NR 509/ NR509 Exam 4 (New 2026/ 2027 Update) Advanced Physical Assessment Guide| Questions & Answers| Grade A| 100% Correct (Accurate Solutions)- Chamberlain

NR 509/ NR509 Exam 4 (New 2026/ 2027 Update) Advanced Physical Assessment Guide| Questions & Answers| Grade A| 100% Correct (Accurate Solutions)- Chamberlain Q. A male client asks the nurse about the purpose of the prostate gland. The nurse should respond that it is a structure that: tes an alkaline substance that neutralizes residual acidic urine in the urethra. des a milky alkaline substance that neutralizes the acidity of the male urethra and the female vagina. 3. secretes a fluid for the health and nutrition ls sperm into the ejaculatory duct. ANSWERS des a milky alkaline substance that neutralizes the acidity of the male urethra and the female Q. 2.A 50-year-old male client has had a prostate-specific antigen test. The nurse realizes that the normal range for this test would be: 1.0 to 2 ng/mL. 2.0 to 3 ng/mL. 3.0 to 4 ng/mL. 4.0 to 5 ng/mL. ANSWERS 3.0 to 4 ng/mL. Q. A male client, having difficulty voiding, tells the nurse that he thinks something is wrong with his penis. The nurse reviews the structures of the penis with the client and explains that the structure that surrounds the urethra is the: s cavernosa. s spongiosum. penis. 4. prepuce. ANSWERS s spongiosum. Q. The nurse is preparing to discuss the male reproductive system with a group of adolescent school students. Which of the following would the nurse not include as a primary function of the male reproductive system? 1.Frequent erectile functioning and increased libido 2.Production of sperm 3.Secretion of testosterone 4.Transportation and depositing of sperm ANSWERS 1.Frequent erectile functioning and increased libido Q. A male client is diagnosed as being infertile. The nurse realizes which of the following structures of the clients reproductive system is affected? 1.Epididymis 2.Rete testes 3.Seminal vesicles 4.Seminiferous tubules ANSWERS 4.Seminiferous tubules Q. The nurse, preparing to discuss the female reproductive system with a group of adolescent females, would include that which of the following is not a primary function of the female reproductive system? 1.Breastfeeding 2.Hormone secretion 3.Pregnancy 4.Sensory innervation ANSWERS 4.Sensory innervation Q. A young adult female client is concerned that she does not have enough eggs since she has not yet become pregnant. The nurse should assure her that the number of ova available to produce a pregnancy would be around: 1.500. 2.10,000. 3.300,000. 4.2,000,000. ANSWERS 3.300,000 Q. 8.During a gynecological exam, it is noted that a clients OS is in the shape of a slit. The nurse realizes that this shape means that the client has: children. started menses. 3. not borne any children. through menopause. ANSWERS children. Q. The nurse, reviewing the reproductive hormones needed to produce sperm and ova, realizes that which of the following hormones is not involved in the formation of sperm and ova? 1.Follicle-stimulating hormone 2.Gonadotropin-releasing hormone 3.Luteinizing hormone 4.Prolactin ANSWERS 4.Prolactin Q. During the examination of the male testes, the nurse should instruct the client on: importance of having an annual prostate examination. ly testicular self-examinations. a colonoscopy is important every 10 years after the age of 50. a condom prevents the spread of sexually transmitted infections. ANSWERS ly testicular self-examinations. Q. A male client has a prostate specific antigen level of 22 nanograms. The nurse realizes that this client will most likely be scheduled for a(n): scan 2.CT scan cular biopsy x ultrasonography ANSWERS scan Q. A female clients Pap test revealed atypical results. The nurse realizes that this client will most likely be scheduled for a(n): scopy. scopy. 3. loop electrosurgical excision. -knife conization. ANSWERS scopy. Q. A female client has an infection of the paraurethral glands. When asked by the client what these glands do, the nurse should respond: (Select all that apply.) 1.These glands function like the prostate gland in the male. 2.These glands secrete mucus near the vaginal opening. 3.These glands secrete mucus. 4. These glands are similar to the Cowpers glands in the male. 5.These glands are located inside the urethra. 6.These glands serve no real function. ANSWERS 1.These glands function like the prostate gland in the male. 3.These glands secrete mucus. 5.These glands are located inside the urethra. Q. The nurse is instructing a postmenopausal client in the importance of having serum lipid levels analyzed because after menopause, which of the following changes can occur? (Select all that apply.) 1.Total cholesterol increases 2. Low-density lipoprotein increases 3.Triglycerides increase 4.High-density lipoprotein decreases 5.Low-density lipoprotein decreases 6.High-density lipoprotein increases ANSWERS 1.Total cholesterol increases 2. Low-density lipoprotein increases 3.Triglycerides increase 4.High-density lipoprotein decreases Q. 3.The nurse is reviewing the physiological sexual response pattern within males and females and realizes that which of the following occur in both genders? (Select all that apply.) 1.Resolution 2.Orgasm 3.Erection 4.Lubrication 5.Plateau 6.Excitement ANSWERS 1.Resolution 2.Orgasm 5.Plateau 6.Excitement Q. A female client is concerned that she has not had sexual intercourse with her husband for over 2 months. Which of the following can the nurse respond as causes for an alteration in sexual functioning? (Select all that apply.) 1.Chronic illnesses 2.Physical disabilities 3.Negative body image 4.Medications 5.Surgical procedures 6.Employment status ANSWERS 1.Chronic illnesses 2.Physical disabilities 3.Negative body image 4.Medications 5.Surgical procedures Q. The nurse is concerned that a female client might be experiencing intimate partner violence. Which of the following assessment questions can be used to gain more information from the client? (Select all that apply.) 1.In the last year have you been hit, slapped, or physically hurt by someone? 2.Are you currently sexually active? 3.Within the last year has someone made you do something sexual that you did not want to do? 4.Is sex satisfying to you? 5.Are you afraid of your partner or anyone else? 6.Do you have discomfort with intercourse? ANSWERS 1.In the last year have you been hit, slapped, or physically hurt by someone? 3.Within the last year has someone made you do something sexual that you did not want to do? 5.Are you afraid of your partner or anyone else? Q. The nurse is instructing a client diagnosed with acute prostatitis. Which of the following instructions would be the least beneficial to the client? 1.Avoid alcohol and caffeine. 2. Sex should be avoided during the acute phase. 3.Sit for as long as you can. 4.Sitz baths may provide ANSWERS 4.Sitz baths may provide Q. The nurse is documenting the health history of a client diagnosed with benign prostatic hyperplasia (BPH). In which of the following areas would the nurse take a careful history? 1.Bowel patterns 2.Eating patterns 3.Sleeping patterns 4.Urinary patterns ANSWERS 4.Urinary patterns A client, diagnosed with benign prostatic hyperplasia (BPH), should be instructed to do which of the following? 1.Do nothing since this disorder does not require any follow-up. 2.Decrease water intake to avoid dribbling. 3.Void every 2 to 3 hours. 4.Wear scrotal support. ANSWERS 3.Void every 2 to 3 hours. 4.A client, recovering from a transurethral resection of the prostate (TURP) with a continuous bladder irrigation system to a three-way indwelling urinary catheter, tells the nurse he has to void. What nursing intervention should the nurse perform? 1.Call the physician. 2. Increase the flow of the irrigant 3.Irrigate the catheter. 4.Tell the client to void. ANSWERS 3.Irrigate the catheter. A client who is 12 hours postoperative after a transurethral resection of the prostate (TURP) is concerned about the blood clots in the catheter and urinary collection bag. How should the nurse respond? 1.I need to call your physician. 2.I will need to stop the bladder irrigation. 3.Blood clots are common during this time frame and will start to decrease in a day. 4.You need to stop moving and irritating the catheter. 3.Blood clots are common during this time frame and will start to decrease in a day. A client is being screened for prostate cancer. What tests would be completed at this time? 1.Digital rectal examination and transrectal ultrasonography 2.Biopsy of the prostate and magnetic resonance imagery 3.Complete blood cell count and prostate-specific antigen 4.Prostate-specific antigen (PSA) and digital rectal examination 4.Prostate-specific antigen (PSA) and digital rectal examination The nurse is instructing a client about testicular self-examination (TSE). Which of the following would not be included in these instructions? 1.The testis should feel smooth and egg-shaped. 2.Perform TSE after a bath or shower. 3.TSE should be performed monthly by every male older than age 40. 4.Any lumps and changes in the testicles should be reported. 3.TSE should be performed monthly by every male older than age 40. A male client is diagnosed with orchitis. The nurse should assess the client for which of the following? 1.Recent infection with mumps 2.Recent diagnosis of prostatitis 3.History of type 2 diabetes mellitus 4.Diagnosis of renal insufficiency 1.Recent infection with mumps A client is diagnosed with a spermatocele. The nurse should instruct the client on which of the following? 1. The use of heat to reduce the size of the inflamed area 2.The potential need for surgery to correct the disorder 3.The use of ice packs to reduce the size of the inflamed area 4.The importance of using antibiotics to treat the disorder 2.The potential need for surgery to correct the disorder A client is diagnosed with a varicocele. The nurse realizes that this client is likely to develop: cele. 2. prostate cancer. atitis. tility. tility. A newborn male child is diagnosed with cryptorchidism. The nurse should prepare to administer which of the following to this client? 1.Intravenous fluids 2.Antipyretic medication 3.Human chorionic gonadotropin medication 4.Antibiotics 3.Human chorionic gonadotropin medication A client is experiencing priapism. Which of the following should the nurse do first to help the client? 1.Apply ice packs to the perineum. 2.Prepare for emergency surgery. 3.Prepare for an aspiration of blood from the penis. 4.Apply heat to the perineum. 1.Apply ice packs to the perineum. A client is diagnosed with testicular torsion. Which of the following might be indicated for this client? (Select all that apply.) 1.Manually untwist the testicle 2.Orchiopexy 3.Testicle removal 4.Pain management 5.Application of ice and a scrotal support 6. Prescribe 1.Manually untwist the testicle 2.Orchiopexy A client is diagnosed with epididymitis. The nurse should instruct the client on which of the following as treatment for the disorder? (Select all that apply.) 1.Broad spectrum antibiotics 2.NSAIDs 3.Bed rest 4. Elevate the scrotum 5.Apply cold packs 6.Apply heat 1.Broad spectrum antibiotics 2.NSAIDs 3.Bed rest 4. Elevate the scrotum 5.Apply cold packs Which of the following should the nurse instruct a client who is recovering from a vasectomy? (Select all that apply.) 1.Use ice packs to control postoperative bleeding. 2.Wear cotton jockey type briefs for scrotal support. 3.Use warm sitz baths to aid in comfort. 4.Recognize the signs and symptoms of postoperative infection. 5.A vasectomy protects the client from sexually transmitted illnesses. 6.Ejaculate will be reduced after the procedure. 1.Use ice packs to control postoperative bleeding. 2.Wear cotton jockey type briefs for scrotal support. 3.Use warm sitz baths to aid in comfort. 4.Recognize the signs and symptoms of postoperative infection. The nurse is assessing a client diagnosed with balanitis and posthitis. Which of the following will the nurse most likely assess in this client? (Select all that apply.) 1.Penile discharge 2.Hematuria 3.Pain 4.Erythema 5.Flank pain 6.Edema 1.Penile discharge 3.Pain 4.Erythema 6.Edema The nurse is assessing a client who is experiencing erectile dysfunction. For which of the following should the nurse assess the client? (Select all that apply.) 1.Diagnosis of diabetes mellitus 2.Thyroid disease 3.Chronic renal failure 4.Multiple sclerosis 5.Parkinsons disease 6. Gastroesophageal reflux 1.Diagnosis of diabetes mellitus 2.Thyroid disease 3.Chronic renal failure 4.Multiple sclerosis 5.Parkinsons disease 1. During data collection the nurse notes the presence of a chancre on a male patients penis. For which sexually transmitted infection should the nurse focus additional data collection? a. Herpes b. Syphilis c. Gonorrhea d. Chlamydia b. Syphilis 2. A patient is diagnosed with a parasitic infection caused by close contact with another persons genitals. For which infection should the nurse plan care? a. Phthirus pubis b. Treponema pallidum c. Neisseria gonorrhoeae d. Chlamydia trachomatis a. Phthirus pubis It is documented in the medical record that a patient has gummas. For which sexually transmitted infection should the nurse plan care? a. Syphilis b. Gonorrhea c. Chlamydia d. Genital herpes a. Syphilis The nurse is assisting with teaching a 22-year-old female patient who is diagnosed with asexually transmitted infection (STI). She says, I dont understand. My boyfriend always wears a condom. Which understanding by the nurse should guide teaching in this situation? a. Condoms are a reliable source of protection against STIs. b. It is a myth that condoms provide any protection against STIs. c. Condoms can decrease the risk of STIs, but they are not foolproof. d. Condoms must be used with a spermicide to guarantee protection against STIs. c. Condoms can decrease the risk of STIs, but they are not foolproof. The nurse is providing care for a patient with genital herpes who has vesicular lesions. What term should the nurse use to describe these lesions to the patient? a. Warts b. Rashes c. Blisters d. Papules c. Blisters Human papillomavirus (HPV) produces verrucous growths. What term should the nurse use to describe these lesions to the patient? a. Warts b. Rashes c. Blisters d. Papules a. Warts 7. The nurse is collecting data on a patient with Chlamydia. Which assessment finding should be reported immediately to the RN or physician? a. Painful urination b. Red conjunctivae c. Vaginal discharge d. Sharp pain at the base of the ribs d. Sharp pain at the base of the ribs Because Trichomonas is relatively large, unusually shaped, and diagnosed quickly, the nurse is asked to assist the physician obtain which type of specimen? a. Culture b. Blood test c. Wet mount d. Litmus paper c. Wet mount A patient diagnosed with Trichomonas asks the nurse how the diagnosis will affect her risk for cervical cancer. Which response by the nurse is best? a. Wet-mount slides should be done yearly to help detect cervical cancer. b. Serological testing will be done to detect tumor proteins and screen for cervical cancer. c. Papanicolaou smears should be done more frequently because results may be altered by Trichomonas. d. Culture and sensitivity testing is done with Papanicolaou (Pap) smears every other year to determine if you have cervical cancer. Papanicolaou smears should be done more frequently because results may be altered by Trichomonas. A patient asks why the physician has recommended systemic interferon treatment for genital warts. Which explanation should the nurse provide to the patient? a. Interferon can improve liver function. b. Interferons can increase your red blood cell count. c. Interferon treatment does not have any side effects. d. Interferon therapy can attack warts all over the body at the same time. Interferon therapy can attack warts all over the body at the same time. A patient with hepatitis B virus (HBV) delivers a 6-pound 2-ounce baby boy. Which action should the nurse anticipate will be needed for the infant? a. Intravenous antibiotics for 12 hours b. Antiviral eye medication less than 2 hours after birth c. There is no treatment that is safe and effective for infants. d. HBV-immune globulin less than 12 hours after birth and then HBV vaccine series HBV-immune globulin less than 12 hours after birth and then HBV vaccine series The nurse must bathe a patient with herpes. What is the nurses best protection against contracting sexually transmitted infections (STIs) from patients while providing perineal hygiene? a. Wearing gloves at all times b. Washing hands following care c. Practicing standard precautions d. Avoiding touching patients who have STIs Practicing standard precautions The nurse is caring for a pregnant woman who is fearful that her unborn child will be born blind because of having a sexually transmitted infection (STI). For which STI should the nurse plan care to prevent ophthalmia neonatorum in the newborn? a. Syphilis b. Gonorrhea c. Genital warts d. Genital herpes b. Gonorrhea 14. The nurse is caring for a young woman who is newly diagnosed with genital warts. She states, I heard you can get cancer from STIs. Is that true? Which response by the nurse is correct? a. No, you cannot get cancer from STIs. b. Yes, most STIs can lead to cancerous changes if not treated promptly. c. Yes, some STIs have been linked to cancer, so adequate treatment is very important. d. No, that is not true, but a diagnosis of cancer does increase the risk of contracting an STI. c. Yes, some STIs have been linked to cancer, so adequate treatment is very important. The nurse is identifying ways for a young adult to reduce the risk of contracting a sexually transmitted infection (STI). What should the nurse teach about the relationship between consumption of alcohol and immediate risk of contracting an STI? a. Alcohol may reduce inhibitions. b. Alcohol increases risk for liver disease. c. Alcohol lowers the bodys resistance to infection. d. Alcohol impairs the integrity of the mucous membranes, providing a portal of entry for infection. a. Alcohol may reduce inhibitions. The nurse reviews the ways to prevent condom breakage with a patient. Which patient statement indicates that more teaching is necessary? a. Condoms should never be reused. b. I should use a water-soluble lubricant. c. Before I use a condom, I should inflate it and check it for holes and leaks. d. I should make sure to leave a half inch extra space at the end of the condom. c. Before I use a condom, I should inflate it and check it for holes and leaks. The nurse is assisting with the admission of a known intravenous drug abuser to a medical unit. In addition to drug abuse, which disorder in the patients history is most consistent with a diagnosis of hepatitis? a. Jaundice b. Diabetes mellitus c. Bowel obstruction d. Chronic headaches a. Jaundice The nurse is teaching a patient the importance of completing treatment for gonorrhea. On which information is the nurse basing this teaching? a. Gonorrhea is not treatable. b. Only men experience symptoms; women are usually asymptomatic. c. Men and women may be asymptomatic and still transmit the infection. d. Treatment is associated with many serious side effects, so compliance is low. c. Men and women may be asymptomatic and still transmit the infection. The nurse is assisting in the preparation of a teaching seminar for adolescents to prevent the development of a sexually transmitted infection (STI). Which nonsexual activity should the nurse teach that may transmit a sexually transmitted infection (STI)? a. Sharing a cigarette b. Borrowing a hairbrush c. Coughing and sneezing d. Sharing intravenous drug equipment d. Sharing intravenous drug equipment A patient asks for the best way to prevent contracting a sexually transmitted infection (STI). What response should the nurse make to this patients question? a. Abstinence b. Oral contraceptives c. Condom with spermicide d. Prophylactic oral antibiotics a. Abstinence A patient diagnosed with genital warts asks how they developed. Which pathogen should the nurse explain as causing genital warts? a. Sarcoptes scabiei b. Hepatitis A and B c. Human papillomavirus d. Chlamydia trachomatis c. Human papillomavirus The nurse is caring for a 76-year-old retired man who is undergoing evaluation for dementia. What would be an important part of the mans history to report to the physician? a. The patient has a history of syphilis. b. The patient was exposed to Chlamydia. c. The patient has a history of hepatitis B. d. The patient has a history of genital warts. a. The patient has a history of syphilis. A patient is undergoing treatment that involves the burning of lesions with heat or chemical agents. The nurse recognizes that this patient most likely has which condition? a. Syphilis b. Chlamydia c. Hepatitis B d. Genital warts d. Genital warts The nurse is providing care for a newborn. Which intervention should the nurse make to prevent development of ophthalmia neonatorum? a. Interferon injection b. Antibiotic eyedrops c. Vitamin K injection d. Hepatitis B virus (HBV)-immune globulin b. Antibiotic eyedrops While reviewing a medical record the nurse notes that patient has a strawberry cervix. For which sexually transmitted infection (STI) would the nurse plan care? a. Gonorrhea b. Herpes simplex c. Trichomoniasis d. Human papillomavirus infection c. Trichomoniasis The nurse is preparing a poster presentation identifying the frequency of sexually transmitted infections (STIs) in the United States. Which STI should the nurse highlight as being the most commonly diagnosed? a. Gonorrhea b. Chlamydia c. Trichomoniasis d. Human papillomavirus b. Chlamydia While assisting a health care provider (HCP) conduct a pelvic examination, the patient complains of severe pain during the bimanual examination. For which health problem should the nurse suspect this patient is going to need care? a. Syphilis b. Gonorrhea c. Pelvic inflammatory disease d. Human papillomavirus infection c. Pelvic inflammatory disease While assisting with care, the nurse counsels the patient diagnosed with a sexually transmitted infection (STI) about notification of sexual partners. Which patient statement indicates the need for further teaching? (Select all that apply.) a. I can contact my sexual partners myself. b. Reporting regulations are the same throughout the country. c. A report form will be completed in my chart that includes a list of my sexual contacts. d. The public health authority can notify a list of sexual contacts without including my identity. b. Reporting regulations are the same throughout the country. The nurse is reviewing prescribed laboratory tests for a patient demonstrating manifestations of syphilis. What diagnostic tests should the nurse expect to be prescribed for this patient? (Select all that apply.) a. RPR b. NAT c. VDRL d. ELISA e. Culture f. CD4 counts a. RPR c. VDRL d. ELISA e. Culture A 24-year-old woman diagnosed with Chlamydia has been prescribed doxycycline. What should be included in the nurses teaching about the drug treatment? (Select all that apply.) a. Take this drug with a meal. b. Do not take with dairy products. c. Avoid unnecessary exposure to sunlight. d. Abstain from alcohol for at least 48 hours after treatment. e. Use birth control methods to ensure you do not become pregnant. b. Do not take with dairy products. c. Avoid unnecessary exposure to sunlight. e. Use birth control methods to ensure you do not become pregnant. The nurse is teaching a patient about the use of condoms to prevent sexually transmitted infections (STIs). Which information should the nurse include in this teaching? Select all that apply. a. Condoms can decrease the risk of transmitting STDs. b. Latex condoms are less likely to break than other types. c. Inflating the condom prior to use allows for effective inspection. d. Condoms should be used no more than twice and then discarded properly. e. Use of a water-soluble lubricant with a condom increases its effectiveness in preventing the spread of an STD. f. Use of a petroleum-based lubricant with a condom increases its effectiveness in preventing the spread of an STD. a. Condoms can decrease the risk of transmitting STDs. b. Latex condoms are less likely to break than other types. e. Use of a water-soluble lubricant with a condom increases its effectiveness in preventing the spread of an STD. The nurse is providing care for a patient recently diagnosed with Chlamydia. Which information should the nurse recommend be included in patient teaching? (Select all that apply.) a. Women with Chlamydia may complain of a sore throat. b. Chlamydia is characterized by the development of chancres. c. Ophthalmia neonatorum is seen in infants born to women with Chlamydia. d. Chlamydia can be transmitted sexually and by blood and body fluid contact. e. The risk of ectopic pregnancy is increased in women with a history of Chlamydia. f. The Chlamydia virus can lie dormant in the nervous system tissues and reactivate when an individual is under stress or has a compromised immune system. d. Chlamydia can be transmitted sexually and by blood and body fluid contact. e. The risk of ectopic pregnancy is increased in women with a history of Chlamydia. The nurse notes that a patient is diagnosed with vulvovaginitis. What should the nurse expect when assessing this patient? (Select all that apply.) a. Vaginal edema b. Vaginal discharge c. Areas of ecchymosis d. Dark brown vaginal bleeding e. Complaints of vaginal itching and burning a. Vaginal edema b. Vaginal discharge e. Complaints of vaginal itching and burning A patient in labor is diagnosed with mucopurulent cervicitis. For which health problems should the nurse anticipate providing care to the newborn? (Select all that apply.) a. Pneumonia b. Conjunctivitis c. Irregular heart rate d. Flaccid extremities e. Cyanotic extremities a. Pneumonia b. Conjunctivitis A patient diagnosed with syphilis reminds the HCP of having an allergy to penicillin. Which medications should the nurse expect to be prescribed for this patient? (Select all that apply.) a. Gentamicin b. Amoxicillin c. Tetracycline d. Doxycycline e. Erythromycin c. Tetracycline d. Doxycycline While providing a bath the nurse suspects that an older female patient has a Trichomonas infection. What type of discharge did the nurse observe to come to this conclusion? (Select all that apply.) a. Frothy discharge b. Foul-smelling discharge c. Yellow-green discharge d. Open sores on the labia majora e. Wart-like growths on the labia minora a. Frothy discharge b. Foul-smelling discharge c. Yellow-green discharge 29. The nurse is assisting with teaching a patient who has been exposed to hepatitis Which symptoms should the nurse explain may occur before jaundice appears? (Select all that apply.) a. Rash b. Nausea c. Confusion d. Dark-colored urine e. Muscle or joint pain f. Elevated blood glucose a. Rash b. Nausea e. Muscle or joint pain What is the most common presenting complaint in congestive heart failure? A. Weight loss B. Palpitations C. Syncope D. Dyspnea D. Dyspnea What should be the initial management for a new wart? A. Tretinoin cream B. Liquid nitrogen cryotherapy C. Salicylic acid D. Watchful waiting D. Watchful waiting A 44-year-old patient with breast cancer is prescribed tamoxifen by her surgeon. She is complaining about hot flashes. Which of the following responses by the clinician would be most appropriate? a. "You must be having menopause." b. "The hot flashes are a result of the antiestrogenic effects of tamoxifen." c. "Tamoxifen will impact your temperature regulation center." d. "The drug destroys your ovaries." b. "The hot flashes are a result of the antiestrogenic effects of tamoxifen." A 23-year-old sexually active woman presents for her first Pap smear. Herhistory includes nulligravida, age at first intercourse 14, and more than 10 sexualpartners. Which of the following conditions should the clinician be particularly alert for during her examination? a. Human papillomavirus (HPV) b. Endometrial hyperplasia c. Vagismus d. Polycystic ovarian syndrome a. Human papillomavirus (HPV) Fred has been diagnosed with a trigger finger of the ring finger. Which of the following management strategies is appropriate? A. Surgical removal of the tendon sheath B. NSAIDs C. Local anesthetic injection into the tendon sheath D. Splinting C. Local anesthetic injection into the tendon sheath A patient is complaining of seeing "flashing lights." What is the provider's next step? A. Send the patient to ophthalmology immediately to evaluate for macular degeneration. B. Tell the patient that it is normal to see flashing lights occasionally. C. Send the patient to ophthalmology immediately to evaluate for a retinal tear or detachment. D. Tell the patient that they can wait to be seen by ophthalmology for 1 month. C. Send the patient to ophthalmology immediately to evaluate for a retinal tear or detachment. The patient weighs 350 pounds and is on a weight loss program. After 6 months which ideal weight in pounds should the clinician observe? A. 335 B. 325 C. 315 D. 305 C. 315 The clinician has instructed a 23 year old patient with lower back strain to use NSAIDS to manage his symptoms of pain. What statement is most appropriate when teaching about the use of NSAIDS? A. "You should start with the lowest dose that is effective in managing your pain, because long-term use of NSAIDs can result in gastrointestinal (GI) disorders such as ulcers and hemorrhage." B. "You should start with the lowest dose that is effective in managing your pain to avoid developing tolerance to the medication." C. "You should take the maximum recommended dose of NSAIDs so that you will not need to take narcotics to control your pain." D. "It is important to take NSAIDs on an empty stomach in order to increase absorption." A. "You should start with the lowest dose that is effective in managing your pain, because long-term use of NSAIDs can result in gastrointestinal (GI) disorders such as ulcers and hemorrhage." Federicka is a A 4o year old Hispanic female with a history of DM, HTN and HIV has a skin test. What is the smallest diameter of induration that would indicate a positive result? A. 2 mm B. 5 mm C. 8 mm D. 10 mm B. 5 mm Which will help a provider determine whether a patient is experiencing paroxysmal supraventricular tachycardia or VT? Frog sign A patient with AML who has a high WBC count & diffused lymphadenopathy is hospitalized during the induction phase of chemo. What monitoring and interventions are critical to assess for complications during this phase of care? Administer sodium bicarb and allopurinol Daily renal function and chemistry values Meticulous assessment of hydration status What meds may be useful in treating tension type headaches? Antiemetics Muscle relaxants NSAIDS triptin drugs A 32 year old woman is seen because she is unable to get pregnant after 12 months. To determine the cause of her infertility the provider should ask about what possible cause? Age Smoking PID PCOS Pelvic Inflammatory Disease a 30 year old male is seen with a complaint of loss of libido. Which lab test helps establish a diagnosis? A. Testosterone level B. Prostate-specific antigen C. Nocturnal penile tumescence and rigidity D. Prolactin level Testosterone Level 22 year old male seen because of a hard lump in his testicle. What risk factor lead the provider to suspect potential testicular Cancer? A. Patient is 65 years old B. Prior cryptorchidism C. Family history of colon cancer D. Living in a city B. Prior cryptorchidism 78 year old man is diagnoses with C2 prostate cancer and asks the provider what that means. In order to answer the patient the provider must have which understanding of the Jewett rating system? A. The cancer involves the seminal vesicles. B. There is metastatic disease to regional lymph nodes .C. The cancer is confined to the capsule. D. There is metastasis to distant organs. A. The cancer involves the seminal vesicles What is true of the IUD? a.The IUD is 80% effective at preventing pregnancy. b.The IUD has an inhibitory effect on sperm capacitation. c.The IUD can only be inserted at menses. d.The IUD can only be inserted in women with multiparity. b.The IUD has an inhibitory effect on sperm capacitation. Which test is essential for a 46 year old woman with suspected perimenopausal? a. Pregnancy b. LH level c. Estrogen level d. Progesterone level a. Pregnancy Which of the following is a complementary therapy for BPH? A. Red raspberry leaf tea B. Saw palmetto C. Black cohosh D. Vitamin A B. Saw palmetto Tyler is a 16-year-old male who the clinician is counseling on sexually transmitted infections (STIs). Which statement made by the clinician is correct? A. "Untreated gonorrhea can lead to many health problems, and if it is not treated it can lead to a syndrome that affects your entire body called disseminated gonococcal infection." B. "Most STIs are untreatable, and, if contracted, you will have potentially fatal health complications." C. "Though STIs are treatable, gonorrhea isn't and always results in permanent penile damage." D. "The only untreatable STI is chlamydia, and it is also the most common." A. "Untreated gonorrhea can lead to many health problems, and if it is not treated it can lead to a syndrome that affects your entire body called disseminated gonococcal infection." Which medication is an oral estrogen product for women with menopause? A. Provera 2.5 mg B. Estrace 0.01% C. Alora 0.025 mg D. Premarin 0.3 mg D. Premarin 0.3 mg A 42 year old woman presents to the clinic with complaint of painful intercourse for the last month. What should be explored as the most likely cause of her dyspareunia? A. Menopause B. Dehydration C. Excess progesterone D. Excess lubrication A. Menopause A 24 year old woman presents with dysuria, dyspareunia and mucopurulent vaginal discharge. Her boyfriend was recently treated for nongonococcal urethritis. What STI has she been exposed to? A. Gonorrhea B. HPV C. Chlamydia D. Trichomoniasis C. Chlamydia A 60 year old woman is seen for an annual checkup. Obstetric history reveals para 6, gravida 6. She went through menopause at age 45. Grandmother died of colon cancer and her father died of lung cancer. What in her history is a risk factor for ovarian cancer? A. Her age at menopause B. Her numerous pregnancies C. Her father's history of lung cancer D. Her grandmother's history of colon cancer D. Her grandmother's history of colon cancer Most common cause of secondary amenorrhea? A) Pregnancy B) Ovarian failure C) Imperforate hymen D) Hypothalamic amenorrhea." Pregnancy Which of the following would be an appropriate treatment for a patient with mild benign prostatic hyperplasia (BPH)? A. Referral to urologist for surgery. B. Prescribe a trial of tamsulosin. C. Recommend cranberry supplements. D. Have a period of watchful waiting. D. Have a period of watchful waiting. Which of the following patients need a cervical cancer screening? A. an 18-year-old who has a history of genital warts B. a 17-year-old with coitarche 3 years ago and four male sexual partners C. a 33 year old who had a negative PAP with negative HPV 5 years ago D. a 21-year-old who has had one male sexual partner and consistent condom use C. a 33 year old who had a negative PAP with negative HPV 5 years ago a 76 year old man is seen for complaints of UTI. Clinician should explore whoc of the following causes of UTI in men? A. Urethral polyps B. Epididymitis C. Selective serotonin reuptake inhibitor (SSRI) medication D. Prostatodynia B. Epididymitis A 35 year old man presents with complaint of painful erections and notices his penis is crooked when erect. What is the most likely diagnosis? A. Peyronie's disease B. Damage to the pudendal artery C. Scarring of the urethra D. Testicular torsion A. Peyronie's disease What is an alternative treatment for breast tenderness and premenstrual symptoms? Evening primrose 250 mg PO up to 3 x daily before menses How does testicular torsion typically present? a. Swelling of the scrotum and fever b. Sudden pain in the scrotum and an absent cremasteric reflex c. A painless testicular mass that cannot be transilluminated d. 'Bag of worms' appearance of the scrotum b. Sudden pain in the scrotum and an absent cremasteric reflex A 15-year-old girl is seen in the clinic because she has not yet had her first period. Which of the following questions would help the clinician determine the cause? a. "Are you sexually active?" b. "How long have you been underweight?" c. "Did your mother take diethylstilbestrol during her pregnancy?" d. "Have you noticed any changes in your moods lately?" b. "How long have you been underweight?" A 40 year old woman is seen for her yearly exam. She is single and not in a monogamous relationship. She smokes cigarettes and drinks 2 beers a day. BMI is 25. She's requesting birth control. What method would be best and most effective? A. withdraw method B. combination oral contraceptive C. IUD D. Condom D. Condom Patient has been diagnosed with breast cancer. Its TNM staging is T2,N1, M0. She wants to know what it means. Which statement is accurate? a.Your tumor is 4 cm, has metastasized to a moveable lymph node, but has not metastasized to another location. b.Your tumor is 5.5 cm and has not metastasized to lymph nodes or anywhere else. c.Your tumor is 1.5 cm, has metastasized to a moveable lymph node, but has not metastasized to another location. d.Your tumor is 3 cm, has metastasized to a moveable lymph node, and has only metastasized to supraclavicular lymph nodes. a.Your tumor is 4 cm, has metastasized to a moveable lymph node, but has not metastasized to another location. a 58 year old patient is receiving leuprolide as treatment for prostate cancer. Provider should instruct the patient about which of these side effects? a. Risk of osteoporosis b. May have hot flushes c. May have impotence b. May have hot flashes A 26 year old woman has complaints of irregular vaginal bleeding. What test is the first priority? a. Pregnancy test b. Pelvic ultrasound c. Endometrial biopsy d. Platelet count a. Pregnancy test A 25 year old woman is complaining of painful menstruation. What pelvic pathologies are the most common cause of secondary dysmenorrhea? a. Pelvic inflammatory disease b. Endometriosis c. Sexually transmitted infections d. Ovarian cyst b. Endometriosis A 22 year old woman is diagnosed with premenstrual syndrome. What lifestyle change would be suggested to help minimize symptoms? a. At least 4 cups of green tea daily b. Regular exercise c. Take vitamin A supplements d. Eat a diet high in iron b. Regular exercise When assessing a woman for fertility which tests should be done first? Semen Analysis A) Hormone analysis B) Endometrial biopsy C) Semen Analysis D) FSH C) Semen Analysis A patient presents complaining of pain and enlarged testes that feel like "a bag of worms." Which diagnosis should the provider most likely assess for? A. Prostate cancer B. Varicocele C. Hydrocele D. Testicular cancer B. Varicocele A 45 year old female complains of mass in left breast, dull nipple pain , tenderness of left nipple and pasty left nipple discharge. What condition should the provider be the most suspicious for? A. Intraductal papilloma B. Hamartomas C. Duct ectasia D. Fibroadenoma C. Duct ectasia A patient reports a decrease in the frequency of stools and asks about treatment for constipation. Which findings are part of the Rome III criteria for diagnosing constipation? (Select all that apply.) a. Feeling of incomplete evacuation b. Fewer than 5 stools per week c. Hard/Lumpy stools d. Presence of irritable bowel syndrome e. Symptoms present for 3 months a. Feeling of incomplete evacuation c. Hard/Lumpy stools e. Symptoms present for 3 months What are causes of secondary Hypertension? NSAID Oral Contraceptives Sleep apnea diabetes NSAID Oral Contraceptives Sleep apnea Which types of chronic noninfectious diarrhea will cause fatty stool? Celiac disease Cystic Fibrosis Pancreatic Insufficiency Celiac disease Cystic Fibrosis Pancreatic Insufficiency Competition in long-term care comes both from other LTC organizations and from other types of organizations. true or false true The influence of managed care on the competitiveness of long-term care: a) is great. b) has not been felt yet. c) has been great, but is diminishing. d) is insignificant. a) is great To date, most integrated health systems have been built around: a) nursing facility chains. b) hospitals. c) government agencies. d) non-healthcare businesses. b) hospitals. The difference between cooperation and integration is largely a matter of degree and structure. true or false true Private certification standards measure minimal acceptable levels of performance. true or false false A "gatekeeper" is a person or agency that determines how much and what type of care is received by an individual. true or false true Nursing facility administrators are licensed by: a) the federal government. b) state governments. c) the Joint Commission on Accreditation of Health Care d) Organizations. e) none of these. b) state governments. Which of the following must be licensed? a) hospital administrators b) nursing facility administrators c) home health care administrators d) all of these b) nursing facility administrators Medicaid serves the "medically indigent," those who have no other coverage and cannot afford to pay for their own care. true or false true Most private long-term care insurance is sold to: a) individuals. b) employers. c) state government. d) managed care organizations a) individuals. The demand for tort reform to reduce liability insurance costs is being led by: a) trial lawyers. b) consumer advocacy groups. c) healthcare providers and insurance companies. d) government regulators. c) healthcare providers and insurance companies. A prospective payment system pays providers based on their actual expenses. true or false false The first step in measuring quality is determining what is meant by quality. true or false true Creating an effective quality improvement program for a long-term care facility or agency is best accomplished by copying one developed by an acute care provider. true or false false The most commonly used types of quality measures are process, outcomes, and: a) documentation. b) activity. c) structure. d) observation. c) structure. The basic concept behind CQI is that quality: a) is not separate from other aspects of the organization's operations. b) must be kept separate from the organization's operations to be objective. c) is best measured by outside entities. d) depends on the financial condition of the organization. a) is not separate from other aspects of the organization's operations. Autonomy, as used in the context of long-term care, means: a) accessibility. b) privacy. c) self-determination. d) beneficence. c) self-determination. Denying care that would prevent pain or suffering is a form of what type of abuse? a) physical abuse b) emotional abuse c) sexual abuse d) fiduciary abuse a) physical abuse Everyday issues such as food, activities, and private space are not of high importance to most residents. true or false false The ethical issue of access deals only with whether a person receives services, not the types of services received, or where they are received. true or false false The interview process Initiating the session Gathering information Physical examination Explanation and planning Closing the session These steps are proving structure and building the relationship interviewing techniques Nonverbal communication Empathy Active listening Validation reassurance partnering summarize Guided questioning Empowerment Setting the stage for examination Explaining point for point what the examination will entail, preparing, privacy, awareness of the setting in which the exam is taking place, do not assume it is ok to have others in the room, being aware of disabilities. Establishing Rapport Earning trust, following through, showing empathy and compassion, being knowledgeable of the information provided Gender Pronouns How a person would like to be referred to. Ex: "She/Her" "He/Him" "They/Them" etc. How would you describe your sexual identity How would you describe your gender identity What is the sex on your original birth certificate FIFE model Feelings Ideas Functioning Expectations Helps explore the patient's perspective about their health and illness Patient-centered medical care Involving the patient in their care and coming up with a plan with the provider. Provider must acknowledge their own personal biases while being aware of what is the safest Sam's most effective plan for the patient Fundamentals of skilled interviewing Active listening, empathetic responses, guided questioning, nonverbal communication, validation, reassurance, partnering, summarization, transitions, empowering the patient verbal communication expressing ideas to others by using spoken words nonverbal communication communication using body movements, gestures, and facial expressions rather than speech Challenging Patient Situations and behaviors Silent Talkative With confusing narrative With altered state or cognition With emotional lability Angry or aggressive Flirtatious Discriminatory With hearing loss With low or impaired vision With limited intelligence Burdened by personal problems Nonadherent With low literacy With low health literacy With limited language proficiency With terminal illness or dying 5 R's off cultural humility Reflection— what did I learn? Respect—did I treat everyone involved w respect? Regard—did unconscious bias drive this encounter? Relevance—how was cultural humility relevant? Resiliency—how did my personal resilience affect this interaction? Core Values of Medical Ethics nonmaleficence, beneficence, respect for autonomy, decisional capacity, confidentiality, informed consent, truth telling, justice Focused Health History ALL components of the Complete Health History with the focus on the specific reason the client is seeking care. Comprehensive Health History includes biographic data, reason for seeking care, present health status, past medical history, family history, personal and psychosocial history, and a review of all body systems Psych Obstetrics Surgery c-section goes here Hospital stays Components of Health History 1) Demographic information 2) Source of history 3) Chief concern 4) History of present illness ——OLDCARTS 5) Past health history and current health status 6) Family history 7) Social history 8) Health promotion behaviors 9) ROS ——all subjective Determining the Scope of patient assessment The patient's symptoms, age, and health history help determine the scope of the focused examination, as does your knowledge of disease patterns. seven attributes of a symptom 1. Location 2. Quality 3. Quantity or severity 4. Timing (including onset, duration, and frequency) 5. The setting in which it occurs 6. factors that have aggravated or relieved the symptom 7. associated manifestations subjective data what the person says about himself or herself during history taking objective data information that is seen, heard, felt, or smelled by an observer; signs Modifying of the clinical interview for various settings Interviews may vary based on where the interview is taking place. Ideal situations are a quiet, uninterrupted environment however the ER setting, home setting, urgent care, nursing home, and inpatient setting will differ greatly from information obtained to what can be visualized by the clinician in the setting. Interruptions are likely during lengthy interview processes. Watch interviewing during the examination. Determining the scope of examination Is the exam going to be focused or comprehensive? Review chart for information to make the decision on what to focus on or be prepared to do a comprehensive assessment. Techniques of Examination 1. Inspection 2. Palpation 3. Percussion 4. Auscultation Head to toe assessment an assessment that organizes the collection of comprehensive physical data by proceeding through the entire body from head to toe General survey Vital signs -skin - head, EENT -neck -back -posterior thorax and lungs -breasts and axillae (ask to lay down) -anterior chest and lungs -cardiac ——elevate the HOB for JVD assessment ——- slight left side for mitral stenosis Then sit and lean forward, aortic regurg —abdomen. (Supine) —-Lower extremity's (supine) nervous/skeletal Then stand up ——-sit down for mental/cranial/motor/reflexes If needed genital and rectal exams The clinical reasoning process Knowledge, Context, Experience Patients story Data acquisition Accurate problem presentation Generation of hypothesis Search for and selection of illness Diagnosis The problem list A list of illnesses, injuries, and other factors that affect the health of an individual patient, usually identifying the time of occurrence or identification and resolution Support a differential dx The differential diagnosis list Generate an exhaustive list Select the most specific and critical findings to support the hypothesis Match finding against all causative conditions (illness scripts) Eliminate Dx possibilities that are not supported by any findings from problem list With competing possibilities and select the most likely Dx Pertinent positives-support Dx Pertinent negatives —r/o Dx The summary statement Chief complaint is placed in context of pt's overall heath status Includes pertinent parts of H&P and labs Succinct and short Demonstrates clinical reasoning skills Make case for diagnosis Distillation of ur understanding of the case Assessment (medical diagnoses) Supports what Dx you are going to use and helps w plan development Planning (treatment and interventions) What you plan to do to treat the diagnosis Teaching, meds, exercise, diet, next follow up, recording of home monitoring I.e. BP, pulse, weight, blood sugars, keeping journals for events that occur, what you ate, when you take pain meds. Using elements of the physical examination as diagnostic tests Elicited through the classic techniques of inspection, palpating, percussion, and auscultation. Evaluating diagnostic tests Validity of the findings Reproducibility off the results SnNOUT ——-a sensitive test with negative result RULES OUT disease SpPIN ——-a specific test with a positive result RULES IN disease. Clinically appraising the evidence Using the approach found in the Users guide to the medical literature, and ask 3 questions 1. Are the results valid? ——-bias 2. What are the results? ——assess the performance of tx or prevention intervention 3. How can you apply the results to patient care? —generalizability Communicating clinical evidence to patients Information should be presented to patients in a way that reduces framing effects and encouraged informed shared decision-making process. 5 A's FRAMES provide ways to support patients facing treatment General Survey physical appearance, body structure, mobility, behavior Dress Color Mood Behavior Personal hygiene Odors Posture Motor Activity Breathing vital signs BP PULSE RESPIRATORY RATE AND TEMPERATURE useful in detecting or monitoring medical problems AND SETS THE TEMPO OF THE EVALUATION Classifying normal and abnormal blood pressure Correct cuff size Comfortably seated Appropriate cuff position 120mmhg and 80 mmhg is normal 120-129/80 elevated 130-139/80-89 stage I HTN 140/90 stage 2 HTN acute pain episode of pain that lasts from seconds to less than 6 months Surgery trauma illness Protective function chronic pain episode of pain that lasts for 6 months or longer; may be intermittent or continuous Cancer Recurring in intervals of months to years Lasting 1 month beyond the course of acute illness anorexia nervosa An eating disorder characterized by an obstinate and willful refusal to eat, a distorted body image, and an intense fear of being fat bulimia nervosa an eating disorder characterized by episodes of overeating, usually of high-calorie foods, followed by vomiting, laxative use, fasting, or excessive exercise Assessing acute and chronic pain Patient pain history Assessing severity Health disparities in pain mental status examination appearance, orientation, speech , affact/mood, impulsive/potential for harm, judgement/insight, thought processesses, intellectual functioning Speech patterns of individuals Dysarthria defective articulation Aphasia language disorder Dysphonia impaired volume, pitch, quality ——-Testing for aphasia—- Comprehension Repetition Naming Reading comprehension Writing Broca aphasia—-expressive Wernicke aphasia——receptive Hallucinations false sensory experiences, such as seeing something in the absence of an external visual stimulus Auditory visual olfactory gustatory tactile somatic May not recognize the experience Can occur in dementia delirium ptsd schizophrenia and substance use assessing abstract thinking ask to interpret a proverb Similarities Concrete responses to abstract thinking assessment are common in intellectual disability delirium or dementia and may reflect limited education. Schizophrenias may answer concrete or with personal and bizarre interpretations screening for depression PHQ-9 Geriatric depression scale Beck depression scale Edinburg post natal Screening for substance abuse Audit-c SASQ CAGE Illusions perceptions that misrepresent physical stimuli Can occur in grief reactions delirium and PTSD OLD CARTS Onset Location Duration Characteristics Aggravating and Alleviating Factors Related Symptoms Treatment Severity Techniques of Examination Mental status exam Skin Anatomy (Layers) epidermis, dermis, Vellum and terminal hair Sweat glands skin lesion morphology Assess lesions for skin cancers throughout the examination Be descriptive when describing ABCD ASSYMETRY BORDER COLOR Diameter. Macule ——freckles moles Patch Papule —raised solid elevation of skin Warts, nevi, bites, cancers Plaque ——flat larger raised area Psoriasis Nodule —-elevated area that extends deeper into tissue ———cysts lipomas Pustule—-filled with fluid. Acne. Vesicle ——clear fluid. Herpes, burns, blisters, poison Bulla —-larger clear fluid area of epidermis ——bullous pemphigus Wheals ——edema of epidermis ——urticaria. Hives. Stings autoimmunity Erosions, ulcers, Petechea, purpura,eccymosis techniques of skin examination Nevi Irregularities Assess for jaundice, eyes, oral Rashes Pallor and cyanosis Turgor Carotene Nail beds Seated then standing —scalp (hair) face neck ears — lean forward for upper back —shoulders arms hands, nails —chest abdomen —anterior thighs feet and toenails —stand up, assess lower back and back of legs—-save genitals and breasts for last Melanoma risk factors Too much exposure to UV radiation (sunlight, tanning lamps or booths) Moles Fair skin, freckling, red or blonde hair Positive family history of melanoma (10% of people with melanoma have a positive family hx) History of immunosuppressive treatment Older age Male gender Past history of melanoma thyroid assessment Posterior approach stand behind pt pt sits up straight bend pt head forward & slightly right use your left fingers push trachea right curl your right fingers between trachea & sternomastiod pt swallow Intolerance to cold, weight gain, dry skin, and slowed heart rate point to hypothyroidism; intolerance to heat, weight loss, moist velvety skin, and palpitations point to possible hyperthyroidism. Examining the head and neck Assess scalp, hair, hair loss Skull Skin on the face Facial muscles and symmetry Facial hair Palpate cervical lymph nodes Trachea Thyroid Lymph note assessment Submental—palpate in the midline a few centimeters behind the tip of the mandible. Submandibular—midway between the angle and the tip of the mandible. These nodes are usually smaller and smoother than the lobulated submandibular gland against which they lie. Preauricular—palpate in front of the ear Posterior auricular—palpate behind the ear and superficial to the mastoid process. Tonsillar (jugulodigastric)—palpate at the angle of the mandible. Occipital—palpate at the base of the skull posteriorly. Anterior superficial cervical—palpate for these nodes anterior and superficial to the SCM muscle. Posterior cervical—palpate along the anterior edge of the trapezius by flexing the patient's neck slightly forward toward the side being examined (Fig. 11-10). Deep cervical chain—deep in the SCM muscle and often inaccessible to examination. Hook your thumb and fingers around either side of the SCM muscle to find them. Supraclavicular—palpate deep in the angle formed by the clavicle and the SCM muscle (Fig. 11-11). (Virchow's node) Thyroid cancer screening recommends against screening for thyroid cancer in asymptomatic adults (Grade D) visual fields assessment Patient faces nurse, one eye closed, nurse closes other eye & moves finger to left and back, switch A visual field is the entire area seen by an eye when it looks at a central point. Fields are conventionally diagrammed on circles from the patient's point of view looking "through" the piece of paper. Static finger wiggle test Assessment of eye history and current state Start with general questions about vision and ocular function: "How is your vision?" and "How are your eyes?" Make sure to ask whether the symptoms involve one eye or both as well as the onset and duration of any symptoms. You can then hone in on the area involved with specific questions. Make sure to ask about inflammatory signs, such as pain, swelling, erythema, warmth, and/or loss of function. In addition to previous medical history, always remember to ask about previous ocular history, including questions about surgery, eye drops, and use of glasses. When asking about eye medications, ask about over-the-counter medications, vitamins, or supplements. Family ocular history can be relevant as well. Extraocular muscle function Having a patient follow a finger in the 6 cardinal positions of gaze is a method of evaluating Cranial nerves associated with extraocular oculomotor, trochlear, abducens 3, 4, 6 The abducens nerve (CN VI) innervates the lateral rectus muscle. The trochlear nerve (CN IV) supplies the superior oblique muscle. The oculomotor nerve (CN III) supplies all the rest of the extraocular muscles. visual acuity assessment testing for distance vision, near vision, peripheral vision, and color vision; perform as first step in eye assessment Snellen chart 20ft Cover 1 eye at a time Visual acuity is expressed as two numbers (e.g., 20/30): the first indicates the distance of the patient from the chart, and the second, the distance at which a normal eye can read the line of letters.11 nystagmus a fine rhythmic oscillation of the eyes. A few beats of nystagmus on extreme lateral gaze are normal. If you see this, bring your finger in to within the field of binocular vision and look again. Can be cerebellar ——gait ataxia ——dysarthria (^ w retinal fixation) ——vestibular disorder ( decrease w retinal fixation) ——internuclear ophthalmoplegia optical neuritis Sudden vision loss with unilateral and can be painful Associated with MS ICP Papilledema of the optic disc Pink Hyperemic Lose of Venus pulsations Disc more visible swollen blurred edges Headache Blurred vision vomiting behavior changes lack of energy. Sleepiness Cotton wool spots Hypertensive retinopathy Diabetes Glaucoma increased intraocular pressure results in damage to the retina and optic nerve with loss of vision Retinal examination reveals pallor and increasing size of the optic cup, which can enlarge to more than half the diameter of the optic disc. Risk factors include age ≥65 years, African American ethnicity, diabetes, myopia, and ocular hypertension (intraocular pressure [IOP] is ≥21 mm Hg). macular degeneration progressive damage to the macula of the retina Fundascopic Exam In general health care, examine your patients' eyes without dilating their pupils. Therefore, your view is limited to the posterior structures of the retina, which can obscure important neurologic findings. Common findings: Retina is visable, arteries and veins, macule, fovea Ear anatomy external ear, middle ear, inner ear Anatomy of thorax and lungs Ribs (12) Sternal angle Costal margins Scapula Spinous process Midsternal, axillary (mid anterior posterior), vertebral, scapular, misclavicukar Trachea and bronchi Encases lungs and heart Diaphragm Clavicles external ear consists of the auricle Helix Antihelix Lobe Tragus middle ear In the air-filled middle ear, there are three ossicles—the malleus, incus, and stapes—which are tiny bones that function to transform sound vibrations from the external ear into mechanical waves that then travel through the inner ear. The middle ear connects to the nasopharynx via the proximal end of the eustachian tube. The eustachian tube acts to ventilate the middle ear space and allows for pressure regulation between the middle ear and surrounding environment. It also functions to drain mucus from the middle ear into the nasopharynx. inner ear The inner ear includes the cochlea; the semicircular canals; the otolith organs housed in the vestibule; and the distal end of the auditory nerve, also known as the vestibulocochlear nerve, or CN VIII. The cochlea is dedicated to hearing, whereas the semicircular canals and otolith organs are dedicated to balance. Together these three structures form the labyrinth. hearing disorders Hearing disorders of the external and middle ear cause conductive hearing loss. External ear causes include cerumen impaction, infection (otitis externa), trauma, squamous cell carcinoma, and benign bony growths such as exostosis or osteoma. Middle ear disorders include otitis media, congenital conditions, cholesteatomas, otosclerosis, tympanosclerosis, tumors, and perforations of the tympanic membrane. Disorders of the inner ear cause sensorineural hearing loss from congenital and hereditary conditions, presbycusis, viral infections such as rubella or cytomegalovirus, Ménière disease, noise exposure, ototoxic drug exposure, and acoustic neuromas.1 Nasal Anatomy Septum Turbinates Frontal sinus the maxillary, ethmoid, frontal, and sphenoid sinuses. Only the frontal and maxillary sinuses are readily accessible on clinical examination sinus assessment 1. Frontal - press up under bony brow, note tenderness. Ta