NUR 568 STUDY GUIDE WITH
COMPLETE SOLUTION
Macule - ANSWER flat, colored spot on the skin <1CM
papule - ANSWER small, solid, raised lesion on surface of the skin <1CM
nodule - ANSWER solid, round or oval elevated lesion <1 cm in diameter
wheal - ANSWER small, round, raised area on the skin that may be
accompanied by itching; usually seen in allergic reactions
plaque - ANSWER a solid mass greater than 1 cm in diameter and limited to
the surface of the skin, common in psoriasis
patch - ANSWER a flat, discolored area on the skin larger than 1 cm
lymph nodes - ANSWER small oval clumps of lymphatic tissue located at
grouped intervals along lymphatic vessels
Should be regular, moveable
If hard and fixed could possibly be neoplasia
- Drainage- Submental, submandibular, tonsillar, drain to mouth, all others
drain externally
Rinne test - ANSWER hearing test using a tuning fork; checks for differences
in bone conduction and air conduction. AC>BC = normal
Weber - ANSWER tuning fork test that evaluates bone conduction of sound
in both ears at the same time. No lateralization= normal
,Cover/uncover test - ANSWER to detect strabismus; Cover one eye;
Watch the uncovered eye for a steady, fixed gaze.
Uncover the first eye and observe the uncovered eye for any movement
Normal aging process changes of the eyes and ears - ANSWER Normal aging
process changes of the ears
Hearing loss - should be gradual
progressive bilateral hearing loss, loss of high pitch- check for cerumen
impaction
Sensorineural loss: inner ear
Not visible
Rinne AC>BC normal, weber lateralized to good ear (inner ear
damage/cochlea damaged)
Higher registers lost, sound distorted, worse in noisy environments, voice is
loud
Cochlear nerve, neuronal transmission to brain
Normal aging process changes of the eyes
Vision loss
Lose ability to see up close, distinguishing colors that are similar, focusing
ability
Presbyopia
Glaucoma, dry eyes, age-related macular degeneration, cataracts, temporal
,arteritis
Allen test - ANSWER test that determines the patency of the radial and ulnar
arteries by compressing one artery site and observing return of skin color as
evidence of patency of the other artery
- Used for cardiac cath circulation tests
Cardiac auscultory areas - ANSWER Aortic A1<A2, 2nd R ICS; Pulmonic
P1<P2, 2nd L ICS;Erb's E1=E2, L 3rd ICS;Tricuspid T1>T2, L 4th ICS; Mitral
M1>M2; L 5th ICS
S1 and S2; what causes them; where are they heard loudest and why -
ANSWER S1 is systole- mitral and tricuspids close, loudest at the apex
S2 diastole, aortic and pulmonic close, loudest at the base
Point of maximal impulse (PMI), what if it's displaced - ANSWER Where
heartbeat is best palpable on chest wall; 5th intercostal space, midclavicular
line. Cardiomegaly - idiopathic, cardiomyopathy, congestive cardiac failure,
aortic regurgitation, mitral regurgitation, ventricular septal defect.
Right-sided tension pneumothorax
If on R side= dextrocardia
, Carotid pulse and heart sounds- how do these correspond to each other -
ANSWER When the apex impulse cannot be seen or felt, the pulsation of the
carotid artery can be used as a guide. A finger on the carotid artery will sense
the palpable arterial upstroke that immediately follows the first heart sound.
S1 is synchronous with the carotid pulse
normal lung sounds - ANSWER 1. Tracheal
Normally heard over the trachea and larynx. Should not be heard over the
lung fields.
2. Vesicular
Expected low-pitched sounds heard over the lung felds. Expected finding:
"Clear to auscultation."
3. Bronchovesicular
Over bronchioles and lungs.
Abnormal lung sounds - ANSWER Rales = fluid in the bases (LA)
Wheezing = asthma bronchial constriction (LA)
Rhonchi = large amount of secretion (midlung)
Stridor = obstruction in (UA) (croup or epiglottitis in children)
Pleural rubs= inflammation of pleura
Crackles= CHF, and Bronchitis
COMPLETE SOLUTION
Macule - ANSWER flat, colored spot on the skin <1CM
papule - ANSWER small, solid, raised lesion on surface of the skin <1CM
nodule - ANSWER solid, round or oval elevated lesion <1 cm in diameter
wheal - ANSWER small, round, raised area on the skin that may be
accompanied by itching; usually seen in allergic reactions
plaque - ANSWER a solid mass greater than 1 cm in diameter and limited to
the surface of the skin, common in psoriasis
patch - ANSWER a flat, discolored area on the skin larger than 1 cm
lymph nodes - ANSWER small oval clumps of lymphatic tissue located at
grouped intervals along lymphatic vessels
Should be regular, moveable
If hard and fixed could possibly be neoplasia
- Drainage- Submental, submandibular, tonsillar, drain to mouth, all others
drain externally
Rinne test - ANSWER hearing test using a tuning fork; checks for differences
in bone conduction and air conduction. AC>BC = normal
Weber - ANSWER tuning fork test that evaluates bone conduction of sound
in both ears at the same time. No lateralization= normal
,Cover/uncover test - ANSWER to detect strabismus; Cover one eye;
Watch the uncovered eye for a steady, fixed gaze.
Uncover the first eye and observe the uncovered eye for any movement
Normal aging process changes of the eyes and ears - ANSWER Normal aging
process changes of the ears
Hearing loss - should be gradual
progressive bilateral hearing loss, loss of high pitch- check for cerumen
impaction
Sensorineural loss: inner ear
Not visible
Rinne AC>BC normal, weber lateralized to good ear (inner ear
damage/cochlea damaged)
Higher registers lost, sound distorted, worse in noisy environments, voice is
loud
Cochlear nerve, neuronal transmission to brain
Normal aging process changes of the eyes
Vision loss
Lose ability to see up close, distinguishing colors that are similar, focusing
ability
Presbyopia
Glaucoma, dry eyes, age-related macular degeneration, cataracts, temporal
,arteritis
Allen test - ANSWER test that determines the patency of the radial and ulnar
arteries by compressing one artery site and observing return of skin color as
evidence of patency of the other artery
- Used for cardiac cath circulation tests
Cardiac auscultory areas - ANSWER Aortic A1<A2, 2nd R ICS; Pulmonic
P1<P2, 2nd L ICS;Erb's E1=E2, L 3rd ICS;Tricuspid T1>T2, L 4th ICS; Mitral
M1>M2; L 5th ICS
S1 and S2; what causes them; where are they heard loudest and why -
ANSWER S1 is systole- mitral and tricuspids close, loudest at the apex
S2 diastole, aortic and pulmonic close, loudest at the base
Point of maximal impulse (PMI), what if it's displaced - ANSWER Where
heartbeat is best palpable on chest wall; 5th intercostal space, midclavicular
line. Cardiomegaly - idiopathic, cardiomyopathy, congestive cardiac failure,
aortic regurgitation, mitral regurgitation, ventricular septal defect.
Right-sided tension pneumothorax
If on R side= dextrocardia
, Carotid pulse and heart sounds- how do these correspond to each other -
ANSWER When the apex impulse cannot be seen or felt, the pulsation of the
carotid artery can be used as a guide. A finger on the carotid artery will sense
the palpable arterial upstroke that immediately follows the first heart sound.
S1 is synchronous with the carotid pulse
normal lung sounds - ANSWER 1. Tracheal
Normally heard over the trachea and larynx. Should not be heard over the
lung fields.
2. Vesicular
Expected low-pitched sounds heard over the lung felds. Expected finding:
"Clear to auscultation."
3. Bronchovesicular
Over bronchioles and lungs.
Abnormal lung sounds - ANSWER Rales = fluid in the bases (LA)
Wheezing = asthma bronchial constriction (LA)
Rhonchi = large amount of secretion (midlung)
Stridor = obstruction in (UA) (croup or epiglottitis in children)
Pleural rubs= inflammation of pleura
Crackles= CHF, and Bronchitis
