Exam 2 Combined Complete PDF

EXAM 2 COMBINED COMPLETE Study online at https://quizlet.com/_frzz5z 1. What are all the types of abuse?: Physical abuse Psychological abuse Economic abuse Sexual abuse 2. What are some history findings that may indicate abuse?: -Past records of violence -unexplained symptoms -multiple ER visi...

EXAM 2 COMBINED COMPLETE Study online at https://quizlet.com/_frzz5z 1. What are all the types of abuse?: Physical abuse Psychological abuse Economic abuse Sexual abuse 2. What are some history findings that may indicate abuse?: -Past records of violence -unexplained symptoms -multiple ER visits -Anxiety -use of sedatives -drug abuse history -depression and suicide attempts -partner/parent criticizes appearance, feelings or actions -delay seeking treatment -inconsistent stories -frequent UTIs 3. What are some behavioral signs of abuse?: -Partner/parent criticizes appear- ance, feelings or actions -Delay seeking treatment -Inconsistent stories -Frequent UTIs 4. some interview questions to detect abuse: -someone hurt you? -do you feel unsafe? -has anyone touched you without you saying it was okay to do so? -sexual physical hurt? -threatened? -sexually forced? -trafficked? -hate crime? -PTSD? -History of respiratory problems or thoracic trauma -history of child abuse? -difficulty performing activities? -stress? -do you participate in activities outside your house? 5. Physical assessment findings that may indicate abuse: -unexplained injuries -bruises in different stages specially on limbs -bilateral or symmetric injuries -burns 1 / 20  EXAM 2 COMBINED COMPLETE Study online at https://quizlet.com/_frzz5z -bad healed fractures -hair loss -internal injuries -signs of restraint -STDs -malnutrition -psychosomatic complains 6. Documentation for victims of abuse: -validate -nonbiased description of what I observe and hear -clarify descriptions -quote descriptions -be objective -use photographs -could be used in court -describe injuries accurately -describe emotional state -document denials or refusals -mandatory reporting Recognize, respond, refer. 7. What is the recommended approach for interviewing a client who has expe- rienced family violence?: A: Use simple, direct questions with a relaxed and calm approach, and patiently listen without interrupting 8. Should you ask a client if they want to press charges when they disclose abuse?: A: No, that decision involves legal counsel and is not part of the clinical assessment. 9. At what age is it recommended to ask screening questions in a secure, private setting without anyone else present?: A: For any client over the age of 3 years. 10. When should screening for abuse be avoided?: A: If there are any safety concerns for either the healthcare provider or the client. 11. What should be discussed with the client prior to screening for abuse?: A: Legal and mandatory reporting requirements and any limits to confidentiality. 12. What is the importance of allowing the client to answer completely during the interview?: A: It provides the client the opportunity to speak freely, and helps ensure accurate data while demonstrating empathy and concern. 13. How should healthcare providers introduce the topic of abuse screening to clients?: A: By saying, "Because violence is common in many people's lives, I routinely ask all clients to complete the following questions, or I can ask you these questions." 2 / 20  EXAM 2 COMBINED COMPLETE Study online at https://quizlet.com/_frzz5z 14. What is the purpose of the HITS (Hurt, Insult, Threaten, Scream) assess- ment tool?: A: To screen for intimate partner violence. A "Yes" to any of the questions indicates potential abuse. 15. What should a healthcare provider convey during an abuse screening to encourage the client to talk?: A: A concerned, nonjudgmental attitude, showing empathy and compassion. 16. What is the IPV screening?: Tell the client that it is important to routinely screen all clients for IPV because it affects so many women and men in society. 17. What should you do if a client discloses abuse during the screening?: A: Acknowledge the abuse and the client's courage in admitting it, and use supportive statements. 18. What are some examples of supportive statements to use when a client discloses abuse?: A: "I'm sorry this is happening to you. This is not your fault. You are not responsible for his behavior. You are not alone. You don't deserve to be treated this way." 19. How should you respect the client's autonomy if they disclose abuse?: A: Acknowledge the client's autonomy and right to self-determination while reiterating confidentiality. 20. What should you say if a client replies "no" to IPV screening questions but you want to maintain rapport?: A: "If your situation ever changes, please call me to talk about it. I am happy to hear that you are not being abused. If that should ever change, this is a safe place to talk." 21. Why is it important to emphasize confidentiality when a client discloses IPV?: A: It helps build trust and reassures the client that their disclosure will be handled with privacy and care. 22. What is the initial approach for assessing suspected elder mistreatment?- : A: Ask the older adult to describe a typical day and their daily routines, then be alert for indicators of abuse or neglect. 23. What are some screening questions to ask when assessing elder abuse?- : A: "Has anyone ever made you sign papers that you did not understand?" "Are you alone often?" "Has anyone refused to help you when you needed help?" "Has anyone ever refused to give you or let you take your medications?" 24. What is the rationale for asking about past respiratory problems, trauma, or surgeries when assessing suspected abuse?: Trauma or surgery to the thorax may alter its appearance and obscure physical evidence of abuse. 3 / 20  EXAM 2 COMBINED COMPLETE Study online at https://quizlet.com/_frzz5z 25. Why is it important to inquire about a personal or family history of abuse when assessing a client for potential abuse?: A: Abuse often runs in families and past episodes of abuse can influence current situations. 26. How can an abusive partner affect a client's lifestyle or health practices?: - A: Abusive partners often control the activities of their partner and may prevent them from engaging in activities outside the home or building friendships. 27. Why might a client experiencing IPV report shortness of breath?: A: IPV is associated with severe emotional stress, which can manifest as shortness of breath. 28. When interviewing a child about suspected abuse, what should you avoid doing?: A: Avoid coercing the child with rewards or asking questions that can be answered with a simple "yes" or "no." 29. What is important to keep in mind when interviewing a child about abuse?- : A: Establish a reassuring environment, remain calm, avoid showing surprise or distaste, and use terms and language the child understands. 30. What type of questions should be used to extract information from children in cases of suspected abuse?: A: Direct, open-ended or multiple-choice ques- tions, avoiding leading questions. 31. How should a nurse prepare a child for a physical examination after suspected abuse?: A: Ensure the child is as comfortable as possible. Be mindful that the accompanying parent may be the abuser, which could complicate the examination. 32. What should a nurse consider when preparing an adult for a physical examination after abuse?: A: The specific injuries will determine the focus of the exam. For rape, consult a Sexual Assault Nurse Examiner (SANE) to collect evidence that may be used in court. 33. What equipment is generally needed for a physical examination for abuse?: A: Equipment to measure vital signs is necessary for a general examina- tion. Additional equipment depends on the specific injuries. 34. What are key points to remember when examining a client suspected of being abused?: A: Provide privacy. Keep hands warm. Remain nonjudgmental. Educate the client about risks and available assistance. 35. When should the HITS (Hurt, Insult, Threaten, Scream) Assessment Tool be used?: A: When time is limited, the HITS tool is useful to quickly assess potential abuse. 4 / 20  EXAM 2 COMBINED COMPLETE Study online at https://quizlet.com/_frzz5z 36. What additional assessments may be required if sexual assault is iden- tified?: A: A further gynecologic exam may be needed, typically performed by a certified Sexual Assault Nurse Examiner (SANE). 37. How should the physical examination be approached if IPV (intimate part- ner violence) is suspected?: A: Follow standard prep for the body system affected but make the client comfortable. Ask them to remove all clothes and wear a gown for full-body assessment. 38. What general screening guidelines should be followed for all clients in healthcare settings?: A: Always be alert to signs of domestic violence during interviews and exams. Use appropriate tools like the Abuse Assessment Screen for at-risk clients. 39. What should be done if there is physical evidence of abuse?: A: Take digital photographs of the abuse with the client's consent and follow the health care facility or agency policy. 40. What is the process of analyzing data to make clinical judgments in family violence cases?: A: After collecting subjective and objective data, identify abnormal findings and client strengths. Cluster the data to reveal significant patterns, which will inform clinical judgments regarding family violence. 41. What are some risk factors for client concerns related to family violence?- : A: Risk for poor family health associated with the presence of violence Risk for injury related to partner violence Risk for violent behavior toward others due to poor coping or substance abuse Risk for PTSD due to inability to leave an abusive relationship Risk for self-harm due to ongoing family abuse 42. What are actual client concerns related to family violence?: A: Lack of personal identity due to the victimized role Postrape traumatic reaction, leading to impaired everyday function Fear of losing an abusive intimate relationship Poor self-esteem linked to prolonged physical, sexual, or emotional abuse 43. Why is it important for nurses to understand culture in patient care?: A: Nurses interact with clients daily who may hold different beliefs about health, illness, and family decision-making. Cultural knowledge helps address health disparities and avoid ethnocentrism and stereotyping. Regulatory standards also require cultural competence. 44. What is cultural competence in nursing?: A: Cultural competence is the ability to integrate cultural assessments into health care, recognizing and addressing normal and abnormal variations in health and beliefs across different cultures. 5 / 20  EXAM 2 COMBINED COMPLETE Study online at https://quizlet.com/_frzz5z 45. What does the ASKED mnemonic stand for, and how does it relate to cultural competence?: A: Awareness: Of your biases and prejudices Skill: In completing cultural assessments Knowledge: About different cultures and beliefs Encounters: Level of interaction with people from different cultures Desire: Genuine interest in becoming culturally competent 46. What are some key contexts that culture includes beyond basic beliefs?: A: Culture includes family structure and function, spirituality and religion, and commu- nity, which influence growth, health, illness, and health care delivery. 47. What is the main purpose of assessing culture in health care?: A: To learn about a client's beliefs and behaviors related to health and illness, compare these with standard Western health care, and assess health relative to diseases prevalent in the client's cultural group. 48. What specific aspects should a nurse assess regarding a client's cultural background?: A: Beliefs about disease causes Caregiving roles Expected treatments (Western and folk practices) Daily hygiene rituals Food preferences and rituals Religious beliefs related to health care 49. How can nurses avoid stereotyping when assessing a client's culture?: A: Compare the client's individual beliefs and practices with both Western health care and others from their cultural background, recognizing individual variations. 50. What should nurses ask to understand a client's view of their illness?: A: Ask, "What does the illness mean to you?" This helps understand the client's perspective and their beliefs regarding the cause and impact of the illness. 51. How should nurses assess how illness affects a client's lifestyle and beliefs?: A: Ask, "How has the illness affected your lifestyle and beliefs?" This helps gauge changes in the client's daily life and any shifts in their personal or spiritual outlook. 52. What question can nurses ask to understand how clients view the cause of their illness?: A: Ask, "What do you think caused your illness?" Clients may attribute illness to factors like poor lifestyle, spiritual beliefs (e.g., punishment from God), or cultural concepts like yin/yang or imbalances in hot and cold. 53. What question helps assess what being healthy means to a client?: A: Ask, "What does being healthy mean to you?" This reveals how clients define health and whether they follow practices like exercise or dietary control to maintain it. 6 / 20  EXAM 2 COMBINED COMPLETE Study online at https://quizlet.com/_frzz5z 54. How do cultural beliefs influence a client's approach to health care?: A: Cultural beliefs affect communication, whom the client seeks help from, and how they perceive health and illness. These beliefs will shape their behavior in seeking treatments and interacting with health care providers. 55. How do cultural beliefs affect perceptions of suffering and pain?: A: Beliefs about suffering and pain vary widely across cultures, and understanding these beliefs helps nurses provide care that respects the client's spiritual or cultural views. 56. How do beliefs about healers affect a client's response to health care?: A: Clients from cultures where traditional healers (e.g., curandero, shaman) play a significant role may not accept Western health care without their involvement. 57. Why is it important not to assume all members of a cultural group follow the same health practices?: A: Assuming all clients from a cultural group follow traditional practices is stereotyping, which may lead to conflict. Nurses must assess the individual's unique beliefs and level of acculturation. 58. Communication Needs/Preferences:: Time Space Eye contact and positioning : Body language and hand gestures Silence Touch 59. Spiritual Assessment - spirit mnemonic: S - Spiritual belief system P - Personal spirituality I - Integration with a spiritual community R - Ritualized practices and restrictions I - Implications for medical care T - Terminal events planning 60. How does cultural conditioning affect the experience of pain?: A: The experience of pain can vary by cultural conditioning; some individuals may see pain as punishment for wrongdoing, while others may view it as atonement. 61. What influences an individual's response to pain?: A: An individual's re- sponse to pain can be influenced by cultural values, which can affect how they express or cope with pain. 62. What challenges arise when the caregiver and client come from different cultures?: A: When caregivers and clients have different cultural backgrounds, it can be difficult to accurately interpret the level of pain the client is experiencing. 63. Why might it be necessary to explain the therapeutic reasons for treating pain to clients from stoic cultures?: A: Clients from stoic cultures may be reluctant 7 / 20  EXAM 2 COMBINED COMPLETE Study online at https://quizlet.com/_frzz5z to express or describe pain, so explaining the therapeutic reasons for pain manage- ment can help them understand the importance of communicating their pain levels. 64. What is the main purpose of a spiritual assessment in nursing?: A: To better understand the client and the client's spiritual perspective related to health. 65. Why is objectivity important during a spiritual assessment?: A: The nurse's personal views on the client's spiritual beliefs should not influence the assessment; the focus is on the client's perspective. 66. What is a clinical tip for conducting a spiritual assessment?: A: Briefly ad- dressing a client's spirituality can establish an open dialogue and lay the foundation for future interventions or care. 67. What components should be integrated into a spiritual assessment?: A: History of present concern, related past history, family history, and lifestyle and practices. 68. what would other people do different in other cultures?: hand gestures eye contact time awarness 69. (pt violented) first thing when interviewing the pt to consider is: pt physical and emotional safety 70. red flags when screening for violence: partner dont let them talk history of physical violence unexplained injuries diff stages of healing injuries dont match story repeated injuries 71. values and beliefs can be divided into 2 categories: 1. those that affect the client's approach to healthcare system 2. those that affect the client's disease, illness or health care 72. factors affecting approach: ethnicity generational status education level religion previous health care experiences occupation and income level beliefs about time and space communication needs 73. spirituality/religion impact on health: -turn in times of stress or illness -refusal of blood transfusion or other treatments -may need ethics committee in some sustaining situations involving pediatrics. 8 / 20  EXAM 2 COMBINED COMPLETE Study online at https://quizlet.com/_frzz5z 74. All of the following could cause a delayed capillary refill except COPD Hypovolemia CHF Lordosis: Lordosis 75. To identify jaundice in an Asian client the RN would assess: sclera 76. all of the following are signs of skin cancer except irregular border change in color discharge asymmetry: discharge 77. all of the following may increase a clients risk for skin breakdown except pulling them up in bed by their armpits low protein diet using a draw sheet positioning on the sacral area: using a draw sheet 78. clubbing may indicate: chronic hypoxia 79. all of the following may be visible in a stage II pressure ulcer except sub q fat undermining muscle tunneling: muscle 80. a pt with an infection may demonstrate all of the following except bradypnea erythema hyperthermia delayed cap refill: bradypnea 81. when assessing the carotid arteries the RN should palpate them bilaterally to compare elasticity T/F: False 82. all of the following symptoms might indicate a migraine headache except nausea sensitivity to light the feeling of a tight band around the head an aura: the feeling of a tight band around the head 83. all of the following are assessment findings that may be associated with TMJD except crepitus around the clavicles aching ears 9 / 20  EXAM 2 COMBINED COMPLETE Study online at https://quizlet.com/_frzz5z mandible locking open clicking or popping when masticating: crepitus around the clavicles 84. the jaeger test is used to assess for presbyopia T/F: True 85. PERRLA is used to assess visual acuity T/F: False 86. when assessing vision with a snellen chart the RN should ask the patient to stand 10 feet from the chart ask the patient to read the line above if they miss a number assess both eyes simultaneously ask the patient to read the line below if they miss one number: ask the patient to read the line below if they miss one number 87. in a pt with PERRLA: There is consensual response in both pupils 88. when both clients eyes constrict simultaneously to light it is called: con- sensual response 89. when performing the Rhinne test the RN should place the tuning fork on top of head: False 90. possible signs of otitis media include all of the following except bulging eardrum tenderness of the mastoid process excessive cerumen purulent discharge: excessive cerumen 91. to conduct a weber test the RN should compare the AC and BC: false 92. tonsils that are midway between the uvula are: 2+ 93. When transilluminating the sinuses a glow indicates fluid or pus: False 94. a wheal is: elevated mass with transparent border, often irregular in shape and size 95. adventitious breath sounds include crackles, wheezes and stridor T/F: T 96. a respiratory condition noted with a symptom of barrel chest: emphysema 97. fine crackles in the lungs....: may indicate bronchitis 98. The bell is used to auscultate?: Low pitch sounds 99. rales or wheezes indicate presence of fluids in lungs?: rales 100. high pitched musical sound auscultating lungs: wheezes 101. age related respiratory assessment changes include all of the following except kyphosis barrel chest they may get tired more easily decreased chest excursion: barrel chest 102. pectus carinatum: prominent sternal protrusion 103. when auscultating healthy lungs the RN hears: resonance 10 / 20  EXAM 2 COMBINED COMPLETE Study online at https://quizlet.com/_frzz5z 104. what nerve is affected by bells palsy: VII 105. where should the nurse assess for cyanosis in a pt with dark skin: mucous membranes 106. what are the three types of skin cancer?: Basal cell carcinoma, Squamous cell carcinoma, Melanoma 107. melanoma characterisitics: -least common -more dangerous -abnormal mole -metastasizes 108. what do we assess in skin?: texture thickness moisture temperature mobility turgor edema 109. crackles are caused by: air passing through fluid 110. what adventitious breath sound will the RN recognize as cause of con- cern? Crackles that clear with a cough. Rhonchi that sounds like snoring and gurgling. Wheezes heard on inspiration and expiration. Stridor present in a toddler in the emergency room.: Rhonchi that sounds like snoring and gurgling. Wheezes heard on inspiration and expiration. Stridor present in a toddler in the emergency room. 111. peripheral vascular disease?: Vascular disease affecting blood vessels out- side of the heart and especially those vessels supplying the extremities. 112. ABCD: signs of skin cancer= asymmetry, border irregular, color variation, diameter >0.5cm 113. functions of skin: physical barrier, temperature regulation, fluid and elec- trolyte balance, sensation, vitamin D synthesis, protection against microorganisms 114. melanin: brown pigment in skin. People with darker skin have more melanin. May be harder to assess cyanosis 115. carotene: yellow pigment in skin. More abundant in Asians. May be harder to assess jaundice 116. vitiligo: patches of skin without melanin, causes by immune system attacking melanin producing cells 11 / 20  EXAM 2 COMBINED COMPLETE Study online at https://quizlet.com/_frzz5z 117. erythema: redness of skin. May be caused by high hematocrit, infection, fever, inflammation, allergic reaction 118. cyanosis: bluish tinge to skin caused b decreased oxygenation of tissue. peripheral cyanosis caused by vasoconstriction, central cyanosis caused by hypoxia 119. pallor: pale skin caused by low hematocrit, anemia or shock. some people genetically have very pale skin 120. jaundice: yellow color to skin, mucous membranes, or sclera of eyes, caused by liver dysfunction 121. primary skin lesion: appears on normal skin as a direct result of a disease process nodule, cyst, bullae, macule, plaque, wheal, vesicle, pustul 122. secondary skin lesion: develops from other causes such as scratching, trau- ma, infection, or wound healing ulcer, fissure, scale, erosion, atrophy 123. skin lesion caused by bleeding, venous pressure: vascular lesion 124. elevated mass with transient border, often irregular in shape and size (rash): wheal 125. elevated, pus-filled area on the skin: pustule 126. raised palpable solid mass with a circumscribed border < 0.5 cm (exam- ple=wart): papule 127. flat, nonpalpable changes in skin color: macule 128. raised palpable solid mass > 0.5 cm (example= psoriasis): plaque 129. small, flat, non palpable skin color change (example=freckle): macule 130. elevated, solid palpable mass that extends deep into dermis < 1cm: nodule 131. elevated, solid , palpable mass extends deep into dermis > 1cm: tumor 132. elevated, palpable fluid filled mass < 0.5 cm (example= varicella): vesicle 133. elevated, palpable fluid filled mass > 1 cm (example= large 2 degree burn blisters): bulla 134. Elevated, encapsulated, fluid-filled or semisolid mass originating in sub- cutaneous tissue or dermis, usually 1 cm or larger: cyst 135. examples of secondary skin lesions: erosions, scars, ulcers, fissures, lichenification 136. caused by excessive rubbing- leathery, thick, patches of skin: lichenifica- tion 137. All types of vascular skin lesions: contusion bruise ecchymosis purpura petechia hematoma 12 / 20  EXAM 2 COMBINED COMPLETE Study online at https://quizlet.com/_frzz5z hemorrhage cherry angioma spider angioma telengiectasias 138. purple area, non elevated, hemorrhagic area on skin, larger than petechi- ae: ecchymosis 139. localized collection of clotted blood in a organ, body cavity, or tissue caused by broken blood vessels: hematoma 140. large amount of bleeding: hemorrhage 141. pinpoint non raised round purple spots , 3mm caused by small vessels leading blood under skin. May be caused by DIC, sepsis: petechia 142. purple spots, non-raised, larger than petechia > 3 mm caused by small vessels leaking blood under skin: purpura 143. small, round, red raised skin growth on trunk or extremities common in elderly: cherry angioma 144. fine hair covering a newborn, especially in premature infants: lanugo 145. areas of parch hair loss or baldness caused by immune system attacking hair follicles: alopecia 146. excessive facial hair growth on a female: hirsutism 147. wide, spoon appearing nails with angle > 180 degrees caused by chronic hypoxia: clubbing 148. soft spoon shaped nails Caused by anemia, endocrine, cardiac, or a liver disease.: koilonychias 149. hard, yellow may be caused by respiratory disease, lymphedema, or AIDS: yellow nail syndrome 150. local nail infection and inflammation: paronychia 151. tiny dents in nails, caused by psoriasis or eczema: pitting nails 152. half and half nails: A white color on the upper part of nails and a reddish brown color below. caused by kidney disease or crones disease 153. normal characteristics of lymph nodes: non palpable or beadlike, mobile, non tender 154. how to assess thyroid gland: palpate neck from behind, ask patient to flex neck and tilt head and swallow. feel for symmetrical movement, nodules 155. characteristics of migraine headaches: may be unilateral and preceded by aura (such as flashing lights), may have light sensitivity and nausea 156. characteristics of tension headaches: dull, tight, band around head 157. characteristics of cluster headaches: stabling sensation , near eye orbit, sudden onset 13 / 20  EXAM 2 COMBINED COMPLETE Study online at https://quizlet.com/_frzz5z 158. characteristics of sinus headaches: pressure and tenderness in frontal or maxillary sinus area. may be accompanied by fever or congestion 159. enlargement of facial features, hands and feet caused by excessive growth hormone: acromegaly 160. flat, puffy moon face and buffalo hump, caused by overproduction or administration of steroids: Cushing syndrome 161. exophthalmos: protruding appearing eyes, may be caused by hyperthyroidism 162. facial drooping and paralysis caused by inflammation of the facial (7th) cranial nerve. usually temporary: bells palsy 163. BEFAST: acronym for a stroke=balance problems, eye visual problems, facial droop, arm drift, speech slurred. time to go to ER 164. 2nd leading cause of blindness, caused by increased intraocular pres- sure, gradual loss of peripheral vision: glaucoma 165. vision loss starts as dry blurred vision, wet crooked lines appearing in visual field, caused by degeneration of macular portion of retina: macular degeneration 166. leading cause of blindness, clouding of eye lens: cataracts 167. how to test distant vision: Snellen chart 20 feet away, cover 1 eye, Can only miss 2 letter or move up a line 168. how to test near vision: Jaeger test 14 inches away 169. impaired near vision: presbyopia 170. PERRLA: pupils equal, round, react to light accommodation with penlight 171. to test alignment of eyes=stare straight ahead and reflection of light on corneas should be equal: corneal light reflext 172. both pupils should react to light equally at the same time: consensual response 173. as object moves closer pupils constrict and eyes converge: accommoda- tion of pupils 174. looking straight ahead cover 1 eye and observe the uncovered eye, remove cover and eyes should remain fixed and not move or drift: cover test 175. eye shakes during cardinal positions test of cranial nerves III, IV, and VI: nystagmus 176. general redness of white (sclera) of eye caused by infection, irritation, or allergic reaction: conjunctivitis 177. drooping of upper eyelid, may be caused by nerve damage or myasthenia gravis: ptosis 178. everted (sags out) lower eyelid. Can cause exposure and drying of eye: - ectropion 14 / 20  EXAM 2 COMBINED COMPLETE Study online at https://quizlet.com/_frzz5z 179. small, usually painless lump on the edge of the eyelid caused by blockage of the gland at the base of an eyelash.: chalazion 180. infection of a gland in the eyelid: hordeolum 181. a inward turning lower eyelid. May cause irritation f eye: entropion 182. staff infection of the eyelid: blepharitis 183. self limiting inflammation of the episclera (thin layer of tissue between conjunctiva and sclera) of eye: diffuse episcleritis 184. caused by coughing, sneezing, or childbirth- broken tiny capillaries on sclera: conjunctival hemmorhage 185. pinpoint pupils caused by narcotics or brain damage: miosis 186. unequal pupils. may be benign, or caused by ocular or parasympathetic nerve damage: anisocoria 187. dilated fixed pupils. caused by anesthesia, shock, or cns dysfunction: my- driasis 188. mechanical problem in outer or inner ear that causes hearing loss: con- ductive hearing loss 189. injury, disease or congenital nerve damage in inner ear causes permanent hearing loss: sensorineural hearing loss 190. test to distinguish between conductive nd Sensineural hearing loss. tun- ing fork place on top of head to assess if sound is unilateral and symmetrical. Conductive loss= hear sound in bad ear. Sensineural = hear sound in good ear: weber test 191. hearing test to compare air to bone conduction. AC should be greater than BC. Conductive hearing loss BC > AC: Rinne test 192. assess for vertigo. close eyes standing with feet together and observe for swaying: romberg test 193. otitis externa: infection of outer ear canal 194. extosis: bone growth in ear canal that can narrow and obstruct ear drum 195. abnormally formed small pinna linked to congenital disorders: microtia 196. uric acid crystal buildup on pinna, related to gout: tophi 197. white patches in mouth associated with cancer, HIV, epstein barr: leuko- plakia or hairy leukoplakia 198. smooth red shiny tongue: associated with vitamin B deficiency 199. grading of tonsils: 1+ visible, 2+ midway to uvula, 3+ touch the uvula, 4+ tonsils touch 200. near sightedness: myopia 201. cross eyed: strabismus 202. high pitched lung breath sound on expiration - acute asthma or chronic emphysema: sibilant wheeze 15 / 20  EXAM 2 COMBINED COMPLETE Study online at https://quizlet.com/_frzz5z 203. low-pitched snoring lung sound. sometimes can clear with coughing: - sonorous wheeze 204. harsh barking sound on inspiration caused by bronchospasm or croup- : stridor 205. low pitched, bubbly, adventitious breath sounds like Velcro. Often caused by pneumonia or pulmonary edema: course crackles 206. high pitched adventitious sound heard on inspiration. cannot clear by coughing. sounds like hair brushing against ears: fine crackles 207. dry grating sound caused by inflammation of lung pleural membrane: - pleural friction rub 208. rapid deep breathing seen with diabetic keto acidosis: kussmall breathing pattern 209. rapid deep breathing followed by periods of apnea, seen in drug overdose, hospice patients before death: cheyne stokes breathing pattern 210. respiratory distress- flaring, tripod position, retractions, desaturations, tachypnea: dyspnea 211. AP diameter enlarged, seen with COPD: barrel chest 212. difficulty breathing laying down. May see in obesity or congestive heart failure: orthopnea 213. what to assess with respirations: quality, pattern, rate, rhythm, depth 214. deformity of chest, sternum points inward: pectus excavatum 215. common in elderly with osteoporosis, abnormal curvature of thoracic spine: kyphosis 216. Braden score categories: sensory perception, moisture, activity, mobility, nu- trition, friction and shear 217. appocrine vs eccrine glands: Apocrine: hair, perineum, axilla, body odor, not till puberty Eccrine: entire skin and thermoregulation 218. Abnormalities in nails: Dirty, broken, poor hygiene (a sign of job or hobby) cyanosis (anemia) hemorrhage (trauma) Discoloration (infection/psoriasis) Pitting (psoriasis) Clubbing (hypoxia) spoon nails (iron deficiency) thick nails (decreases circulation/onychomycosis) Paronychia (infection) ridging half and half 16 / 20  EXAM 2 COMBINED COMPLETE Study online at https://quizlet.com/_frzz5z koilonychia yellow nails 219. What does capillary refill indicate?: status of peripheral circulation 220. slow capillary refill (+2 seconds) sign of: respiratory or cardio problem that causes hypoxia 221. pressure ulcer Stage I: nonblanchable erythema of intact skin 222. pressure ulcer stage II: Partial-thickness skin erosion with loss of epidermis or also the dermis. Superficial ulcer looks shallow like an abrasion or open blister with a red-pink wound bed. 223. pressure ulcer stage III: Full-thickness pressure ulcer extending into the subcutaneous tissue and resembling a crater. May see subcutaneous fat but not muscle, bone, or tendon. 224. Pressure Ulcer stage IV: full thickness skin loss with damage to bone, muscle, or underlying tissues 225. What are lymph nodes?: non palpable small bead like non tender mobile 226. what do we palpate in lymph nodes for?: size, shape, delimitation, mobility, consistency, tenderness 227. lymph nodes names: preauricular postauricular tonsillar occipital submandibular submental superficial cervical posterior cervical deep cervical 228. what do we assess on neck?: -position, symmetry, lumps, mass, swelling -thyroid cartilage and cricoid cartilage (move up) -cervical vertebra palpable -ROM -trachea in midline 229. palpation of TMJ: for swelling, tenderness, crepitation, ROM 230. Types of headaches: tension: forehead migraine: unilateral and travels (women, light sound sensitivity) cluster: ice pick (men/need O2) sinus: on sinuses 231. sinus headache: Deep, constant throbbing pain, may be moderate to severe Occurs after a cold One area of the face 17 / 20  EXAM 2 COMBINED COMPLETE Study online at https://quizlet.com/_frzz5z 232. migraine headache: N/V, sensitivity to noise and light, unilateral 233. cluster headache: Stabbing pain; may be accompanied by tearing, eyelid drooping, reddened eye, or runny nose eye and orbit 234. tension headache: Dull, tight, diffuse frontal, temporal and occipital region 235. accessing distant visual acuity: Snellen chart: letters, eye level, 20ft, cover one eye. common is 20/20 an miss 2,document 20/20 -2. Miss morethan 2, move up a line. 236. accessing near visual acuity: Jaeger test, 40+ yo, test at 14 inches 237. position test: cardinal positions - assess eye strength and cranial nerve function - ask pt to focus on an object that is 12 inches away and move the object through six positions in a clockwise direction -if shaking its called nystagmus 238. Name two things a nurse should educate a patient about to prevent a traumatic brain injury: Wear a helmet during activities like biking or skateboarding. Use seat belts in vehicles to reduce the risk of head injury in accidents. 239. Assess eye on: red reflex optic disc retina conjunctiva eyelids lacrimal apparatus pupil gauge accommodation 240. eye illness/injuries risk factors: Increasing age Exposure to ultraviolet B light Diabetes mellitus Cigarette smoking Alcohol use Diet low in antioxidant vitamins High blood pressure Eye injuries/surgery Steroid use Female gender Persistent diarrhea Gout 18 / 20  EXAM 2 COMBINED COMPLETE Study online at https://quizlet.com/_frzz5z Abdominal obesity Beta-blocker use 241. external ear structures assessment: Inspection and palpation Inspect the auricle, tragus, and lobule for size, shape, position, lesions/discol- oration, and discharge. Palpate the auricle and mastoid process for tenderness. 242. Internal Ear: Otoscopic Examination: Inspect the external auditory canal for discharge, color, consistency of cerumen, canal walls, and nodules. Inspect the tympanic membrane for shape, consistency, and landmarks. 243. otoscope assessment: Otoscope: Inspect theTM, should be pearly gray,shiny, no bulging orretraction. Inspect thecanal. 244. whisper test: Test in which an examiner whispers a sentence and asks the patient to repeat it to evaluate loss of high-frequency sounds. 245. weber test: Test done by placing the stem of a vibrating tuning fork on the midline of the head and having the patient indicate in which ear the tone can be heard. 246. Rinne test: hearing test using a tuning fork; checks for differences in bone conduction and air conduction 247. Romberg test: assesses ability of vestibular apparatus in inner ear to help maintain standing balance 248. Abnormalities of external ear and ear canal: -malignant lesions -polyps -otitis externa -exostosis - buildup of cerumen -microtia -tophi 249. abnormalities of tympanic membrane: -Serous Otitis Media -Acute Otitis Media -ruptured tympanic membrane with blood -retracted tympanic membrane -Scarred tympanic membrane -ear tube placement drainage of internal ear 250. Bell Palsy vs CVA: Bell's Palsy Signs -Facial droop whole side (one side) -Inability to close eye -Forehead affected (can't wrinkle) CVA (Stroke) Signs -Facial droop from eye down (one side) 19 / 20  EXAM 2 COMBINED COMPLETE Study online at https://quizlet.com/_frzz5z -Arm weakness -Slurred speech -Forehead spared (can wrinkle) 251. what 3 things do you do to assess sinuses?: palpate, percuss, transillumi- nating 252. sinus palpation findings: tenderness crepitus 253. Age-Related Changes in the Mouth, Nose, Throat, and Sinuses: Gums recede, ischemic, and undergo fibrotic changes Tooth surfaces worn down Decreased ability to smell and taste Oral mucosa drier and more fragile Varicose veins in ventral surface of tongue 254. abnormalities of the mouth and throat: kaposi's sarcoma lesion cheilosis carcinoma leukoplakia hairy leukoplakia candida albicans canker sore receding gums gingivitis carcinoma of the tongue black hairy tongue vitamin deficiency tonsillitis 255. Risk Reduction Tips for Cancer of the OralCavity: Stop smoking Limit alcohol consumption Balanced diet Precautionary measures at workplace Avoid excessive exposure to ultraviolet light Avoid sources of oral irritation 256. Risk Factors for Cancer of the Oral Cavity: Tobacco use Alcohol consumption Age over 40 Male gender Genetic predisposition and family history Occupation: nickel refining, woodworking, textile fibers Vitamin A deficiency UV exposure 20 / 20