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445 Cards in this Set
- Front
- Back
The basis for the nursing process is the _____.
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health assessment
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A health assessment provides _____ for which you can compare subsequent assessments.
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baseline data
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The health assessment gives information about the client's ____ and _____.
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health status
health problems they have |
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Components of the health assessment include:
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health history and the physical examination or assessment
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Health history provides ____ data.
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subjective
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____ history focuses the physical assessment.
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Health
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The physical assessment provides ______ data.
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objective
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The ____ data can validate or refute a client's complaint.
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objective
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_____ data are the signs and ____ data are the symptoms.
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Objective
Subjective |
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Guidelines for performing a physical assessment include:
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-having a sequence (head to toe/ system approach)
-having instruments/equipment that are working, organized, and warmed |
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The instrument used to examine the eyes is the _____.
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opthalmoscope
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The instrument used to examine the ears is the ______.
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otoscope
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The instrument used to examine distance vision is the _______.
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snellen chart
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The instrument used to examine the nares is the ______.
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nasal speculum
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The instrument used to examine the cervix and vagina is the _____.
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vaginal speculum
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The instrument used to determine the difference between a conductive or sensory neural hearing loss is the _____.
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tuning fork
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The instrument used to examine the deep tendon reflexes is the ______.
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percussion/reflex hammer
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When positioning a patient for physical assessment the following considerations should be made:
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-age of client
-health status of client -mobility and physical condition of client -privacy and comfort |
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The ____ position has the client on his/her back.
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supine
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The ____ position has the client on his/her back with the knees bent and feet on the table.
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dorsal recumbent
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The ____ position has the client in a side-lying position.
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sims'
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In the ____ position, the client is on his/her abdomen.
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prone
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In the ____ position the client lies on her back with legs in stirrups.
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lithotomy
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The _____ and _____ positions are uncomfortable and embarrassing therefore the client should be in the position for as little time as possible.
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lithotomy and knee-chest
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When preparing the environment for an assessment, the following should be done...
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-provide privacy
-prepare the patient by telling them what you are going to do -limit noise -provide comfort to patient (voiding, temperature, pain) -lighting -have needed equipment -work around meals, treatments and visiting hours |
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What are the 4 assessment techniques?
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inspection
palpation auscultation palpation |
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_____ is deliberate, purposeful observation.
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Inspection
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When performing inspection it is important to assess for:
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-size, shape, color
-position -symmetry -deviations from normal |
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During inspection the nurse will use the senses of
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sight, smell and hearing.
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_____ is assessment through touch.
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Palpation
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When performing palpation it is important to assess for:
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-temperature, texture
-moisture, turgor -pain, tenderness -vibration, pulsation -edema, distention -masses |
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_____ is the presence of fluid in the interstitial spaces.
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Edema
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______ means swollen.
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Distention
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When palpating a mass you should note:
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-size, shape, location
-consistency/surface -mobility -tenderness |
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Use the _____ surface of the hand to palpate for vibrations.
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palmar
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Use the ____ surface of the hand to palpate lymph nodes, the breasts, and pulse.
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finger pads
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Use the _____ surface of the hand to palpate temperature.
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dorsum
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____ palpation is used to assess for pain or tenderness.
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Light
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____ palpation is used to assess underlying organs and masses.
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Deep
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____ is the striking of one object against another producing vibrations which cause a sound.
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Percussion
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Percussion is helpful in assessing the...
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location, size, shape, and density of tissues
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The five percussion tones are:
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flatness
dullness resonance hyperresonance tympany |
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____ is the percussion tone heard over dense tissue like muscle or bone.
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Flatness
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____ is the percussion tone heard over fluid filled tissue.
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Dullness
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____ is the percussion tone heard over air filled tissue.
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Resonance
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_____ is the percussion tone heard in overinflated air filled lungs.
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Hyperresonance
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_____ is the percussion tone heard over enclosed air containing structures.
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Tympany
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Flatness may be heard when percussing _____.
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bone or muscle
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Dullness may be heard when percussing _____.
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liver and spleen
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Resonance may be heard when percussing _____.
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normal lung
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Hyperresonance may be heard when percussing _____.
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an overinflated air filled lung
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Tympany may be heard when percussing ______.
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abdomen
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___ is described as a soft, high-pitch, short dull sound.
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Flatness
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____ is described as a soft to moderately loud; medium pitch; and "thudding."
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Dullness
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____ is described as a moderated to loud sound; low pitch; hollow.
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Resonance
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_____ is described as a loud, low-pitch, "booming" sound.
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Hyperresonance
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____ is described as a loud, high-pitch, "drum-like" and "musical."
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Tympany
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Percussion is useful because it can tell _____ and indicate ____.
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size/shape of organ
presence or growth/tumor |
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_____ is listening with a stethoscope to sounds produced within the body.
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Auscultation
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When auscultation is used as an assessment technique, the following characteristics are noted:
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pitch
amplitude quality duration |
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____ of an auscultated sound is the frequency of vibrations per second.
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Pitch
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____ of an auscultated sound is loudness.
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Amplitude
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____ of an auscultated sound is a subjective description.
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Quality
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_____ of an auscultated sound tells whether the sound is short/long.
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Duration
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You should not auscultate over ____.
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bone
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A _____ should occur at first interaction with the client.
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general survey
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____ means there is no outward expression of internal emotion.
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Flat affect
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1 year olds should be weighed _____.
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totally nude
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When measuring the height of 2 year olds they should be in the ____ position with _____.
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recumbent
extremities stretched |
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Measure the head circumference of children up to age ____.
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2
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A general survey includes:
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-sex, age, race
-general appearance and behavior -vital signs, height, and weight - |
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A nursing history should include:
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-current symptoms
-past history -family history -lifestyle and health practice (diet, smoking, alcohol, drugs) -Current symptoms (OLDCARTSS) |
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OLDCARTSS stands for what when discussing current symptoms?
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Onset
Location Duration Characteristics Associated symptoms Relieving/aggravating factors Treatment Sequence Summarize |
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The primary function of the integumentary system is ____.
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protection
also regulated body temperature |
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When taking the health history of the skin document...
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-rashes, lesions, itching, skin diseases
-bruising, bleeding, -hair loss or changes -woulds, bruises, abrasions, burns -change in color, size, shape of mole -family history |
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____ is redness of the skin. It can be caused by sunburn, fever, inflammation, or allergic reactions.
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Erythema
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____ is blueness of the skin. It can be caused by cardiac or respiratory disease.
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Cyanosis
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Cyanosis is the presence of _____.
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deoxygenated hemoglobin.
|
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In dark skinned people cyanosis can be seen by looking at...
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the conjunctiva of the eye or oral mucous membrane.
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In dark skinned people jaundice can be assessed for by looking at the...
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sclera of the eye, nail beds, palms/soles
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_____ appears as yellowing of the skin.
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Jaundice
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____ is paleness of the skin.
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Pallor
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To assess for pallor one should look at...
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oral mucous membranes, nail beds, palms/soles
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_____ is seen as patches of hypopigmented skin. It may be an autoimmune response.
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Vitiligo
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During inspection of the integument you should assess:
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-vascularity
-lesions -wounds -rashes -nails -hair and scalp |
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When assessing ____ you look for ecchymosis, hematoma, and petechiae.
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vascularity
|
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When assessing lesions, the different types are...
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macule
papule pustule vesicle |
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When assessing nails look for
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brittleness, thickness and clubbing
|
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When assessing the hair and scalp look at
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color, texture, and distribution
alopecia hirsutism |
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_____ is bleeding into the subcutaneous tissue; a bruise.
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Ecchymosis
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_____ is accumulation of blood in tissue or an organ (swelling).
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Hematoma
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_____ are pinpoint red hemorrhages.
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Petechiae
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A ____ is a flat unelevated change in color; freckles, measles rash, port wine stain.
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macule
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A ____ is a solid elevation of skin that may or may not have a change in color; mole or wart.
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papule
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A ____ is a vesicle filled with puss; acne vulgaris.
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pustule
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A _____ is a round or oval thin translucent mass filled with serous fluid; chicken pox rash, blood blister, poison ivy, burn blisters.
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vesicle
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Nails should be _____ and ____.
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convex and smooth
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____ is the thickening and flattening of distal phalanges and comes from long term inadequate oxygenation.
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Clubbing
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____ is loss of hair.
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Alopecia
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____ is the growth of coarse hair on the face and trunk. It can be caused by ovarian dysfunction.
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Hirsutism
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When assessing the integument through palpation you should assess:
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temperature, moisture
turgor edema texture |
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____ is excessive sweating.
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Diaphoresis
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When palpating the skin for temperature, and moisture you should make note of whether the client shows signs of ____ or _____.
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diaphoresis or dehydration
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____ is elasticity.
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Turgor
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Decreased turgor can be seen because the skin will show _____, evidence of dehydration.
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tenting
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_____ individuals have less skin elasticity.
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Elderly
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When assessing for edema it can be rated as ____.
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0 thru 4+
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A child in the first 28 days of life is referred to as _____.
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neonate/newborn
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A child between 28 days and 1 year old is called a _____.
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infant
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In a newborn, skin turgor should be assessed...
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on the abdomen
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A newborn has skin that is smooth and thin meaning that the blood vessels are close to the surface which predisposes them to
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heat loss and moisture loss.
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_____ is fine hair over the body of a newborn.
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Lanugo
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_____ is the yellowish-whitish cheese substance that is in the folds/creases of a newborns skin. It is a mixture of epithelial cells and sebum that moisturizes.
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Vernix Caseosa
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_____ is baby acne.
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Milia
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______ looks like a dark bruise-patch over the sacral area.
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Mongolian Spot
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____ jaundice is a normal variation.
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Physiologic
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In adolescents, _____ indicates the onset of puberty.
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axillary and pubic hair development
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Several variations in the skin of elderly adults include:
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-wrinkles, dryness
-lentigines ("age spots") -telangiectasias (spider veins) -hair changes -nail changes |
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Wrinkles and dryness occur in elderly adults because of decreased...
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-elasitcity
-sweat and sebaceous glands -subcutaneous fat |
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____ is nose bleeds.
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Epistaxis
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Assessment of the head and neck include:
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inspection, palpation, and percussion
|
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When assessing the skull you should assess for
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size, shape, symmetry and any other abnormal findings.
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____ means normal in size, shape, and symmetry.
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Normocephalic
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____ is a small head.
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Microcephaly
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____ is a large head.
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Hydrocephaly
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When assessing the face, assess for
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color, symmetry, hair, and other abnormal findings such as edema, tics, tremors, and nodules/masses.
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____ are abnormal involuntary facial movements.
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Tics
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____ are involuntary movements like shaking.
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Tremors
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When assessing the eyes you should look for
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-position, alignment, symmetry, color
-pupils (PERRLA) -visual acuity -extra-ocular movements -visual fields -other abnormal findings |
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_____ is the constriction of your pupil that occurs when the focus of vision moves from a far to a near object.
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Accommodation
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In the pupils response to light you should expect to see
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constriction of both pupils.
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In ____ response to light the pupil of the eye you shine light in constricts.
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direct
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In ____ response the light the pupils of both eyes constrict.
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conscentual
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____ happens when you bring something close to the eyes and the eyes move in.
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Convergence
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____ is abnormal dilation of the pupils.
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Mydriasis
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____ is abnormal constriction of the pupils.
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Miosis
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_____ is unequal pupils.
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Anisocoria
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Abnormal findings of the eyes include:
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-mydriasis
-miosis -anisocoria -decreased/absent response |
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____ is the assessment of distance vision.
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Visual acuity
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____ is nearsightedness.
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Myopia
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_____ is farsightedness.
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Hyperopia
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____ is abnormal curvature of the cornea that prevents light rays from focusing on the retina.
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Astigmatism
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____ is a droopy eyelid.
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Ptosis
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____ is called a lazy eye.
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Strabismus
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____ is involuntary eye movement.
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Nystagmus
|
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Ear assessment should consider:
|
external ear
ear canal tympanic membrane and other abnormal findings |
|
When assessing the external ear assess
|
-shape, size
-symmetry |
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When assessing the ear canal it should be
|
smooth and pink
|
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When assessing the tympanic membrane it should be
|
translucent and gray
clearly defined landmarks |
|
Abnormal findings of the ear include:
|
drainage, pain and redness
|
|
There are 3 types of hearing loss:
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conductive
sensory neural mixed |
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In ____ hearing loss there is a problem with the transmission of sound waves through the outer and middle ear.
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conductive
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In ____ hearing loss the damage is in the inner ear.
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sensory neural
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Two tests of hearing loss that are done with a tuning form to differentiate between conductive and sensory neural hearing loss are...
|
Webers Test and Rinne's test
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The hearing test that uses headphones allowing the person to hear beeps at varying frequencies is called an _____.
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audiometry
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Assessment of the mouth includes
|
lips, tongue, gums
hard and soft palates teeth abnormal findings |
|
Assessment of the pharynx should include
|
tonsils and other abnormal findings such as exudate, swelling, bleeding and discharge
|
|
When assessing the nose check
|
patency
nasal septum and other abnormal findings such as polyps |
|
____ are smooth, pale gray growths that are associated with chronic allergies.
|
Polyps
|
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When assessing the sinuses check for
|
pain and edema.
|
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In the mouth the mucous membranes should be
|
moist and pink
|
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Assess the palate of an infant by palpating for _____.
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cleft palate
|
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A ____ mouth odor signals possible diabetes.
|
acetone
|
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A ____ mouth odor signals possible uremia.
|
ammonia
|
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A ____ mouth odor signals possible liver disease.
|
musty
|
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The sinuses that can be percussed are the
|
frontal and maxillary
|
|
Assessment of the neck include:
|
inspection and palpation
|
|
When assessing the neck you should check
|
-ROM
-trachea -thyroid -lymph nodes -venous distension |
|
The thyroid is not normally ___.
|
palpable
|
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Venous distension in the ___ position is never normal and may indicate CHF or venous overload.
|
upright
|
|
____ are enlarged lymph nodes.
|
Lymphadenopathy
|
|
Enlarged lymph nodes are caused by
|
infection
autoimmune diseases cancer |
|
The anterior fontanel of infants should close by
|
18-24 months
|
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The posterior fontanel of infants is smaller and should close by
|
8 weeks of age.
|
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Inspect babies hard and soft palates for ____.
|
clefts
|
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____ is when babies appear to have strabismus because they have an epicanthal fold that covers the inner corner of sclera of eye.
|
Pseudostrabismus
|
|
All deciduous teeth should erupt in children by age
|
2 1/2 years
|
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Visual acuity should be 20/20 by ___ years of age.
|
6
|
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____ is generalized loss of hearing acuity that occurs with age- especially high frequency sounds.
|
Presbycusis
|
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____ is impaired near vision in elderly adults.
|
Presbyopia
|
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____ is an inversion of the lower lid.
|
Entropion
|
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____ is an eversion of the lower lid.
|
Ectropion
|
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Lymph glands in elderly adults are _____.
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smaller
|
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Neck veins in elderly adults are _____ because there is loss of subcutaneous fat.
|
more prominent
|
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The ____ is elderly adults is more nodular.
|
thyroid gland
|
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_____ are yellowing of the lens of the eye.
|
Cataracts
|
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____ is an abnormal fluid balance causing increased intraocular pressure.
|
Glaucoma
|
|
____ is the leading cause of blindness in people over age 40.
|
Glaucoma
|
|
The functions of the lungs are
|
gas exchange and promote acid base balance.
|
|
The right lung has ____ lobes.
|
3
|
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The left lung has ____ lobes.
|
2
|
|
The ____ lung sits higher because of the placement of the liver.
|
right
|
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The ____ lung is more narrow because of the placement of the heart.
|
left
|
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Gas exchange takes place in the _____.
|
alveoli
|
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The _____ pleura lines the chest cavity.
|
parietal
|
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The _____ pleura covers the lungs.
|
visceral
|
|
The primary muscles used in breathing are the
|
diaphragm and intercostals.
|
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_____ means you need to be upright to breath.
|
Orthopnea
|
|
Cardiac pain is different than chest pain because cardiac pain...
|
can radiate or move to other areas.
|
|
Important information to get regarding the history of the thorax and lungs includes:
|
-trauma or surgery
-difficulty breathing -use of pillows to breathe when sleeping -chest pain with deep breathing -persistent cough -allergies -environmental exposure, smoking -lung disease -respiratory infections -family history |
|
Equipment needed for assessment of the lungs and thorax include:
|
hands, stethoscope and pulse oximeter
|
|
The best position for assessing the lungs and thorax is
|
sitting upright because it allows optimum expansion of the lungs.
|
|
When we assess the lungs we are assessing ____ which is the person's ability to take in oxygen and blow off carbon dioxide.
|
aeration status
|
|
Assessment techniques used with the lungs and thorax include:
|
inspection
palpation percussion auscultation |
|
On inspection of the lungs note the
|
-color
-shape, symmetry -contour -respiratory rate |
|
The ____ diameter should be larger than the ______ diameter.
|
transverse
anteroposterior |
|
The anteroposterior diameter should be about ____ the transverse diameter.
|
1/2
|
|
Abnormal findings upon inspection of the lungs and thorax include:
|
-barrel chest
-retractions -unequal chest expansion -nasal flaring -pursed lip breathing -adventitious breath sounds -abnormal breathing patterns |
|
______ is the use of accessory muscles to breathe.
|
Retraction
|
|
During retraction the person is trying to
|
increase compliance and recoil of the lungs.
|
|
Retractions can be classified as
|
supracostal
intercostal subcostal |
|
____ is a way that the body tries to get more oxygen into the lungs and it occurs on inspiration.
|
Nasal flaring
|
|
Palpation of the lungs and thorax allows you to assess for
|
-temperature
-moisture -chest expansion -tactile fremitus -Abnormal findings -pain, tenderness -masses -unequal chest expansion -vibratory sensations -crepitus |
|
_____ is a mild vibratory sensation that occurs as sound waves move thru the upper respiratory tract, lower respiratory tract and to the chest wall.
|
fremitus
|
|
____ is subcutaneous air in the chest; it feels like a crackling in your chest.
|
Crepitus
|
|
Percussion allows you to assess the lungs and thorax for
|
-lung size and position
-presence of air, liquids, or solids -percussion tones |
|
The normal percussion tone in the lungs is ______.
|
resonance
|
|
_____ is a percussion tone of the lungs that occurs with increased air or air trapping.
|
Hyperresonance
|
|
____ could indicate the presence of fluid, a tumor, or another solid mass in the lungs.
|
Dullness
|
|
____ is listening for movement of air into and out of the respiratory tract.
|
Auscultation
|
|
There are ___ areas to auscultate on the anterior thorax.
|
7
|
|
There are ___ areas to auscultate on the posterior thorax.
|
10
|
|
When discussing breath sounds auscultated in the lungs it is important to note ____, ____, and _____.
|
duration, pitch, and intensity
|
|
Normal breath sounds include:
|
bronchial
bronchovesicular vesicular |
|
_____ breath sounds are heard anteriorly over the trachea.
|
Bronchial
|
|
_____ breath sounds are heard over the main stem of the bronchus (either side of sternum) or between the scapula.
|
Bronchovesicular
|
|
_____ breath sounds are heard over smaller airways (alveoli) and everywhere else.
|
Vesicular
|
|
_____ breath sounds are short on inspiration and long on expiration. They sound like air blowing thru a pipe.
|
Bronchial
|
|
_____ breath sounds have equal inspiration and expiration.
|
Bronchovesicular
|
|
_____ breath sounds are softer sounds kind of like a sigh. The inspiration is longer that the expiration.
|
Vesicular
|
|
Stertuous breathing, stridor, crackles, rhonchi, wheezes, pleural friction rub, and diminished or absent breath sounds are all examples of ____ breath sounds.
|
adventitious
|
|
____ are heard when air moves thru airways filled with fluids/secretions. It is discontinuous.
|
Crackles
|
|
Crackles means there is _____ in airways.
|
secretions/fluids
|
|
_____ occur when the airway is narrowed due to secretions, swelling, tumor, etc...
|
Rhonchi
|
|
Rhonchi can be heard over _____.
|
larger airways
|
|
____ are heard over smaller airways and are generally heard more on expiration.
|
Wheezes
|
|
_____ is due to inflammation of pleural linings. It is heard on inspiration and expiration.
|
Pleural friction rub
|
|
_____ is noisy strenuous respirations.
|
Stertuous breathing
|
|
____ is due to narrowing of the upper airway, particularly around the larynx and trachea.
|
Stridor
|
|
Stridor can be heard ____ a stethoscope.
|
without
|
|
_____ are anything other than normal, occur when air passes thru an airway that is narrow, filled with fluid or mucous, or the pleural linings are inflamed.
|
Adventitious breath sounds
|
|
The following are thorax/lung variations among children:
|
-more rapid respiratory rate
-nose breathers -thorax rounded -abdominal muscles used during respiration |
|
The following are thorax/lung variations among elderly:
|
-increased AP chest diameter
-lungs less elastic, thorax more rigid -kyphosis -decreased ciliary action -decreased surfactant production |
|
____ is an increase in the dorsal spinal curve (hump back) and it can affect the ability of the lungs to expand.
|
Kyphosis
|
|
Decreased surfactant production in the elderly is dangerous because it leads to an increased risk for...
|
alveoli to collapse
|
|
____ is ventricular filling while ventricles relax.
|
Diastole
|
|
____ is contraction of the ventricles which causes them to empty.
|
Systole
|
|
During diastole the ___ valves are open and the ____ valves are closed.
|
a/v
SL |
|
During systole the ___ valves are open and the ____ valves are closed.
|
SL
AV |
|
The ___ of the lungs points towards the back of the body.
|
base
|
|
The apex touches the chest wall at the 5th intercostal space and midclavicular line. This is called the ____.
|
PMI
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PMI stands for
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point of maximum impulse
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____ are when you can feel your heart beating in your chest.
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Palpitations
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When collecting history related to the cardiovascular system is it important to note:
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-chest pain, palpitations
-dyspnea; pillows to sleep -HTN, coronary artery disease, CHF, myocardial infarction, etc -heart surgery -edema, color changes, temp. of extremities -sores on legs that don't heal -cholesterol levels, smoking, alcohol -diet, activity -family history |
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Edema, changes in color or temperature of extremities and sores on legs that do not heal are examples of
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peripheral vascular disease
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Cardiovascular Assessment
Equipment- Position- Environment- Assessment Techniques- |
Equipment- stethoscope, hands, BP cuff
Position- upright Environment- well-lit and quiet Assessment Techniques- all except percussion |
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The 4 cardiac landmarks that are auscultated are the
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aortic valve- 2nd intercostal R
pulmonary valve- 2nd inter. L tricuspid valve- 4th inter. L mitral valve- 5th inter. mid clav line |
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The ____ is the area of the chest that overlies the heart.
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precordium
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When inspecting the cardiovascular system note the
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-epigastric area
-pulsations -abnormal findings such as -neck vein distention -visible pulsations |
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The only place that visible pulsations are normal is the ___.
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PMI
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_____ are vibratory sensations int he cardiovascular system that are usually associated with murmurs.
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Precordial thrills
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____ are rises along the sternal border that occur with each heart beat.
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Lifts or heaves
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Heart sounds are caused by
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closure of the heart valves.
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Assess heart sounds for
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-rate and rhythm
-abnormal sounds -extra heart sounds |
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The first heart sound is
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Lub (S1)
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The second heard sound is
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dub (S2)
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The lub heart sound is louder in the ____ and ____ valve areas.
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mitral and tricuspid
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The dub heart sound is louder in the ____ and ____ valve areas.
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aortic and pulmonic
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Lub corresponds with ventricular ____.
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systole
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Dub corresponds with ventricular ____.
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diastole
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____ are heard when the valve is deformed and doesn't open all the way.
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Ejection clicks
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A ____ is due to turbulent blood flow in the heart or great vessels. It is heard over the heart and great vessels.
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murmur
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A ____ is turbulence to the blood flow thru the great vessels. It is heard over the carotid, epigastric, and femoral areas.
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bruit
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____ heart sounds are normal in children and young adults.
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S3
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____ heart sounds are normal in elderly adults.
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S4
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____ is blood supply to the extremities.
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Perfusion
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Capillary refill should be less than ____ seconds.
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2
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The peripheral vascular system includes
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blood pressure, peripheral pulses, and perfusion
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Abnormal findings of the peripheral vascular system that may indicate PVD are:
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-pallor
-edema -ulcers, changes in pigmentation (brownish) -hair loss -thickened toenails |
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During assessment of the peripheral vascular system you should check
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capillary refill and pedal pulse.
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A 1+ peripheral pulse is hard to feel, easily obliterated by slight finger pressure and described as
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weak and thready.
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A 0 peripheral pulse is
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absent
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A 2+ peripheral pulse is easily palpable and can be obliterated by strong pressure. It is considered
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normal
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A 4+ peripheral pulse is readily palpable, forceful and not easily obliterated. It is described as
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bounding
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An ____ peripheral pulse is strong on one side and not on the other.
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assymetric
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____ is inflammation of a vein.
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Phlebitis
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Homan's sign is a type of phlebitis. It is assessed by
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dorsiflexion of the foot.
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Normal variations in the pediatric cardiovascular system are:
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-acrocyanosis
-S3 sounds -heart rate more rapid -sinus arrhythmia |
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____ is increased heart rate on inspiration and decreased heart rate on expiration.
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Sinus arrhythmia
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____ is when children have blue hands and feet but a pink body.
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Acrocyanosis
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Cardiovascular variations in elderly adults include:
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-S4 heart sounds
-distal arteries diff. to palpate -blood vessels prominent -varicosities common -decreased cardiac output and strength of contraction -increased blood pressure -hardened arteries |
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Varicose veins in elderly adults are common because
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ineffective veins allow backflow.
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Distal arteries are difficult to palpate in elderly adults because they have
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inadequate circulation.
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Breast self exams should be completed ____.
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monthly after the menstrual period.
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Mammograms should be started at
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35-39 years for a baseline and yearly after age 40.
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_____ is enlargement of breast tissue in men.
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Gynecomastia
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Breast growth generally begins around age ___. Menarche usually happens with ___ yrs.
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8
two |
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Organs in the RUQ are:
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liver
gallbladder duodenum head of pancreas right adrenal gland upper lobe of right kidney hepatic flexure of colon section of ascending colon section of transverse colon |
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Organs in the LUQ are:
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left lobe of liver
stomach spleen upper lobe of left kidney pancreas left adrenal gland splenic flexure of colon section of transverse colon section of descending colon |
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Organs in the RLQ are:
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lower lobe of right kidney
cecum appendix section of ascending colon right ovary right fallopian tube right ureter right spermatic cord part of uterus |
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Organs in the LLQ are:
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lower lobe of left kidney
sigmoid colon section of descending colon left ovary left fallopian tube left ureter left spermatic cord part of uterus |
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When assessing the abdomen, be sure to ___ and ____ before ____ or ____.
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inspect and auscultate
palpating or percussing |
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When assessing the abdomen, the ___ position is best.
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supine
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On inspection of the abdomen you should not see
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peristalsis, pulsations, masses.
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____ are stretch marks; breakdown of elastic tissue.
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Striae
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The normal percussion sound of the stomach is _____.
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tympany
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Use the ___ of the stethoscope to auscultate the abdomen.
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diaphragm
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____ bowel sounds are described as gurgling and occur every 5-20 seconds.
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Normal
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____ bowel sounds are soft and infrequent. They may be due to an obstruction or surgery.
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Hypoactive
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____ bowel sounds are high pitched, loud, rushing sounds that are very frequent.
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Hyperactive
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_____ are bowel sounds.
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Borborygmi
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When auscultating the abdomen go in the following order:
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RLQ, RUQ, LUQ, and LLQ
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Cannot document absent bowel sounds unless you listen for ____ minutes in each quadrant.
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3-5
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Abdominal variations in pediatrics are:
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-pot belly
-visible peristaltic waves -liver and spleen more easily palpated |
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Abdominal variations in geriatrics are:
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decreased
-bowel sounds -muscle tone -motility in GI tract -absorption of oral meds and Increased incidence of colon cancer |
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The musculoskeletal system includes:
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bones, muscles, tendons, cartilage, and ligaments
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____ disorders often manifest with the musculoskeletal system.
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Neurologic
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3 things we assess with the the musculoskeletal system are:
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ROM, muscle tone, and muscle strength
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The positions used when assessing the musculoskeletal system are
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standing, sitting, and supine
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On inspection of the musculoskeletal system look at the
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symmetry, gait, posture, and balance
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Palpate parts of the musculoskeletal system for
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tenderness and obvious enlargement
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___ is the condition of the muscle at rest.
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Tone
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___ is assessed by having the patient move against resistance.
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Strength
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Abnormal findings of the muscular assessment include:
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-atrophy
-hypertrophy -tremors -flaccidity -ataxia -decreased ROM -selling, pain contractures |
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____ is muscle wasting.
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Atrophy
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____ is an increase in muscle size.
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Hypertrophy
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____ are involuntary muscle movement.
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Tremors
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_____ is muscle weakness.
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Flaccidity
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_____ is clumsiness; lack of coordination.
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Ataxia
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_____ are permanent shortening of a muscle.
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Contractures
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____ tremors become more apparent when the individual attempts a voluntary activity.
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Intention
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____ tremors are more apparent at rest and diminish with activity.
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Resting
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____ is bone rubbing against bone.
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Crepitation
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11 joint movements are
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extension
flexion abduction adduction supination pronation circumduction inversion eversion hyperextension rotation |
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____ is decreasing the angle of the joint. ex. bending elbow
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Flexion
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____ is increasing the angle of the joint. ex. straightening of the elbow
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Extension
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____ is further extension or straightening of a joint. ex. bending the head backwards
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Hyperextension
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____ is movement of the bone away from the midline of the body.
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Abduction
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____ is movement of the bone toward the midline of the body.
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Adduction
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____ is movement of the bone around its central axis.
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Rotation
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____ is movement of the distal part of the bone in a circle while the proximal end remains fixed.
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Circumduction
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_____ is turning the sole of the foot outward by moving the ankle joint.
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Eversion
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_____ is turning the sole of the foot inward by moving the ankle joint.
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Inversion
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____ is moving the bones of the forearm so that the palm of the hand faces downward when held in front of the body.
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Pronation
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____ is moving the bones of the forearm so that the palm of the hand faces upward when held in front of the body.
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Supination
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Pediatric muscular variations include:
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hip dysplasia
lordosis (sway back) genu varum (bow legged) scoliosis (curvature of spine) |
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_____ or sway back is accentuation of the cervical or lumbar curvature associated with muscular dystrophy but may be normal during pubertal growth spurt.
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Lordosis
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____ is called bow legged.
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Genum varum
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____ is a lateral curvature of the spine.
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Scoliosis
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Skeletal variations in geriatric patients include:
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-loss of muscle mass and strength
-decreased ROM -decreased bone density -decreased height -kyphosis -osteoarthritic joint changes |
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____ is hump back.
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Kyphosis
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Osteoarthritic joint changes happen when ____ wears away.
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cartilage
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____ is movement of the bone toward the midline of the body.
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Adduction
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____ is movement of the bone around its central axis.
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Rotation
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____ is movement of the distal part of the bone in a circle while the proximal end remains fixed.
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Circumduction
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_____ is turning the sole of the foot outward by moving the ankle joint.
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Eversion
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_____ is turning the sole of the foot inward by moving the ankle joint.
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Inversion
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____ is moving the bones of the forearm so that the palm of the hand faces downward when held in front of the body.
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Pronation
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____ is moving the bones of the forearm so that the palm of the hand faces upward when held in front of the body.
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Supination
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Pediatric muscular variations include:
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hip dysplasia
lordosis (sway back) genu varum (bow legged) scoliosis (curvature of spine) |
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_____ or sway back is accentuation of the cervical or lumbar curvature associated with muscular dystrophy but may be normal during pubertal growth spurt.
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Lordosis
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____ is called bow legged.
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Genum varum
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_____ is clumsiness; lack of coordination.
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Ataxia
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_____ are permanent shortening of a muscle.
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Contractures
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____ tremors become more apparent when the individual attempts a voluntary activity.
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Intention
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____ tremors are more apparent at rest and diminish with activity.
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Resting
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____ is bone rubbing against bone.
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Crepitation
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11 joint movements are
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extension
flexion abduction adduction supination pronation circumduction inversion eversion hyperextension rotation |
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____ is decreasing the angle of the joint. ex. bending elbow
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Flexion
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____ is increasing the angle of the joint. ex. straightening of the elbow
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Extension
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____ is further extension or straightening of a joint. ex. bending the head backwards
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Hyperextension
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____ is movement of the bone away from the midline of the body.
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Abduction
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____ is movement of the bone toward the midline of the body.
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Adduction
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____ is movement of the bone around its central axis.
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Rotation
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____ is movement of the distal part of the bone in a circle while the proximal end remains fixed.
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Circumduction
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_____ is turning the sole of the foot outward by moving the ankle joint.
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Eversion
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_____ is turning the sole of the foot inward by moving the ankle joint.
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Inversion
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____ is moving the bones of the forearm so that the palm of the hand faces downward when held in front of the body.
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Pronation
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____ is moving the bones of the forearm so that the palm of the hand faces upward when held in front of the body.
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Supination
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Pediatric skeletal variations include:
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hip dysplasia
lordosis (sway back) genu varum (bow legged) scoliosis (curvature of spine) |
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_____ or sway back is accentuation of the cervical or lumbar curvature associated with muscular dystrophy but may be normal during pubertal growth spurt.
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Lordosis
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____ is called bow legged.
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Genum varum
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Assessment of the neurologic system includes:
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-mental status
-cranial nerve function -motor function -sensory function -reflexes |
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Neurologic System Assessment
Position- Equipment- |
Position- sitting
Equipment- pen light and reflex hammer |
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____ is difficulty swallowing.
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Dysphagia
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Oriented times 3 means
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patient knows person, place and thing
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Levels of consciousness
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awake and alert
lethargic stuporous comatose |
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A person who is ____ is sluggish and sleepy.
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lethargic
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A person who is ____ sleeps most of the time, is hard to awaken, confused, and will respond to pain with purposeful movements.
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stuporous
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A person who is ____ cannot be aroused even with painful stimuli.
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comatose
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The Glasgow Coma Scale assesses the ____. A score of ___ or less is indicative of a coma.
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level of consciousness
7 |
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The Glasgow Coma Scale assesses 3 things:
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eye opening
motor response verbal response |
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When a person loses orientation or level of awareness, the first thing to go is
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time. Then place and last is person.
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Language is controlled by the _____.
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cerebral cortex
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Assessment of mental status is accomplished thru looking at
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language
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____ is a disorder of language ability.
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Aphasia
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____ aphasia means that the person can understand what is said but cannot write or speak to communicate effectively.
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Expressive
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____ aphasia means the person does not understand written or spoken words. They have impaired comprehension.
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Receptive
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You can assess expressive aphasia by
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telling the patient to do something.
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Assessment of motor function includes:
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balance, gait, and coordination
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Assessment of sensory function includes
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response to pain, light, touch, and vibration
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5 reflexes that are assessed are
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biceps
triceps patellar achilles babinski |
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The ___ reflex is tested at the inner bend of the arm.
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biceps
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The ____ reflex is tested at the back side of the elbow.
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triceps
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The ____ reflex is at the knee.
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patellar
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The ___ reflex is at the ankle.
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achilles
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The ____ reflex is on the bottom of the foot.
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Babinski
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A normal Babinski is when the
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toes curl.
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Reflex of 0 means
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no reflex response
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Reflex of +1 means
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minimal activity
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Reflex of +2 means
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normal response
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Reflex of +3 means
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more active than normal
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Reflex of +4 means
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maximal activity
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Additional pediatric reflexes are:
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rooting
grasp startle (Moro) positive Babinski Parachute |
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Additional pediatric reflexes usually disappear by
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4 months
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The positive Babinski reflex disappears
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after a baby starts to walk.
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Motor control in pediatrics occurs ____.
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cephalocaudaly
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Geriatric lifespan variations in regards to reflexes, motor control and sensory function are:
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-slower thought processes
-short term memory loss -decreased sensory abilities -slower coordination and voluntary movement -decreased reflex responses -confused in unfamiliar surroundings -slower, wider based gait -senile tremors |
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History of female genitalia assessment includes
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-menstrual history
-sexual and pregnancy history -vaginal discharge, itching, and pain on urination -history of reproductive/genital cancer -smoking pelvic exam/pap smear |
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Female genitalia is assessed thru
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inspection and palpation
|
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History of male genitalia assessment includes
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-difficulty urinating/incontinence
-erectile dysfunction -discharge, STD's -contraceptive use -prostrate cancer -frequency of rectal exams and testicular self exams |
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The ____ should be at the head of the penis.
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urinary meatus
|
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The ____ reflex is the testes response to retract into the inguinal canal when in contact with cold or touch.
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cremasteric
|
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____ is an abnormal collection of fluid in the scrotal sac.
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Hydrocele
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____ is abnormal dilation of a vein within the spermatic cord.
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Varicocele
|
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____ is when the urinary meatus is on the underside of the penis head.
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Hypospadias
|
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____ is when the urinary meatus is on the upperside of the penis head.
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Epispadias
|
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The testes and ___ scrotal sac are usually lower than the other side.
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left
|
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Pediatric genital variations in females include:
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- vaginal discharge
-pseudo-menstruation -enlarged labia and clitoris |
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Pediatric genital variations in males include:
|
-placement of urinary meatus
-foreskin tight at birth |
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Geriatric genital variations in females include:
|
-decreased vaginal secretions
-atrophy of urethra, fallopian tubes, and ovaries -cervix and uterus decrease in size -need assistance with lithotomy exam |
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Geriatric genital variations in males include:
|
-decrease penis size
-prostate gland enlarges -may experience frequency, nocturia, dribbling, and difficulty beginning stream |
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Elderly males may experience frequency, dribbling, nocturia, and difficulty beginning stream which are all related to ____ and symptoms of ____.
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enlargement of the prostate
symptoms of BPH or prostate cancer |
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Olfactory (I)
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sensory
ask client to close eyes and identify smells |
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Optic (II)
|
sensory
Snellen type chart, check visual fields, and opthalmoscopic exam |
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Oculomotor (III)
|
motor
assess ocular movements and pupil reaction |
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Trochlear (IV)
|
motor
assess ocular movements |
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Abducens (VI)
|
motor
assess directions of gaze |
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Trigeminal (V)
|
sensory
elicit blink reflex, light sensation and deep sensation |
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Facial (VII)
|
motor and sensory
ask client to smile, frown, raise eyebrows, puff cheeks, close eyes tightly, and identify tastes |
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Acoustic (VIII)
|
sensory
Romberg test and use tuning fork |
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Glossopharyngeal (IX)
|
motor and sensory
move tongue and recognize tastes at back of tongue |
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Vagus (X)
|
motor and sensory
assess with IX for hoarse speech |
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Accessory (XI)
|
motor
shrug shoulders and turn head side to side against resistance |
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Hypoglossal (XII)
|
motor
protrude tongue at midline and move side to side |