person who has problem who cannot swallow well
dysphagia
A patient is having difficulty swallowing medications and food. The nurse would document that this patient has:
dysphagia
the spleen is located
Left Upper Quadrant
When palpating the abdomen of a 20-year-old patient, the nurse notices the presence of tenderness in the left upper quadrant with deep palpation. Which of these structures is most likely to be involved?
Spleen
when the spleen enlarges
do not palpate it, it can burst (water balloon)
A 22-year-old man comes to the clinic for an examination after falling off his motorcycle and landing on his left side on the handlebars. The nurse suspects that he may have injured his spleen. Which of these statements is TRUE regarding the assessment of the spleen in this situation?
An enlarged spleen should not be palpated because it can easily rupture
A patient's abdomen is bulging and stretched in appearance. The nurse should describe this finding as:
pertuberant
The nurse is describing a scaphoid abdomen. To the horizontal plane, a scaphoid contour of the abdomen depicts a _____ profile.
concave
abdominal pulsations on a skinny person
(aorta) normal
While examining a patient, the nurse observes abdominal pulsations between the xiphoid process and umbilicus. The nurse would suspect that these are:
Normal abdominal aortic pulsations
inflamed appendix
diminish bowel sounds (due to obstruction)
The nurse is listening to bowel sounds. Which of these statements is
TRUE of bowel sounds?
Bowel sounds:
A. Are usually loud,
high-pitched, rushing, and tinkling sounds.
B. Are usually
high-pitched, gurgling, and irregular sounds.
C. Sound like two
pieces of leather being rubbed together.
D. Originate from the
movement of air and fluid through the large intestine.
Are usually high-pitched, gurgling, and irregular sounds.
If no bowel sounds are heard, listen for
5 minutes PER quadrant
During an abdominal assessment, the nurse is unable to hear bowel sounds in a patient's abdomen. Before reporting this finding as SILENT BOWEL SOUNDS, the nurse should listen for at least:
5 minutes
borborygmi
stomach growling sound heard during hyperactive bowel sounds
A patient has hypoactive bowel sounds. The nurse knows that a potential cause of hypoactive bowel sounds is:
peritonitis
assessing abdomen
assess, auscultate, palpate
The nurse is watching a new graduate nurse perform auscultation of a patient's abdomen. Which statement by the new graduate shows a correct understanding of the reason auscultation precedes percussion and palpation of the abdomen?
"It prevents distortion of bowel sounds that might occur after percussion and palpation."
normal bowel sounds are
high pitched, gurgley, cascading type sounds, irregular pattern. 5-30 times a min is considered average.
The nurse is listening to bowel sounds. Which of these statements is true of bowel sounds?
They are usually high-pitched, gurgling, irregular sounds.
The physician comments that a patient has abdominal borborygmi. The nurse knows that this term refers to:
hyperactive bowel sounds
Assessing tibial angle on the back- tenderness on the tibial angle on the back would signify
kidney issues
costovertebral angle tenderness suggests what?
Kidney inflammation
A patient is complaining of sharp pain along with the costovertebral angles. The nurse is aware that this symptom is most often indicative of:
Kidney inflammation
A nurse notices that a patient has ascites, which indicates the presence of:
fluid
ascites
protuberant abdomen filled with fluid
Peritoneal inflammation; Ascites is free fluid build up in the
peritoneal cavity; source could be ovarian cancer
Ascites occur with heart failure, portal hypertension, cirrhosis (most commonly seen), hepatitis, pancreatitis and cancer
Black tarry stools indicative of
Gastrointestinal bleeding
The nurse notices that a patient has had a black, tarry stool and recalls that a possible cause would be:
gastrointestinal bleeding
right lower quad pain
appendix (area btw large and small intestines) mucous stools
Abdomen RLQ-
Cecum, Appendix, Right ovary and tube, Right ureter, Right spermatic cord
During an abdominal assessment, the nurse elicits tenderness on light palpation in the right lower quadrant. The nurse interprets that this finding could indicate a disorder of which of these structures?
Appendix
the gallbladder is located in
the RUQ
Abdomen RUQ
Liver, Gallbladder, Duodenum, Head of Pancreas, Right kidney and adrenal, Hepatic flexure of the colon, part of ascending and transverse colon
The organ in the right upper quadrant of the abdomen is the
liver
Abdomen LUQ
Stomach, Spleen, Left lobe of liver, Body of pancreas, Left kidney
and
adrenal, splenic flexure of colon, part of transverse and
descending colon
spleen is located in
LUQ
Abdomen LLQ
Part of descending colon, sigmoid colon, left ovary and tube, left ureter, left spermatic cord
Which structure is located in the left lower quadrant of the abdomen?
Sigmoid colon
pyloric stenosis what is it and how would it manifest
Thickening of the pylorus (muscle between the stomach and intestines)--causes forceful vomiting, dehydration and weight loss in infants, seen more in infant males.
Pyloric stenosis is a(n):
congenital narrowing of the pyloric sphincter
During an assessment of a newborn infant, the nurse recalls that pyloric stenosis would be exhibited by:
Projectile vomiting
aortic aneurysm – define and assessment from
Aortic aneurysm is a balloon-like bulge in the aorta; murmur is
harsh, systolic, or continuous and accentuated with
systole
Marked pulsation of the aorta occurs with widened pulse
pressure (ex: aortic aneurysm)
You will hear a bruit.
When palpating, the pulsation will cause
your fingers to separate
The nurse is reviewing the assessment of an aortic aneurysm. Which of these statements is true regarding an aortic aneurysm?
A pulsating mass is usually present
Which of these percussion findings would the nurse expect to find in a patient with a large amount of ascites?
Dullness across the abdomen
Full of air palpating sound
Tympany
Full of fluid palpating sound
dull
flat sound could mean
there is a mass
Percussion of ascites would feel like
Tympany at the top where intestines are located and dullness on the
bottom where the ascites is located when the patient is in supine position
Fluid wave test: Place your left hand on the person’s right
flank. With your right hand reach across the abdomen and give the left
flank a firm strike.
If ascites is present, the blow will generate a fluid wave through the abdomen, and you will feel a distinct tap on your left hand
Hernia define and recognize assessment of
Hernia is when an organ (commonly the intestines but not always)
pushed
through a muscle or tissue that holds it in place;
the umbilicus enlarged and everted with hernia
A 40-year-old man states that his physician told him that he has a hernia. He asks the nurse to explain what a hernia is. Which response by the nurse is appropriate?
A hernia is a loop of bowel protruding through a weak spot in the abdominal muscles.
During an assessment the nurse notices that a patient's umbilicus is enlarged and everted. It is midline, and there is no change in skin color. The nurse recognizes that the patient may have which condition?
Umbilical hernia
Most of us have _______ belly buttons
inverted
Hepatomegaly define
enlarged liver
During report, the student nurse hears that a patient has "hepatomegaly" and recognizes that this term refers to
an enlarged liver
If you have a tender area abdomen... assess first or last?
Assess last because of guarding and for patient comfort
The nurse is preparing to examine a patient who has been complaining of right lower quadrant pain. Which technique is correct during the assessment? The nurse should:
Examine the tender area last
knee is capable of what movements (ROM)
flexion and extension
The nurse is checking the range of motion in a patient's knee and knows that the knee is capable of which movement(s)?
flexion and extension
A patient tells the nurse that she is having a hard time bringing her hand to her mouth when she eats or tries to brush her teeth. The nurse knows that for her to move her hand to her mouth, she must perform which movement?
flexion
moving arm toward the center of the body
adduction
Functional units of Musculoskeletal system
The joints are the functional units of the musculoskeletal system because they permit the mobility needed for ADLs
The functional units of the musculoskeletal system are the:
the joints
What are tendons?
Tendons connect muscle to bone
During the assessment of deep tendon reflexes, the nurse finds that a patient's responses are bilaterally normal. What number is used to indicate normal deep tendon reflexes when the documenting this finding? ____+
Responses to assessment of deep tendon reflexes are graded on a 4-point scale. A rating of 2+ indicates normal or average response. A rating of 0 indicates no response, and a rating of 4+ indicates very brisk, hyperactive response with clonus, which is indicative of disease.
What are ligaments?
Ligaments connect two bones at a joint
Fibrous bands running directly from one bone to another that strengthen the joint and help prevent movement in undesirable directions are called:
ligaments
Shoulder can do
circumduction
The nurse notices that a woman in an exercise class is unable to jump rope. The nurse is aware that to jump rope, ones shoulder has to be capable of:
circumduction
Articulation of mandible and temporal bone
TMJ=temporomandibular joint-->palpated anterior to the tragus
Of the 33 vertebrae in the spinal column, there are
5 lumbar
Different sections and number of each vertebrae in spinal column
There are 33 vertebrae in the spine:
-cervical vertebrae:
7
-thoracic vertebrae: 12
-lumbar vertebrae: 5
-sacral
vertebrae: 5
-coccyx: 3-4
The nurse is explaining to a patient that there are shock absorbers in his back to cushion the spine and to help it move. The nurse is referring to his:
Intervertebral disks.
osteoporosis defined
Gradual loss of bone density (bones look spongy)
A patient has been diagnosed with osteoporosis and asks the nurse, "What is osteoporosis?" The nurse explains that osteoporosis is defined as
loss of bone density
term for having more than normal number of digits
Polydactyly
During a neonatal examination, the nurse notices that the newborn infant has six toes. This finding is documented as
Polydactyly
assessment of a system
Head to toe, proximal to distal, from the midline outward.
When performing a musculoskeletal assessment, the nurse knows that
the correct approach for the examination should be:
A. Proximal
to distal.
B. Distal to proximal.
C. Posterior to
anterior.
D. Anterior to posterior.
proximal to distal
nervous system-
Central nervous system includes the brain and spinal cord
Peripheral nervous system includes all the nerve fibers outside the brain and spinal cord (12 pairs of cranial nerves and 31 pairs of spinal nerves)
Frontal lobe
in front of brain, primary center for personality, behavior, emotions and intellectual function
The wife of a 65-year-old man tells the nurse that she is concerned because she has noticed a change in her husband's personality and ability to understand. He also cries and becomes angry very easily. The nurse recalls that the cerebral lobe responsible for these behaviors is the _____ lobe.
frontal
Area where balance is located within the brain
cerebellum
A 30-year-old woman tells the nurse that she has been very unsteady and has had difficulty in maintaining her balance. Which area of the brain that is related to these findings would concern the nurse?
cerebellum
Parietal lobe
behind frontal and is center for sensation
Occipital lobe
at back of brain behind occipital is the primary visual receptor center
Temporal lobe
behind the ear has the primary auditory reception center with the functions of hearing, taste and smell
Advice for client who gets dizzy when arising
Sign of orthostatic hypotension---rise to a standing position slowly
A 70-year-old woman tells the nurse that every time she gets up in the morning or after she's been sitting, she gets really dizzy and feels like she is going to fall over. The nurses best response would be:
You need to get up slowly when you've been lying down or sitting.
Term for room spinning sensation
vertigo
During the history, a client tells the nurse that "it feels like the room is spinning around me." The nurse would document this as:
vertigo
thalamus-
sensory pathway
A female client is in the clinic with weakness in her left arm and leg that she has noticed for the past week. which type of neurologic examination would be most appropriate for this client?
Complete Neurologic Examination
Cranial nerve VII
facial nerve. Note mobility and facial symmetry as the person smiles, frowns, closes eyes tight, lift eyebrows, shows teeth, puff cheeks. Press puff cheeks and note that air should escape equally from both sides
During a neurological assessment, the nurse finds the following: asymmetry when the client smiles or frowns, uneven lifting of eyebrows, sagging of the lower eyelids, and escape of air from one side only when the nurse presses against the puffed cheeks. This would indicate dysfunction of which of these cranial nerves?
Cranial nerve VII
Cranial nerve XI
Spinal Accessory--resistance movements of the shoulder and neck
elicit DTR, ask patients to pull their own hands apart
The nurse is testing the deep tendon reflexes of a 30-year-old woman who is in the clinic for an annual physical examination. When striking the Achilles and quadriceps, the nurse is unable to elicit a reflex. The nurse s next response should be to:
ask the patient to lock her fingers and pull.
How do you assess the level of consciousness?
Ask their name, where there are, facts of the area, president of the time, facts that everyone knows. If not able to answer they are not oriented x5
While the nurse is taking the history of a 68-year-old patient who sustained a head injury 3 days earlier, he tells the nurse that he is on a cruise ship and is 30 years old. The nurse knows that this finding is indicative of a(n):
Decreased level of consciousness.
Anal canal define
is the very end of the GI tract 3-4 cms in length
Which statement concerning the anal canal is true? The anal canal:
is the outlet for the gastrointestinal tract.
Which statement concerning the anal canal is true? The anal canal:
is the outlet for the gastrointestinal tract
Sphincters define and difference in internal and external
The internal sphincter is under involuntary control by the autonomic nervous system. The external sphincter surrounds the internal sphincter but also has a small section overriding the tip of the internal sphincter at the opening. It is under voluntary control. The inter sphincteric groove separates the internal and external sphincters and is palpable
External sphincter and internal sphincter info
Sometimes during childbirth, the sphincters rupture due to a bigger and need to be put back together. The external sphincter is the one you have control of
Which statement concerning the sphincters is correct?
The external sphincter is under voluntary control.
painful bowel movements can be caused by
hemorroids
A 30-year-old woman is visiting the clinic because of pain in my bottom when I have a bowel movement. The nurse should assess for which problem?
hemorroids
pilonidal cyst
hair containing cyst (specifically located at the tailbone above the anus)
During an assessment of a 20-year-old man, the nurse finds a small palpable lesion with a tuft of hair located directly over the coccyx. The nurse knows that this lesion would most likely be
Pilonidal cyst
Black,tarry stool
from GI bleeding
steatorrhea
excessive fat in the stool from malabsorption of fat as in celiac disease, cystic fibrosis, chronic pancreatitis, and Crohn's disease
enzymes cannot get out because they are full of mucous seen in malabsorption syndrome cystic fibrosis
The nurse notices that a patient has had a pale, yellow, greasy stool, or steatorrhea, and recalls that this is caused by:
Increased fat content
Red blood in stool
indicates GI bleeding closer to the outlet (no time to turn black) may indicated hemorrhoid bleeding. also seen in rectal and colon cancer
Clay colored stool
indicative of absence of bile pigment as with biliary cirrhosis, gallstones, alcoholic or viral hepatitis
While assessing a patient who is hospitalized and bedridden, the nurse notices that the patient has been incontinent of stool. The stool is loose and gray-tan in color. The nurse recognizes that this finding indicates which of the following?
absence of bile pigment
Occult bleeding in stool
usually indicates cancer of the colon.
A patient who is visiting the clinic complains of having stomach pains for 2 weeks and describes his stools as being soft and black for approximately the last 10 days. He denies taking any medications. The nurse is aware that these symptoms are mostly indicative of:
Occult bleeding in stool
Be familiar with high fiber foods
High fiber foods include legumes, nuts, and seeds such as split peas,
lentils, black beans, baked beans, and chia seeds
Green peas,
broccoli, and raspberries are also good sources of fiber
High-fiber foods of the soluble type (beans, prunes, barley, carrots, broccoli, cabbage) lower cholesterol levels
during a health history of a patient who complains of chronic
constipation, the patient asks the nurse about high-fiber foods. The
nurse relates that an example of a d be:
a. Broccoli.
b.
Hamburger.
c. Iceberg lettuce.
d. Yogurt.
Broccoli
Fecal impaction assessment -
Abdominal pvalpation or DRE (digital rectal exam)--Fecal
Impaction
Distended abdomen will be present with abdominal pain
and discomfort; a hard fecal mass will be palpable along the colon in
thin individuals
DRE= digital rectal examination; mass will be
felt and can be digitally removed
During a digital examination of the rectum, the nurse notices that the patient has hard feces in the rectum. The patient complains of feeling full, has a distended abdomen, and states that she has not had a bowel movement for several days. The nurse suspects which condition?
Fecal impaction