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