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NURS 6512 Final Exam NURS/6512 Advanced Health Assessment and Diagnostic Reasoning Walden University
NURS 6512 Final Exam (Latest 2019 Version) Already Graded A Walden University
Course NURS-6512D-1/NURS-6512N-1-NURS-6512D- 1/NURS-6512N-1- Advanced Health Assessment and Diagnostic ReasoningTest Final Exam Started 8/1/19 11:30 AM Submitted 8/1/19 1:20 PMDue Date 8/12/19 1:59 AMStatus Completed Attempt Score 93 out of 100 pointsTime Elapsed 1 hour, 34 minutes out of 1 hour and 50 minutes1. Costovertebral angle tenderness should be assessed whenever you suspect the patient may have: - Polynephritis2. In older adults, overflow fecal incontinence is commonly due to: -Fecal impaction3. A 1 month old boy has been vomiting for 2 weeks. How is this symptom of GERD and pyloric stenosis further differentiated in this child’s assessment? – The infant has regurgitation with pyloric stenosis4. Auscultation of borborygmi is associated with: - Gastroenteritis, early intestinal obstruction, or hunger5. When auscultating the abdomen, which finding would indicate collateral circulation between the portal and systemic venous systems? – Venous hum6. Conversion of fat-soluble wastes to water-soluble material for renal excretion is a function of the: - Liver7. The major function of the large intestine is: -Water absorption8. Which structure is located in the hypogastric region of the abdomen? –Ileum, bladder, andpregnant uterus9. A 45 year old man relates a several week history of severe intermittent abdominal burning sensations. He relates that the pain is relieved with small amounts of food. Before starting the physical examination, you review his laboratory work, anticipating a (n): -Positive Helicobacter pylori result10. You are caring for a patient with trigeminal neuralgia. During the assessment, the patient would describe the pain as: - Burning or shocklike11. Your 85 year old patient is complaining of right knee pain. She has a history of osteoarthritis for which she is given anti-inflammatory medication. To assess her right knee pain, you should ask her if: - The pain gets better when she sits12. A 5 year old is complaining of nondescriptive “belly pain.” Your next action should be to ask him to: - Point to the area of pain13. The perception of pain: - Is variable and is affected by emotions, and cultural background14. Patients presenting with ascites, jaundice, cutaneous spider veins, and nonpalpable liver exhibit signs of: - Cirrhosis15. A patient presents to the emergency department after a motor vehicle accident. The patient sustained blunt trauma to the abdomen and complains of pain in the upper left quadrant that radiates to the left shoulder. What organ is most likely injured? – Spleen16. Imaging studies reveal that a patient has dilation of the renal pelvis from an obstruction in the ureter, what condition will be documented in this patient’s health record? – Hydronephrosis17. Visible intestinal peristalsis may indicate: - Intestinal obstruction18. Infants born weighing less than 1500g are at higher risk for: - Necrotizing enterocolitis19. Which of the following factors is not known to affect patient compliance with his or her treatment regimen? – The patient’s age and social status20. One of the most important aspects to consider in the orthopedic screening examination is: -Symmetry21. The sequence of the physical examination should be individualized to: -22. As you greet the patient, which examination technique is first implemented? - Inspection23. Which of the following is most likely to enhance examiner reliability? – The examiner attempts to qualify data24. A 7 year old boy is brought to your office with a chief complaint of possible fracture to his left third finger. He jammed it while playing basketball 2 days ago. The mother states that she really does not think it is broken because he can move it. What is your best response? – This is common misconception, and the finger may be broken. An x-ray is indicated.25. A patient presenting for the first time with typical low back pain should receive which of the following diagnostic tests?26. Skeletal changes in older adults are the result of: -Increased bone resorption 27. A positive straight leg raise test usually indicates: - Lumbar nerve root irritation28. What technique is performed at every infant examination during the first year of life to detect hip dislocation? – Barlow-Ortolani maneuvers29. Expected normal findings during inspection of spinal alignment include: - Convex lumbar curvenumber of times the patient has to change positions to conserve the patient’s energyMinimize theusually musculoskeletal etiology.– None of the above. X-ray is not indicated because lumbar pain is30. Temporalis and masseter muscles are evaluated by: - Having the patient clench his or her teeth31. When palpating joints, crepitus may be caused when: - Irregular bony surfaces rub together32. A 3 year old is brought to the clinic complaining of a painful right elbow. He is holding the right arm slightly flexed and pronated and refuses to move it. the mother states that symptoms started right after his older brother had been swinging him around by his arms. This presentation supports a diagnosis of: - Radial head subluxation33. Light skin and thin body habitus are risk factors for: - Osteoporosis34. Risk factors for sports-related injuries include: - Failure to warm up before activity35. Injuries to long bones and joints are more likely to result in fractures than in sprains until: -Adolescence36. Ligaments are stronger than bone until: - Adolescence37. The family history for a patient with joint pain should include information about siblings with: -Genetic disorders38. The Thomas test is used to detect: - Flexion contractures of the hip39. A goniometer is used to assess: - Range of motion40. During a football game, a player was struck on the lateral side of the left leg while his feet were firmly planted. He is complaining of left knee pain. To examine the left knee you should initially perform the ________ test. – Valgus stress41. You note that a child has a positive Gower Sign. You know that this indicates generalized: -Muscle weakness42. The dowager hump is: - The hallmark of osteoporosis43. What temporary disorder may be experienced by pregnant women during the third trimester because of fluid retention? –Carpal tunnel syndrome44. A common finding in markedly obese and pregnant women is: - Lordosis45. A 45 year old laborer presents with low back pain, stating that the pain comes from the right buttock and shoots down and across the right anterior thigh, down the shin to the ankle. Which examination finding is considered more indicative of nerve root compression? – Positive straight leg raise result46. Mrs. Bower is a 57 year old patient who comes in for an office visit. Which of the following disorders is known to be hereditary? – Huntington chorea47. Testing of cranial nerve ________ is not routinely performed unless a problem is suspected.–I48. The patient is able to rapidly touch each finger to his thumb in rapid sequence. What does this finding mean? – The patient has appropriate cerebellar function49. Which question asked by the examiner may hellp to determine prevention strategies for seizures that a patient is experiencing? – “Are there any factors or activities that seem to start the seizures?”50. A patient has a complaint of dizziness. The patient makes the following statement: “I sometimes feel as if the whole room is spinning.” What type of neurologic dysfunction should the examiner suspect? – Inner ear dysfunction affecting the acoustic nerve51. The examiner asks the patient to close her eyes, then places a vibrating tuning fork on the patient’s ankle and asks her to indicate what is felt. What is being assessed? – Peripheral nerve sensory function52. Which of the following findings should an examiner consider a normal finding if associated with pregnancy? – Acroparesthesia52. Jack is a 52 year old obese man with a history of poorly controlled diabetes. He also smokes. Based on the above data, the examiner should recognize that Jack has several risk factors for: - Cerebrovascular accident53. Mrs. Jones is a 24 year old patient who presents to your office 2 days postpartum. She complains that she is experiencing foot drop. Which of the following problems should the examiner consider? – Lumbosacral plexopathy54. The examiner is assessing deep tendon reflex response in a 12 year old boy. The response is an expected reflex response. Which of the following scores should be documented? – 2 55. A 68 year old patient presents to your office for follow-up. He tells you, “I have a hard time finding the right words when I am talking;” he also is experiencing numbness. On examination, you note postural instability. This symptom may be: - A late symptom of Parkinson’s disease56. Motor maturation proceeds in an orderly progression from: - Head to toe 57. The thalamus is the major integration center for perception of: - Pain58. The examiner should be concerned about neurologic competence if a social smile cannot be elicited by the time a child is ________old. – 3 months59. Normal changes of the aging brain include: -60. When interviewing a 70 year old female clinic patient, she tells you that she takes ginkgo biloba and St. John’s Wort. You make a short note to check for results of the: -Mini-mental state examination61. The area of body surface innervated by a particular spinal nerve is called a: - Dermatome 62. If a patient cannot shrug the shoulders against resistance, which cranial nerve (CN) requiresfurther evaluation? – CN XI, spinal accessory63. The finger-to-nose test allows assessment of: - Coordination and fine motor function64. You ask the patient to follow a series of short commands to assess: - Attention span65. As Mr. B. enters the room, you observe that his gait is wide based and he staggers from side to side while swaying his trunk. You would document Mr. B.’s pattern as: - Cerebellar ataxia66. When is the mental status portion of the neurologic system examination performed? –Constantly throughout the entire interaction with a client67. An aversion to touch or being held, along with delayed or absent language development, is a characteristic of: -Autism68. The autonomic nervous system coordinates which of the following? – Internal environment of the body69. The major function of the sympathetic nervous system is to: - Orchestrate the stress response70. The parasympathetic nervous system maintains the day-to-day function of: - Digestion 71. Cerebrospinal fluid serves as a: - Shock absorber72. You are performing a two-point discrimination test as part of a well physical examination. The area with the ability to discern two points in the shortest distance is the: -Finger tips73. Which type of hallucination is most commonly associated with alcohol withdrawal? – Visual- bugs, pink elephantsDiminished perception of touch. -- this is byprocess of elimination/educated guess. I could not find direct information addressing this inSeidel74. On a scale of 0 to 4 , which deep tendon reflex score is appropriate for a finding of clonus in a patient? –3 75. Which statement is true regarding mental status changes in older adults? – There is an increased risk of delirium with acute illness or metabolic derangement.76. A characteristic related to syphilis or diabetic neuropathy is testicular: -Insensitivity to painful stimulation77. When collecting personal and social history data from a woman complaining of breast discomfort, you should question her regarding: - Alcohol, tobacco, and caffeine use78. What risk factor is associated with cervical cancer? – HPV79. A 23 year old female presents with severe right lower quadrant tenderness. All of thefollowing should be considered in the differential except: - Classis diverticulitis80. What is the initial diagnostic radiology test that should be ordered if you suspect a rupturedovarian cyst? – Abdominal and transvaginal ultrasound81. A 17 year old male was brought into the emergency room with testicular/scrotal pain. Thedifferential diagnosis should include all except: - Inguinal herniation82. The nursing mother complains that her breasts are tender. You assess hard, shiny, and erythremic breasts bilaterally. You should advise the patient to: - Massage gently and continue nursing83. A normal vas deferens should feel: - Smooth84. In a woman complaining of a breast lump, it is most important to ask about: - Itsrelationship to menses85. The finding of a painless indurated lesion on the glans penis is most consistent with: -Chancre86. Thrombosed hemorrhoids are: - Blue, shiny, painful masses87. Pregnancy-related cervical changes include: - Softening and bluish coloring88. You are inspecting the genitalia of an uncircumcised adult male. The foreskin is tight and cannot be easily retracted. You should: - Inquire about previous penile infections89. An adolescent male is being seen for acute onset of left testicular pain. The pain started 3 hours ago. He complains of nausea and denies dysuria or fever. Your prioritized assessment should be to: - Establish absent cremasteric reflex90. A 23 year old white woman has come to the clinic because she has missed two menstrual periods. She states that her breasts have enlarged and that her nipples have turned a darker color. Your further response to this finding is: - Suggest pregnancy testing91. What accommodations should be used in the position of a hearing-impaired woman for a pelvic examination? – The head of the table should be elevated92. Sexual differentiation in the fetus has occurred by _______weeks gestation. - 1293. You are performing a clinical breast examination for a 55 year old woman. While palpating the supraclavicular area, you suspect that you felt a node. In order to improve your hooked technique, you should: -Ask the patient to turn her head toward that side94. If a firm, transverse ridge of compressed tissue is felt bilaterally along the lower edge of a 40 year old patient’s breast, you should: -Record the finding in the patient’s record95. A therapeutic technique for dealing with grieving individuals is to: - Tell them that is good to cry and to share feelings96. The examination of the newborn should begin with: - Inspection noting skin color, flaccidity, tension, gross deformities, or distortions of facies97. Which one of the following patient characteristics is most likely to limit patient reliability during history taking? – Patient is sleep and sensory deprived98. In crying infants, it is often difficult to: - Auscultate heart sounds99. Which of the following statements accurately reflects the sensitivity and specificity oflaboratory tests? – No test has 100% sensitivity and specificity100. Which medical condition would exclude one from sports participation? – Fever101. Your 15 year old patient is athletic and thin. Radiography of an ankle injury reveals a stress fracture. You question this patient about her: - Menstrual cycles102. Which of the following are examined with the patient in a reclining 45 degree position? –Jugular venous pulsation and pressure103. Functional assessment is most important during the examination of a(n): -Older adult104. The best way to ease the apprehension of a 3 year old child before a physical examination is to: - Encourage child’s participation105. An ophthalmoscopic eye examination involves: - Lens inspection106. When conducting a geriatric assessment, basic activities of daily living (ADLs) include: -Bathing107. The checkout station for preparticipation physical evaluation (PPE) is critical because at this point: - The coordination of follow-ups is reviewed108. Which of the following is true regarding the relationship between the examiner and the patient? – The patient is a full partner with the examiner109. Which of the following factors is not known to affect patient compliance with his or her treatment regimen? – The patient’s age and social status110. One of the most important aspects to consider in the orthopedic screening examination is:- To look for symmetry of muscle, stature, and joint movement111. As you greet the patient, which examination technique is first implemented? – Inspection 112. Which portion of the physical examination is best done with the patient standing? –Spinal 113. Which patient position facilitates inspection of the chest and shoulders? – Sitting114. The least reliable indicator of newborn distress is: - Color115. Proprioception should be assessed while the patient is: - Standing116. Part of the screening orthopedic component of the examination includes evaluating the person while: - Duck walkingHealth Assessment Final Review ExamMust have 78% to pass between both exams Always go with the text bookMENTAL ASSESSMENT (Ch 5 pgs 64-78)1. What does orientation to person, place, and time assess? When you perform assessment, what exactly are you looking for? Pg. 67Person, place and time assess state of consciousness. When performing this assessment you are looking for cognitive function. Person disorientation is a result of cerebral trauma, seizures, or amnesia; Place disorientation occurs with psychiatric disorders, delirium, and cognitive impairment; Time disorientation is associated with anxiety, delirium, depression, and cognitive impairment.8. Assessing orientation to person, place, and time helps determineANS: DOrientation to person, place, and time are measures of states of consciousness and awareness, not degrees of attention span. Analogies and abstract reasoning are higher functions than orientation. Emotional status can be better evaluated by observing behaviors.2. How many serial numbers should most people be able to repeat? For example: counting backwards. How many should the average person be able to repeat? Pg. 70Five to eight numbers forward or four to six backward can usually be repeated.10.Under most conditions, adult patients should be able to repeat a series of _____ numbers.ANS: BMost adults should be able to recall immediately a series of five to eight numbers forward and four to six numbers backward.3. How do you assess recent memory if you’ve had a patient your worried about memory? What technique and how would you assess recent memory? Pg. 70Give the patient a short time to view four or five test objects, telling them you will ask them about them in a few minutes. Ten minutes later, ask the patient to list the objects.14.Recent memory may be tested ability to understand act tion of onal to to eightc.10 to 15d.15 to than g the patient to do simple g the patient to listen to and repeat a series of ng the patient four items and asking him or her to list the items about 10 minutes g the patient about verifiable past events, such as his or her mother’s maiden g the patient to name the past four presidents.ANS: CShowing the patient four or five objects, saying you will ask about them in a few minutes, and then 10 minutes later asking the patient to list the objects is a technique to measure recent memory. The other choices are not tests of recent memory. Asking the patient to listen and then repeat tests immediate recall.4. What pysch or mental condition is considered progressive and not reversible? Pg. 76, 78 Dementia (see differential diagnosis).27. Which condition is considered progressive rather than reversible?ANS: BDementia is considered progressive and irreversible, delirium and coma have the potential for reversal, and depression and anxiety are reversible.26. An older adult is administered the Set Test and scores a 14. The nurse interprets this score as indicative ofANS: EScores of less than 15 on this mental function test indicate dementia.28.Which of the following is usually related to structural diseases of the brain?ANS: BOne of the distinguishing characteristics that distinguishes dementia from the others is that it is usually related to structural diseases of the brain such as abnormal deposits, or recurrent strokes.5. If patient is delirious do they maintain orientation and attention span? Look up delirium and see what you expect patient to maintain. Pg. 75,76a.Deliriumb.Dementiac.Depressiond.Anxietye.Ctive tia.a.Deliriumb.Dementiac.Depressiond.Anxietye.Psychosis2Patient suffering from delirium is usually disoriented (usually oriented to person only) and have an impaired attentiveness. (pg 461 in Adv. Assessment) In spite of the confusion, the patient’s sensorium (consciousness) is usually intact although some condition (intoxication and severe metabolic derangements) result in altered level of consciousness.9.A state of impaired cognition, consciousness, mood and behavioral dysfunction of acute onset refers toANS: BDelirium is a state of impaired cognition, consciousness, mood and behavioral dysfunction of acute onset. Stupor describes arousals for short periods of time after a stimulus for arousal (e.g., visual, verbal, or painful). Lethargy relates to sleepiness with ease of arousal; coma is nonarousal and nonawareness. Confusion relates to inappropriate responses to questions with decreased attention span and memory.6. Who should you give a mini mental exam to? Everyone or certain patients? Pg. 67,68The mini mental exam should be given to elderly patients when there is a concern about their cognitive function. This testdetects probable dementia.34.The Mini-Mental State Examination should be administered for a patient whoANS: AThe MMSE is a tool used to estimate cognitive function quantitatively or document cognitive changes serially. Getting lost in a familiar territory is a sign of possible cognitive impairment.6. The Mini-Mental State Examination (MMSE)ANS: AThe MMSE is a standard tool that functions to estimate cognitive function quantitatively7.While interviewing a 70-year-old female clinic patient, she tells you that she takes ginkgo biloba and St. John’s wort. You make a short note to check for results of lost in her or his s an excessive amount of repetitive ritualistic illegal hallucinogenic a fear of leaving the be used to estimate cognitive changes be used to estimate personality disorders s do not vary with regard to age or determine the cause of memory a good tool to diagnose neurologic disorders.a.Denver II.b.Mini-Mental State Examination.3c.Glasgow Coma Scale.d.Goodenough-Harris Drawing Test.e.CAGE Questionnaire.ANS: BGinkgo biloba and St. John’s wort are herbal remedies used to improve mental alertness and elevate mood. As side effects, they can also result in disorientation and confusion that can be monitored with the Mini-Mental State Examination. The Denver and Goodenough- Harris tests are used for childhood development, and the Glasgow Coma Scale is used to rate coma depth. The CAGE Questionnaire is a useful tool for approaching a discussion of the use of alcohol.BREAST EXAM1. With documenting breast exams, how do you divide the breasts? If you want a radiologist to concentrate on one particular area of the breast, how do you divide to communicate findings? Pg. 351The breast is divided into five segments, four quadrants and a tail (upper inner, upper outer, lower inner, and lower outer).Either the right or left breast should be communicated. The terms: upper inner, upper outer, lower inner, lower outer, and tail of Spence should be communicated to the radiologist in terms of how to communicate findings.3.For purposes of examination and communication of physical findings, the breast is divided intoANS: CThe breast is referenced according to five segments: four quadrants and a tail.11. When conducting a clinical breast examination, the examiner shouldANS: DInspection with simultaneous observation of both breasts is essential in order to detect differences between the breast size, symmetry, contour, and skin color.2. If you have a pt c/o breast lump, what questions do you ask? For example you have a 50 year-old with breast lump, how do you begin exam compared to a 30 year-old pt?(just arbitrary ages) What assessment do you do and what questions would you ask based on age? Pg.9. Which breast change is typical after menopause?s (upper and lower).s (left, middle, and right). quadrants plus a es (six consecutive rings, each 1 inch farther away from nipple).l portions 1 through the examination if the patient has had a recent the patient covered to respect the lights to minimize ct both breasts with palpation of the breasts.a.Thickening of the inframammary ridgeb.Hypertrophy of glandular tissuec.Increase in number of lactiferous ductsd.Reduction of fat deposits4e.Shortening of Cooper’s ligamentsANS: A. After menopause, the breast tissue atrophies and is replaced by fat deposit, the inframammary ridge at the lower edge of the breast thickens, and the breast hangs more loosely as Cooper’s ligaments relax.10. In a woman complaining of a breast lump, it is most important to ask aboutANS: AHormonal changes of menstruation can result in breast tenderness, swelling, and enlarged nodes that can be felt on palpation.12. A 50-year-old woman presents as a new patient. Which finding in her personal and social history would increase her risk profile for developing breast cancer?ANS: CNulliparity or late age at birth of first child (after 30 years old) is a risk factor for breast cancer. Other risk factors include late menopause, early menarche, and drinking more than one alcoholic drink daily.1. What position do you put a patient in for a breast exam? What position is the examiner standing in? Axillary nodes what position does the patient need to be in? Pg. 355-3622. 14. To begin the clinical breast examination (CBE) for a man, ask him toANS: B Inspection begins the CBE. Ask the patient to sit with his arms hanging loosely at his sides. The technique is the same for both men and women.15.Inspection of the breasts usually begins with the patient in which position?ANS: BInspection begins with the patient in a sitting position with arms hanging loosely at the sides. Inspection (pg. 355): As the patient sits with arms hanging loosely at the sides, inspect each breast and compare it with the other for size, symmetry, contour, skin color, and texture, venous pattern, and lesions. Re-inspect the woman’s breasts with the patient in the following positions (pg. 357-358): relationship to t ization ol consumption.a.Drinking three glasses of wine per weekb.Early menopausec.Nulliparityd.Late menarchee.Young age at birth of first ne on the table with his arms with his arms hanging at his with his hands on his with his arms clasped behind his leaning forward.a.Lateralb.Sittingc.Standingd.Supinee.Proneo Seated with arms over the head or flexed behind the neck. This adds tension to the suspensory ligaments, accentuates dimpling, and may reveal variations in contour and symmetryo Steadied with hands pressed against hip with shoulders rolled forward (or alternatively have the patient push her palms together): This contracts the pectoral muscles, which can reveal deviations in contour and symmetryo Seated and leaning forward from the waist: This also causes tension in the suspensory ligaments. The breasts should hang equally. This maneuver can be particularly helpful in assessing the contour and symmetry of large breasts because the breasts fall away from the chest wall and hang freely. As the patient leans forward, support her by the hands. Patient in Seated Position (pg. 360)o Chest Wall Sweep: Have the patient sit with arms handing freely at the sideso Bimanual Digital Palpation: Place on hand, palmar surface facing up, under the patient’s right breasto Lymph Node Palpation: To palpation the axillae, have the patient seated with arm flexed at the elbow. Support the patient’s left lower arm with your left hand while examining the left axilla with your right hand. Patient in Supine Position (pg. 360): Have the patient raise one arm behind her head; then place a small pillow or folded towel under that shoulder to spread the breast tissue more evenly over the chest wall. The ideal position for examination is to have the nipple pointing toward the ceiling.b.) Axillary nodes what position does the patient need to be in? (pg. 360)Lymph Node Palpation: To palpation the axillae, have the patient seated with arm flexed at the elbow. Support the patient’s left lower arm with your left hand while examining the left axilla with your right hand.3. What’s the difference between fibrotic breast tissue and breast cancer? How do you expect each to feel? What are the characteristics of the two?17.Which finding, found on inspection, is related to fibrotic tissue changes that occur with breast carcinoma?ANS: BSkin dimpling or retraction signifies the contraction of fibrotic tissue that occurs with carcinoma. The other choices are normal variations without significance to cancer development.18. Venous patterns on breasts are suggestive of pathology when they areANS: CMalignant tumors require more blood flow. Superficial veins dilate to provide more flow and can be assessed as unilateral venous patterns. Bilateral findings are of no concern and are more commonly seen in pregnant or obese women. Nevi that are long-standing, unchanging, or nontender are of little concern.21.In patients with breast cancer, peau d’orange skin is often first evidenta.Convex or conical shapeb.Skin dimpling or retractionc.Pendulous and loose breastsd.Unequal shape or contoure.Lifelong inverted erally in obese ved during iated with a long-standing unchanging the the upper inner or around the the inframammary the tail of Spence.ANS: CThe areola is the most common initial site to visualize peau d’orange skin.24.Recent unilateral inversion of a previously everted nipple suggestsANS: BRecent unilateral inversion or retraction of a previously everted nipple suggests malignancy rather than a benign condition.41.You are conducting a clinical breast examination for a 30-year-old patient. Her breasts are symmetrical with bilateral, multiple tender masses that are freely moveable with well-defined borders. You recognize that these symptoms and assessment findings are consistent withANS: EFibrocystic changes are tender masses, usually bilateral, with multiple round, mobile, well-delineated borders. Fibroadenoma and cancer are usually nontender; Paget disease is an eczema-like condition of the nipple that signals an underlying cancer. Mammary duct ectasia most commonly occurs in menopausal women. Fibrocystic Changes (pg. 366):o Benign fluid-filled cyst formation caused by duct enlargement o Pathophysiology Usually bilateral and multiple Most common in women 30 to 55 years of age Associated with long follicular or luteal phase of the menstrual cycleo SubjectiveData Tender and painful breasts and/or palpable lumps that fluctuate with menses Usually worse premenstruallyo ObjectiveData Round, soft to firm, tense, mobile masses with well-delineated borders Usually tender Usually bilateral Multiple or single Fibroadenoma (pg. 366): n breast adenoma.b.Paget ry duct cystic changes.o Pathophysiology May occur in girls and women of any age during their reproductive years After menopause, the tumors may regresso SubjectiveData Painless lumps that do not fluctuate with the menstrual cycle May be symptomatic with discovery on clinical breast examination or breast imagingo ObjectiveData Round or discoid, firm, rubbery, mobile masses with well-delineated borders Usually non-tender Usually bilateral Single; may be multiple Biopsy often performed to rule out carcinoma Malignant Breast Tumors (pg. 366): Ductal carcinoma arises from the epithelial lining of ducts; lobular carcinoma originates in the glandular tissue of the lobuleso Pathophysiology Mutations to normal cells results in uncontrolled cell division and tumor formation; as the tumor grows andinvades surrounding tissue, metastases occurs through the lymph and vascular systems Peak incidence between the ages of 40 and 75 years, with the majority of malignant breast tumors occurring in women older than 50o SubjectiveData Painless lump; change in size, shape, or contour of breast Axilla may be tender if lymph nodes involved May be asymptomatic with discovery on clinical breast examination or breast imagineo ObjectiveData May be palpable mass that is usually single, unilateral, irregular, or stellate in shape; poorly delineatedborders; fixed; hard or stone-like; and non-tender Breast may have dimpling, retraction, prominent vasculature Skin may have peau d’orange or thickened appearance Nipple may be inverted or deviated in position(Differential diagnosis pg. 365)Fibrotic: usually bilateral, multiple or single, round, soft to firm; tense, mobile, absent retraction signs, usually tender, bordersare well delineated, and they vary with menses.Cancer: Usually unilateral, single, irregular or stellate, hard/stonelike, fixed, retraction signs are often present, usually nontender, the borders are poorly delineated; irregular, and they do not vary with menses.4. Breast Exam- What part of the hand do you use? Fingertips, pads, palms, entire hands? Pg. 361Palpate using your finger pads as they are more sensitive than your fingertips. Palpate systematically, pushing gently but firmly toward the chest wall, as you rotate your fingers in a clockwise or counterclockwise pattern. At each point, as you rotate your fingers press inward, using three depths of palpation: light then medium and finally deep. The exact sequence you select for palpation is not critical, but a systematic approach will help ensure that all portions of the breast are examined.26.When palpating breast tissue, the examiner should use the _____ at each r of the surface of the sANS: BThe finger pads are used for breast palpation because they are more sensitive than the fingertips.5. What is Peau d'orange skin? Look, feel, mean? Pg. 356The skin has an orange peel appearance. This indicates edema of the breast caused by blocked lymph drainage in advanced orinflammatory breast cancer. The skin appears thickened with enlarged pores and accentuated skin markings.6. What is the tail of Spence? Where is it anatomically? Pg. 351The tail of Spence is (extends from) the greatest amount of glandular tissue that lies in the upper outer quadrant and extendsinto the axilla. ??????2.The largest amount of glandular breast tissue lies in theANS: DThe greatest amount of glandular tissue in the breast lies in the upper outer quadrant.31.The tail of Spence extendsANS: DThe tail of Spence extends from the upper outer breast quadrant into the axillae.7. Breast Exam: Certain groups of lymph nodes are enlarge, where would they be for examiner to expect Breast Cancer? Pg. 360The axilla, supraclavicular and infraclavicular areas. Nodes that are detected should be described according to location, size, shape, consistency, tenderness, fixation, and delineation of borders.34.When examining axillary lymph nodes, the patient’s arm inner of S outer the midclavicular d the supraclavicular into the inframammary the the sternal d full above the ded at the ed against the ed over the d at the elbow.ANS: ETo examine the axilla, support the patient’s lower arm with the elbow flexed with one of your hands and use your other hand to palpate the axilla.35.Lymphatic flow of the breast primarily drainsANS: CEach breast contains a lymphatic network that drains the breast radially and deeply to underlying lymphatics.36. The greatest concern for breast cancer is when you palpate _____ nodes.ANS: DThe supraclavicular and infraclavicular nodal areas are sentinel nodes; any enlargement in these areas is especially significant.37.You are performing a clinical breast examination for a 55-year-old woman. While palpating the supraclavicular area, you suspect that you felt a node. To improve your hooked technique, you shouldANS: EHaving the patient turn her head toward the examination side, as well as raising the shoulder on that same side, gives your fingers more room to palpate deeper into the fossa.8. What if you have a 20-30 year-old with freely moveable, well-defined lump, tender with cycle, cancer or more likely fibrotic? Fibrotic (see page 365)iorly toward the ally toward the corresponding lly toward the omedially toward the ior nal lotion to your both hands the patient to press both palms the patient to lower her shoulder on that the patient to turn her head toward that side.1041.You are conducting a clinical breast examination for a 30-year-old patient. Her breasts are symmetrical with bilateral, multiple tender masses that are freely moveable with well-defined borders. You recognize that these symptoms and assessment findings are consistent withANS: EFibrocystic changes are tender masses, usually bilateral, with multiple round, mobile, well-delineated borders. Fibroadenoma and cancer are usually nontender; Paget disease is an eczema-like condition of the nipple that signals an underlying cancer. Mammary duct ectasia most commonly occurs in menopausal women.9. Then you have a 50 year-old-lump firm, fixed, doey-like, cancer or fibrotic? Cancer FEMALE GENITALIA1. Pelvic Exam-anatomy of vagina and location of glands-5 O’clock, 7 O’clock for example, just know the anatomy of the male and female genitals.2. What structures are located at the 5 o’clock and the 7 o’clock positions of the vaginal orifice and open onto the sides of the vestibule in the groove between the labia minora and the hymen?ANS: DBartholin glands are found posteriorly on each side of the vaginal orifice and open onto the sides of the vestibule.2. Cervical Cancer- know patient’s history and what questions to ask patients that put them at high risk for cervical cancer.12. Which factor is associated with an increased risk of cervical cancer?ANS: EWomen who were younger than 17 years when they had their first full-term pregnancy are almost 2 times more likely to get cervical cancer later in life than women who were not pregnant until they were 25 years or adenoma.b.Paget ry duct cystic changes.a.Skene glandsb.Perineal bodiesc.Labia majorad.Bartholin glandse.Labia minoraa.Endometriosisb.Low parityc.HPV vaccinationd.High socioeconomic statuse.Early parity113. What history increases your risk for ovarian cancer? (pg. 425)Risk factors for ovarian cancer (box on p. 425 below cervical risk factors): Age (increases with age), inherited genetic mutation (BRCA1 or BRCA2 gene), family history, obesity, reproductive history (nulliparity increases risk), and the use of fertility drugs, personal history, hormone replacement therapy, and high-fat diet.13.The risk of ovarian cancer is increased by a history ofANS: EThere is a relationship between nulliparity and an increased risk of ovarian cancer. Although the risk increases with age, most ovarian cancers develop after menopause; half are found in women older than 63 years. The other choices have no relationship with ovarian cancer.4. What is a normal cervix and an abnormal cervix? What does an abnormal one look like (not cancerous) what tests might you and what might indicate? Disorder?22. During digital examination of the vagina, the cervix is noted to be positioned posteriorly. Upon bimanual examination of this woman, you would expect to palpate a(n) _____ uterus.ANS: BThe position of the cervix correlates with the position of the uterus. A cervix that is pointing posteriorly indicates an anteverted uterus.23. The presence of cervical motion tenderness may indicateANS: CPainful cervical motion tenderness suggests a pelvic inflammatory disease or a ruptured tubal pregnancy. The cervix is expected to move 1 to 2 cm without discomfort under normal conditions.25.During a routine vaginal examination, you insert the speculum and visualize the cervix. The cervix projection into the vaginal vault -fat ette between 35 and 50 body ally c inflammatory nancy.12approximately 5 cm. Upon bimanual examination, you would expect to find the the midline the retroverted the anteverted ted to the left or the retroflexed position.ANS: DNormally, the cervix protrudes into the vagina 1 to 3 cm. Longer projections suggest a pelvic or uterine mass. A pelvic mass would cause the uterus to be deviated to the right or left, but an anteverted, retroverted, or retroflexed uterus would still be in the midline regardless of its position.26.Small, pale yellow, raised, and rounded areas are visualized on the surface of the cervix. You shouldANS: AThis describes nabothian cysts, which are retention cysts of the endocervical glands and are considered a normal variant. No further testing is this as nabothian this as a friable n a viral the pH of the cervical this as an eroded cervix.a.b.c.Normal cervix: covered with pink squamous epithelium that is uniform in consistency. It should be in an anterior- posterior position that correlates with the position of the uterus. The os is small and round. A small area of ectropion is visible inferior to the os. Cervix should feel firm (during pregnancy will be softer) and be smooth.Abnormal cervix: Bluish color indicates increased, which may indicate pregnancy. A pale cervix is associated with anemia. If the cervix is pointed anteriorly it indicates a retroverted uterus; pointing posteriorly indicated an anteverted uterus. Horizontal indicated a uterus in midposition; deviation indicated a pelvic mass, uterine adhesions, or pregnanacy. Projection greater than 3 cm may indicate a pelvic or uterine mass. Small, white or yellow raised, round areas may indicate nabothian cysts. Friable tissue, red patchy areas, granular areas, and white patches could indicate cervicitis, infection, or carcinoma.Feel for nodules, harness, and roughness. Note the position of the cervix, it should be in the midline and may point anteriorly or posteriorly. Grasp the cervix between your fingers and move it gently from side to side (should move 1-2 cm). There should be no pain or discomfort. Painful cervical movement suggests a pelvic inflammatory disease or a ruptured tubal pregnancy which would require immediate surgery.5. What structure or organs are examined during a Bimanual exam? (pg 436-437). Cervix, Uterus, Adnexa, and Ovaries33.The assessment of which structure is not part of the bimanual examination?a.Cervixb.Bladderc.Uterusd.Ovariese.Adnexa13ANS: BThe bimanual examination consists of assessing the cervix, uterus, adnexa, and ovaries.6. When do PAP smears begin? Age of non-sexually active versus sexually active women? (pg. 437) 21 for non-sexually and sexually active women because cervical cancer is rare for women under age 21.40.When a woman is not sexually active, cervical cancer screening should beginANS: DWomen who are not sexually active should have their first examination by the age of 21 years. Women under age 21 should not be tested.7. Menopausal women- what does the vagina and mucosa of the walls feel like? (pg. 447)The vagina is narrower and shorter. You will see and feel the absence of rugae. The cervix is smaller and paler but the osshould still be palpable and the cervix may be less mobile.43.During a pelvic examination for a postmenopausal woman, you would expect to assessANS: BExpected findings in the pelvic examination for an older woman include a narrower and shorter vagina, absence of rugation, a less mobile cervix, and a palpable cervical os. The ovaries are rarely palpable because of atrophy.MALE GU1. Males-history or what alerts the examiner of the possibility of testicular cancer? (pg. 470).Undescended testicle, personal hx of testicular CA, family hx of testicular CA, abnormal testicle development (klinefelter syn), 20-54 yr male, the most prominent in white race ( 5 times that of black; more than 3 times that of Asian American and Native American men).13.Which of the following is a risk factor for testicular cancer? age 15 age 18 age 21 age 30 years.a.a wider and longer vaginal ce of vaginal wall rugation.c.a nonpalpable cervical os.d.a more mobile ble ovaries.a.Circumcisionb.Condyloma acuminatumc.Cryptorchidism14d.Poor hygienee.Multiple sexual partnersANS: CCryptorchidism (testes that fail to descend by 12 months of age) is a risk factor for testicular cancer.27.The most common cancer in young men age 15 to 30 years isANS: ABecause testicular tumors are the most common cancer occurring in young adults, self-examination is encouraged.37.Self-examination of the male genitaliaANS: BMonthly self-examination is recommended as a screening test for testicular cancer as well as sexually transmitted infections for all young men starting at 15 years of age. It is encouraged during bathing because the scrotal skin is less thick at this time and because the scrotum hangs looser because of the warmth. Inspection is done first followed by palpation.2. What alerts us to do further testing and the need to further and fully assess for testicular cancer? How do we do this?o Irregular, contender mass fixed to the testiso Does not transilluminateo May also have hydrocele(that doesn't transilluminate) o InguinalLymphadenopathyo Painless mass in testicleo Scrotalenlargementorswellingo Heavy feel in in scrotumo Dull ache in lower abdomen, back or groino fluid in scrotumThis can be done by performing a Testicular exam ( inspect and palpate), Scrotal US, Lab work including: Chemistry, WBC count, biochemical markers AFP and B-hCg.21.Mr. L. has an unusually thick scrotum with edema and pitting. He has a history of cardiac problems. The appearance of his scrotum is more likely a(n)ANS: BGeneral fluid retention can cause scrotal thickening and pitting edema and is more often seen as a result of cardiac, renal, or hepatic disease. This swelling does not imply a condition of the genitalia but rather a condition of these related d be restricted to adults with prior d be performed while s with palpation and then d be performed t be adequately performed due to poor visualization of the nital defect that has ation of general fluid l consequence of ication to the development of quence of prior STDs.1525.An enlarged, painless testicle in an adolescent or adult may cular torsion.c.a undescended padias.ANS: CA hard, enlarged, painless testicle can indicate a tumor in an adolescent or adult male. Epididymitis and torsion are painful; an undescended testicle is common in infants and is usually resolved by 12 months. Hypospadias is a congenital defect of the urethral opening causing the meatus to be located ventral to its normal position.26.You palpate a soft, slightly tender mass in the right scrotum of a man. You attempt to reduce the size of the mass, and there is no change in the mass size. Your next assessment maneuver is toANS: DA soft mass is either a hernia or hydrocele. If the mass can be reduced, it is probably a hernia; a nonreducible mass should be transilluminated to determine whether it contains fluid and is possibly caused by a hydrocele. Lifting the scrotum should be done when epididymitis is suspected. Urethral cultures are not indicated at this point.29.An adolescent male is being seen for acute onset of left testicular pain. The pain started 3 hours ago. He complains of nausea and denies dysuria and fever. Your prioritized assessment should be toANS: CThe patient is displaying symptoms of testicular torsion. An absent cremasteric reflex is a supporting finding to differentiate torsion from epididymitis.38. A 12-year-old boy says that his left scrotum has a soft swollen mass. The scrotum is not painful upon palpation. The left inguinal canal is without masses. The mass does transilluminate with a penlight. This collection of symptoms is consistent withANS: BA hydrocele is a soft scrotal mass that occurs from fluid accumulation and therefore does transilluminate. Orchitis results in a swollen, tender testis. A rectocele does not result in scrotal swelling. A scrotal hernia would also be palpable along the inguinal canal. Epididymitis is an extremely painful condition.41.A cremasteric reflex should result two fingers to attempt to reduce the te the left scrotum the right testicle, then compare pain illuminate the re the meatus for gonococcal n urine and DNA probe urethral the left scrotum to confirm lish absent cremasteric illuminate the left and right the patient stand and observe the scrotum for a “bag of worms.”al scrotum appear to contain a “bag of worms.”e deviation to the left um to elevate iate erection of the cle and scrotal rise on the stroked side.ANS: EUpon stroking the inner thigh with a blunt instrument or finger, the testicle and scrotum should rise on the stroked side.3. How do you assess for an inguinal hernia? Pg. 472-473Have the pt. stand and bear down. While he is straining inspect the area of the inguinal canal and the region of the fossa ovalis. After the pt. relaxes, insert your examining finger into the lower part of the scrotum and carry it upward along the vas deferens into the inguinal canal. You can also auscultate for bowel sounds, which will be present in uncomplicated reducible hernias.18.Which technique is appropriate to detect an inguinal hernia?ANS: EExamination for inguinal hernias is performed with the patient standing. Inspect the groin while the patient performs a Valsalva maneuver. Insert your examination finger into the lower part of the scrotum and follow upward along the vas deferens to screen for a hernia.19. Which type of hernia lies within the inguinal canal?ANS: CHernias found within the inguinal canal are called indirect hernias.4. What does Vas deferens feel like? Normal? Abnormal? Pg. 473The Vas deferens feels smooth and discrete; abnormal findings are beaded or lumpy feeling. This may indicate diabetes or oldinflammatory changes, especially tuberculosis.2.What structure of the male genitalia travels through the inguinal canal and unites with the seminal vesicle to form the ejaculatory duct?ANS: Da.Conduct percussion while the patient coughs.b.Have the patient strain as you pinch the testes.c.Inspect rectal areas as the patient bears down.d.Conduct the examination only in the supine position.e.Move your finger upward along the vas deferens.a.Umbilicalb.Directc.Indirectd.Femorale.Incisionala.Epididymisb.Corpus cavernosumc.Urethrad.Vas deferense.Ureter17The vas deferens begins at the end of the epididymis, travels the spermatic cord, goes through the inguinal canal, and then unites with the seminal vesicle to form the ejaculatory duct.23.A normal vas deferens should feelANS: BThe vas deferens should normally feel smooth, discrete, and nontender.5. Young man- what is an emergent cause of testicular pain? Pg. 482 Testicular Torsion is twisting of the spermatic cord and is a surgical emergency.29.An adolescent male is being seen for acute onset of left testicular pain. The pain started 3 hours ago. He complains of nausea and denies dysuria and fever. Your prioritized assessment should be toANS: CThe patient is displaying symptoms of testicular torsion. An absent cremasteric reflex is a supporting finding to differentiate torsion from epididymitis.28.The most emergent cause of testicular pain in a young male isANS: ETesticular torsion is a surgical emergency. If surgery is performed within 12 hours after the onset of symptoms, the testis can be saved in about 90% of cases. Delayed treatment results in a much lower salvage rate.6. Understand hernias, where located and how to assess each kind. Pg. 476, 477(see differential diagnosis).Hernia is protrusion of a peritoneal-lined sac through some defect in the abdominal wall. There are indirect, direct and femoral.7. What is the most common type of hernia? Pg. 477 Indirect Inguinal hernias are the most common type.31.The most common type of hernia occurring in young males n urine and DNA probe urethral the left scrotum to confirm lish absent cremasteric illuminate the left and right the patient stand and observe the scrotum for a “bag of worms.”cular cerated ect al.ANS: CThe most common type of hernia in children and young males is an indirect inguinal hernia.MUSCULOSKELETAL1. What is the difference between osteoarthritis versus rheumatoid arthritis?During an assessment what do you expect to see in a patient with osteoarthritis vs. RA? Findings in joints? Describe. OA (pg411)-A progressive disorder associated with age and wear and tear. There is loss of cartilage and progressive erosion of bone. Affects mostly larger bones like hips and knees, but frequently involves small joints of hands, especially distal and proximal interphalangeal joints. Asymmetrical distribution. Pain and stiffness improves with activity, and worsens with rest. Xrays show changes. Sed rate(-), Rheumatoid factor (-) RA (pg410)-If 3 or more metacarpophalangeal joints are swollen is RA. It’s a progressive, inflammatory, and erosive condition that usually affects multiple joints. It’s an autoimmune condition. Affects joints symmetrically. Affects small joints of hands and feet. Joints are tender, swollen with effusion, warm, inflamed. Nodules and deformities are noted. RA associated with: subluxation of metacarpophalgeal joins, hyperextension of joints, but also with changes in eye (scleritis, episcleritis, interstitial lung disease and pericardial disease.1. When does a musculoskeletal exam begin? (text tells you) pg405-The musculoskeletal examination is primarily limited to inspection and palpation. The focused musculoskeletal examination begins withinspection.2. How do you assess the strength of the trapezius muscle? (pg518)The strength of trapezius and sternocleoidomastoid muscle is tested by evaluating the cervical spine and asking patients to do certainmovement. Bend the head forward, chin to chest, and expect flexion of 45 degrees. Bend head to each side, ear to each shoulder and expect lateral bending of 40 degrees. Bend head backward, chin toward ceiling, and expect extension of 45 degrees.3. Patient with scoliosis, bend at waist, what is expected finding? Describe what it looks like (Pg541)When looking form the rear, the spine looks more like an “S” or a “C” than a straight line. There is no known cause. Associated with leg length discrepancy. There’s lateral curvature of spine as patient flexes forward to touch the toes. In severe deformities, patient has uneven shoulder and hip levels, and may have crease on one side of waist.194. Carpal Tunnel-What expect to feel like, how do you assess for? During assessment, particular nerve is tested, what is it? What sensation will the patient have?(pg430,524) The carpal tunnel is a space located on the anterior aspect of the wrist between the carpal bones and a ligamentous band through which the median nerve and several tendons transverse. With overuse and repetitive movements there’s a hypertrophy of tissues, causing a lot of space and impingement on the median nerve. Nighttime pain-early sign. Swelling at wrist related to inactivity of flexion at night, pain can radiate up the forearm to shoulder with numbness and tingling along the median nerve, and paresthesia involves anterior aspects of wrist, medial palm and first three digits of affected nerve. Relief is found by shaking affected hand in downward fashion. To assess, first ask patient to mark specific site using the Katz hand diagram.o Thumb abduction test isolates strength of abductor pollicis brevis muscle, innervated only by median nerve. Pt will place the hand palm up and raise the thumb perpendicular to it. Apply downward pressure on thumb to test muscle strength. Weakness=Carpal tunnel syndromeo Tinel sign: Strike pt’s wrist with your index or middle finger, where median nerve passes under the flexor retinaculum and volar carpal ligament(fig21.42). Tingling, means ( ) tiner sign and ( ) CPT syndrome.o Phalen test: pt holds both wrist in fully palmar-flexed position with dorsal surfaces pressed together for one min. Numbness and paresthesia in the distribution of median nerve is ( ) CPT syndrome.ABDOMINAL1. When conducting an abdominal exam, what position should the patient be in? Examiner? Techniques with rigid abdomen or anxious pt, what are relaxation techniques? (pg377)Need good light source; full exposure of abdomen; warm hands with short fingernails. Have pt empty bladder. Place pt is supine position with arms at sides. Approach pt from right side. Place small pillow under pt’s head and another under slightly flexed knees. Drape a towel or sheet over the patient’s chest for warmth and privacy. Be slow and gentle, avoid sudden movements.Percussion of the abdomen begins with establishinga. liver dullness.b. spleen dullness.c. gastric bubble tympany.d. overall dullness and tympany in all quadrants.e. bladder fullness.ANS: DPercussion begins with a general establishment over all quadrants for areas of dullness and tympany and then proceeds to specific target organs22. Before performing an abdominal examination, the examiner shoulda. ascertain the patient’s HIV status.b. have the patient empty his or her bladder.c. don double gloves.d. completely disrobe the patient.e. uncover only the painful areas of the abdomen.ANS: BThe patient should empty the bladder to ensure an accurate examination of organs as well as to provide comfort for the patient.2024. When examining a patient with tense abdominal musculature, a helpful technique is to have the patienta. hold his or her breath.b. sit upright.c. flex his or her knees.d. raise his or her head off the pillow.e. fully extend the legs.ANS: CTo help relax the abdominal musculature, it is helpful to place a small pillow under the patient’s head and under slightly flexed knees. The other choices increase muscle flexion.28. After thorough inspection of the abdomen, the next assessment step is toa. percuss.b. palpate nonpainful areas.c. auscultate.d. perform a rectal examination.e. palpate painful areas.ANS: CAssessment of the abdomen begins with inspection followed by auscultation. This break from the usual system examination sequence is because palpation and percussion can alter the frequency as well as the intensity of bowel sounds. Therefore, auscultation is done first.2. How long do you auscultate for BS? (pg380)Bowel sounds range from 5-35/min. If you’re unable to hear BS after 5 min of continues listening, associated with abdominal pain andrigidity then is surgical emergency.To correctly document absent bowel sounds, one must listen continuously fora. 30 seconds.b. 1 minute.c. 3 minutes.d. 5 minutes.e. 10 minutes.ANS: DAbsent bowel sounds are confirmed after listening to each quadrant for 5 minutes.3. What is the technique for percussing the liver border? Where to start, how you move, what are you listening for? (pg381)Begin liver percussion at the right midclavicular line over an area of tympany. Always begin with an area of tympany and proceed to area of dullness for easiness. Percuss upward along the midclavicular line to determine lower border of liver. The area of liver dullness is usually heard at the costal margin or slightly below it. Mark with a pen. A lower liver border that is more than 2-3 cm below costal margin may indicate organ enlargement or downward displacement of diaphragm because of emphysema or other pulmonary disease. Upper border of liver, begin percussion on the right midclavicular line at an area of lung resonance around the third intercostal space. Cont downward until the percussion tone changes to one of dullness; this marks upper border of the liver mark with pen. It’s usually in the fifth intercostal space. Measure the distance between the marks, estimates vertical span of liver, usually 6-12cm. If larger=enlargement, if smaller=atrophy.2137. To assess for liver enlargement in an obese person, you shoulda. use the hook method.b. test for cutaneous hypersensitivity.c. auscultate using the scratch technique.d. attempt palpation during deep exhalation.e. have the patient lean over at the waist.ANS: CIf the abdomen is obese or distended or if the abdominal muscles are tight, you should plan on auscultating the liver using the scratch method to estimate the lower border of the liver. Cutaneous hypersensitivity is a sign of peritonitis and does not contribute to determining liver size.Percussion at the right midclavicular line, below the umbilicus, and continuing upward is the correct technique for locating thea. descending aorta.b. lower liver border.c. medial border of the spleen.d. upper right kidney ridge.e. stomach.ANS: BPercussing along the right midclavicular line upward from the umbilicus determines the lower border of the liver. A liver border more than 2 to 3 cm signifies hepatomegaly.When palpating the abdomen, you should note whether the liver is enlarged in thea. left upper quadrant.b. midepigastric region.c. periumbilical area.d. right upper quadrant.e. right lower quadrant.ANS: DAn examiner can recognize a friction rub in the liver by a sound that isa. clicking, gurgling, and irregular.b. high pitched and associated with respirations.c. loud, prolonged, and gurgling.d. soft, low-pitched, and continuous.e. low pitched, tinkling, and unrelated to respirations.ANS: BAn abdominal friction rub is rare and can be identified when high-pitched sounds are auscultated in association with respirations. The liver is located in the right upper quadrant of the abdomen4. CVA tenderness-what might it be a sign of?Costovertebral angle tenderness should be assessed whenever you suspect the patient may havea. cholecystitis.b. pancreatitis.c. pyelonephritis.d. ulcerative colitis.e. intussusception.22ANS: CPyelonephritis is characterized by flank pain and costovertebral angle tendernessNEURO1. Autonomic Nervous System- what are you assessing? Coordinate?(Pg477)The Nervous system with its central and peripheral divisions maintains and controls all body functions by its voluntary and autonomic responses. The evaluation of motor, sensory, autonomic, cognitive and behavioral elements. The CNS is the main network of coordination and control for the body.(PG446) Coordination tests fluidity of movements. Inability to coordinate movements suggests cerebellar dysfunction. Finger to nose testing-ask pt to touch your index finger with his or her index finger, then touch his/her noserepeatedly. Poor coordination of movement indicates dysmetria. Rapid alternating movements-Ask pt to perform rapid pronation and supination of the hand on his/her thigh or on examination table Heel to shin testing-Ask pt to take the heel of one side and repeatedly move up and down the shin of the opposite leg Romberg- Ask pt to stand with feet together, arms abducted outward with palms up, and eyes closed. PostiveRomberg is observed as a swaying motion, or inability to maintain balance, and indicates cerebellar dysfunction.2. Motor Cortex of Brain- What does it control?3. Know EACH Cranial Nerve (several questions)- how to assess each, what testing for, what each do, abnormal findingsvs. expected findings. (pg553) Olfactory (1)- Sensory: smell reception and interpretation. Have available 2-3 vials of aromatic odors. Ensure patient’s nasal passages are patent. Occlude one naris at a time and ask patient to breathe in and out, while closing her eyes. Use different odor to test the other side. Assess the ability of patient to differentiate between diff odors. Sense of smell diminishes with age. Anosmia (loss of sense of smell). Optic (ll)- Sensory: visual acuity and visual field (chapter 11) Oculomotor (lll)-Motor: raise eyelids, most extraocular movements. Parasympathetic: pupillary constriction,change lens shape Trochlear (lV)- Motor: downward, inward eye movement(lll, lV, Vl)- Movement of eyes through the six cardinal points of gaze, pupil size, shape, response, to light and accommodation and opening of the upper eyelids. When assessing pt with severe unremitting headaches, the experienced examiner evaluates movement of the eyes for the presence of absence of lateral gaze. The sixth cranial nerve is commonly one of the first to lose function in the presence of increased intracranial pressure. Trigeminal (V)- Motor: jaw opening and clenching, chewing and mastication. Sensory: sensation to cornea, iris, lacrimal glands, conjunctiva, eyelids, forehead, nose, nasal and mouth mucosa, teeth, tongue, ear, facial skin. Evaluate for muscle atrophy. Have patient clench teeth as you palpate the muscles over the jaw, evaluating tone, which should be symmetric, without fasciculations. The three divisions of the trigeminal nerve are evaluated for the sharp, dull and light sensations. With pt closing eyes, touch each side of face at the scalp, cheek and chin, alternating sharp and smooth edges of a broken23tongue blade or a paper clip. Ask patient to report feeling. Then stroke face with cotton wisp. If sensation is impaired, ask pt to differ btw hot/cold. Abducens (Vl)- Motor: lateral eye movement Facial (Vll)- ask pt to raise eyebrows, squeeze the eyes shut, wrinkle the forehead, frown, smile, show the teeth, purse the lips to whistle, and puff out the cheeks. Observe for ticks, unusual movements and symmetry of expression. Drooping of one side of mouth or sagging of lower eyelid will indicate muscle weakness. Ie: Bells palsyTo evaluate taste, a sensory fx of cranial nerves Vll and lX: have patient have tongue protruded and have 4 solutions with Bitter, sour,
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