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health assessment
nursing 255 test 4
| Question | Answer |
|---|---|
| the breast lie | anterior to the pectoralis major and serratus anterior muscles |
| just below the center of each breast | is the nipple |
| the nipple surrounds the | areola for a 1- to 2-centimeter radius |
| Montgomery’s glands secrete a | protective lipid material during lactation |
| the superior lateral corner of the breast tissue is called | the axillary tail of spence |
| The breast is composed of | glandular, fibrous, and adipose tissue. |
| The glandular tissue contains 15 to 20 | lobes that radiate from the nipple and are composed of lobules. |
| Each lobe in the breast empties | into a lactiferous duct |
| collecting duct system converging toward the nipple | lactiferous duct |
| lactiferous duct that carries milk to | the lactiferous sinuses, |
| stores milk behind the nipple | lactiferous sinuses |
| fibrous tissue includes | Cooper’s ligaments that support the breast tissue |
| fibrous bands extending vertically from the surface to attach on chest wall muscles | cooper's ligaments |
| Adipose tissue houses the | lobes and provides most of the bulk of the breast |
| central axillary nodes are | high in the middle of the axilla. |
| pectoral (or anterior) nodes lie along the | lateral edge of the pectoralis major muscle. |
| subscapular (or posterior) nodes are found along the | lateral edge of the scapula. |
| lateral nodes exist along the | humerus, inside the upper arm |
| from the central axillary nodes, drainage flows | up to the infraclavicular and supreaclavicular nodes |
| supernumerary nipple | and extra nipple |
| five stages of breast development follow this classic description of sexual maturity rating or | tanner staging |
| thick, yellow fluid that is a precursor for milk | colostrum |
| begins 1-3 days postpartum | milk production |
| mastalgia occurs with | trauma, inflammation, infection and benign breast disease |
| a sudden increase in the size of one breast signifies | inflammation or new growth |
| the skin is normally | smooth and of even color |
| the nipples should be | symmetrically placed on the same plane on the two breasts |
| lymph nodes feel | small, soft, and non-tender |
| the vertical strip pattern currently is | recommended as the best way to detect a breast mass |
| heat, redness and swelling in non lactating and non-postpartum breasts indicates | inflammation |
| best time to do a self breast exam is | after the menstrual period, or the 4th through 7th day of the menstrual cycle, when breasts are the smallest |
| gynecomastia is a | benign growth of men's breast tissue |
| premature thelarche is early | breast development with no other hormone dependent signs (pubic hair, menses) |
| adolescent breast development begins on an average between | 8- 10 years of age |
| in pregnant women a delicate blue vascular | pattern is visible over the breast |
| in a pregnant woman, colostrum can be expressed | after the first trimester |
| colostrum changes to milk production | around the 3rd postpartum day |
| lymphatic obstruction produces | edema |
| edema in the breast produces and | orange peel look |
| cyst are | discrete, fluid filled sacs |
| breast lumps that are irregular, star-shaped, fixed, and firm to stony hard are | cancerous |
| breast lumps that are round, lobular, mobile, firm to soft, and rubbery are | benign breast disease |
| breast lumps that round, lobular, very mobile, usually firm and rubbery are | fibroadenoma |
| one section of the breast is tender, may be reddened with no infection could indicate a | plugged duct |
| area is red, swollen, tender, very hot and hard, an uncommon inflammatory mass before abscess formation | mastitis |
| musculoskeletal system consists of the body's | bones, joints and muscles |
| musculoskeletal system also functions to | produce the red blood cells in the bone marrow |
| non synovial joint | joints that are immovable |
| synovial joint | joints that are freely movable |
| ligaments are | fibrous bands running directly from one bone to another that strengthen the joint and help prevent movement in undesirable directions |
| bursa is an | enclosed sac filled with viscous synovial fluid |
| a bursa helps | muscles and tendons glide smoothly over bone |
| muscles account for | 40-50% of the body's weight |
| 3 types of muscles | muscles, skeletal and cardiac |
| flexion | bending limb at a joint |
| extension | straightening a limb at a joint |
| abduction | moving a limb away from midline |
| adductin | moving a limb toward midline |
| pronation | palm is down |
| supination | palm is up |
| circumduction | moving arm in a circle around the shoulder |
| inversion | moving the sole of the foot inward at the ankle |
| eversion | moving the sole of the foot outward at the ankle |
| rotation | moving the head around a central axis |
| protraction | moving a body part forward and parallel to the ground |
| retraction | moving a body part backward and parallel to the ground |
| elevation | raising the body part |
| depression | lowering the body part |
| the TMJ is the | articulation of the mandible and the temporal joint |
| humans have ___ cervical vertebrae | 7 |
| humans have ___ thoracic vertebrae | 12 |
| humans have ___ lumbar vertebrae | 5 |
| humans have ___ sacral vertebrae | 5 |
| humans have ___ coccygeal vertebrae | 3-4 |
| spinous processes of C7 and T1 are | at the base of the neck, |
| Bone lengthening occurs at the | epiphyses, or growth plates. |
| the vertebral column has ___ curves | 4 |
| pregnancy, the most characteristic posture change is | progressive lordosis, which adjusts the center of balance as the fetus grows. |
| intervertebral disks are | elastic fibrocartilaginous plates that constitute one fourth of the length of the column |
| glenohumeral joint is the | articulation of the humerus with the glenoid fossa of the scapula |
| acromion process can be felt at the | very top of the shoulder |
| the elbow allows for | flexion and extension |
| palpable landmarks of the elbow are the | medial and lateral epicondyles of the humerus and the large olecranon process of the ulna in between them |
| half of the body's bones are in the | feet and hands |
| the radiocarpal joint is the | articulation of the radius and a row of the carpal bones |
| the knee joint is the articulation of 3 bones | femur, tibia and the patella |
| largest synovial membrane in the body is the | knees synovial membrane |
| suprapatellar pouch is a | sac at the superior border of the patella |
| gradual loss of bone density is | osteoporosis |
| kyphosis is a | hunchback, is a condition of over-curvature of the thoracic vertebrae |
| Rheumatoid arthritis involves | symmetric joints and other musculoskeletal illnesses involve isolated or unilateral joints |
| RA pain is worse | in the morning |
| osteoarthritis is worse | later in the day |
| myalgia is | usually felt as cramping or aching |
| a fracture causes a | sharp pain that increases with movement |
| dislocation is a | complete loss of contact between the two bones in a joint |
| subluxation is when | two bones in a joint stay in contact but their alignment is off |
| contracture is the | shortening of a muscle leading to limited ROM of a joint |
| ankylosis is the | stiffness of fixation of a joint |
| inflammation is indicated by | warmth and tenderness |
| active ROM is when | the patient does the work |
| passive ROM is when | you help the patient do the work |
| crepitation is an | audible and palpable crunching or grating that accompanies movement |
| mcMurray test is to be performed when the person has reported a | history of trauma followed by locking, giving away, or local pain in the knee |
| in infants the tibial torsion is a | twisting of the tibia |
| in infants the ortolani maneuver checks the | hips for congenital dislocation |
| allis test checks for hip dislocation by | comparing leg lengths |
| genu varum is | the lateral bowing of the legs (bow legged) |
| genu valgum is | knees together |
| in adolescents kyphosis is common because of | chronic poor posture |
| screen for scoliosis in adolescents by | doing a forward bend test |
| osteoarthritis is located in the | larger joints due to normal wear and tear |
| ankylosis is when the | wrist is in extreme flexion due to severe RA |
| heberden nodes is a | bone over growth of the distal interphalangeal joint toward the wrist |
| bouchard node is a | bone over growth of the proximal interphalangeal joint towards finger tips |
| spina bifida is the | incomplete closure of posterior part of the vertebrae resulting in a neural tube defect |
| The anal canal is the | outlet of the GI tract |
| is about 3.8 cm long. | the anal canal |
| lined with modified skin that merges with rectal mucosa at the anorectal junction | The anal canal |
| The rectum contains only | autonomic nerves but numerous somatic sensory nevers are present in the anal canal and external skin, so people can feel sharp pain. |
| The internal sphincter is under | involuntary control by the autonomic nervous system. |
| The sphincters keep the anal canal | tightly closed |
| The external sphincter surrounds the | internal sphincter and is under voluntary control. |
| The intersphincteric groove separates the | internal and external sphincter and is palpable. |
| The anal columns (or columns of morgagni) are | folds of mucosa. |
| anal columns extend | vertically down from the rectum and end in the anorectal junction. |
| The anorectal junction | isn’t palpable. |
| The rectum is | 12 cm long and is the distal portion of the large intestine |
| A hemorrhoid is an | enlarged vein in the anal column |
| 3 transverse folds of the interior of the rectum | Valves of Houston |
| The peritoneum covers only | the upper 2/3’s of the rectum |
| The prostate gland lies in front of the | anterior wall of the rectum and 2 cm behind the symphysis pubis |
| The prostate gland has | 15 to 30 ducts that open into the urethra |
| The prostate secretes a | thin, milky, alkaline fluid that helps sperm viability. |
| The prostate is | 2.5 cm long and 4 cm in diameter |
| The two lobes of the prostate are | separated by a shallow groove called the median sulcus. |
| where are the seminal vesicles located on the prostate gland | on either side |
| the seminal vesicles secrete fluid that is | rich in fructose, which nourishes the sperm and contains prostaglandins |
| The bulbourethral is about the size of | a pea |
| the bulbourethral is inferior to the | prostate and secretes a clear, viscid mucus. |
| In a female, The uterine cervix lies | in front of the anterior rectal wall and may be palpated through it. |
| In an adult, The combined length of the anal canal and the rectum is | 16 cm. |
| The sigmoid colon is | 40cm long and only accessible through examination. |
| The sigmoid colon extends from the | iliac flexure of the descending colon and ends at the rectum. |
| The first stool in newborns is | dark green in color and occurs within 24-48 hours. |
| Response to eating and having a stool is called the | gastrocolic reflex. |
| Voluntary control of the anal sphincter can’t occur until the | nerve supplies have become fully myelinated. |
| BPH is an | enlarged prostate, and occurs in 1 of 10 males older than 40. |
| Dyschezia is pain due to a | local condition, hemorrhoid, fissure or constipation. |
| Black tarry stool indicates | upper GI bleeding with blood being partially digested. |
| Red blood in stools occurs with | GI bleeding or local bleeding around the anus and with anal and rectal cancer. |
| Gray, Clay color stools indicate | absent bile pigments (jaundice). |
| The anus normally looks | moist and hairless, with coarse, folded skin that is more pigmented that the perianal skin. |
| A soft, slightly movable mass may be a | polyp. |
| If a Hematest is positive it means that there is | occult blood in the stool. |
| Meconium is the | first stool that a baby passes, usually within 24-48 hours. |
| To assess a newborns anal reflex | gently stroke the anal area and note a quick contraction of the sphincter |
| The external female genitalia are called | the vulva, or pudendum. |
| The mons pubis is a | round, firm pad of adipose tissue covering the symphysis pubis. |
| The mons pubis is covered with | hair in an inverted triangle after puberty. |
| The labia majora are | two rounded folds of adipose tissue that extend down the mons pubis around the perineum. |
| Inside the labia majora are | two smaller, darker folds of skin called the labia minora. |
| labia minora join anteriorly to | form the clitoris. |
| The clitoris is a | small, pea-shaped erectile body that is sensitive to touch. |
| The urethral meatus appears | 2.5 cm posterior to the clitoris. |
| The paraurethral gland (Skene’s ) are not | visible but open posterior to the urethra at 5 an 7 o’clock. |
| The vestibular (bartholin’s) gland are | on either side and posterior to the vaginal orifice and secrete a clear lubricating mucus during intercourse. |
| The vagina is a | flattened, tubular canal extending up and backward into the pelvis. |
| The vagina is | 9 cm long and sits between the rectum posteriorly and the bladder and urethra anteriorly. |
| The os is a smooth | doughnut shaped area with a small circular hole |
| the uterus is a | pear shaped, thick-walled, muscular origin |
| the uterus is flattened and measures | 5.5 to 8 cm long by |
| two pliable, trumpet shaped tubes that are 10 cm in length | the fallopian tubes |
| are located on each side of the uterus | ovaries |
| the ovaries are | oval shaped, 3 cm long by 2 cm wide |
| serves to develop ova (eggs) and the female hormone | the ovaries |
| the first signs of puberty are | breast and pubic hair development which begins between 8 in a half to 13 yrs old |
| tanner's table is on the | 5 stages of pubic hair development |
| cervix softens is called | goodell sign |
| goodell signs start between | 4 to 6 weeks |
| vaginal mucosa and cervix looks cyanotic are | chadwicks sign |
| chadwicks sign start between | 8-12 weeks |
| isthmus of the uterus softens is known as the | hegar sign |
| hegar sign happens between | 6 to 8 weeks |
| during pregnancy the uterus increases its capacity by | 500-1000 times |
| menopause is the | cessation of menses |
| menopause usually occurs around | 48-51 years old |
| during menopause the ovaries | stop producing progesterone and estrogen |
| infibulation is known as | a female circumcision or female genital mutilation |
| invasive surgical procedure done on girls before puberty | infibulation |
| gravida is the | number of pregnancies |
| para is the | number of births |
| menstrual cycle is normally every | 18 to 45 days |
| amenorrhea is the | absents of menses |
| menstrual duration is an | average of 3 to 7 days |
| menorrhagia is known as | heavy menses |
| begin cervical cancer screening within | 3 years after first vaginal intercourse or age 21 years, continue annually until age 30. |
| in women over 30, who have had 3 consecutive normal pap tests | women may be screened every 2 to 3 years |
| urge incontinence is | involuntary urine loss from overactive detrussor muscle in bladder |
| stress incontinence is | involuntary urine loss with physical strain, sneezing, or coughing |
| toilet training begins normally between the ages of | 2 to 2 in a half |
| infertility is considered after | 1 year of engaging in unprotected sexual intercourse without conceiving |
| for pap tests a woman should be put in | lithotomy position and feet in stirrups |
| external genitalia skin tone should be | color should be even, labia minora are a darker pink |
| labia majora are normally | symmetric, plump and well formed |
| to assess the bartholins glands, palpate the | posterior parts of the labia majora with the index finger in the vagina and your thumb outside |
| normally the color of the cervix is | pink and even |
| during the 2nd month of pregnancy the color of the cervix | appears blue (chadwick's sign) |
| after menopause the color of the cervix | is pale |
| the os is | small and round in nulliparous woman ( haven't had a baby yet) |
| cervical eversion, or ectropion may occur | normally after vaginal deliveries |
| nabothian cysts are | benign growths that commonly appear on the cervix after childbirth |
| pap tests screen for | cervical cancer and not endometrial or ovarian cancer |
| acetic acid wash test screens for | asymptomatic human papillomavirus (HPV) |
| the male genital structures include the | penis and scrotum externally and the testis, epididymis and vas deferens internally |
| the penis is composed of | three cylindric columns of erectile tissue |
| the penis has | two corpora cavernosa and one corpus spongiosum |
| at the distal end of the corpus spongiosum expands into a cone of erectile tissue called the | glans |
| where the glans joins the shaft is | the corona |
| conduit for both the genital and urinary systems | urethra |
| over the glans the skin folds in and back on itself forming a hood known as | the foreskin or prepuce |
| the scrotum is a | loose protective sac |
| the cremaster muscle | controls the size of the scrotum by responding to ambient temperature. |
| the scrotum keeps the testes | 3 degrees C below abdominal temperature |
| produces sperm and is suspended vertically by a spermatic cord is a | testis |
| the main storage site of sperm is known as the | epididymis |
| the epididymis is a | comma shaped structure, curved over the top and the posterior surface of the testis |
| the vas deferens joins with the duct of the seminal vesicle to form the | ejaculatory duct |
| the ejaculatory duct empties into | the urethra |
| the lymphatics of the penis and scrotal surface drain | into the inguinal lymph nodes |
| puberty in males begins between the ages of | 9 1/2 and 13 1/2 years |
| the first sign of puberty in males is | enlargement of the testis |
| for male puberty, stages are defined in | Tanner's sexual maturity ratings SMR |
| decreased kidney function or kidney damage lasting 3 months or longer is known as | chronic kidney disease |
| chronic kidney disease can lead to | end stage renal disease (ESRD) |
| ESRD is when | the person survives only by kidney transplant or dialysis |
| phimosis is the | narrowed opening of prepuce so cannot retract the foreskin |
| paraphimosis is the | painful constriction of glans by retracted foreskin |
| hypospadias is when | the urethral meatus opens on the ventral (under) side of the glans penis |
| epispadias is when | the urethral meatus opens on the dorsal (upper) side of the glans penis |
| scrotal swelling may be | taut and pitting, occurs with heart or renal failure or with local inflammation |
| the CNS includes the | brain and spinal cord |
| the PNS includes all the | nerve fibers outside the brain and spinal cord: 12 pairs of cranial nerves and 31 pairs of spinal nerves and all their branches |
| sensory messages are | afferent and go TO the CNS from sensory receptors |
| motor messages are | efferent and are FROM the CNS out to muscles and glands |
| cerebral cortex is the cerebrum's | outer layer of nerve cell bodies |
| cerebral cortex looks grey because | it lacks myelin |
| myelin is the | white insulation on the axon that increases the conduction velocity of nerve impulses |
| the cerebral cortex is the center for | human's highest functions, governing thought, memory, reasoning, sensation and voluntary movement |
| the left hemisphere is dominant in | most (95%) people, including those who are left-handed |
| each hemisphere is divided into | 4 lobes |
| the frontal lobe has areas concerned with | personality, behavior, emotions, and intellectual function |
| the parietal lobe's postcentral gyrus is | the primary center for sensation |
| the occipital lobe is | the primary visual receptor center |
| the temporal lobe behind the ear has the | primary auditory reception center with functions of hearing, taste, and smell |
| wernicke's area in the temporal lobe is associated with | language comprehension |
| broca's area in the frontal lobe mediates | motor speech |
| when the broca's area is messed up a person | cannot talk, they understand language and know what they want to say but can't find the words to say |
| the basal ganglia are the | large bands of gray matter buried deep within the two cerebral hemispheres that form the subcortical associated motor system |
| the thalamus is the | main relay station where the sensory pathways of the spinal cord, cerebellum and brainstem form synapses |
| the hypothalamus is a major | respiratory center with basic vital functions: temperature, appetite, sex drive, heart rate and BP |
| the cerebellum is a coiled structure located | under the occipital love that is concerned with motor coordination of voluntary movements, equilibrium and muscle tone |
| the brainstem is the | central core of the brain consisting of mostly nerve fibers |
| cranial nerves 3-12 originate from | nuclei in the brainstem |
| the midbrain is the | most anterior part of the brainstem |
| the pons is an | enlarged area containing ascending sensory and descending motor tracts |
| the medulla is the | continuation of the spinal cord in the brain that contains all ascending and descending fiber tracts |
| the spinal cord is the | long, cylindric structure of nervous tissue about as big around as the little finger |
| the spinothalamic tract contains fibers | that transmit the sensations of pain, temperature and crude or light touch |
| stereognosis is where | a person can identify an object by touch without looking |
| the extrapyramidal tracts include all the | motor nerve fibers originating in the motor cortex, basal ganglia, brainstem, and spinal cord that are outside the pyramidal tract. |
| the upper motor neurons are a | complex of all the descending motor fibers that can influence or modify the lower motor neurons |
| upper motor neurons are located | completely within the CNS |
| upper motor neuron diseases are | cerebrovascular accident, cerebral palsy and multiple sclerosis |
| lower motor neurons are located | mostly in the peripheral nervous system |
| examples of lower motor neurons diseases are | spinal cord lesions, poliomyelitis, and amyotrophic lateral sclerosis |
| a nerve is a | bundle of fibers outside the CNS |
| reflexes are basic | defense mechanisms of the nervous system |
| there are four types of reflexes | deep tendon, superficial, visceral, pathologic |
| cranial nerves enter and | exit the brain rather than the spinal cord |
| dermal segmentation is the | cutaneous distribution of the various spinal nerves |
| dermatome is a | circumscribed skin are that is supplied mainly from one spinal cord segment through a particular spinal nerve |
| the thumb, middle finger and fifth finger are each in the dermatomes of | C6, C7, and C8 |
| the axilla is at the level of | T1 |
| the nipple is at the level of | T4 |
| the umbilicus is at the level of | T10 |
| the groin is in the region of | L1 |
| the knee is at the level of | L4 |
| paresis is a | partial or incomplete paralysis |
| dysmetria is the | inability of to control the distance, power and speed of a muscular action |
| dysarthria is the | difficulty forming words |
| dysphasia is the | difficulty with language comprehension of expression |
| cranial nerve 1 is the | olfactory nerve |
| cranial nerve 2 is the | optic nerve |
| cranial nerve 3 is the | oculotmotor nerve |
| cranial nerve 4 is the | trochlear nerve |
| cranial nerve 5 is the | trigeminal nerve |
| cranial nerve 6 is the | abducens nerve |
| cranial nerve 7 is the | facial nerve |
| cranial nerve 8 is the | acoustic nerve |
| cranial nerve 9 is the | glossopharyngeal nerve |
| cranial nerve 10 is the | vagus nerve |
| cranial nerve 11 is the | spinal nerve |
| cranial nerve 12 is the | hypoglossal nerve |
| positive romberg test is a | loss of balance that occurs when closing the eyes |
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