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223 Cards in this Set
- Front
- Back
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Select the phrase that reflects the most narrow description of health |
the absence of disease
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The most complete description of a database
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subjective and objective data gathered from a patient plus the results of any diagnostic studies
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The best description of a nursing diagnosis is
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a concise description of actual or potential health problems or of wellness strengths
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A focused database is described as
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concerning mainly one problem
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Individuals should be seen at regular intervals for health care. The frequency of these visits
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varies, depending on the persons illness and wellness needs
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Cultural diversity is currently considered when discussing health assessment and care. From a nursing perspective, the most accurate description of this phenomenon is
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nursingis inherently a transcultural phenomenon. The process of helping people involves at least two people having different cultural orientations
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Evidence based nursing practice is described as
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combining clinical expertise with the use of nursing research to provide the best care
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What can be determined when the nurse clusters data as part of the critical thinking process?
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the nurse recognizes patterns and relationships among data
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Religion is best described as
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belief in a divine or superhuman spirit to be obeyed and worshipe
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The major factor contributing to the need for cultural care nursing is
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demographic change
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Culturally competent implies the nurse
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understands the cultural context of the patients situation
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Many of the traditional defitions of health tend to focus on
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physical, mental and spiritual harmony
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illness may be described as an imbalance of hot and cold among people of
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hispanic-american heritage
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an amulet may be used to protect a person from
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the evil eye
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the term empacho can be explained as
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an example of a culture bound syndrome that has no equivalent biomedical perspective
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the first step in cultural competency by a nurse is to
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understand your own heritage and its basis in cultural values
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An accurate understanding of the other persons feelings within a communication context is an example of
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empathy
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students frequently ask teachers "May I ask you a question? this is an example of a
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closed question
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during a patient interview, you recognize the need to use interpretation. this verbal response:
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is based on the interviewer's inference from that data that has been presented
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A good rule for an interviewer is
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spend more time listening to the patient than talking
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During an interview, the patient denies anxiety by shows symptoms during interview. The interviewer should:
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use confrontation to bring the discrepancy between verbal and nonverbal behavior to the patients attention
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Touch should be used during the interview:
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only if the interviewer knows the person well
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Children are usually brough for health care by a parent. At what age should the interviewer begin to question the patient?
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seven years
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When assessing adolsecents which interviewing techniques should be avoided
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silence and reflection
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Personal distance is generally to be considered
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1.5 to 4 feet
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Mr. B tells you "Everyone here ignores me. You respond, "ignores you?" this is desribed as
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reflecting
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Active listening skills include all of the following except
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taking detailed notes during the interview
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With older adults the best approach to take with the interview is?
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consider the fatigue of the aging person and break the interview into shorter segments
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When reading a medical record, you see the following: I have had a cold for about a week, and now I am having difficulty breathing. This is an example of:
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a reason for seeking care
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You have reason to question the reliability of the information being provided by a patient. One way to verify the reliability within the context of the interview is:
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rephrase the same questions later in the interview
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The statement reason for seeking care replaced chief complaint. This change is significant because
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the newer term incorporates wellness needs
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During an initial interview, the examiner says Mrs. J tell me what you do when your headaches occur?
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aggravating or relieving factors
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Which of the following is an appropraite recording of a patients reason for seeking care
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"grabbing" chest pain for 2 hours
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A genogram is useful for showing information concisely. It is used for
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family history
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Review of systems
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the evaluation of the past and present health state of each body system
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Which of the following is considered to be subjective?
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pain lasting two hours
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When taking a health history for a child, what informaiton, in addition to that for an adult is usually obtained?
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a review of immunizations
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FUnctional assessment measures how a person manages day to day activites. The impact of disease on the daily activities is known as:
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disease burden
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You must be aware of the four main headings of the assessment while performing the interview and physical assessment. These headings are:
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appearance, behavior, cognition and thought processes
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Select the finding that most accurately describes the appearance of a patient
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tense posture and restless activity
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The ability to lay down new memories is part of the assessment of cognitive function. One way to accomplish this is by
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use of the four unrelated words test
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Additional assessments may be required for the patient with aphasia. These may be accomplished by asking the patient
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to demonstrate word comprehension by naming articles in the room
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The patient complains about bugs on the bed. The bed is clean. This is an example of
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perception
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One way to assess cognitive function and to detect dementia is with
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the mini-cog
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the behavioral checklist is to be used to assess mental status of
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children 7 to 11
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A major characteristic of dementia is
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impairment of short term memory
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Dysarthria
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word choice and grammar are correct, but sounds are distorted so speech is unintelligable
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The part of the hand used for assessment of vibration is
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ulnar surface of the hand
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When performing indirect percussion, the stationary finger is struck at
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the distal interphalangeal joint
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The best description of the pitch of a sounds wave obtained by percussion is
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the number of vibrations per second
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the bell of the stethoscope
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is used for soft, low pitched sounds
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the sequence of an examination changes from beginning with thorax to that of head to toe with a child age?
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school age
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When inspecting the ear canal with speculum should be used for the otoscope?
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the largest that will fit
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4 areas to consider during the general survey are
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physical appearance, body structure, mobility and behavior
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during the general survey part of the exam, gait is assessed. When walking the base is?
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as wide as shoulder width
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What changes in head circumfrence measurements in relation to cheast measurement will occur from infancy through childhood?
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the newborns head will be 2cm larger than the chest, and will equal out between 6 months and 2 years
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Accurate assessment of patients pulse
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beging counting with zero and count for thirty seconds
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pulse pressure is
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the difference between systolic and diastolic
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In an individual with coarctation the thigh pressure would be :
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lower than in the arm
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mean arterial pressure is
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diastolic pressure plus one-third pulse pressure
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at what phase during nociception does the individual become aware of a painful sensation
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perception
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During the exam, the patient is diaphoretic and pale and complains of pain over left upper quadrant. this would be categorized as
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visceral pain
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When caring for a preterm infant,
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the preterm infant is more sensitive to painful stimuli
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Older post-op patients with poorly controlled pain are at higher risk for
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atelectasis, increased myocardial oxygen demand, impaired wound healing
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The CRIES is an appropriate pain assessment for
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preterm and term neonates
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A pain problem should be anticipated for an older adult with history of
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peripheral vascular disease
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a common physiologic change assoiated with pain is
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tachycardia
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Secretion of the eccrine glands
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dilute saline solution
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Nevus is the medical term for
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a mole
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To assess for early jaundice you look for
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sclera and hard palate
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Checking skin temperature should be done with
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dorsal surface of hand
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An area of thin, shinny skin with decreased visibility of normal skin markings is called
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atrophy
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Configuration for individual lesions arranged in circles is
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annular
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A in ABCDE is
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asymmetry
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Lyme disease is more prevalent
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may through september
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herpes zoster
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lesion on only one side of the body; does not cross midline
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milia occur because
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sebum occludes skin follicles
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The facial bone that articulates at a joint instead of a suture
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mandible
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blood vessel that runs diagnally across the sternocleidomastoid muscle is
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external jugular vein
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isthmus of the thyroid gland lies below the
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cricoid cartilage
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True statement regarding cluster headaches
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precipitated by alcohol and daytime naps
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Fontanels should feel
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firm, slightly concave and well defined
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Characteristics of healthy nodes
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mobile, soft, nontender
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Cephalhematoma
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subperiosteal hemorrhage
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normal cervical lymph nodes are
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smaller than one cm
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bell's palsyis
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unilateral paralysis of half of the face
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palpebral fissure i
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the open space between the eyelids
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corneal reflex is mediated by CN
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5,7
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The examiner records positive consensual light reflex. this is
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simultaneous constriction of the other pupil when one eye is exposed to bright light
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several changes occur in the eye with the aging process. the thickening and yellowing of the lens is
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senile cataract
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The cover test is used for
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muscle weakness
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A person with normal vision would see your moving finger at
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90 degrees
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an interruption of the red reflex occurs when
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there is an opacity in the cornea or lens
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One cause of visual impairment in an aging adult is
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glaucoma
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Sensorineural hearing loss is related to
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gradual nerve degeneration
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During the otoscopic examination of a child younger than 3, the examiner should
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pull the pinna down
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While viewing with the otoscope, the examiner has the person hold the nose and swallow. during this the eardrum should
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flutter
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in examining an adult, the canal is straightened by
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pulling the ear up and back
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darwins tubercle is
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a congenital, painless nodule at the helix
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Hearing receptors are located in the
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cochlea
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The sensation of vertigo is
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pathology of the semicircular canals
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A common cause of conductive hearing loss is
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impacted cerumen
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Risk reduction for acute otitis media includes
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eliminating smoking in the house and car
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When assessing hearing in a six month old child, the examiner should
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watch for heading turning when saying the childs name
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The most common site of nosebleeds is
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kiesselbach plexus
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the sinuses the are accessible to examination are
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frontal and maxillary
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the frenulum is
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the midline fold of tissue that connects the tongue to the floor of the mouth
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the largest salivary gland is located
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within the cheeks in front of the ear
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A deviated septum is noted. the best action is to
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document the deviation in the medical record in case the person needs to be suctioned
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oral malignancies are most likely to develop
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in the mucosal gutter under the tongue
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Tonsils graded as 3+
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tonsils touching the uvula
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The function of the nasal turbinates are
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to warm the inhaled air
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The opening of an adults parotid gland (stensons duct) is opposite the
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upper second molar
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Which is false of a nasal polyp
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the polyp is highly vascularized
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Epstein pearls
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small, round, white, shiny papules on gums of 2 month old
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the reservoirs for storing milk in the breast are
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lactigerous sinuses
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the most common site of breast tumors is
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upper outer quadrant
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The best time to conduct a breast self exam is
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on the fourth to seventh day of the cycle
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The examiner is looking for retraction of breasts. the best position for this is
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hands pushing on hips
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A bimanual technique may be the preferred approach for a woman
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with pendulous breasts
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Description most consistent with cancer
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round, firm, well demarcated
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During the exam of the breasts of a pregnant woman, you would expect to find
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blue vascular patterns over both breasts
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Characteristic of malignant lesion
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irregular shaped
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the manubriosternal angle is
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the articulation of the manubrium and the body of the sternum
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correct description of left lung
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narrower than the right lung with two lobes
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some conditions have cough with characteristic timing. the cough associated with chronic bronchitis is
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productive cough for at least three months of the year for two years in a row
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absence of diaphragmatic excursion occurs with
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pleural effusion or atelectasis of the lower lobes
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Bronchovesicular breath sounds
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moderate pitched, inspration equal to expiration
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Increased respiratory rate, chest expansion decreased on left side, dull to percussion over left lower lobe, are consistent with
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lobar pneumonia
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Coarse, low pitched sounds during inspiration and expiration are consistent with
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pleural friction rub
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the pulse oximeter measures
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arterial oxygen saturation
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a pleaural friction rub is detected by
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auscultation
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barel shaped chest is
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equal in horizontal and diameter
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precordium is
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the area on the anterior chest overlying the heart and great vessels
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tricuspid valve is
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right atrioventricular valve
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function of the pulmonic valve is
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protect the orifice between the right ventricle and the pulmonary artery
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atrial systole occurs
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during ventricular diastole
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the second heart sound is the result of
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closing of the aortic and pulmonic valves
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the normal size of the apical impulse is
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2 cm
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Differentiates a split S2 from S3
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S3 is lower pitched and is heard at the apex
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Listening for pericardial friction rub
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with the diaphragm, patient sitting and leaning forward, breath held in expiration
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When auscultating the heart, the first step is to
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identify s1 and s2
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You will hear a split S2 most clearly in
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pulmonic area
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The stethoscope bell should be placed lightly against skin so that
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it does not act as diaphragm
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A murmur heard after S1 and before S2 is
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systolic probably benign
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Function of the venous system is
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to hold more blood when blood volume increases
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the organs that aid the lympatic system are
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spleen, tonsils and thymus
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a 3+ pulse is
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increased, full
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inspection of a persons right hand reveals a red, swollen area. to further assess you would palpate the
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epitrochlear node
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to screen for deep vein thrombosis you would
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measure the widest point with a tape measure
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The examiner wishes to assess for arterial deficit in the lower extremities. After raising the legs 12 inches off the table and then having the person sit up and dangle the led the color should return in
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ten seconds or less
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Most characteristic sign of varicose veins is
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dilated, tortuous superficial bluish vessels
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Atrophic skin changes that occur with peripheral arterial insufficiency include
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thin, shiny skin with loss of hair
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intermittent claudication is
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muscular pain brought on by exercise
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risk factor for venous ulcer development is
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obesity
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brawny edema is
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nonpitting
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arteriosclerosis is the
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loss of elasticity of the walls of the blood vessels
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Raynaud's phenomenon occurs
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in hands and feet as a result of exposure to cold, vibration and stress
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Sequence of techniqes for exam of abdomen
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inspection auscultation percussion palpation
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Right upper quadrant tenderness may indicate pathology in the
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liver, pancreas, ascending colon
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hyperactive bowel sounds are
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high pitched, rushing, tinkling
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Auscultation of the abdomen may reveal bruits of the
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aortic, renal, femoral, iliac arteries
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The upper left quadrant contains the
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spleen
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Auscultation of the abdomen starts in right lower quadrant because
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bowel sounds are almost always present here
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A dull percussion note forward to the left midaxillary line is
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indicative of splenic enlargement
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Shifting dullness tests for
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ascites
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Tenderness during palpation is expected when palpating
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the sigmoid colon
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Murphy sign is
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pain felt with taking a deep breath when the examiners fingers are on the approximate location of the inflammed gallbladder
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A positive blumberg sign is
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peritoneal inflammation
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During an assessment of the spine the patient would be asked to
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flex, extend, abduct, and rotate
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Pronation and supination fo the hand and forearm are the result of articulation of
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the radius and ulna
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anterior and posterior stability are provided to the knee by
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anterior and posterior cruciate ligamentd
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Common age related curvature of spinal column
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kyphosis
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The joint pain associated with rhuematic fever would
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occur 10 to 14 days after an untreated sore thorat
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The bulge sign is
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swelling in the suprapatellar pouch
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Legs should be
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within one cm of eachother
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a common finding in the spine of a two year old would be
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lordosis
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positive phalen test and tinel sign are seen in patients with
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carpel tunnel syndrome
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when assessing an infant, the examiner should do the ortolani maneuver by
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gently lifting and abducting the infants flexed kneww wihle palpating the trochanter
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Injury to the brocas area
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difficulty speaking
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during the exam of an infant, use a cotton tipped applicator to stimulate the anal sphincter. the absence of the response suggests
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lesion of S2
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The tendon reflex fails to appear. Before striking again, the examiner might use the technique of
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reinforcement
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Cerebellar function is assessed by which of the following tests
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coordination-hop on one foot
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Babinski reflex
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stroke the lateral aspect of the sole of the foot from heel to the ball
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Positive babinski reflex is
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dorsiflexion of the big toe and fanning of the remaining toes
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The cremasteric response
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is positive when the ipsilateral testicle elevates upon stroking of the inner thigh
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To examine the trigeminal nerve in a baby you would
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give the infant a bottle
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Senile tremors do not include
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rigidity and weakness of voluntary movement
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People with parkinsons disease usually have which of the following characteristics of styles of speech
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slow, monotonous
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The glasgow coma scale is divided into three areas:
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eye opening, motor response to stimuli, verbal response
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the landau reflex
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the baby raised the head and arches the back as in a swan dive
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The examiner is going to inspect and palpate for hernia. The man is instructed to
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bear down when the examiners finger is in the inguinal canal
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During examination of the scrotum a normal finding would be
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the left testicle hangs lower than the right
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The class of medication is most likely to cause impotence, the nurse should explored
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antihypertensives
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Prostatic hypertrophy is indicated by
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straining, loss of force, and sense of residual urine
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A normal age related change in the scrotum would be
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pendulous scrotum
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Normal findings of palpation of the testicles are
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rubbery, firm, smooth
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The congenital displacement of the urethral meatus to the inferior surface of the penis is
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hypospadias
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An adhesion of the prepuce to the head of the penis, making it impossible to retract is
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phimosis
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the first physical sign associated with puberty in boys is
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testes enlargement
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A patient has soft, moist, fleshy, painless papules around the anus. This condition is most likely
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HPV
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The gastrocolic reflex is
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a peristalic wave
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The incidence of benigh prostatic hypertrophy is highest among
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african americans
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select the best description of the anal canal
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3.8 cm long, outlet of the GI tract
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Which finding suggests prostate cancer
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diffuse hardness
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The bulbourethral gland is assessed
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during an examination of a male patient
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Inspection of stool is an important part of the rectal exam. Normal stool is
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brown in color and soft
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Which symptoms suggest benign prostatic hypertrophy
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difficulty urinating and weak stream
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A false positive fecal occult blood tests of the stool if the person has ingested significant amounts of
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red meat
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Frothy, fould smelling, stools that float on the surface of the wate
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steatorrhea
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Vaginal lubrication is provided during intercoarse
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bartholins glands
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Gynecologic exam of young woman with no kids, Cervical OS should appear
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smooth and circular
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Cervix appears slightly cyanotic
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Chadwick sign
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For a woman, history of her mothers health during pregnancy is important. A medication that requires follow up is
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diethylstillbesterol
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To prepare for vaginal speculun for insertion
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lubricates with warm water
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To insert the speculun as comfortably as possible
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presses the introitus down with one hand and inserts the blades obliquely with the other
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Swabbing the cervix with a swab soaked in acetic acid assesses
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HPV
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Best description of the uterus
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pear shaped, thick walled organ, flattened
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In placing a finger on either side of the cervix and moving it side to side, you are assessing for
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cervical motion tenderness
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Which of the following are normal findings on the palpation of the vulva and perineum
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labia majora are wide apart and gaping
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Which is the most common STI
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chlamydia
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What does G2 P3 Ab0
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woman has been pregnant twice with 3 children, all are living
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Problems associated with smoking and oral contraceptives
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thrombophlebitis and pulmonary emboli
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