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HA Test #3
Test on April 28, 2014
| Question | Answer |
|---|---|
| You suspect that a patient is suffering from appendicitis. Which of the following procedures would not be helpful in assessing for appendicitis? | Murphy's sign |
| A 45-year-old male has come to the clinic for an abdominal assessment. Upon percussion, you note an area of dullness above the right costal margin of about 10 cm. You would: | consider this a normal finding and proceed with the examination. |
| A patient is having difficulty in swallowing her medications and her food. In your charting, you would say that she is experiencing: | Dysphagia |
| A 22 yr old male comes to the clinic for an exam after falling off his motorcycle & landing on his left side on the handlebars. You suspect that he may have injured his spleen. Which is true regarding assessment of his spleen in this situation? | The spleen can be enlarged due to trauma. |
| The main reason auscultation precedes percussion and palpation of the abdomen is: | to prevent distortion of bowel sounds that might occur after percussion and palpation. |
| A patient is complaining of tenderness along the costovertebral angles. This is most often indicative of: | kidney inflammation. |
| Which of the following statements regarding the aging adult and abdominal assessment is true? | The abdominal musculature is thinner. |
| To detect diastasis recti, you should have the patient perform which of the following maneuvers? | Raise the head and shoulders while remaining supine |
| Which of the following is a risk factor for peptic ulcer disease? | Frequent use of nonsteroid antiinflammatory drugs |
| 55 yr old man has severe pain of sudden onset in scrotal area-somewhat relieved by elevation, with enlarged red scrotum & is very tender to palpation. It is hard to distinguish the epididymis from testis & scrotal skin is thick & edematous. What is this? | Epididymitis |
| When performing a genitourinary assessment on a 16-year-old boy, you notice a swelling in the scrotum that increases with increased intraabdominal pressure and decreases when he is lying down. Pt complains of pain when straining. What is this? | an indirect inguinal hernia. |
| When performing a genitourinary assessment, you note that the urethral meatus is positioned ventrally. This is: | called hypospadius. |
| A 59-year-old patient has been diagnosed with prostatitis and is being seen at the clinic for complaints of burning and pain during urination. He is experiencing: | Dysuria |
| When performing a scrotal assessment, you note that the scrotal contents transilluminate and show a red glow. Based on this finding you would: | suspect the presence of serous fluid in the scrotum |
| During an exam, you note that a male patient has a red, round, superficial ulcer with a yellowish-serous discharge on his penis. Upon palpation, you note a nontender base that feels like a small button between your thumb & fingers. What is this? | syphilitic chancre. |
| When one is eliciting an initial sexual history from an adolescent, which of the following statements is most appropriate? | “Often boys your age have questions about sexual activity.” |
| Which of the following statements is most appropriate when one is obtaining a genitourinary history from an elderly man? | “Do you need to get up at night to urinate?” |
| You are inspecting the scrotum and testes of a 43-year-old man. Which finding would require additional follow-up and evaluation? | The skin on the scrotum is shiny and smooth. |
| When assessing the scrotum of a male patient, you note the presence of multiple firm, nontender, yellow 1-cm nodules. These are most likely: | Sebaceous cysts |
| During your interview with Mrs. K. you gather data that leads you to believe that she is perimenopausal. Which of the following statements made by Mrs. K. leads to this conclusion? | “I have been noticing that I sweat a lot more than I used to, especially at night.” |
| During the interview your patient reveals that she has some vaginal discharge. She is worried that it may be a sexually transmitted disease. Your most appropriate response to this would be: | “I’d like some information about the discharge. What color is it?” |
| The order of examination of the internal genitalia is important. Which statement best describes the proper order of examination? | Speculum examination, bimanual examination, rectovaginal examination |
| In performing the bimanual examination, you note that the cervix feels smooth and firm, is round, and is fixed in place (doesn’t move). Your cervical palpation produces some pain. Which of the following statements is true regarding these results? | The cervix should move when palpated; an immobile cervix may indicate malignancy. |
| Purpose of a nutritional assessment? | Identify individuals who are at risk for developing malnutrition, provide data for designing a care plan to prevent development and establish a baseline medicine |
| optimal nutritional status? | achieved when sufficient nutrients are consumed to support day to day body needs |
| people who have optimal nutritional status? | more active, fewer illnesses, and live longer |
| undernutrition | reserves are depleted and do not meet day to day metabolic activities |
| overnutrition | consumption of nutrients in excess of body needs |
| breastfeeding | recommended for full term infants for the 1st year of life, fewer food allergies and intolerances, decrease in overfeeding, less cost, increased mother-infant interaction time, HIV mothers should not breastfeed b/c it is transmitted through milk |
| nutrition and the older client | elderly have decrease in energy requirements because of loss of lean body mass and increase in fat mass |
| iron deficiency | lower than normal number of blood cells. Also called anemia. Easily treatable disease that occurs with insufficient iron to body. Low levels are due to blood loss, poor diet, or inability to absorb enough iron from food |
| nutrition and medications | medications can affect interaction with nutrients, some medications cause loss of appetite, while others stimulate appetite |
| 24 hour diet recall | Easiest/most popular. Advantage: elicits specific info over a specific period of time (24 hours). Disadv: may not be able to recall type or amount of food eaten, may be atypical of usual intake, may alter the truth, snacks may be underreported |
| Food diaries | Most complete/accurate if used properly. Records everything consumed for a certain period of time (3 days-2 weekdays and 1 weekend) |
| Problems with food diaries | noncompliance, inaccurate recording, atypical intake on recording days, conscious alteration of diet during the recording period |
| Food frequency questionnaire | Record information on how many times per day, week, or month of a particular food the individual's intakes |
| Downside of food frequency questionnaires | Does not always quantify amount of intake. Like the 24 hr recall, it relies on the individual's or family member's memory for how often a food was eaten |
| direct observation | Screening of feeding & eating process that can detect problems not readily identified through standard nutrition interview. Allows nurse & pt to create individualized nutrition and health plans. Easily adapted to people w/ various cultural backgrounds |
| Example of direct observation | Parent and child feeding techniques & interactions can help assess failure to thrive in children or weight loss |
| Medications that interact with nutrients, impairing their digestion, absorption, metabolism, or utilization | analgesics, antacids, anticonvulsants, antibiotics, diuretics, laxatives, antineoplastic drugs, steroids, oral contraceptives |
| surface anatomy of the breast | lies anterior to the pectoralis major & serratus anterior muscle, located between the 2nd and 6th ribs |
| Tail of Spence | surface anatomy: superior lateral corner of breast tissue |
| Montgomery's gland | surface anatomy: areola surround nipple and contains sebaceous glands called Montgomery's gland |
| Internal anatomy of the breast | Composed of glandular, adipose, and fibrous tissue |
| Glandular tissue of the breast | contains 15 to 20 lobes radiating from the nipple that are composed of lobules. In the lobules are alveoli that produce milk |
| Fibrous tissue of the breast, including the suspensory ligaments | Also called Cooper's ligaments. Fibrous bands extending vertically from the surface to attach on chest walls. These support the breast tissue |
| Adipose tissue of the breast | Lobes are embedded in this. Contains subcutaneous and retromammary fat that provide most of the bulk of the breast |
| supranumerary nipple | normal and common variation (congenital finding). Extra nipple along embryonic "milk line" on the thorax or abdomen. At birth, the only breast structures present are lactiferous ducts in the nipple. No alveoli at birth. Little change occurs until puberty |
| position during breast examination | Patient should first be sitting in position facing examiner. During palpation, patient is supine |
| breast self examination instructions | after menstrual period or the 4th or 7th day of menstrual cycle; do on same day every month; focus on positive aspects; describe correct technique & rationale & expected findings; emphasize ABSENCE of lumps, not the presence of them |
| anatomy and breast tumors | tumors can cause skin and nipple retraction, deviation, and fixation; this is caused because cancer causes fibrosis, which contracts the suspensory ligaments |
| lymphatic edema | Blockage of lymph causes edema indicative of cancer |
| Breast pain | Also called mystalgia. Occurs with trauma, inflammation, infections, and benign breast disease |
| Cyclic pain in the breast | Common with normal breasts, oral contraceptives, and benign breast (fibrocystic) disease |
| Other pains in the breast | Some pain can be related to specific cause such as underwire bra, stenuous exercise, and manipulation during sex |
| Breast symmetry, size, and shape | Breast should be symmetric with a slight asymmetry in size; left breast slightly larger than the right |
| assessment of bladder | assess to make sure that pt does not have a distended bladder |
| contour of the abdomen | describes the nutritional state of the patient. Stand on the person's RIGHT side and look down on the abdomen. Then stoop or sit to gaze across the abdomen. Head should be slightly higher than abdomen. Determine profile from the rib to public bone |
| flat contour | person has a flat abdomen |
| rounded contour | slightly rounded abdomen |
| scaphoid contour | abdomen caves in (concave). Associated with dehydration or malnutrition in a child |
| protuberant contour | large extended abdomen (obese) |
| significance of examination order of abdomen | Inspection, Auscultation, Percussion, Palpation. This is done because the percussion and palpation can increase peristalsis and give a false interpretation of bowel sounds |
| When will you sometimes see pulsation from the aorta beneath the skin in the epigastric area? | In a very thin person with good muscle wall relaxation |
| When are waves of peristalsis sometimes visible? | In very thin persons |
| Who may respiratory movements be seen in the abdomen? | Males |
| When does marked pulsation of the aorta occur? | With widened pulse pressure (hypertension, aortic insufficiency, thyrotoxicosis) and with aortic aneurysm |
| What does a marked visible peristalsis with a distended (swelling) abdomen indicate? | Intestinal obstruction |
| Is the liver palpable | May not be |
| Is the spleen palpable | Normally is not |
| bowel sounds in abdomen | should be present. Must auscultate bowel sounds for 5 minutes before determining they are completely absent |
| Liver span | between 6-12 cm |
| Splenic dullness area should not be wider than _____ | 7 cm |
| When ascites (fluid in abdomen) is suspected there may be _____ | distended abdomen, bulging flanks, or an umbilicus that is protruding an displaced downward |
| Fluid wave test | Determine is there is ascites. Have patient hold one of their hands midline on their abdomen. Place your left hand on patient's right flank. With your right hand reach across abdomen and give left flank a strike |
| carpal tunnel | atrophy occurs from interference with motor function from compression of the median nerve inside the carpal tunnel. Caused by chronic repetitive motion; occurs b/w 30-60 years. 5x more common in women than men |
| Tinel sign | Direct percussion of the location of the median nerve at the wrist produces no symptoms in the normal hand. Positive Tinel sign= pt has carpal tunnel and percussion produces burning and tingling aling its distribution |
| active voluntary range of motion | patient is able to move their joint through full range of motion without assistance |
| passive motion | nurse moves the patients joint through full range of motion |
| range of motion general | active and passive range of motion should be equal; joint motion should not cause tenderness, pain or crepidation; joint motion should feel stable |
| crepitation | audible and palpable crunching or grating that accompanies movement. Occurs when articular surfaces in joints are roughened, like with rheumatoid arthritis. DO NOT confuse with a "crack" when tendon/ligament slips over bone (knee bend) |
| Limitation of ROM is the most sensitive sign of ______ | joint disease |
| normal convex | thoracic curve |
| normal concave | lumbar curve |
| kyphosis | pronounced thoracic curve (hump on back). Common age related change in the curvature of the spinal column |
| lordosis | promounced lumbar curve common to obese people |
| spinous processes | palpate (they should be straight and not tender) |
| paravertebral muscles | palpate (they should feel firm with no tenderness or spasm) |
| tape measurer for ROM | measures leg discrepancy and protractor to measure angle of flexion and extension |
| McMurray's Test for ROM | for meniscal tears |
| Phalen's Test for ROM | Ask person to hold both hands back to back while flexing wrist 90 degrees. Should produce no symptoms. Produces numbness and burning in a person with carpal tunnel |
| bone growth | bone continues to grow after birth, rapidly during infancy and then steadily during childhood, until adolescence |
| long bone | grows in two dimensions. Increase in diameter by deposition of a new bony tissue around the shafts |
| Lengthening of bones | occurs at the epiphyses or growth plates. Continues until growth plates close about age 20 |
| osteoporosis | decrease in skeletal bone mass occurring when rate of bone resorption is greater than that of bone formation. occurs primarily in post menopausal women |
| risk factors of osteoporosis | smaller height and weight, young age at menopause, lack of physical activity, and lack of estrogen in women |
| osteoporosis causes an increased risk of fractures where? | wrist, hip, and vertebrae |
| penis | composed of three cylindrical columns of erectile tissue (2 corpora cavernosa on dorsal side and corpus sponginosum on ventral side, glans is at distal) |
| foreskin | also called prepuce; skin flap that folds over the glans. often removed shortly after birth by circumcision |
| scrotum | loose protective sac that contains the testis and epididymis |
| testis | produce sperm and testosterone. solid oval shape |
| epididymis | duct that is main storage site of sperm |
| vas deferens | duct that transports sperm to be ejaculated |
| inguinal area | juncture of lower abdominal wall and the thigh. Knowledge of this is useful because they are potential sites for hernia, which is a loop of bowel protruding through a weak spot in the musculature |
| testicular function | function of the testis is to produce testosterone and sperm. Located outside of body because sperm develop best at temperatures lower than the body's; declines with age |
| examination of older male genitalia | thinner graying public hair; decreased size of penis; size of testes may be decreased and may feel less firm; scrotal sac is pendulous (hanging loosely) with less rugae and may become excoriated (remove part of surface) if man continually sits |
| difficulty with urination in older male | hesitancy with the following symptoms: straining, loss of force/decreased caliber, terminal dribbling, sense of residual urine, recurrent episodes of acute cystitis- these all suggest progressive prostatic obstruction |
| external anatomy of male genitalia | scrotum and penis |
| external genitalia of women | vulva/penendum |
| mons pubis | round, firm pad of adipose tissue covering the symphysis pubis. After puberty covered with hair in pattern of inverted triangle |
| labia majora | two rounded folds of adipose tissue on either side that extend from mons pubis to perineum |
| inside the labia majora | two smaller, darker folds of skin called the labia minora. These are joined anteriorly at the clitoris where they form a hood, or prepuce and are joined together by the frenulum |
| the majora and minora encircle the.... | vertibule (urethral meastus, opening of stene's gland, hymen, and opening of bartholin's gland) |
| vagina (tubular canal) | internal genitalia. Walls have thick rugae. At the end of this tube is the cervix. In nulliparous (women w/o children) female it appears as a smooth donut shaped area w/ small circular hole, or os. After childbirth, os is slightly enlarged & irregular |
| Tanner's table and teaching | Tanner's table on the five stages of pubic hair development is useful when teaching girls the expected sequence of sexual development |
| What to teach to adolescents | STI risk reduction |
| Do normal breast development and pubic hair develop concurrently? | NO |
| perimenopause history | period between 40-55 years of age |
| ovarian cancer preventative recommendations | HPV vaccine, oral contraceptive reduces the risk of epithelial ovarian cancer, yearly check ups, women over 40 should have a thorough pelvic exam every year; annual transvaginal ultrasonography may detect at an earlier stage for high risk patients |
| discussion of sexuality with adolescents | start with permission statements like "often girls your age have questions about sexual activity" or "are you using condoms" or "do you and your bf have intercourse"; ask if they have discussed STD's with anyone. Teach STI risk reduction |
| 2 months to 7 years female genitalia | labia majora are flat and labia minora thin, clitoris is relatively small and the hymen is tissue paper thin |
| an older adult client visits the clinic and tells the nurse that she has had shooting pains in both of her legs. The nurse should assess the client for signs and symptoms of | herniated intervertebral disk |
| client visits the clinic and tells the nurse that after playing softball yesterday, he thinks his knee is "locking up". The nurse should perform McMurray's test by asking the client to: | flex the knee and hip while in a supine position |
| articulation between the head of the femur and the acetabulum is in the | hip joint |
| pronation and supination of the hand and forearm are the result of articulation of the | radius and ulna |
| when observing the vestibule, the nurse should be able to see the | urethral meatus and vaginal orifice |
| during the inspection of the vagina, the nurse would expect to see what at the end of the vagina? | cervix |
| which of the following statements about the testes is true? | The cremaster muscle contracts in response to cold and draws the testicles closer to the body |
| changes normally associated with menopause occur generally because the cells in the reproductive tract are | estrogen dependent |
| the mother of a 10 year old boy asks the nurse to discuss the recognition of puberty. The nurse should reply: | the first sign of puberty is enlargement of the testes |
Created by:
heatherodom12