NURS 190 Midterm for Physical Assessment 2 Questions with Answers

NURS 190 Midterm for PA 2 Questions & Answers 1. Pt with malignant melanoma; risk factors; what will the skin look like? ABCDE ABCDE of Melanoma • Asymmetry • Border Irregularity • Color Variation • Diameter Greater than 6mm • Evolving Changes Risk Factors • Sun sensitivity, difficulty tanning, hx of prolonged sun exposure, use of tanning booths, occupational exposure to chemicals like tar and radiation QUIZ QUESTION: Nevi this big and has color variation should be alerted for? – Malignant Melanoma 2. How to assess for central cyanosis? Look at patient’s oral mucosa QUIZ QUESTION: How to assess central cyanosis? – check the oral mucosa 3. Contact dermatitis Inflammation of the skin due to an allergy to a substance that comes into contact with the skin Redness, hives, vesicles or scales accompanied by intense itching 4. 3 Tineas; signs and symptom Tinea Corporis – fungal infection of the body Tinea Capitis – fungal infection of the scalp • Need to further assess the cause of pruritus of the scalp because this can be due to lice Tinea Pedis – fungal infection of the feet (athlete’s foot) 5. COPD, configuration of chest Barrel chest; AP:T diameter is equal QUIZ QUESTION: Expected finding with patient with COPD? • Barrel chest • Kyphosis • Hollow Clavicle • Protruding Sternum  angle of Louie 6. Scoliosis, kyphosis, lordosis, torticollis Scoliosis – lateral curvature and rotation of the thoracic and lumbar spine (S back); most common in female Kyphosis – exaggerated posterior curvature of the thoracic spine (hunchback); associated with aging. Lordosis – exaggerated curvature of the lumbar spine (swayback); compensation for pregnancy, obesity, and skeletal changes. Torticollis – muscle spasm by spinal accessory nerve, causing lateral flexion contracture of neck muscle 7. Physiological changes in older adult for all the systems discussed Skin, Hair, and Nails • Decreased elasticity, sebum production, perspiration, and melanin • Increased sensitivity to light • Nails become thicker, and more brittle Head, Neck and Lymphatics • Loss of subcutaneous fat in the face • Decreased reproductive hormone • Hair change, tooth loss, limited ROM • Complaints of tired or weak feeling due to thyroid dysfunction Eye • Decreased vision acuity • Presbyopia – age-related near vision difficulty • Cataract – thickened yellow lens; decreased lens clarity • Macular Degeneration – loss of central vision Ears, Nose, Mouth and Throat • Loss of hearing frequency • Gradual hearing loss (presbycusis) • Chelitis (angular stomatitis) • Decreased sense of taste and smell, saliva production, • Receding gum, tooth loss Respiratory • Decreased respiratory efficiency, cough ability • Changes in breath depth • Increased RR, effect of infection Breast and Axillae • Limited ROM for examinations • Modification of BSE • Changes in breast tissue composition • Gynecomastia in males • Increased breast cancer risk with aging Cardiovascular • Loss of ventricular compliance and vascular rigidity • Conduction system loses automaticity Peripheral Vascular • Increased BP • Decreased pulse with irregularities • Enlarged calf vessel 8. Different types of color – jaundice, pallor etc; What requires immediate intervention Cyanosis – mottled blue color in skin (REQUIRES IMMEDIATE INTERVENTION) Pallor – loss of skin color due to the absence of oxygen Uremia – pale yellow tone due to urinary retention Erythema – redness of the skin due to increase visibility of the oxyhemoglobin Jaundice – yellow undertone due to increase bilirubin in the blood QUIZ QUESTION: CYANOSIS is a priority because it indicates hypoxemia 9. How to assess jaundice, central cyanosis? Look for discoloration with the patient’s oral mucosa, then conjunctiva next 10. How to assess temperature Use the dorsal surface of the hand and feel for the temp QUIZ QUESTION: If assessing for temperature, use the DORSAL surface of the hand 11. Sxs of infection; patient suspecting with infection Older patient with pneumonia will present CONFUSION QUIZ QUESTION: patient suspected of fungal infection? – have you taken antibiotics recently 12. Assessing for pain; expected findings with acute pain /chronic pain Self-reported pain from patient is the most accurate assessment of pain QUIZ QUESTION: Best way to assess for pain is SELF-REPORTED pain from patient 13. Cranial nerves I, II, III,IV, VI; how to assess the different cranial nerves? CN I: Olfactory – smell • Assessment: have the patient close their eyes, obstruct one nare then make patient sniff a common substance, and then do the other nare • Anosmia – inability to detect odor • Unilateral or bilateral anosmia CN II: Optic – sight • Assessment: Snelling and Rosenbaum • Optic atrophy, papilledema, amblyopia, field defects CN III: Oculomotor – eyelids and pupil • Direct Constriction – shine light directly to the pupil; failure of the pupil to constrict shows defect in the direct pupillary response; defect in CN III • Consensual Constriction – simultaneous constriction of the pupil that is not illuminated. • 6 Cardinal Fields of Gaze – evaluates the movement of the eyes o Nystagmus – weakness of the extraocular muscles; repetitive uncontrolled eye movements o Looking up and down without moving the head • Confrontational Test – tests peripheral vision by covering one eye together with patient; examiner moves finger in peripheral field • ABNORMAL: can’t move eye upward, and downward • Diplopia, ptosis, dilated pupils, inability to focus on close objects CN IV: Trochlear – eyeball • ABNORMAL: can’t move eye down or nasally • Convergent strabismus, diplopia CN VI: Abducens – eyeball • ABNORMAL: can’t move eye temporally • Diplopia, strabismus QUIZ QUESTIONS: • Test for CN II (Optic Nerve) – Snellen and Rosenbaum • CN III (Oculomotor Nerve) – look up and down without moving the head 14. Assess for clubbing Normal nails will form a diamond-shaped opening when put together; convex curve have the dorsal surface of the fingers together QUIZ QUESTION: How to assess for clubbing of fingers? – dorsal surface of fingers next to each other 15. Assessing for coordination? What tests? What is positive and negative Romberg’s Romberg’s Test • Used to test for equilibrium • Have the patient stand with feet together and arms to the side, eyes open first then closed. • Mild swaying is a NEGATIVE Romberg • If patient is unable to maintain balance or needs to have feet further apart, then there may be a problem with the vestibular apparatus (inner ear). QUIZ QUESTION: • Minimal swaying during Romberg’s test – NEGATIVE FINDING • Swaying and feet apart – POSITIVE ROMBERG 16. Assess for weber or Rinne or whisper test? Normal and abnormal findings Weber Test • Use of tuning fork; • Place activated tuning fork on top of head; sound should be heard equally (no lateralization) • Lateralization may be due to poor conduction (sound heard better in impaired ear) or nerve damage (sound is referred to the better ear) Rinne Test – use of tuning fork • Bone Conduction – tuning fork against the mastoid process • Air Conduction – tuning fork in front of the external meatus • Air conduction should be TWICE longer than Bone Conduction (AC 2x BC) Whisper Test • Whisper a phrase or sentence from a distance and have the patient repeat it; inability to repeat phrase may indicate hearing loss; check for high frequency sounds QUIZ QUESTIONS: • Rinne Test – air conduction is twice longer than the bone conduction • Hearing Test – whisper random phrases to the patient and make them repeat it • Rinne Test – air conduction of 32 and bone conduction of 15; still normal finding, slight difference is okay. 17. Types of adventitious breath sounds and normal breath sounds NORMAL BREATH SOUNDS • Tracheal – harsh, high pitched • Bronchial – loud, high pitched • Bronchovesicular – medium loudness, medium pitch • Vesicular – soft, low pitched ADVENTITIOUS BREATH SOUNDS (ABNORMAL) • Fine Rales/Crackles – high pitched, short crackling • Coarse Rales/Crackles – loud, moist, low pitched bubbling • Wheezes – high pitched, continuous • Rhonchi – low pitched, continuous, snoring, rattling • Stridor – loud, high pitched, crowing heard without a stethoscope • Friction rub – low-pitched grating, rubbing QUIZ QUESTIONS: • Low-pitched continuous, snoring sound – RHONCHI • Asthma like symptoms -WHEEZING 18. Patient with breast cancer, mastectomy with dissection with lymph nodes; precautions? No BP on the affected arm QUIZ QUESTION: What to tell nurse during assessment? – don’t take BP on the side of mastectomy 19. Assess for orthostatic hypotension Orthostatic Hypotension – temporary drop of BP that occurs after changing positions quickly Signs: decrease in systolic by 20mmHg or diastolic by 10mmHg within 3 minutes of standing, palpitations, syncope Symptoms: dizziness, blurred vision, weakness, nausea, headache, chest pain 20. How to assess for orthopnea Orthopnea – difficulty breathing when lying down Patient may have orthopnea if they require number of pillows to prop themselves, or sit up while sleeping 21. Different types of breathing patterns Eupnea – even depth and regular pattern Tachypnea – rapid, shallow respirations; pneumonia Bradypnea – slow, regular respirations; intracranial pressure Hyperventilation – rapid, deep respirations; Kussmaul’s respiration ketoacidosis Hypoventilation – irregular, shallow respirations; narcotic OD, chest splinting Cheyne-Stokes – periods of deep breathing alternating with periods of apnea; heart failure, respiratory depression Sighing – frequent sighs; dyspnea, dizziness Biot’s Respirations (Ataxic) – shallow, deep respirations with periods of apnea; respiratory depression, brain damage Obstructive Breathing – prolonged expiration; COPD, asthma, chronic bronchitis 22. Pneumonia, pneumothorax, atelectasis Lobar Pneumonia – infection that causes fluid, bacteria, and cellular debris fill the alveoli • Signs: decreased O2 sat, bronchial breath sounds, crackles, productive cough, dullness • Symptoms: dyspnea, fatigue, chills Pneumothorax – air move into the pleural space and causes partial, or complete collapse of the lung • Signs: tracheal deviation to unaffected side, diminished or absent breath sounds, hyperresonance • Symptoms: SOB, sharp chest pain, anxiety Atelectasis– collapsed or impaired inflation of the lungs, can be due to airway obstruction • Signs: decreased or absent breath sounds, increased RR, decreased O2 sat, use of accessory muscle, wheezing, rhonchi • Symptoms: dyspnea, fatigue r/t increased work of breathing QUIZ QUESTION: chest expansion on only one side – PNEUMOTHORAX 23. Malignancy, lymph node: possible indication of malignant or benign breast cancer Common Sxs • Dimpling of the skin • Deviation of nipple • Nipple retraction • Change in shape of ONE breast • Edema • Discharge Enlargement of breast DOES NOT necessarily mean cancer because pregnancy and menstrual cycle affect the size of breasts Lymph nodes are HARD and FIXATED Benign breast or fibrocystic breast disease • Lumps, pain or tenderness, and nipple discharge QUIZ QUESTION: SATA – NO tenderness before period and breast enlargement 24. How to assess for thyroid. Normal and abnormal finding Thyroid gland should not be observable until the patient swallows Thyroid should not be palpable, not until swallowing ABNORMAL FINDINGS • HYPERthyroidism – weight loss; exophthalmos; irritable o Graves’ Disease • HYPOthyroidism – weight gain; weak and tired feeling; depressed o Myxedema, Hashimoto’s Thyroiditis QUIZ QUESTION: sign of HYPOTHYROIDISM – weight gain 25. How to assess for carotid pulse Inspect the neck for pulsations • Absence of pulsations may indicate obstruction Palpate carotid pulse one at a time located between neck and trachea • Weak thread pulse, irregular rhythm and unequal bilaterally are abnormal Auscultate carotid pulse • Should hear very quiet sound, with no swishing sounds • Bruits – swishing sounds; obstruction causing turbulence, like narrowing of vessels due to cholesterol build up • Hyperthyroidism or anemia can produce bruits 26. Landmarks for different pulses; APETM Aortic: RSB, 2nd ICS (right sternal border, 2nd intercostal space) Pulmonic: LSB, 2nd ICS (Left sternal border) Erb’s Point: LSB, 3rd ICS Tricuspid: LSB, 4th ICS Mitral/Apical: LMCL, 5th ICS (Left Midclavicular Line, 5th intercostal space) 27. How to assess for TMJ TMJ dysfunction is suspected if there’s facial pain, limited jaw movement accompanied by clicking sound as the jaw opens and closes (crepitus) QUIZ QUESTION: expected finding when examining for TMJ syndrome – CREPITUS 28. Location for precordial heart sounds; know the exact location by picture and description 29. Ataxia; how to assess if coordination is an issue? Ataxia – loss of control of body movements CN VIII (Auditory) – the vestibular nerve is responsible for equilibrium Romberg’s test to test for coordination • Have the patient stand with arms to the side with feet together • Test with eyes open, then close • Mild swaying is NEGATIVE • Need to have feet further apart, and moderate swaying are POSITIVE 30. Sxs of peripheral artery disease; early and late signs Arterial Insufficiency – inadequate circulation in the arterial system due to fatty plaque; pain in the thigh, calf, or buttocks (claudication) • Sxs: claudication, rubor, cool, shiny skin, diminished pulses Arterial Aneurysm – bulging or dilation caused by weakness in wall of an artery 31. What is A fib? Characteristics, subjective and objective findings; What is a complication? Dysrhythmic atrial contraction with no regularity of pattern Results to poor blood flow Sxs: confusion, fatigue, heart palpitations, SOB, weakness Complications: stroke, heart failure 32. Pulse deficit; how to measure; nursing interventions? Apical pulse Carotid pulse  pulse deficit Both pulses should be synchronous 33. Sxs asthma and COPD Asthma – chronic hyperreactive condition, resulting in bronchospasm, mucous edema, and increased mucous secretion • Signs: wheezing, diminished breath sounds, increased RR, use of accessory muscle, decreased O2 sat • Symptoms: dyspnea, anxiety, chest pain COPD – barrel chest, SOB 34. Irregular pulse, radial, carotid, etc, what to do? Measure apical pulse for a full minute QUIZ QUESTION: absent pedal pulse – use DOPPLER ULTRA SOUND 35. Sxs of DVT Deep Vein Thrombosis – occlusion of a deep vein, such as the femoral, or pelvic circulation, by a clot. Obj: unilateral edema, low-grade fever, tachycardia Subj: absence of symptoms; pain along iliac crest, popliteal space or calf muscle; increase pain with sharp dorsiflexion of the foot (Homan’s sign) 36. Patient with AV fistula, what is being assessed? And how to assess Arteriovenous Fistula – abnormal connection between an artery and vein, commonly caused by piercing injuries like stab, and gunshot wounds Obj: machinery murmur, bulging veins near the surface of the skin, decreased BP, increased HR, HF, cyanosis, clubbing of fingers Subj: fatigue, SOB, dizziness, and lightheadedness 37. Restraints Check for pulse, cap refill  NEUROVASCULAR CHECK Assess q 2 hours Provide hydration and assist with elimination Tie the restraint onto the moveable part of the bed UAP can help but RN should ASSESS 38. How to assess for strabismus Cover/Uncover Test • Uncovered eyes should be fixated when the other eye is covered o Movement of the uncovered eye (strabismus) signifies weakness Strabismus – eyes do not align simultaneously under normal condition • Exophoria – one eye outwards • Esophoria – one eye inwards QUIZ QUESTION: strabismus – cover/uncover test 39. Cardinal fields of gaze, normal and abnormal Evaluates eye movement and eye muscles (CN III) Presence of nystagmus could mean weakness of CN III QUIZ QUESTION: jerking movement of the eye when doing the 6 cardinal fields of gaze -NYSTAGMUS 40. Direct pupillary and consensual response Direct pupillary response – illuminated pupil should constrict Consensual pupillary response – pupil not illuminated should constrict simultaneously with the illuminated eye Tests CN III 41. Cover uncover test