question

culturally competence

answer

the caregiver understands and attend to the total context of the individuals situation, including awareness of immigration status, stress factors, and cultural similarities and differences

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Four parts of culturally competence

answer

1. cultural awareness 2. cultural knowledge 3. cultural skill 4. cultural encounter

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Ethnocentrism

answer

own way of life, values, beliefs is most desirable. So many view others with superiority.

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Cultural Assessment Process

answer

professional interactions, etiquette, perceptions of space/distance, and gender

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Cultural Assessment Content

answer

includes the cultural information gathered

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Culturally sensitive

answer

caregivers possess some basic knowledge of and constructive attitudes toward the diverse cultural populations found in the setting in which they are practicing

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Culturally appropriate

answer

the caregivers apply the underlying background knowledge that must be possessed to provide a given person

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Cultural characteristics

answer

learned at birth: usually aware of it- usually you go by what your family's culture is- but not always

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Universal Phenomenon

answer

no two cultures are alike, yet may be very similar. All people are born, live and die within a cultural context

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Leininger (Univ. Phen.)

answer

the culture is a culture of caring, and it may differ widley

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Differences (Univ. Phen)

answer

Differences occur because of religion, ethnicity, education, occupation, age, gender, region where they live, and region where you are born

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Subculture

answer

large groups of people within a culture (gender, ethnicity, religion, sexual preference and health related characteristics such as diabetes, heart disease, and diagnosis)

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Cultural Values

answer

Values: desirable or undesirable state of affairs

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Cultural Norms

answer

rules by which human behavior is governed, many times us not specifically articulated.

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Dominant Value Orientation:

answer

shared because of early life experiences- innate nature of humans, time dimension, purpose of life, relationship to others

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Human Nature

answer

basically good, basically evil, or mixed

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Destiny

answer

have little choice- genetic

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Harmony

answer

people exist with nature

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Matery

answer

are to overcome the environment, natural forces

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Culture in the past

answer

value long standing traditions, and value ancestors

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Culture in the present

answer

concerned with now, difficult to get to change lifestyle

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Culture in the future

answer

Progress and change, concerned with old fashioned health care providers

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Being (Purpose of life)

answer

spontaneous express of impulses, integral of existence

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Being in becoming (purpose of life)

answer

detachment, inner control, mediation, desire to realize the self

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Doing (purpose of life)

answer

active striving and accomplishment, externally applied standards

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Relationship with others (Lineal)

answer

ordered succession continuity, may seek help from family, and allow others to make decisions

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Relationship with others (collateral)

answer

group goals: family honor is more important than personal goal _amish, illness affects the whole group

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Relationship with others (individual)

answer

personal autonomy, independence, individuals make own health decisions

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Nuclear family

answer

husband, wife, and children

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Extended family

answer

nuclear family plus relatives, maybe even non biological relatives

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Blended family

answer

husband, wife, with blended children

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Communal family

answer

group of men, women and children

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Cohabitation family

answer

not legally married, sharing household and maybe children

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Siblings in western culture (our culture)

answer

siblings mean same biologic or adoptive or step parents

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Siblings in Asian cultures

answer

siblings mean children who were breastfed by the same woman

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Siblings in African cultures

answer

siblings may consider all people in a village as brother and sister

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Interviewing for health care needs: Basic questions

answer

1. What do you think caused your illness? 2. Why do you think your illness started when it did? 4. What do you think your illness does to you? 4. How severe is your illness 5. What are chief problems your illness has caused you? 6. What do you fear most about your illness 7. What kind of treatment do you think you should receive? 8. How do you hope to benefit from treatment?

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Religion and Spirituality

answer

concerned with mysteries of life, good and evil, birth and death, and pain and suffering

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Spirituality

answer

an effort to find meaning that arises from someones personal experiences to find meaning from someones life

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Religion

answer

An organized system of beliefs concerning the cause, nature, and purpose of the universe, especially the belief in or the worship of God or gods

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Assess the pt. for

answer

1. satisfaction with life 2. future plans 3. purpose for life 4. harmony between beliefs and cultures 5. family values 6. spiritual support system

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Needs assessment includes:

answer

1. privacy for prayer 2. special foods 3. spiritual distress

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Assess for nurse: Own spirituality:

answer

helps to gain and maintain the necessary spirituality to help patients face spiritual crisis

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First developmental Stage of Faith

answer

Intuitive- projective faith: early childhood imagination, perception, and feelings, involves positive and negative powers

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Second developmental Stage of Faith

answer

Mythic-Liberal Faith: beyond development of logical thinking- understand world order and meaning of life

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Third developmental Stage of Faith

answer

Synthetic-Conventional Faith: adolescence and beyond- personal, mostly reflective, values and beliefs, relies on conventional belief systems

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Fourth developmental stage of faith

answer

Individualistic-reflective faith: young adulthood and beyond- critical reflection on values and beliefs, understanding of self and social system, choice made about ideology and life-style

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Fifth developmental stage of faith

answer

Conjunctive Faith: mid-life and beyond- realizes multiple interpretations of reality, reinterpretation of life and appreciation of symbols, metaphors, and myths to understand truth

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Sixth developmental stage of faith

answer

Universalizing Faith: mid-life and beyond- oneness with the power of being, devotes self to overcoming oppression and division

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Formal Interviewing

answer

a specific list of questions (health history)

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Informal interviwing

answer

less formal, not a list, just some questions

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Open ended questions

answer

more for them to say- longer responses

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closed endeed questions

answer

yes or no answers- short answers

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Empathy

answer

try not to ask why- reflect on what they say "my mom ignores me" "she ignores you"?

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medical Jarvin

answer

don't use too much medical terminology because not everyone understands- try to explain things to them in the simplest terms possible- and make sure they understand.

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What do you end an interview with?

answer

Can I get you anything before leaving, or talk about anything with you?

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Example of subcultures

answer

catholics, school of nursing, sororities

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What does our culture view health as?

answer

the absence of disease

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Philosophy of life

answer

personal goals and beliefs

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Beware of messages you send to pt:

answer

you're busy, disinterested, or making poor eye contact

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When interviewing a pt you should:

answer

take your time, act interested, and make good eye contact

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Nonverbal communication when interviewing the pt:

answer

posture, physical appearance, gestures, facial expressions, eye contact, and tone of voice

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3 parts of Philosophical stance

answer

1. goodness of fit in nursing: (generally liking people, and accepting peoples weaknesses and strengths, being optimistic about people) 2. Empathetic: viewing from others frame of reference, but remain true to own self, understanding from other's frame of reference 3. Ability to listen: note what they are saying, and not what is being said

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Interviewing environment

answer

1. privacy: confidentiality 2. Avoid interruptions if possible 3. Physical enviroment: room temp, good lighting, reduce noise, avoid clutter, note taking

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Things to be careful with when interviewing pt.

answer

1. providing false assurance 2. authority- taking down on pt. 3. using avoiding language- acting like you don't want to talk about what they want to 4. Talking too much 5. using why questions 6. Biased questions: "you're not like those ther teen-agers are you"

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What is the oral cavity divided into?

answer

the mouth, and the vestibule

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Vestibule

answer

the space between the buccal mucosa and the outer surface of the teeth and gums

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Mouth

answer

the anterior opening of the oral pharynx

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Roof of the mouth

answer

the bony arch of hard palate and fibrous sofy palate

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Uvula

answer

hangs from posterior margin of the soft palate

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What is the tongue anchored down to the mouth by?

answer

the frenulum

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Dorsal surface of the tongue is covered by?

answer

thick mucous membrane- and supports the filiform papillae

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Ventral surface of tongue

answer

visible veins, thin mucous membrane with ridges

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Gingiva

answer

fibrous tissue covered by mucous membrane- attached directly to alveolar surface

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How many adult teeth do we have?

answer

32 teeth

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Tonsils

answer

sit in between cavity and collect cellular debris, and other debris

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Salvation

answer

increases by 3 months- they drool until they learn how to swallow

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History for mouth:

answer

Present: dental problems, mouth lesions, sore throat, difficulty swallowing Past: hypertension, diabetes, bleeding disorder, throat infections, strep Personal care: oral care patterns, last dental appt, condition of teeth, dentures, crowns, etc. history of mouth cancers

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Exam

answer

inspect and palpate

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Lips (exam)

answer

get lip stick off, look for symmetry, edema, lesions

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Teeth (exam)

answer

close mouth, ask to clench teeth, upper incisors should override lower, look at color and condition, check for mobility and count

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Gingiva (exam)

answer

pink to coral, hypertrophy, reddened swelling, pockets of debris,

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Tongue

answer

symmetry and movement, color pink,

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Infants and Children

answer

-drooling is common up to 1 years old, should not extend over 2 years old -tongue should fit into floor of mouth and be midline -buccal mucosa should be pink without lesions

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Koplik

answer

small blue dots in children mouth- usually a sign of onset of measles

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Leukoplakia

answer

chalky white on the tongue

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Nose

answer

indication of odors

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allergic solute

answer

happens from wiping their nose up because they have snot running out their nose

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apnoids

answer

when these get plugged it sounds like they have a cold all the time because air can't get through- sometimes need to get removed

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When expecting nose

answer

be careful because the nose is tender and bleeds easily

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What you examine on the nose

answer

-look at placement on the face -size, shape, and color -discharge, and describe the discharge -inspect inside the nose with penlight -nasal mucosa: color, discharge, masses, lesions, swelling

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Redness in the nose indicated?

answer

infection

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Nasal Septum (exam)

answer

close to the midline and straight asymmetry

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Sinuses (exam)

answer

-inspect for redness or swelling -palpate zygomatic process for tenderness -hang head forward for tenderness or sinus pressure

question

Transilluminate

answer

-dark room: use a light to see if you can see through sinuses are plugged

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Infants and children (nose exam)

answer

-symmetry -unusual shapes can indicate congenital anomalies -inspect inner nose * obligatory nose breathers

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Alimentary Tract

answer

27 feet long- extends from mouth to anus

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What does the alimentary tract consist of?

answer

mouth, esophagus, stomach, small intestine, large intestine

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What is the function of the large intestine?

answer

ingest and digest food, absorb nutrients electrolytes and water, and excrete waste products

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Peristalsis

answer

moves products of digestion along and is under autonomic control

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Esophagus

answer

long, collapsible, and connects pharynx to the stomach

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Stomach

answer

flask shaped, lies transversely in upper abd. cavity- below the diaphragm

question

Three sections of the stomach

answer

1. Fundus: above and left of cardiac orifice 2. Body: mid 2/3 3. Pylorus: most distal portion narrows and terminated in pyloric orifice

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Small intestine (where it starts)

answer

begins at pyloric orifice

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Duodenum

answer

-forms a C around the head of the pancreas -common duct and pancreatic duct open into duodenum

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Jejunum

answer

- gradually becomes larger and thicker

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Ileum

answer

ileocecal valve between the ileum and large intestine- prevents back flow of fecal matter

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What happens in the small intestine?

answer

-Digestion is completed here through action of pancreatic enzymes, bile and several small intestine enzymes -nutrients are absorbed through walls of small intestine- the surface area is increased through circular folds and villi

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Where does large intestine begin?

answer

cecum

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Ascending colon

answer

beings at cecum and continues to the right post abdomen wall to the under surface of the liver- hepatic flexure

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Transverse colon

answer

crosses the abdomen cavity toward the spleen, where i flexes downward- splenic flexure

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Descending colon

answer

continues along abdomen wall to the rim of the pelvis- turns medially inward to form the S shape sigmoid colon

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Rectum

answer

extends from the sigmoid colon to the muscles of the pelvic floor and continues as the anal canal

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Liver (where is it located)

answer

upper right quadrant of the abdomen- below the diaphragm- surrounds the gallbladder, stomach and colon-

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What is the heaviest organ in the body?

answer

liver

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Liver (function)

answer

- stores several vitamins and iron -metabolizes carbohydrates, fats, protein -produces antibodies and substances for blood coagulation -produces most of proteins that circulate in the plasma

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Gallbladder (function)

answer

stores bile from the liver

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Pancreas (location)

answer

lies behind and beneath the stomach

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Pancreas (function)

answer

-pancreatic enzymes help to break down proteins, fats, and carbohydrates -insulin and glucagon regulate the body's level of glucose

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Spleen (location)

answer

upper quadrant above the left kidney, and below the stomach

question

Spleen (function)

answer

-white pulp: lymphoid tissue which comprimses most of the organ -red pulp: capillary network and allows for storage and release of blood

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Kidney (location)

answer

- extends from vertebral level of T 12 to L3 - right kidney is lower than left (because of liver)

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Kidney (function)

answer

produces renin, which controls aldosterone secretion

question

Order of exam for Abdomen

answer

1. inspection 2. auscultation 3. percussion 4. palpation

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Bowel sounds

answer

high pitched sounds- should hear 5-35 sounds per minute

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ARIF (vascular sounds)

answer

aortal, renal artery, ilial artery, femoral artery

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History (abdomen exam)

answer

HPI: abdomen pain, indigestion, vomiting, fecal incontinence, jaundice, urinary frequency etc.

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Personal and Social hirsory (abdomen)

answer

-24 hr dietary recall -recent stressful life events -exposure to infectious disease -trauma, physical activity, work, or abuse -street drugs

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Infant history (abdomen)

answer

-jaundice -vomiting -enlarged abdomen

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Inspection for abdomen

answer

-skin: color, scars, dilated veins, rashes, lesions -Color changes: jaundice, cyanosis, silvery white -lesions: nodules may indicate lymphoma

question

Auscultation for abdomen

answer

-bowel sounds -vascular sounds (use bell)

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Percuss for abdomen

answer

-percuss four quadrants for tymphany -percuss liver (start below umbilicus and move up, then in thorax move down) - should be 6-12cm

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Palpation for abdomen

answer

- feel muscle tone and tenderness -check for masses on abdomen

question

Rebound pain

answer

when you push down on the pain, pain will decrease, when you let go pain will intensify agai

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Positive Blumberg

answer

sharp stabbing pain at site of peritoneal tenderness

question

Positive Mcburney

answer

-lower abdomen -usually a diagnostic for appendicitis

question

Iliopsos muscle test

answer

1. hand on lower rt. thigh and ask pt to raise and flex thigh 2. pt on left, raise rt. let while examiner resists 3. pt on rt hyperextended leg by drawing backwards -if positive will cause lower right quadrant pain

question

Obturator muscle test

answer

use when you suspect appendix or pelvic abscess

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Examination techniques

answer

1. inspection 2. palpation 3.percussion 4. auscultation

question

Inspection

answer

observation-first step -subjective questions first -inspect only what you need to inspect -explain the reason why you are doing something

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Palpation

answer

uses hands and fingers to find out information -mobility: elasticity of skin, and tugor (dehydration of skin) -check temperature of the body

question

Light Palpation

answer

about 1 cm

question

Deep Palpation

answer

about 4 cm

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Bimanual

answer

putting one hand behind and one hand in front and push your hands together- assess kidneys or ovaries

question

Percussion

answer

the action is in the wrist -middle finger is only finger that should be touching, and use it like a "hammer" hit a couple times and move over

question

Tymphany (percussion)

answer

stomach or intestine: usually loud cause it is filled with air

question

Resonance

answer

when hitting down between the ribs, this is the normal sound you will hear

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Dullness (percussion)

answer

usually over an organ- should be a dull sound

question

Flatness (percussion)

answer

usually over a muscle or bone

question

Direct percussion

answer

just one finger on one area, such as the sinuses

question

Indirect percussion

answer

one finger over more than one area

question

Auscultation

answer

use a stethoscope to hear sounds -bell: to hear low pitch sounds -diaphragm: to hear high pitch sounds

question

Things you listen to for auscultation

answer

heart sounds, lung sounds, bowel sounds, vascular sounds

question

Calories (% of food groups)

answer

-50% calories should be carbohydrates -20% calories should be protein -30& calories should be fat

question

How much of our body is made up of water?

answer

55-65%

question

BMI

answer

body mass index -18.5-24.9 is normal weight -25 or over is considered overweight

question

What is the largest organ in our body?

answer

our skin

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Skin (function)

answer

-elastic and mobile -provides mechanic barrier, and regulates body temperature -retards body fluid loss -protects against microbial and foreign substance invasion

question

Conduction

answer

warmer area to cooler area- loss of heat such as our warm bodies going into a cool bed

question

Skin Function

answer

produced vitamin D repairs wounds excretes sweat, urea, and lactic acid expresses emotions

question

Epidermis

answer

outside of the skin

question

Dermis

answer

separates epidermis from the subcutaneous tissue - elastin in this layer (as we get older we lose this) -sensory fibers (pain, touch, and temperatures)

question

Hypodermis

answer

eccrine sweat glans- regular body temo made up of loose connective tissue

question

Xerosis

answer

dry skin- skin doesn't get enough hydration

question

What does the color of your hair depend on?

answer

How many melanocytes - the darker the hair, the more melanocytes

question

Three stages of hair growth

answer

1. anagen- growth 2. catagen- atrophy 3.telogen- rest

question

What are your nails made up of?

answer

Epidermal cells that get turned into hard plates of keratin cells

question

Perincia

answer

enlargement, pain, lesions of fingers

question

What is the fine hair on babies called?

answer

lanugo

question

petechia

answer

more than .5 diameter- children's eyes or throat -nonblanchable, intravascular defects and infections

question

Purpura

answer

less than .5 diameters -nonblanchable, intravascular defects and infections

question

Ecchymosis

answer

size variable -nonblanchable, vascular wall destruction, trauma, vasculitis -brusing

question

Spider Angioma

answer

Blanch with pressure

question

Venous star

answer

Nonblanching

question

Telangiectasia

answer

-fine, irregular, dilated capillaries

question

Capillary Hemangioma

answer

red irregular macular patches

question

Primary lesions

answer

occurring as initial manifestations many times of a pathologic process

question

Secondary lesions

answer

something of that pathologic lesion changes-scratch it and it becomes infected it then becomes secondary

question

Characteristics of lesions

answer

measure(diameter), shape, color, texture, elevation

question

Exudates from lesions

answer

color, amount, consistency,

question

Pattern of Arrangement of lesions

answer

annular rings, grouped, linear, arciform (bow shaped), diffuse, zosteriform (on a nerve path)

question

Location and Distribution of lesions

answer

generalized, localized, region of body, discrete, confluent

question

Border or margin of lesions

answer

discrete, indistinct, active, irregular, advancing

question

Thorax

answer

thorax cage of bone, cartilage, and muscles move as lung expands

question

Anterior portion

answer

-sternum -manubrium -xyphoid process -costal cartilage

question

Lateral portion

answer

12 pairs of ribs

question

Posterior portion

answer

12 thoracic vertebrae -all 12 ribs are attached to vertebrae

question

Primary muscles of respiration

answer

Diaphragm and intercostals

question

Interior chest- three major spaces

answer

1. right left pleural cavities 2. pleural cavities lined with pariteal and visceral pleura 3. serous membrane that encloses the lungs

question

Trachea

answer

lies anterior to esophagus

question

Coryza

answer

another word for a cold

question

History (respiratory)

answer

-do they have a cough?(productive, wet, dry) -are they coughing anything up?(color, texture) -whooping cough?(sounds like a bark)

question

Cheyne Stoke

answer

caused by CHF, and brain damage -breath regular and then stop breathing for 10-15 seconds, and then start breathing regular again

question

Biot's Respirations

answer

Similar to cheyne stoke, but the breathing pattern is irregular

question

adventitious sounds

answer

sounds you should NOT be hearing in the lungs

question

Bronchi

answer

snoring sounds in lungs -take a deep breath and cough for me (if it canbe cleared than thats a good sign, if not then theres a problem

question

Wheezing

answer

inflammation of the lungs

question

Bronchovesicular

answer

equal inspiration and expiration

question

Crackel

answer

caused by small airway with sticky exudate- or liquid in lungs

question

Bronchophony

answer

99 is spoken- sound should decrease the further down your back you go

question

Whisper pectoriloquy

answer

99 whispered- sound should decrease the further down the back you go

question

Obligate nose breather (age)

answer

age 1

question

Egophony

answer

E- spoken if it sounds more like an A than there is a problem

question

Kussmaul

answer

rapid deep breathing -metabolic acidosis

question

Ataxic

answer

varying depths, and irregular, not organized

question

Air trapping

answer

not time for sufficient expirations- especially with increase respiration rate- becomes shallow

question

Dyspnea onset of 10 P's

answer

1. pneumonia 2. pneumothorax (collapsed lung) 3. pulmonary constriction (asthma) 4.Peanut=foreign body 5. pulmonary embolism (blockage in pulmonary artery) 6.pericardial tamponade (heart can't pump enough blood) 7. pump failure 8. peak seekers 9. psychogenic (psychological cause) 10. posions

question

Collapsed lung

answer

extra pleural air, fluid, or mass

question

Auscultation is characterized by

answer

1. intensity: loud, soft 2. pitch: low, high, med high 3. quality: sonorous, musical, crackling 4. duration: long, short -Listen for complete inspiration and expiration

question

What is the sequence of techniques used during an examination of the abdomen? a: percussion, inspection, palpation, auscultation b: inspection, palpation, percussion, auscultation c: inspection, auscultation, percussion, palpation d: auscultation, inspection, palpation, percussion

answer

C: inspection, auscultation, percussion, palpation

question

Which of the following can be noted through inspection of a patient's abdomen? a: fluid waves and abdominal rigidity b: umbilical eversion and Murphy's sign c: venous pattern, peristaltic waves, and abdominal contour d: peritoneal irritation, general tymphany, and peristaltic waves

answer

C: venous pattern, peristaltic waves, and abdominal contour

question

Right upper quadrant tenderness may indicate pathology in the: a: liver, pancreas, or ascending colon b: liver and stomach c: sigmoid colon, spleen, or rectum d: appendix or ileocecal valve

answer

A: liver, pancreas, or ascending colon

question

Hyperactive bowel sounds are: a: high-pitched b: rushing c: tinkling d: all of the above

answer

D: all of the above

question

The absence of bowel sounds is established after listening for: a: 1 full minute b: 3 full minutes c: 5 full minutes d: none of the above

answer

C: 5 full minutes

question

Auscultation of the abdomen may reveal bruits of the _______ arteries: a: aortic, renal, iliac, and femoral b: jugular, aortic, carotid, and femoral c: pulmonic, aortic, and portal d: renal, iliac, internal jugular, and basilic

answer

A: aortic, renal, iliac, and femoral

question

The normal range of liver span in the right midclavicular line in the adult is: a: 2-6 cm b: 4-8 cm c: 8-14 cm d: 6-12 cm

answer

D: 6-12 cm

question

The left upper quadrant contains the: a: liver b:appendix c: left ovary d: spleen

answer

D: Spleen

question

A female patient has striae on the abdomen. Which color indicates ling-standing striae? a: pink b: blue c: purple-blue d: silvery white

answer

D: silvery white

question

Auscultating the abdomen is begun in the right lower quadrant because: a: bowel sounds are always present here b: peristalsis through the descending colon is usually active c:this is the location of the pyloric sphincter d: vascular sounds are best heard in this area

answer

A: bowel sounds are always present here

question

A dull percussion note forward of the left midaxillary line is: a: normal; an expected finding during splenic percussion b:expected between the 8th and 12th ribs c: found is the examination follows a large meal d: indicative of splenic enlargement

answer

D: indicative of splenic enlargement

question

Shifting dullness is a test for: a: ascites b: splenic enlargement c: inflammation of the kidney d: hepatomegaly

answer

A: ascites

question

Tenderness during abdominal palpation is expected when palpating the: a: liver b: spleen c: sigmoid colon d: kidneys

answer

C: sigmoid colon

question

A positive Murphy's sign is best described as: a: the pain felt when the examiner;s hand is rapidly removed from an inflamed appendix b: pain felt when taking a deep breath when the examiners fingers are on the approximate location of the inflamed gallbladder c: a sharp pain felt by the patient when one hand of the examiner is used to thump the other at the costovertebral angle d: this is not a valid examination technique

answer

B: pain felt when taking a deep breath when the examiners fingers are on the approximate location of the inflamed gallbladder

question

A positive Blumberg sign indicates: a: possible aortic aneurysm b: presence of renal artery stenosis c: enlarged, nodular liver d: peritoneal inflammation

answer

D: peritoneal inflammation

question

What are the three types of normal breath sounds?

answer

Bronchial, Bronchovesicular, and Vesicular

question

The manubriosternal angle is: a: the articulation of the manubrium and the body of the sternum b: a hollow, U-shaped depression just above the sternum c: also known as the breastbone d: a term synonymous with costochondral junction

answer

A: the articulation of the manubrium and the body of the sternum

question

Select the correct description of the left lung: a: narrower than the right lung with three lobes b: narrower than the right lung with two lobes c: wider than the right lung with two lobes d: shorter than the right lung with three lobes

answer

B: narrower than the right lung with two lobes

question

You assess a patient who reports a cough. The characteristic timing of the cough of chronic bronchitis is described as: a: continuous throughout the day b: productive cough for at least three months of the year for two years in a row c: occurring in the afternoon or evening because of exposure to irritants at work d: occurring early in the morning

answer

B: productive cough for at least three months of the year, for two years in a row

question

Which of the following assessments best confirms symmetric check expansion?

answer

Placing hands on the posterolateral chest wall with thumbs at level of T9 and T10 and then sliding the hands up to pinch a small fold of skin between the thumbs

question

Absence of diaphragmatic excursion occurs with: a: asthma b:an usually thick chest wall c:pleural effusion or atelectasis of the lower lobes d: age-related changes in the chest wall

answer

C: pleural effusion or atelectasis of the lower lobes

question

You are auscultating breath sounds on a patient. Whats the procedure to do so?

answer

Hold the diaphragm of the stethoscope against the chest wall; listen to one full respiration in each location, being sure to do side to side comparisons

question

Select the best description of bronchovesicular breath sounds: a: high-pitched, of longer duration on inspiration than expiration b:moderate-pitched, inspiration equal to expiration c: low-pitched sounds, inspiration greater than expiration d: rustling sounds, like the wind in trees

answer

B: moderate-pitched, inspiration equal to expiration

question

After examining a patient you make the following notation: increased respiratory rate, chest expansion decreased on left side, dull to percussion over left lower lobe, breath sounds louder with fine crackles over left lower lobe. These findings are consistent with: a: bronchitis b: asthma c: pleural effusion d: lobar pneumonia

answer

D: lobar pneumonia

question

Pleural Effusion

answer

excess fluid that accumulates in the pleural cavity, the fluid-filled space that surrounds the lungs. This excess can impair breathing by limiting the expansion of the lungs

question

On examining a patient's nails, you note that the angle of the nail base is >160 degrees and the nail base feels spongy to palpation. These findings are consistent with: a: acute respiratory distress syndrome b: normal findings for the nails c: congenital heart disease and COPD d: atelectasis

answer

C: congenital heart disease and COPD

question

Atelectasis

answer

partial or complete collapse of the lung.

question

On auscultating a patient you note a coarse, low-pitched sound during bother inspiration and expiration. The patient reports pain with breathing. These findings are consistent with: a: fine crackles b: wheezes c: atelectatic cracks d: pleural friction rub

answer

D: pleural friction rub

question

To use the techniques if egophony, ask the patient to: a: take several deep breaths and then hold for 5 seconds b: say "eeeee" each time the stethoscope is moved c: repeat the phrase "99" each time the stethoscope is moved d: whisper a phrase as auscultation is performed

answer

B: say "eeee" each time the stethoscope is moved

question

When examining for tactile fremitus, it is important to: a: ask the patient to breath quickly b: ask the patient to cough c: palpate the chest symmetrically d: use the bell of the stethoscope

answer

C: palpate the chest symmetrically

question

Tactile(touch) fremitus

answer

Fremitus refers to vibratory tremors that can be felt through the chest by palpation.

question

Pulse oximetry means: a: arterial oxygen saturation of hemoglobin b: venous oxygen saturation of hemoglobin c: combined saturation of arterial and venous blood d: carboxyhemoglobin levels

answer

A: arterial oxygen saturation of hemoglobin

question

A pleural friction rub is best described by: a: observation b: palpation c: auscultation d: percussion

answer

C: auscultation

question

A patient has a barrel-shaped chest, characterized by: a: equal anteroposterior transverse diameter and ribs being horizontal b: anteroposterior transverse diameter of 1:2 and an elliptic shape c: anteroposterior transverse diameter of 2:1 and ribs being elevated d: anteroposterior transverse diameter of 3:7 and ribs sloping back

answer

A: equal anteroposterior transverse diameter and ribs being horizontal

question

Apex

answer

3-4 cm above the inner third of the clavicles

question

Base

answer

rests on the diaphragm

question

Lateral Left

answer

sixth rib, midclavicular line

question

Lateral Right

answer

fifth intercostal

question

Posterior apex

answer

C7

question

Normal chest

answer

Elliptic shape with an anteroposterior to transverse diameter in the ratio of 1:2

question

Barrel chest

answer

Anteroposterior= transverse diameter

question

Pectus excavatum

answer

Sunken sternum and adjacent cartilages

question

Pectus carinatum

answer

Forward protrusion of the sternum with ribs sloping back at either side

question

Scoliosis

answer

Later S-shaped curvature of the thoracic and lumbar spines

question

Kyphosis

answer

Exaggerated posterior curvature of the thoracic spine

question

The concept of health and healing has evolved over the years. What is the best description of health?

answer

Health depends on the interaction of mind, body, and spirit within the environment

question

What would be included in the database for a new patient admission to a surgical unit?

answer

all subjective and objective, and data gathered from a patient and the results of any laboratory or diagnostic studies completed

question

A patient is in the emergency room with nausea and vomiting. What would you include in the database?

answer

a diet and GI history

question

A patient recently received health insurance and would like to know how often he should visit his provider. How to you respond?

answer

" your visits may vary, depending on your level of wellness"

question

You are reviewing concepts related to steps in the nursing process for determining prioritization and developing patient outcomes. To what are these actions attributed? a: planning b: assessment c: implementation d: diagnosis

answer

A: Planning

question

What is a risk diagnosis?

answer

identifying potential problems the individual may develop

question

What would be included in a holistic model of assessment?

answer

A patient's perception of her or her health status

question

PERIOTINITIS

answer

P-Pain E-Electrolytes R-Ridgity/rebound I- immobile T- Tenderness O-Obstruction N- Nausea and vomiting I- incrrease in pulse/decrease BP T- Temperature I- Increased girth S- silent abdomen

question

PQRSTU

answer

P-Palliative/Provocative Q-Quantity/Quality R-Region S- Severity T-Temporal U-You

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