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NUR 1060C - Health Assessment Questions and answers | Updated 2024/25 Newest
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NUR 1060C - Health Assessment Questions and answers | Updated 2024/25 Newest
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NUR 1060C - Health AssessmentQuestions and answers | Updated
2024/25 Newest
What are the three parts of the ear? - *inner ear* (cochlea/labryinth), *middle ear*
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(eustachian tube - necessitate tubes to help drain fluid bc kids' eustachian tubes are more
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horizontal), *outer ear* = "what we can see" (external auditory canal) + the end of the
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outer ear is marked by the tympanic membrane
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II Are lymph nodes normally palpable? - No and they aren't normally visible either
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What are the names of these lymph nodes and location? (11 nodes) - 1. Preauricular
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2. Posterior auricular
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3. Occiptal
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4. Submental
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5. Submandibular
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6. Tonsillar/jugulodigastric/retropharyngeal
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7. Superficial Cervical
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8. Deep Cervical Chain
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9. Posterior Cervical
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10. Supraclavicular
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11. Parotid (below #1)
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What is a nurse looking for during an inspection of the neck? - - ROM
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- Symmetry
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- Trachea is midline - e.g. trachea may be *deviated* w/ tension from a pneumothorax
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- There shouldn't be any swelling, you shouldn't be able to see the butterfly shape of the
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thyroid
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What is some subjective data to ask a pt during a neck assessment? - - Do you have
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neck pain? - usually an orthopedic issue, r/t to movement, any stiffness or HA
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- Is there any lumps or swelling? -Tonsillitis, any tenderness? if so, may indicate infection
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(lymphadenopathy), if not, may be cancer and it will feel "like a rock" and immovable/fixed
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- Hx of neck/head surgery - might have muscles removed
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- Decreased or increased fatigue? i.e. hyperthyroidism - antsy and agitated
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hypothyroidism - extreme fatigue
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- Any smoking?
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- Dysphagia - difficulty swallowing
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- Do they use chewing tobacco?
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What are some unexpected findings during the inspection of the neck? - - Enlarged
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thyroid gland
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,> note the location, size (cm) (normally 4 cm wide and the right side is slightly large than
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the left), consistency, tenderness, shape, movability or fixation
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- Enlarged cervical lymph glands
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What can a nurse palpate during an assessment of the neck? - - Is the trachea midline? -
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use fingers and go along the trachea and make sure that it's straight and in the middle of
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your neck
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- To palpate the neck use circular motions and feel the edges
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- Thyroid gland is NOT palpable (meaning you shouldn't feel any masses), but you feel it
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move when the pt swallows
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What is the expected finding of trachea during inspection and palpation? - the rings of
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the trachea are distinct and non-tender
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II What is the enlargement of lymph nodes a sign of? - infection
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How does a nurse palpate the thyroid using a posterior approach? - The nurse stands
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behind the pt and uses their right hand to displace the trachea slightly and palpates with
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the left hand then does the same with the opposite hands
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You should feel movement, but no masses
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How are a child's lymph nodes different from an adults? - A child's lymph nodes unlike an
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adult's nodes are small, round, firm, discrete, movable and nontender
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these are typical finding for newborns, young children, and preadolescents especially
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their occiptal, postauricular, and deep cervical chain nodes
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~ @ 6 yrs old they're thyroid will be @ adult size
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What are 3 other places you can palpate lymph nodes? - groin, axilla, and behind the
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knees
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What three systems make up the Nervous System? - Central - CNS - Brain & spinal cord
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Peripheral - PNS - Cranial nerves (12), Peripheral nerves , and spinal nerves (31) II II II II II II II II II II II II II
Autonomic - ANS - is a part of the PNS - main f(x) is stimulus to smooth muscles II II II II II II II II II II II II II II II II II II
*remember that the entire nervous system is interconnected II II II II II II II
What are the differences between chronic, acute, and cancerous enlargement of lymph
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nodes? - Acute - associated with infection, less than 14 days
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Cancerous - hard nodules, rock like, immobile/ fixed II II II II II II II
Chronic - lymph nodes clump together II II II II II
What are some other names for parotid lymph nodes? - jugulodigastric or
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retropharyngeal
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, What is the central nervous system? - - CNS consists of the brain and spinal cord
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- 31 pairs of spinal nerves 8 cervical, 12 thoracic, 5 lumbar, 5 sacral, 1 coccygeal
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- rarely do we see fully severed spinal cord injury which means that there's complete loss
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of motor movement and sensory input
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- "the higher the injury the more the impact"
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What is the brain and it's major functions? - - mass of nerve tissue that is the main control
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center of the nervous system
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- *Cerebral Cortex* - outer layer that covers thecerebrum
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- *Cerebrum* - the part of our brain that is responsible for our higher functions divided into
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4 lobes
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> frontal lobe = personality, intelligence, emotions, behavior, decision making
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> parietal lobe = sensation
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> temporal lobe = hearing, taste, smell
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> occiptal lobe = vision , sight mechanisms
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- *Cerebellum* - no intiation, but coordination, equillibrium, balance
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- *Wernicke's Area* - speech comprehension, temporal
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- *Broca's area* - speech production, frontal lobe
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What are two examples of dz that have enlarged or inflammed lymph nodes as one of
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their clinical manifestations? - HIV (occiptal nodes enlarged) Non-hodgkin lymphoma
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(supraclavicular is enlarged)
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What is the peripheral nervous system? - - the nervous system outside the brain and
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spinal cord
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- 12 Cranial Nerves
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- 31 spinal nerves
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- includes the ANS and Somatic NS
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- Somatic and Autonomic NS
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- The Somatic NS = Sensory/ Afferent info *to* CNS and Motor/Efferent info *from* the
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CNS to muscles
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- The Autonomic NS = "automatic" f(x)s
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What is a common effect of stroke/TIAs on pts? - Aphasia - problems with speech, either
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the pt can't speak or can not comprehend speech
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What are dermatomes? - - Derma = skin
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- an area of *skin* that is innervated by nerves from a single nerve root
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- used w/ spinal block
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- effected by shingles
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- one spinal cord segment >> one pinal nerve
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- less dangerous, less risk than full anesthesia
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