MATC NRSAD 102 EXAM 2 Questions And Answers Well Elaborated

General Survey - correct answers appearance, orientation, vital signs, height and weight inspection - correct answers visual, using naked or a lighted instrument, active process of knowing what to look for Flatness percussion sound - correct answers dull sound over bone or muscle Dullness on percussion - correct answers Thud like sound produced by dense tissue such as the liver, spleen or heart tympany percussion - correct answers drumlike sound over air filled spaces resonance - correct answers hollow sound over the lungs indirect percussion - correct answers Requires both hands and is done by different methods, depending on which body system is being assessed. direct percussion - correct answers involves striking a finger or hand directly against the patient's body Direct Ascultation - correct answers hearing sound out loud ( wheezing) Indirect ascultation - correct answers using a stethoscope hypopigmentation - correct answers Absence of pigment, resulting in light or white splotches.(vitiligo/albinism) hyperpigmentation - correct answers darkened areas of skin caused by excessive amounts of melanin(age spots) primary lesions - correct answers lesions arising from previously normal skin(ulcer or cut) secondary lesion - correct answers skin lesion that evolves from a primary lesion or that is caused by external forces, such as infection, scratching, trauma, or the healing process(scar) Macule - correct answers flat, colored spot on the skin (freckle) primary lesion Papules - correct answers Firm, raised areas such as pimples and the eruptions seen in some stages of chickenpox and syphilis.(primary lesion) Pustules - correct answers pus-filled sacs such as those seen in acne, or pimples(infection) primary lesion wheal - correct answers raised red skin lesion due to interstitial fluid(allergic reaction) primary lesion ulcer - correct answers open sore or lesion in the skin or mucous membrane(secondary lesion) turgor - correct answers Elasticity of the skin, should spring back to normal quickly, may be slower in older adults edema - correct answers Abnormal accumulation of fluid in interstitial spaces of tissues. alopecia - correct answers loss of hair hirutism - correct answers abnormal condition characterized by excessive growth of hair, especially in women spoon nails - correct answers iron deficiency anemia clubbing of nails - correct answers deformity of fingers and fingernails associated with underlying medical conditions or diseases that cause the finger tissue to increase and nails to curve downward Hyperresonance - correct answers lower-pitched, booming sound found when too much air is present such as in emphysema or pneumothorax cyanosis - correct answers bluish discoloration of the skin nailbed Nail pallor - correct answers white nail beds paronychia - correct answers infection around the nail / hangnail thick nails - correct answers poor circulation, older adults, chronic fungal infection Thin nails can be a sign of - correct answers Chronic Iron Deficient Anemia, presence of grooves of furrows moon face - correct answers edema in the face microcephaly - correct answers abnormally small head hydrocephalus - correct answers accumulation of fluid in the spaces of the brain globes eyes - correct answers bulging sunken eyes palpebral fissures - correct answers spaces between the eyelids, should be equal in size ectropion - correct answers outward turning of the rim of the eyelid entropion - correct answers inward turning of the rim of the eyelid ptosis - correct answers drooping eyelids Normal blinking rate - correct answers 15 - 20 times/min normal sclera - correct answers china white, blacks have a gray-blue or "muddy" color, in dark skinned people you normally may see small brown macules (like freckles) on the sclera, blacks have a yellowish fatty deposit beneath the lids (not jaundice) hyperopia - correct answers farsightedness myopia - correct answers nearsightedness presbyopia - correct answers impairment of vision as a result of old age (bifocals) nystagmus - correct answers involuntary, jerking movements of the eyes convergence - correct answers crossing of the eyes visual acuity - correct answers gross assesment of distant & close vision hearing acuity - correct answers normal voice tone, whisper with back turned Tragus of the ear - correct answers Cartilage projection anterior to the external opening of the ear mastoid process - correct answers round projection on the temporal bone behind the ear typmanic membrane - correct answers normal is clear, redness is infection lymph nodes - correct answers usually non-palpable tender, swollen nodes = inflammation hard, fixed nodes = malignancy respiratory distress - correct answers sitting in a tripod position kyphosis - correct answers excessive outward curvature of the spine, causing hunching of the back. lordosis - correct answers abnormal anterior curvature of the lumbar spine (sway-back condition) tactile fremitus - correct answers a tremulous vibration of the chest wall during speaking that is palpable on physical examination bronchial breath sounds - correct answers loud, high-pitched, hollow sounds normally heard over the trachea and the large bronchi Bronchovesicular - correct answers moderate blowing sounds heard over the major bronchi, heard between scapula and sternum at 1st and 2nd ICS vesicular breath sounds - correct answers soft, fine, breezy, low-pitched sounds heard over peripheral lung tissue, movement thru bronchoils and alveoli, best heard at the bases crackles or rales - correct answers clicking, rattling, or crackling noises that may be made by one or both lungs of a human with a respiratory disease during inhalation(CHF) Gurgles (rhonchi) - correct answers Continuous, low-pitched, coarse, gurgling, harsh, louder sounds with a moaning or snoring quality, can be cleared with coughing, heard on expiration wheezes - correct answers continuous, high-pitched squeak or musical sound made as air moves through narrowed or partially obstructed airway passages heard on expiration over all lung fields, asthma friction rub - correct answers grating or creaking sounds caused by inflamed pleural surfaces thrills - correct answers Vibration produced by turbulent blood flow within the heart (murmurs) bruit - correct answers abnormal blowing or swishing sound heard during auscultation of an artery or organ Thromobophlebitis - correct answers inflammation of a vein associated with a clot formation abdominal assessment preparation - correct answers • empty bladder • Keep room warm • supine, arms down; knees slightly bent, arms at sides • short nails, warm hands & stethoscope • ask about painful areas: do last • distraction peritoneum inspection - correct answers membrane that lines the abdominal cavity no bruits over arteries of friction rubs Joint Crepitation - correct answers crackling sound Ecchymosis - correct answers bruise bleeding under the skin exophthalmos - correct answers abnormal protrusion of the eyeball palpebral fissure - correct answers the elliptical open space between the eyelids Stereognosis - correct answers ability to recognize objects by feeling their form, size, and weight while the eyes are closed parasthesia - correct answers abnormal sensation such as numbness and tingling deep tendon reflexes (DTR) - correct answers involuntary muscle contraction in response to striking muscle tendon with reflex hammer; test used to determine whether muscles respond properly Positive Babinski sign - correct answers dorsiflexion of the big toe and fanning of all toes, may be a sign of a neurological problem Reflex Assessment Scale - correct answers Done bilaterally. Should be symmetrical. Rated 0 to +4 0=none +1=hypoactive (minimal) +2=normal +3=increased response +4=hyperactive (maximal activity) Glasgow Coma Scale (GCS) - correct answers a scale used to assess the consciousness of a patient upon physical examination, typically in patients with neurological concerns or complaints Romberg test - correct answers assesses ability of vestibular apparatus in inner ear to help maintain standing balance, negative romberg normal, positive romberg cannot maintain upright posture Neuro assessment older adult - correct answers Assessment may take longer- may need several sessions Learning & intelligence remain unchanged. Many factors, however, inhibit learning (anxiety, illness, pain, or cultural barriers) Less efficient short term memory More prone to stress & depression May fatigue easier Reflexes may be decreased or increased Slower reaction time Snellen chart - correct answers chart containing symbols that is used in the testing of visual acuity 20/20 is normal finding Common Deviations with the Older Adult's Eyes - correct answers lower visual acuity, especially near vision Drooping lids ↓skin elasticity ↓ tear production ↓ peripheral vision Weber's test results - correct answers Unilateral conductive hearing loss - sound localizes to affected ear Unilateral sensorineural hearing loss - sound localizes to unaffected ear Negative(no lateralization of sound) Rinne test - correct answers hearing test using a tuning fork; checks for differences in bone conduction and air conduction Common Ear Deviations with Older Adults - correct answers Loss of connective tissue causes external ear to be dryer and less resilient Earwax is drier Hearing loss occurs