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West Coast University - NURS 190 PA FINAL Exam - Latest - Already graded A
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West Coast University - NURS 190 PA FINAL Exam - Latest - Already graded A
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what assessment technique does the nurse auscultationuses when listening to the HEART SOUNDS
and LUNG SOUNDS?
what technique will the nurse will use elicit to percussion
diaphragmatic excursion
Which percussion technique is used to indirect percussion
assess full or distended bladder
assessment for sinus direct percussion
For CVAT (costovertebral angle tenderness) blunt percussion
-doppler: assess pulses when they cant be palpated
-woodlamp: used to assess fungal infection on the skin
stadiometer: used to measure height of patient
goniometer used to measure the degree of joint flexion and extension
transilluminator instrument used to detect air, blood, fluid, or a mass in the body cavity
Skin fold measure thickness of sub-q tissue
0+= No pulse
1+ = weak thready
grading pulses 2+ = Normal
3+ = brisk
4+ = bounding
popliteal : behind the knee medially
Locations of pulses:
brachial: antecubital (brachial pulses)
popliteal
brachial
radial: thumb (radial pulses)
radial
ulnar
ulnar: small finger (ulnar pulses)
femoral
femoral: inguinal area
what part of the hand do you assess skin dorsal part
temperature?
what part of the hand do you uses to middle finger
percuss "INDIRECT PERCUSSION"
-Annular: only has one circle
Annular vs. Target lesions
-Target: has concentric circles, sometimes has a dot in the center (bullseye)
target lesion is usually seen in patient with? lyme dx. (tick bite)
annular lesion example is ring worm
, -Annular: one circle-
Different types of lesions: Target: lesions with concentric circles of color
annular
target Discrete: separated
discrete
confluent Confluent: run together-Linear: lesions that form a line
grouped
wheal Grouped: lesions that are together
Wheal: caused by insect bite or hive (reddened and irregular border)
-Vesicle: elevated, round or oval shape, palpable mass with thin translucent wall, filled
with clear fluid >0.5 cm
Difference between vesicle & bullae
Bullae: type of vesicle but LARGER <0.5 cm (burn blister)
bullae is bigger than vesicle
When a vesicle or a bullae becomes infected pustule (lesion is filled with pus)
what does it become
0=no edema
1+=2mm
Grading of skin edema: push hard around
2+=4mm
bony prominences with 3 finger pads
3+=6mm
4+=8mm
assessment technique for lymph nodes? gentle circular motion
flat, irregular shape, pale red to deep purple red, color deeps in response to exertion
Port-wine stain (vascular lesion)
or emotional response (crying or exposure to extreme temperature)
-epidermis: first layer
-dermis: second layer (contains nerves, blood, and hair follicles)
Layers of the skin
-subcutaneous tissue: third layer
-last layer: muscle and bone
lesion bright, raised, 2-10cm, doesn't blanch with pressure, usually present at birth and
Hemangioma (vascular)
disappears by age 10.
-Stage 1: 1 layer affected; epidermis reddened
-Stage 2: 2 layer affected; open lesion
Bed sores/pressure sores stages
-Stage 3: 3 layers affected
-Stage 4: 4 layers affected, epidermis, dermis, subcutaneous, muscle/bone
Wheal lesion (primary) reddened with irregular borders (insect bites/hives)
Macular lesion (primary) lesions that are flat, change in color <1cm (freckles or petechiae)
Patch (primary) type of macule lesion that is >1cm (mongolian spots, port wine stain, vitilligo)
lesion on face, neck, ears, and lips, usually present in elderly. Soft compressible, slightly
Venous lake (vascular)
elevated and ranges from dark blue to purple in color.
elevated, fluid filled, round or oval, translucent wall, <0.5cm (chicken pox, poision ivy,
Vessicle (primary)
and blisters)
Bulle (primary) type of vessivle that is >0.5cm (large or blister)
Flat, bright red dot, with tiny radiating blood vessels ranging from pin point to 2 cm and
Spider angioma (vascular)
blanches with pressure
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