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130 Cards in this Set
- Front
- Back
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The nurse is testing a patients visual accommodation which refers to:
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pupillary constriction when looking at a near object
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A pt has a normal pupillary light reflex. The nurse recognizes that this indicated that:
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constriction of both pupils occurs in response to bright light
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The nurse is assessing a pt's eyes for the accommodation response and would expect to see?
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convergence of the axes of the eyes
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The vertebra prominence is where?
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the spinous process of C7
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The costal angle is approximately 90 degrees. This characteristic is?
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a normal finding in a healthy adult
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The left lung consist of ??
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two lobes
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It is normal to feel tactile fremitus most intensely over which location?
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3rd intercostal space, MCL
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The trachea bifurcates anteriorly at the ??
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sternal angle
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Normal adult lung include the presence of?
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muffled voice sounds and symmetrical tactile fremitus
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The primary muscles of respiration include the?
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diaphragm and intercostals
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The nurse is aware that tactile fremitus is produced by?
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sounds generated from the larynx
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During percussion, a dull percussion note elicited over a lung lobe most likely results from?
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increased density of lung tissue
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When auscultating the chest in an adult, use the?
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diaphragm of the stethoscope held firmly against the chest
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Percussion over an area of atalactasis in the lungs would reveal?
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dullness
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When the bronchial tree is obstructed, what would most likely be heard?
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decreased breath sounds
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hyperresonant percussion tones are ???? when percussing the thorax of an infant
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considered normal
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decreased mobility of the thorax is a normal finding when assessing the respiratory system of ??
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an elderly adult
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a 3-month old has nasal flaring and sternal and intercostal retractions. What should the nurse do?
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recognize that these are serious signs and contact the physician
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The presence of bronchovesicular breath sounds in the peripheral lung fields are normal in ?
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in the respiratory system of a child
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the nurse should inspect the anterior chest of an adult and assess for?
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the shape and configuration of the chest wall
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Fine crackles would most likely be noted in ??
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the immediate newborn period
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an unequal chest expansion occurs when?
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part of the lung is obstructed or collapsed
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Bronchophony heard upon auscultation is associated with?
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pulmonary consolidation
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Bronchovesicular breath sounds are?
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expected near the major airways
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Air passing thru narrowed bronchioles would produce what adverse sound?
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wheezes
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an anterioposterior-to-transverse diameter ration of 1:1 is most likely seen in ??
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a COPD patient
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A pt with a history of allergies compains of wheezing and difficulty in breathing when working in his yard. the pt most likely has?
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Asthma, if the findings include tachypnea, use of accessory neck muscles, prolong expiration, wheezes etc
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Lungs are less elastic and distensible, decreased ability to collapse and recoil is normal in ??
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older adults
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A pt complains of cough, has a rust-colored sputum, low grade fever and night sweats for the past 2 months may be suffering from?
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tuberculosis
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Shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, ankle edema is associated with what?
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a pt with exacerbation of heart failure
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a cough that is worse at nigh and not as bad during the day may be?
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postnasal drip or sinusitis
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A pt's sputum is frothy and pink. What condition could this finding indicate?
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pulmonary edema
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Listening to at least one full respiration of each location with the stethoscope is ?
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correct when auscultation of breath sounds
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Chest pain that is worse on deep inspiration, [dyspnea] is related to what condition?
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pulmonary embolism
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Crepitus is ?
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when palpation of the anterior chest wall a coarse crackling sensation over the skin surface
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Atalectatic crackles that are not pathologic are what?
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short popping crackling sounds that stop after a few breaths after someone has just woke up
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A normal sound when percussing the 7th rt intercostal space at the MCL over the liver is?
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dullness
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what is located in the left lower quadrant of the abdomen?
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sigmoid colon
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a pt has difficulty in swallowing medications and food, this is called?
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dysphagia
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a distended bladder is assessed how and where?
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percuss and palpate in the hypogastric region
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Aging adults gastrointestinal system may change how?
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decreased gastric acid secretion
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If a pt is suspected of having a spleen injury, what should you not do>
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an enlarged spleen should not be palpated because it can rupture easily
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A pt's abdomen is bulging and stretched in appearance, this is described as?
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protuberant
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Th the horizontal plane, a scaphoid contour of the abdomen depicts?
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a concave profile
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A normal abdominal aortic pulsation is observed where?
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between the xiphoid and umbilicus
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A potential cause of hypoactive bowel sounds is
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peritonitis
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Why does a nurse ausculate before percussion and palpation of the abdomen?
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to prevent distortion of bowel sounds that might occur after percussion and palpation
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What is a normal bowel sound?
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They are usually high-pitched, gurgling, irregular sounds
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The term "borborygmi" means?
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hyperactive bowel sounds
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A normal finding in the abdominal assessment is?
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a tympanic percussion note in the umbilical region
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the esophageal reflux during pregnancy cause cause?
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pyrosis (heartburn)
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Percussion notes heard during the abdominal assessment may include?
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tympany, hyperresonance, and dullness
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tenderness along the costovertebral angles is most often indicative of?
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Kidney inflammation
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Ascites is an indication of what?
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fluid is present
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deep palpation is used to what during an abdominal assessment?
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determine enlarged organs
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A possible cause of black, tarry stool is?
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gastrointestinal bleeding
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Tenderness on light palpation in the rt lower quadrant could indicate a disorder of what structure?
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appendix
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the abdominal musculature is thinner in who?
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the aging adult, when assessing the abdominal region
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in newborns, pyloric stenosis would manifest what?
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projectile vomiting
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To detect diastasis recti, the patient should perform what maneuvers?
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raise the head while remaining supine
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What is true regarding an aortic aneurysm?
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a pulsating mass is usually present
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A nurse should listen for bowel sounds for at least ?? long
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5 minutes
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Murphy's sign is used to assess for what?
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a pt who is suspected of having inflammation of the gallbladder, or cholecystitis.
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The umbilical cord of a new born falls off when?
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in 10-14 days
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percussion findings would be found in a pt with a large amount of ascites is what?
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dullness across the abdomen
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A loop of bowel protruding thru a weak spot in the abdominal muscles is what?
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A hernia
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Tenderness in the left upper quadrant with deep palpations is most likely involving what?
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the spleen
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Lactose intolerance is higher in what ethnic group?
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American indians
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Peptic ulcer disease is often caused by what?
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frequent use of nonsteroidal anti-inflammatory drugs
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Hepatomegaly refers to?
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enlarged liver
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A pt with umbilicus that is enlarged and everted is called what?
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umbilical hernia
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A positive fluid wave test on the abdominal region occurs with?
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ascites
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The nurse should examine the tender area first or last during an abdominal assessment?
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examine the tender area last
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What is Murphy's sign?
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liver test-inspiration arrest
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What is Blumberg's sign?
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rebound tenderness
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A movement of an arm in toward the center of the body is called
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adduction
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A movement of a hand to the mouth is called
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flexion
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the functional units of the musculoskeletal system are the?
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joints
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Hematopoiesis takes place in the?
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bone marrow
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Fibrous bands running directly from one BONE to another that strengthen the joint and help prevent movement in undesirable directions are called?
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ligaments
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When using a jump rope, one's shoulder has to be capable of?
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circumduction
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The articulation of the mandible and the temporal bone is known as the
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temporomandibular joint
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the anterior to the tragus of the ear is used to finde what?
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the temporomandibular joint
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Of the 33 vertebrae in the spinal column, there are?
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7 cervical
12 thoracic 5 lumbar (5 sacral and 3-4 ccoygeal) |
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The imaginary line connecting the highest point on each iliac crest would cross what?
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the 4th lumbar vertebra
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The "shock absorbers" in our back are there to cushion the spine and to help it move, this is referring to?
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the intervertebral discs
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The glenohumeral joint is injured when?
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rotator cuff injury
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The bump on the top of both shoulders is called what?
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the acromion process
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the knee is capable of what movements?
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flexion and extension
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If a knuckle above a ring is swollen, this joint is called?
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metacarpophalangeal joint
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To palpate the ischial tuberosity, the pt should do what?
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flex the hip
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the knee joint is the articulation of the femur, the tibia and the?
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patella
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The ankle joint is the articulation of the tibia, the fibula and the?
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talus
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The lengthening of bone growth occurs at the?
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epiphyses
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During pregnancy a women may have a posture shift to compensate for the fetus is called?
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lordosis
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A decrease in hight occurs with aging because?
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of the shortening of the vertebral column
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What is osteoporosis?
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the loss of bone density
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A possible increase in foot pain while jogging could be?
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a second toe that is longer than the great toe
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The incidence of osteoporosis is greatest in what group?
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white women
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With a fractured wrist, expected pain would be?
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a sharp pain that increases with movement
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Pain in joints that are worse in the morning, get better after moving around and get worse when siting for long periods may have?
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rheumatoid arthritis
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A pt states they can hear crunching or grating sounds when they kneel, and pain/stiffness in joints in the morning is called?
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crepitation
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rotator cuff lesions are what?
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pain when abduct arm and muscle spasms
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Tennis elbow is where?
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medial and lateral epicondyle
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A patents knee is found to have a positive bulge sign, this is suspected of what?
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swelling from fluids in the suprapatellar pouch
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A pt has a lateral tilt when bend forward and when leg is raised straight up, complains of a pain running down his buttock in to the leg, this could be what?
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herniated nucleus pulposus
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A newborn infant with six toes documented as?
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polydactyly
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A male complains of extreme tenderness to his toes, and his toes are swollen, reddened and warm to touch, this may be?
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acute gout
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Olecranon bursitis is ?
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raised, firm, nontender nodules at the olecranon bursa and along the ulna
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A change associated with rheumatoid arthritis includes?
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Heberden's nodes
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A lateral curvature of the thoracic and lumbar segments of the spine that disappears with a forward bend is called?
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functional scoliosis
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A assessment of muscle strength, complete range of motions against gravity with full resistance is recored as?
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5+
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A positive Allis sign and suggestion of hip dislocation is when?
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in a baby, fleet flat on table and flexes knees up, when knee is significantly lower than the other
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When measuring a pt's angles of joint flexion, what instrument is used?
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goniometer
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what test is used to check for large amounts of fluid around the patella?
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ballottement
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Another term for "knock knees" is?
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genu valgum
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A diagnosis of a gangloin cyst is what?
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a common benign tumor
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A hard, painless nodules on a toe of a pt with gout that had burst open with a chalky discharge is called
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tophi
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The correct approach for examination when performing a musculoskeletal assessment is
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proximal to distal
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Symptoms of osteoarthritis include?
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asymmetric
pain with motion of affected joints affected joints swollen with hard, bony protuberances |
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The two parts of the nervous system are?
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central and peripheral
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A noted change in personality and ability to understand, become angry or cry is what part the the cerebral lobe?
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frontal
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the hypothalamus controls?
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temperature, heart rate, blood pressure, sleep, anterior and posterior pituitary gland and the autonomic nervous system activity and emotional status
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The area of the nervous system that is responsible for mediating reflexes is the?
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spinal cord
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To interpret a pin prick, what area must be intact?
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Lateral spinothalamic tract, thalamus, and the sensory cortex
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Why during an heart attack do you feel pain possibly in the shoulder, arms, or jaw?
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the sensory cortex does not have the ability to localize pain in the heart, so the pain is felt elsewhere
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Very skilled movements such as writing is controlled by the?
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extrapyramidal tract
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What area of the brain is affected if a person reports being unsteady and has had difficulty in maintaing balance?
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cerebellum
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The peripheral nervous system carries input to the central nervous system by?
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afferent fibers and away by efferent fibers
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Vertigo is what?
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a feeling like the room is spinning around
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