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UTA NURS 3320 Final

UTA NURS 3320 Assessment Final Exam

QuestionAnswer
Light palpation depth 1 cm
Deep palpation depth 5-8 cm (2-3")
Location of Liver RUQ; Left lobe LUQ
Location of Gallbladder RUQ
Location of Duodenum RUQ
Location of Pancreas Head RUQ; Body LUQ
Location of Right kidney RUQ
Location of Stomach LUQ
Location of Spleen LUQ
Location of Left kidney LUQ
Location of Cecum RLQ
Location of Appendix RLQ
Location of Ovary & tube RLQ/LLQ
Location of ureter RLQ/LLQ
Location of spermatic cord RLQ/LLQ
Location of Sigmoid colon LLQ
Location of Ascending colon RUQ/RLQ
Location of transverse colon RUQ/LUQ
Location of Descending colon LUQ/LLQ
Location of Aorta Midline
Location of Uterus (if enlarged) Midline
Location of Bladder (if distended) Midline
Where tympany is heard should predominate because air in the intestines rises to the surface when the person is supine.
Where Dullness is heard occurs over a distended bladder, adipose tissue, fluid, or a mass
General survey components physical appearance, body structure, mobility, and behavior.
Orthostatic hypotension a drop in systolic pressure of more than 20 mm Hg or orthostatic pulse increases of 20 bpm or more occurs with a quick change to a standing position.
Orthopenea difficulty breathing when supine.
Speculum size for Otoscope inspection largest that fits comfortably
Head position for Otoscope inspection slightly away from you toward the opposite shoulder
Straighten ear canal by pulling pinna _______ on an adult up and back
Straighten ear canal by pulling pinna _______ on an child (< 3yrs) down and out
Position to hold otoscope "upside down" along your fingers with dorsa (back) of your hand along person's cheek braced to steady otoscope.
Position of ophthalmoscope Hold the ophthalmoscope right up to your eye, braced firmly against the cheek and brow. Match sides with the person.
Diopter unit of strength of each lens on an ophthalmoscope
PQRST Provocative/Palliative, Quality/Quantity, Region/Radiation, Severity Scale, Timing, Understand Patient's Perception
Symptom subjective sensation that the person feels from the disorder
Sign an objective abnormality that you as the examiner could detect on physical examination or in laboratory reports
subjective data what the person says about himself or herself.
objective data what you observe through measurement, inspection, palpation, percussion, and auscultation.
General Survey purpose Get an ovreall impression, a "gestalt," of a person
Delirium an acute confusional change or loss of consciousness and perceptual disturbance, may accompany acute illness (e.g., pneumonia, alcohol/drug intoxication), and is usually resolved when the underlying cause is treated.
Dementia a gradual progressive process, causing decreased cognitive function, even though the person is fully conscious and awake, and is not reversible. Alzheimer disease accounts for about 2/3 of cases of dementia in older adults. Not part of normal aging.
Alert LOC Awake or readily aroused, oriented, fully aware of external and internal stimuli and responds appropriately, conducts meaningful interpersonal interactions.
Lethargic (or Somnolent) LOC Not fully alert, drifts off to sleep, can be aroused to name when called in normal voice but looks drowsy, responds appropriately to questions/commands, thinking slow/fuzzy, inattentive, loses train of thought, decreased spontaneous movements
Obtuned Sleeps most of time, difficult to arouse—needs loud shout or vigorous shake, acts confused when is aroused, converses in monosyllables, speech may be mumbled and incoherent, requires constant stimulation for even marginal cooperation.
Stupor or Semi-Coma Spontaneously unconscious, responds only to persistent and vigorous shake or pain; has appropriate motor response (i.e., withdraws hand to avoid pain); otherwise can only groan, mumble, or move restlessly; reflex activity persists.
Coma Completely unconscious, no response to pain or to any external or internal stimuli (e.g., when suctioned, does not try to push the catheter away), light coma has some reflex activity but no purposeful movement, deep coma has no motor response.
CVA s/s Sudden weakness, usually ipsilateral; sudden confusion, trouble speaking, or understanding, sudden vision change; sudden trouble walking; sudden severe headache
Parkinsons s/s Posture stooped; trunk pitched forward; elbows, hips, & knees flexed. Steps short & shuffling. Hesitation to begin walking, & difficult to stop suddenly. Holds body rigid. Walks and turns body as one fixed unit. Difficulty with any change in direction.
Right Hemisphere Visual spatial skills; expressing emotion; concentration & attention; sense of direction
Left Hemisphere Language; speech; reading & writing; math; verbal communication
Frontal lobe contains primary motor cortex; personality, behavior, emotions, and intellectual function; Precentral gyrus (voluntary movement); Broca's area (speech)
Precentral gyrus in the frontal lobe; initiates voluntary movement.
Broca's area in the frontal lobe; mediates motor speech. When injured in the dominant hemisphere, expressive aphasia results.
Parietal lobe contains primary sensory cortex; position sense, touch, shape, & texture of objects
Postcentral gyrus in the Parietal lobe; the primary center for sensation.
Temporal lobe behind the ear; the primary auditory cortex; Wernicke's area (language comprehension); interprets auditory, visual & somatic input; hearing, taste, and smell.
Occipital lobe the primary visual cortex; receives visual information.
Wernicke's area in the temporal lobe; associated with language comprehension. When damaged in the person's dominant hemisphere, receptive aphasia results. The person hears sound, but it has no meaning, like hearing a foreign language.
Basal ganglia create smooth, coordinated voluntary movement by balancing the production of acetylcholine & dopamine (neurotransmitters) – Automatic movements like arm swing alternate with legs when walk
Thalamus Relay station for the nervous system; Sensory pathways of the spinal cord and brainstem form synapses
Hypothalamus (Homeostasis); Temperature, HR, BP, sleep center; ANS responses; Storage & secretion of pituitary gland hormones
Cerbellum motor coordination of voluntary movements, equilibrium & muscle tone; hemisphere controls ipsilateral side of body
Midbrain relay info r/t muscle movement to brain
Pons Relays senosry info; regulates respiration
Medulla involuntary functions (e.g., breathing)
CN I Olfactory - Smell
CN II Optic - Vision
CN III Oculomotor - Extraocular Movement, opening eyelids; pupil constriction, lens shape
CN IV Trochlear - Down & inward eye movement
CN V Trigeminal - mastication muscles; sensation of face & scalp, cornea, mucous membranes of mouth and nose
CN VI Abducens - Lateral eye movement
CN VII Facial - facial muscles, close eye, labial speech, close mouth; taste (sweet, salty, sour, bitter) on anterior two thirds of tongue; saliva and tear secretion
CN VIII Acoustic - Hearing & equilibrium
CN IX Glossopharyngeal - pharynx movement (phonation & swallowing); taste on posterior 1/3 of tongue, pharynx (gag reflex); parotid gland, carotid reflex
CN X Vagus - Pharynx & larynx movement (talking & swallowing); sensation from carotid body, carotid sinus, pharynx, viscera; carotid reflex
CN XI Spinal Accessory - Trapezius & sternomastoid muscle movement
CN XII Hypoglossal - tongue movement
Dorsiflexion Flexion of the ankle (tibiotalar joint)
Plantar flexion Extension of the ankle (tibiotalar joint)
Flexion bending a limb at a joint
Extension straightening a limb at a joint
Abduction moving a limb away from the midline of the body
Adduction moving a limb toward the midline of the body
Pronation turning the forearm so that the palm is down
Supination turning the forearm so that the palm is up
Circumduction moving the 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 a body part
Depression lowering a body part
Osteoarthritis Noninflammatory, localized, progressive disorder involving deterioration of articular cartilages and subchondral bone and formation of new bone (osteophytes) at joint surfaces.
Rheumatoid Arthritis Chronic, systemic inflammatory disease of joints and surrounding connective tissue. symmetric and bilateral and is characterized by heat, redness, swelling, and painful motion of the affected joints.
ROM of Spine flexion (bending forward), extension (bending back), abduction (to either side), and rotation
CHF s/s Dilated pupils; pale/gray/cyanotic cool/moist skin; Dyspnea/Orthopnea, Crackels/Wheeze/Cough; low BP; n/v; Ascites; edema; Anxiety; low O2; Confusion; Jug vein distention; Fatigue; S3 gallop, tachycardia; enlarged spleen/liver; low urine; Weak pulse
S1 First heart sound. Beginning of systole. Caused by closure of AV valves.
S2 Second heart sound. End of systole. Caused by closure of semilunar valves
S3 Third heart sound. Heard immediately after S2. Ventricle filling sound heard at apex (left-sided) or LSB (right-sided). Dull, soft sound, and low pitched, like "distant thunder".
Physiologic S3 heard frequently in children and young adults; it occasionally may persist after age 40 years, especially in women. The normal S3 usually disappears when the person sits up. (Jarvis 2012, p. 491)
Pathologic S3 Ventricular gallop or S3 gallop. Persists when sitting. indicates decreased compliance of the ventricles, as in heart failure.
S4 Fourth heart sound. Heard just before S1. Ventricular filling sound heard when atria contract late in diastole. Very soft & low-pitched.
Physiologic S4 may occur in adults older than 40 or 50 years with no evidence of cardiovascular disease, especially after exercise. (Jarvis 2012, p. 491)
Pathologic S4 Atrial gallop or S4 gallop. Left-sided occurs with coronary artery disease, cardiomyopathy, systolic overload, including outflow obstruction to the ventricle (aortic stenosis) and systemic HTN. Right-sided occurs with pulmonary stenosis or pulmonary HTN.
COPD s/s Hypertrophied neck muscles; sitting in tripod position; Tense, strained, tired face; Pursed lips; Accessory muscles to force expiration.
Pneumothorax s/s Unequal chest expansion; Decreased fremitus; Hyperresonance; Diminished breath sounds.
Atelectasis s/s Collapse: Cough; Decreased ches expansion (on affected side); Decreased fremitus; Tracheal shift toward affected side; Dull; Deminished breath sounds; May hear fine crackles.
Pulmonary Embolism s/s Chest pain; dyspnea; Respiratory alkalosis; Diaphoresis; Hypotension; Tachycardia; Cracles, wheezes.
Acute Respiratory Distress Syndrome (ARDS) s/s Acute dyspnea; thin, frothy sputum; Respiratory alkalosis; pulmonary infiltrates; Hypotension; Tachycardia; Crackles, ronchi.
Bronchial breath sounds Located in trachea & larynx. High pitched, loud, harsh, hollow tubular. Inspiration < expiration.
Bronchovesicular breath sounds Located over bronchi: btwn scapulae, around upper sternum in 1st & 2nd ICS. Moderate pitch, moderate sound. Inspiration
Vesicular breath sounds Located over peripheral lung fields. Low pitched, soft, rustling. Inspiration > expiration.
Glaucoma s/s Increased intraocular pressure; decrease in peripheral vision
Acute (Narrow-angle) glaucoma s/s circumcorneal redness; pupil oval/dilated; cornea looks "steamy"; sudden clouding of vision, eye pain, & halos around lights.
Chronic (open-angle) glaucoma s/s Excessive Cup-Disc ratio; Painless; No early s/s; gradual peripheral vision loss, eventually tunnel vision if untreated
Cataracts s/s Lens opacity resulting from a clumping of proteins in the lens. (Jarvis 2012, p. 285)
Macular degeneration s/s breakdwon of cells in the macula of the retina; loss of central vision.
Corneal abrasion s/s Top layer of corneal epithelium removed, from scratches or poorly fitting or overworn contact lenses. Feel intense pain, a foreign body sensation, and lacrimation, redness, and photophobia.
Abnormal tonsils acute infection: bright red & swollen (2+ to 4+) and may have exudate or large white spots. Mononucleosis, leukemia, or diptheria: white membrane covering tonsils.
Normal tonsils pink, peppered with indentations (crypts) that may collect small plugs of whitish debris. No exudate. No swelling (1+ or 2+)
Grade 1+ Tonsils Visible
Grade 2+ Tonsils Halfway between tonsillar pillars and uvula
Grade 3+ Tonsils Touching the uvula
Grade 4+ Tonsils Touching eachother
Dizziness light-headed, swimming sensation, feeling of falling
Vertigo rotational spinning from neurologic disease
Nursing process steps Assessing, Diagnosing, Planning, Implementing, Evaluating
Steps to Cultural Competency Self-understanding; Identify the meaning of HEALTH to other people; Understand the health care delivery system; Know about social background of your patients; Be familiar with the language people speak & resources to interpret
Assimilation the process by which a person develops a new cultural identity and becomes like the members of the dominant culture
Spirituality Arising from each person’s unique life experience and the personal effort to find purpose and meaning in life
Underweight BMI <18.5 (adults) or <5th percentile (children)
Normal BMI 18.5-24.9 (adults) or 5th-85th percentile (children)
Overweight BMI 25-29.9 (adults) or 85th-95th percentile (children)
Obese BMI ≥30 (adults, extreme if ≥40) or ≥95th percentile (children)
Glucose Normal <100 mg/dL
HbA1c Normal 5-7%
Hemoglobin Normal males—14 to 18 g/dL, females—12 to 16 g/dL
Hematocric Normal males—37% to 49%, females—36% to 46%
LDL Cholesterol Normal <130 mg/dL
HDL Cholesterol Normal men, 35-65 mg/dL; women, 35-80 mg/dL
Triglycerides Normal <150 mg/dL
Serum Albumin Normal 3.5 to 5.5 g/dL
Serum Transferrin Normal 170 to 250 mg/dL
Prealbumin Normal 15 to 25 mg/dL
C-reactive protein (CRP) Normal <0.1 mg/dL
Hyperactive Bowel Sounds Loud, gurgling sounds, “borborygmi,” signal increased motility. They occur with early mechanical bowel obstruction (high-pitched), gastroenteritis, brisk diarrhea, laxative use, and subsiding paralytic ileus.
Hypoactive Bowel Sounds Diminished or absent bowel sounds signal decreased motility as a result of inflammation as seen with peritonitis; from paralytic ileus as following abdominal surgery; or from late bowel obstruction. Occurs also with pneumonia.
Aortic Aneurysm s/s Most (>95%) located below renal arteries & extend to umbilicus. Focal bulging >5 cm is palpable in abt 80% of cases and feels like a pulsating mass in the upper abdomen just to the left of midline. Bruit is heard. Femoral pulses are present but decreased.
Red Reflex Red glow filling pupil when Ophthalmoscope light reflects off inner retina. Opaque black areas against red reflex is sign of Cataracts.
Allen test Picture cards used to screen visual acuity of children from 2 1/2 to 2 yrs and 11 months.
Modified Allen test evaluates adequacy of collateral circulation before cannulating the radial artery. Depress radial & ulnar arteries; open/close fist; release ulnar. Normal if blood returns or occluded if no blood return.
Respiratory distress s/s tachypnea/bradypnea, low O2 sat, cap refill >2 secs, use of accessory muscles, adventitious or decreased breath sounds, anxiety, pallor, diaphoresis (due to work of breathing), unable to complete sentences when speaking due to shortness of breath.
Elevated Hgb & Hct Polycythemia vera or dehydration
Decreased Hgb & Hct Anemia, recent hemorrhage, or hemodilution caused by fluid retention
Elevated Cholesterol or Triglycerides increased risk for coronary artery disease
Decreased Serum Albumin & Transferrin Protein-calorie malnutrition, altered hydration status, and decreased liver function
Elevated Prealbumiin renal desease
Decreased Prealbumin surgery, trauma, burns, and infection
Elevated CRP increased risk for atherosclerosis, infections, rheumatoid arthritis, TB; contraceptive use & last 4-5 months of pregnancy
Created by: camellia