Exam 3: NSG 3009/ NSG3009 (2026/2027 Update) Principles of Assessment | Verified Q&A | 100% Accurate Solutions | – South University

Exam 3: NSG 3009/ NSG3009 (2026/2027 Update) Principles of Assessment | Verified Q&A | 100% Accurate Solutions | – South University Q. A patient with a tracheostomy has thick tenacious secretions. To maintain the airway, the most appropriate action for the nurse includes: A. Tracheal suctioning B. Oropharyngeal suctioning C. Nasotracheal suctioning D. Orotracheal suctioning Answer: A Q. When evaluating a post-thoracotomy patient with a chest tube, the best method to properly maintain the chest tube would be to: A. strip the chest tube every hour to maintain drainage B. place the device below the patient's chest C. double clamp the tube except during assessment D. remove the tubing from the drainage device to check for proper suctioning Answer: B "Handle the chest drainage unit carefully and maintain the drainage device below the patient's chest," (pg. 899). Chest tubes are not routinely stripped or milked to move clots or increase chest drainage. Clamping can result in a tension pneumothorax and a chest tube is only clamped when replacing the chest drainage system, assessing for an air leak, or during removal. You do not want to remove the tubing because it requires patient preparation due to the burning, pulling, and painful sensation. Q. A patient complains of chest pain. When assessing the pain, you decide that its origin is cardiac - rather than respiratory or gastrointestinal - when it: A. does not occur with respiratory variations B. is peripheral and may radiate to the scapular region C. is aggravated by inspiratory movements D. is non radiating and occurs during inspiration Answer: A C & D have the words "inspiratory" and "inspiration" both indicating respiration. Q. During rounds on the night shift, you note that a patient stops breathing for 1 to 2 minutes several times during the shift. This condition is know as: A. Cataplexy B. Insomnia C. Narcolepsy D. Sleep Apnea Answer: D Q. A patient suffers from sleep pattern disturbance. To promote adequate sleep, the most important nursing intervention is... A. Administering a sleep aid B. Synchronizing the medication, treatment, and vital signs schedule C. Encouraging the patient to exercise immediately before sleep D. Discussing with the patient the benefits of beginning a long-term night-time medication regimen Answer: B Q. An elderly patient who lives in an adult assisted-living facility mentions that he is experiencing hearing and vision changes. During your assessment, you would associate this type of sensory deprivation with... A. Stable affect B. Altered perception C. Improved task completion D. Increased need for social interaction Answer: B Q. A patient with glaucoma is being discharged from the hospital. When teaching the patient and family ways to improve home safety, the nurse tells the family to... A. Use throw rugs to prevent tripping B. Paint the floor black and white to improve perception C. Install extra incandescent lighting D. Install handrails painted the same color as the walls Answer: C Q. When a smiling and cooperative patient complains of discomfort, nurses caring for this patient often harbor misconceptions about the patient's pain. Which of the following is true? A. Chronic pain is psychological in nature B. Patients are the best judges of their pain C. Regular use of narcotic analgesics lead to drug addiction D. Amount of pain is reflective of actual tissue damage Answer: B Q. A patient has just undergone an appendectomy. When discussing with the patient several pain-relief interventions, the most appropriate recommendation would be... A. Adjunctive therapy B. Nonopioids C. NSAIDs D. PCA Pain Management Answer: D This is the best answer since they just got out of the hospital! Q. A postoperative patient is using PCA. You will evaluate the effectiveness of the medication when... A. You compare assessed pain with baseline pain B. Body language is incongruent with reports of pain relief C. Family members report that pain has subsided D. Vital signs have returned to baseline Answer: A Q. Which skills can the nurse delegate to assistive personnel (AP)? (Select all that apply) A. Initiate oxygen therapy via nasal cannula B. Perform nasotracheal suctioning of a patient C. Educate the patient about the use of an incentive spirometer D. Assist with care of an established tracheostomy tube E. Reposition a patient with a chest tube Answer: D & E Q. The nurse is caring for a patient with pneumonia. On entering the room, the nurse finds the patient lying in bed, coughing, and unable to clear secretions. What should the nurse do first? A. Start oxygen at 2 L/min via nasal cannula B. Elevate the head of the bed at 45 degrees C. Encourage the patient to use the incentive spirometer D. Notify the health care provider Answer: B Q. The nurse is performing discharge teaching for a patient with chronic obstructive pulmonary disease (COPD). What statement, made by the patient, indicates the need for further teaching? A. "Pursed-lip breathing is like exercise for my lungs and will help me strengthen my breathing muscles." B. "When I am sick, I should limit the amount of fluids I drink so that I don't produce excess mucus." C. "I will ensure that I receive an influenza vaccine every year, preferably in the fall." D. "I will look for a smoking-cessation support group in my neighborhood." Answer: B Q. Which assessment findings indicate that the patient is experiencing an acute disturbance in oxygenation and requires immediate intervention? (Select all that apply) A. SpO2 value of 95% B. Retractions C. Respiratory rate of 28 bpm D. Nasal flaring E. Clubbing of fingers Answer: B, C, & D Q. The nurse has just witnessed her patient go into cardiac arrest. What priority interventions should the nurse perform at this time? (Select all that apply) A. Perform chest compressions B. Ask someone to bring the defibrillator to the room for immediate defibrillation C. Apply oxygen via nasal cannula D. Place the patient in the high Fowler's position E. Educate the family about the need for CPR Answer: A & B Q. A nurse is developing a plan for a patient who was diagnosed with narcolepsy. Which interventions should the nurse include on the plan? (Select all that apply) A. Take brief, 20-minute naps no more than twice a day B. Drink a glass of wine with dinner C. Eat a large meal at lunch rather than dinner D. Establish a regular exercise program E. Teach the patient about the side effects of modafinil Answer: A, D, & E Which statements from a patient indicate an understanding of behaviors that will promote sleep? (Select all that apply) A. "I will not watch tv in bed" B. "I will not drink caffeine later in the day" C. "A short nap late in the evening will lead to a more restful night of sleep" D. "I am going to start eating dinner closer to my bedtime" E. "I will start to exercise regularly during the day" Answers: A, B, & E A 72-year-old patient asks the nurse about using an OTC antihistamine as a sleeping pill to help her get to sleep. What is the nurse's best response? A. "Antihistamines are better than prescription medications because prescriptions medications can cause a lot of problems" B. "Antihistamines should not be used because they can cause confusion and increase your risk of falls" C. "Antihistamines are effective sleep aids because they do not have many side effects" D. "Over-the-counter medications when combined with sleep-hygiene measures are a good plan for sleep" Answer: B Which statement made by the patient indicates an understanding of sleep-hygiene practices? A. "I usually drink a cup of warm milk in the evening to help me sleep" B. "If I exercise right before bedtime, I will be tired and fall asleep faster" C. "I know it does not matter what time I go to bed as long as I am tired" D. "If I use hypnotics for a long time, my insomnia will be cured" Answers: A Which statement made by a mother being discharged to home with her newborn infant indicates that she understands the discharge teaching related to best sleep practices? A. "I'll give the baby a bottle to help her fall asleep" B. "We'll place the baby on her back to sleep" C. "We put the baby's stuffed animals in the crib to make her feel safe" D. "I know the baby will not need to be fed until morning" Answer: B A nurse is taking a sleep history from a patient. Which statement made by the patient needs further follow-up? A. "I feel refreshed when I wake up in the morning" B. "I use soft music at night to help me relax" C. "It takes me about 45 to 60 minutes to fall asleep" D. "I take the pain medication for my leg pain about 30 minutes before I go to bed" Answer: C Which of the following signs or symptoms in a patient who is opioid-naive is of greatest concern to the nurse when assessing the patient 1 hour after administering an opioid? A. Oxygen saturation of 95% B. Difficulty arousing the patient C. Respiratory rate of 12 breaths per minute D. Pain intensity rating of 5 on a scale of 0 to 10 Answer: B A patient has been on contact isolation for 4 days because of a hospital-acquired infection. He has had few visitors and few opportunities to leave his room. His ambulation is also still limited. Which are the correct nursing interventions to reduce sensory deprivation? (Select all that apply) A. Teaching how activities such as reading and using crossword puzzles provide stimulation B. Moving him to a room away from the nurses' station C. Turning on the lights and opening the room blinds D. Sitting down, speaking, touching, and listening to his feelings and perceptions E. Providing auditory stimulation for the patient by keeping the television on continuously Answers: A, C, D An older adult patient with bilateral hearing loss wears a hearing aid in her let ear. Which of the following approaches best facilitates communication with her? (Select all that apply) A. Talk to the patient at a distance so they may read your lips B. Keep your arms at your side; speak directly into the patient's left ear C. Face the patient when speaking; demonstrates ideas you wish to convey D. Position the patient so that the light is on their face when speaking E. Verify that the information that has been given has been clearly understood Answer: C & E A patient with progressive vision impairments had to surrender his driver's license 6 months ago. He comes to the medical clinic for a routine checkup. He is accompanied by his son. His wife died 2 years ago, and he admits to feeling lonely much of the time. Which of the following interventions reduce loneliness? (Select all that apply) A. Sharing information about senior transportation services B. Reassuring the patient that loneliness is a normal part of aging C. Maintaining distance while talking to avoid overstimulating the patient D. Providing information about local social groups in the patient's neighborhood E. Recommending that the patient consider making living arrangements that will put him closer to family or friends Answers: A, D, & E A patient who is on aspirin therapy for pain relief reports that there has been no change in the pain even after taking the drug. On assessment, the nurse finds that the patient has a history of a bleeding gastric ulcer and obstructive sleep apnea. Which immediate action would the nurse take? A. Add an opioid analgesic B. Stop the aspirin administration C. Increase the dose of aspirin D. Stop the aspirin and give ibuprofen Answer: B NSAIDs should not be given to a patient with a history of gastrointestinal bleeding or renal insufficiency. Therefore administration of aspirin should be stopped for this patient. Opioids should not be given to a patient with a history of obstructive sleep apnea because they cause respiratory depression. An 82-year-old man tells the nurse that he is having difficulty hearing and that he has "too much earwax." Considering the patient's age, which question would the nurse ask? A. "Have you ever experienced impacted earwax?" B. "Do you have an upper respiratory infection?" C. "Do you swim in a pool with chlorinated water?" D. "Have you noted a change in the color of the earwax?" Answer: A Obstruction of the ear is most often caused by impacted cerumen. In which situation would drug administration be considered palliative? A. Thyroid hormone replacement B. Pain management for a patient with terminal cancer C. Antibiotic therapy for a patient with a bacterial infection D. Iron supplements for the treatment of iron deficiency anemia Answer: B Palliative means to alleviate without curing; end-of-stage illness The patient rates his pain as a 6 on a scale of 0 to 10. The patient's wife says that he cannot be in that much pain because he has been sleeping for 30 minutes. Which resource is most accurate for assessing the pain? A. The patient's wife is the best resource for determining the level of pain because she has been with him continually for the entire day B. The patient's report of pain is the best method for assessing the pain C. The patient's health care provider has the best knowledge of the level of pain that the patient should be experiencing D. The nurse is the most experienced at assessing pain Answer: B The nurse explains patient-controlled analgesia (PCA) to a patient. If the patient has understood this information, which statement by the patient would be the most appropriate? A. The device reduces the risk of an overdose of medication B. The caregivers can operate the device if the patient is unable to do so C. The patient will be lying in a prone position during the procedure D. The patient will decide about the loading dose of the analgesic drug Answer: A A patient returning to the nursing unit after knee surgery is verbalizing pain at the surgical site. What is the nurse's first action? A. Call the patient's health care provider B. Administer pain medication as prescribed C. Check the patient's vital signs D. Asses the characteristics of the pain Answer: D Which assessment finding would indicate the patient needs airway suctioning? A. Coughing thick sputum only occasionally B. After nebulization, coughing up thin sputum C. Decreased independent ability to cough D. Clear lung sounds only after coughing Answer: C The nurse has to administer opioids to a female patient after a surgical procedure. Which condition may require special consideration before the administration of opioids? (Select all that apply) A. Breastfeeding B. Dialysis C. Respiratory Disease D. History of orthopedic surgery E. Chronic headache Answers: A, B, & C Which pulmonary manifestation would the nurse assess for in a patient with underlying left-sided heart failure? (Select all that apply) A. Paroxysmal nocturnal dyspnea B. Difficulty breathing C. Green-colored sputum D. Crackles in base lungs on auscultation E. Crackles in apex of lungs on auscultation Answers: A, B, & D Which phrase defines hypoxia? A. Inadequate tissue oxygenation at the cellular level B. Decreased amount of arterial oxygen C. Loss of extracellular fluid and reduced circulating blood volume D. Rapid removal of carbon dioxide faster than it is produced by cellular metabolism Answer: A A patient with a history of chronic obstructive pulmonary disease (COPD) is hospitalized with respiratory failure. Which laboratory value does the nurse assess to determine adequate oxygenation? A. Arterial blood gases (ABGs) B. Glyosylated hemoglobin A1c (HbA1c) C. Complete blood count (CBC) D. Comprehensive metabolic panel (CMP) Answer: A Paget disease -intraductal carcinoma in the breast -is cancer within the ducts of the breast. Goes from the ducts to spreading into the skin area Edema (peau d' orange) -Lymphatic obstruction produces edema. -This thickens the skin giving it a "pigskin", orange peel appearance on breast can be suggestive of breast cancer, requires further investigation Supernumerary nipple Small, extra nipple along the embryonic milk line; congenital defect, could be up to 8 nipples, but should recede into themselves Gynecomastia Excessive breast development in males; normal during adolescence and aging, benign (excess estrogen compared to testosterone) Dimpling/nipple retraction Nipple appears flatter, broader, underlying crater occurs when tumor is attacking the duct, which causes nipple to be pulled in Benign "fibrocystic" breast disease -Multiple tender masses that occur w/ numerous symptoms and physical findings: swelling/ tenderness, severe pain, lumpiness, cysts, nipple discharge, infection/inflammation -Nodularity occurs bilaterally -- firm, mobile, well demarcated, and rubbery like small water balloons Breast cancer -We all have certain tumor suppressor genes termed BRCA1 and BRCA2, women who inherit a mutation on one or both have a significantly increased risk of developing breast or ovarian cancer -Second major cause of death from cancer in women -White women have higher incidence of breast cancer than African American women starting at 45 years -Most common in upper outer quadrant -Usually found in women 30-80 years; increased risk across all ages until 80 years -Lifestyle factors: limiting alcohol consumption, maintaining healthy weight, exercise -Signs: Non-tender, hard, solitary, unilateral, 3D, dense, borders irregular & poorly delineated, grows constantly As cancer advances, firm or hard irregular axillary nodes, skin dimpling, nipple retraction, elevation, discharge Male breast cancer -Most often seen between age 60-70 -1% of breast cancers occur in men -No standard mammography; it is detectable by clinical symptoms: painless, palpable mass, hard, irregular, and non-tender -Nipple discharge may be an early warning sign Retraction and ulceration may also be present Mastitis -An inflammatory mass before abscess formation, hot, tender, hard, usually during first 4 months of breast feeding begins by blocked duct -Treated with rest, local heat and antibiotics Frequent nursing recommended to keep it empty Fibroadenoma -Benign tumors, self-detected in adolescence, solitary, non-tender mass is solid, firm, rubbery, freely movable, slippery, round (1-5 cm), usually not associated w/ lymphadenopathy but frequently painful -Diagnose by palpation, ultrasound and needle biopsy Lung examination (Inspect) Anterior-Posterior ratio -Normal outcome: 1:2 -Abnormal outcome: barrel chest, Pectus Carinatum "pigeon chest", funnel chest, clubbing from reduced oxygen in blood Lung examination (Palpate) Fremitus: -Patient says "1, 2, 3" repeatedly -Nurse uses ulnar part of the hand to feel the vibrations Normal outcome: vibration felt all the way down (indicated air) Abnormal outcome: vibration diminishes (indicates fluid) Lung examination (Percussion) Take palmar part of hand, place across the patient's chest -Middle finger of hand placed between the intercostal spaces, tap with opposite finger on the middle digit ----Normal outcome: Resonance heard across the lung fields (indicates air) ----Abnormal outcome: dull or diminished sounds across the lung fields (indicates fluid) Lung examination (Auscultation)- Anterior Technique: compare both sides with each other as you work your way down Lung examination (Auscultation)- Posterior Technique: compare both sides with each other as you work your way down Lung examination (Sounds) Normal sounds: clear, smooth -Adventitious/Abnormal Sounds: ---Crackles (rales): Abnormal lung sounds heard on inspiration ---Rhonchi: Low-pitched, musical snoring caused by airflow obstruction through secretions ---Wheezing: High-pitched, musical, squeaking, abnormal lung sounds Chronic Obstructive Pulmonary Disease (COPD) Lung disease that makes it difficult to breath, inflammation and obstruction of airflow inside of the lungs. Also, more mucous production --Risk factors: smoking = leading cause, second hand smoke, air pollution, age What does COPD include? emphysema, asthma, chronic bronchitis Emphysema characterized by enlargement (damage) of the alveoli distal to the bronchioles; causes breathlessness Asthma abnormal respiratory op condition associated w/ allergic hypersensitivity to certain inhaled allergens characterized by inflammation, bronchospasm, wheezing, and difficulty breathing Chronic bronchitis inflammation of the bronchi Pneumothorax (lung collapse) a collection of air in the pleural space between the lungs and the chest wall (med emergency) --Symptoms: sudden onset of sharp pain, one-sided chest pain and shortness of breath Atelectasis collapsed, shrunken, deflated sections of alveoli (area appears black in x-ray) Hypercapnia increased levels of CO2 in the blood ---Symptoms: dimmed sight, reduced hearing, drowsiness, confusion, headache, unconsciousness, sweating, shortness of breath, increased HR & BP ---COPD patients adapt to this b/c of their low levels of oxygen Pneumonia infection that inflames the air sacs in one or both lungs, which may fill w/ fluid; airspace disease and consolidation Lobar pneumonia: involving one or both lobes of the lung --Consolidation: solidification of portions of lung tissue as it fills up w/ infections exudate --Airspace opacity, lobar consolidation, interstitial opacities (opacity = lacking transparency/translucence) Tuberculosis (TB) airborne, infectious disease that affects lungs ---Symptoms: fever, chills, night sweats, loss of appetite, weight loss, and fatigue, nail clubbing Lung Cancer can be caused by gene mutations, smoking, radiation, viruses, cancer causing chemicals, obesity, hormones, chronic inflammation, lack of exercise Pleural effusion abnormal fluid between the layers of the pleura Pulmonary embolism a blockage of an artery in the lungs by a substance that has moved from elsewhere in the body through bloodstream ---Symptoms: shortness of breath, chest pain, and coughing up blood Respiratory Distress difficulty breathing Cardiac Examination (Inspection) Check for JVD Cardiac Examination (Palpate) across precordium (anterior chest) -Carotid artery one at a time, moderate strength bilaterally --Apical pulse ----Pulse points: Superficial temporal, facial, common carotid, brachial, radial, femoral, popliteal, posterior tibial, doralis pedis Cardiac Examination (Auscultation) note rate & rhythm, identify S1 & S2 (assess separately) --Aortic, Pulmonic, Erb's point, Tricuspid, Mitral Heart Sounds & meaings --S1 (lub): long compared to S2, in early systole by initial movement of the ventricles, abrupt arrest of blood flow as the AV valves close and early part of ejection --S2 (dub): shorter and higher pitched sound compared to S1, produced by reversal of blood flow in the aorta and pulmonary trunk and semilunar valves closure at the end of systole --S3: end of rapid ventricular filling in early diastole, shortly after S2 (lower frequency) --S4: after atrial contraction in late diastole, heard just before S1 Heart Sounds (normal) S1 & S2 S3 & S4 normal in kids and young adults Heart murmurs caused by turbulent blood flow and currents which sounds like a gentle blowing or swooshing sound that can be heard in chest wall --Conditions that can result in murmur: increases of blood flow velocity (such as w/ exercise), anemia (increase blood viscosity), regurgitation or incompetent valve Arrhythmias --Atrial flutter: rapid irregular rhythm --Ventricular flutter: a tachycardia affecting the ventricles with a rate over 250-350 beats/min --V-fib: when the heart quivers instead of pumping due to disorganized electrical activity in the ventricles. Jugular veins distention caused by right-side heart failure, pulmonary hypertension, tricuspid valve stenosis, superior vena cava obstruction, constrictive pericarditis Angina pectoris pressure-like discomfort tightness, squeezing, burning, heaviness lasting 3 -5 mins precipitated by activity and often resolves w/ rest Prinzmetal's or variant angina pressure-like discomfort often occurring at rest and early morning hours Acute coronary syndrome heaviness, viselike, pain, squeezing, crushing, tightness; localized pain lasting 20-30 mins to hours, does not resolve w/ rest Tetralogy of Fallot (Congenital birth defect) Four components: right ventricular outflow stenosis, ventricular septal defect, right ventricular hypertrophy, overriding aorta. Atrial Septal Defect (Congenital birth defect) Abnormal opening in the atrial septum resulting in left to right shunt of blood flow. Patent Ductus Arteriosus (Congenital birth defect) A channel that joins the left pulmonary artery to the aorta. This is normal in the fetus and usually closes spontaneously within hours of birth. Ventricular Septal Defect (Congenital birth defect) Abnormal opening in the septum between the ventricles Coarctation of the Aorta (Congenital birth defect) Severe narrowing of the descending aorta that results in increased workload on the left ventricle Regurgitation (valvular defect) blood vessel that does not close tightly and allows backflow of blood to leak back in Mitral regurgitation mitral valve doesn't close tightly ---Symptoms: shortness breath, chest pain, confusion, lightheadedness and tachycardia Aortic regurgitation aortic valve doesn't properly close, allows some of the blood that was pumped out to leak back in, PT feels fatigue and short of breath Pulmonic regurgitation pulmonary valve incompetent and allows backflow from the pulmonary artery to the right ventricles of the heart during diastole; sign = a murmur heard when the heart is between heart beats Tricuspid regurgitation valve doesn't close tightly, blood backflows into the right upper chamber when the right lower chamber contracts ---Symptoms: fatigue, swelling in ab, legs, or veins in neck, abnormal heart rhythms, and shortness of breath w/ activity Developmental competencies of Lungs --Costal cartilage becomes calcified and the thorax is less mobile --These changes result in an increase in small airway closure, which yields decrease vital capacity and an increased residual volume Developmental competencies of the Heart --Depends on lifestyle, habits, and disease --Hemodynamic changes: increase in systolic BP caused by thickening and stiffening of the large arteries, which creates an increase in pulse velocity --Dysrhythmias: the presence of supraclavicular and ventricular dysrhythmias increases with age --Electrocardiograms: ECG changes occur as a result of changes in the heart's conduction system: prolonged P-R interval, Q-T interval, QRS remains unchanged, the incidence of cardiovascular diseases increases --Culture & Genetics: causes include an interaction of genetic, environmental (pollution), and lifestyle factors (obesity, high BP, high cholesterol, diabetes, lack of exercise, alcohol, poor diet, smoking Abnormal developmental competencies --Alters appearance of the abdomen --Changes in GI system (constipation) --salivation decreases, esophageal emptying, and acid secretion delayed --incidence of gallstones increases, liver size decreases, drug metabolism impaired Signs of respiratory distress shortness of breath, fast breathing, coughing, wheezing, deep respirations, tripod position, blue skin from poor circulation, nose flaring, sweating Paroxysmal nocturnal dyspnea sudden awakening from sleeping, with shortness of breath Hyperventilation increased rate and depth of breathing Hypercapnia increase in CO2 in the blood Pulse grading system --0 no pulse --1+ diminished --2+ normal --3+ increased --4+ bounding pulse Risk factors of cardiac disease -Weight -Age -Family history -High blood pressure (HTN) -High cholesterol -Smoking Nursing consideration for Digoxin --HIGHLY toxic; hold if HR is less than 60beats/minute --Monitor BP periodically in patients receiving IV digoxin --Monitor ECG during IV administration and 6hr after each dose --Notify health care professional if bradycardia or new arrhythmias occur --Observe IV site for redness or infiltration; extravasation can lead to tissue irritation and sloughing --Toxicity: anorexia, nausea, vomiting and neurological symptoms How do you perform a breast exam? Interview: Begin by asking the right questions Equipment: small pillow, ruler marked in cm, pamphlet for BSE Physical Exam: Women is sitting up, facing you inspect both breast Lift each arm and palpate high in axillae and move firmly in every direction Have women lay in supine position cover one breast and palpate other w/ three fingers in rotary motion and then vertical zig zag motion, don't forget to go over nipple For documentation of findings - each breast is divided into 4 quadrants (UIQ, UOQ, LIQ, LOQ) What are the normal findings of a breast exam? --Skin: Symmetrical, slight asymmetry in size, skin is smooth and of even color w/ no redness, a fine blue vascular network normally visible in lightly pigmented women during pregnancy, pale linear striae, stretch marks, no edema --Lymphatic drainage areas: axillary or supraclavicular regions have no bulging, discoloration, or edema, nodes are non-tender, non-palpable --Nipple: symmetrically located, usually protrude although some can be flat/inverted since childhood What are the abnormal findings of a breast exam? --Skin: hyperpigmentation, redness, heat, inflammation, rash, edema, unilateral dilated superficial veins in non-pregnant women, dimpling/pucker --Lymphatic drainage areas: nodes enlarged, tender Nipple: recent nipple retraction, discharge, deviation in pointing How do you perform an abdominal assessment? Assessment; Inspection: --Look for lumps, bumps, bruising, cuts, incisions, etc. --Look at skin color and texture Auscultation: Performing: --Patient laying down with knees bent --Listen for bowel sounds in all four quadrants --Listen a minute- 5 minutes if you don't hear any --Begin in the right lower quadrant (RLQ), and move in sequence up to the right upper quadrant (RUQ), left upper quadrant (LUQ), and finally the left lower quadrant (LLQ). Percussion: --Tap middle joint of finger with opposite hand in all four quadrants What are the normal findings of an abdominal exam? No bruits heard over the aorta, renal arteries, iliac arteries, and femoral arteries. Percussion: Tympanitic sound Dull sounds are heard where solid viscera, fluid, or stool predominate is located Palpation: No pain, no tenderness No lumps or bumps (masses) felt No enlarged organs What are the abnormal findings of an abdominal exam? Rapid sounds = bowels are hyperactive Slow sounds = bowels are hypoactive Percussion: Resonance sound means air and gas trapped in the abdomen Palpation: Rebound tenderness (pain or tenderness when pressure is released from the abdomen)- often when patient has appendicitis How do you perform a musculoskeletal exam? What are the normal findings of the exam? Exam: Inspection Carefully inspect your patient, examining the symmetry of the joints, muscles, and bones and checking for swelling, redness, and ease of movement Palpation/Testing Performing: Over the joints, noting any areas of warmth or tenderness Testing muscle tests Muscles and Joints: Abduction, Adduction, Pronate, Supinate, Rotation, Protraction, Retraction, Elevation, Depression, Flexion (in), Extension (out) Movement Active- they do it themselves Movement Passive - you have to move the patient What are the normal findings of a musculoskeletal exam? Exam: Inspection Normal findings: No redness No swelling No stiffness or rigid movements Palpation/Testing Normal Findings: Full ROM - active or passive Temperature the same throughout the body What are the abnormal findings of a musculoskeletal exam? Abnormal Findings: Redness, swelling, stiffness, rigid movements Shuffling gate Abnormal Findings: Stiffness or limited ROM Tenderness or pain Dosage conversions 1 tbsp = 3 tsp 1 fl oz = 2 tbsp 1 cup = 8 fl oz 1 tsp = 5 mL 1 tbsp = 15 mL 1 fl oz = 30 mL 1 cup = 250 mL 1 L = 1,000 mL 1 mL = 1 cc 1 mL = 1,000 mcg Preload Is the venous return that builds during diastole (increased in hypervolemia, regurgitation of cardiac valves, and heart failure) Afterload Is the opposing pressure the ventricle must generate to one the aortic valve against the higher aortic pressure. It's the resistance against which the ventricle just pump blood (Increased in hypotension and vasoconstriction) (higher cardiac workload) Peripheral vascular disease is listening to carotid artery. 3 fingers for carotid artery to palpate & press in The Lymphatic system conserves fluid and plasma proteins that leak out of capillaries, form a major part of the immune system that defends the body against disease, and absorb lipids in the small intestine. (It protects the body!) Spleen destroys old RBC, produces antibodies, stores RBX, and filters microorganisms from the blood OA degenerative wear and tear 40 y/o LT pressure on joints affects one area/joint no associating factors RA autoimmune disorder 20 y/o unclear etiology widespread affects A/W fatigue and fever Mammogram --Annual mammograms recommended starting at age 40-54, every other year for patients over 55 --Can detect small, potentially curable cancers What is appropriate patient education for a BSE? And a mammogram? 1. Start by looking in the mirror in 3 positions: arms down by sides, hands on hips, and hands on head 2. Then touch breasts with tips of fingers in 3 motions: up & down, circles, and wedges, making sure to cover the entire breast 3. While lying down repeat touching motions 4. Lastly, make sure to check lymph nodes ----Best time is 3-5 days after the start of your period cause the breasts are likely to be less tender; encourage to do BSE at the same time every month for consistency. Can be performed in the shower. ---For post-menopausal women: do BSE on the same day every month for consistency