Nursing 2000 Exam #2 Cedarville
University
what organs are in the right upper quadrant? - ANS-liver, right kidney, gall bladder, and
the right portion of the transverse colon
what organs are in the left upper quadrant? - ANS-spleen, pancreas, left kidney, and left
portion of the transverse colon
what organs are in the right lower quadrant? - ANS-appendix, ascending colon, right
ovary and fallopian tube
what organs are in the left lower quadrant? - ANS-descending colon, sigmoid colon, and
left ovary and fallopian tube
what organs are in the epigastric area? - ANS-stomach, vena cava, aorta
what order do you examine the abdomen? - ANS-Inspect, Auscultate, Percuss, Palpate
what are strategies that promote effective examination of the abdomen? - ANS-1. warm
your hands
2. use tangential lighting
3. head of bed slightly raised, knees bent slightly
4. proper draping
what are actions that could hinder effective examination of the abdomen? - ANS-1. cold
hands
2. lying flat
3. not telling them youre going to palpate hurtful spot
what are 5 different contour's you could have for abdomen? - ANS-flat, scaphoid,
rounded, distended (distension), protuberant
what is scaphoid? - ANS-concave, sucks down
what is distended (distension)? - ANS-big, tight, due to accumulation of gas
can be monitored by measuring abdominal girth serially
what is protuberant? - ANS-bigger than distended, due to fatty tissue
,what is respiratory enhancement? - ANS-palpating deeply, breathe a certain way, go in
deep
what does it mean when a peristaltic wave moves right to left? - ANS-about to vomit
what does it mean when a peristaltic wave moves left to right? - ANS-about to poop
what is peristalsis? - ANS-not absorbing nutrients, not getting rid of waste, bowel
obstructions
what is borborygmi? - ANS-hyperactive, really loud
how long should you listen if there are absent bowel sounds? - ANS-5 minutes
what is hypoactive bowl sounds? - ANS-5 or 6 bowel sounds in a minute
what is hyperactive bowel sounds? - ANS-nonstop; borborygmi
what is another word for vascular sounds? - ANS-bruits
what is hepatomegaly? - ANS-enlarged liver; use index finger; around 12 cm
how do you percuss the liver span? - ANS-1. right side of the patient
2. start in abdomen in MCL and percuss up to mark change from tympany to dullness.
This is the lower border of the liver
3. start at the 4th ICS in the MCL and percuss down from resonance to dullness; this is
the upper border of the liver
4. measure the distance between the markings, that is the liver span (6-12 cm)
what is shifting dullness? - ANS-area of dullness moves; roll them to the other side and
see if it shifts
if there is shifting dullness what could this mean? - ANS-fluid in the peritneum (ascites)-
in dependent position; organ compression could be a result of too much
what are you looking for with light palpation? - ANS-abdominal wall lesions
what are you looking for with deep palpation? - ANS-abdominal cavity lesions; more
than 1 cm
what is another word for bending the knee? - ANS-gatching
what is a MSQ? - ANS-a questionairre; 10-15 q's; basic questions (who is the
president?)
,what is a MMSE? - ANS-mini mental status exam; the top score is 30, anyone with a
score of 21 or less is considered to have cognitive impairment and need further
assessment; nonculturally biased.
what is level of consciousness? - ANS-LOC; how interactive they are with the
environment
How could naming go wrong with level of consciousness? - ANS-1. subjective- 2 nurses
are going to say different things
2. timing- when you assess them
3. different personalities
what is the Glasgow Coma Scale? - ANS-total of 15 points possible; best eye, best
verbal, best motor; advantages: detects the subtlety, cerebral cortex working
who is behavior and appearance especially important for? - ANS-elderly and children
what is aphasia? - ANS-without ability to order; can't speak in a language- cannot
mediate language
what are 2 other words for sensory? - ANS-afferent or receptive
what is sensory? - ANS-inability to mediate incoming language, they can speak but it
doesn't make any sense because they didnt understand what you asked; temporal
lobes
what are 2 other words for motor? - ANS-efferent and expressive
what is motor? - ANS-they understand what you asked but cannot formulate a response
that is intelligible to you. Frontal lobe problem; cannot write it down
is short term or long term memory more commonly lost? - ANS-short term
what is immediate recall? - ANS-what was just said or heard (sequence of #'s 7-9 digits)
what is abstract thinking? - ANS-figuring out a problem
in cranial nerve testing, what are you assessing function of? - ANS-the central brain
to assess midbrain function or for any increased pressure in the cranium, what do you
test? - ANS-the pupillary response to light; here you are testing cranial nerves 2 and 3.
what do you test when you want to test the pons? - ANS-the cornea reflex
how do you test direct response? - ANS-shine light and pupil gets smaller (left direct,
right direct)
, how do you test indirect response? - ANS-shine in right; look in left- pupil should
constrict; consensual
to test the medulla what do you check? - ANS-check for a gag reflex
what is PERLA? - ANS-pupils equal react to light accomodation
what does sluggish mean with pupillary constriction? - ANS-reaction not brisk; some
pressure on the midbrain
what does fixed and dilated mean? - ANS-pupil is big; 3rd cranial nerve paralyzed due
to pressure; not reacting to light, really bad
If you are blind in your right eye what kind of direct and indirect responses will you get?
what will happen in the left eye? - ANS-right: absent direct; present consensual
left: present direct; absent consensual
to assess the 8th cranial nerve, what should you assess? - ANS-hearing
what 4 principles should you do when assessing sensory function? - ANS-1. see when
you touch them- ask them to tell you if they felt it; have them close their eyes
2. test symmetrical- both sides
3. random interval
4. random pattern
what do you assess to test the cerebellar function? - ANS-coordination, balance,
stereognosis, graphesthesia, proprioception
if there is no coordination, what kind of problem could that be? - ANS-cerebellum
problem
what is the rhomberg test used for? - ANS-assessing balance; DUI test
what is stereognosis? - ANS-many ways to know things, knowing an object without
looking at it
what is graphesthesia? - ANS-feeling writing on your palm
what is proprioception? - ANS-perceiving position/location
what are the 4 things required for a reflex? - ANS-1. tendon recognizes pressure
2. intact afferent neuron
3. intact efferent lower motor neuron
4. functioning muscle
University
what organs are in the right upper quadrant? - ANS-liver, right kidney, gall bladder, and
the right portion of the transverse colon
what organs are in the left upper quadrant? - ANS-spleen, pancreas, left kidney, and left
portion of the transverse colon
what organs are in the right lower quadrant? - ANS-appendix, ascending colon, right
ovary and fallopian tube
what organs are in the left lower quadrant? - ANS-descending colon, sigmoid colon, and
left ovary and fallopian tube
what organs are in the epigastric area? - ANS-stomach, vena cava, aorta
what order do you examine the abdomen? - ANS-Inspect, Auscultate, Percuss, Palpate
what are strategies that promote effective examination of the abdomen? - ANS-1. warm
your hands
2. use tangential lighting
3. head of bed slightly raised, knees bent slightly
4. proper draping
what are actions that could hinder effective examination of the abdomen? - ANS-1. cold
hands
2. lying flat
3. not telling them youre going to palpate hurtful spot
what are 5 different contour's you could have for abdomen? - ANS-flat, scaphoid,
rounded, distended (distension), protuberant
what is scaphoid? - ANS-concave, sucks down
what is distended (distension)? - ANS-big, tight, due to accumulation of gas
can be monitored by measuring abdominal girth serially
what is protuberant? - ANS-bigger than distended, due to fatty tissue
,what is respiratory enhancement? - ANS-palpating deeply, breathe a certain way, go in
deep
what does it mean when a peristaltic wave moves right to left? - ANS-about to vomit
what does it mean when a peristaltic wave moves left to right? - ANS-about to poop
what is peristalsis? - ANS-not absorbing nutrients, not getting rid of waste, bowel
obstructions
what is borborygmi? - ANS-hyperactive, really loud
how long should you listen if there are absent bowel sounds? - ANS-5 minutes
what is hypoactive bowl sounds? - ANS-5 or 6 bowel sounds in a minute
what is hyperactive bowel sounds? - ANS-nonstop; borborygmi
what is another word for vascular sounds? - ANS-bruits
what is hepatomegaly? - ANS-enlarged liver; use index finger; around 12 cm
how do you percuss the liver span? - ANS-1. right side of the patient
2. start in abdomen in MCL and percuss up to mark change from tympany to dullness.
This is the lower border of the liver
3. start at the 4th ICS in the MCL and percuss down from resonance to dullness; this is
the upper border of the liver
4. measure the distance between the markings, that is the liver span (6-12 cm)
what is shifting dullness? - ANS-area of dullness moves; roll them to the other side and
see if it shifts
if there is shifting dullness what could this mean? - ANS-fluid in the peritneum (ascites)-
in dependent position; organ compression could be a result of too much
what are you looking for with light palpation? - ANS-abdominal wall lesions
what are you looking for with deep palpation? - ANS-abdominal cavity lesions; more
than 1 cm
what is another word for bending the knee? - ANS-gatching
what is a MSQ? - ANS-a questionairre; 10-15 q's; basic questions (who is the
president?)
,what is a MMSE? - ANS-mini mental status exam; the top score is 30, anyone with a
score of 21 or less is considered to have cognitive impairment and need further
assessment; nonculturally biased.
what is level of consciousness? - ANS-LOC; how interactive they are with the
environment
How could naming go wrong with level of consciousness? - ANS-1. subjective- 2 nurses
are going to say different things
2. timing- when you assess them
3. different personalities
what is the Glasgow Coma Scale? - ANS-total of 15 points possible; best eye, best
verbal, best motor; advantages: detects the subtlety, cerebral cortex working
who is behavior and appearance especially important for? - ANS-elderly and children
what is aphasia? - ANS-without ability to order; can't speak in a language- cannot
mediate language
what are 2 other words for sensory? - ANS-afferent or receptive
what is sensory? - ANS-inability to mediate incoming language, they can speak but it
doesn't make any sense because they didnt understand what you asked; temporal
lobes
what are 2 other words for motor? - ANS-efferent and expressive
what is motor? - ANS-they understand what you asked but cannot formulate a response
that is intelligible to you. Frontal lobe problem; cannot write it down
is short term or long term memory more commonly lost? - ANS-short term
what is immediate recall? - ANS-what was just said or heard (sequence of #'s 7-9 digits)
what is abstract thinking? - ANS-figuring out a problem
in cranial nerve testing, what are you assessing function of? - ANS-the central brain
to assess midbrain function or for any increased pressure in the cranium, what do you
test? - ANS-the pupillary response to light; here you are testing cranial nerves 2 and 3.
what do you test when you want to test the pons? - ANS-the cornea reflex
how do you test direct response? - ANS-shine light and pupil gets smaller (left direct,
right direct)
, how do you test indirect response? - ANS-shine in right; look in left- pupil should
constrict; consensual
to test the medulla what do you check? - ANS-check for a gag reflex
what is PERLA? - ANS-pupils equal react to light accomodation
what does sluggish mean with pupillary constriction? - ANS-reaction not brisk; some
pressure on the midbrain
what does fixed and dilated mean? - ANS-pupil is big; 3rd cranial nerve paralyzed due
to pressure; not reacting to light, really bad
If you are blind in your right eye what kind of direct and indirect responses will you get?
what will happen in the left eye? - ANS-right: absent direct; present consensual
left: present direct; absent consensual
to assess the 8th cranial nerve, what should you assess? - ANS-hearing
what 4 principles should you do when assessing sensory function? - ANS-1. see when
you touch them- ask them to tell you if they felt it; have them close their eyes
2. test symmetrical- both sides
3. random interval
4. random pattern
what do you assess to test the cerebellar function? - ANS-coordination, balance,
stereognosis, graphesthesia, proprioception
if there is no coordination, what kind of problem could that be? - ANS-cerebellum
problem
what is the rhomberg test used for? - ANS-assessing balance; DUI test
what is stereognosis? - ANS-many ways to know things, knowing an object without
looking at it
what is graphesthesia? - ANS-feeling writing on your palm
what is proprioception? - ANS-perceiving position/location
what are the 4 things required for a reflex? - ANS-1. tendon recognizes pressure
2. intact afferent neuron
3. intact efferent lower motor neuron
4. functioning muscle
