Download NURS 190 West Coast University -NURS 190 Quiz #3 Questions With Complete Solutions and more Exams Nursing in PDF only on Docsity!
Questions With Complete Solutions
#Basic Assessment Techniques - correct answerFor all others -Inspection -Auscultation -Percussion -Palpation Abdm -Palpation -Percussion When the client refuses to continue the examination - correct answerDocument what was done & What was refused Inspection - correct answerObserve -beginning to end -in a systemic manner Talk (speech) Observe for -Symmetry, color size, shape, contour, movement, drainage Sound Smell Palpation - correct answerUsed to find -Size -Shape -Location -Mobility -Position -Vibrations
Fremitus
Questions With Complete Solutions
-Temperature -Texture -Moisture -Tenderness -Edema Sensitive Areas of the Hand for Palpation - correct answerDorsal surface Finger tips Finger pads Ulnar surface of the hand Metacarpophalangeal-base of fingers Palmar surface of the fingers Sensitive Areas of the Hand for Palpation (Dorsal surface) - correct answerSkin Temp Sensitive Areas of the Hand for Palpation (Finger tips) - correct answerPercussion Sensitive Areas of the Hand for Palpation (Finger pads) - correct answerPulses Crepitus & Lymph nodes Sensitive Areas of the Hand for Palpation (Ulnar surface of the hand) - correct answerFremitus Sensitive Areas of the Hand for Palpation (Metacarpophalangeal) - correct answerBase of the fingers Fremitus Sensitive Areas of the Hand for Palpation (Palmar surface of the hand) - correct answerFremitus
Questions With Complete Solutions
-Use w/ CAUTION Ex.
Bladder Uterus Kidney Spleen Deep palpation may use a hand behind back to palpate deep Percussion - correct answerFrom the latin work "Percutire" -means to strike through Used to assess -Pain/tenderness -Size -Shape -Masses Solid, air, fluid Types of Percussion - correct answerDirect-directly tap the site Indirect-Putting your and down and tapping it (block and tap) Blunt-blocking your hand and striking bottom of your fist Percussion Sounds (Tympany) - correct answerLoud high pitched drum-like tone Area ex. Organ filled w/ air (gastric bubble) Percussion Sounds (Resonance) - correct answerLoud, low-pitched hollow tone of long duration Ex. Normal lung sound -can be hear between the ribs to the lungs Percussion Sounds (Hyperresonance) - correct answerAbnormally loud, low tone of longer duration Ex. Air trapped in lungs
Questions With Complete Solutions
Percussion Sounds (Dullness) - correct answerThud like sound over consolidated area Ex. Liver & Heart Percussion Sounds (Flatness) - correct answerFlat, extremely dull, very soft, very short Ex. Bone Stethoscope - correct answer Stethoscope (Diaphragm & Bell) - correct answerDiaphragm=High frequency Bell=Low frequency Ophthalmoscope - correct answer Otoscope - correct answerYounger than 3 y/o=straight back After 3 y/o=Up and back Adults=Down & Back To check the inner ear Reflex hammer - correct answerUsed to test Deep Tendon Reflex (DTR) Tongue blade - correct answerUsed to test gag reflex Tuning Fork - correct answerTo test for hearing Air & Bone conduction Goniometer - correct answerUsed to measure the degree of joint extension and flexion Skinfold caliper - correct answerUsed to measure thickness of subcutaneous tissue Wood's lamp - correct answerUsed to detect fungal infection of the skin Doppler - correct answerUsed to assess non-palpable pulses
Questions With Complete Solutions
Bones of the Skull (Parietal) - correct answer Bones of the Skull (Temporal) - correct answer Bones of the Skull (Occipital) - correct answer Bones of the Skull (Sphenoid) - correct answer Bones of the Skull (Ethmoid) - correct answer Sutures of the Skull - correct answer-Lambdoid suture -Sagittal suture -Coronal suture -Squamous suture -Frontonasal suture Sutures of the Skull (Lambdoid) - correct answer Sutures of the Skull (Sagittal) - correct answer Sutures of the Skull (Coronal) - correct answer Sutures of the Skull (Squamous) - correct answer Sutures of the Skull (Frontonasal) - correct answer Bones of the Face - correct answer-Maxillae (paired) -Palatine (paired) -Nasal (paired) -Inferior nasal conchae (paired) -Zygomatic (paired) -Lacrimal (paired) -Vomer (single) -Mandible (single) Bones of the Face (Maxillae) - correct answer Bones of the Face (Palatine) - correct answer Bones of the Face (Nasal) - correct answer Bones of the Face (Inferior nasal conchae) - correct answer
Questions With Complete Solutions
Bones of the Face (Zygomatic) - correct answer Bones of the Face (Lacrimal) - correct answer Bones of the Face (Volmer) - correct answer Bones of the Face (Mandible) - correct answer Temporal Mandibular join - correct answerImportant -common w/ pain Mastoid process - correct answer Nasal Septum - correct answer Muscles of the Face - correct answer Thyroid - correct answerBetween the sternocleidomastoid muscles Below the Hyoid bone Blue=Thyroid cartilage -below is cricoid cartilage Around the trachea Isthmus of thyroid -segment that narrow mid of the gland Muscles of the Neck - correct answerAnterior triangle Posterior triangle Sternocleidomastoid muscle Trapezius muscle Omohydoid muscle Bones of a child's skulll - correct answerFrontal Parietal Occipital
Questions With Complete Solutions
Skin and tissue integrity Assessment of the Head (Palpation) - correct answerHead and scalp Temporal artery# Testing ROM of temporomandibular joint (TMJ-possible pain)# Assessment of the Head (Auscultation) - correct answerTemporal artery (bruit)* Woosh sound=obstruction/clot Assessment of the Neck (Inspection) - correct answerSkin ROM Carotid arteries & jugular veins Thyroid gland Assessment of the Neck (Palpation) - correct answerTrachea Thyroid Gland* Assessment of the Neck (Ausultation) - correct answerThyroid gland Palpation of Thyroid (Assess for) - correct answerMasses Bulges Symmetry -palpate then move to one side & then feel on the opposite side (ask pt to swallow) Assessment of Lymphatics (How) - correct answer10 sets of lymph nodes drain the head & neck Palpation of lymph nodes gentle circular motion -do not push hard it may result in false normal findings Normal: Adults-nonpalpable
Questions With Complete Solutions
Children-can be nonpalpable or swollen; sometimes palpable and it is normal for them Assessment of Lymphatics (Nodes) - correct answerPreauricular (ears front) Postauricular (ears back) Occipital (back of head) Submental (Chin) Submandibular (Middle of Jaw) Retropharyngeal or Tonsillar (Back of the jaw) Superficial cervical chain (top of the sternocleidomastoid muslce-near ear) Deep cervical chain (w/n sternocleidomastoid muscle) Posterior cervical chain (Behind the sternocleidomastoid muscle) Supraclavicular (Above the clavicle) Lymph Nodes-Preauricular - correct answerIn front of ears Lymph Nodes-Postauricular - correct answerBack of ears Lymph Nodes-Occipital - correct answerback of the head Lymph Nodes-Submental - correct answerChin Lymph Nodes-Submandibular - correct answerMiddle of the Jaw Lymph Nodes-Retropharyngeal or Tonsillar - correct answerBack of the jaw Lymph Nodes-Superficial cervical chain - correct answernear the ear and the top of the sternocleidomastoid muscle Lymph Nodes-Deep cervical chain - correct answerw/n sternocleidomastoid muscle Lymph Nodes-Posterior cervical chain - correct answerBehind the sternocleidomastoid muscle Lymph Nodes-Lymph Nodes-Supraclavicular - correct answerAbove the clavicle
Questions With Complete Solutions
-slanted eyes -a flat nasal bridge -a flat nose -a protruding tongue & -a short, broad neck Abnormal Findings (Head, Skull, & Face-Bell's Palsy) - correct answerA sudden, temporary disorder affecting cranial nerve VII (Facial) that produces unilateral facial paralysis. It may be caused by a virus Abnormal Findings (Thyroid) - correct answerHypothyroidism -weight gain & tiredness -low metabolism Hyperthyroidism -weight loss (high metabolism) -High HR -Sweating & irritability Goiter -lack of iodine -gland will grow large Developmental Considerations (Types) - correct answerPregnant female Geriatric Pediatric Psychosocial considerations Developmental Considerations (Pregnant female) - correct answerSkin Edema Thyroid Developmental Considerations (Geriatric) - correct answerFacial fat Hair changes Teeth loss
Questions With Complete Solutions
ROM limitations Developmental Considerations (Pediatric) - correct answerHead -will be larger than the body Developmental Considerations (Psychosocial considerations) - correct answerStress #Healthy People of 2020 (Head, Neck, & Lymphatics) - correct answerReduce sports and recreational injuries Reduce deaths caused by motor vehicle accident Increase the use of safety belts Increased use of helmets Reduce death by falls #Integumentary System - correct answerSkin and accessory structures Hair Nails Skin - correct answerLargest organ of the body Composed of epidermal and dermal layers Layers of the Skin - correct answerEpidermis Dermis -Papillary layer -Reticular layer Subcutaneous layer (hypodermis) Epidermis - correct answer-Protects dermis from abrasion/chemicals/pathogens -Controls permeability (prevents water loss) -Synthesizes vitamin D3 -Sensory receptors (detect touch, pressure, pain, & temp.)
Questions With Complete Solutions
Excretion Sensation -Touch -Pressure -Temperature -Pain Unique identification Skin Glands (Types) - correct answerSweat Glands Sebaceous or Oil Glands Sweat Glands (Two types) - correct answerEccrine -Major sweat gland -Mix of H2O and NaCl -Widely distributed throughout the body Apocrine -Located in areas abundant of hairfollicles -Produce thick milky secreation -Musky odor is result of bacteria mixed w/ sweat Sebaceous or Oil Glands - correct answerProduces sebum Lubricate skin & hair Located everywhere except on palms & soles Abundant in scalp, forehead, face, & chin Hair - correct answerThin fiber compound of dead keratinized cells Hair (Types) - correct answerVellus -Short, fine, hair -Located on most parts of they body except
lips palms soles
Questions With Complete Solutions
some external genitals Terminal -Thick, long, dark -Located on scalp, eyebrows, axillary, pubic region, legs, face/chest of males Nails - correct answerThin plates of keratinized epidermal cells that cover the distal ends of fingerws and toes -Free edge -Hyponychium (Below the free edge) -Lateral nail fold -Body of the nail -Lunula (white back) -Eponychium (Cuticle) -Root of the nail -Nail matrix Skin Focused Interview (General Questions) - correct answerDescribe your skin today How much and how easily do you sweat? -Any sweating episodes at night Are more oily/dry lately? Any allergies, rashes, skin problems in your family? Skin Focused Interview (Specific Questions) - correct answerIllness or infections Symptoms Pain Behaviors Infants & children
Questions With Complete Solutions
-fungus Skin, Hair, & Nails (Assessment) - correct answerEnviroment Instructions Removal of -clothing -jewelry -cosmetics -wigs -hairpieces Lighting Skin Assessment (Skills Used) - correct answerInspection Palpation Skin Assessment (Inspection) - correct answerPosition the client Instruct the client -explain Use your senses -See, smell? Skin tone -pink, blue, yellow Pigmentation Superficial arteries & veins Skin Assessment (Palpation) - correct answerTemperature Moisture Texture Thickness Elasticity
Questions With Complete Solutions
Lesions -primary/secondary lesions Sensitivity Skin assessment (Normal findings) - correct answerNormal skin perfusion -pink undertone -color even -warm & dry -intact -no lesions -no mass -no rash -no tattoos Check for edema (normal=0) -1=2mm -2=4mm -3=6mm -4=8mm Check for skin tugor/skin tenting -Below the clavicle and on top of the hand Types of Headaches - correct answerClassic migraines Cluster Sinus Tension Skin assessment (Checking for Jaundince) - correct answerInspect palm of the hand, conjunctiva, sclera, lips, and oral mucosa Types of Headaches (Classic migraines) - correct answerAura; recurring type of headache Will causes moderate to severe pain that is throbbing or pulsing Pain is often on one side of your head Types of Headaches (Cluster) - correct answerseries of relatively short but extremely painful headaches everyday for weeks or months at a time
