing normal findings from abnormal ones -communicating significant changes and abnormal findings to the clinical instructor as soon as data obtained. |
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how would you introduce yourself to a client in a professional manner?
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greet the client w/ a handshake, and if this is the first encounter, clearly state your name and your title.
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How would you prepare the client for a physical exam?
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-inform the client of what will be done, when, where and why it is important.
-State the info is confidential (HIPPA) -move pt into low Fowlers or a sitting position. -timeframe is approx 15-20 min -give the pt the opportunity to void (urinate) before the exam, for it may need to be collected. |
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What type of palpation do we use in basics?
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light (superficial) palpation by placing the hand parallel to the client's skin surface and press gently while moving in a circle.
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shortness of breath |
dyspnea
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blue; blue-gray |
cyanotic
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patchy areas of blue |
mottled
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pale, white |
pallor
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reddish hue |
flushed
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skin moist with perspiration, (sweating) |
diaphoretic
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which is the client's awareness of his surroundings |
level of consciousness (LOC)
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what would be documented as adjunct equipment?
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includes any medical equipment or devices in use. May document these at any time. Includes this as oxygen delivery systems, nasogastric tubes, tubes, anti-embolic hosiery,SCDs (sequential compression devices), wound dressing, etc.
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What is important to identify if adjunct equipment is ________ __ ______?
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creating a probelm. ex break in the skin, pressure marks on the skin, redness, etc.
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armpits |
axillae
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mouth odor |
halitosis
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cavities |
dental caries
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sweet, fruity smell, nuild-up of ketones |
diabetic acidosis
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difficulty with speech (expressive) or difficulty understanding the spoken word (receptive) |
dysphasia
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Normal Body Mass Index?
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BMI 20-25
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bluish color,most evident in the nail beds, lips, mouth, buccal mucosa or mucous membranes (mm); in dark-skinned clients, close inspection of the palpebral conjunctiva (the linning of the eyelids), palms, and soles of feet. |
cyanotic
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loss of color due to inadequate circulating blood or hemoglobin; or decreased oxygenation of the hemoglobin. assess for this in the conjunctiva, lips, palms, and mucous membranes (mm). |
pallor
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yellowish-orange skin, sclera, mm; in dark-skinned: assess hard palate; excess bilirubin; liver or hemolytic deseases. |
jaundice
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red; increased blood flow; inflammation; rashes |
erythema
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brown age spots due to sun exposure in the elderly. |
senile lentigo
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skin's elasticity and state of hydration |
turgor
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when released, the skin quickly snaps back to pre-tested position. |
supple
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visible superficial blood vessels |
vascularity
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bruising, extravasion of blood under the skin. |
ecchymosis
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pinpoint red-purple spots caused by small hemorrhages |
petechiae
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the abnormal presence of fluid in the body |
edema
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fluid formed around the eyes |
periorbital
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prescense of fluid in the abdominal cavity |
ascites
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generalized edema (all over) the body |
anasarca
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if a indentation remains, the nurse should measure depth of the indention. |
pitting edema
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what are some causes of edema?
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Trauma and the inflammatory response; kidneys overloaded/damaged; cannot "clear out" fluid/wastes (ex renal or cardiac failure; excess Na intake, nephrotoxins); impairment of venous return which override the capacity of the veins (ex pregnancy); decreased serum protein levels allow fluid to shift out of the blood vessels (liver diseases; malnutrition)
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any abnormal (pathological) area of the skin; (ex wound, cyst, rash, boil, pustule, tumor, etc). |
lesions
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small, raised red papules |
cherry angiomas
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a normal head size is referred to as |
normocephalic
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enlargement of the head |
hydrocephalus
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nearsightedness |
myopia
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farsightedness |
hyperopia
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difficulty reading small print (elderly) |
presbyopia
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drooping of the eyelid |
ptosis
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benign (not serious), bilateral gray ring around the iris; lipis deposits, occurs in the elderly |
arcus senilis
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opacity or cloudiness of the lens |
cataracts
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What controls the opening and closing of the pupils?
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CN III Oculomotor
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What does PERRLA stand for?
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P-upils E-qual, R-ound, R-eact to L-ight and A-ccommodation
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What is the normal size of the pupil?
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3-7 mm
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dilation for distant |
mydriasis
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pinpoint constriction for close |
miosis
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the glands secrete earwax which lubricates and protects the canal of the ear. What do the glands create? |
cerumen
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hearing deficit (hard of hearing) |
presbycusis
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no teeth, or number of teeth missing |
edentulous
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The size of the airway determines the characteristice of the lung sounds. The ________ the airway diameter, the harsher and louder the sound should be.
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larger
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when listening to the lungs unequal sounds, or if the incorrect sound is heard in a location, they are referred to as? |
adventitious sounds
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atelectasis or fluid in the alveoli sacs. Pneumonia, PE, CHF |
crackles
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narrowed bronchial airways. Asthma, bronchitis |
wheezes
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snoring sound, sputum in bronchi; various causes. |
rhonchi
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crowing; obstruction of trachea or larynx; FBAO, anaphylactic or allergic reaction, croup, tumor etc. |
stridor
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is produced by the closure of the (atrioventricular valve) AV valves (mitral, tricuspid). This represents systole or the ejection phase and creates the peripheral pulses. |
S1
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is produced by the closure of the semi-lunar valves (aortic, pulmonic). Represent diastole or filling phase. no pulse is produced
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S2
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a period in which the ventricles contract. |
systole
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a period in which the ventricles relax. |
diastole
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Normal apical pulse (AP-rate) rate is?
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60-100/min
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How many quadrants do you divide the abdomen in and what are they?
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4 quadrants
RLQ right lower quadrant RUQ right upper quadrant LUQ left upper quadrant LLQ left lower quadrant |
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Bowel sounds occur within ?
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5-20 seconds
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