NSG6420 Week 1 to Week 9 Quiz, NSG6420 Week 5 Midterm Quiz (5 versions): Answers Marked and Explained The major impact of the physiological changes that occur with aging is: Student Answer: Reduced physiological reserve Reduced homeostatic mechanisms Impaired immunological response All of the above Instructor Explanation: The major impact of all of these physiological changes can be highlighted with three primary points. First, there is a reduced physiological reserve of most body systems, particularly cardiac, respiratory, and renal. Second, there are reduced homeostatic mechanisms that fail to adjust regulatory systems such as temperature control and fluid and electrolyte balance. Third, there is impaired immunological function: infection risk is greater, and autoimmune diseases are more prevalent. (Kennedy-Malone 3) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. Points Received: 2 of 2 Comments: Question 2. Question : Men have faster and more efficient biotransformation of drugs and this is thought to be due to: Student Answer: Less obesity rates than women Prostate enlargement Testosterone Less estrogen than women Instructor Explanation: Men have faster and more efficient biotransformation, presumably because of serum testosterone. Conditions of increased or decreased liver perfusion alter the overall level of the drug that is absorbed and how it is metabolized. (Kennedy-Malone 5) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. Points Received: 2 of 2 Comments: Question 3. Question : The cytochrome p system involves enzymes that are generally: Student Answer: Inhibited by drugs Induced by drugs Inhibited or induced by drugs Associated with decreased liver perfusion Instructor Explanation: Biotransformation occurs in all body tissues but primarily in the liver, where enzymatic activity (cytochrome P [CYP] system) alters and detoxifies the drug and prepares it for excretion. (Kennedy-Malone 5) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. Points Received: 2 of 2 Comments: Question 4. Question : Functional abilities are best assessed by: Student Answer: Self-report of function Observed assessment of function A comprehensive head-to-toe examination Family report of function Instructor Explanation: Two well-established tools used to evaluate function in older adults are the Katz Activities of Daily Living Scale (Katz et al., 1963) and the Lawton and Brody scale for Instrumental Activities of Daily Living (Lawton & Brody, 1969). It is important to be cautious about self-report of function (rather than direct observation of function) and to ask, “Do you …?” instead of “Can you …?” in order to determine if patients actually perform the activity. (Kennedy-Malone 40) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. Points Received: 2 of 2 Comments: Question 5. Question : Iron Deficiency Anemia (IDA) is classified as a microcytic, hypochromic anemia. This classification refers to which of the following laboratory data? Student Answer: Hemoglobin and Hematocrit Mean Corpuscular Volume (MCV) and Mean Corpuscular Hemoglobin (MCH) Serum ferritin and serum iron Total iron binding capacity and transferrin saturation Instructor Explanation: RBC indices reveal an MCV (mean corpuscular volume/RBC size) that will be decreased to <80 fL in adults; MCH (mean corpuscular hemoglobin/RBC color) will show hypochromia or pale cells; RBC distribution width (RDW)/volume variation will be increased. (Kennedy-Malone page 519) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. Points Received: 0 of 2 Comments: Question 6. Question : When interpreting laboratory data, you would expect to see the following in a patient with Anemia of Chronic Disease (ACD): Student Answer: Hemoglobin <12 g/dl, MCV decreased, MCH decreased Hemoglobin >12 g/dl, MCV increased, MCH increased Hemoglobin <12 g/dl, MCV normal, MCH normal Hemoglobin >12 g/dl, MCV decreased, MCH increased Instructor Explanation: Hemoglobin (Hgb): <12 g/dL (120 g/L) women <13 g/dL (130 g/L) men Rarely <10 g/dL (100 g/L) Mean corpuscular volume: 80–96 mcm3 (normocytic) Mean corpuscular hemoglobin Normochromic (normal color) RBC distribution width: normal (Kennedy-Malone page 517) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. Points Received: 0 of 2 Comments: Question 7. Question : The pathophysiological hallmark of ACD is: Student Answer: Depleted iron stores Impaired ability to use iron stores Chronic uncorrectable bleeding Reduced intestinal absorption of iron Instructor Explanation: The pathophysiological hallmark of ACD is a disregulation of iron homeostasis, characterized by an increased uptake and retention of iron within the cells of the reticuloendothelial system (liver/spleen), resulting in decreased RBC production. Essentially, iron is present but inaccessible for use in the production of Hgb with the erythrocytes (Bross et al., 2010). A shortened RBC survival is also a contributing factor to ACD. (Kennedy-Malone page 516-517) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. Points Received: 0 of 2 Comments: Question 8. Question : The main focus of treatment of patients with ACD is: Student Answer: Replenishing iron stores Providing for adequate nutrition high in iron Management of the underlying disorder Administration of monthly vitamin B12 injections Instructor Explanation: Treatment: Treatment of ACD focuses on management of the underlying disorder. Iron supplementation is of no benefit in ACD, except in cases of coexisting IDA. A therapeutic trial of iron supplementation of no longer than 1 month may be useful in delineating between ACD and IDA. In ACD, there would be no hematological response to iron therapy (Chen & Gandhi, 2004). (Kennedy-Malone page 518) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. Points Received: 2 of 2 Comments: Question 9. Question : In addition to the complete blood count (CBC) with differential, which of the following laboratory tests is considered to be most useful in diagnosing ACD and IDA? Student Answer: Serum iron Total iron binding capacity Transferrin saturation Serum ferritin Instructor Explanation: Treatment: Treatment of ACD focuses on management of the underlying disorder. Iron supplementation is of no benefit in ACD, except in cases of coexisting IDA. A therapeutic trial of iron supplementation of no longer than 1 month may be useful in delineating between ACD and IDA. In ACD, there would be no hematological response to iron therapy (Chen & Gandhi, 2004). (Kennedy-Malone page 518) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. Points Received: 2 of 2 Comments: Question 10. Question : Symptoms in the initial human immunodeficiency virus (HIV) infection include all of the following except: Student Answer: Sore throat Fever Weight loss Headache Instructor Explanation: Signal symptoms: The initial HIV infection is characterized by mononucleosis-like illness with fever, sore throat, lymphadenopathy, headache, and fatigue. A roseola-like rash may also develop. These initial symptoms are followed by an asymptomatic phase, which may last 10 years or more. Later, if untreated, lymphadenopathy, weight loss, myalgias, and diarrhea may develop (Cohen, Kuritzkes, & Sax, 2011). In advanced disease, malignancies and opportunistic infections occur. Co-infection with hepatitis B or C is common (25% to 30%) in IV drug users, so hepatitis symptoms may also appear (Centers for Disease Control and Prevention [CDC], 2010a). (Kennedy-Malone page 521) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. Points Received: 0 of 2 Comments: Question 11. Question : Essential parts of a health history include all of the following except: Student Answer: Chief complaint History of the present illness Current vital signs All of the above are essential history components Instructor Explanation: Vital signs are part of the physical examination portion of patient assessment, not part of the health history. Points Received: 2 of 2 Comments: Question 12. Question : Which of the following clinical reasoning tools is defined as evidence-based resource based on mathematical modeling to express the likelihood of a condition in select situations, settings, and/or patients? Student Answer: Clinical practice guideline Clinical decision rule Clinical algorithm Clinical recommendation Instructor Explanation: Clinical decision (or prediction) rules provide another support for clinical reasoning. Clinical decision rules are evidence-based resources that provide probabilistic statements regarding the likelihood that a condition exists if certain variables are met with regard to the prognosis of patients with specific findings. Decision rules use mathematical models and are specific to certain situations, settings, and/or patient characteristics. Goolsby page 7 Points Received: 2 of 2 Comments: Question 13. Question : The first step in the genomic assessment of a patient is obtaining information regarding: Student Answer: Family history Environmental exposures Lifestyle and behaviors Current medications Instructor Explanation: A critical first step in genomic assessment, including assessment of risk, is the use of family history. Family history is considered the first genetic screen (Berry & Shooner 2004) and is a critical component of care because it reflects shared genetic susceptibilities, shared environment, and common behaviors (Yoon, Scheuner, & Khoury 2003). Goolsby page 18 Points Received: 2 of 2 Comments: Question 14. Question : In autosomal recessive (AR) disorders, individuals need: Student Answer: Only one mutated gene on the sex chromosomes to acquire the disease Only one mutated gene to acquire the disease Two mutated genes to acquire the disease Two mutated genes to become carriers Instructor Explanation: In autosomal recessive (AR) disorders, the offspring inherits the condition by receiving one copy of the gene mutation from each of the parents. Autosomal recessive disorders must be inherited through both parents (Nussbaum et al. 2007). Individuals who have an AR disorder have two mutated genes, one on each locus of the chromosome. Parents of an affected person are called carriers because each carries one copy of the mutation on one chromosome and a normal gene on the other chromosome. Carriers typically are not affected by the disease. Goolsby page 28 Points Received: 0 of 2 Comments: Question 15. Question : In AR disorders, carriers have: Student Answer: Two mutated genes; two from one parent that cause disease A mutation on a sex chromosome that causes a disease A single gene mutation that causes the disease One copy of a gene mutation but not the disease Instructor Explanation: Individuals who have an AR disorder have two mutated genes, one on each allele of the chromosome. Parents of an affected person are called carriers because each parent carries one copy of the mutation on one chromosome and a normal gene on the other chromosome. Carriers typically are not affected by the disease. In pedigrees with an AR inheritance patterns, males and females will be equally affected because the gene mutation is on an autosome. Goolsby page 28 Points Received: 2 of 2 Comments: Question 16. Question : A woman with an X-linked dominant disorder will: Student Answer: Not be affected by the disorder herself Transmit the disorder to 50% of her offspring (male or female) Not transmit the disorder to her daughters Transmit the disorder to only her daughters Instructor Explanation: Everyone born with an X-linked dominant disorder will be affected with the disease. Transmission of the disorder to the next generation varies by gender, however. A woman will transmit the mutation to 50% of all her offspring (male or female). Goolsby page 29 Points Received: 0 of 2 Comments: Question 17. Question : According to the Genetic Information Nondiscrimination Act (GINA): Student Answer: Nurse Practitioners (NPs) should keep all genetic information of patients confidential NPs must obtain informed consent prior to genetic testing of all patients Employers cannot inquire about an employee’s genetic information All of the above Instructor Explanation: On May 21, 2008, President George W. Bush signed the Genetic Information Nondiscrimination Act (GINA) to protect Americans against discrimination based upon their genetic information when it comes to health insurance and employment, paving the way for patient personalized genetic medicine without fear of discrimination (National Human Genome Research Institute 2012). Goolsby page 43 Points Received: 2 of 2 Comments: Question 18. Question : Which of the following would be considered a “red flag” that requires more investigation in a patient assessment? Student Answer: Colon cancer in family member at age 70 Breast cancer in family member at age 75 Myocardial infarction in family member at age 35 All of the above Instructor Explanation: Early onset cancer syndromes, heart disease, or dementia are red flags that warrant further investigation regarding hereditary disorders. Goolsby page 36 Points Received: 0 of 2 Comments: Question 19. Question : Your 2-year-old patient shows facial features, such as epicanthal folds, up-slanted palpebral fissures, single transverse palmar crease, and a low nasal bridge. These are referred to as: Student Answer: Variable expressivity related to inherited disease Dysmorphic features related to genetic disease De novo mutations of genetic disease Different penetrant signs of genetic disease Instructor Explanation: Assessing for dysmorphic features may enable identification of certain syndromes or genetic or chromosomal disorders (Jorde, Carey, & Bamshad 2010; Prichard & Korf 2008). Dysmorphology is defined as “the study of abnormal physical development” (Jorde, Carey, & Bamshad 2010, 302). Goolsby page 37 Points Received: 2 of 2 Comments: Question 20. Question : In order to provide a comprehensive genetic history of a patient, the NP should: Student Answer: Ask patients to complete a family history worksheet Seek out pathology reports related to the patient’s disorder Interview family members regarding genetic disorders All of the above Instructor Explanation: Asking the patient to complete a family history worksheet prior to the appointment saves time in the visit while offering the patient an opportunity to contribute to the collection of an accurate family history. Reviewing the family information can also help establish family rapport while verifying medical conditions in individual family members. If a hereditary condition is being considered but family medical information is unclear or unknown, requesting medical records and pathology or autopsy reports may be warranted. Goolsby page 32 1. Question : An 86-year-old patient who wears a hearing aid complains of poor hearing in the affected ear. In addition to possible hearing aid malfunction, this condition is often due to: Student Answer: Acoustic neuroma Cerumen impaction Otitis media Ménière’s disease Instructor Explanation: Elderly clients frequently present with complaints of hardened cerumen and decreased hearing resulting from cerumen impaction aggravated by hearing aid wear. (Goolsby 137-138) Conductive hearing loss is caused by a lesion involving the outer and middle ear to the level of the oval window. Various structural abnormalities, cerumen impaction, perforation of the tympanic membrane, middle ear fluid, damage to the ossicles from trauma or infection, otosclerosis, tympanosclerosis, cholesteatoma, middle ear tumors, temporal bone fractures, injuries related to trauma, and congenital problems are some of the causes. (Kennedy-Malone 170-171) Points Received: 2 of 2 Comments: Question 2. Question : In examination of the nose, the clinician observes gray, pale mucous membranes with clear, serous discharge. This is most likely indicative of: Student Answer: Bacterial sinusitis Allergic rhinitis Drug abuse Skull fracture Instructor Explanation: When examining the nose, assess the mucosa for integrity, color, moistness, and edema/lesions and the nasal septum for patency. The turbinates should be assessed for color and size. Pale, boggy turbinates suggest allergies; erythematous, swollen turbinates are often seen with infection. Any discharge should be noted. Clear, profuse discharge is often associated with allergies. (Goolsby 128-129) Patients with seasonal allergic rhinitis report rhinorrhea, sneezing, obstructed nasal passages, and pruritic eyes, nose, and oropharynx during the spring and fall. Patients with perennial allergic rhinitis have similar symptoms associated with exposure to environmental allergens typically in their homes. Physical examination may reveal a pale, boggy nasal mucosa, injected conjunctiva, enlarged turbinates, dark discoloration or bags under the eyes, and mouth breathing; absence of pale, boggy nasal mucosa does not rule out allergic rhinitis. (Kennedy-Malone 182-183) Points Received: 2 of 2 Comments: Question 3. Question : A 45 year old patient presents with ‘sore throat’ and fever for one week. After a quick strep screen you determine the patient has Strep throat. You know that streptococcal pharyngitis should be treated with antibiotics to prevent complications and to shorten the course of disease. Which of the following antibiotics should be considered when a patient is allergic to Penicillin? Student Answer: Amoxicillin EES (erythromycin) Bicillin L-A Dicloxacillin Instructor Explanation: MedU Card #1 Points Received: 2 of 2 Comments: Question 4. Question : Presbycusis is the hearing impairment that is associated with: Student Answer: Physiologic aging Ménière’s disease Cerumen impaction Herpes zoster Instructor Explanation: Presbycusis is an age-related cause of gradual sensorineural hearing loss and involves diminished hairy cell function within the cochlea as well as decreased elasticity of the TM. Although the changes associated with presbycusis often start in early adulthood, the decreased hearing acuity is usually not noticed until the individual is older than 65. (Goolsby 138) Because presbycusis is gradual and insidious, hearing loss may go unnoticed until it has progressed significantly. (Kennedy-Malone 170) Points Received: 2 of 2 Comments: Question 5. Question : Epistaxis can be a symptom of: Student Answer: Over-anticoagulation Hematologic malignancy Cocaine abuse All of the above Instructor Explanation: Cocaine abuse, which is more common than might be expected, frequently causes epistaxis. Hematologic disorders likely to cause bleeding include thrombocytopenia, leukemia, aplastic anemia, and hereditary coagulopathies. High doses of anticoagulants can cause epistaxis and bleeding from the gums. (Goolsby 142) Epistaxis results from a spontaneous rupture of a blood vessel in the nose, usually in the anterior septum in Kiesselbach\'s plexus (Nguyen, 2012). The bleeding may be secondary to local infections, systemic infections, drying of the nasal mucous membrane, trauma, arteriosclerosis, hypertension, or bleeding disorders. Trauma is usually the primary mechanism of disruption of the nasal mucosa. Posterior epistaxis can result in nausea and respiratory compromise. In older adults, nasal and paranasal tumors may be involved (Mäkitie, 2010). (Kennedy-Malone 168-169) Points Received: 2 of 2 Comments: Question 6. Question : Your patient has been using chewing tobacco for 10 years. On physical examination, you observe a white ulceration surrounded by erythematous base on the side of his tongue. The clinician should recognize that very often this is: Student Answer: Malignant melanoma Squamous cell carcinoma Aphthous ulceration Behcet’s syndrome Instructor Explanation: Most oral malignancies are painless until quite advanced, so patients are often unaware of the lesion unless the lip or anterior portion of the tongue is involved. The patient may become aware of the lesion if it bleeds. Squamous cell cancer lesions vary in appearance, from the reddened patches of erythroplakia to areas of induration/thickening, ulceration, or necrotic lesions. Lesions of malignant melanoma have varied pigmentation, including brown, blue, and black. Even lesions that appear flat and smooth may be nodular, indurated, or fixed to adjacent tissue on palpation. Even though patients with squamous cell malignancies often have a history of heavy alcohol and/or tobacco use or poor dentition, these are not risk factors for malignant melanoma. In Behcet’s syndrome, the patient complains of recurrent episodes of oral lesions that are consistent with aphthous ulcers. The number of lesions ranges from one to several; the size of the ulcers varies from less than to greater than 1 cm. Like aphthous ulcers, the lesions are well defined, with a pale yellow or gray base surrounded by erythema. The majority of patients also develop lesions on the genitals and eyes. (Goolsby 153) Tobacco use and heavy alcohol consumption, alone or synergistically, are strongly related to the development of oral cancer. Pipe smoking and sun exposure have been implicated in lip cancer. Leukoplakia and erythroplasia are often precursors to oral cancer. Relationships between oral cancer and Epstein-Barr virus, HPV, herpes simplex virus, and immunodeficiency states also have been found (Stenson, 2011). (Kennedy-Malone 177). Points Received: 2 of 2 Comments: Question 7. Question : A 26 year old patient presents with cough and general malaise for 3 days. They note that their eyes have been watering clear fluid and a ‘runny nose’ since yesterday. They note they ‘feel miserable’ and demand something to make them feel better. What would be the best first plan of treatment? Student Answer: Saline nasal spray for congestion and acetaminophen as needed for pain. Z-pack (azithromycin) for infection and Cromolyn nasal for congestion Hydrococone/acetaminophen as needed for pain and Guaifensin for congestion Cephalexin for infection and Cromolyn ophthalmic for congestion Instructor Explanation: MedU Card #4 Points Received: 0 of 2 Comments: Question 8. Question : Which of the following findings should trigger an urgent referral to a cardiologist or neurologist? Student Answer: History of bright flash of light followed by significantly blurred vision History of transient and painless monocular loss of vision History of monocular severe eye pain, blurred vision, and ciliary flush All of the above Instructor Explanation: Amaurosis fugax is a monocular, transient loss of vision. It stems from transient ischemia of the retina and presents an important warning sign for impending stroke. Depending on the circumstances reported, the patient should be immediately referred to either a cardiovascular or neurological specialist. (Goolsby 108) Points Received: 2 of 2 Comments: Question 9. Question : Dizziness that is described as \"lightheaded\" or, \"like I\'m going to faint,\" is usually caused by inadequate cerebral perfusion and is classified as? Student Answer: Presyncope Disequilibrium Vertigo Syncope Instructor Explanation: MedU Card #5 Points Received: 0 of 2 Comments: Question 10. Question : It is important to not dilate the eye if ____ is suspected. Student Answer: Cataract Macular degeneration Acute closed-angle glaucoma Chronic open-angle glaucoma Instructor Explanation: If the patient has experienced sudden onset of eye pain, it is important not to dilate the eyes before determining whether acute closed-angle glaucoma is present because dilating the eye may increase the intraocular pressure. (Goolsby 108) Acute glaucoma, also known as angle-closure or narrow-angle glaucoma, is an obstruction to the outflow of aqueous humor from the posterior to the anterior chamber through the trabecular meshwork, canal of Schlemm, and associated structures. It results in an elevation of intraocular pressure, damaging the optic nerve and causing loss of peripheral vision, eye pain, and redness. This type of glaucoma is uncommon but may occur as a primary disease or secondary to other conditions and constitutes an ophthalmic emergency (Kennedy-Malone 161) Points Received: 2 of 2 Comments: Question 11. Question : Mr. GC presents to the clinic with nausea and vomiting for 2 days, prior to that time he reports occasional ‘dizziness’ that got better with change in position. He denies a recent history of URI or any history of headaches or migraines. What would the most likely diagnosis be? Student Answer: Vestibular neruitis Benign paroxysmal positional vertigo Vestibular migraine Benign hypertensive central vertigo Instructor Explanation: MedU Card #9 Points Received: 2 of 2 Comments: Question 12. Question : Which of the following patients with vertigo would require neurologic imaging? Student Answer: A 68-year-old woman with a history of hypertension and sudden acute onset constant vertigo. She has right nystagmus that changes direction with gaze and that does not disappear when she focuses. A 45-year-old man with recurrent episodes of brief intense vertigo every time he turns his head rapidly. He has no other neurologic signs or symptoms. He has a positive Dix-Hallpike maneuver. A 66-year-old man with recurrent episodes of vertigo associated with tinnitus and hearing loss. His head thrust test is positive. A 28-year-old otherwise well woman with new onset constant vertigo with no other neurologic symptoms. On physical exam, she has unidirectional nystagmus that disappears when her gaze is fixed. Instructor Explanation: MedU Card #11. There are multiple reasons to be concerned about a central lesion and possible infarct in this patient. Her age puts her at risk as does her hypertension. Her physical exam shows nystagmus that changes direction and that does not inhibit with focus. Both of these findings are consistent with a central lesion. She needs an urgent MRI. Points Received: 0 of 2 Comments: Question 13. Question : A patient presents with eye redness, scant discharge, and a gritty sensation. Your examination reveals the palpable preauricular nodes, which are most likely with: Student Answer: Bacterial conjunctivitis Allergic conjunctivitis Chemical conjunctivitis Viral conjunctivitis Instructor Explanation: Preauricular nodes are nonpalpable and nontender in allergic conjunctivitis, usually nonpalpable in bacterial conjunctivitis, and palpable in viral conjunctivitis. (Goolsby 112) Points Received: 2 of 2 Comments: Question 14. Question : In assessing the eyes, which of the following is considered a “red flag” finding when associated with eye redness? Student Answer: History of prior red-eye episodes Grossly visible corneal defect Exophthalmos Photophobia Instructor Explanation: Red flag warnings for eye redness include pain (not discomfort or irritation), decreased vision, profuse discharge, and corneal defect grossly visible. (Goolsby 112) Points Received: 2 of 2 Comments: Question 15. Question : A 64-year-old male presents with erythema of the sclera, tearing, and bilateral pruritus of the eyes. The symptoms occur intermittently throughout the year and he has associated clear nasal discharge. Which of the following is most likely because of the inflammation? Student Answer: Bacterium Allergen Virus Fungi Instructor Explanation: Patients with seasonal allergic rhinitis report rhinorrhea, sneezing, obstructed nasal passages, and pruritic eyes, nose, and oropharynx during the spring and fall. Patients with perennial allergic rhinitis have similar symptoms associated with exposure to environmental allergens typically in their homes. Physical examination may reveal a pale, boggy nasal mucosa, injected conjunctiva, enlarged turbinates, dark discoloration or bags under the eyes, and mouth breathing; absence of pale, boggy nasal mucosa does not rule out allergic rhinitis. (Kennedy-Malone 182-183) Points Received: 2 of 2 Comments: Question 16. Question : Patients that have atopic disorders are mediated by the production of Immunoglobulin E (IgE) will have histamine stimulated as an immediate phase response. This release of histamine results in which of the following? Student Answer: Sinus pain, increased vascular permeability, and bronchodilation Bronchospasm, vascular permeability, and vasodilatation Contraction of smooth muscle, decreased vascular permeability, and vasoconstriction Vasodilatation, bronchodilation, and increased vascular permeability Instructor Explanation: Rhinitis may be either allergic or nonallergic. Allergic rhinitis results as a response of the nasal mucosa to airborne allergens in atopic genetically prone individuals. This response is mediated by the production of immunoglobulin E (IgE). IgE antibodies produced in response to the initial and subsequent exposure to allergens bind to the nasal mucosa. With repeated exposure, immediate type 1 hypersensitivity reactions may occur (Simoens & Laekeman, 2009). Antigen-specific T cells are activated through the lymphatic system in response to the antigen. The activated antigen-specific T cells activate B cells, and IgE is created in lymphoid tissue and at local tissue sites (Adelman, Casale, & Corren, 2002; Novak, 2009). The newly created antigen-specific IgE is released by plasma cells and binds to high-affinity IgE receptors located on the basophils and mast cells. This leads to the sensitization of the cells in the tissues of the nose, lung, or skin (Adelman et al., 2002; Cirillo, Pistorio, Tosca, & Ciprandi, 2009). IgE also binds with the antigen protein, beginning degranulation of the mast cells and basophils. These actions start the allergic cascade. Mediators are released as a result of the degranulation and include histamine, proteoglycans, enzymes, leukotrienes, cytokines, and many others. The chain in the release of mediators is responsible for the immediate and late phase responses of the cells. Histamine may be fully released within 30 minutes of degranulation, whereas cytokines may be released over many hours (Adelman et al., 2002; Derendorf & Meltzer, 2008). (Kennedy-Malone 181-182) Points Received: 2 of 2 Comments: Question 17. Question : You have a patient complaining of vertigo and want to know what could be the cause. Knowing there are many causes for vertigo, you question the length of time the sensation lasts. She tells you several hours to days and is accompanied by tinnitus and hearing loss. You suspect which of the following conditions? Student Answer: Ménière’s disease Benign paroxysmal positional vertigo Transient ischemic attack (TIA) Migraine Instructor Explanation: Ménière\'s disease commonly involves a triad of symptoms—severe vertigo, tinnitus, and hearing loss (Goolsby 140) Points Received: 2 of 2 Comments: Question 18. Question : In examining the mouth of an older adult with a history of smoking, the nurse practitioner finds a suspicious oral lesion. The patient has been referred for a biopsy to be sent for pathology. Which is the most common oral precancerous lesion? Student Answer: Fictional keratosis Keratoacanthoma Lichen planus Leukoplakia Instructor Explanation: The cause of most episodes of leukoplakia is not determined. However, this condition, which results in the development of white patches on the oral mucosa, is associated with an increased risk of oral squamous cell cancer. Risk factors for the development of leukoplakia include chronic/recurrent trauma to the affected site and the use of smokeless and smoked tobacco and alcohol. (Goolsby 152) Points Received: 2 of 2 Comments: Question 19. Question : Rheumatic heart disease is a complication that can arise from which type of infection? Student Answer: Epstein-Barr virus Diphtheria Group A beta hemolytic streptococcus Streptococcus pneumoniae Instructor Explanation: Group A beta-hemolytic streptococcal (GABHS) pharyngitis is a bacterial infection of the pharynx, commonly called strep throat. Complications of GABHS pharyngitis, although rare, include rheumatic heart disease and glomerulonephritis, and the condition requires prompt diagnosis and definitive treatment. Most patients with GABHS pharyngitis are children and youths. Other bacterial causes of pharyngitis include mycoplasmal pneumonia, gonorrhea, and diphtheria. (Goolsby 156) Points Received: 2 of 2 Comments: Question 20. Question : A patient complains of fever, fatigue, and pharyngitis. On physical examination there is pronounced cervical lymphadenopathy. Which of the following diagnostic tests should be considered? Student Answer: Mono spot Strep test Throat culture All of the above Instructor Explanation: The physical examination for sore throat should include a comprehensive assessment of the upper and lower respiratory systems, including ears, nose, mouth, throat, and lungs. The neck assessment should include, at a minimum, assessment of the cervical lymph nodes. Strep screens, throat cultures, and mononucleosis screens are common diagnostic studies used to narrow the differential diagnosis of sore throat. A CBC with differential count is helpful in determining the cause of sore throat. (Goolsby 156) 1. Question : Susan P., a 60-year-old woman with a 30 pack year history, presents to your primary care practice for evaluation of a persistent, daily cough with increased sputum production, worse in the morning, occurring over the past three months. She tells you, “I have the same thing, year after year.” Which of the following choices would you consider strongly in your critical thinking process? Student Answer: Seasonal allergies Acute bronchitis Bronchial asthma Chronic bronchitis Instructor Explanation: The pulmonary component includes an abnormal inflammatory response to noxious stimuli, principally tobacco, but also occupational and environmental pollutants. The hallmark of chronic bronchitis is a daily chronic cough with increased sputum production lasting for at least 3 consecutive months in at least 2 consecutive years, usually worse on awakening; this may or may not be associated with COPD (GOLD, 2011). Emphysema is characterized by obstruction to airflow caused by abnormal airspace enlargement distal to terminal bronchioles. Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. (page 206) & Goolsby, Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file. (page 213) Points Received: 2 of 2 Comments: Question 2. Question : A patient presents complaining of a 5 day history of upper respiratory symptoms including nasal congestion and drainage. On the day the symptoms began he had a low-grade fever that has now resolved. His nasal congestion persisted and he has had yellow nasal drainage for three days associated with mild headaches. On exam he is afebrile and in no distress. Examination of his tympanic membranes and throat are normal. Examination of his nose is unremarkable although a slight yellowish-clear drainage is noted. There is tenderness when you lightly percuss his maxillary sinus. What would your treatment plan for this patient be? Student Answer: Observation and reassurance Treatment with an antibiotic such as amoxicillin Treatment with an antibiotic such as a fluoroquinoline or amoxicillin-clavulanate Combination of a low dose inhaled corticosteroid and a long acting beta2 agonist inhaler. Instructor Explanation: MedU Card #4. According to the American Academy of Ortolaryngology—Head and Neck Surgery Foundation guidelines (2007) on sinusitis, making the distinction between a lingering viral upper respiratory infection that affects the nose and sinuses (viral rhinosinusitis) or early acute bacterial sinusitis can be difficult. It is more likely to be a viral rhinosinusitis if the duration of symptoms is less than ten days and they are not worsening. In this case, you can continue to observe the patient and reassure him that antibiotics are not necessary at this time. Points Received: 2 of 2 Comments: Question 3. Question : Emphysematous changes in the lungs produce the following characteristic in COPD patients? Student Answer: Asymmetric chest expansion Increased lateral diameter Increased anterior-posterior diameter Pectus excavatum Instructor Explanation: In COPD, patients commonly develop a barrel-shaped chest due to emphysematous changes in the lungs. A barrel shape is due to an increased anterior-posterior (AP) diameter. In emphysema, there is a 1:1 ratio of AP to lateral diameter; AP diameter equals the lateral diameter. Normally the AP diameter is twice the lateral diameter. Goolsby, Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file( page 213-214) & Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. (page 206) Points Received: 2 of 2 Comments: Question 4. Question : When palpating the posterior chest, the clinician notes increased tactile fremitus over the left lower lobe. This can be indicative of pneumonia. Areas of increased fremitus should raise the suspicion of conditions resulting in increased solidity or consolidation in the underlying lung tissue, such as in pneumonia, tumor, or pulmonary fibrosis. In the instance of an extensive bronchial obstruction: Student Answer: No palpable vibration is felt Decreased fremitus is felt Increased fremitus is felt Vibration is referred to the non-obstructed lobe Instructor Explanation: Areas of increased fremitus should raise the suspicion of conditions resulting in increased solidity or consolidation in the underlying lung tissue, such as in pneumonia, tumor, or pulmonary fibrosis. Conversely, areas of decreased fremitus raise the suspicion of abnormal fluid- or air-filled spaces, such as occurs with pleural effusion, pneumothorax, or emphysema. In the instance of an extensive bronchial obstruction, no palpable vibration is felt in the related field. Goolsby, Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file. (page 209) & Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. (page 193) Points Received: 2 of 2 Comments: Question 5. Question : Your patient presents with complaint of persistent cough. After you have finished obtaining the History of Present Illness, you realize that the patient may be having episodes of wheezing, in addition to his cough. The most common cause of cough with wheezing is asthma. What of the following physical exam findings will support your tentative diagnosis of asthma? Student Answer: Clear, watery nasal drainage with nasal turbinate swelling Pharyngeal exudate and lymphadenopathy Clubbing, cyanosis and edema. Diminished lung sounds with rales in both bases Instructor Explanation: MedU Card #9 Points Received: 2 of 2 Comments: Question 6. Question : Which of the following imaging studies should be considered if a pulmonary malignancy is suspected? Student Answer: Computed tomography (CT) scan Chest X-ray with PA, lateral, and lordotic views Ultrasound Positron emission tomography (PET) scan Instructor Explanation: For pulmonary malignancy, chest films are often nondiagnostic, although they may reveal a nodule, mass, or other abnormality. A CT scan of the chest is typically diagnostic. Goolsby, Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file. (page 217-218) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. (page 251) Points Received: 2 of 2 Comments: Question 7. Question : A 26-year-old, non-smoker, male presented to your clinic with SOB with exertion. This could be due to: Student Answer: Exercise-induced cough Bronchiectasis Alpha-1 deficiency Pericarditis Instructor Explanation: When younger patients or nonsmokers develop findings consistent with COPD, alpha-1 antitrypsin deficiency should be suspected. Currently, the American Thoracic Society (2003) recommends that all individuals with COPD or asthma with chronic obstructive changes be tested for alpha-1 antitrypsin deficiency. If alpha-1 antitrypsin deficit is suspected, a qualitative serum should be performed as a screen, followed by quantitative study, as indicated. Goolsby, Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file. (page 213) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. (page 206) Points Received: 2 of 2 Comments: Question 8. Question : Upon assessment of respiratory excursion, the clinician notes asymmetric expansion of the chest. One side expands greater than the other. This could be due to: Student Answer: Pneumothorax Pleural effusion Pneumonia Pulmonary embolism Instructor Explanation: The respiratory excursion, or expansion, is determined by placing hands around the patient’s posterior rib cage with the thumbs approximately at the level of the 10th rib between the thumbs, and then asking the patient to take a deep breath and observing the movement of the hands. The motion should be symmetrical. Less than anticipated movement occurs with advanced COPD and many restrictive processes, such as interstitial lung disease. Asymmetry of movement occurs with atelectasis, lobar collapse, pneumothorax, and several other conditions. Goolsby, Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file (page 208-209) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. (pages 193 & 227) Points Received: 2 of 2 Comments: Question 9. Question : A 72-year-old woman and her husband are on a cross-country driving vacation. After a long day of driving, they stop for dinner. Midway through the meal, the woman becomes very short of breath, with chest pain and a feeling of panic. Which of the following problems is most likely? Student Answer: Pulmonary edema Heart failure Pulmonary embolism Pneumonia Instructor Explanation: The problem may occur when these symptoms are attributed to aging or existing comorbidities. Dyspnea (acute onset), anxiety or apprehension, pleuritic chest pain, cough, tachypnea, and accentuation of the pul-monic component of S2 are frequently present and may be accompanied by diaphoresis, syncope, tachycardia, S3 or S4 gallop, hypoxemia, or hemoptysis . Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. (page 246) Goolsby, Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file (page 202) Points Received: 2 of 2 Comments: Question 10. Question : A cough is described as chronic if it has been present for: Student Answer: 2 weeks or more 8 weeks or more 3 months or more 6 months or more Instructor Explanation: Cough is classified as acute (less than 3 weeks in duration), subacute (lasting 3 to 8 weeks), and chronic (8 or more weeks in duration), and these distinctions help to narrow the potential differential diagnoses. Goolsby, Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file. (page 211) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. ((page 206) Points Received: 2 of 2 Comments: Question 11. Question : Testing is necessary for the diagnosis of asthma because history and physical are not reliable means of excluding other diagnoses or determining the extent of lung impairment. What is the study that is used to evaluate upper respiratory symptoms with new onset wheeze? Student Answer: Chest X-ray Methacholine challenge test Spirometry, both with and without bronchodilation Ventilation/perfusion scan Instructor Explanation: MedU Card #10 Points Received: 2 of 2 Comments: Question 12. Question : In classifying the severity of your patient presenting with an acute exacerbation of asthma. You determine that they have moderate persistent symptoms based on the report of symptoms and spirometry readings of the last 3 weeks. The findings that support moderate persistent symptoms include: Student Answer: Symptoms daily with nighttime awakening more than 1 time a week. FEV1 >60%, but predicted <80%. FEV1/FVC reduced 5% Symptoms less than twice a week and less than twice a week nighttime awakening. FEV1 >80% predicted. FEV1/FVC normal Symptoms more than 2 days a week, but not daily. Nighttime awakenings 3-4 times a month. FEV1 >80% predicted. FEV1/FVC normal Symptoms throughout the day with nighttime awakenings every night. FEV1< 60% predicted. FEV1/FVC reduced >5% Instructor Explanation: MedU Card #15 Points Received: 2 of 2 Comments: Question 13. Question : The following criterion is considered a positive finding when determining whether a patient with asthma can be safely monitored and treated at home: Student Answer: Age over 40 Fever greater than 101 Tachypnea greater than 30 breaths/minute Productive cough Instructor Explanation: Decision Rule: CURB-65 provides framework for determining whether the patient diagnosed with community-acquired pneumonia can be safely monitored and treated at home. One point is awarded for each of the following factors present: • Confusion of new onset • BUN greater than 20mg/dL • Respiratory rate of ≥ 30 breaths/minute • Blood pressure is less than 90 mmHg systolic or diastolic ≤ 60 mm Hg • Age 65 or older Patients scoring 3 to 5 typically require hospitalization for observation and therapy. Scores of 0 to 1 indicate likelihood that outpatient management is appropriate. A score of 2 is inconclusive. Goolsby, Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file (page 214-216) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file.( page 241) Points Received: 2 of 2 Comments: Question 14. Question : Medications are chosen based on the severity of asthma. Considering the patient that is diagnosed with moderate persistent asthma, the preferred option for maintenance medication is: Student Answer: High-dose inhaled corticosteroid and leukotriene receptor antagonist Oral corticosteroid—high and low dose as appropriate Short acting beta2 agonist inhaler and theophylline Low dose inhaled corticosteroid and long acting beta2 agonist inhaler Instructor Explanation: MedU Card #16 Points Received: 2 of 2 Comments: Question 15. Question : A 75-year-old patient with community-acquired pneumonia presents with chills, productive cough, temperature of 102.1, pulse 100, respiration 18, BP 90/52, WBC 12,000, and blood urea nitrogen (BUN) 22 mg/dl. He has a history of mild dementia and his mental status is unchanged from his last visit. These findings indicate that the patient: Student Answer: Can be treated as an outpatient Requires hospitalization for treatment Requires a high dose of parenteral antibiotic Can be treated with oral antibiotics Instructor Explanation: Decision Rule: CURB-65 provides framework for determining whether the patient diagnosed with community-acquired pneumonia can be safely monitored and treated at home. One point is awarded for each of the following factors present: • Confusion of new onset • BUN is greater than 20mg/dl • Respiratory rate of ≥ 30 breaths/minute • Blood pressure is less than 90 mmHg systolic or diastolic ≤ 60 mm Hg • Age 65 or older Patients scoring 3 to 5 typically require hospitalization for observation and therapy. Scores of 0 to 1 indicate likelihood that outpatient management is appropriate. A score of 2 is inconclusive. Goolsby, Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file (page 214-216) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. (page 241) Points Received: 0 of 2 Comments: Question 16. Question : Which of the following is considered a “red flag” when diagnosing a patient with pneumonia? Student Answer: Fever of 102 Infiltrates on chest X-ray Pleural effusion on chest X-ray Elevated white blood cell count Instructor Explanation: With pneumonia, the chest film typically reveals an area of infiltrate. It is a red flag if a pleural effusion is also visualized, in which case adequate follow-up to exclude development of an empyema is mandatory. This often involves prompt referral to a pulmonologist for possible thoracentesis. Cultures and Gram stains of sputum are usually not ordered for outpatients. The white blood cell count is often elevated. Goolsby, Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file. (page 214) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. (page 240) Points Received: 2 of 2 Comments: Question 17. Question : A 23-year-old patient who has had bronchiectasis since childhood is likely to have which of the following: Student Answer: Barrel-shaped chest Clubbing Pectus excavatum Prolonged capillary refill Instructor Explanation: In bronchiectasis, there is usually a history of chronic, productive cough. Sputum is typically mucopurulent and produced in increased amounts. Other common findings include shortness of breath, wheezing, fatigue, and possibly hemoptysis. Physical examination reveals rhonchi and/or wheezing. In advanced disease, clubbing and cyanosis may be present. Goolsby, Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file (page 216) Points Received: 2 of 2 Comments: Question 18. Question : Your patient has just returned from a 6-month missionary trip to Southeast Asia. He reports unremitting cough, hemoptysis, and an unintentional weight loss of 10 pounds over the last month. These symptoms should prompt the clinician to suspect: Student Answer: Legionnaires\' disease Malaria Tuberculosis Pneumonia Instructor Explanation: Many times, patients with active tuberculosis are essentially symptom free. Some complain of malaise and/or fevers but have no significantly disruptive complaints. When respiratory symptoms occur with tuberculosis, cough is common; the cough is nonproductive at first and is later associated with sputum production. Additionally, patients with tuberculosis may experience progressive dyspnea, night sweats, weight loss, and hemoptysis. It is important to suspect tuberculosis when the patient has travelled to a country where TB is endemic, such as Asia. Goolsby, Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file. (page 217) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. (page 249) Points Received: 2 of 2 Comments: Question 19. Question : A 76-year-old patient with a 200-pack year smoking history presents with complaints of chronic cough, dyspnea, fatigue, hemoptysis, and weight loss over the past 2 months. The physical exam reveals decreased breath sounds and dullness to percussion over the left lower lung field. The chest X-ray demonstrates shift of the mediastinum and trachea to the left. These are classic signs of: Student Answer: Lung cancer Tuberculosis Pneumonia COPD Instructor Explanation: Dyspnea is the most common symptom associated with pleural effusion, but effusion may be accompanied by cough, pain, and systemic symptoms, such as malaise and fever. Abnormal physical findings become evident as the effusion increases in volume. These include decreased lung sounds, dullness over the effusion, decreased fremitus, egophony, and whispered pectoriloquy. With extremely large effusions, the mediastinum and trachea may shift to the opposite side. The exception involves effusion related to malignancy, in which case the mediastinum and trachea may be pulled toward the malignancy. Goolsby, Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file (page 217-218) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file.(page 232) Points Received: 2 of 2 Comments: Question 20. Question : A 24-year-old patient presents to the emergency department after sustaining multiple traumatic injuries after a motorcycle accident. Upon examination, you note tachypnea, use of intercostal muscles to breathe, asymmetric chest expansion, and no breath sounds over the left lower lobe. It is most important to suspect: Student Answer: Pulmonary embolism Pleural effusion Pneumothorax Fracture of ribs Instructor Explanation: Pneumothorax involves air in the pleural cavity. A pneumothorax can occur spontaneously in otherwise healthy individuals or be secondary to trauma or intrinsic lung disease. There is history of sudden onset of shortness of breath associated with chest pain. The patient usually presents in great distress, with tachycardia and tachypnea, and is often splinting the chest. There is decreased fremitus and increased hyperresonance on the affected side. Lung sounds are diminished or absent. The trachea may shift away from the affected side if a large pneumothorax is present. Goolsby, Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file (page 221) 1. Question : Which of the following is the most important question to ask during cardiovascular health history? Student Answer: Number of offspring Last physical exam Sudden death of a family member Use of caffeine Instructor Explanation: The sudden death of a family member is an important question to ask in the health history because it reveals the cardiovascular disease risk of the patient. Sudden death is usually due to an acute cardiovascular event, such as myocardial infarction, cardiac dysrhythmia, or stroke. Family history is particularly important for cardiac assessment because CVD, HTN, hyperlipidemia, and other vascular diseases often have a familial association that is not easily ameliorated by lifestyle changes. If there are deaths in the family related to CVD, determine the age and exact cause of death, because CVD at a young age in the immediate family carries an increased risk compared with CVD in an elderly family member. Ask about sudden death, which might indicate a congenital disease such as Marfan\'s syndrome. This is especially important to ask during pre-sports physicals because sudden death in athletes is often related to congenital or familial heart disease. Familial hyperlipidemia is autosomal dominant and often leads to CAD and MI at a young age. Family history of obesity and type 2 diabetes are also secondary risk factors for heart disease because the familial tendency for these is strong. Ask about smoking in the house, as secondhand smoke is a risk factor for respiratory and cardiac disease. (Goolsby 167-168) Goolsby, Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file. Points Received: 2 of 2 Comments: Question 2. Question : A key symptom of ischemic heart disease is chest pain. However, angina equivalents may include exertional dyspnea. Angina equivalents are important because: Student Answer: Women with ischemic heart disease many times do not present with chest pain Some patients may have no symptoms or atypical symptoms; diagnosis may only be made at the time of an actual myocardial infarction Elderly patients have the most severe symptoms A & B only Instructor Explanation: The key symptom of IHD is chest pain, but other common symptoms include arm pain, lower jaw pain, shortness of breath, and diaphoresis. These symptoms are referred to as angina equivalents and can also include fatigue or breathlessness. Some patients may have no symptoms or atypical ones so that CAD may not be diagnosed until they experience a myocardial infarction. (Kennedy-Malone 227) Kennedy-Malone, Laurie, Kathleen Fletcher, Lori Martin-Plank. Advanced Practice Nursing in the Care of Older Adults. F.A. Davis Company, 2014-01-14. VitalBook file. Points Received: 2 of 2 Comments: Question 3. Question : A 55-year-old post-menopausal woman with a history of hypertension complains of jaw pain on heavy exertion. There were no complaints of chest pain. Her ECG indicates normal sinus rhythm without ST segment abnormalities. Your plan may include: Student Answer: Echocardiogram Exercise stress test Cardiac catheterization Myocardial perfusion imaging Instructor Explanation: Once all the results of the initial laboratory and ECG testing are reviewed, a pretest probability of disease can be generated and additional tests can be ordered.2 The probability of CAD can be calculated by considering the chosen noninvasive test\'s sensitivity and specificity.2 Selection of the proper cardiac test (see Table 115-1) for an individual depends on the person\'s risk stratification, age, and tolerable level of activity. The most common and least invasive test for diagnosis of CAD is the stress test, also called the exercise tolerance test (ETT) or treadmill exercise. (Buttaro 488) Buttaro, Terry, JoAnn Trybulski, Patricia Bailey, Joanne Sandberg-Cook. Primary Care, 4th Edition. Mosby, 2013. VitalBook file. Points Received: 2 of 2 Comments: Question 4. Question : Jenny is a 24 year old graduate student that presents to the clinic today with complaints of fever, midsternal chest pain and generalized fatigue for the past two days. She denies any cough or sputum production. She states that when she takes Ibuprofen and rest that the chest pain does seem to ease off. Upon examination the patient presents looking very ill. She is leaning forward and states that this is the most comfortable position for her. Temp is 102. BP= 100/70. Heart rate is 120/min and regular. Upon auscultation a friction rub is audible. Her lung sounds are clear. With these presenting symptoms your initial diagnosis would be: Student Answer: Mitral Valve Prolapse Referred Pain from Cholecystitis Pericarditis Pulmonary Embolus Instructor Explanation: Pericarditis Pericarditis, inflammation of the pericardium, is usually not a solo disease process but is seen in conjunction with other diseases or conditions. Pericarditis may occur as a complication of MI (Dressler\'s syndrome) or coronary artery bypass surgery. It is also more commonly seen in patients with connective tissue disorders such as rheumatoid arthritis, systemic lupus erythematosus (SLE), scleroderma, and sarcoidosis. Bacterial, viral, or fungal infections, including HIV, are risk factors for pericarditis. Pericarditis can occur with kidney failure or metastatic neoplasias or as a reaction to medication, particularly phenytoin, hydralazine, and procainamide. Rarely, it is idiopathic and the cause unknown, although a common viral infection is suspected. Cardiac tamponade can occur as a serious complication, and it is an emergency requiring immediate pericardiocentesis. Constrictive pericarditis can occur over time due to scarring of the pericardial sac. Signs and Symptoms Unlike the symptoms associated with ACS, the pain accompanying pericarditis is sharp and stabbing; it may worsen with inspiration or when lying flat or leaning forward. Associated symptoms may include shortness of breath, fever, chills, and malaise. (Goolsby 179) Goolsby, Mary J., Laurie Grubbs. Advanced Assessment Interpreting Findings and Formulating Differential Diagnoses, 3rd Edition. F.A. Davis Company, 11/2014. VitalBook file. Points Received: 2 of 2 Comments: Question 5. Question : Which symptom is more characteristic of Non-Cardiac chest pain? Student Answer: Pain often radiates to the neck, jaw, epi

Abnormal Psychology - IB Psychology - Detailed Essay Plans A 26-page document which has everything you need to fully prepare for the topic Abnormal Psychology. The document has an essay plan for all the possible essay titles, which are: 1. To what extent do biological, cognitive and sociocultural factors influence abnormal behaviour? 2. Evaluate psychological research (that is, theories and/or studies) relevant to the study of abnormal behaviour. 3. Discuss cultural and ethical considerations in diagnosis. 4. Examine the concepts of normality and abnormality. 5. Discuss validity and reliability of diagnosis. 6. Discuss cultural and ethical considerations in diagnosis. 7. Describe symptoms and prevalence of one anxiety/affective/eating disorder. 8. Analyse etiologies (in terms of biological, cognitive and/or sociocultural factors) of one anxiety/affective/eating disorder. 9. Discuss cultural and gender variations in prevalence of disorders. 10. Examine/evaluate biomedical, individual and group approaches to treatment. 11. Discuss the use of eclectic approaches to treatment. 12. Discuss the relationship between etiology and therapeutic approach in relation to one disorder. Note: I used these notes for my Psychology exams and my final grade was a 7 - they work!

Chapter 18 Disorders of the Central and Peripheral Nervous Systems and the Neuromuscular Junction. 100% Correct Diffuse axonal injuries (DAIs) of the brain often result in: a. Reduced levels of consciousness c. Fine motor tremors b. Mild but permanent dysfunction d. Visual disturbances Focal brain injuries account for more than two-thirds of head injury deaths; DAIs accounts for less than one third. However, more severely disabled survivors, including those in an unresponsive state or reduced level of consciousness, have DAIs. The other options do not appropriately complete the stem. PTS: 1 REF: Page 582 2. What event is most likely to occur to the brain in a classic cerebral concussion? a. Brief period of vital sign instability b. Cerebral edema throughout the cerebral cortex c. Cerebral edema throughout the diencephalon d. Disruption of axons extending from the diencephalon and brainstem Transient cessation of respiration can occur with brief periods of bradycardia, and a decrease in blood pressure occurs, lasting 30 seconds or less. Vital signs stabilize within a few seconds to within normal limits. The other options do not accurately describe an event associated with a classic cerebral concussion. PTS: 1 REF: Page 588 3. Which disorder has clinical manifestations that include decreased consciousness for up to 6 hours, as well as retrograde and posttraumatic amnesia? a. Mild concussion c. Cortical contusion b. Classic concussion d. Acute subdural hematoma Evidence of a classic concussion is the immediate loss of consciousness, which lasts less than 6 hours. Retrograde and anterograde (posttraumatic) amnesia is also present. The other options do not apply. PTS: 1 REF: Page 588 4. What group is most at risk of spinal cord injury from minor trauma? a. Children c. Adults b. Adolescents d. Older adults Because of preexisting degenerative vertebral disorders, older adults are particularly at risk for minor trauma, resulting in serious spinal cord injury, especially from falls. The risk to the other age groups is less than that of the older adult. PTS: 1 REF: Page 634 5. The edema of the upper cervical cord after spinal cord injury is considered life threatening because of which possible outcome? a. Hypovolemic shock from blood lost during the injury b. Breathing difficulties from an impairment to the diaphragm c. Head injury that likely occurred during the injury d. Spinal shock immediately after the injury In the cervical region, spinal cord swelling may be life threatening because of the possibility of resulting impairment of the diaphragm function (phrenic nerves exit C3-C5). The other options do not appropriately explain the threat. PTS: 1 REF: Page 591 6. What indicates that spinal shock is terminating? a. Voluntary movement below the level of injury b. Reflex emptying of the bladder c. Paresthesia below the level of injury d. Decreased deep tendon reflexes and flaccid paralysis Indications that spinal shock is terminating include the reappearance of reflex activity, hyperreflexia, spasticity, and reflex emptying of the bladder. Termination of a spinal cord injury is not evidenced by any of the other options. PTS: 1 REF: Page 592 7. What term is used to describe the complication that can result from a spinal cord injury above T6 that is producing paroxysmal hypertension, as well as piloerection and sweating above the spinal cord lesion? a. Craniosacral dysreflexia c. Autonomic hyperreflexia b. Parasympathetic dysreflexia d. Retrograde hyperreflexia Individuals most likely to be affected have lesions at the T6 level or above. Paroxysmal hypertension (up to 300 mm Hg systolic), a pounding headache, blurred vision, sweating above the level of the lesion with flushing of the skin, nasal congestion, nausea, piloerection caused by pilomotor spasm, and bradycardia (30 to 40 beats/minute) characterize autonomic hyperreflexia. No other options appropriately describe this complication. PTS: 1 REF: Pages 593-594 8. Why does a person who has a spinal cord injury experience faulty control of sweating? a. The hypothalamus is unable to regulate body heat as a result of damage to the sympathetic nervous system. b. The thalamus is unable to regulate body heat as a result of damage to the sympathetic nervous system. c. The hypothalamus is unable to regulate body heat as a result of damage to the parasympathetic nervous system. d. The thalamus is unable to regulate body heat as a result of damage to spinal nerve roots. A spinal cord injury results in disturbed thermal control because the hypothalamus is unable to regulate a damaged sympathetic nervous system. This damage causes faulty control of sweating and radiation through capillary dilation. The other options do not appropriately describe the process that causes faulty control of sweating. PTS: 1 REF: Page 592 9. Autonomic hyperreflexia–induced bradycardia is a result of stimulation of the: a. Sympathetic nervous system to ß-adrenergic receptors to the sinoatrial node b. Carotid sinus to the vagus nerve to the sinoatrial node c. Parasympathetic nervous system to the glossopharyngeal nerve to the atrioventricular node d. Bundle branches to the -adrenergic receptors to the sinoatrial node The intact autonomic nervous system reflexively responds with an arteriolar spasm that increases blood pressure. Baroreceptors in the cerebral vessels, the carotid sinus, and the aorta sense the hypertension and stimulate the parasympathetic system. The heart rate decreases, but the visceral and peripheral vessels do not dilate because efferent impulses cannot pass through the cord. The process is not appropriately described by the other options. PTS: 1 REF: Pages 593-595 | Figure 18-13 10. A herniation of which disk will likely result in motor and sensory changes of the lateral lower legs and soles of the feet? a. L2-L3 c. L5-S1 b. L3-L5 d. S2-S3 Clinical manifestations of posterolateral protrusions include radicular pain exacerbated by movement and straining (medial calf suggests L5; lateral calf suggests S1 root compression). Herniation of any of the other vertebrae will not result in the described symptoms. PTS: 1 REF: Pages 595-596 | Figure 18-14 11. Which condition poses the highest risk for a cerebrovascular accident (CVA)? a. Insulin-resistant diabetes mellitus c. Polycythemia b. Hypertension d. Smoking Hypertension is the single greatest risk factor for stroke. The other options are recognized risk factors but do not carry the intensity of hypertension. PTS: 1 REF: Page 598 12. A right hemisphere embolic CVA has resulted in left-sided paralysis and reduced sensation of the left foot and leg. Which cerebral artery is most likely affected by the emboli? a. Middle cerebral c. Posterior cerebral b. Vertebral d. Anterior cerebral Symptoms of an embolic stroke in only the right anterior cerebral artery would include left-sided contralateral paralysis or paresis (greater in the foot and thigh) and mild upper extremity weakness with mild contralateral lower extremity sensory deficiency with loss of vibratory and/or position sense and loss of two-point discrimination. PTS: 1 REF: Page 600 | Table 18-5 13. Atrial fibrillation, rheumatic heart disease, and valvular prosthetics are risk factors for which type of stroke? a. Hemorrhagic c. Embolic b. Thrombotic d. Lacunar High-risk sources for the onset of embolic stroke are atrial fibrillation (15% to 25% of strokes), left ventricular aneurysm or thrombus, left atrial thrombus, recent myocardial infarction, rheumatic valvular disease, mechanical prosthetic valve, nonbacterial thrombotic endocarditis, bacterial endocarditis, patent foramen ovale, and primary intracardiac tumors. These are not risk factors for the other options provided. PTS: 1 REF: Page 599 14. Microinfarcts resulting in pure motor or pure sensory deficits are the result of which type of stroke? a. Embolic c. Lacunar b. Hemorrhagic d. Thrombotic A lacunar stroke (lacunar infarct) is a microinfarct smaller than 1 cm in diameter. Because of the subcortical location and small area of infarction, these strokes may have pure motor and sensory deficits. The other options would not result in the complications described. PTS: 1 REF: Page 599 15. Which vascular malformation is characterized by arteries that feed directly into veins through vascular tangles of abnormal vessels? a. Cavernous angioma c. Arteriovenous angioma b. Capillary telangiectasia d. Arteriovenous malformation In only an arteriovenous malformation (AVM), do arteries feed directly into veins through a vascular tangle of malformed vessels. PTS: 1 REF: Pages 604-605 16. Which clinical finding is considered a diagnostic indicator for an arteriovenous malformation (AVM)? a. Systolic bruit over the carotid artery b. Decreased level of consciousness c. Hypertension with bradycardia d. Diastolic bruit over the temporal artery A systolic bruit over the carotid in the neck, the mastoid process, or (in a young person) the eyeball is almost always diagnostic of an AVM. The other options are not as indicative as the systolic bruit. PTS: 1 REF: Page 605 17. Which cerebral vascular hemorrhage causes meningeal irritation, photophobia, and positive Kernig and Brudzinski signs? a. Intracranial c. Epidural b. Subarachnoid d. Subdural Assessment findings related to only a subarachnoid hemorrhage include meningeal irritation and inflammation, causing neck stiffness (nuchal rigidity), photophobia, blurred vision, irritability, restlessness, and low-grade fever. A positive Kernig sign, in which straightening the knee with the hip and knee in a flexed position produces pain in the back and neck regions, and a positive Brudzinski sign, in which passive flexion of the neck produces neck pain and increased rigidity, may appear. PTS: 1 REF: Pages 605-606 18. In adults, most intracranial tumors are located: a. Infratentorially c. Laterally b. Supratentiorially d. Posterolaterally Approximately 70% to 75% of all intracranial tumors diagnosed in adults are located supratentorially (above the tentorium cerebella). The other options are not primary locations for intracranial tumors in adults. PTS: 1 REF: Page 626 19. In children, most intracranial tumors are located: a. Infratentorially c. Laterally b. Supratentiorially d. Posterolaterally Approximately 70% of all intracranial tumors in children are located infratentorially (below the tentorium cerebelli) and not in the locations provided by the other options. PTS: 1 REF: Page 626 20. The most common primary central nervous system (CNS) tumor is the: a. Microglioma c. Astrocytoma b. Neuroblastoma d. Neuroma Astrocytomas are the most common primary CNS tumors (50% of all brain and spinal cord tumors). The other options do not occur as frequently. PTS: 1 REF: Page 629 21. Meningiomas characteristically compress from: a. Within neural tissues c. Outside the spinal cord b. Outside spinal nerve roots d. Within the subarachnoid space Extramedullary spinal cord tumors produce dysfunction by compression of adjacent tissue, not by direct invasion. The pathologic characteristic of meningiomas is not appropriately described by the other options. PTS: 1 REF: Page 633 22. What is the central component of the pathogenic model of multiple sclerosis? a. Myelination of nerve fibers in the peripheral nervous system (PNS) b. Demyelination of nerve fibers in the CNS c. Development of neurofibrillary tangles in the CNS d. Inherited autosomal dominant trait with high penetrance Multiple sclerosis (MS) is an autoimmune disorder diffusely involving the degeneration of CNS myelin and loss of axons. The other options are not central components of the pathogenic model of MS. PTS: 1 REF: Pages 618-619 23. A blunt force injury to the forehead would result in a coup injury to which region of the brain? a. Frontal c. Parietal b. Temporal d. Occipital Coup injuries occur directly below the point of impact. Objects striking the front of the head usually produce only coup injuries (contusions and fractures) because the inner skull in the occipital area is smooth. A coup injury is not nearly as likely when other portions of the brain are affected. PTS: 1 REF: Page 583 24. A blunt force injury to the forehead would result in a contrecoup injury to which region of the brain? a. Frontal c. Parietal b. Temporal d. Occipital The focal injury produces a contrecoup (on the pole opposite the site of impact) injury. The frontal portion of the brain is opposite of the site of impact. Objects striking the back of the head usually result in both coup and contrecoup injuries because of the irregularity of the inner surface of the frontal bones. A contrecoup injury is not nearly as likely when other portions of the brain are affected. PTS: 1 REF: Page 583 25. Spinal cord injuries most likely occur in which region? a. Cervical and thoracic c. Lumbar and sacral b. Thoracic and lumbar d. Cervical and thoracic-lumbar Vertebral injuries most often occur at vertebrae C1-C2 (cervical), C4-C7, and T1-L2 (thoracic lumbar). None of the other options are applicable. PTS: 1 REF: Pages 590-591 26. The most likely rationale for body temperature fluctuations after cervical spinal cord injury is that the person has: a. Developed bilateral pneumonia or a urinary tract infection. b. Sustain sympathetic nervous system damage resulting in disturbed thermal control. c. Sustained a head injury that damaged the hypothalamus’s ability to regulate temperature. d. Developed septicemia from posttrauma infection. Spinal cord injuries result in disturbed thermal control because the sympathetic nervous system is damaged. None of the remaining options explain this complication. PTS: 1 REF: Page 592 27. A man who sustained a cervical spinal cord injury 2 days ago suddenly develops severe hypertension and bradycardia. He reports severe head pain and blurred vision. The most likely explanation for these clinical manifestations is that he is: a. Experiencing acute anxiety b. Developing spinal shock c. Developing autonomic hyperreflexia d. Experiencing parasympathetic areflexia Autonomic hyperreflexia is the only option that is characterized by paroxysmal hypertension (up to 300 mm Hg systolic), a pounding headache, blurred vision, sweating above the level of the lesion with flushing of the skin, nasal congestion, nausea, piloerection caused by pilomotor spasm, and bradycardia (30 to 40 beats per minute). PTS: 1 REF: Pages 593-594 28. The type of vascular malformation that most often results in hemorrhage is: a. Cavernous angioma c. Capillary telangiectasia b. Venous angioma d. Arteriovenous malformation In an arteriovenous malformation (AVM), arteries feed directly into veins through a vascular tangle of malformed vessels, causing venous hemorrhaging. The other options are not as likely to result in a hemorrhage. PTS: 1 REF: Pages 604-605 29. Atheromatous plaques are most commonly found: a. In larger veins c. At branches of arteries b. Near capillary sphincters d. On the venous sinuses Over 20 to 30 years, atheromatous plaques (stenotic lesions) tend to form at branchings and curves in the cerebral circulation, not at any of the other options provided. PTS: 1 REF: Page 598 30. Multiple sclerosis is best described as a(an): a. Central nervous system demyelination, possibly from an immunogenetic virus b. Inadequate supply of acetylcholine at the neurotransmitter junction as a result of an autoimmune disorder c. Depletion of dopamine in the central nervous system as a result of a virus d. Degenerative disorder of lower and upper motor neurons caused by viral-immune factors Multiple sclerosis (MS) is an autoimmune disorder diffusely involving the degeneration of central nervous system (CNS) myelin and loss of axons. MS is described as occurring when a previous infectious insult to the CNS has occurred in a genetically susceptible individual with a subsequent abnormal immune response in the CNS. The other options do not adequately describe MS. PTS: 1 REF: Pages 618-619 31. What is the most common opportunistic infection associated with acquired immunodeficiency syndrome (AIDS)? a. Non-Hodgkin lymphoma c. Toxoplasmosis b. Kaposi sarcoma d. Cytomegalovirus Toxoplasmosis is the most common opportunistic infection and occurs in approximately one third of individuals with AIDS. Cytomegalovirus encephalitis is common in those with AIDS but is often not diagnosed while the person is alive. Other neoplasms associated with human immunodeficiency virus (HIV) include systemic non-Hodgkin lymphoma and metastatic Kaposi sarcoma. PTS: 1 REF: Page 617 32. It is true that Guillain-Barré syndrome (GBS): a. Is preceded by a viral illness. c. Results in asymmetric paralysis. b. Involves a deficit in acetylcholine. d. Is an outcome of HIV. GBS is considered to be an autoimmune disease triggered by a preceding bacterial or viral infection. None of the other options are true of GBS. PTS: 1 REF: Pages 622-623 33. It is true that myasthenia gravis: a. Is an acute autoimmune disease. c. May result in adrenergic crisis. b. Affects the nerve roots. d. Causes muscle weakness. Exertional fatigue and weakness that worsens with activity, improves with rest, and recurs with resumption of activity characterizes myasthenia gravis. None of the other options are true of myasthenia gravis. PTS: 1 REF: Page 626 34. In which disorder are acetylcholine receptor antibodies (IgG antibodies) produced against acetylcholine receptors? a. Guillain-Barré syndrome c. Myasthenia gravis b. Multiple sclerosis d. Parkinson disease The main defect of myasthenia gravis is the formation of autoantibodies (an immunoglobulin G [IgG] antibody) against receptors at the Ach-binding site on the postsynaptic membrane. This defect is not found in any of the other options. PTS: 1 REF: Pages 625-626 35. Multiple sclerosis and Guillain-Barré syndrome are similar in that they both: a. Result from demyelination by an immune reaction. b. Cause permanent destruction of peripheral nerves. c. Result from inadequate production of neurotransmitters. d. Block acetylcholine receptor sites at the myoneuronal junction. Acute inflammatory demyelinating polyneuropathy (AIDP) accounts for most occurrences of Guillain- Barré syndrome (GBS). Multiple sclerosis (MS) is an autoimmune disorder diffusely involving degeneration of CNS myelin and loss of axons. Only the correct option accurately describes the similarity between MS and GBS PTS: 1 REF: Page 618 | Pages 622-623 MULTIPLE RESPONSE 36. Which clinical manifestation is characteristic of cluster headaches? (Select all that apply.) a. Preheadache aura b. Severe unilateral tearing c. Gradual onset of a tight band around the head d. Significant unilateral, temporal pain e. Pain lasting from 30 to 120 minutes The cluster headache attack usually begins without warning and is characterized by severe, unilateral tearing, burning, periorbital, and retrobulbar or temporal pain lasting 30 minutes to 2 hours. Neither preheadache aura nor significant unilateral, temporal pain is clinical manifestation characteristic of cluster headaches. PTS: 1 REF: Pages 608-609 37. What are the initial clinical manifestations immediately noted after a spinal cord injury? (Select all that apply.) a. Headache b. Bladder incontinence c. Loss of deep tendon reflexes d. Hypertension e. Flaccid paralysis A complete loss of reflex function in all segments below the level of the lesion characterizes a spinal cord injury. Severe impairment below the level of the lesion is obvious; it includes paralysis and flaccidity in muscles, absence of sensation, loss of bladder and rectal control, transient drop in blood pressure, and poor venous circulation. Neither headache nor hypertension is an initial clinical manifestation related to a spinal cord injury. PTS: 1 REF: Page 592 MATCHING Match the terms with the corresponding descriptions. ______ A. Complication of mastoiditis ______ B. Opportunistic infection ______ C. CNS manifestation of tuberculosis ______ D. Mosquito-borne viral infection ______ E. Tick-borne bacterial infection 38. Meningitis 39. Encephalitis 40. Cryptococcus neoformans 41. Brain abscess 42. Lyme disease 38. ANS: C PTS: 1 REF: Pages 611-612 MSC: Tubercular meningitis is the most common and serious form of central nervous system (CNS) tuberculosis. 39. ANS: D PTS: 1 REF: Page 614 MSC: Encephalitis is an acute febrile illness, usually of viral origin, with nervous system involvement. Arthropod-borne (mosquito-borne) viruses and herpes simplex cause the most common encephalitides. 40. ANS: B PTS: 1 REF: Page 617 MSC: Opportunistic infections may be bacterial, fungal, protozoal, or viral in origin and produce nervous system disease. Cryptococcus neoformans is an example of such an infection. 41. ANS: A PTS: 1 REF: Page 613 MSC: Abscesses may occur in association with a contiguous spread of infection, such as the middle ear, mastoid cells, nasal cavity, and nasal sinuses. 42. ANS: E PTS: 1 REF: Page 617 MSC: Lyme disease, a tick-borne spirochete bacterial infection, is a common arthropod-borne infection in the United States. Question 1 (1 point) Question 1 Saved Cheyne–Stokes respirations are described as a: Question 19 (1 point) Question 19 Saved In which disorder are acetylcholine receptor antibodies (immunoglobulin G [IgG] antibodies) produced against acetylcholine receptors? Question 19 options: Guillain-Barré syndrome (GBS) Multiple sclerosis Myasthenia gravis Parkinson disease Question 20 (1 point) Question 20 Saved What data confer the link between bipolar disorders and schizophrenia? Question 20 options: Individuals with bipolar disorder who exhibit psychotic behaviors have deficits in reelin expression linked to genetic loci located on chromosome 22. Individuals with schizophrenia who exhibit psychotic behaviors have deficits in serotonin linked to genetic loci located on chromosome 16. Individuals with bipolar disorder who exhibit psychotic behaviors have deficits in gamma-aminobutyric acid (GABA) linked to genetic loci located on chromosome 20. Individuals with schizophrenia who exhibit psychotic behaviors have deficits in reelin expression linked to genetic loci located on chromosome 18.

Final Exam - NURS 6512 - Walden University - Advanced Health Assessment and Diagnostic Reasoning Final Exam - NURS 6512 - Walden University - Advanced Health Assessment and Diagnostic Reasoning Course NURS-6512D-1/NURS-6512N-1-NURS-6512D- 1/NURS-6512N-1- Advanced Health Assessment and Diagnostic ReasoningTest Final Exam
Started 8/1/19 11:30 AM Submitted 8/1/19 1:20 PMDue Date 8/12/19 1:59 AMStatus Completed
Attempt Score 93 out of 100 pointsTime Elapsed 1 hour, 34 minutes out of 1 hour and 50 minutes1. Costovertebral angle tenderness should be assessed whenever you suspect the patient may have: - Polynephritis2. In older adults, overflow fecal incontinence is commonly due to: -Fecal impaction3. A 1 month old boy has been vomiting for 2 weeks. How is this symptom of GERD and pyloric stenosis further differentiated in this child’s assessment? – The infant has regurgitation with pyloric stenosis4. Auscultation of borborygmi is associated with: - Gastroenteritis, early intestinal obstruction, or hunger5. When auscultating the abdomen, which finding would indicate collateral circulation between the portal and systemic venous systems? – Venous hum6. Conversion of fat-soluble wastes to water-soluble material for renal excretion is a function of the: - Liver7. The major function of the large intestine is: -Water absorption8. Which structure is located in the hypogastric region of the abdomen? –Ileum, bladder, andpregnant uterus9. A 45 year old man relates a several week history of severe intermittent abdominal burning sensations. He relates that the pain is relieved with small amounts of food. Before starting the physical examination, you review his laboratory work, anticipating a (n): -Positive Helicobacter pylori result10. You are caring for a patient with trigeminal neuralgia. During the assessment, the patient would describe the pain as: - Burning or shocklike11. Your 85 year old patient is complaining of right knee pain. She has a history of osteoarthritis for which she is given anti-inflammatory medication. To assess her right knee pain, you should ask her if: - The pain gets better when she sits12. A 5 year old is complaining of nondescriptive “belly pain.” Your next action should be to ask him to: - Point to the area of pain13. The perception of pain: - Is variable and is affected by emotions, and cultural background14. Patients presenting with ascites, jaundice, cutaneous spider veins, and nonpalpable liver exhibit signs of: - Cirrhosis15. A patient presents to the emergency department after a motor vehicle accident. The patient sustained blunt trauma to the abdomen and complains of pain in the upper left quadrant that radiates to the left shoulder. What organ is most likely injured? – Spleen16. Imaging studies reveal that a patient has dilation of the renal pelvis from an obstruction in the ureter, what condition will be documented in this patient’s health record? – Hydronephrosis17. Visible intestinal peristalsis may indicate: - Intestinal obstruction18. Infants born weighing less than 1500g are at higher risk for: - Necrotizing enterocolitis19. Which of the following factors is not known to affect patient compliance with his or her treatment regimen? – The patient’s age and social status20. One of the most important aspects to consider in the orthopedic screening examination is: -Symmetry21. The sequence of the physical examination should be individualized to: -22. As you greet the patient, which examination technique is first implemented? - Inspection23. Which of the following is most likely to enhance examiner reliability? – The examiner attempts to qualify data24. A 7 year old boy is brought to your office with a chief complaint of possible fracture to his left third finger. He jammed it while playing basketball 2 days ago. The mother states that she really does not think it is broken because he can move it. What is your best response? – This is common misconception, and the finger may be broken. An x-ray is indicated.25. A patient presenting for the first time with typical low back pain should receive which of the following diagnostic tests?26. Skeletal changes in older adults are the result of: -Increased bone resorption 27. A positive straight leg raise test usually indicates: - Lumbar nerve root irritation28. What technique is performed at every infant examination during the first year of life to detect hip dislocation? – Barlow-Ortolani maneuvers29. Expected normal findings during inspection of spinal alignment include: - Convex lumbar curvenumber of times the patient has to change positions to conserve the patient’s energyMinimize theusually musculoskeletal etiology.– None of the above. X-ray is not indicated because lumbar pain is30. Temporalis and masseter muscles are evaluated by: - Having the patient clench his or her teeth31. When palpating joints, crepitus may be caused when: - Irregular bony surfaces rub together32. A 3 year old is brought to the clinic complaining of a painful right elbow. He is holding the right arm slightly flexed and pronated and refuses to move it. the mother states that symptoms started right after his older brother had been swinging him around by his arms. This presentation supports a diagnosis of: - Radial head subluxation33. Light skin and thin body habitus are risk factors for: - Osteoporosis34. Risk factors for sports-related injuries include: - Failure to warm up before activity35. Injuries to long bones and joints are more likely to result in fractures than in sprains until: -Adolescence36. Ligaments are stronger than bone until: - Adolescence37. The family history for a patient with joint pain should include information about siblings with: -Genetic disorders38. The Thomas test is used to detect: - Flexion contractures of the hip39. A goniometer is used to assess: - Range of motion40. During a football game, a player was struck on the lateral side of the left leg while his feet were firmly planted. He is complaining of left knee pain. To examine the left knee you should initially perform the ________ test. – Valgus stress41. You note that a child has a positive Gower Sign. You know that this indicates generalized: -Muscle weakness42. The dowager hump is: - The hallmark of osteoporosis43. What temporary disorder may be experienced by pregnant women during the third trimester because of fluid retention? –Carpal tunnel syndrome44. A common finding in markedly obese and pregnant women is: - Lordosis45. A 45 year old laborer presents with low back pain, stating that the pain comes from the right buttock and shoots down and across the right anterior thigh, down the shin to the ankle. Which examination finding is considered more indicative of nerve root compression? – Positive straight leg raise result46. Mrs. Bower is a 57 year old patient who comes in for an office visit. Which of the following disorders is known to be hereditary? – Huntington chorea47. Testing of cranial nerve ________ is not routinely performed unless a problem is suspected.–I48. The patient is able to rapidly touch each finger to his thumb in rapid sequence. What does this finding mean? – The patient has appropriate cerebellar function49. Which question asked by the examiner may hellp to determine prevention strategies for seizures that a patient is experiencing? – “Are there any factors or activities that seem to start the seizures?”50. A patient has a complaint of dizziness. The patient makes the following statement: “I sometimes feel as if the whole room is spinning.” What type of neurologic dysfunction should the examiner suspect? – Inner ear dysfunction affecting the acoustic nerve51. The examiner asks the patient to close her eyes, then places a vibrating tuning fork on the patient’s ankle and asks her to indicate what is felt. What is being assessed? – Peripheral nerve sensory function52. Which of the following findings should an examiner consider a normal finding if associated with pregnancy? – Acroparesthesia52. Jack is a 52 year old obese man with a history of poorly controlled diabetes. He also smokes. Based on the above data, the examiner should recognize that Jack has several risk factors for: - Cerebrovascular accident53. Mrs. Jones is a 24 year old patient who presents to your office 2 days postpartum. She complains that she is experiencing foot drop. Which of the following problems should the examiner consider? – Lumbosacral plexopathy54. The examiner is assessing deep tendon reflex response in a 12 year old boy. The response is an expected reflex response. Which of the following scores should be documented? – 2 55. A 68 year old patient presents to your office for follow-up. He tells you, “I have a hard time finding the right words when I am talking;” he also is experiencing numbness. On examination, you note postural instability. This symptom may be: - A late symptom of Parkinson’s disease56. Motor maturation proceeds in an orderly progression from: - Head to toe 57. The thalamus is the major integration center for perception of: - Pain58. The examiner should be concerned about neurologic competence if a social smile cannot be elicited by the time a child is ________old. – 3 months59. Normal changes of the aging brain include: -60. When interviewing a 70 year old female clinic patient, she tells you that she takes ginkgo biloba and St. John’s Wort. You make a short note to check for results of the: -Mini-mental state examination61. The area of body surface innervated by a particular spinal nerve is called a: - Dermatome 62. If a patient cannot shrug the shoulders against resistance, which cranial nerve (CN) requiresfurther evaluation? – CN XI, spinal accessory63. The finger-to-nose test allows assessment of: - Coordination and fine motor function64. You ask the patient to follow a series of short commands to assess: - Attention span65. As Mr. B. enters the room, you observe that his gait is wide based and he staggers from side to side while swaying his trunk. You would document Mr. B.’s pattern as: - Cerebellar ataxia66. When is the mental status portion of the neurologic system examination performed? –Constantly throughout the entire interaction with a client67. An aversion to touch or being held, along with delayed or absent language development, is a characteristic of: -Autism68. The autonomic nervous system coordinates which of the following? – Internal environment of the body69. The major function of the sympathetic nervous system is to: - Orchestrate the stress response70. The parasympathetic nervous system maintains the day-to-day function of: - Digestion 71. Cerebrospinal fluid serves as a: - Shock absorber72. You are performing a two-point discrimination test as part of a well physical examination. The area with the ability to discern two points in the shortest distance is the: -Finger tips73. Which type of hallucination is most commonly associated with alcohol withdrawal? – Visual- bugs, pink elephantsDiminished perception of touch. -- this is byprocess of elimination/educated guess. I could not find direct information addressing this inSeidel74. On a scale of 0 to 4 , which deep tendon reflex score is appropriate for a finding of clonus in a patient? –3 75. Which statement is true regarding mental status changes in older adults? – There is an increased risk of delirium with acute illness or metabolic derangement.76. A characteristic related to syphilis or diabetic neuropathy is testicular: -Insensitivity to painful stimulation77. When collecting personal and social history data from a woman complaining of breast discomfort, you should question her regarding: - Alcohol, tobacco, and caffeine use78. What risk factor is associated with cervical cancer? – HPV79. A 23 year old female presents with severe right lower quadrant tenderness. All of thefollowing should be considered in the differential except: - Classis diverticulitis80. What is the initial diagnostic radiology test that should be ordered if you suspect a rupturedovarian cyst? – Abdominal and transvaginal ultrasound81. A 17 year old male was brought into the emergency room with testicular/scrotal pain. Thedifferential diagnosis should include all except: - Inguinal herniation82. The nursing mother complains that her breasts are tender. You assess hard, shiny, and erythremic breasts bilaterally. You should advise the patient to: - Massage gently and continue nursing83. A normal vas deferens should feel: - Smooth84. In a woman complaining of a breast lump, it is most important to ask about: - Itsrelationship to menses85. The finding of a painless indurated lesion on the glans penis is most consistent with: -Chancre86. Thrombosed hemorrhoids are: - Blue, shiny, painful masses87. Pregnancy-related cervical changes include: - Softening and bluish coloring88. You are inspecting the genitalia of an uncircumcised adult male. The foreskin is tight and cannot be easily retracted. You should: - Inquire about previous penile infections89. An adolescent male is being seen for acute onset of left testicular pain. The pain started 3 hours ago. He complains of nausea and denies dysuria or fever. Your prioritized assessment should be to: - Establish absent cremasteric reflex90. A 23 year old white woman has come to the clinic because she has missed two menstrual periods. She states that her breasts have enlarged and that her nipples have turned a darker color. Your further response to this finding is: - Suggest pregnancy testing91. What accommodations should be used in the position of a hearing-impaired woman for a pelvic examination? – The head of the table should be elevated92. Sexual differentiation in the fetus has occurred by _______weeks gestation. - 1293. You are performing a clinical breast examination for a 55 year old woman. While palpating the supraclavicular area, you suspect that you felt a node. In order to improve your hooked technique, you should: -Ask the patient to turn her head toward that side94. If a firm, transverse ridge of compressed tissue is felt bilaterally along the lower edge of a 40 year old patient’s breast, you should: -Record the finding in the patient’s record95. A therapeutic technique for dealing with grieving individuals is to: - Tell them that is good to cry and to share feelings96. The examination of the newborn should begin with: - Inspection noting skin color, flaccidity, tension, gross deformities, or distortions of facies97. Which one of the following patient characteristics is most likely to limit patient reliability during history taking? – Patient is sleep and sensory deprived98. In crying infants, it is often difficult to: - Auscultate heart sounds99. Which of the following statements accurately reflects the sensitivity and specificity oflaboratory tests? – No test has 100% sensitivity and specificity100. Which medical condition would exclude one from sports participation? – Fever101. Your 15 year old patient is athletic and thin. Radiography of an ankle injury reveals a stress fracture. You question this patient about her: - Menstrual cycles102. Which of the following are examined with the patient in a reclining 45 degree position? –Jugular venous pulsation and pressure103. Functional assessment is most important during the examination of a(n): -Older adult104. The best way to ease the apprehension of a 3 year old child before a physical examination is to: - Encourage child’s participation105. An ophthalmoscopic eye examination involves: - Lens inspection106. When conducting a geriatric assessment, basic activities of daily living (ADLs) include: -Bathing107. The checkout station for preparticipation physical evaluation (PPE) is critical because at this point: - The coordination of follow-ups is reviewed108. Which of the following is true regarding the relationship between the examiner and the patient? – The patient is a full partner with the examiner109. Which of the following factors is not known to affect patient compliance with his or her treatment regimen? – The patient’s age and social status110. One of the most important aspects to consider in the orthopedic screening examination is:- To look for symmetry of muscle, stature, and joint movement111. As you greet the patient, which examination technique is first implemented? – Inspection 112. Which portion of the physical examination is best done with the patient standing? –Spinal 113. Which patient position facilitates inspection of the chest and shoulders? – Sitting114. The least reliable indicator of newborn distress is: - Color115. Proprioception should be assessed while the patient is: - Standing116. Part of the screening orthopedic component of the examination includes evaluating the person while: - Duck walkingHealth Assessment Final Review ExamMust have 78% to pass between both exams Always go with the text bookMENTAL ASSESSMENT (Ch 5 pgs 64-78)1. What does orientation to person, place, and time assess? When you perform assessment, what exactly are you looking for? Pg. 67Person, place and time assess state of consciousness. When performing this assessment you are looking for cognitive function. Person disorientation is a result of cerebral trauma, seizures, or amnesia; Place disorientation occurs with psychiatric disorders, delirium, and cognitive impairment; Time disorientation is associated with anxiety, delirium, depression, and cognitive impairment.8. Assessing orientation to person, place, and time helps determineANS: DOrientation to person, place, and time are measures of states of consciousness and awareness, not degrees of attention span. Analogies and abstract reasoning are higher functions than orientation. Emotional status can be better evaluated by observing behaviors.2. How many serial numbers should most people be able to repeat? For example: counting backwards. How many should the average person be able to repeat? Pg. 70Five to eight numbers forward or four to six backward can usually be repeated.10.Under most conditions, adult patients should be able to repeat a series of _____ numbers.ANS: BMost adults should be able to recall immediately a series of five to eight numbers forward and four to six numbers backward.3. How do you assess recent memory if you’ve had a patient your worried about memory? What technique and how would you assess recent memory? Pg. 70Give the patient a short time to view four or five test objects, telling them you will ask them about them in a few minutes. Ten minutes later, ask the patient to list the objects.14.Recent memory may be tested ability to understand act tion of onal to to eightc.10 to 15d.15 to than g the patient to do simple g the patient to listen to and repeat a series of ng the patient four items and asking him or her to list the items about 10 minutes g the patient about verifiable past events, such as his or her mother’s maiden g the patient to name the past four presidents.ANS: CShowing the patient four or five objects, saying you will ask about them in a few minutes, and then 10 minutes later asking the patient to list the objects is a technique to measure recent memory. The other choices are not tests of recent memory. Asking the patient to listen and then repeat tests immediate recall.4. What pysch or mental condition is considered progressive and not reversible? Pg. 76, 78 Dementia (see differential diagnosis).27. Which condition is considered progressive rather than reversible?ANS: BDementia is considered progressive and irreversible, delirium and coma have the potential for reversal, and depression and anxiety are reversible.26. An older adult is administered the Set Test and scores a 14. The nurse interprets this score as indicative ofANS: EScores of less than 15 on this mental function test indicate dementia.28.Which of the following is usually related to structural diseases of the brain?ANS: BOne of the distinguishing characteristics that distinguishes dementia from the others is that it is usually related to structural diseases of the brain such as abnormal deposits, or recurrent strokes.5. If patient is delirious do they maintain orientation and attention span? Look up delirium and see what you expect patient to maintain. Pg. 75,76a.Deliriumb.Dementiac.Depressiond.Anxietye.Ctive tia.a.Deliriumb.Dementiac.Depressiond.Anxietye.Psychosis2Patient suffering from delirium is usually disoriented (usually oriented to person only) and have an impaired attentiveness. (pg 461 in Adv. Assessment) In spite of the confusion, the patient’s sensorium (consciousness) is usually intact although some condition (intoxication and severe metabolic derangements) result in altered level of consciousness.9.A state of impaired cognition, consciousness, mood and behavioral dysfunction of acute onset refers toANS: BDelirium is a state of impaired cognition, consciousness, mood and behavioral dysfunction of acute onset. Stupor describes arousals for short periods of time after a stimulus for arousal (e.g., visual, verbal, or painful). Lethargy relates to sleepiness with ease of arousal; coma is nonarousal and nonawareness. Confusion relates to inappropriate responses to questions with decreased attention span and memory.6. Who should you give a mini mental exam to? Everyone or certain patients? Pg. 67,68The mini mental exam should be given to elderly patients when there is a concern about their cognitive function. This testdetects probable dementia.34.The Mini-Mental State Examination should be administered for a patient whoANS: AThe MMSE is a tool used to estimate cognitive function quantitatively or document cognitive changes serially. Getting lost in a familiar territory is a sign of possible cognitive impairment.6. The Mini-Mental State Examination (MMSE)ANS: AThe MMSE is a standard tool that functions to estimate cognitive function quantitatively7.While interviewing a 70-year-old female clinic patient, she tells you that she takes ginkgo biloba and St. John’s wort. You make a short note to check for results of lost in her or his s an excessive amount of repetitive ritualistic illegal hallucinogenic a fear of leaving the be used to estimate cognitive changes be used to estimate personality disorders s do not vary with regard to age or determine the cause of memory a good tool to diagnose neurologic disorders.a.Denver II.b.Mini-Mental State Examination.3c.Glasgow Coma Scale.d.Goodenough-Harris Drawing Test.e.CAGE Questionnaire.ANS: BGinkgo biloba and St. John’s wort are herbal remedies used to improve mental alertness and elevate mood. As side effects, they can also result in disorientation and confusion that can be monitored with the Mini-Mental State Examination. The Denver and Goodenough- Harris tests are used for childhood development, and the Glasgow Coma Scale is used to rate coma depth. The CAGE Questionnaire is a useful tool for approaching a discussion of the use of alcohol.BREAST EXAM1. With documenting breast exams, how do you divide the breasts? If you want a radiologist to concentrate on one particular area of the breast, how do you divide to communicate findings? Pg. 351The breast is divided into five segments, four quadrants and a tail (upper inner, upper outer, lower inner, and lower outer).Either the right or left breast should be communicated. The terms: upper inner, upper outer, lower inner, lower outer, and tail of Spence should be communicated to the radiologist in terms of how to communicate findings.3.For purposes of examination and communication of physical findings, the breast is divided intoANS: CThe breast is referenced according to five segments: four quadrants and a tail.11. When conducting a clinical breast examination, the examiner shouldANS: DInspection with simultaneous observation of both breasts is essential in order to detect differences between the breast size, symmetry, contour, and skin color.2. If you have a pt c/o breast lump, what questions do you ask? For example you have a 50 year-old with breast lump, how do you begin exam compared to a 30 year-old pt?(just arbitrary ages) What assessment do you do and what questions would you ask based on age? Pg.9. Which breast change is typical after menopause?s (upper and lower).s (left, middle, and right). quadrants plus a es (six consecutive rings, each 1 inch farther away from nipple).l portions 1 through the examination if the patient has had a recent the patient covered to respect the lights to minimize ct both breasts with palpation of the breasts.a.Thickening of the inframammary ridgeb.Hypertrophy of glandular tissuec.Increase in number of lactiferous ductsd.Reduction of fat deposits4e.Shortening of Cooper’s ligamentsANS: A. After menopause, the breast tissue atrophies and is replaced by fat deposit, the inframammary ridge at the lower edge of the breast thickens, and the breast hangs more loosely as Cooper’s ligaments relax.10. In a woman complaining of a breast lump, it is most important to ask aboutANS: AHormonal changes of menstruation can result in breast tenderness, swelling, and enlarged nodes that can be felt on palpation.12. A 50-year-old woman presents as a new patient. Which finding in her personal and social history would increase her risk profile for developing breast cancer?ANS: CNulliparity or late age at birth of first child (after 30 years old) is a risk factor for breast cancer. Other risk factors include late menopause, early menarche, and drinking more than one alcoholic drink daily.1. What position do you put a patient in for a breast exam? What position is the examiner standing in? Axillary nodes what position does the patient need to be in? Pg. 355-3622. 14. To begin the clinical breast examination (CBE) for a man, ask him toANS: B Inspection begins the CBE. Ask the patient to sit with his arms hanging loosely at his sides. The technique is the same for both men and women.15.Inspection of the breasts usually begins with the patient in which position?ANS: BInspection begins with the patient in a sitting position with arms hanging loosely at the sides. Inspection (pg. 355): As the patient sits with arms hanging loosely at the sides, inspect each breast and compare it with the other for size, symmetry, contour, skin color, and texture, venous pattern, and lesions. Re-inspect the woman’s breasts with the patient in the following positions (pg. 357-358): relationship to t ization ol consumption.a.Drinking three glasses of wine per weekb.Early menopausec.Nulliparityd.Late menarchee.Young age at birth of first ne on the table with his arms with his arms hanging at his with his hands on his with his arms clasped behind his leaning forward.a.Lateralb.Sittingc.Standingd.Supinee.Proneo Seated with arms over the head or flexed behind the neck. This adds tension to the suspensory ligaments, accentuates dimpling, and may reveal variations in contour and symmetryo Steadied with hands pressed against hip with shoulders rolled forward (or alternatively have the patient push her palms together): This contracts the pectoral muscles, which can reveal deviations in contour and symmetryo Seated and leaning forward from the waist: This also causes tension in the suspensory ligaments. The breasts should hang equally. This maneuver can be particularly helpful in assessing the contour and symmetry of large breasts because the breasts fall away from the chest wall and hang freely. As the patient leans forward, support her by the hands. Patient in Seated Position (pg. 360)o Chest Wall Sweep: Have the patient sit with arms handing freely at the sideso Bimanual Digital Palpation: Place on hand, palmar surface facing up, under the patient’s right breasto Lymph Node Palpation: To palpation the axillae, have the patient seated with arm flexed at the elbow. Support the patient’s left lower arm with your left hand while examining the left axilla with your right hand. Patient in Supine Position (pg. 360): Have the patient raise one arm behind her head; then place a small pillow or folded towel under that shoulder to spread the breast tissue more evenly over the chest wall. The ideal position for examination is to have the nipple pointing toward the ceiling.b.) Axillary nodes what position does the patient need to be in? (pg. 360)Lymph Node Palpation: To palpation the axillae, have the patient seated with arm flexed at the elbow. Support the patient’s left lower arm with your left hand while examining the left axilla with your right hand.3. What’s the difference between fibrotic breast tissue and breast cancer? How do you expect each to feel? What are the characteristics of the two?17.Which finding, found on inspection, is related to fibrotic tissue changes that occur with breast carcinoma?ANS: BSkin dimpling or retraction signifies the contraction of fibrotic tissue that occurs with carcinoma. The other choices are normal variations without significance to cancer development.18. Venous patterns on breasts are suggestive of pathology when they areANS: CMalignant tumors require more blood flow. Superficial veins dilate to provide more flow and can be assessed as unilateral venous patterns. Bilateral findings are of no concern and are more commonly seen in pregnant or obese women. Nevi that are long-standing, unchanging, or nontender are of little concern.21.In patients with breast cancer, peau d’orange skin is often first evidenta.Convex or conical shapeb.Skin dimpling or retractionc.Pendulous and loose breastsd.Unequal shape or contoure.Lifelong inverted erally in obese ved during iated with a long-standing unchanging the the upper inner or around the the inframammary the tail of Spence.ANS: CThe areola is the most common initial site to visualize peau d’orange skin.24.Recent unilateral inversion of a previously everted nipple suggestsANS: BRecent unilateral inversion or retraction of a previously everted nipple suggests malignancy rather than a benign condition.41.You are conducting a clinical breast examination for a 30-year-old patient. Her breasts are symmetrical with bilateral, multiple tender masses that are freely moveable with well-defined borders. You recognize that these symptoms and assessment findings are consistent withANS: EFibrocystic changes are tender masses, usually bilateral, with multiple round, mobile, well-delineated borders. Fibroadenoma and cancer are usually nontender; Paget disease is an eczema-like condition of the nipple that signals an underlying cancer. Mammary duct ectasia most commonly occurs in menopausal women. Fibrocystic Changes (pg. 366):o Benign fluid-filled cyst formation caused by duct enlargement o Pathophysiology Usually bilateral and multiple Most common in women 30 to 55 years of age Associated with long follicular or luteal phase of the menstrual cycleo SubjectiveData Tender and painful breasts and/or palpable lumps that fluctuate with menses  Usually worse premenstruallyo ObjectiveData Round, soft to firm, tense, mobile masses with well-delineated borders  Usually tender Usually bilateral Multiple or single Fibroadenoma (pg. 366): n breast adenoma.b.Paget ry duct cystic changes.o Pathophysiology May occur in girls and women of any age during their reproductive years  After menopause, the tumors may regresso SubjectiveData Painless lumps that do not fluctuate with the menstrual cycle May be symptomatic with discovery on clinical breast examination or breast imagingo ObjectiveData Round or discoid, firm, rubbery, mobile masses with well-delineated borders  Usually non-tender Usually bilateral Single; may be multiple Biopsy often performed to rule out carcinoma Malignant Breast Tumors (pg. 366): Ductal carcinoma arises from the epithelial lining of ducts; lobular carcinoma originates in the glandular tissue of the lobuleso Pathophysiology Mutations to normal cells results in uncontrolled cell division and tumor formation; as the tumor grows andinvades surrounding tissue, metastases occurs through the lymph and vascular systems Peak incidence between the ages of 40 and 75 years, with the majority of malignant breast tumors occurring in women older than 50o SubjectiveData Painless lump; change in size, shape, or contour of breast Axilla may be tender if lymph nodes involved May be asymptomatic with discovery on clinical breast examination or breast imagineo ObjectiveData May be palpable mass that is usually single, unilateral, irregular, or stellate in shape; poorly delineatedborders; fixed; hard or stone-like; and non-tender Breast may have dimpling, retraction, prominent vasculature Skin may have peau d’orange or thickened appearance Nipple may be inverted or deviated in position(Differential diagnosis pg. 365)Fibrotic: usually bilateral, multiple or single, round, soft to firm; tense, mobile, absent retraction signs, usually tender, bordersare well delineated, and they vary with menses.Cancer: Usually unilateral, single, irregular or stellate, hard/stonelike, fixed, retraction signs are often present, usually nontender, the borders are poorly delineated; irregular, and they do not vary with menses.4. Breast Exam- What part of the hand do you use? Fingertips, pads, palms, entire hands? Pg. 361Palpate using your finger pads as they are more sensitive than your fingertips. Palpate systematically, pushing gently but firmly toward the chest wall, as you rotate your fingers in a clockwise or counterclockwise pattern. At each point, as you rotate your fingers press inward, using three depths of palpation: light then medium and finally deep. The exact sequence you select for palpation is not critical, but a systematic approach will help ensure that all portions of the breast are examined.26.When palpating breast tissue, the examiner should use the _____ at each r of the surface of the sANS: BThe finger pads are used for breast palpation because they are more sensitive than the fingertips.5. What is Peau d'orange skin? Look, feel, mean? Pg. 356The skin has an orange peel appearance. This indicates edema of the breast caused by blocked lymph drainage in advanced orinflammatory breast cancer. The skin appears thickened with enlarged pores and accentuated skin markings.6. What is the tail of Spence? Where is it anatomically? Pg. 351The tail of Spence is (extends from) the greatest amount of glandular tissue that lies in the upper outer quadrant and extendsinto the axilla. ??????2.The largest amount of glandular breast tissue lies in theANS: DThe greatest amount of glandular tissue in the breast lies in the upper outer quadrant.31.The tail of Spence extendsANS: DThe tail of Spence extends from the upper outer breast quadrant into the axillae.7. Breast Exam: Certain groups of lymph nodes are enlarge, where would they be for examiner to expect Breast Cancer? Pg. 360The axilla, supraclavicular and infraclavicular areas. Nodes that are detected should be described according to location, size, shape, consistency, tenderness, fixation, and delineation of borders.34.When examining axillary lymph nodes, the patient’s arm inner of S outer the midclavicular d the supraclavicular into the inframammary the the sternal d full above the ded at the ed against the ed over the d at the elbow.ANS: ETo examine the axilla, support the patient’s lower arm with the elbow flexed with one of your hands and use your other hand to palpate the axilla.35.Lymphatic flow of the breast primarily drainsANS: CEach breast contains a lymphatic network that drains the breast radially and deeply to underlying lymphatics.36. The greatest concern for breast cancer is when you palpate _____ nodes.ANS: DThe supraclavicular and infraclavicular nodal areas are sentinel nodes; any enlargement in these areas is especially significant.37.You are performing a clinical breast examination for a 55-year-old woman. While palpating the supraclavicular area, you suspect that you felt a node. To improve your hooked technique, you shouldANS: EHaving the patient turn her head toward the examination side, as well as raising the shoulder on that same side, gives your fingers more room to palpate deeper into the fossa.8. What if you have a 20-30 year-old with freely moveable, well-defined lump, tender with cycle, cancer or more likely fibrotic? Fibrotic (see page 365)iorly toward the ally toward the corresponding lly toward the omedially toward the ior nal lotion to your both hands the patient to press both palms the patient to lower her shoulder on that the patient to turn her head toward that side.1041.You are conducting a clinical breast examination for a 30-year-old patient. Her breasts are symmetrical with bilateral, multiple tender masses that are freely moveable with well-defined borders. You recognize that these symptoms and assessment findings are consistent withANS: EFibrocystic changes are tender masses, usually bilateral, with multiple round, mobile, well-delineated borders. Fibroadenoma and cancer are usually nontender; Paget disease is an eczema-like condition of the nipple that signals an underlying cancer. Mammary duct ectasia most commonly occurs in menopausal women.9. Then you have a 50 year-old-lump firm, fixed, doey-like, cancer or fibrotic? Cancer FEMALE GENITALIA1. Pelvic Exam-anatomy of vagina and location of glands-5 O’clock, 7 O’clock for example, just know the anatomy of the male and female genitals.2. What structures are located at the 5 o’clock and the 7 o’clock positions of the vaginal orifice and open onto the sides of the vestibule in the groove between the labia minora and the hymen?ANS: DBartholin glands are found posteriorly on each side of the vaginal orifice and open onto the sides of the vestibule.2. Cervical Cancer- know patient’s history and what questions to ask patients that put them at high risk for cervical cancer.12. Which factor is associated with an increased risk of cervical cancer?ANS: EWomen who were younger than 17 years when they had their first full-term pregnancy are almost 2 times more likely to get cervical cancer later in life than women who were not pregnant until they were 25 years or adenoma.b.Paget ry duct cystic changes.a.Skene glandsb.Perineal bodiesc.Labia majorad.Bartholin glandse.Labia minoraa.Endometriosisb.Low parityc.HPV vaccinationd.High socioeconomic statuse.Early parity113. What history increases your risk for ovarian cancer? (pg. 425)Risk factors for ovarian cancer (box on p. 425 below cervical risk factors): Age (increases with age), inherited genetic mutation (BRCA1 or BRCA2 gene), family history, obesity, reproductive history (nulliparity increases risk), and the use of fertility drugs, personal history, hormone replacement therapy, and high-fat diet.13.The risk of ovarian cancer is increased by a history ofANS: EThere is a relationship between nulliparity and an increased risk of ovarian cancer. Although the risk increases with age, most ovarian cancers develop after menopause; half are found in women older than 63 years. The other choices have no relationship with ovarian cancer.4. What is a normal cervix and an abnormal cervix? What does an abnormal one look like (not cancerous) what tests might you and what might indicate? Disorder?22. During digital examination of the vagina, the cervix is noted to be positioned posteriorly. Upon bimanual examination of this woman, you would expect to palpate a(n) _____ uterus.ANS: BThe position of the cervix correlates with the position of the uterus. A cervix that is pointing posteriorly indicates an anteverted uterus.23. The presence of cervical motion tenderness may indicateANS: CPainful cervical motion tenderness suggests a pelvic inflammatory disease or a ruptured tubal pregnancy. The cervix is expected to move 1 to 2 cm without discomfort under normal conditions.25.During a routine vaginal examination, you insert the speculum and visualize the cervix. The cervix projection into the vaginal vault -fat ette between 35 and 50 body ally c inflammatory nancy.12approximately 5 cm. Upon bimanual examination, you would expect to find the the midline the retroverted the anteverted ted to the left or the retroflexed position.ANS: DNormally, the cervix protrudes into the vagina 1 to 3 cm. Longer projections suggest a pelvic or uterine mass. A pelvic mass would cause the uterus to be deviated to the right or left, but an anteverted, retroverted, or retroflexed uterus would still be in the midline regardless of its position.26.Small, pale yellow, raised, and rounded areas are visualized on the surface of the cervix. You shouldANS: AThis describes nabothian cysts, which are retention cysts of the endocervical glands and are considered a normal variant. No further testing is this as nabothian this as a friable n a viral the pH of the cervical this as an eroded cervix.a.b.c.Normal cervix: covered with pink squamous epithelium that is uniform in consistency. It should be in an anterior- posterior position that correlates with the position of the uterus. The os is small and round. A small area of ectropion is visible inferior to the os. Cervix should feel firm (during pregnancy will be softer) and be smooth.Abnormal cervix: Bluish color indicates increased, which may indicate pregnancy. A pale cervix is associated with anemia. If the cervix is pointed anteriorly it indicates a retroverted uterus; pointing posteriorly indicated an anteverted uterus. Horizontal indicated a uterus in midposition; deviation indicated a pelvic mass, uterine adhesions, or pregnanacy. Projection greater than 3 cm may indicate a pelvic or uterine mass. Small, white or yellow raised, round areas may indicate nabothian cysts. Friable tissue, red patchy areas, granular areas, and white patches could indicate cervicitis, infection, or carcinoma.Feel for nodules, harness, and roughness. Note the position of the cervix, it should be in the midline and may point anteriorly or posteriorly. Grasp the cervix between your fingers and move it gently from side to side (should move 1-2 cm). There should be no pain or discomfort. Painful cervical movement suggests a pelvic inflammatory disease or a ruptured tubal pregnancy which would require immediate surgery.5. What structure or organs are examined during a Bimanual exam? (pg 436-437). Cervix, Uterus, Adnexa, and Ovaries33.The assessment of which structure is not part of the bimanual examination?a.Cervixb.Bladderc.Uterusd.Ovariese.Adnexa13ANS: BThe bimanual examination consists of assessing the cervix, uterus, adnexa, and ovaries.6. When do PAP smears begin? Age of non-sexually active versus sexually active women? (pg. 437) 21 for non-sexually and sexually active women because cervical cancer is rare for women under age 21.40.When a woman is not sexually active, cervical cancer screening should beginANS: DWomen who are not sexually active should have their first examination by the age of 21 years. Women under age 21 should not be tested.7. Menopausal women- what does the vagina and mucosa of the walls feel like? (pg. 447)The vagina is narrower and shorter. You will see and feel the absence of rugae. The cervix is smaller and paler but the osshould still be palpable and the cervix may be less mobile.43.During a pelvic examination for a postmenopausal woman, you would expect to assessANS: BExpected findings in the pelvic examination for an older woman include a narrower and shorter vagina, absence of rugation, a less mobile cervix, and a palpable cervical os. The ovaries are rarely palpable because of atrophy.MALE GU1. Males-history or what alerts the examiner of the possibility of testicular cancer? (pg. 470).Undescended testicle, personal hx of testicular CA, family hx of testicular CA, abnormal testicle development (klinefelter syn), 20-54 yr male, the most prominent in white race ( 5 times that of black; more than 3 times that of Asian American and Native American men).13.Which of the following is a risk factor for testicular cancer? age 15 age 18 age 21 age 30 years.a.a wider and longer vaginal ce of vaginal wall rugation.c.a nonpalpable cervical os.d.a more mobile ble ovaries.a.Circumcisionb.Condyloma acuminatumc.Cryptorchidism14d.Poor hygienee.Multiple sexual partnersANS: CCryptorchidism (testes that fail to descend by 12 months of age) is a risk factor for testicular cancer.27.The most common cancer in young men age 15 to 30 years isANS: ABecause testicular tumors are the most common cancer occurring in young adults, self-examination is encouraged.37.Self-examination of the male genitaliaANS: BMonthly self-examination is recommended as a screening test for testicular cancer as well as sexually transmitted infections for all young men starting at 15 years of age. It is encouraged during bathing because the scrotal skin is less thick at this time and because the scrotum hangs looser because of the warmth. Inspection is done first followed by palpation.2. What alerts us to do further testing and the need to further and fully assess for testicular cancer? How do we do this?o Irregular, contender mass fixed to the testiso Does not transilluminateo May also have hydrocele(that doesn't transilluminate) o InguinalLymphadenopathyo Painless mass in testicleo Scrotalenlargementorswellingo Heavy feel in in scrotumo Dull ache in lower abdomen, back or groino fluid in scrotumThis can be done by performing a Testicular exam ( inspect and palpate), Scrotal US, Lab work including: Chemistry, WBC count, biochemical markers AFP and B-hCg.21.Mr. L. has an unusually thick scrotum with edema and pitting. He has a history of cardiac problems. The appearance of his scrotum is more likely a(n)ANS: BGeneral fluid retention can cause scrotal thickening and pitting edema and is more often seen as a result of cardiac, renal, or hepatic disease. This swelling does not imply a condition of the genitalia but rather a condition of these related d be restricted to adults with prior d be performed while s with palpation and then d be performed t be adequately performed due to poor visualization of the nital defect that has ation of general fluid l consequence of ication to the development of quence of prior STDs.1525.An enlarged, painless testicle in an adolescent or adult may cular torsion.c.a undescended padias.ANS: CA hard, enlarged, painless testicle can indicate a tumor in an adolescent or adult male. Epididymitis and torsion are painful; an undescended testicle is common in infants and is usually resolved by 12 months. Hypospadias is a congenital defect of the urethral opening causing the meatus to be located ventral to its normal position.26.You palpate a soft, slightly tender mass in the right scrotum of a man. You attempt to reduce the size of the mass, and there is no change in the mass size. Your next assessment maneuver is toANS: DA soft mass is either a hernia or hydrocele. If the mass can be reduced, it is probably a hernia; a nonreducible mass should be transilluminated to determine whether it contains fluid and is possibly caused by a hydrocele. Lifting the scrotum should be done when epididymitis is suspected. Urethral cultures are not indicated at this point.29.An adolescent male is being seen for acute onset of left testicular pain. The pain started 3 hours ago. He complains of nausea and denies dysuria and fever. Your prioritized assessment should be toANS: CThe patient is displaying symptoms of testicular torsion. An absent cremasteric reflex is a supporting finding to differentiate torsion from epididymitis.38. A 12-year-old boy says that his left scrotum has a soft swollen mass. The scrotum is not painful upon palpation. The left inguinal canal is without masses. The mass does transilluminate with a penlight. This collection of symptoms is consistent withANS: BA hydrocele is a soft scrotal mass that occurs from fluid accumulation and therefore does transilluminate. Orchitis results in a swollen, tender testis. A rectocele does not result in scrotal swelling. A scrotal hernia would also be palpable along the inguinal canal. Epididymitis is an extremely painful condition.41.A cremasteric reflex should result two fingers to attempt to reduce the te the left scrotum the right testicle, then compare pain illuminate the re the meatus for gonococcal n urine and DNA probe urethral the left scrotum to confirm lish absent cremasteric illuminate the left and right the patient stand and observe the scrotum for a “bag of worms.”al scrotum appear to contain a “bag of worms.”e deviation to the left um to elevate iate erection of the cle and scrotal rise on the stroked side.ANS: EUpon stroking the inner thigh with a blunt instrument or finger, the testicle and scrotum should rise on the stroked side.3. How do you assess for an inguinal hernia? Pg. 472-473Have the pt. stand and bear down. While he is straining inspect the area of the inguinal canal and the region of the fossa ovalis. After the pt. relaxes, insert your examining finger into the lower part of the scrotum and carry it upward along the vas deferens into the inguinal canal. You can also auscultate for bowel sounds, which will be present in uncomplicated reducible hernias.18.Which technique is appropriate to detect an inguinal hernia?ANS: EExamination for inguinal hernias is performed with the patient standing. Inspect the groin while the patient performs a Valsalva maneuver. Insert your examination finger into the lower part of the scrotum and follow upward along the vas deferens to screen for a hernia.19. Which type of hernia lies within the inguinal canal?ANS: CHernias found within the inguinal canal are called indirect hernias.4. What does Vas deferens feel like? Normal? Abnormal? Pg. 473The Vas deferens feels smooth and discrete; abnormal findings are beaded or lumpy feeling. This may indicate diabetes or oldinflammatory changes, especially tuberculosis.2.What structure of the male genitalia travels through the inguinal canal and unites with the seminal vesicle to form the ejaculatory duct?ANS: Da.Conduct percussion while the patient coughs.b.Have the patient strain as you pinch the testes.c.Inspect rectal areas as the patient bears down.d.Conduct the examination only in the supine position.e.Move your finger upward along the vas deferens.a.Umbilicalb.Directc.Indirectd.Femorale.Incisionala.Epididymisb.Corpus cavernosumc.Urethrad.Vas deferense.Ureter17The vas deferens begins at the end of the epididymis, travels the spermatic cord, goes through the inguinal canal, and then unites with the seminal vesicle to form the ejaculatory duct.23.A normal vas deferens should feelANS: BThe vas deferens should normally feel smooth, discrete, and nontender.5. Young man- what is an emergent cause of testicular pain? Pg. 482 Testicular Torsion is twisting of the spermatic cord and is a surgical emergency.29.An adolescent male is being seen for acute onset of left testicular pain. The pain started 3 hours ago. He complains of nausea and denies dysuria and fever. Your prioritized assessment should be toANS: CThe patient is displaying symptoms of testicular torsion. An absent cremasteric reflex is a supporting finding to differentiate torsion from epididymitis.28.The most emergent cause of testicular pain in a young male isANS: ETesticular torsion is a surgical emergency. If surgery is performed within 12 hours after the onset of symptoms, the testis can be saved in about 90% of cases. Delayed treatment results in a much lower salvage rate.6. Understand hernias, where located and how to assess each kind. Pg. 476, 477(see differential diagnosis).Hernia is protrusion of a peritoneal-lined sac through some defect in the abdominal wall. There are indirect, direct and femoral.7. What is the most common type of hernia? Pg. 477 Indirect Inguinal hernias are the most common type.31.The most common type of hernia occurring in young males n urine and DNA probe urethral the left scrotum to confirm lish absent cremasteric illuminate the left and right the patient stand and observe the scrotum for a “bag of worms.”cular cerated ect al.ANS: CThe most common type of hernia in children and young males is an indirect inguinal hernia.MUSCULOSKELETAL1. What is the difference between osteoarthritis versus rheumatoid arthritis?During an assessment what do you expect to see in a patient with osteoarthritis vs. RA? Findings in joints? Describe. OA (pg411)-A progressive disorder associated with age and wear and tear. There is loss of cartilage and progressive erosion of bone. Affects mostly larger bones like hips and knees, but frequently involves small joints of hands, especially distal and proximal interphalangeal joints. Asymmetrical distribution. Pain and stiffness improves with activity, and worsens with rest. Xrays show changes. Sed rate(-), Rheumatoid factor (-) RA (pg410)-If 3 or more metacarpophalangeal joints are swollen is RA. It’s a progressive, inflammatory, and erosive condition that usually affects multiple joints. It’s an autoimmune condition. Affects joints symmetrically. Affects small joints of hands and feet. Joints are tender, swollen with effusion, warm, inflamed. Nodules and deformities are noted. RA associated with: subluxation of metacarpophalgeal joins, hyperextension of joints, but also with changes in eye (scleritis, episcleritis, interstitial lung disease and pericardial disease.1. When does a musculoskeletal exam begin? (text tells you) pg405-The musculoskeletal examination is primarily limited to inspection and palpation. The focused musculoskeletal examination begins withinspection.2. How do you assess the strength of the trapezius muscle? (pg518)The strength of trapezius and sternocleoidomastoid muscle is tested by evaluating the cervical spine and asking patients to do certainmovement. Bend the head forward, chin to chest, and expect flexion of 45 degrees. Bend head to each side, ear to each shoulder and expect lateral bending of 40 degrees. Bend head backward, chin toward ceiling, and expect extension of 45 degrees.3. Patient with scoliosis, bend at waist, what is expected finding? Describe what it looks like (Pg541)When looking form the rear, the spine looks more like an “S” or a “C” than a straight line. There is no known cause. Associated with leg length discrepancy. There’s lateral curvature of spine as patient flexes forward to touch the toes. In severe deformities, patient has uneven shoulder and hip levels, and may have crease on one side of waist.194. Carpal Tunnel-What expect to feel like, how do you assess for? During assessment, particular nerve is tested, what is it? What sensation will the patient have?(pg430,524) The carpal tunnel is a space located on the anterior aspect of the wrist between the carpal bones and a ligamentous band through which the median nerve and several tendons transverse. With overuse and repetitive movements there’s a hypertrophy of tissues, causing a lot of space and impingement on the median nerve. Nighttime pain-early sign. Swelling at wrist related to inactivity of flexion at night, pain can radiate up the forearm to shoulder with numbness and tingling along the median nerve, and paresthesia involves anterior aspects of wrist, medial palm and first three digits of affected nerve. Relief is found by shaking affected hand in downward fashion. To assess, first ask patient to mark specific site using the Katz hand diagram.o Thumb abduction test isolates strength of abductor pollicis brevis muscle, innervated only by median nerve. Pt will place the hand palm up and raise the thumb perpendicular to it. Apply downward pressure on thumb to test muscle strength. Weakness=Carpal tunnel syndromeo Tinel sign: Strike pt’s wrist with your index or middle finger, where median nerve passes under the flexor retinaculum and volar carpal ligament(fig21.42). Tingling, means ( ) tiner sign and ( ) CPT syndrome.o Phalen test: pt holds both wrist in fully palmar-flexed position with dorsal surfaces pressed together for one min. Numbness and paresthesia in the distribution of median nerve is ( ) CPT syndrome.ABDOMINAL1. When conducting an abdominal exam, what position should the patient be in? Examiner? Techniques with rigid abdomen or anxious pt, what are relaxation techniques? (pg377)Need good light source; full exposure of abdomen; warm hands with short fingernails. Have pt empty bladder. Place pt is supine position with arms at sides. Approach pt from right side. Place small pillow under pt’s head and another under slightly flexed knees. Drape a towel or sheet over the patient’s chest for warmth and privacy. Be slow and gentle, avoid sudden movements.Percussion of the abdomen begins with establishinga. liver dullness.b. spleen dullness.c. gastric bubble tympany.d. overall dullness and tympany in all quadrants.e. bladder fullness.ANS: DPercussion begins with a general establishment over all quadrants for areas of dullness and tympany and then proceeds to specific target organs22. Before performing an abdominal examination, the examiner shoulda. ascertain the patient’s HIV status.b. have the patient empty his or her bladder.c. don double gloves.d. completely disrobe the patient.e. uncover only the painful areas of the abdomen.ANS: BThe patient should empty the bladder to ensure an accurate examination of organs as well as to provide comfort for the patient.2024. When examining a patient with tense abdominal musculature, a helpful technique is to have the patienta. hold his or her breath.b. sit upright.c. flex his or her knees.d. raise his or her head off the pillow.e. fully extend the legs.ANS: CTo help relax the abdominal musculature, it is helpful to place a small pillow under the patient’s head and under slightly flexed knees. The other choices increase muscle flexion.28. After thorough inspection of the abdomen, the next assessment step is toa. percuss.b. palpate nonpainful areas.c. auscultate.d. perform a rectal examination.e. palpate painful areas.ANS: CAssessment of the abdomen begins with inspection followed by auscultation. This break from the usual system examination sequence is because palpation and percussion can alter the frequency as well as the intensity of bowel sounds. Therefore, auscultation is done first.2. How long do you auscultate for BS? (pg380)Bowel sounds range from 5-35/min. If you’re unable to hear BS after 5 min of continues listening, associated with abdominal pain andrigidity then is surgical emergency.To correctly document absent bowel sounds, one must listen continuously fora. 30 seconds.b. 1 minute.c. 3 minutes.d. 5 minutes.e. 10 minutes.ANS: DAbsent bowel sounds are confirmed after listening to each quadrant for 5 minutes.3. What is the technique for percussing the liver border? Where to start, how you move, what are you listening for? (pg381)Begin liver percussion at the right midclavicular line over an area of tympany. Always begin with an area of tympany and proceed to area of dullness for easiness. Percuss upward along the midclavicular line to determine lower border of liver. The area of liver dullness is usually heard at the costal margin or slightly below it. Mark with a pen. A lower liver border that is more than 2-3 cm below costal margin may indicate organ enlargement or downward displacement of diaphragm because of emphysema or other pulmonary disease. Upper border of liver, begin percussion on the right midclavicular line at an area of lung resonance around the third intercostal space. Cont downward until the percussion tone changes to one of dullness; this marks upper border of the liver mark with pen. It’s usually in the fifth intercostal space. Measure the distance between the marks, estimates vertical span of liver, usually 6-12cm. If larger=enlargement, if smaller=atrophy.2137. To assess for liver enlargement in an obese person, you shoulda. use the hook method.b. test for cutaneous hypersensitivity.c. auscultate using the scratch technique.d. attempt palpation during deep exhalation.e. have the patient lean over at the waist.ANS: CIf the abdomen is obese or distended or if the abdominal muscles are tight, you should plan on auscultating the liver using the scratch method to estimate the lower border of the liver. Cutaneous hypersensitivity is a sign of peritonitis and does not contribute to determining liver size.Percussion at the right midclavicular line, below the umbilicus, and continuing upward is the correct technique for locating thea. descending aorta.b. lower liver border.c. medial border of the spleen.d. upper right kidney ridge.e. stomach.ANS: BPercussing along the right midclavicular line upward from the umbilicus determines the lower border of the liver. A liver border more than 2 to 3 cm signifies hepatomegaly.When palpating the abdomen, you should note whether the liver is enlarged in thea. left upper quadrant.b. midepigastric region.c. periumbilical area.d. right upper quadrant.e. right lower quadrant.ANS: DAn examiner can recognize a friction rub in the liver by a sound that isa. clicking, gurgling, and irregular.b. high pitched and associated with respirations.c. loud, prolonged, and gurgling.d. soft, low-pitched, and continuous.e. low pitched, tinkling, and unrelated to respirations.ANS: BAn abdominal friction rub is rare and can be identified when high-pitched sounds are auscultated in association with respirations. The liver is located in the right upper quadrant of the abdomen4. CVA tenderness-what might it be a sign of?Costovertebral angle tenderness should be assessed whenever you suspect the patient may havea. cholecystitis.b. pancreatitis.c. pyelonephritis.d. ulcerative colitis.e. intussusception.22ANS: CPyelonephritis is characterized by flank pain and costovertebral angle tendernessNEURO1. Autonomic Nervous System- what are you assessing? Coordinate?(Pg477)The Nervous system with its central and peripheral divisions maintains and controls all body functions by its voluntary and autonomic responses. The evaluation of motor, sensory, autonomic, cognitive and behavioral elements. The CNS is the main network of coordination and control for the body.(PG446) Coordination tests fluidity of movements. Inability to coordinate movements suggests cerebellar dysfunction. Finger to nose testing-ask pt to touch your index finger with his or her index finger, then touch his/her noserepeatedly. Poor coordination of movement indicates dysmetria. Rapid alternating movements-Ask pt to perform rapid pronation and supination of the hand on his/her thigh or on examination table Heel to shin testing-Ask pt to take the heel of one side and repeatedly move up and down the shin of the opposite leg Romberg- Ask pt to stand with feet together, arms abducted outward with palms up, and eyes closed. PostiveRomberg is observed as a swaying motion, or inability to maintain balance, and indicates cerebellar dysfunction.2. Motor Cortex of Brain- What does it control?3. Know EACH Cranial Nerve (several questions)- how to assess each, what testing for, what each do, abnormal findingsvs. expected findings. (pg553) Olfactory (1)- Sensory: smell reception and interpretation. Have available 2-3 vials of aromatic odors. Ensure patient’s nasal passages are patent. Occlude one naris at a time and ask patient to breathe in and out, while closing her eyes. Use different odor to test the other side. Assess the ability of patient to differentiate between diff odors. Sense of smell diminishes with age. Anosmia (loss of sense of smell). Optic (ll)- Sensory: visual acuity and visual field (chapter 11) Oculomotor (lll)-Motor: raise eyelids, most extraocular movements. Parasympathetic: pupillary constriction,change lens shape Trochlear (lV)- Motor: downward, inward eye movement(lll, lV, Vl)- Movement of eyes through the six cardinal points of gaze, pupil size, shape, response, to light and accommodation and opening of the upper eyelids. When assessing pt with severe unremitting headaches, the experienced examiner evaluates movement of the eyes for the presence of absence of lateral gaze. The sixth cranial nerve is commonly one of the first to lose function in the presence of increased intracranial pressure. Trigeminal (V)- Motor: jaw opening and clenching, chewing and mastication. Sensory: sensation to cornea, iris, lacrimal glands, conjunctiva, eyelids, forehead, nose, nasal and mouth mucosa, teeth, tongue, ear, facial skin. Evaluate for muscle atrophy. Have patient clench teeth as you palpate the muscles over the jaw, evaluating tone, which should be symmetric, without fasciculations. The three divisions of the trigeminal nerve are evaluated for the sharp, dull and light sensations. With pt closing eyes, touch each side of face at the scalp, cheek and chin, alternating sharp and smooth edges of a broken23tongue blade or a paper clip. Ask patient to report feeling. Then stroke face with cotton wisp. If sensation is impaired, ask pt to differ btw hot/cold. Abducens (Vl)- Motor: lateral eye movement Facial (Vll)- ask pt to raise eyebrows, squeeze the eyes shut, wrinkle the forehead, frown, smile, show the teeth, purse the lips to whistle, and puff out the cheeks. Observe for ticks, unusual movements and symmetry of expression. Drooping of one side of mouth or sagging of lower eyelid will indicate muscle weakness. Ie: Bells palsyTo evaluate taste, a sensory fx of cranial nerves Vll and lX: have patient have tongue protruded and have 4 solutions

NURS 6531 Final Exam 2019 Walden University.docx NURS 6531 Final Exam 2019 Walden U NURSING 6531 NURS 6531 Primary Care of Adults Across the Lifespan CourseNURS-6531D-1/NURS-6531N-1-Adv. Practice Care of Adults 2019TestFinal ExamStarted8/1/19 11:30 AMSubmitted8/1/19 1:20 PMDue Date8/12/18 1:59 AMStatusCompletedAttempt Score97 out of 100 points Time Elapsed1 hour, 34 minutes out of 1 hour and 50 minutes• Question 10 out of 0 pointsWhen completing this quiz, did you comply with Walden University’s Code of Conduct including the expectations for academic integrity?• Question 21 out of 1 pointsA patient complains of generalized joint pain and stiffness associated with activity and relieved with rest. This patient history is consistent with which of the following disorders?Osteoarthritis• Question 31 out of 1 pointsWhat diabetic complications result from hyperglycemia?1.1. Retinopathy2. Hypertension resistant to treatment3. Peripheral neuropathy4. Accelerated atherogenesis5.• Question 41 out of 1 pointsWhich factors are associated with high risk for foot complications in a patient with diabetes mellitus?1. Obesity2. Abnormal nails3. Abnormal gait4. Poorly controlled lipids5.• Question 51 out of 1 pointsWhich of the following is not a common early sign of benign prostatic hyperplasia (BPH)? What are common early signs of BPH – frequency, urgency, nocturia TX with alpha adrenergic Terazosin and doxazosin • Question 61 out of 1 pointsA 63-year-old man presents to the office with hematuria, hesitancy, and dribbling. Digital rectal exam (DRE) reveals a moderately enlarged prostate that is smooth. The PSA is 1.2. What is the most appropriate management strategy for you to follow at this time?Prescribe an alpha adrenergic blocker• Question 71 out of 1 pointsA 30 year old female patient presents to the clinic with heat intolerance, tremors, nervousness, and weight loss inconsistent with increased appetite. Which test would be most likely to confirm the suspected diagnosis? Graves hyperthyroid• Question 81 out of 1 pointsWhich history is commonly found in a patient with glomerulonephritis? Ask about recent infections (skin or upper respiratory); recent travel (possible exposure to viruses, bacteria, fungi, or parasites); recent illnesses, surgery, or invasive procedures (possible infection); any systemic diseases (Systemic Lupus Erythematosus -SLE)• Question 91 out of 1 points A 60 year old male patient with multiple health problems presents with a complaint of erectile dysfunction (ED). Of the following, which medication is most likely to be causing the problem? diabetes• Question 101 out of 1 points Which of the following is not a characteristic of type 2 diabetes mellitus? characterized by high blood sugar, insulin resistance, and relative lack of insulin. Common symptoms include increased thirst, frequent urination, and unexplained weight loss.• Question 111 out of 1 pointsA patient has been diagnosed with hypothyroidism and thyroid hormone replacement therapy is prescribed. How long should the nurse practitioner wait before checking the patient’s TSH? Six to 8 weeks• Question 121 out of 1 pointsA patient has been diagnosed with generalized anxiety disorder (GAD). Which of the following medications may be used to treat generalized anxiety disorder? Treatment may include counseling and medications, such as antidepressants. Selective Serotonin Reuptake Inhibitor (SSRI), Anxiolytic, and AntidepressantPaxil Effexor Lexapro and cymbalta• Question 131 out of 1 points What is the most common cause of Cushing’s syndrome? exogenous administration of exogenous glucocorticoids• Question 140 out of 1 pointsWhich of the following is the most cause of low back pain?Lumbar disc disease• Question 151 out of 1 pointsWarfarin (Coumadin) is prescribed for a frail, elderly male with new onset atrial fibrillation. The goal INR for this patient should be: 2.0 to 3.0• Question 161 out of 1 pointsA 72 year old patient exhibits sudden onset of fluctuating restlessness, agitation, confusion, and impaired attention. This is accompanied by visual hallucinations and sleep disturbance. What is the most likely cause of this behavior? delirium• Question 171 out of 1 pointsWhich of the following is the most common causative organism of nongonococcal urethritis?which of the following does not cause nongonococcal urethritis

a chlamydia – most common 
b. mycoplasma
c. neisseria
d. ureaplasma• Question 181 out of 1 pointsWhich appropriate test for the initial assessment of Alzheimer’s disease provides the performance ratings on 10 complex, higher order activities? FAQ• Question 191 out of 1 pointsWhat conditions must be met for you to bill “incident to” the physician, receiving 100% reimbursement from Medicare? the physician must be on-site and engaged in client care.• Question 201 out of 1 pointsDiagnostic evaluation for urinary calculi includes:A.Urinalysis and cultureB.Non contrast CTC.Serum calciumD.All of the above• Question 211 out of 1 pointsReed-Sternberg B lymphocytes are associated with which of the following disorders:Hodgkin’s lymphoma• Question 221 out of 1 pointsMarsha presents with symptoms resembling both fibromyalgia and chronic fatigue syndrome, which have many similarities. Which of the following is more characteristic of fibromyalgia?Musculoskeletal pain is not characteristic of chronic
fatigue syndrome; rather, it is characteristic of
fibromyalgia• Question 231 out of 1 pointsBeth, age 49, comes in with low back pain. An x-ray of the lumbosacral spine is within normal limits. Which of the following diagnoses do you explore further?herniated nucleus pulposus.• Question 241 out of 1 pointsSteve, age 69, has gastroesophageal reflux disease (GERD). When teaching him how to reduce his lower esophageal sphincter pressure, which substances do you recommend that he avoid?avoid chocolate, alcohol, carbonated drinks, peppermint, coffee, citrus, onion, and garlic. And weight loss• Question 250 out of 1 pointsThe cornerstone of treatment for stress fracture of the femur or metatarsal stress fracture is:Rest the affected part of the body
- Once pain free, the person can gradually begin the sporting activity again
- Air splinting can reduce pain and decrease the time until return to full participation or intensity of exercise.
- NSAIDs to reduce pain and inflammation• Question 261 out of 1 pointsWhich of the following is not a risk factor associated with the development of syndrome X and type 2 diabetes mellitus?Post-prandial hypoglycemia• Question 271 out of 1 pointsA thymectomy is usually recommended in the early treatment of which disease?Thymectomy is an important treatment option for Myasthenia Gravis• Question 281 out of 1 pointsThe most common cause of elevated liver function tests is:Chronic alcohol abuse.• Question 291 out of 1 pointsA 14 year old female cheerleader reports gradual and progressive dull anterior knee pain, exacerbated by kneeling. The nurse practitioner notes swelling and point tenderness at the tibial tuberosity. X-ray is negative. What is the most likely diagnosis?OsgoodThe most likely diagnosis based on the reports of gradual progressive dull anterior knee pain cause of kneeling and the complains of sore lump on the patient’s knee which the result of the assessment notes were swelling and point tenderness is likely Arthritis or gout. It is the symptoms of Arthritis or gouts usually complaining having knee pain and swelling.• Question 301 out of 1 pointsWhich of the following is a contraindication for metformin therapy?Creatinine > 1.5• Renal dysfunction.• Congestive cardiac failure needing drug treatment.• Hypersensitivity to metformin.• Acute or chronic metabolic acidosis.• Impaired hepatic function.• Question 311 out of 1 pointsThe best test to determine microalbuminuria to assist in the diagnosis of diabetic neuropathy: albumin-to-creatinine ratio with a spot urine • Question 321 out of 1 pointsWhich is the most common cause of end-stage renal disease in the United States?Diabetic Neuropahty, hypertenson, glomerulonephritis, systemic lupus, cystic kidney disease• Question 331 out of 1 pointsA middle-aged female presents complaining of recent weight loss. The physical exam reveals an enlarged painless cervical lymph node. The differential diagnosis for this patient’s problem includes:All of the above (mono, toxoplasmosis, and infection)• Question 341 out of 1 pointsRisk factors for prostate cancer include all of the following except: History of genital trauma and bph• Question 351 out of 1 pointsPhalen’s test, 90°wrist flexion for 60 seconds, reproduces symptoms of: carpal tunnels• Question 361 out of 1 pointsThe most effective intervention(s) to prevent stroke is (are): smoking cessation and treatment of hypertension• Question 371 out of 1 pointsA diabetic patient is taking low-dose enalapril for hypertension. A record of the patient’s blood pressure over 4 weeks ranges from 130 to 142 mmHg systolic and 75 to 85 mmHg diastolic. How should the nurse practitioner respond?increase the dosage of the current BP medication• Question 381 out of 1 pointsMicroalbuminuria is a measure of: endothelial dysfunction, dm neuropathy, diabetic kidney disease and end organ damage r/t htn• Question 391 out of 1 pointsMartin, age 24, presents with an erythematous ear canal, pain, and a recent history of swimming. What do you suspect?External otitis• Question 401 out of 1 points A 32 year old male patient complains of urinary frequency and burning on urination for 3 days. Urinalysis reveals bacteriuria. He denies any past history of urinary tract infection. The initial treatment should be:: cipro or Levaquin fluoroquinolones 10 to 14 days trimethoprim sulfamethoxazole for 14 days UTI in males should be treated with fluoroquinolones for 10 to 14 days. Acute bacterial prostatitis requires 2 weeks of oral antibiotic treatment with trimethoprim-sulfamethoxazole (TMP-SMX) or fluoroquinolones. Chronic bacterial prostatitis may require 4 to 6 weeks of treatment.• Question 411 out of 1 points A 21-year-old female presents to the office complaining of urinary frequency and urinary burning. The nurse practitioner suspects a urinary tract infection when the urinalysis reveals10 WBC/ HPPyuria (neutrophils in the urine)
Bacteriuria
Hematuria
Positive leukocyte esterase and/or nitrite dipstick

(Leukocyte esterase = indicates presence of WBCs; suggests bacterial cause)
(Positive nitrite = indicates gram - organism)Urine culture indicated in symtpoms and negative urinalysis• Question 421 out of 1 pointsWhich of the following medications increase the risk for metabolic syndrome? Antihistamine and protease inhibitor• Question 431 out of 1 pointsThe most accurate measure of diabetes control is: a1c• Question 441 out of 1 pointsThe 4 classic features of Parkinson’s disease are: shaking (tremor) of the hands, arms, legs and face; stiffness; slow movement (bradykinesia); and difficulty with balance and coordination.• Question 451 out of 1 pointsA child with type 1 diabetes mellitus has experienced excessive hunger, weight gain and increasing hyperglycemia. The Somogyi effect is suspected. What steps should be taken to diagnose and treat this condition?Testing blood sugar levels at 3.00 a.m. and again in the morning can help distinguish between the Somogyi effect and the dawn phenomenon. ’s relatively easy to test for the Somogyi effect. For several consecutive nights:• Check your blood sugar just before bed.• Set an alarm to check it again around 3:00 a.m.• Test it again upon waking.If your blood glucose is low when you check it at 3:00 a.m., it’s likely the Somogyi effect.• Question 461 out of 1 pointsA patient presents with dehydration, hypotension, and fever. Laboratory testing reveals hyponatremia, hyperkalemia, and hypoglycemia. These imbalances are corrected, but the patient returns 6 weeks later with the same symptoms of hyperpigmentation, weakness, anorexia, fatigue, and weight loss. What action(s) should the nurse practitioner take? the correct next step is to measure baseline serum cortisol, to test ACTH levels, and to order an ACTH stimulation test with cosyntropin.Primary adrenocortical insufficiency work up for• Question 471 out of 1 pointsOther than smoking cessation, which of the following slows the progression of COPD in smokers? Engaging in moderate-to-high levels of physical activity• Question 481 out of 1 pointsA 75-year-old female is diagnosed with primary hyperparathyroidism and asks the nurse practitioner what the treatment for this disorder is. The nurse practitioner explains: Primary hyperparathyroidism is treated with parathyroidectomy• Question 491 out of 1 pointsThe hallmark of neurofibromatosis (von Recklinghausen’s disease) present in almost 100% of patients is:Café au lait spots• Question 501 out of 1 pointsA patient has HIV infection and is having a problem with massive diarrhea. You suspect the cause is: . Cryptosporidiosis
- When patients with HIV infection have massive diarrhea, a protozoa of the cryptosporidium genus is the most likely cause.• Question 511 out of 1 pointsHow do you respond when Jessica, age 42, asks you what constitutes a good minimum cardiovascular workout?Exercising for at least 20 minutes 3 or more days per week.• Question 521 out of 1 pointsThe treatment of choice for chronic bacterial prostatitis (CBP) is: Fluoroquinolones (Ciprofloxacin, levofloxacin, others)- antibiotics of choice
Trimethoprim-sulfamethoxazole - less effective but still an option
Other antibiotics - doxycycline, cephalexin, erythromycin
Treat for 4 weeks minimum• Question 531 out of 1 pointsSally, a computer programmer, has just been given a new diagnosis of carpal tunnel syndrome. Your next step is to: try neutral position wrist splinting and order an oral NSAID• Question 541 out of 1 pointsUrine cultures should be obtained for which of the following patients? All of the above (pregnant females, males, and febrile patients)• Question 551 out of 1 pointsWhich of the following is the best response to a woman who has just admitted she is a victim of spousal abuse?• Question 561 out of 1 pointsThe diagnosis which must be considered in a patient who presents with a severe headache of sudden onset, with neck stiffness and fever, is: migrane or meningitis• Question 571 out of 1 pointsAn 81-year-old female is diagnosed with type 2 diabetes. When considering drug therapy for this patient, the nurse practitioner is most concerned with which of the following side effects? hypogyclemia• Question 581 out of 1 pointsWhich patient would benefit most from screening for type 2 diabetes? Gdma, black, htn, pcos, black, family hx• Question 591 out of 1 pointsThe intervention known to be most effective in the treatment of severe depression, with or without psychosis, is: electroconvulsive therapy (ECT).• Question 601 out of 1 pointsJennifer says that she has heard that caffeine can cause osteoporosis and asks you why. How do you respond?The effect of caffeine in causing osteoporosis is
controversial, but it is postulated to result from
caffeine \' s diuretic effect that causes calcium to be
excreted more rapidly• Question 611 out of 1 pointsWhich of the following patients most warrants screening for hypothyroidism?Screening whole populations for hypothyroidism is not warranted. There is a high prevalence of hypothyroidism among the elderly with cognitive impairment.• Question 621 out of 1 pointsSuccessful management of a patient with attention deficit hyperactivity disorder (ADHD) may be achieved with:psychostimulant Ritalin 
ii. Dexedrine 
iii. Focalin 
iv. Adderall 
v. Concerta 
vi. Strattera• Question 631 out of 1 pointsDiabetes screening recommendations for asymptomatic adults age 45 and over include which of the following:A.HbA1CB.2-hour 75 gram oral glucose tolerance testC.C-peptide levelD.A and BE.All of the above• Question 641 out of 1 pointsProlonged PT suggests: Liver disease, DIC (early)Warfarin, Factor VII deficiency• Question 651 out of 1 pointsDiagnostic confirmation of acute leukemia is based on: Bone marrow aspiration and biopsy• Question 661 out of 1 pointsWhich of the following is not appropriate suppression therapy for chronic bacterial prostatitis?• Question 671 out of 1 pointsThe most effective treatment of non-infectious bursitis includes: Need options rest, cold and heat treatments, elevation, administration of nonsteroidal anti-inflammatory drugs (NSAIDs), bursal aspiration, and intrabursal steroid injections (with or without local anesthetic agents).• Question 681 out of 1 pointsDifferential diagnosis of proteinuria includes which of the following?Differential diagnosis of proteinuria includes which of the following?A.Orthostatic proteinuriaB.Nephrotic syndromeC.InfectionD.TraumaE.A and B• Question 691 out of 1 pointsYou are assessing a patient after a sports injury to his right knee. You elicit a positive anterior/posterior drawer sign. This test indicates an injury to the: cruciatanklee ligament• Question 701 out of 1 pointsA positive drawer sign supports a diagnosis of: cruciate ligament• Question 711 out of 1 pointsA patient presenting for an annual physical exam has a BMI of 25 kg/m2 This patient would be classified as: overweight• Question 721 out of 1 pointsA patient has been taking fluoxetine (Prozac) since being diagnosed with major depression, first episode, 2 months ago. She reports considerable improvement in her symptoms and her intention to discontinue the medication. What should be the nurse practitioner’s recommendation? Recommend that the patient continue the antidepressant medication for at least 4 more months.• Question 731 out of 1 pointsDiagnostic radiological studies are indicated for low back pain: Xray• Question 741 out of 1 pointsA 32 year old female patient presents with fever, chills, right flank pain, right costovertebral angle tenderness, and hematuria. Her urinalysis is positive for leukocytes and red blood cells. The nurse practitioner diagnoses pyelonephritis. The most appropriate management is: Cipro if symptoms does not go away within 2 days hospitalization• Question 750 out of 1 pointsWhich of the following symptoms suggests a more serious cause of back pain? Pain with lying• Question 761 out of 1 pointsWhat is the first step in the treatment of uric acid kidney stones? Encouraging hydration• Question 771 out of 1 pointsA 20 year old male patient complains of “scrotal swelling.” He states his scrotum feels heavy, but denies pain. On examination, the nurse practitioner notes transillumination of the scrotum. What is the most likely diagnosis? Nonseminoma• Question 781 out of 1 pointsWhat is the first symptom seen in the majority of patients with Parkinson’s disease? Resting tremor• Question 791 out of 1 pointsA 60 year old female patient complains of sudden onset unilateral, stabbing, surface pain in the lower part of her face lasting a few minutes, subsiding, and then returning. The pain is triggered by touch or temperature extremes. Physical examination is normal. Which of the following is the most likely diagnosis? Trigeminal neuralgia• Question 801 out of 1 pointsWhich of the following set of symptoms should raise suspicion of a brain tumor? Holocranial headaches present in the morning and accompanied by projectile vomiting without nausea• Question 811 out of 1 pointsThe most reliable indicator(s) of neurological deficit when assessing a patient with acute low back pain is(are): straight leg raise test is performed to assess for damage to L5-S1• Question 821 out of 1 points A 25 year old overweight patient presents with a complaint of dull achiness in his groin and history of a palpable lump in his scrotum that “comes and goes”. On physical examination, the nurse practitioner does not detect a scrotal mass. There is no tenderness, edema, or erythema of the scrotum, the scrotum does not transilluminate. What is the most likely diagnosis? Inguinal hernia• Question 831 out of 1 pointsWhich of the following characteristics are associated with prepatellar bursitis?Repetitive knee trauma• Question 841 out of 1 pointsWhich drug category contains the drugs that are the first line Gold standard therapy for COPD? anticholenergic• Question 851 out of 1 pointsWhich of the following physical modalities recommended for treatment of rheumatoid arthritis provides the most effective long term pain relief? Physiotherapy• Question 861 out of 1 pointsWhich of the following accounts for half of the bladder tumors among men and one-third in women? Cigarette smoke, both active and passive inhalation Cigarette smoke, both active and passive inhalation• Question 871 out of 1 points A 35 year old male presents with a complaint of low pelvic pain, dysuria, hesitancy, urgency, and reduced force of stream. The nurse practitioner suspects acute bacterial prostatitis. Which of the following specimens would be least helpful for diagnosis? Post voidOrdered test – that are helpful Midstream urine specimens for culture and sensitivity CBC and differential Blood urea nitrogen Creatinine Imaging• Question 881 out of 1 pointsIn which of the following presentations is further diagnostic testing not warranted? Bilateral gynecomastia in a pre-pubertal• Question 891 out of 1 pointsMartin is complaining of erectile dysfunction. He also has a condition that has reduced arterial blood flow to his penis. The most common cause of this condition is: htn dm• Question 901 out of 1 pointsWhich of the following is the most common complication of the myelodysplastic syndromes? Fatigue• Question 911 out of 1 pointsYou have a new patient that presents with generalized lymphadenopathy. You know that this is indicative of:A. Infection 
B. Malignancy 
C. Inflammation
D. Drug 
E. EndocrineB. A. Infection 
- Viral: infectious mononucleosis (CMV, EBP), HIV 
- Bacterial: skin infection, TB
- Fungal: cryptococcal 

B. Malignancy
- Hematological: lymphoma, leukemia 
- Solid tumour LN met 

C. Inflammatory 
- Castleman ds
- Kimura ds
- Kikuchi ds 
- SLE, RA 
- Amyloidosis, sarcoidosis 

D. Drug 
- Phenytoin (anti-seizure) 
- Hydralazine (HF)

E. Endocrine [rare]
- Addison\'s disease 
- Hypothyroidism• Question 921 out of 1 pointsA 15 year-old female patient is 5 feet tall and weighs 85 pounds. You suspect anorexia and know that the best initial approach is to:confront Julie with the fact that you suspect an eating disorder• Question 931 out of 1 points A patient taking levothyroxine is being over-replaced. What condition is he at risk for?Osteoporosis, arrhythmias, afib• Question 941 out of 1 pointsA nurse practitioner diagnoses a 60 year old male with balanitis. Which disease is commonly associated with balanitis? diabetes• Question 951 out of 1 pointsThe diagnosis of human papilloma virus (HPV) infection in males is usually made by: warts• Question 961 out of 1 pointsMartin, a 58 year old male with diabetes, is at your office for his PRO follow up. On examining his feet with monofilament, you discover that he has developed decreased sensation in both feet. There are no open areas or signs of infection on his feet. What health teaching should Martin receive today regarding the care if his feet?See a podiatrist yearly; wash your feet daily with warm, soapy water and towel dry between the toes; inspect your feet daily for any lesions; and apply lotion to any dry areas.• Question 971 out of 1 pointsWhich of the following is a potential acquired cause of thrombophilia? 1. Lupus anticoagulant
2. antiphospholipid antibody syndrome --antibody to phospholipids• Question 981 out of 1 pointsDeficiency of which nutritional source usually presents with an insidious onset of paresthesias of the hands and feet that are usually painful? B 12• Question 991 out of 1 pointsWhat information should patients with diabetes and their families receive about hypoglycemia? Hypoglycemia is serious, dangerous, and can be fatal if not treated quickly.• Question 1001 out of 1 pointsJosh, age 22, is a stock boy and has an acute episode of low back pain. You order and NSAID and tell him which of the following? 3200mg max dose alternate with Tylenol if needed• Question 1011 out of 1 pointsA 28-year-old female presents to the office requesting testing for diagnosis of hereditary thrombophilia. Her father recently had a deep vein thrombosis and she is concerned about her risk factors. The nurse practitioner explains that:A.The patient should start anticoagulant therapy immediately.B.Hereditary thrombophilia does not always require anticoagulation therapy.C.Women of childbearing age cannot take anticoagulant therapy.D.Genetic and risk management counseling are recommended.E.B and D Question 11 out of 1 pointsWhich of the following is the most common cause of low back pain?Lumbar disc disease Question 21 out of 1 pointsThe cardinal sign of infectious arthritis is:Affected joint is painful at rest, with movement, and weight bearing Question 31 out of 1 pointsWhich of the following best reflects the National Osteoporosis Foundation daily calcium recommendations for adults?1000-1200 mg of calcium daily Question 41 out of 1 pointsRisk factors for osteoporosis include:having RA is (page 960 in Buttaro et al., 2017) Question 51 out of 1 pointsThe Institute of Medicine’s recommended daily allowance (RDA) for Vitamin D in adults over age 70 years of age is:800 IU daily Question 61 out of 1 pointsA middle-aged man presents to urgent care complaining of pain of the medial condyle of the lower humerus. The man works as a carpenter and describes a gradual onset of pain. On exam, the medial epicondyle is tender and pain is increased with flexion and pronation. Range of motion is full The most likely cause of this patient’s pain is:epicondylitis Question 71 out of 1 pointsWhich of the following characteristics are associated with prepatellar bursitis?Repetitive knee trauma Question 81 out of 1 pointsA patient complains of generalized joint pain and stiffness associated with activity and relieved with rest. This patient history is consistent with which of the following disorders?Osteoarthritis Question 91 out of 1 pointsA 77-year-old female presents to the office complaining a sudden swelling on her right elbow. She denies fever, chills, trauma, or pain. The physical exam reveals a non-tender area of swelling over the extensor surface over the right elbow with evidence of trauma or irritation. The nurse practitioner suspects:Olecranon bursitis Question 101 out of 1 pointsPotential causes of septic arthritis include which of the following?A &B Lyme disease and prosthetic joint infectionFriday, November 9, 2018 1:21:00 PM ESTYour patient has an elevated mean cell volume (MCV). What should you be considering in terms of diagnosis?Iron-deficiency anemia
 Hemolytic anemia
 Lead poisoning
 Liver diseaseUNSURERisk factors for Addison’s disease include which of the following?Tuberculosis
 Autoimmune disease
 AIDS
 All of the aboveALLWhich of the following is not a common early sign of benign prostatic hyperplasia (BPH)?Difficulty initiating a urine stream
 Nocturia
 Urinary retention
 Increased force of urine flowThe physiological explanation of syncope is:Accelerated venous return and increased stroke volume resulting in deactivation of the parasympathetic nervous system. 
 A cycle of inappropriate vasodilation, bradycardia, and hypotension.
 A sudden rise in blood pressure due to overly efficient vasoconstriction. 
 Emotional stress resulting in hypertension, tachycardia, and increased venous return.A 65-year-old patient complains of a recurrent bilateral temporal headaches, malaise, muscle aches, and low grade fever. The headache is described as superficial tenderness rather than deep pain. Giant cell arteritis is suspected. Appropriate treatment is: refer for temporal artery biopsy and initiation of oral prednisoneYou have a new patient that presents with generalized lymphadenopathy. You know that this is indicative of:Sjogren’s syndrome
 Pancreatic cancer
 Disseminated malignancy of the hematologic system
 Cancer of the liverWhich history is commonly found in a patient with glomerulonephritis?Beta-hemolytic strep infection
 Frequent urinary tract infections
 Kidney stones
 HypotensionSam, age 42, has had persistent proteinuria on the previous two office visits. Which action is warranted next?Order and intravenous pyelogram
 Admit Sam to the hospital
 Schedule extensive blood work
 Have Sam collect one urine specimen on first arising and then another 2 hours laterThe best test to determine microalbuminuria to assist in the diagnosis of diabetic neuropathy:A dipstick strip done during routine urinalysis in the office
 A 24-hour urine collection
 An early morning spot urine collection
 A serum albumin testA typical description of a tension headache is:Periorbital pain, sudden onset, often explosive in quality, and associated with nasal stuffiness, lacrimation, red eye, and nausea. 
 Bilateral, occipital, or frontal tightness or fullness, with waves of aching pain. 
 Hemicranial pain that is accompanied by vomiting and photophobia. 
 Steadily worsening pain that interrupts sleep, is exacerbated by orthostatic changes, and may be preceded by nausea and vomiting.The treatment of choice for chronic bacterial prostatitis (CBP) is:Erythromycin 4 times daily for 7 to 10 days
 Doxycycline twice daily for 7 to 10 days
 A fluoroquinolone daily for 3 weeks to 4 months
 Bactrim DS daily for 4 to 16 weeksThe obligatory criteria for diagnosis of muscular dystrophy (MD) are:Progressive, genetic myopathy with degeneration and death of muscle fibers
 Asymmetric overgrowth of extremities, angiomas, thickening of bones, and excessive muscle growth 
 Hypotonia that persists into adulthood, and recurrent joint dislocation
 Hypotonicity, developmental delay, and symmetric congenital absence of individual musclesThe primary goals of treatment for patients with alcohol abuse disorder are:Reduction in withdrawal symptoms and reduction in desire for alcohol
 Psychotherapeutic and pharmacological interventions to decrease desire for and effects of alcohol
 Abstinence or reduction in use, relapse prevention, and rehabilitation
 Marital satisfaction, improvement in family functioning, and reduction in psychiatric impairmentThe most common presentation of thyroid cancer is:Generalized enlargement of the thyroid gland. 
 A solitary thyroid nodule. 
 A multinodular goiter. 
 Abnormal thyroid function tests.

NURS 6512 Advanced Health Assessment and Diagnostic Reasoning Final Exam NURS 6512 Advanced Health Assessment and Diagnostic Reasoning Final Exam Course NURS-6512D-1/NURS-6512N-1-NURS-6512D- 1/NURS-6512N-1- Advanced Health Assessment and Diagnostic ReasoningTest Final Exam
Started 8/1/19 11:30 AM Submitted 8/1/19 1:20 PMDue Date 8/12/19 1:59 AMStatus Completed
Attempt Score 93 out of 100 pointsTime Elapsed 1 hour, 34 minutes out of 1 hour and 50 minutes1. Costovertebral angle tenderness should be assessed whenever you suspect the patient may have: - Polynephritis2. In older adults, overflow fecal incontinence is commonly due to: -Fecal impaction3. A 1 month old boy has been vomiting for 2 weeks. How is this symptom of GERD and pyloric stenosis further differentiated in this child’s assessment? – The infant has regurgitation with pyloric stenosis4. Auscultation of borborygmi is associated with: - Gastroenteritis, early intestinal obstruction, or hunger5. When auscultating the abdomen, which finding would indicate collateral circulation between the portal and systemic venous systems? – Venous hum6. Conversion of fat-soluble wastes to water-soluble material for renal excretion is a function of the: - Liver7. The major function of the large intestine is: -Water absorption8. Which structure is located in the hypogastric region of the abdomen? –Ileum, bladder, andpregnant uterus9. A 45 year old man relates a several week history of severe intermittent abdominal burning sensations. He relates that the pain is relieved with small amounts of food. Before starting the physical examination, you review his laboratory work, anticipating a (n): -Positive Helicobacter pylori result10. You are caring for a patient with trigeminal neuralgia. During the assessment, the patient would describe the pain as: - Burning or shocklike11. Your 85 year old patient is complaining of right knee pain. She has a history of osteoarthritis for which she is given anti-inflammatory medication. To assess her right knee pain, you should ask her if: - The pain gets better when she sits12. A 5 year old is complaining of nondescriptive “belly pain.” Your next action should be to ask him to: - Point to the area of pain13. The perception of pain: - Is variable and is affected by emotions, and cultural background14. Patients presenting with ascites, jaundice, cutaneous spider veins, and nonpalpable liver exhibit signs of: - Cirrhosis15. A patient presents to the emergency department after a motor vehicle accident. The patient sustained blunt trauma to the abdomen and complains of pain in the upper left quadrant that radiates to the left shoulder. What organ is most likely injured? – Spleen16. Imaging studies reveal that a patient has dilation of the renal pelvis from an obstruction in the ureter, what condition will be documented in this patient’s health record? – Hydronephrosis17. Visible intestinal peristalsis may indicate: - Intestinal obstruction18. Infants born weighing less than 1500g are at higher risk for: - Necrotizing enterocolitis19. Which of the following factors is not known to affect patient compliance with his or her treatment regimen? – The patient’s age and social status20. One of the most important aspects to consider in the orthopedic screening examination is: -Symmetry21. The sequence of the physical examination should be individualized to: -22. As you greet the patient, which examination technique is first implemented? - Inspection23. Which of the following is most likely to enhance examiner reliability? – The examiner attempts to qualify data24. A 7 year old boy is brought to your office with a chief complaint of possible fracture to his left third finger. He jammed it while playing basketball 2 days ago. The mother states that she really does not think it is broken because he can move it. What is your best response? – This is common misconception, and the finger may be broken. An x-ray is indicated.25. A patient presenting for the first time with typical low back pain should receive which of the following diagnostic tests?26. Skeletal changes in older adults are the result of: -Increased bone resorption 27. A positive straight leg raise test usually indicates: - Lumbar nerve root irritation28. What technique is performed at every infant examination during the first year of life to detect hip dislocation? – Barlow-Ortolani maneuvers29. Expected normal findings during inspection of spinal alignment include: - Convex lumbar curvenumber of times the patient has to change positions to conserve the patient’s energyMinimize theusually musculoskeletal etiology.– None of the above. X-ray is not indicated because lumbar pain is30. Temporalis and masseter muscles are evaluated by: - Having the patient clench his or her teeth31. When palpating joints, crepitus may be caused when: - Irregular bony surfaces rub together32. A 3 year old is brought to the clinic complaining of a painful right elbow. He is holding the right arm slightly flexed and pronated and refuses to move it. the mother states that symptoms started right after his older brother had been swinging him around by his arms. This presentation supports a diagnosis of: - Radial head subluxation33. Light skin and thin body habitus are risk factors for: - Osteoporosis34. Risk factors for sports-related injuries include: - Failure to warm up before activity35. Injuries to long bones and joints are more likely to result in fractures than in sprains until: -Adolescence36. Ligaments are stronger than bone until: - Adolescence37. The family history for a patient with joint pain should include information about siblings with: -Genetic disorders38. The Thomas test is used to detect: - Flexion contractures of the hip39. A goniometer is used to assess: - Range of motion40. During a football game, a player was struck on the lateral side of the left leg while his feet were firmly planted. He is complaining of left knee pain. To examine the left knee you should initially perform the ________ test. – Valgus stress41. You note that a child has a positive Gower Sign. You know that this indicates generalized: -Muscle weakness42. The dowager hump is: - The hallmark of osteoporosis43. What temporary disorder may be experienced by pregnant women during the third trimester because of fluid retention? –Carpal tunnel syndrome44. A common finding in markedly obese and pregnant women is: - Lordosis45. A 45 year old laborer presents with low back pain, stating that the pain comes from the right buttock and shoots down and across the right anterior thigh, down the shin to the ankle. Which examination finding is considered more indicative of nerve root compression? – Positive straight leg raise result46. Mrs. Bower is a 57 year old patient who comes in for an office visit. Which of the following disorders is known to be hereditary? – Huntington chorea47. Testing of cranial nerve ________ is not routinely performed unless a problem is suspected.–I48. The patient is able to rapidly touch each finger to his thumb in rapid sequence. What does this finding mean? – The patient has appropriate cerebellar function49. Which question asked by the examiner may hellp to determine prevention strategies for seizures that a patient is experiencing? – “Are there any factors or activities that seem to start the seizures?”50. A patient has a complaint of dizziness. The patient makes the following statement: “I sometimes feel as if the whole room is spinning.” What type of neurologic dysfunction should the examiner suspect? – Inner ear dysfunction affecting the acoustic nerve51. The examiner asks the patient to close her eyes, then places a vibrating tuning fork on the patient’s ankle and asks her to indicate what is felt. What is being assessed? – Peripheral nerve sensory function52. Which of the following findings should an examiner consider a normal finding if associated with pregnancy? – Acroparesthesia52. Jack is a 52 year old obese man with a history of poorly controlled diabetes. He also smokes. Based on the above data, the examiner should recognize that Jack has several risk factors for: - Cerebrovascular accident53. Mrs. Jones is a 24 year old patient who presents to your office 2 days postpartum. She complains that she is experiencing foot drop. Which of the following problems should the examiner consider? – Lumbosacral plexopathy54. The examiner is assessing deep tendon reflex response in a 12 year old boy. The response is an expected reflex response. Which of the following scores should be documented? – 2 55. A 68 year old patient presents to your office for follow-up. He tells you, “I have a hard time finding the right words when I am talking;” he also is experiencing numbness. On examination, you note postural instability. This symptom may be: - A late symptom of Parkinson’s disease56. Motor maturation proceeds in an orderly progression from: - Head to toe 57. The thalamus is the major integration center for perception of: - Pain58. The examiner should be concerned about neurologic competence if a social smile cannot be elicited by the time a child is ________old. – 3 months59. Normal changes of the aging brain include: -60. When interviewing a 70 year old female clinic patient, she tells you that she takes ginkgo biloba and St. John’s Wort. You make a short note to check for results of the: -Mini-mental state examination61. The area of body surface innervated by a particular spinal nerve is called a: - Dermatome 62. If a patient cannot shrug the shoulders against resistance, which cranial nerve (CN) requiresfurther evaluation? – CN XI, spinal accessory63. The finger-to-nose test allows assessment of: - Coordination and fine motor function64. You ask the patient to follow a series of short commands to assess: - Attention span65. As Mr. B. enters the room, you observe that his gait is wide based and he staggers from side to side while swaying his trunk. You would document Mr. B.’s pattern as: - Cerebellar ataxia66. When is the mental status portion of the neurologic system examination performed? –Constantly throughout the entire interaction with a client67. An aversion to touch or being held, along with delayed or absent language development, is a characteristic of: -Autism68. The autonomic nervous system coordinates which of the following? – Internal environment of the body69. The major function of the sympathetic nervous system is to: - Orchestrate the stress response70. The parasympathetic nervous system maintains the day-to-day function of: - Digestion 71. Cerebrospinal fluid serves as a: - Shock absorber72. You are performing a two-point discrimination test as part of a well physical examination. The area with the ability to discern two points in the shortest distance is the: -Finger tips73. Which type of hallucination is most commonly associated with alcohol withdrawal? – Visual- bugs, pink elephantsDiminished perception of touch. -- this is byprocess of elimination/educated guess. I could not find direct information addressing this inSeidel74. On a scale of 0 to 4 , which deep tendon reflex score is appropriate for a finding of clonus in a patient? –3 75. Which statement is true regarding mental status changes in older adults? – There is an increased risk of delirium with acute illness or metabolic derangement.76. A characteristic related to syphilis or diabetic neuropathy is testicular: -Insensitivity to painful stimulation77. When collecting personal and social history data from a woman complaining of breast discomfort, you should question her regarding: - Alcohol, tobacco, and caffeine use78. What risk factor is associated with cervical cancer? – HPV79. A 23 year old female presents with severe right lower quadrant tenderness. All of thefollowing should be considered in the differential except: - Classis diverticulitis80. What is the initial diagnostic radiology test that should be ordered if you suspect a rupturedovarian cyst? – Abdominal and transvaginal ultrasound81. A 17 year old male was brought into the emergency room with testicular/scrotal pain. Thedifferential diagnosis should include all except: - Inguinal herniation82. The nursing mother complains that her breasts are tender. You assess hard, shiny, and erythremic breasts bilaterally. You should advise the patient to: - Massage gently and continue nursing83. A normal vas deferens should feel: - Smooth84. In a woman complaining of a breast lump, it is most important to ask about: - Itsrelationship to menses85. The finding of a painless indurated lesion on the glans penis is most consistent with: -Chancre86. Thrombosed hemorrhoids are: - Blue, shiny, painful masses87. Pregnancy-related cervical changes include: - Softening and bluish coloring88. You are inspecting the genitalia of an uncircumcised adult male. The foreskin is tight and cannot be easily retracted. You should: - Inquire about previous penile infections89. An adolescent male is being seen for acute onset of left testicular pain. The pain started 3 hours ago. He complains of nausea and denies dysuria or fever. Your prioritized assessment should be to: - Establish absent cremasteric reflex90. A 23 year old white woman has come to the clinic because she has missed two menstrual periods. She states that her breasts have enlarged and that her nipples have turned a darker color. Your further response to this finding is: - Suggest pregnancy testing91. What accommodations should be used in the position of a hearing-impaired woman for a pelvic examination? – The head of the table should be elevated92. Sexual differentiation in the fetus has occurred by _______weeks gestation. - 1293. You are performing a clinical breast examination for a 55 year old woman. While palpating the supraclavicular area, you suspect that you felt a node. In order to improve your hooked technique, you should: -Ask the patient to turn her head toward that side94. If a firm, transverse ridge of compressed tissue is felt bilaterally along the lower edge of a 40 year old patient’s breast, you should: -Record the finding in the patient’s record95. A therapeutic technique for dealing with grieving individuals is to: - Tell them that is good to cry and to share feelings96. The examination of the newborn should begin with: - Inspection noting skin color, flaccidity, tension, gross deformities, or distortions of facies97. Which one of the following patient characteristics is most likely to limit patient reliability during history taking? – Patient is sleep and sensory deprived98. In crying infants, it is often difficult to: - Auscultate heart sounds99. Which of the following statements accurately reflects the sensitivity and specificity oflaboratory tests? – No test has 100% sensitivity and specificity100. Which medical condition would exclude one from sports participation? – Fever101. Your 15 year old patient is athletic and thin. Radiography of an ankle injury reveals a stress fracture. You question this patient about her: - Menstrual cycles102. Which of the following are examined with the patient in a reclining 45 degree position? –Jugular venous pulsation and pressure103. Functional assessment is most important during the examination of a(n): -Older adult104. The best way to ease the apprehension of a 3 year old child before a physical examination is to: - Encourage child’s participation105. An ophthalmoscopic eye examination involves: - Lens inspection106. When conducting a geriatric assessment, basic activities of daily living (ADLs) include: -Bathing107. The checkout station for preparticipation physical evaluation (PPE) is critical because at this point: - The coordination of follow-ups is reviewed108. Which of the following is true regarding the relationship between the examiner and the patient? – The patient is a full partner with the examiner109. Which of the following factors is not known to affect patient compliance with his or her treatment regimen? – The patient’s age and social status110. One of the most important aspects to consider in the orthopedic screening examination is:- To look for symmetry of muscle, stature, and joint movement111. As you greet the patient, which examination technique is first implemented? – Inspection 112. Which portion of the physical examination is best done with the patient standing? –Spinal 113. Which patient position facilitates inspection of the chest and shoulders? – Sitting114. The least reliable indicator of newborn distress is: - Color115. Proprioception should be assessed while the patient is: - Standing116. Part of the screening orthopedic component of the examination includes evaluating the person while: - Duck walkingHealth Assessment Final Review ExamMust have 78% to pass between both exams Always go with the text bookMENTAL ASSESSMENT (Ch 5 pgs 64-78)1. What does orientation to person, place, and time assess? When you perform assessment, what exactly are you looking for? Pg. 67Person, place and time assess state of consciousness. When performing this assessment you are looking for cognitive function. Person disorientation is a result of cerebral trauma, seizures, or amnesia; Place disorientation occurs with psychiatric disorders, delirium, and cognitive impairment; Time disorientation is associated with anxiety, delirium, depression, and cognitive impairment.8. Assessing orientation to person, place, and time helps determineANS: DOrientation to person, place, and time are measures of states of consciousness and awareness, not degrees of attention span. Analogies and abstract reasoning are higher functions than orientation. Emotional status can be better evaluated by observing behaviors.2. How many serial numbers should most people be able to repeat? For example: counting backwards. How many should the average person be able to repeat? Pg. 70Five to eight numbers forward or four to six backward can usually be repeated.10.Under most conditions, adult patients should be able to repeat a series of _____ numbers.ANS: BMost adults should be able to recall immediately a series of five to eight numbers forward and four to six numbers backward.3. How do you assess recent memory if you’ve had a patient your worried about memory? What technique and how would you assess recent memory? Pg. 70Give the patient a short time to view four or five test objects, telling them you will ask them about them in a few minutes. Ten minutes later, ask the patient to list the objects.14.Recent memory may be tested ability to understand act tion of onal to to eightc.10 to 15d.15 to than g the patient to do simple g the patient to listen to and repeat a series of ng the patient four items and asking him or her to list the items about 10 minutes g the patient about verifiable past events, such as his or her mother’s maiden g the patient to name the past four presidents.ANS: CShowing the patient four or five objects, saying you will ask about them in a few minutes, and then 10 minutes later asking the patient to list the objects is a technique to measure recent memory. The other choices are not tests of recent memory. Asking the patient to listen and then repeat tests immediate recall.4. What pysch or mental condition is considered progressive and not reversible? Pg. 76, 78 Dementia (see differential diagnosis).27. Which condition is considered progressive rather than reversible?ANS: BDementia is considered progressive and irreversible, delirium and coma have the potential for reversal, and depression and anxiety are reversible.26. An older adult is administered the Set Test and scores a 14. The nurse interprets this score as indicative ofANS: EScores of less than 15 on this mental function test indicate dementia.28.Which of the following is usually related to structural diseases of the brain?ANS: BOne of the distinguishing characteristics that distinguishes dementia from the others is that it is usually related to structural diseases of the brain such as abnormal deposits, or recurrent strokes.5. If patient is delirious do they maintain orientation and attention span? Look up delirium and see what you expect patient to maintain. Pg. 75,76a.Deliriumb.Dementiac.Depressiond.Anxietye.Ctive tia.a.Deliriumb.Dementiac.Depressiond.Anxietye.Psychosis2Patient suffering from delirium is usually disoriented (usually oriented to person only) and have an impaired attentiveness. (pg 461 in Adv. Assessment) In spite of the confusion, the patient’s sensorium (consciousness) is usually intact although some condition (intoxication and severe metabolic derangements) result in altered level of consciousness.9.A state of impaired cognition, consciousness, mood and behavioral dysfunction of acute onset refers toANS: BDelirium is a state of impaired cognition, consciousness, mood and behavioral dysfunction of acute onset. Stupor describes arousals for short periods of time after a stimulus for arousal (e.g., visual, verbal, or painful). Lethargy relates to sleepiness with ease of arousal; coma is nonarousal and nonawareness. Confusion relates to inappropriate responses to questions with decreased attention span and memory.6. Who should you give a mini mental exam to? Everyone or certain patients? Pg. 67,68The mini mental exam should be given to elderly patients when there is a concern about their cognitive function. This testdetects probable dementia.34.The Mini-Mental State Examination should be administered for a patient whoANS: AThe MMSE is a tool used to estimate cognitive function quantitatively or document cognitive changes serially. Getting lost in a familiar territory is a sign of possible cognitive impairment.6. The Mini-Mental State Examination (MMSE)ANS: AThe MMSE is a standard tool that functions to estimate cognitive function quantitatively7.While interviewing a 70-year-old female clinic patient, she tells you that she takes ginkgo biloba and St. John’s wort. You make a short note to check for results of lost in her or his s an excessive amount of repetitive ritualistic illegal hallucinogenic a fear of leaving the be used to estimate cognitive changes be used to estimate personality disorders s do not vary with regard to age or determine the cause of memory a good tool to diagnose neurologic disorders.a.Denver II.b.Mini-Mental State Examination.3c.Glasgow Coma Scale.d.Goodenough-Harris Drawing Test.e.CAGE Questionnaire.ANS: BGinkgo biloba and St. John’s wort are herbal remedies used to improve mental alertness and elevate mood. As side effects, they can also result in disorientation and confusion that can be monitored with the Mini-Mental State Examination. The Denver and Goodenough- Harris tests are used for childhood development, and the Glasgow Coma Scale is used to rate coma depth. The CAGE Questionnaire is a useful tool for approaching a discussion of the use of alcohol.BREAST EXAM1. With documenting breast exams, how do you divide the breasts? If you want a radiologist to concentrate on one particular area of the breast, how do you divide to communicate findings? Pg. 351The breast is divided into five segments, four quadrants and a tail (upper inner, upper outer, lower inner, and lower outer).Either the right or left breast should be communicated. The terms: upper inner, upper outer, lower inner, lower outer, and tail of Spence should be communicated to the radiologist in terms of how to communicate findings.3.For purposes of examination and communication of physical findings, the breast is divided intoANS: CThe breast is referenced according to five segments: four quadrants and a tail.11. When conducting a clinical breast examination, the examiner shouldANS: DInspection with simultaneous observation of both breasts is essential in order to detect differences between the breast size, symmetry, contour, and skin color.2. If you have a pt c/o breast lump, what questions do you ask? For example you have a 50 year-old with breast lump, how do you begin exam compared to a 30 year-old pt?(just arbitrary ages) What assessment do you do and what questions would you ask based on age? Pg.9. Which breast change is typical after menopause?s (upper and lower).s (left, middle, and right). quadrants plus a es (six consecutive rings, each 1 inch farther away from nipple).l portions 1 through the examination if the patient has had a recent the patient covered to respect the lights to minimize ct both breasts with palpation of the breasts.a.Thickening of the inframammary ridgeb.Hypertrophy of glandular tissuec.Increase in number of lactiferous ductsd.Reduction of fat deposits4e.Shortening of Cooper’s ligamentsANS: A. After menopause, the breast tissue atrophies and is replaced by fat deposit, the inframammary ridge at the lower edge of the breast thickens, and the breast hangs more loosely as Cooper’s ligaments relax.10. In a woman complaining of a breast lump, it is most important to ask aboutANS: AHormonal changes of menstruation can result in breast tenderness, swelling, and enlarged nodes that can be felt on palpation.12. A 50-year-old woman presents as a new patient. Which finding in her personal and social history would increase her risk profile for developing breast cancer?ANS: CNulliparity or late age at birth of first child (after 30 years old) is a risk factor for breast cancer. Other risk factors include late menopause, early menarche, and drinking more than one alcoholic drink daily.1. What position do you put a patient in for a breast exam? What position is the examiner standing in? Axillary nodes what position does the patient need to be in? Pg. 355-3622. 14. To begin the clinical breast examination (CBE) for a man, ask him toANS: B Inspection begins the CBE. Ask the patient to sit with his arms hanging loosely at his sides. The technique is the same for both men and women.15.Inspection of the breasts usually begins with the patient in which position?ANS: BInspection begins with the patient in a sitting position with arms hanging loosely at the sides. Inspection (pg. 355): As the patient sits with arms hanging loosely at the sides, inspect each breast and compare it with the other for size, symmetry, contour, skin color, and texture, venous pattern, and lesions. Re-inspect the woman’s breasts with the patient in the following positions (pg. 357-358): relationship to t ization ol consumption.a.Drinking three glasses of wine per weekb.Early menopausec.Nulliparityd.Late menarchee.Young age at birth of first ne on the table with his arms with his arms hanging at his with his hands on his with his arms clasped behind his leaning forward.a.Lateralb.Sittingc.Standingd.Supinee.Proneo Seated with arms over the head or flexed behind the neck. This adds tension to the suspensory ligaments, accentuates dimpling, and may reveal variations in contour and symmetryo Steadied with hands pressed against hip with shoulders rolled forward (or alternatively have the patient push her palms together): This contracts the pectoral muscles, which can reveal deviations in contour and symmetryo Seated and leaning forward from the waist: This also causes tension in the suspensory ligaments. The breasts should hang equally. This maneuver can be particularly helpful in assessing the contour and symmetry of large breasts because the breasts fall away from the chest wall and hang freely. As the patient leans forward, support her by the hands. Patient in Seated Position (pg. 360)o Chest Wall Sweep: Have the patient sit with arms handing freely at the sideso Bimanual Digital Palpation: Place on hand, palmar surface facing up, under the patient’s right breasto Lymph Node Palpation: To palpation the axillae, have the patient seated with arm flexed at the elbow. Support the patient’s left lower arm with your left hand while examining the left axilla with your right hand. Patient in Supine Position (pg. 360): Have the patient raise one arm behind her head; then place a small pillow or folded towel under that shoulder to spread the breast tissue more evenly over the chest wall. The ideal position for examination is to have the nipple pointing toward the ceiling.b.) Axillary nodes what position does the patient need to be in? (pg. 360)Lymph Node Palpation: To palpation the axillae, have the patient seated with arm flexed at the elbow. Support the patient’s left lower arm with your left hand while examining the left axilla with your right hand.3. What’s the difference between fibrotic breast tissue and breast cancer? How do you expect each to feel? What are the characteristics of the two?17.Which finding, found on inspection, is related to fibrotic tissue changes that occur with breast carcinoma?ANS: BSkin dimpling or retraction signifies the contraction of fibrotic tissue that occurs with carcinoma. The other choices are normal variations without significance to cancer development.18. Venous patterns on breasts are suggestive of pathology when they areANS: CMalignant tumors require more blood flow. Superficial veins dilate to provide more flow and can be assessed as unilateral venous patterns. Bilateral findings are of no concern and are more commonly seen in pregnant or obese women. Nevi that are long-standing, unchanging, or nontender are of little concern.21.In patients with breast cancer, peau d’orange skin is often first evidenta.Convex or conical shapeb.Skin dimpling or retractionc.Pendulous and loose breastsd.Unequal shape or contoure.Lifelong inverted erally in obese ved during iated with a long-standing unchanging the the upper inner or around the the inframammary the tail of Spence.ANS: CThe areola is the most common initial site to visualize peau d’orange skin.24.Recent unilateral inversion of a previously everted nipple suggestsANS: BRecent unilateral inversion or retraction of a previously everted nipple suggests malignancy rather than a benign condition.41.You are conducting a clinical breast examination for a 30-year-old patient. Her breasts are symmetrical with bilateral, multiple tender masses that are freely moveable with well-defined borders. You recognize that these symptoms and assessment findings are consistent withANS: EFibrocystic changes are tender masses, usually bilateral, with multiple round, mobile, well-delineated borders. Fibroadenoma and cancer are usually nontender; Paget disease is an eczema-like condition of the nipple that signals an underlying cancer. Mammary duct ectasia most commonly occurs in menopausal women. Fibrocystic Changes (pg. 366):o Benign fluid-filled cyst formation caused by duct enlargement o Pathophysiology Usually bilateral and multiple Most common in women 30 to 55 years of age Associated with long follicular or luteal phase of the menstrual cycleo SubjectiveData Tender and painful breasts and/or palpable lumps that fluctuate with menses  Usually worse premenstruallyo ObjectiveData Round, soft to firm, tense, mobile masses with well-delineated borders  Usually tender Usually bilateral Multiple or single Fibroadenoma (pg. 366): n breast adenoma.b.Paget ry duct cystic changes.o Pathophysiology May occur in girls and women of any age during their reproductive years  After menopause, the tumors may regresso SubjectiveData Painless lumps that do not fluctuate with the menstrual cycle May be symptomatic with discovery on clinical breast examination or breast imagingo ObjectiveData Round or discoid, firm, rubbery, mobile masses with well-delineated borders  Usually non-tender Usually bilateral Single; may be multiple Biopsy often performed to rule out carcinoma Malignant Breast Tumors (pg. 366): Ductal carcinoma arises from the epithelial lining of ducts; lobular carcinoma originates in the glandular tissue of the lobuleso Pathophysiology Mutations to normal cells results in uncontrolled cell division and tumor formation; as the tumor grows andinvades surrounding tissue, metastases occurs through the lymph and vascular systems Peak incidence between the ages of 40 and 75 years, with the majority of malignant breast tumors occurring in women older than 50o SubjectiveData Painless lump; change in size, shape, or contour of breast Axilla may be tender if lymph nodes involved May be asymptomatic with discovery on clinical breast examination or breast imagineo ObjectiveData May be palpable mass that is usually single, unilateral, irregular, or stellate in shape; poorly delineatedborders; fixed; hard or stone-like; and non-tender Breast may have dimpling, retraction, prominent vasculature Skin may have peau d’orange or thickened appearance Nipple may be inverted or deviated in position(Differential diagnosis pg. 365)Fibrotic: usually bilateral, multiple or single, round, soft to firm; tense, mobile, absent retraction signs, usually tender, bordersare well delineated, and they vary with menses.Cancer: Usually unilateral, single, irregular or stellate, hard/stonelike, fixed, retraction signs are often present, usually nontender, the borders are poorly delineated; irregular, and they do not vary with menses.4. Breast Exam- What part of the hand do you use? Fingertips, pads, palms, entire hands? Pg. 361Palpate using your finger pads as they are more sensitive than your fingertips. Palpate systematically, pushing gently but firmly toward the chest wall, as you rotate your fingers in a clockwise or counterclockwise pattern. At each point, as you rotate your fingers press inward, using three depths of palpation: light then medium and finally deep. The exact sequence you select for palpation is not critical, but a systematic approach will help ensure that all portions of the breast are examined.26.When palpating breast tissue, the examiner should use the _____ at each r of the surface of the sANS: BThe finger pads are used for breast palpation because they are more sensitive than the fingertips.5. What is Peau d\'orange skin? Look, feel, mean? Pg. 356The skin has an orange peel appearance. This indicates edema of the breast caused by blocked lymph drainage in advanced orinflammatory breast cancer. The skin appears thickened with enlarged pores and accentuated skin markings.6. What is the tail of Spence? Where is it anatomically? Pg. 351The tail of Spence is (extends from) the greatest amount of glandular tissue that lies in the upper outer quadrant and extendsinto the axilla. ??????2.The largest amount of glandular breast tissue lies in theANS: DThe greatest amount of glandular tissue in the breast lies in the upper outer quadrant.31.The tail of Spence extendsANS: DThe tail of Spence extends from the upper outer breast quadrant into the axillae.7. Breast Exam: Certain groups of lymph nodes are enlarge, where would they be for examiner to expect Breast Cancer? Pg. 360The axilla, supraclavicular and infraclavicular areas. Nodes that are detected should be described according to location, size, shape, consistency, tenderness, fixation, and delineation of borders.34.When examining axillary lymph nodes, the patient’s arm inner of S outer the midclavicular d the supraclavicular into the inframammary the the sternal d full above the ded at the ed against the ed over the d at the elbow.ANS: ETo examine the axilla, support the patient’s lower arm with the elbow flexed with one of your hands and use your other hand to palpate the axilla.35.Lymphatic flow of the breast primarily drainsANS: CEach breast contains a lymphatic network that drains the breast radially and deeply to underlying lymphatics.36. The greatest concern for breast cancer is when you palpate _____ nodes.ANS: DThe supraclavicular and infraclavicular nodal areas are sentinel nodes; any enlargement in these areas is especially significant.37.You are performing a clinical breast examination for a 55-year-old woman. While palpating the supraclavicular area, you suspect that you felt a node. To improve your hooked technique, you shouldANS: EHaving the patient turn her head toward the examination side, as well as raising the shoulder on that same side, gives your fingers more room to palpate deeper into the fossa.8. What if you have a 20-30 year-old with freely moveable, well-defined lump, tender with cycle, cancer or more likely fibrotic? Fibrotic (see page 365)iorly toward the ally toward the corresponding lly toward the omedially toward the ior nal lotion to your both hands the patient to press both palms the patient to lower her shoulder on that the patient to turn her head toward that side.1041.You are conducting a clinical breast examination for a 30-year-old patient. Her breasts are symmetrical with bilateral, multiple tender masses that are freely moveable with well-defined borders. You recognize that these symptoms and assessment findings are consistent withANS: EFibrocystic changes are tender masses, usually bilateral, with multiple round, mobile, well-delineated borders. Fibroadenoma and cancer are usually nontender; Paget disease is an eczema-like condition of the nipple that signals an underlying cancer. Mammary duct ectasia most commonly occurs in menopausal women.9. Then you have a 50 year-old-lump firm, fixed, doey-like, cancer or fibrotic? Cancer FEMALE GENITALIA1. Pelvic Exam-anatomy of vagina and location of glands-5 O’clock, 7 O’clock for example, just know the anatomy of the male and female genitals.2. What structures are located at the 5 o’clock and the 7 o’clock positions of the vaginal orifice and open onto the sides of the vestibule in the groove between the labia minora and the hymen?ANS: DBartholin glands are found posteriorly on each side of the vaginal orifice and open onto the sides of the vestibule.2. Cervical Cancer- know patient’s history and what questions to ask patients that put them at high risk for cervical cancer.12. Which factor is associated with an increased risk of cervical cancer?ANS: EWomen who were younger than 17 years when they had their first full-term pregnancy are almost 2 times more likely to get cervical cancer later in life than women who were not pregnant until they were 25 years or adenoma.b.Paget ry duct cystic changes.a.Skene glandsb.Perineal bodiesc.Labia majorad.Bartholin glandse.Labia minoraa.Endometriosisb.Low parityc.HPV vaccinationd.High socioeconomic statuse.Early parity113. What history increases your risk for ovarian cancer? (pg. 425)Risk factors for ovarian cancer (box on p. 425 below cervical risk factors): Age (increases with age), inherited genetic mutation (BRCA1 or BRCA2 gene), family history, obesity, reproductive history (nulliparity increases risk), and the use of fertility drugs, personal history, hormone replacement therapy, and high-fat diet.13.The risk of ovarian cancer is increased by a history ofANS: EThere is a relationship between nulliparity and an increased risk of ovarian cancer. Although the risk increases with age, most ovarian cancers develop after menopause; half are found in women older than 63 years. The other choices have no relationship with ovarian cancer.4. What is a normal cervix and an abnormal cervix? What does an abnormal one look like (not cancerous) what tests might you and what might indicate? Disorder?22. During digital examination of the vagina, the cervix is noted to be positioned posteriorly. Upon bimanual examination of this woman, you would expect to palpate a(n) _____ uterus.ANS: BThe position of the cervix correlates with the position of the uterus. A cervix that is pointing posteriorly indicates an anteverted uterus.23. The presence of cervical motion tenderness may indicateANS: CPainful cervical motion tenderness suggests a pelvic inflammatory disease or a ruptured tubal pregnancy. The cervix is expected to move 1 to 2 cm without discomfort under normal conditions.25.During a routine vaginal examination, you insert the speculum and visualize the cervix. The cervix projection into the vaginal vault -fat ette between 35 and 50 body ally c inflammatory nancy.12approximately 5 cm. Upon bimanual examination, you would expect to find the the midline the retroverted the anteverted ted to the left or the retroflexed position.ANS: DNormally, the cervix protrudes into the vagina 1 to 3 cm. Longer projections suggest a pelvic or uterine mass. A pelvic mass would cause the uterus to be deviated to the right or left, but an anteverted, retroverted, or retroflexed uterus would still be in the midline regardless of its position.26.Small, pale yellow, raised, and rounded areas are visualized on the surface of the cervix. You shouldANS: AThis describes nabothian cysts, which are retention cysts of the endocervical glands and are considered a normal variant. No further testing is this as nabothian this as a friable n a viral the pH of the cervical this as an eroded cervix.a.b.c.Normal cervix: covered with pink squamous epithelium that is uniform in consistency. It should be in an anterior- posterior position that correlates with the position of the uterus. The os is small and round. A small area of ectropion is visible inferior to the os. Cervix should feel firm (during pregnancy will be softer) and be smooth.Abnormal cervix: Bluish color indicates increased, which may indicate pregnancy. A pale cervix is associated with anemia. If the cervix is pointed anteriorly it indicates a retroverted uterus; pointing posteriorly indicated an anteverted uterus. Horizontal indicated a uterus in midposition; deviation indicated a pelvic mass, uterine adhesions, or pregnanacy. Projection greater than 3 cm may indicate a pelvic or uterine mass. Small, white or yellow raised, round areas may indicate nabothian cysts. Friable tissue, red patchy areas, granular areas, and white patches could indicate cervicitis, infection, or carcinoma.Feel for nodules, harness, and roughness. Note the position of the cervix, it should be in the midline and may point anteriorly or posteriorly. Grasp the cervix between your fingers and move it gently from side to side (should move 1-2 cm). There should be no pain or discomfort. Painful cervical movement suggests a pelvic inflammatory disease or a ruptured tubal pregnancy which would require immediate surgery.5. What structure or organs are examined during a Bimanual exam? (pg 436-437). Cervix, Uterus, Adnexa, and Ovaries33.The assessment of which structure is not part of the bimanual examination?a.Cervixb.Bladderc.Uterusd.Ovariese.Adnexa13ANS: BThe bimanual examination consists of assessing the cervix, uterus, adnexa, and ovaries.6. When do PAP smears begin? Age of non-sexually active versus sexually active women? (pg. 437) 21 for non-sexually and sexually active women because cervical cancer is rare for women under age 21.40.When a woman is not sexually active, cervical cancer screening should beginANS: DWomen who are not sexually active should have their first examination by the age of 21 years. Women under age 21 should not be tested.7. Menopausal women- what does the vagina and mucosa of the walls feel like? (pg. 447)The vagina is narrower and shorter. You will see and feel the absence of rugae. The cervix is smaller and paler but the osshould still be palpable and the cervix may be less mobile.43.During a pelvic examination for a postmenopausal woman, you would expect to assessANS: BExpected findings in the pelvic examination for an older woman include a narrower and shorter vagina, absence of rugation, a less mobile cervix, and a palpable cervical os. The ovaries are rarely palpable because of atrophy.MALE GU1. Males-history or what alerts the examiner of the possibility of testicular cancer? (pg. 470).Undescended testicle, personal hx of testicular CA, family hx of testicular CA, abnormal testicle development (klinefelter syn), 20-54 yr male, the most prominent in white race ( 5 times that of black; more than 3 times that of Asian American and Native American men).13.Which of the following is a risk factor for testicular cancer? age 15 age 18 age 21 age 30 years.a.a wider and longer vaginal ce of vaginal wall rugation.c.a nonpalpable cervical os.d.a more mobile ble ovaries.a.Circumcisionb.Condyloma acuminatumc.Cryptorchidism14d.Poor hygienee.Multiple sexual partnersANS: CCryptorchidism (testes that fail to descend by 12 months of age) is a risk factor for testicular cancer.27.The most common cancer in young men age 15 to 30 years isANS: ABecause testicular tumors are the most common cancer occurring in young adults, self-examination is encouraged.37.Self-examination of the male genitaliaANS: BMonthly self-examination is recommended as a screening test for testicular cancer as well as sexually transmitted infections for all young men starting at 15 years of age. It is encouraged during bathing because the scrotal skin is less thick at this time and because the scrotum hangs looser because of the warmth. Inspection is done first followed by palpation.2. What alerts us to do further testing and the need to further and fully assess for testicular cancer? How do we do this?o Irregular, contender mass fixed to the testiso Does not transilluminateo May also have hydrocele(that doesn\'t transilluminate) o InguinalLymphadenopathyo Painless mass in testicleo Scrotalenlargementorswellingo Heavy feel in in scrotumo Dull ache in lower abdomen, back or groino fluid in scrotumThis can be done by performing a Testicular exam ( inspect and palpate), Scrotal US, Lab work including: Chemistry, WBC count, biochemical markers AFP and B-hCg.21.Mr. L. has an unusually thick scrotum with edema and pitting. He has a history of cardiac problems. The appearance of his scrotum is more likely a(n)ANS: BGeneral fluid retention can cause scrotal thickening and pitting edema and is more often seen as a result of cardiac, renal, or hepatic disease. This swelling does not imply a condition of the genitalia but rather a condition of these related d be restricted to adults with prior d be performed while s with palpation and then d be performed t be adequately performed due to poor visualization of the nital defect that has ation of general fluid l consequence of ication to the development of quence of prior STDs.1525.An enlarged, painless testicle in an adolescent or adult may cular torsion.c.a undescended padias.ANS: CA hard, enlarged, painless testicle can indicate a tumor in an adolescent or adult male. Epididymitis and torsion are painful; an undescended testicle is common in infants and is usually resolved by 12 months. Hypospadias is a congenital defect of the urethral opening causing the meatus to be located ventral to its normal position.26.You palpate a soft, slightly tender mass in the right scrotum of a man. You attempt to reduce the size of the mass, and there is no change in the mass size. Your next assessment maneuver is toANS: DA soft mass is either a hernia or hydrocele. If the mass can be reduced, it is probably a hernia; a nonreducible mass should be transilluminated to determine whether it contains fluid and is possibly caused by a hydrocele. Lifting the scrotum should be done when epididymitis is suspected. Urethral cultures are not indicated at this point.29.An adolescent male is being seen for acute onset of left testicular pain. The pain started 3 hours ago. He complains of nausea and denies dysuria and fever. Your prioritized assessment should be toANS: CThe patient is displaying symptoms of testicular torsion. An absent cremasteric reflex is a supporting finding to differentiate torsion from epididymitis.38. A 12-year-old boy says that his left scrotum has a soft swollen mass. The scrotum is not painful upon palpation. The left inguinal canal is without masses. The mass does transilluminate with a penlight. This collection of symptoms is consistent withANS: BA hydrocele is a soft scrotal mass that occurs from fluid accumulation and therefore does transilluminate. Orchitis results in a swollen, tender testis. A rectocele does not result in scrotal swelling. A scrotal hernia would also be palpable along the inguinal canal. Epididymitis is an extremely painful condition.41.A cremasteric reflex should result two fingers to attempt to reduce the te the left scrotum the right testicle, then compare pain illuminate the re the meatus for gonococcal n urine and DNA probe urethral the left scrotum to confirm lish absent cremasteric illuminate the left and right the patient stand and observe the scrotum for a “bag of worms.”al scrotum appear to contain a “bag of worms.”e deviation to the left um to elevate iate erection of the cle and scrotal rise on the stroked side.ANS: EUpon stroking the inner thigh with a blunt instrument or finger, the testicle and scrotum should rise on the stroked side.3. How do you assess for an inguinal hernia? Pg. 472-473Have the pt. stand and bear down. While he is straining inspect the area of the inguinal canal and the region of the fossa ovalis. After the pt. relaxes, insert your examining finger into the lower part of the scrotum and carry it upward along the vas deferens into the inguinal canal. You can also auscultate for bowel sounds, which will be present in uncomplicated reducible hernias.18.Which technique is appropriate to detect an inguinal hernia?ANS: EExamination for inguinal hernias is performed with the patient standing. Inspect the groin while the patient performs a Valsalva maneuver. Insert your examination finger into the lower part of the scrotum and follow upward along the vas deferens to screen for a hernia.19. Which type of hernia lies within the inguinal canal?ANS: CHernias found within the inguinal canal are called indirect hernias.4. What does Vas deferens feel like? Normal? Abnormal? Pg. 473The Vas deferens feels smooth and discrete; abnormal findings are beaded or lumpy feeling. This may indicate diabetes or oldinflammatory changes, especially tuberculosis.2.What structure of the male genitalia travels through the inguinal canal and unites with the seminal vesicle to form the ejaculatory duct?ANS: Da.Conduct percussion while the patient coughs.b.Have the patient strain as you pinch the testes.c.Inspect rectal areas as the patient bears down.d.Conduct the examination only in the supine position.e.Move your finger upward along the vas deferens.a.Umbilicalb.Directc.Indirectd.Femorale.Incisionala.Epididymisb.Corpus cavernosumc.Urethrad.Vas deferense.Ureter17The vas deferens begins at the end of the epididymis, travels the spermatic cord, goes through the inguinal canal, and then unites with the seminal vesicle to form the ejaculatory duct.23.A normal vas deferens should feelANS: BThe vas deferens should normally feel smooth, discrete, and nontender.5. Young man- what is an emergent cause of testicular pain? Pg. 482 Testicular Torsion is twisting of the spermatic cord and is a surgical emergency.29.An adolescent male is being seen for acute onset of left testicular pain. The pain started 3 hours ago. He complains of nausea and denies dysuria and fever. Your prioritized assessment should be toANS: CThe patient is displaying symptoms of testicular torsion. An absent cremasteric reflex is a supporting finding to differentiate torsion from epididymitis.28.The most emergent cause of testicular pain in a young male isANS: ETesticular torsion is a surgical emergency. If surgery is performed within 12 hours after the onset of symptoms, the testis can be saved in about 90% of cases. Delayed treatment results in a much lower salvage rate.6. Understand hernias, where located and how to assess each kind. Pg. 476, 477(see differential diagnosis).Hernia is protrusion of a peritoneal-lined sac through some defect in the abdominal wall. There are indirect, direct and femoral.7. What is the most common type of hernia? Pg. 477 Indirect Inguinal hernias are the most common type.31.The most common type of hernia occurring in young males n urine and DNA probe urethral the left scrotum to confirm lish absent cremasteric illuminate the left and right the patient stand and observe the scrotum for a “bag of worms.”cular cerated ect al.ANS: CThe most common type of hernia in children and young males is an indirect inguinal hernia.MUSCULOSKELETAL1. What is the difference between osteoarthritis versus rheumatoid arthritis?During an assessment what do you expect to see in a patient with osteoarthritis vs. RA? Findings in joints? Describe. OA (pg411)-A progressive disorder associated with age and wear and tear. There is loss of cartilage and progressive erosion of bone. Affects mostly larger bones like hips and knees, but frequently involves small joints of hands, especially distal and proximal interphalangeal joints. Asymmetrical distribution. Pain and stiffness improves with activity, and worsens with rest. Xrays show changes. Sed rate(-), Rheumatoid factor (-) RA (pg410)-If 3 or more metacarpophalangeal joints are swollen is RA. It’s a progressive, inflammatory, and erosive condition that usually affects multiple joints. It’s an autoimmune condition. Affects joints symmetrically. Affects small joints of hands and feet. Joints are tender, swollen with effusion, warm, inflamed. Nodules and deformities are noted. RA associated with: subluxation of metacarpophalgeal joins, hyperextension of joints, but also with changes in eye (scleritis, episcleritis, interstitial lung disease and pericardial disease.1. When does a musculoskeletal exam begin? (text tells you) pg405-The musculoskeletal examination is primarily limited to inspection and palpation. The focused musculoskeletal examination begins withinspection.2. How do you assess the strength of the trapezius muscle? (pg518)The strength of trapezius and sternocleoidomastoid muscle is tested by evaluating the cervical spine and asking patients to do certainmovement. Bend the head forward, chin to chest, and expect flexion of 45 degrees. Bend head to each side, ear to each shoulder and expect lateral bending of 40 degrees. Bend head backward, chin toward ceiling, and expect extension of 45 degrees.3. Patient with scoliosis, bend at waist, what is expected finding? Describe what it looks like (Pg541)When looking form the rear, the spine looks more like an “S” or a “C” than a straight line. There is no known cause. Associated with leg length discrepancy. There’s lateral curvature of spine as patient flexes forward to touch the toes. In severe deformities, patient has uneven shoulder and hip levels, and may have crease on one side of waist.194. Carpal Tunnel-What expect to feel like, how do you assess for? During assessment, particular nerve is tested, what is it? What sensation will the patient have?(pg430,524) The carpal tunnel is a space located on the anterior aspect of the wrist between the carpal bones and a ligamentous band through which the median nerve and several tendons transverse. With overuse and repetitive movements there’s a hypertrophy of tissues, causing a lot of space and impingement on the median nerve. Nighttime pain-early sign. Swelling at wrist related to inactivity of flexion at night, pain can radiate up the forearm to shoulder with numbness and tingling along the median nerve, and paresthesia involves anterior aspects of wrist, medial palm and first three digits of affected nerve. Relief is found by shaking affected hand in downward fashion. To assess, first ask patient to mark specific site using the Katz hand diagram.o Thumb abduction test isolates strength of abductor pollicis brevis muscle, innervated only by median nerve. Pt will place the hand palm up and raise the thumb perpendicular to it. Apply downward pressure on thumb to test muscle strength. Weakness=Carpal tunnel syndromeo Tinel sign: Strike pt’s wrist with your index or middle finger, where median nerve passes under the flexor retinaculum and volar carpal ligament(fig21.42). Tingling, means ( ) tiner sign and ( ) CPT syndrome.o Phalen test: pt holds both wrist in fully palmar-flexed position with dorsal surfaces pressed together for one min. Numbness and paresthesia in the distribution of median nerve is ( ) CPT syndrome.ABDOMINAL1. When conducting an abdominal exam, what position should the patient be in? Examiner? Techniques with rigid abdomen or anxious pt, what are relaxation techniques? (pg377)Need good light source; full exposure of abdomen; warm hands with short fingernails. Have pt empty bladder. Place pt is supine position with arms at sides. Approach pt from right side. Place small pillow under pt’s head and another under slightly flexed knees. Drape a towel or sheet over the patient’s chest for warmth and privacy. Be slow and gentle, avoid sudden movements.Percussion of the abdomen begins with establishinga. liver dullness.b. spleen dullness.c. gastric bubble tympany.d. overall dullness and tympany in all quadrants.e. bladder fullness.ANS: DPercussion begins with a general establishment over all quadrants for areas of dullness and tympany and then proceeds to specific target organs22. Before performing an abdominal examination, the examiner shoulda. ascertain the patient’s HIV status.b. have the patient empty his or her bladder.c. don double gloves.d. completely disrobe the patient.e. uncover only the painful areas of the abdomen.ANS: BThe patient should empty the bladder to ensure an accurate examination of organs as well as to provide comfort for the patient.2024. When examining a patient with tense abdominal musculature, a helpful technique is to have the patienta. hold his or her breath.b. sit upright.c. flex his or her knees.d. raise his or her head off the pillow.e. fully extend the legs.ANS: CTo help relax the abdominal musculature, it is helpful to place a small pillow under the patient’s head and under slightly flexed knees. The other choices increase muscle flexion.28. After thorough inspection of the abdomen, the next assessment step is toa. percuss.b. palpate nonpainful areas.c. auscultate.d. perform a rectal examination.e. palpate painful areas.ANS: CAssessment of the abdomen begins with inspection followed by auscultation. This break from the usual system examination sequence is because palpation and percussion can alter the frequency as well as the intensity of bowel sounds. Therefore, auscultation is done first.2. How long do you auscultate for BS? (pg380)Bowel sounds range from 5-35/min. If you’re unable to hear BS after 5 min of continues listening, associated with abdominal pain andrigidity then is surgical emergency.To correctly document absent bowel sounds, one must listen continuously fora. 30 seconds.b. 1 minute.c. 3 minutes.d. 5 minutes.e. 10 minutes.ANS: DAbsent bowel sounds are confirmed after listening to each quadrant for 5 minutes.3. What is the technique for percussing the liver border? Where to start, how you move, what are you listening for? (pg381)Begin liver percussion at the right midclavicular line over an area of tympany. Always begin with an area of tympany and proceed to area of dullness for easiness. Percuss upward along the midclavicular line to determine lower border of liver. The area of liver dullness is usually heard at the costal margin or slightly below it. Mark with a pen. A lower liver border that is more than 2-3 cm below costal margin may indicate organ enlargement or downward displacement of diaphragm because of emphysema or other pulmonary disease. Upper border of liver, begin percussion on the right midclavicular line at an area of lung resonance around the third intercostal space. Cont downward until the percussion tone changes to one of dullness; this marks upper border of the liver mark with pen. It’s usually in the fifth intercostal space. Measure the distance between the marks, estimates vertical span of liver, usually 6-12cm. If larger=enlargement, if smaller=atrophy.2137. To assess for liver enlargement in an obese person, you shoulda. use the hook method.b. test for cutaneous hypersensitivity.c. auscultate using the scratch technique.d. attempt palpation during deep exhalation.e. have the patient lean over at the waist.ANS: CIf the abdomen is obese or distended or if the abdominal muscles are tight, you should plan on auscultating the liver using the scratch method to estimate the lower border of the liver. Cutaneous hypersensitivity is a sign of peritonitis and does not contribute to determining liver size.Percussion at the right midclavicular line, below the umbilicus, and continuing upward is the correct technique for locating thea. descending aorta.b. lower liver border.c. medial border of the spleen.d. upper right kidney ridge.e. stomach.ANS: BPercussing along the right midclavicular line upward from the umbilicus determines the lower border of the liver. A liver border more than 2 to 3 cm signifies hepatomegaly.When palpating the abdomen, you should note whether the liver is enlarged in thea. left upper quadrant.b. midepigastric region.c. periumbilical area.d. right upper quadrant.e. right lower quadrant.ANS: DAn examiner can recognize a friction rub in the liver by a sound that isa. clicking, gurgling, and irregular.b. high pitched and associated with respirations.c. loud, prolonged, and gurgling.d. soft, low-pitched, and continuous.e. low pitched, tinkling, and unrelated to respirations.ANS: BAn abdominal friction rub is rare and can be identified when high-pitched sounds are auscultated in association with respirations. The liver is located in the right upper quadrant of the abdomen4. CVA tenderness-what might it be a sign of?Costovertebral angle tenderness should be assessed whenever you suspect the patient may havea. cholecystitis.b. pancreatitis.c. pyelonephritis.d. ulcerative colitis.e. intussusception.22ANS: CPyelonephritis is characterized by flank pain and costovertebral angle tendernessNEURO1. Autonomic Nervous System- what are you assessing? Coordinate?(Pg477)The Nervous system with its central and peripheral divisions maintains and controls all body functions by its voluntary and autonomic responses. The evaluation of motor, sensory, autonomic, cognitive and behavioral elements. The CNS is the main network of coordination and control for the body.(PG446) Coordination tests fluidity of movements. Inability to coordinate movements suggests cerebellar dysfunction. Finger to nose testing-ask pt to touch your index finger with his or her index finger, then touch his/her noserepeatedly. Poor coordination of movement indicates dysmetria. Rapid alternating movements-Ask pt to perform rapid pronation and supination of the hand on his/her thigh or on examination table Heel to shin testing-Ask pt to take the heel of one side and repeatedly move up and down the shin of the opposite leg Romberg- Ask pt to stand with feet together, arms abducted outward with palms up, and eyes closed. PostiveRomberg is observed as a swaying motion, or inability to maintain balance, and indicates cerebellar dysfunction.2. Motor Cortex of Brain- What does it control?3. Know EACH Cranial Nerve (several questions)- how to assess each, what testing for, what each do, abnormal findingsvs. expected findings. (pg553) Olfactory (1)- Sensory: smell reception and interpretation. Have available 2-3 vials of aromatic odors. Ensure patient’s nasal passages are patent. Occlude one naris at a time and ask patient to breathe in and out, while closing her eyes. Use different odor to test the other side. Assess the ability of patient to differentiate between diff odors. Sense of smell diminishes with age. Anosmia (loss of sense of smell). Optic (ll)- Sensory: visual acuity and visual field (chapter 11) Oculomotor (lll)-Motor: raise eyelids, most extraocular movements. Parasympathetic: pupillary constriction,change lens shape Trochlear (lV)- Motor: downward, inward eye movement(lll, lV, Vl)- Movement of eyes through the six cardinal points of gaze, pupil size, shape, response, to light and accommodation and opening of the upper eyelids. When assessing pt with severe unremitting headaches, the experienced examiner evaluates movement of the eyes for the presence of absence of lateral gaze. The sixth cranial nerve is commonly one of the first to lose function in the presence of increased intracranial pressure. Trigeminal (V)- Motor: jaw opening and clenching, chewing and mastication. Sensory: sensation to cornea, iris, lacrimal glands, conjunctiva, eyelids, forehead, nose, nasal and mouth mucosa, teeth, tongue, ear, facial skin. Evaluate for muscle atrophy. Have patient clench teeth as you palpate the muscles over the jaw, evaluating tone, which should be symmetric, without fasciculations. The three divisions of the trigeminal nerve are evaluated for the sharp, dull and light sensations. With pt closing eyes, touch each side of face at the scalp, cheek and chin, alternating sharp and smooth edges of a broken23tongue blade or a paper clip. Ask patient to report feeling. Then stroke face with cotton wisp. If sensation is impaired, ask pt to differ btw hot/cold. Abducens (Vl)- Motor: lateral eye movement Facial (Vll)- ask pt to raise eyebrows, squeeze the eyes shut, wrinkle the forehead, frown, smile, show the teeth, purse the lips to whistle, and puff out the cheeks. Observe for ticks, unusual movements and symmetry of expression. Drooping of one side of mouth or sagging of lower eyelid will indicate muscle weakness. Ie: Bells palsyTo evaluate taste, a sensory fx of cranial nerves Vll and lX: have patient have tongue protruded and have 4 solutions with Bitter, sour, salty

NURS6512 Final Exam Walden University NURS6512 Final Exam Walden University NURS6512 Final Exam Walden University NURS6512 Final Exam Walden University NURS6512 Final Exam Walden University NURS6512 Final Exam Walden University Course NURS-6512D-1/NURS-6512N-1-NURS-6512D- 1/NURS-6512N-1- Advanced Health Assessment and Diagnostic ReasoningTest Final Exam
Started 8/1/19 11:30 AM Submitted 8/1/19 1:20 PMDue Date 8/12/19 1:59 AMStatus Completed
Attempt Score 93 out of 100 pointsTime Elapsed 1 hour, 34 minutes out of 1 hour and 50 minutes1. Costovertebral angle tenderness should be assessed whenever you suspect the patient may have: - Polynephritis2. In older adults, overflow fecal incontinence is commonly due to: -Fecal impaction3. A 1 month old boy has been vomiting for 2 weeks. How is this symptom of GERD and pyloric stenosis further differentiated in this child’s assessment? – The infant has regurgitation with pyloric stenosis4. Auscultation of borborygmi is associated with: - Gastroenteritis, early intestinal obstruction, or hunger5. When auscultating the abdomen, which finding would indicate collateral circulation between the portal and systemic venous systems? – Venous hum6. Conversion of fat-soluble wastes to water-soluble material for renal excretion is a function of the: - Liver7. The major function of the large intestine is: -Water absorption8. Which structure is located in the hypogastric region of the abdomen? –Ileum, bladder, andpregnant uterus9. A 45 year old man relates a several week history of severe intermittent abdominal burning sensations. He relates that the pain is relieved with small amounts of food. Before starting the physical examination, you review his laboratory work, anticipating a (n): -Positive Helicobacter pylori result10. You are caring for a patient with trigeminal neuralgia. During the assessment, the patient would describe the pain as: - Burning or shocklike11. Your 85 year old patient is complaining of right knee pain. She has a history of osteoarthritis for which she is given anti-inflammatory medication. To assess her right knee pain, you should ask her if: - The pain gets better when she sits12. A 5 year old is complaining of nondescriptive “belly pain.” Your next action should be to ask him to: - Point to the area of pain13. The perception of pain: - Is variable and is affected by emotions, and cultural background14. Patients presenting with ascites, jaundice, cutaneous spider veins, and nonpalpable liver exhibit signs of: - Cirrhosis15. A patient presents to the emergency department after a motor vehicle accident. The patient sustained blunt trauma to the abdomen and complains of pain in the upper left quadrant that radiates to the left shoulder. What organ is most likely injured? – Spleen16. Imaging studies reveal that a patient has dilation of the renal pelvis from an obstruction in the ureter, what condition will be documented in this patient’s health record? – Hydronephrosis17. Visible intestinal peristalsis may indicate: - Intestinal obstruction18. Infants born weighing less than 1500g are at higher risk for: - Necrotizing enterocolitis19. Which of the following factors is not known to affect patient compliance with his or her treatment regimen? – The patient’s age and social status20. One of the most important aspects to consider in the orthopedic screening examination is: -Symmetry21. The sequence of the physical examination should be individualized to: -22. As you greet the patient, which examination technique is first implemented? - Inspection23. Which of the following is most likely to enhance examiner reliability? – The examiner attempts to qualify data24. A 7 year old boy is brought to your office with a chief complaint of possible fracture to his left third finger. He jammed it while playing basketball 2 days ago. The mother states that she really does not think it is broken because he can move it. What is your best response? – This is common misconception, and the finger may be broken. An x-ray is indicated.25. A patient presenting for the first time with typical low back pain should receive which of the following diagnostic tests?26. Skeletal changes in older adults are the result of: -Increased bone resorption 27. A positive straight leg raise test usually indicates: - Lumbar nerve root irritation28. What technique is performed at every infant examination during the first year of life to detect hip dislocation? – Barlow-Ortolani maneuvers29. Expected normal findings during inspection of spinal alignment include: - Convex lumbar curvenumber of times the patient has to change positions to conserve the patient’s energyMinimize theusually musculoskeletal etiology.– None of the above. X-ray is not indicated because lumbar pain is30. Temporalis and masseter muscles are evaluated by: - Having the patient clench his or her teeth31. When palpating joints, crepitus may be caused when: - Irregular bony surfaces rub together32. A 3 year old is brought to the clinic complaining of a painful right elbow. He is holding the right arm slightly flexed and pronated and refuses to move it. the mother states that symptoms started right after his older brother had been swinging him around by his arms. This presentation supports a diagnosis of: - Radial head subluxation33. Light skin and thin body habitus are risk factors for: - Osteoporosis34. Risk factors for sports-related injuries include: - Failure to warm up before activity35. Injuries to long bones and joints are more likely to result in fractures than in sprains until: -Adolescence36. Ligaments are stronger than bone until: - Adolescence37. The family history for a patient with joint pain should include information about siblings with: -Genetic disorders38. The Thomas test is used to detect: - Flexion contractures of the hip39. A goniometer is used to assess: - Range of motion40. During a football game, a player was struck on the lateral side of the left leg while his feet were firmly planted. He is complaining of left knee pain. To examine the left knee you should initially perform the ________ test. – Valgus stress41. You note that a child has a positive Gower Sign. You know that this indicates generalized: -Muscle weakness42. The dowager hump is: - The hallmark of osteoporosis43. What temporary disorder may be experienced by pregnant women during the third trimester because of fluid retention? –Carpal tunnel syndrome44. A common finding in markedly obese and pregnant women is: - Lordosis45. A 45 year old laborer presents with low back pain, stating that the pain comes from the right buttock and shoots down and across the right anterior thigh, down the shin to the ankle. Which examination finding is considered more indicative of nerve root compression? – Positive straight leg raise result46. Mrs. Bower is a 57 year old patient who comes in for an office visit. Which of the following disorders is known to be hereditary? – Huntington chorea47. Testing of cranial nerve ________ is not routinely performed unless a problem is suspected.–I48. The patient is able to rapidly touch each finger to his thumb in rapid sequence. What does this finding mean? – The patient has appropriate cerebellar function49. Which question asked by the examiner may hellp to determine prevention strategies for seizures that a patient is experiencing? – “Are there any factors or activities that seem to start the seizures?”50. A patient has a complaint of dizziness. The patient makes the following statement: “I sometimes feel as if the whole room is spinning.” What type of neurologic dysfunction should the examiner suspect? – Inner ear dysfunction affecting the acoustic nerve51. The examiner asks the patient to close her eyes, then places a vibrating tuning fork on the patient’s ankle and asks her to indicate what is felt. What is being assessed? – Peripheral nerve sensory function52. Which of the following findings should an examiner consider a normal finding if associated with pregnancy? – Acroparesthesia52. Jack is a 52 year old obese man with a history of poorly controlled diabetes. He also smokes. Based on the above data, the examiner should recognize that Jack has several risk factors for: - Cerebrovascular accident53. Mrs. Jones is a 24 year old patient who presents to your office 2 days postpartum. She complains that she is experiencing foot drop. Which of the following problems should the examiner consider? – Lumbosacral plexopathy54. The examiner is assessing deep tendon reflex response in a 12 year old boy. The response is an expected reflex response. Which of the following scores should be documented? – 2 55. A 68 year old patient presents to your office for follow-up. He tells you, “I have a hard time finding the right words when I am talking;” he also is experiencing numbness. On examination, you note postural instability. This symptom may be: - A late symptom of Parkinson’s disease56. Motor maturation proceeds in an orderly progression from: - Head to toe 57. The thalamus is the major integration center for perception of: - Pain58. The examiner should be concerned about neurologic competence if a social smile cannot be elicited by the time a child is ________old. – 3 months59. Normal changes of the aging brain include: -60. When interviewing a 70 year old female clinic patient, she tells you that she takes ginkgo biloba and St. John’s Wort. You make a short note to check for results of the: -Mini-mental state examination61. The area of body surface innervated by a particular spinal nerve is called a: - Dermatome 62. If a patient cannot shrug the shoulders against resistance, which cranial nerve (CN) requiresfurther evaluation? – CN XI, spinal accessory63. The finger-to-nose test allows assessment of: - Coordination and fine motor function64. You ask the patient to follow a series of short commands to assess: - Attention span65. As Mr. B. enters the room, you observe that his gait is wide based and he staggers from side to side while swaying his trunk. You would document Mr. B.’s pattern as: - Cerebellar ataxia66. When is the mental status portion of the neurologic system examination performed? –Constantly throughout the entire interaction with a client67. An aversion to touch or being held, along with delayed or absent language development, is a characteristic of: -Autism68. The autonomic nervous system coordinates which of the following? – Internal environment of the body69. The major function of the sympathetic nervous system is to: - Orchestrate the stress response70. The parasympathetic nervous system maintains the day-to-day function of: - Digestion 71. Cerebrospinal fluid serves as a: - Shock absorber72. You are performing a two-point discrimination test as part of a well physical examination. The area with the ability to discern two points in the shortest distance is the: -Finger tips73. Which type of hallucination is most commonly associated with alcohol withdrawal? – Visual- bugs, pink elephantsDiminished perception of touch. -- this is byprocess of elimination/educated guess. I could not find direct information addressing this inSeidel74. On a scale of 0 to 4 , which deep tendon reflex score is appropriate for a finding of clonus in a patient? –3 75. Which statement is true regarding mental status changes in older adults? – There is an increased risk of delirium with acute illness or metabolic derangement.76. A characteristic related to syphilis or diabetic neuropathy is testicular: -Insensitivity to painful stimulation77. When collecting personal and social history data from a woman complaining of breast discomfort, you should question her regarding: - Alcohol, tobacco, and caffeine use78. What risk factor is associated with cervical cancer? – HPV79. A 23 year old female presents with severe right lower quadrant tenderness. All of thefollowing should be considered in the differential except: - Classis diverticulitis80. What is the initial diagnostic radiology test that should be ordered if you suspect a rupturedovarian cyst? – Abdominal and transvaginal ultrasound81. A 17 year old male was brought into the emergency room with testicular/scrotal pain. Thedifferential diagnosis should include all except: - Inguinal herniation82. The nursing mother complains that her breasts are tender. You assess hard, shiny, and erythremic breasts bilaterally. You should advise the patient to: - Massage gently and continue nursing83. A normal vas deferens should feel: - Smooth84. In a woman complaining of a breast lump, it is most important to ask about: - Itsrelationship to menses85. The finding of a painless indurated lesion on the glans penis is most consistent with: -Chancre86. Thrombosed hemorrhoids are: - Blue, shiny, painful masses87. Pregnancy-related cervical changes include: - Softening and bluish coloring88. You are inspecting the genitalia of an uncircumcised adult male. The foreskin is tight and cannot be easily retracted. You should: - Inquire about previous penile infections89. An adolescent male is being seen for acute onset of left testicular pain. The pain started 3 hours ago. He complains of nausea and denies dysuria or fever. Your prioritized assessment should be to: - Establish absent cremasteric reflex90. A 23 year old white woman has come to the clinic because she has missed two menstrual periods. She states that her breasts have enlarged and that her nipples have turned a darker color. Your further response to this finding is: - Suggest pregnancy testing91. What accommodations should be used in the position of a hearing-impaired woman for a pelvic examination? – The head of the table should be elevated92. Sexual differentiation in the fetus has occurred by _______weeks gestation. - 1293. You are performing a clinical breast examination for a 55 year old woman. While palpating the supraclavicular area, you suspect that you felt a node. In order to improve your hooked technique, you should: -Ask the patient to turn her head toward that side94. If a firm, transverse ridge of compressed tissue is felt bilaterally along the lower edge of a 40 year old patient’s breast, you should: -Record the finding in the patient’s record95. A therapeutic technique for dealing with grieving individuals is to: - Tell them that is good to cry and to share feelings96. The examination of the newborn should begin with: - Inspection noting skin color, flaccidity, tension, gross deformities, or distortions of facies97. Which one of the following patient characteristics is most likely to limit patient reliability during history taking? – Patient is sleep and sensory deprived98. In crying infants, it is often difficult to: - Auscultate heart sounds99. Which of the following statements accurately reflects the sensitivity and specificity oflaboratory tests? – No test has 100% sensitivity and specificity100. Which medical condition would exclude one from sports participation? – Fever101. Your 15 year old patient is athletic and thin. Radiography of an ankle injury reveals a stress fracture. You question this patient about her: - Menstrual cycles102. Which of the following are examined with the patient in a reclining 45 degree position? –Jugular venous pulsation and pressure103. Functional assessment is most important during the examination of a(n): -Older adult104. The best way to ease the apprehension of a 3 year old child before a physical examination is to: - Encourage child’s participation105. An ophthalmoscopic eye examination involves: - Lens inspection106. When conducting a geriatric assessment, basic activities of daily living (ADLs) include: -Bathing107. The checkout station for preparticipation physical evaluation (PPE) is critical because at this point: - The coordination of follow-ups is reviewed108. Which of the following is true regarding the relationship between the examiner and the patient? – The patient is a full partner with the examiner109. Which of the following factors is not known to affect patient compliance with his or her treatment regimen? – The patient’s age and social status110. One of the most important aspects to consider in the orthopedic screening examination is:- To look for symmetry of muscle, stature, and joint movement111. As you greet the patient, which examination technique is first implemented? – Inspection 112. Which portion of the physical examination is best done with the patient standing? –Spinal 113. Which patient position facilitates inspection of the chest and shoulders? – Sitting114. The least reliable indicator of newborn distress is: - Color115. Proprioception should be assessed while the patient is: - Standing116. Part of the screening orthopedic component of the examination includes evaluating the person while: - Duck walkingHealth Assessment Final Review ExamMust have 78% to pass between both exams Always go with the text bookMENTAL ASSESSMENT (Ch 5 pgs 64-78)1. What does orientation to person, place, and time assess? When you perform assessment, what exactly are you looking for? Pg. 67Person, place and time assess state of consciousness. When performing this assessment you are looking for cognitive function. Person disorientation is a result of cerebral trauma, seizures, or amnesia; Place disorientation occurs with psychiatric disorders, delirium, and cognitive impairment; Time disorientation is associated with anxiety, delirium, depression, and cognitive impairment.8. Assessing orientation to person, place, and time helps determineANS: DOrientation to person, place, and time are measures of states of consciousness and awareness, not degrees of attention span. Analogies and abstract reasoning are higher functions than orientation. Emotional status can be better evaluated by observing behaviors.2. How many serial numbers should most people be able to repeat? For example: counting backwards. How many should the average person be able to repeat? Pg. 70Five to eight numbers forward or four to six backward can usually be repeated.10.Under most conditions, adult patients should be able to repeat a series of _____ numbers.ANS: BMost adults should be able to recall immediately a series of five to eight numbers forward and four to six numbers backward.3. How do you assess recent memory if you’ve had a patient your worried about memory? What technique and how would you assess recent memory? Pg. 70Give the patient a short time to view four or five test objects, telling them you will ask them about them in a few minutes. Ten minutes later, ask the patient to list the objects.14.Recent memory may be tested ability to understand act tion of onal to to eightc.10 to 15d.15 to than g the patient to do simple g the patient to listen to and repeat a series of ng the patient four items and asking him or her to list the items about 10 minutes g the patient about verifiable past events, such as his or her mother’s maiden g the patient to name the past four presidents.ANS: CShowing the patient four or five objects, saying you will ask about them in a few minutes, and then 10 minutes later asking the patient to list the objects is a technique to measure recent memory. The other choices are not tests of recent memory. Asking the patient to listen and then repeat tests immediate recall.4. What pysch or mental condition is considered progressive and not reversible? Pg. 76, 78 Dementia (see differential diagnosis).27. Which condition is considered progressive rather than reversible?ANS: BDementia is considered progressive and irreversible, delirium and coma have the potential for reversal, and depression and anxiety are reversible.26. An older adult is administered the Set Test and scores a 14. The nurse interprets this score as indicative ofANS: EScores of less than 15 on this mental function test indicate dementia.28.Which of the following is usually related to structural diseases of the brain?ANS: BOne of the distinguishing characteristics that distinguishes dementia from the others is that it is usually related to structural diseases of the brain such as abnormal deposits, or recurrent strokes.5. If patient is delirious do they maintain orientation and attention span? Look up delirium and see what you expect patient to maintain. Pg. 75,76a.Deliriumb.Dementiac.Depressiond.Anxietye.Ctive tia.a.Deliriumb.Dementiac.Depressiond.Anxietye.Psychosis2Patient suffering from delirium is usually disoriented (usually oriented to person only) and have an impaired attentiveness. (pg 461 in Adv. Assessment) In spite of the confusion, the patient’s sensorium (consciousness) is usually intact although some condition (intoxication and severe metabolic derangements) result in altered level of consciousness.9.A state of impaired cognition, consciousness, mood and behavioral dysfunction of acute onset refers toANS: BDelirium is a state of impaired cognition, consciousness, mood and behavioral dysfunction of acute onset. Stupor describes arousals for short periods of time after a stimulus for arousal (e.g., visual, verbal, or painful). Lethargy relates to sleepiness with ease of arousal; coma is nonarousal and nonawareness. Confusion relates to inappropriate responses to questions with decreased attention span and memory.6. Who should you give a mini mental exam to? Everyone or certain patients? Pg. 67,68The mini mental exam should be given to elderly patients when there is a concern about their cognitive function. This testdetects probable dementia.34.The Mini-Mental State Examination should be administered for a patient whoANS: AThe MMSE is a tool used to estimate cognitive function quantitatively or document cognitive changes serially. Getting lost in a familiar territory is a sign of possible cognitive impairment.6. The Mini-Mental State Examination (MMSE)ANS: AThe MMSE is a standard tool that functions to estimate cognitive function quantitatively7.While interviewing a 70-year-old female clinic patient, she tells you that she takes ginkgo biloba and St. John’s wort. You make a short note to check for results of lost in her or his s an excessive amount of repetitive ritualistic illegal hallucinogenic a fear of leaving the be used to estimate cognitive changes be used to estimate personality disorders s do not vary with regard to age or determine the cause of memory a good tool to diagnose neurologic disorders.a.Denver II.b.Mini-Mental State Examination.3c.Glasgow Coma Scale.d.Goodenough-Harris Drawing Test.e.CAGE Questionnaire.ANS: BGinkgo biloba and St. John’s wort are herbal remedies used to improve mental alertness and elevate mood. As side effects, they can also result in disorientation and confusion that can be monitored with the Mini-Mental State Examination. The Denver and Goodenough- Harris tests are used for childhood development, and the Glasgow Coma Scale is used to rate coma depth. The CAGE Questionnaire is a useful tool for approaching a discussion of the use of alcohol.BREAST EXAM1. With documenting breast exams, how do you divide the breasts? If you want a radiologist to concentrate on one particular area of the breast, how do you divide to communicate findings? Pg. 351The breast is divided into five segments, four quadrants and a tail (upper inner, upper outer, lower inner, and lower outer).Either the right or left breast should be communicated. The terms: upper inner, upper outer, lower inner, lower outer, and tail of Spence should be communicated to the radiologist in terms of how to communicate findings.3.For purposes of examination and communication of physical findings, the breast is divided intoANS: CThe breast is referenced according to five segments: four quadrants and a tail.11. When conducting a clinical breast examination, the examiner shouldANS: DInspection with simultaneous observation of both breasts is essential in order to detect differences between the breast size, symmetry, contour, and skin color.2. If you have a pt c/o breast lump, what questions do you ask? For example you have a 50 year-old with breast lump, how do you begin exam compared to a 30 year-old pt?(just arbitrary ages) What assessment do you do and what questions would you ask based on age? Pg.9. Which breast change is typical after menopause?s (upper and lower).s (left, middle, and right). quadrants plus a es (six consecutive rings, each 1 inch farther away from nipple).l portions 1 through the examination if the patient has had a recent the patient covered to respect the lights to minimize ct both breasts with palpation of the breasts.a.Thickening of the inframammary ridgeb.Hypertrophy of glandular tissuec.Increase in number of lactiferous ductsd.Reduction of fat deposits4e.Shortening of Cooper’s ligamentsANS: A. After menopause, the breast tissue atrophies and is replaced by fat deposit, the inframammary ridge at the lower edge of the breast thickens, and the breast hangs more loosely as Cooper’s ligaments relax.10. In a woman complaining of a breast lump, it is most important to ask aboutANS: AHormonal changes of menstruation can result in breast tenderness, swelling, and enlarged nodes that can be felt on palpation.12. A 50-year-old woman presents as a new patient. Which finding in her personal and social history would increase her risk profile for developing breast cancer?ANS: CNulliparity or late age at birth of first child (after 30 years old) is a risk factor for breast cancer. Other risk factors include late menopause, early menarche, and drinking more than one alcoholic drink daily.1. What position do you put a patient in for a breast exam? What position is the examiner standing in? Axillary nodes what position does the patient need to be in? Pg. 355-3622. 14. To begin the clinical breast examination (CBE) for a man, ask him toANS: B Inspection begins the CBE. Ask the patient to sit with his arms hanging loosely at his sides. The technique is the same for both men and women.15.Inspection of the breasts usually begins with the patient in which position?ANS: BInspection begins with the patient in a sitting position with arms hanging loosely at the sides. Inspection (pg. 355): As the patient sits with arms hanging loosely at the sides, inspect each breast and compare it with the other for size, symmetry, contour, skin color, and texture, venous pattern, and lesions. Re-inspect the woman’s breasts with the patient in the following positions (pg. 357-358): relationship to t ization ol consumption.a.Drinking three glasses of wine per weekb.Early menopausec.Nulliparityd.Late menarchee.Young age at birth of first ne on the table with his arms with his arms hanging at his with his hands on his with his arms clasped behind his leaning forward.a.Lateralb.Sittingc.Standingd.Supinee.Proneo Seated with arms over the head or flexed behind the neck. This adds tension to the suspensory ligaments, accentuates dimpling, and may reveal variations in contour and symmetryo Steadied with hands pressed against hip with shoulders rolled forward (or alternatively have the patient push her palms together): This contracts the pectoral muscles, which can reveal deviations in contour and symmetryo Seated and leaning forward from the waist: This also causes tension in the suspensory ligaments. The breasts should hang equally. This maneuver can be particularly helpful in assessing the contour and symmetry of large breasts because the breasts fall away from the chest wall and hang freely. As the patient leans forward, support her by the hands. Patient in Seated Position (pg. 360)o Chest Wall Sweep: Have the patient sit with arms handing freely at the sideso Bimanual Digital Palpation: Place on hand, palmar surface facing up, under the patient’s right breasto Lymph Node Palpation: To palpation the axillae, have the patient seated with arm flexed at the elbow. Support the patient’s left lower arm with your left hand while examining the left axilla with your right hand. Patient in Supine Position (pg. 360): Have the patient raise one arm behind her head; then place a small pillow or folded towel under that shoulder to spread the breast tissue more evenly over the chest wall. The ideal position for examination is to have the nipple pointing toward the ceiling.b.) Axillary nodes what position does the patient need to be in? (pg. 360)Lymph Node Palpation: To palpation the axillae, have the patient seated with arm flexed at the elbow. Support the patient’s left lower arm with your left hand while examining the left axilla with your right hand.3. What’s the difference between fibrotic breast tissue and breast cancer? How do you expect each to feel? What are the characteristics of the two?17.Which finding, found on inspection, is related to fibrotic tissue changes that occur with breast carcinoma?ANS: BSkin dimpling or retraction signifies the contraction of fibrotic tissue that occurs with carcinoma. The other choices are normal variations without significance to cancer development.18. Venous patterns on breasts are suggestive of pathology when they areANS: CMalignant tumors require more blood flow. Superficial veins dilate to provide more flow and can be assessed as unilateral venous patterns. Bilateral findings are of no concern and are more commonly seen in pregnant or obese women. Nevi that are long-standing, unchanging, or nontender are of little concern.21.In patients with breast cancer, peau d’orange skin is often first evidenta.Convex or conical shapeb.Skin dimpling or retractionc.Pendulous and loose breastsd.Unequal shape or contoure.Lifelong inverted erally in obese ved during iated with a long-standing unchanging the the upper inner or around the the inframammary the tail of Spence.ANS: CThe areola is the most common initial site to visualize peau d’orange skin.24.Recent unilateral inversion of a previously everted nipple suggestsANS: BRecent unilateral inversion or retraction of a previously everted nipple suggests malignancy rather than a benign condition.41.You are conducting a clinical breast examination for a 30-year-old patient. Her breasts are symmetrical with bilateral, multiple tender masses that are freely moveable with well-defined borders. You recognize that these symptoms and assessment findings are consistent withANS: EFibrocystic changes are tender masses, usually bilateral, with multiple round, mobile, well-delineated borders. Fibroadenoma and cancer are usually nontender; Paget disease is an eczema-like condition of the nipple that signals an underlying cancer. Mammary duct ectasia most commonly occurs in menopausal women. Fibrocystic Changes (pg. 366):o Benign fluid-filled cyst formation caused by duct enlargement o Pathophysiology Usually bilateral and multiple Most common in women 30 to 55 years of age Associated with long follicular or luteal phase of the menstrual cycleo SubjectiveData Tender and painful breasts and/or palpable lumps that fluctuate with menses  Usually worse premenstruallyo ObjectiveData Round, soft to firm, tense, mobile masses with well-delineated borders  Usually tender Usually bilateral Multiple or single Fibroadenoma (pg. 366): n breast adenoma.b.Paget ry duct cystic changes.o Pathophysiology May occur in girls and women of any age during their reproductive years  After menopause, the tumors may regresso SubjectiveData Painless lumps that do not fluctuate with the menstrual cycle May be symptomatic with discovery on clinical breast examination or breast imagingo ObjectiveData Round or discoid, firm, rubbery, mobile masses with well-delineated borders  Usually non-tender Usually bilateral Single; may be multiple Biopsy often performed to rule out carcinoma Malignant Breast Tumors (pg. 366): Ductal carcinoma arises from the epithelial lining of ducts; lobular carcinoma originates in the glandular tissue of the lobuleso Pathophysiology Mutations to normal cells results in uncontrolled cell division and tumor formation; as the tumor grows andinvades surrounding tissue, metastases occurs through the lymph and vascular systems Peak incidence between the ages of 40 and 75 years, with the majority of malignant breast tumors occurring in women older than 50o SubjectiveData Painless lump; change in size, shape, or contour of breast Axilla may be tender if lymph nodes involved May be asymptomatic with discovery on clinical breast examination or breast imagineo ObjectiveData May be palpable mass that is usually single, unilateral, irregular, or stellate in shape; poorly delineatedborders; fixed; hard or stone-like; and non-tender Breast may have dimpling, retraction, prominent vasculature Skin may have peau d’orange or thickened appearance Nipple may be inverted or deviated in position(Differential diagnosis pg. 365)Fibrotic: usually bilateral, multiple or single, round, soft to firm; tense, mobile, absent retraction signs, usually tender, bordersare well delineated, and they vary with menses.Cancer: Usually unilateral, single, irregular or stellate, hard/stonelike, fixed, retraction signs are often present, usually nontender, the borders are poorly delineated; irregular, and they do not vary with menses.4. Breast Exam- What part of the hand do you use? Fingertips, pads, palms, entire hands? Pg. 361Palpate using your finger pads as they are more sensitive than your fingertips. Palpate systematically, pushing gently but firmly toward the chest wall, as you rotate your fingers in a clockwise or counterclockwise pattern. At each point, as you rotate your fingers press inward, using three depths of palpation: light then medium and finally deep. The exact sequence you select for palpation is not critical, but a systematic approach will help ensure that all portions of the breast are examined.26.When palpating breast tissue, the examiner should use the _____ at each r of the surface of the sANS: BThe finger pads are used for breast palpation because they are more sensitive than the fingertips.5. What is Peau d\'orange skin? Look, feel, mean? Pg. 356The skin has an orange peel appearance. This indicates edema of the breast caused by blocked lymph drainage in advanced orinflammatory breast cancer. The skin appears thickened with enlarged pores and accentuated skin markings.6. What is the tail of Spence? Where is it anatomically? Pg. 351The tail of Spence is (extends from) the greatest amount of glandular tissue that lies in the upper outer quadrant and extendsinto the axilla. ??????2.The largest amount of glandular breast tissue lies in theANS: DThe greatest amount of glandular tissue in the breast lies in the upper outer quadrant.31.The tail of Spence extendsANS: DThe tail of Spence extends from the upper outer breast quadrant into the axillae.7. Breast Exam: Certain groups of lymph nodes are enlarge, where would they be for examiner to expect Breast Cancer? Pg. 360The axilla, supraclavicular and infraclavicular areas. Nodes that are detected should be described according to location, size, shape, consistency, tenderness, fixation, and delineation of borders.34.When examining axillary lymph nodes, the patient’s arm inner of S outer the midclavicular d the supraclavicular into the inframammary the the sternal d full above the ded at the ed against the ed over the d at the elbow.ANS: ETo examine the axilla, support the patient’s lower arm with the elbow flexed with one of your hands and use your other hand to palpate the axilla.35.Lymphatic flow of the breast primarily drainsANS: CEach breast contains a lymphatic network that drains the breast radially and deeply to underlying lymphatics.36. The greatest concern for breast cancer is when you palpate _____ nodes.ANS: DThe supraclavicular and infraclavicular nodal areas are sentinel nodes; any enlargement in these areas is especially significant.37.You are performing a clinical breast examination for a 55-year-old woman. While palpating the supraclavicular area, you suspect that you felt a node. To improve your hooked technique, you shouldANS: EHaving the patient turn her head toward the examination side, as well as raising the shoulder on that same side, gives your fingers more room to palpate deeper into the fossa.8. What if you have a 20-30 year-old with freely moveable, well-defined lump, tender with cycle, cancer or more likely fibrotic? Fibrotic (see page 365)iorly toward the ally toward the corresponding lly toward the omedially toward the ior nal lotion to your both hands the patient to press both palms the patient to lower her shoulder on that the patient to turn her head toward that side.1041.You are conducting a clinical breast examination for a 30-year-old patient. Her breasts are symmetrical with bilateral, multiple tender masses that are freely moveable with well-defined borders. You recognize that these symptoms and assessment findings are consistent withANS: EFibrocystic changes are tender masses, usually bilateral, with multiple round, mobile, well-delineated borders. Fibroadenoma and cancer are usually nontender; Paget disease is an eczema-like condition of the nipple that signals an underlying cancer. Mammary duct ectasia most commonly occurs in menopausal women.9. Then you have a 50 year-old-lump firm, fixed, doey-like, cancer or fibrotic? Cancer FEMALE GENITALIA1. Pelvic Exam-anatomy of vagina and location of glands-5 O’clock, 7 O’clock for example, just know the anatomy of the male and female genitals.2. What structures are located at the 5 o’clock and the 7 o’clock positions of the vaginal orifice and open onto the sides of the vestibule in the groove between the labia minora and the hymen?ANS: DBartholin glands are found posteriorly on each side of the vaginal orifice and open onto the sides of the vestibule.2. Cervical Cancer- know patient’s history and what questions to ask patients that put them at high risk for cervical cancer.12. Which factor is associated with an increased risk of cervical cancer?ANS: EWomen who were younger than 17 years when they had their first full-term pregnancy are almost 2 times more likely to get cervical cancer later in life than women who were not pregnant until they were 25 years or adenoma.b.Paget ry duct cystic changes.a.Skene glandsb.Perineal bodiesc.Labia majorad.Bartholin glandse.Labia minoraa.Endometriosisb.Low parityc.HPV vaccinationd.High socioeconomic statuse.Early parity113. What history increases your risk for ovarian cancer? (pg. 425)Risk factors for ovarian cancer (box on p. 425 below cervical risk factors): Age (increases with age), inherited genetic mutation (BRCA1 or BRCA2 gene), family history, obesity, reproductive history (nulliparity increases risk), and the use of fertility drugs, personal history, hormone replacement therapy, and high-fat diet.13.The risk of ovarian cancer is increased by a history ofANS: EThere is a relationship between nulliparity and an increased risk of ovarian cancer. Although the risk increases with age, most ovarian cancers develop after menopause; half are found in women older than 63 years. The other choices have no relationship with ovarian cancer.4. What is a normal cervix and an abnormal cervix? What does an abnormal one look like (not cancerous) what tests might you and what might indicate? Disorder?22. During digital examination of the vagina, the cervix is noted to be positioned posteriorly. Upon bimanual examination of this woman, you would expect to palpate a(n) _____ uterus.ANS: BThe position of the cervix correlates with the position of the uterus. A cervix that is pointing posteriorly indicates an anteverted uterus.23. The presence of cervical motion tenderness may indicateANS: CPainful cervical motion tenderness suggests a pelvic inflammatory disease or a ruptured tubal pregnancy. The cervix is expected to move 1 to 2 cm without discomfort under normal conditions.25.During a routine vaginal examination, you insert the speculum and visualize the cervix. The cervix projection into the vaginal vault -fat ette between 35 and 50 body ally c inflammatory nancy.12approximately 5 cm. Upon bimanual examination, you would expect to find the the midline the retroverted the anteverted ted to the left or the retroflexed position.ANS: DNormally, the cervix protrudes into the vagina 1 to 3 cm. Longer projections suggest a pelvic or uterine mass. A pelvic mass would cause the uterus to be deviated to the right or left, but an anteverted, retroverted, or retroflexed uterus would still be in the midline regardless of its position.26.Small, pale yellow, raised, and rounded areas are visualized on the surface of the cervix. You shouldANS: AThis describes nabothian cysts, which are retention cysts of the endocervical glands and are considered a normal variant. No further testing is this as nabothian this as a friable n a viral the pH of the cervical this as an eroded cervix.a.b.c.Normal cervix: covered with pink squamous epithelium that is uniform in consistency. It should be in an anterior- posterior position that correlates with the position of the uterus. The os is small and round. A small area of ectropion is visible inferior to the os. Cervix should feel firm (during pregnancy will be softer) and be smooth.Abnormal cervix: Bluish color indicates increased, which may indicate pregnancy. A pale cervix is associated with anemia. If the cervix is pointed anteriorly it indicates a retroverted uterus; pointing posteriorly indicated an anteverted uterus. Horizontal indicated a uterus in midposition; deviation indicated a pelvic mass, uterine adhesions, or pregnanacy. Projection greater than 3 cm may indicate a pelvic or uterine mass. Small, white or yellow raised, round areas may indicate nabothian cysts. Friable tissue, red patchy areas, granular areas, and white patches could indicate cervicitis, infection, or carcinoma.Feel for nodules, harness, and roughness. Note the position of the cervix, it should be in the midline and may point anteriorly or posteriorly. Grasp the cervix between your fingers and move it gently from side to side (should move 1-2 cm). There should be no pain or discomfort. Painful cervical movement suggests a pelvic inflammatory disease or a ruptured tubal pregnancy which would require immediate surgery.5. What structure or organs are examined during a Bimanual exam? (pg 436-437). Cervix, Uterus, Adnexa, and Ovaries33.The assessment of which structure is not part of the bimanual examination?a.Cervixb.Bladderc.Uterusd.Ovariese.Adnexa13ANS: BThe bimanual examination consists of assessing the cervix, uterus, adnexa, and ovaries.6. When do PAP smears begin? Age of non-sexually active versus sexually active women? (pg. 437) 21 for non-sexually and sexually active women because cervical cancer is rare for women under age 21.40.When a woman is not sexually active, cervical cancer screening should beginANS: DWomen who are not sexually active should have their first examination by the age of 21 years. Women under age 21 should not be tested.7. Menopausal women- what does the vagina and mucosa of the walls feel like? (pg. 447)The vagina is narrower and shorter. You will see and feel the absence of rugae. The cervix is smaller and paler but the osshould still be palpable and the cervix may be less mobile.43.During a pelvic examination for a postmenopausal woman, you would expect to assessANS: BExpected findings in the pelvic examination for an older woman include a narrower and shorter vagina, absence of rugation, a less mobile cervix, and a palpable cervical os. The ovaries are rarely palpable because of atrophy.MALE GU1. Males-history or what alerts the examiner of the possibility of testicular cancer? (pg. 470).Undescended testicle, personal hx of testicular CA, family hx of testicular CA, abnormal testicle development (klinefelter syn), 20-54 yr male, the most prominent in white race ( 5 times that of black; more than 3 times that of Asian American and Native American men).13.Which of the following is a risk factor for testicular cancer? age 15 age 18 age 21 age 30 years.a.a wider and longer vaginal ce of vaginal wall rugation.c.a nonpalpable cervical os.d.a more mobile ble ovaries.a.Circumcisionb.Condyloma acuminatumc.Cryptorchidism14d.Poor hygienee.Multiple sexual partnersANS: CCryptorchidism (testes that fail to descend by 12 months of age) is a risk factor for testicular cancer.27.The most common cancer in young men age 15 to 30 years isANS: ABecause testicular tumors are the most common cancer occurring in young adults, self-examination is encouraged.37.Self-examination of the male genitaliaANS: BMonthly self-examination is recommended as a screening test for testicular cancer as well as sexually transmitted infections for all young men starting at 15 years of age. It is encouraged during bathing because the scrotal skin is less thick at this time and because the scrotum hangs looser because of the warmth. Inspection is done first followed by palpation.2. What alerts us to do further testing and the need to further and fully assess for testicular cancer? How do we do this?o Irregular, contender mass fixed to the testiso Does not transilluminateo May also have hydrocele(that doesn\'t transilluminate) o InguinalLymphadenopathyo Painless mass in testicleo Scrotalenlargementorswellingo Heavy feel in in scrotumo Dull ache in lower abdomen, back or groino fluid in scrotumThis can be done by performing a Testicular exam ( inspect and palpate), Scrotal US, Lab work including: Chemistry, WBC count, biochemical markers AFP and B-hCg.21.Mr. L. has an unusually thick scrotum with edema and pitting. He has a history of cardiac problems. The appearance of his scrotum is more likely a(n)ANS: BGeneral fluid retention can cause scrotal thickening and pitting edema and is more often seen as a result of cardiac, renal, or hepatic disease. This swelling does not imply a condition of the genitalia but rather a condition of these related d be restricted to adults with prior d be performed while s with palpation and then d be performed t be adequately performed due to poor visualization of the nital defect that has ation of general fluid l consequence of ication to the development of quence of prior STDs.1525.An enlarged, painless testicle in an adolescent or adult may cular torsion.c.a undescended padias.ANS: CA hard, enlarged, painless testicle can indicate a tumor in an adolescent or adult male. Epididymitis and torsion are painful; an undescended testicle is common in infants and is usually resolved by 12 months. Hypospadias is a congenital defect of the urethral opening causing the meatus to be located ventral to its normal position.26.You palpate a soft, slightly tender mass in the right scrotum of a man. You attempt to reduce the size of the mass, and there is no change in the mass size. Your next assessment maneuver is toANS: DA soft mass is either a hernia or hydrocele. If the mass can be reduced, it is probably a hernia; a nonreducible mass should be transilluminated to determine whether it contains fluid and is possibly caused by a hydrocele. Lifting the scrotum should be done when epididymitis is suspected. Urethral cultures are not indicated at this point.29.An adolescent male is being seen for acute onset of left testicular pain. The pain started 3 hours ago. He complains of nausea and denies dysuria and fever. Your prioritized assessment should be toANS: CThe patient is displaying symptoms of testicular torsion. An absent cremasteric reflex is a supporting finding to differentiate torsion from epididymitis.38. A 12-year-old boy says that his left scrotum has a soft swollen mass. The scrotum is not painful upon palpation. The left inguinal canal is without masses. The mass does transilluminate with a penlight. This collection of symptoms is consistent withANS: BA hydrocele is a soft scrotal mass that occurs from fluid accumulation and therefore does transilluminate. Orchitis results in a swollen, tender testis. A rectocele does not result in scrotal swelling. A scrotal hernia would also be palpable along the inguinal canal. Epididymitis is an extremely painful condition.41.A cremasteric reflex should result two fingers to attempt to reduce the te the left scrotum the right testicle, then compare pain illuminate the re the meatus for gonococcal n urine and DNA probe urethral the left scrotum to confirm lish absent cremasteric illuminate the left and right the patient stand and observe the scrotum for a “bag of worms.”al scrotum appear to contain a “bag of worms.”e deviation to the left um to elevate iate erection of the cle and scrotal rise on the stroked side.ANS: EUpon stroking the inner thigh with a blunt instrument or finger, the testicle and scrotum should rise on the stroked side.3. How do you assess for an inguinal hernia? Pg. 472-473Have the pt. stand and bear down. While he is straining inspect the area of the inguinal canal and the region of the fossa ovalis. After the pt. relaxes, insert your examining finger into the lower part of the scrotum and carry it upward along the vas deferens into the inguinal canal. You can also auscultate for bowel sounds, which will be present in uncomplicated reducible hernias.18.Which technique is appropriate to detect an inguinal hernia?ANS: EExamination for inguinal hernias is performed with the patient standing. Inspect the groin while the patient performs a Valsalva maneuver. Insert your examination finger into the lower part of the scrotum and follow upward along the vas deferens to screen for a hernia.19. Which type of hernia lies within the inguinal canal?ANS: CHernias found within the inguinal canal are called indirect hernias.4. What does Vas deferens feel like? Normal? Abnormal? Pg. 473The Vas deferens feels smooth and discrete; abnormal findings are beaded or lumpy feeling. This may indicate diabetes or oldinflammatory changes, especially tuberculosis.2.What structure of the male genitalia travels through the inguinal canal and unites with the seminal vesicle to form the ejaculatory duct?ANS: Da.Conduct percussion while the patient coughs.b.Have the patient strain as you pinch the testes.c.Inspect rectal areas as the patient bears down.d.Conduct the examination only in the supine position.e.Move your finger upward along the vas deferens.a.Umbilicalb.Directc.Indirectd.Femorale.Incisionala.Epididymisb.Corpus cavernosumc.Urethrad.Vas deferense.Ureter17The vas deferens begins at the end of the epididymis, travels the spermatic cord, goes through the inguinal canal, and then unites with the seminal vesicle to form the ejaculatory duct.23.A normal vas deferens should feelANS: BThe vas deferens should normally feel smooth, discrete, and nontender.5. Young man- what is an emergent cause of testicular pain? Pg. 482 Testicular Torsion is twisting of the spermatic cord and is a surgical emergency.29.An adolescent male is being seen for acute onset of left testicular pain. The pain started 3 hours ago. He complains of nausea and denies dysuria and fever. Your prioritized assessment should be toANS: CThe patient is displaying symptoms of testicular torsion. An absent cremasteric reflex is a supporting finding to differentiate torsion from epididymitis.28.The most emergent cause of testicular pain in a young male isANS: ETesticular torsion is a surgical emergency. If surgery is performed within 12 hours after the onset of symptoms, the testis can be saved in about 90% of cases. Delayed treatment results in a much lower salvage rate.6. Understand hernias, where located and how to assess each kind. Pg. 476, 477(see differential diagnosis).Hernia is protrusion of a peritoneal-lined sac through some defect in the abdominal wall. There are indirect, direct and femoral.7. What is the most common type of hernia? Pg. 477 Indirect Inguinal hernias are the most common type.31.The most common type of hernia occurring in young males n urine and DNA probe urethral the left scrotum to confirm lish absent cremasteric illuminate the left and right the patient stand and observe the scrotum for a “bag of worms.”cular cerated ect al.ANS: CThe most common type of hernia in children and young males is an indirect inguinal hernia.MUSCULOSKELETAL1. What is the difference between osteoarthritis versus rheumatoid arthritis?During an assessment what do you expect to see in a patient with osteoarthritis vs. RA? Findings in joints? Describe. OA (pg411)-A progressive disorder associated with age and wear and tear. There is loss of cartilage and progressive erosion of bone. Affects mostly larger bones like hips and knees, but frequently involves small joints of hands, especially distal and proximal interphalangeal joints. Asymmetrical distribution. Pain and stiffness improves with activity, and worsens with rest. Xrays show changes. Sed rate(-), Rheumatoid factor (-) RA (pg410)-If 3 or more metacarpophalangeal joints are swollen is RA. It’s a progressive, inflammatory, and erosive condition that usually affects multiple joints. It’s an autoimmune condition. Affects joints symmetrically. Affects small joints of hands and feet. Joints are tender, swollen with effusion, warm, inflamed. Nodules and deformities are noted. RA associated with: subluxation of metacarpophalgeal joins, hyperextension of joints, but also with changes in eye (scleritis, episcleritis, interstitial lung disease and pericardial disease.1. When does a musculoskeletal exam begin? (text tells you) pg405-The musculoskeletal examination is primarily limited to inspection and palpation. The focused musculoskeletal examination begins withinspection.2. How do you assess the strength of the trapezius muscle? (pg518)The strength of trapezius and sternocleoidomastoid muscle is tested by evaluating the cervical spine and asking patients to do certainmovement. Bend the head forward, chin to chest, and expect flexion of 45 degrees. Bend head to each side, ear to each shoulder and expect lateral bending of 40 degrees. Bend head backward, chin toward ceiling, and expect extension of 45 degrees.3. Patient with scoliosis, bend at waist, what is expected finding? Describe what it looks like (Pg541)When looking form the rear, the spine looks more like an “S” or a “C” than a straight line. There is no known cause. Associated with leg length discrepancy. There’s lateral curvature of spine as patient flexes forward to touch the toes. In severe deformities, patient has uneven shoulder and hip levels, and may have crease on one side of waist.194. Carpal Tunnel-What expect to feel like, how do you assess for? During assessment, particular nerve is tested, what is it? What sensation will the patient have?(pg430,524) The carpal tunnel is a space located on the anterior aspect of the wrist between the carpal bones and a ligamentous band through which the median nerve and several tendons transverse. With overuse and repetitive movements there’s a hypertrophy of tissues, causing a lot of space and impingement on the median nerve. Nighttime pain-early sign. Swelling at wrist related to inactivity of flexion at night, pain can radiate up the forearm to shoulder with numbness and tingling along the median nerve, and paresthesia involves anterior aspects of wrist, medial palm and first three digits of affected nerve. Relief is found by shaking affected hand in downward fashion. To assess, first ask patient to mark specific site using the Katz hand diagram.o Thumb abduction test isolates strength of abductor pollicis brevis muscle, innervated only by median nerve. Pt will place the hand palm up and raise the thumb perpendicular to it. Apply downward pressure on thumb to test muscle strength. Weakness=Carpal tunnel syndromeo Tinel sign: Strike pt’s wrist with your index or middle finger, where median nerve passes under the flexor retinaculum and volar carpal ligament(fig21.42). Tingling, means ( ) tiner sign and ( ) CPT syndrome.o Phalen test: pt holds both wrist in fully palmar-flexed position with dorsal surfaces pressed together for one min. Numbness and paresthesia in the distribution of median nerve is ( ) CPT syndrome.ABDOMINAL1. When conducting an abdominal exam, what position should the patient be in? Examiner? Techniques with rigid abdomen or anxious pt, what are relaxation techniques? (pg377)Need good light source; full exposure of abdomen; warm hands with short fingernails. Have pt empty bladder. Place pt is supine position with arms at sides. Approach pt from right side. Place small pillow under pt’s head and another under slightly flexed knees. Drape a towel or sheet over the patient’s chest for warmth and privacy. Be slow and gentle, avoid sudden movements.Percussion of the abdomen begins with establishinga. liver dullness.b. spleen dullness.c. gastric bubble tympany.d. overall dullness and tympany in all quadrants.e. bladder fullness.ANS: DPercussion begins with a general establishment over all quadrants for areas of dullness and tympany and then proceeds to specific target organs22. Before performing an abdominal examination, the examiner shoulda. ascertain the patient’s HIV status.b. have the patient empty his or her bladder.c. don double gloves.d. completely disrobe the patient.e. uncover only the painful areas of the abdomen.ANS: BThe patient should empty the bladder to ensure an accurate examination of organs as well as to provide comfort for the patient.2024. When examining a patient with tense abdominal musculature, a helpful technique is to have the patienta. hold his or her breath.b. sit upright.c. flex his or her knees.d. raise his or her head off the pillow.e. fully extend the legs.ANS: CTo help relax the abdominal musculature, it is helpful to place a small pillow under the patient’s head and under slightly flexed knees. The other choices increase muscle flexion.28. After thorough inspection of the abdomen, the next assessment step is toa. percuss.b. palpate nonpainful areas.c. auscultate.d. perform a rectal examination.e. palpate painful areas.ANS: CAssessment of the abdomen begins with inspection followed by auscultation. This break from the usual system examination sequence is because palpation and percussion can alter the frequency as well as the intensity of bowel sounds. Therefore, auscultation is done first.2. How long do you auscultate for BS? (pg380)Bowel sounds range from 5-35/min. If you’re unable to hear BS after 5 min of continues listening, associated with abdominal pain andrigidity then is surgical emergency.To correctly document absent bowel sounds, one must listen continuously fora. 30 seconds.b. 1 minute.c. 3 minutes.d. 5 minutes.e. 10 minutes.ANS: DAbsent bowel sounds are confirmed after listening to each quadrant for 5 minutes.3. What is the technique for percussing the liver border? Where to start, how you move, what are you listening for? (pg381)Begin liver percussion at the right midclavicular line over an area of tympany. Always begin with an area of tympany and proceed to area of dullness for easiness. Percuss upward along the midclavicular line to determine lower border of liver. The area of liver dullness is usually heard at the costal margin or slightly below it. Mark with a pen. A lower liver border that is more than 2-3 cm below costal margin may indicate organ enlargement or downward displacement of diaphragm because of emphysema or other pulmonary disease. Upper border of liver, begin percussion on the right midclavicular line at an area of lung resonance around the third intercostal space. Cont downward until the percussion tone changes to one of dullness; this marks upper border of the liver mark with pen. It’s usually in the fifth intercostal space. Measure the distance between the marks, estimates vertical span of liver, usually 6-12cm. If larger=enlargement, if smaller=atrophy.2137. To assess for liver enlargement in an obese person, you shoulda. use the hook method.b. test for cutaneous hypersensitivity.c. auscultate using the scratch technique.d. attempt palpation during deep exhalation.e. have the patient lean over at the waist.ANS: CIf the abdomen is obese or distended or if the abdominal muscles are tight, you should plan on auscultating the liver using the scratch method to estimate the lower border of the liver. Cutaneous hypersensitivity is a sign of peritonitis and does not contribute to determining liver size.Percussion at the right midclavicular line, below the umbilicus, and continuing upward is the correct technique for locating thea. descending aorta.b. lower liver border.c. medial border of the spleen.d. upper right kidney ridge.e. stomach.ANS: BPercussing along the right midclavicular line upward from the umbilicus determines the lower border of the liver. A liver border more than 2 to 3 cm signifies hepatomegaly.When palpating the abdomen, you should note whether the liver is enlarged in thea. left upper quadrant.b. midepigastric region.c. periumbilical area.d. right upper quadrant.e. right lower quadrant.ANS: DAn examiner can recognize a friction rub in the liver by a sound that isa. clicking, gurgling, and irregular.b. high pitched and associated with respirations.c. loud, prolonged, and gurgling.d. soft, low-pitched, and continuous.e. low pitched, tinkling, and unrelated to respirations.ANS: BAn abdominal friction rub is rare and can be identified when high-pitched sounds are auscultated in association with respirations. The liver is located in the right upper quadrant of the abdomen4. CVA tenderness-what might it be a sign of?Costovertebral angle tenderness should be assessed whenever you suspect the patient may havea. cholecystitis.b. pancreatitis.c. pyelonephritis.d. ulcerative colitis.e. intussusception.22ANS: CPyelonephritis is characterized by flank pain and costovertebral angle tendernessNEURO1. Autonomic Nervous System- what are you assessing? Coordinate?(Pg477)The Nervous system with its central and peripheral divisions maintains and controls all body functions by its voluntary and autonomic responses. The evaluation of motor, sensory, autonomic, cognitive and behavioral elements. The CNS is the main network of coordination and control for the body.(PG446) Coordination tests fluidity of movements. Inability to coordinate movements suggests cerebellar dysfunction. Finger to nose testing-ask pt to touch your index finger with his or her index finger, then touch his/her noserepeatedly. Poor coordination of movement indicates dysmetria. Rapid alternating movements-Ask pt to perform rapid pronation and supination of the hand on his/her thigh or on examination table Heel to shin testing-Ask pt to take the heel of one side and repeatedly move up and down the shin of the opposite leg Romberg- Ask pt to stand with feet together, arms abducted outward with palms up, and eyes closed. PostiveRomberg is observed as a swaying motion, or inability to maintain balance, and indicates cerebellar dysfunction.2. Motor Cortex of Brain- What does it control?3. Know EACH Cranial Nerve (several questions)- how to assess each, what testing for, what each do, abnormal findingsvs. expected findings. (pg553) Olfactory (1)- Sensory: smell reception and interpretation. Have available 2-3 vials of aromatic odors. Ensure patient’s nasal passages are patent. Occlude one naris at a time and ask patient to breathe in and out, while closing her eyes. Use different odor to test the other side. Assess the ability of patient to differentiate between diff odors. Sense of smell diminishes with age. Anosmia (loss of sense of smell). Optic (ll)- Sensory: visual acuity and visual field (chapter 11) Oculomotor (lll)-Motor: raise eyelids, most extraocular movements. Parasympathetic: pupillary constriction,change lens shape Trochlear (lV)- Motor: downward, inward eye movement(lll, lV, Vl)- Movement of eyes through the six cardinal points of gaze, pupil size, shape, response, to light and accommodation and opening of the upper eyelids. When assessing pt with severe unremitting headaches, the experienced examiner evaluates movement of the eyes for the presence of absence of lateral gaze. The sixth cranial nerve is commonly one of the first to lose function in the presence of increased intracranial pressure. Trigeminal (V)- Motor: jaw opening and clenching, chewing and mastication. Sensory: sensation to cornea, iris, lacrimal glands, conjunctiva, eyelids, forehead, nose, nasal and mouth mucosa, teeth, tongue, ear, facial skin. Evaluate for muscle atrophy. Have patient clench teeth as you palpate the muscles over the jaw, evaluating tone, which should be symmetric, without fasciculations. The three divisions of the trigeminal nerve are evaluated for the sharp, dull and light sensations. With pt closing eyes, touch each side of face at the scalp, cheek and chin, alternating sharp and smooth edges of a broken23tongue blade or a paper clip. Ask patient to report feeling. Then stroke face with cotton wisp. If sensation is impaired, ask pt to differ btw hot/cold. Abducens (Vl)- Motor: lateral eye movement Facial (Vll)- ask pt to raise eyebrows, squeeze the eyes shut, wrinkle the forehead, frown, smile, show the teeth, purse the lips to whistle, and puff out the cheeks. Observe for ticks, unusual movements and symmetry of expression. Drooping of one side of mouth or sagging of lower eyelid will indicate muscle weakness. Ie: Bells palsyTo evaluate taste, a sens

NURS 6512 Final Exam NURS/6512 Advanced Health Assessment and Diagnostic Reasoning Walden University NURS 6512 Final Exam (Latest 2019 Version) Already Graded A Walden University Course NURS-6512D-1/NURS-6512N-1-NURS-6512D- 1/NURS-6512N-1- Advanced Health Assessment and Diagnostic ReasoningTest Final Exam
Started 8/1/19 11:30 AM Submitted 8/1/19 1:20 PMDue Date 8/12/19 1:59 AMStatus Completed
Attempt Score 93 out of 100 pointsTime Elapsed 1 hour, 34 minutes out of 1 hour and 50 minutes1. Costovertebral angle tenderness should be assessed whenever you suspect the patient may have: - Polynephritis2. In older adults, overflow fecal incontinence is commonly due to: -Fecal impaction3. A 1 month old boy has been vomiting for 2 weeks. How is this symptom of GERD and pyloric stenosis further differentiated in this child’s assessment? – The infant has regurgitation with pyloric stenosis4. Auscultation of borborygmi is associated with: - Gastroenteritis, early intestinal obstruction, or hunger5. When auscultating the abdomen, which finding would indicate collateral circulation between the portal and systemic venous systems? – Venous hum6. Conversion of fat-soluble wastes to water-soluble material for renal excretion is a function of the: - Liver7. The major function of the large intestine is: -Water absorption8. Which structure is located in the hypogastric region of the abdomen? –Ileum, bladder, andpregnant uterus9. A 45 year old man relates a several week history of severe intermittent abdominal burning sensations. He relates that the pain is relieved with small amounts of food. Before starting the physical examination, you review his laboratory work, anticipating a (n): -Positive Helicobacter pylori result10. You are caring for a patient with trigeminal neuralgia. During the assessment, the patient would describe the pain as: - Burning or shocklike11. Your 85 year old patient is complaining of right knee pain. She has a history of osteoarthritis for which she is given anti-inflammatory medication. To assess her right knee pain, you should ask her if: - The pain gets better when she sits12. A 5 year old is complaining of nondescriptive “belly pain.” Your next action should be to ask him to: - Point to the area of pain13. The perception of pain: - Is variable and is affected by emotions, and cultural background14. Patients presenting with ascites, jaundice, cutaneous spider veins, and nonpalpable liver exhibit signs of: - Cirrhosis15. A patient presents to the emergency department after a motor vehicle accident. The patient sustained blunt trauma to the abdomen and complains of pain in the upper left quadrant that radiates to the left shoulder. What organ is most likely injured? – Spleen16. Imaging studies reveal that a patient has dilation of the renal pelvis from an obstruction in the ureter, what condition will be documented in this patient’s health record? – Hydronephrosis17. Visible intestinal peristalsis may indicate: - Intestinal obstruction18. Infants born weighing less than 1500g are at higher risk for: - Necrotizing enterocolitis19. Which of the following factors is not known to affect patient compliance with his or her treatment regimen? – The patient’s age and social status20. One of the most important aspects to consider in the orthopedic screening examination is: -Symmetry21. The sequence of the physical examination should be individualized to: -22. As you greet the patient, which examination technique is first implemented? - Inspection23. Which of the following is most likely to enhance examiner reliability? – The examiner attempts to qualify data24. A 7 year old boy is brought to your office with a chief complaint of possible fracture to his left third finger. He jammed it while playing basketball 2 days ago. The mother states that she really does not think it is broken because he can move it. What is your best response? – This is common misconception, and the finger may be broken. An x-ray is indicated.25. A patient presenting for the first time with typical low back pain should receive which of the following diagnostic tests?26. Skeletal changes in older adults are the result of: -Increased bone resorption 27. A positive straight leg raise test usually indicates: - Lumbar nerve root irritation28. What technique is performed at every infant examination during the first year of life to detect hip dislocation? – Barlow-Ortolani maneuvers29. Expected normal findings during inspection of spinal alignment include: - Convex lumbar curvenumber of times the patient has to change positions to conserve the patient’s energyMinimize theusually musculoskeletal etiology.– None of the above. X-ray is not indicated because lumbar pain is30. Temporalis and masseter muscles are evaluated by: - Having the patient clench his or her teeth31. When palpating joints, crepitus may be caused when: - Irregular bony surfaces rub together32. A 3 year old is brought to the clinic complaining of a painful right elbow. He is holding the right arm slightly flexed and pronated and refuses to move it. the mother states that symptoms started right after his older brother had been swinging him around by his arms. This presentation supports a diagnosis of: - Radial head subluxation33. Light skin and thin body habitus are risk factors for: - Osteoporosis34. Risk factors for sports-related injuries include: - Failure to warm up before activity35. Injuries to long bones and joints are more likely to result in fractures than in sprains until: -Adolescence36. Ligaments are stronger than bone until: - Adolescence37. The family history for a patient with joint pain should include information about siblings with: -Genetic disorders38. The Thomas test is used to detect: - Flexion contractures of the hip39. A goniometer is used to assess: - Range of motion40. During a football game, a player was struck on the lateral side of the left leg while his feet were firmly planted. He is complaining of left knee pain. To examine the left knee you should initially perform the ________ test. – Valgus stress41. You note that a child has a positive Gower Sign. You know that this indicates generalized: -Muscle weakness42. The dowager hump is: - The hallmark of osteoporosis43. What temporary disorder may be experienced by pregnant women during the third trimester because of fluid retention? –Carpal tunnel syndrome44. A common finding in markedly obese and pregnant women is: - Lordosis45. A 45 year old laborer presents with low back pain, stating that the pain comes from the right buttock and shoots down and across the right anterior thigh, down the shin to the ankle. Which examination finding is considered more indicative of nerve root compression? – Positive straight leg raise result46. Mrs. Bower is a 57 year old patient who comes in for an office visit. Which of the following disorders is known to be hereditary? – Huntington chorea47. Testing of cranial nerve ________ is not routinely performed unless a problem is suspected.–I48. The patient is able to rapidly touch each finger to his thumb in rapid sequence. What does this finding mean? – The patient has appropriate cerebellar function49. Which question asked by the examiner may hellp to determine prevention strategies for seizures that a patient is experiencing? – “Are there any factors or activities that seem to start the seizures?”50. A patient has a complaint of dizziness. The patient makes the following statement: “I sometimes feel as if the whole room is spinning.” What type of neurologic dysfunction should the examiner suspect? – Inner ear dysfunction affecting the acoustic nerve51. The examiner asks the patient to close her eyes, then places a vibrating tuning fork on the patient’s ankle and asks her to indicate what is felt. What is being assessed? – Peripheral nerve sensory function52. Which of the following findings should an examiner consider a normal finding if associated with pregnancy? – Acroparesthesia52. Jack is a 52 year old obese man with a history of poorly controlled diabetes. He also smokes. Based on the above data, the examiner should recognize that Jack has several risk factors for: - Cerebrovascular accident53. Mrs. Jones is a 24 year old patient who presents to your office 2 days postpartum. She complains that she is experiencing foot drop. Which of the following problems should the examiner consider? – Lumbosacral plexopathy54. The examiner is assessing deep tendon reflex response in a 12 year old boy. The response is an expected reflex response. Which of the following scores should be documented? – 2 55. A 68 year old patient presents to your office for follow-up. He tells you, “I have a hard time finding the right words when I am talking;” he also is experiencing numbness. On examination, you note postural instability. This symptom may be: - A late symptom of Parkinson’s disease56. Motor maturation proceeds in an orderly progression from: - Head to toe 57. The thalamus is the major integration center for perception of: - Pain58. The examiner should be concerned about neurologic competence if a social smile cannot be elicited by the time a child is ________old. – 3 months59. Normal changes of the aging brain include: -60. When interviewing a 70 year old female clinic patient, she tells you that she takes ginkgo biloba and St. John’s Wort. You make a short note to check for results of the: -Mini-mental state examination61. The area of body surface innervated by a particular spinal nerve is called a: - Dermatome 62. If a patient cannot shrug the shoulders against resistance, which cranial nerve (CN) requiresfurther evaluation? – CN XI, spinal accessory63. The finger-to-nose test allows assessment of: - Coordination and fine motor function64. You ask the patient to follow a series of short commands to assess: - Attention span65. As Mr. B. enters the room, you observe that his gait is wide based and he staggers from side to side while swaying his trunk. You would document Mr. B.’s pattern as: - Cerebellar ataxia66. When is the mental status portion of the neurologic system examination performed? –Constantly throughout the entire interaction with a client67. An aversion to touch or being held, along with delayed or absent language development, is a characteristic of: -Autism68. The autonomic nervous system coordinates which of the following? – Internal environment of the body69. The major function of the sympathetic nervous system is to: - Orchestrate the stress response70. The parasympathetic nervous system maintains the day-to-day function of: - Digestion 71. Cerebrospinal fluid serves as a: - Shock absorber72. You are performing a two-point discrimination test as part of a well physical examination. The area with the ability to discern two points in the shortest distance is the: -Finger tips73. Which type of hallucination is most commonly associated with alcohol withdrawal? – Visual- bugs, pink elephantsDiminished perception of touch. -- this is byprocess of elimination/educated guess. I could not find direct information addressing this inSeidel74. On a scale of 0 to 4 , which deep tendon reflex score is appropriate for a finding of clonus in a patient? –3 75. Which statement is true regarding mental status changes in older adults? – There is an increased risk of delirium with acute illness or metabolic derangement.76. A characteristic related to syphilis or diabetic neuropathy is testicular: -Insensitivity to painful stimulation77. When collecting personal and social history data from a woman complaining of breast discomfort, you should question her regarding: - Alcohol, tobacco, and caffeine use78. What risk factor is associated with cervical cancer? – HPV79. A 23 year old female presents with severe right lower quadrant tenderness. All of thefollowing should be considered in the differential except: - Classis diverticulitis80. What is the initial diagnostic radiology test that should be ordered if you suspect a rupturedovarian cyst? – Abdominal and transvaginal ultrasound81. A 17 year old male was brought into the emergency room with testicular/scrotal pain. Thedifferential diagnosis should include all except: - Inguinal herniation82. The nursing mother complains that her breasts are tender. You assess hard, shiny, and erythremic breasts bilaterally. You should advise the patient to: - Massage gently and continue nursing83. A normal vas deferens should feel: - Smooth84. In a woman complaining of a breast lump, it is most important to ask about: - Itsrelationship to menses85. The finding of a painless indurated lesion on the glans penis is most consistent with: -Chancre86. Thrombosed hemorrhoids are: - Blue, shiny, painful masses87. Pregnancy-related cervical changes include: - Softening and bluish coloring88. You are inspecting the genitalia of an uncircumcised adult male. The foreskin is tight and cannot be easily retracted. You should: - Inquire about previous penile infections89. An adolescent male is being seen for acute onset of left testicular pain. The pain started 3 hours ago. He complains of nausea and denies dysuria or fever. Your prioritized assessment should be to: - Establish absent cremasteric reflex90. A 23 year old white woman has come to the clinic because she has missed two menstrual periods. She states that her breasts have enlarged and that her nipples have turned a darker color. Your further response to this finding is: - Suggest pregnancy testing91. What accommodations should be used in the position of a hearing-impaired woman for a pelvic examination? – The head of the table should be elevated92. Sexual differentiation in the fetus has occurred by _______weeks gestation. - 1293. You are performing a clinical breast examination for a 55 year old woman. While palpating the supraclavicular area, you suspect that you felt a node. In order to improve your hooked technique, you should: -Ask the patient to turn her head toward that side94. If a firm, transverse ridge of compressed tissue is felt bilaterally along the lower edge of a 40 year old patient’s breast, you should: -Record the finding in the patient’s record95. A therapeutic technique for dealing with grieving individuals is to: - Tell them that is good to cry and to share feelings96. The examination of the newborn should begin with: - Inspection noting skin color, flaccidity, tension, gross deformities, or distortions of facies97. Which one of the following patient characteristics is most likely to limit patient reliability during history taking? – Patient is sleep and sensory deprived98. In crying infants, it is often difficult to: - Auscultate heart sounds99. Which of the following statements accurately reflects the sensitivity and specificity oflaboratory tests? – No test has 100% sensitivity and specificity100. Which medical condition would exclude one from sports participation? – Fever101. Your 15 year old patient is athletic and thin. Radiography of an ankle injury reveals a stress fracture. You question this patient about her: - Menstrual cycles102. Which of the following are examined with the patient in a reclining 45 degree position? –Jugular venous pulsation and pressure103. Functional assessment is most important during the examination of a(n): -Older adult104. The best way to ease the apprehension of a 3 year old child before a physical examination is to: - Encourage child’s participation105. An ophthalmoscopic eye examination involves: - Lens inspection106. When conducting a geriatric assessment, basic activities of daily living (ADLs) include: -Bathing107. The checkout station for preparticipation physical evaluation (PPE) is critical because at this point: - The coordination of follow-ups is reviewed108. Which of the following is true regarding the relationship between the examiner and the patient? – The patient is a full partner with the examiner109. Which of the following factors is not known to affect patient compliance with his or her treatment regimen? – The patient’s age and social status110. One of the most important aspects to consider in the orthopedic screening examination is:- To look for symmetry of muscle, stature, and joint movement111. As you greet the patient, which examination technique is first implemented? – Inspection 112. Which portion of the physical examination is best done with the patient standing? –Spinal 113. Which patient position facilitates inspection of the chest and shoulders? – Sitting114. The least reliable indicator of newborn distress is: - Color115. Proprioception should be assessed while the patient is: - Standing116. Part of the screening orthopedic component of the examination includes evaluating the person while: - Duck walkingHealth Assessment Final Review ExamMust have 78% to pass between both exams Always go with the text bookMENTAL ASSESSMENT (Ch 5 pgs 64-78)1. What does orientation to person, place, and time assess? When you perform assessment, what exactly are you looking for? Pg. 67Person, place and time assess state of consciousness. When performing this assessment you are looking for cognitive function. Person disorientation is a result of cerebral trauma, seizures, or amnesia; Place disorientation occurs with psychiatric disorders, delirium, and cognitive impairment; Time disorientation is associated with anxiety, delirium, depression, and cognitive impairment.8. Assessing orientation to person, place, and time helps determineANS: DOrientation to person, place, and time are measures of states of consciousness and awareness, not degrees of attention span. Analogies and abstract reasoning are higher functions than orientation. Emotional status can be better evaluated by observing behaviors.2. How many serial numbers should most people be able to repeat? For example: counting backwards. How many should the average person be able to repeat? Pg. 70Five to eight numbers forward or four to six backward can usually be repeated.10.Under most conditions, adult patients should be able to repeat a series of _____ numbers.ANS: BMost adults should be able to recall immediately a series of five to eight numbers forward and four to six numbers backward.3. How do you assess recent memory if you’ve had a patient your worried about memory? What technique and how would you assess recent memory? Pg. 70Give the patient a short time to view four or five test objects, telling them you will ask them about them in a few minutes. Ten minutes later, ask the patient to list the objects.14.Recent memory may be tested ability to understand act tion of onal to to eightc.10 to 15d.15 to than g the patient to do simple g the patient to listen to and repeat a series of ng the patient four items and asking him or her to list the items about 10 minutes g the patient about verifiable past events, such as his or her mother’s maiden g the patient to name the past four presidents.ANS: CShowing the patient four or five objects, saying you will ask about them in a few minutes, and then 10 minutes later asking the patient to list the objects is a technique to measure recent memory. The other choices are not tests of recent memory. Asking the patient to listen and then repeat tests immediate recall.4. What pysch or mental condition is considered progressive and not reversible? Pg. 76, 78 Dementia (see differential diagnosis).27. Which condition is considered progressive rather than reversible?ANS: BDementia is considered progressive and irreversible, delirium and coma have the potential for reversal, and depression and anxiety are reversible.26. An older adult is administered the Set Test and scores a 14. The nurse interprets this score as indicative ofANS: EScores of less than 15 on this mental function test indicate dementia.28.Which of the following is usually related to structural diseases of the brain?ANS: BOne of the distinguishing characteristics that distinguishes dementia from the others is that it is usually related to structural diseases of the brain such as abnormal deposits, or recurrent strokes.5. If patient is delirious do they maintain orientation and attention span? Look up delirium and see what you expect patient to maintain. Pg. 75,76a.Deliriumb.Dementiac.Depressiond.Anxietye.Ctive tia.a.Deliriumb.Dementiac.Depressiond.Anxietye.Psychosis2Patient suffering from delirium is usually disoriented (usually oriented to person only) and have an impaired attentiveness. (pg 461 in Adv. Assessment) In spite of the confusion, the patient’s sensorium (consciousness) is usually intact although some condition (intoxication and severe metabolic derangements) result in altered level of consciousness.9.A state of impaired cognition, consciousness, mood and behavioral dysfunction of acute onset refers toANS: BDelirium is a state of impaired cognition, consciousness, mood and behavioral dysfunction of acute onset. Stupor describes arousals for short periods of time after a stimulus for arousal (e.g., visual, verbal, or painful). Lethargy relates to sleepiness with ease of arousal; coma is nonarousal and nonawareness. Confusion relates to inappropriate responses to questions with decreased attention span and memory.6. Who should you give a mini mental exam to? Everyone or certain patients? Pg. 67,68The mini mental exam should be given to elderly patients when there is a concern about their cognitive function. This testdetects probable dementia.34.The Mini-Mental State Examination should be administered for a patient whoANS: AThe MMSE is a tool used to estimate cognitive function quantitatively or document cognitive changes serially. Getting lost in a familiar territory is a sign of possible cognitive impairment.6. The Mini-Mental State Examination (MMSE)ANS: AThe MMSE is a standard tool that functions to estimate cognitive function quantitatively7.While interviewing a 70-year-old female clinic patient, she tells you that she takes ginkgo biloba and St. John’s wort. You make a short note to check for results of lost in her or his s an excessive amount of repetitive ritualistic illegal hallucinogenic a fear of leaving the be used to estimate cognitive changes be used to estimate personality disorders s do not vary with regard to age or determine the cause of memory a good tool to diagnose neurologic disorders.a.Denver II.b.Mini-Mental State Examination.3c.Glasgow Coma Scale.d.Goodenough-Harris Drawing Test.e.CAGE Questionnaire.ANS: BGinkgo biloba and St. John’s wort are herbal remedies used to improve mental alertness and elevate mood. As side effects, they can also result in disorientation and confusion that can be monitored with the Mini-Mental State Examination. The Denver and Goodenough- Harris tests are used for childhood development, and the Glasgow Coma Scale is used to rate coma depth. The CAGE Questionnaire is a useful tool for approaching a discussion of the use of alcohol.BREAST EXAM1. With documenting breast exams, how do you divide the breasts? If you want a radiologist to concentrate on one particular area of the breast, how do you divide to communicate findings? Pg. 351The breast is divided into five segments, four quadrants and a tail (upper inner, upper outer, lower inner, and lower outer).Either the right or left breast should be communicated. The terms: upper inner, upper outer, lower inner, lower outer, and tail of Spence should be communicated to the radiologist in terms of how to communicate findings.3.For purposes of examination and communication of physical findings, the breast is divided intoANS: CThe breast is referenced according to five segments: four quadrants and a tail.11. When conducting a clinical breast examination, the examiner shouldANS: DInspection with simultaneous observation of both breasts is essential in order to detect differences between the breast size, symmetry, contour, and skin color.2. If you have a pt c/o breast lump, what questions do you ask? For example you have a 50 year-old with breast lump, how do you begin exam compared to a 30 year-old pt?(just arbitrary ages) What assessment do you do and what questions would you ask based on age? Pg.9. Which breast change is typical after menopause?s (upper and lower).s (left, middle, and right). quadrants plus a es (six consecutive rings, each 1 inch farther away from nipple).l portions 1 through the examination if the patient has had a recent the patient covered to respect the lights to minimize ct both breasts with palpation of the breasts.a.Thickening of the inframammary ridgeb.Hypertrophy of glandular tissuec.Increase in number of lactiferous ductsd.Reduction of fat deposits4e.Shortening of Cooper’s ligamentsANS: A. After menopause, the breast tissue atrophies and is replaced by fat deposit, the inframammary ridge at the lower edge of the breast thickens, and the breast hangs more loosely as Cooper’s ligaments relax.10. In a woman complaining of a breast lump, it is most important to ask aboutANS: AHormonal changes of menstruation can result in breast tenderness, swelling, and enlarged nodes that can be felt on palpation.12. A 50-year-old woman presents as a new patient. Which finding in her personal and social history would increase her risk profile for developing breast cancer?ANS: CNulliparity or late age at birth of first child (after 30 years old) is a risk factor for breast cancer. Other risk factors include late menopause, early menarche, and drinking more than one alcoholic drink daily.1. What position do you put a patient in for a breast exam? What position is the examiner standing in? Axillary nodes what position does the patient need to be in? Pg. 355-3622. 14. To begin the clinical breast examination (CBE) for a man, ask him toANS: B Inspection begins the CBE. Ask the patient to sit with his arms hanging loosely at his sides. The technique is the same for both men and women.15.Inspection of the breasts usually begins with the patient in which position?ANS: BInspection begins with the patient in a sitting position with arms hanging loosely at the sides. Inspection (pg. 355): As the patient sits with arms hanging loosely at the sides, inspect each breast and compare it with the other for size, symmetry, contour, skin color, and texture, venous pattern, and lesions. Re-inspect the woman’s breasts with the patient in the following positions (pg. 357-358): relationship to t ization ol consumption.a.Drinking three glasses of wine per weekb.Early menopausec.Nulliparityd.Late menarchee.Young age at birth of first ne on the table with his arms with his arms hanging at his with his hands on his with his arms clasped behind his leaning forward.a.Lateralb.Sittingc.Standingd.Supinee.Proneo Seated with arms over the head or flexed behind the neck. This adds tension to the suspensory ligaments, accentuates dimpling, and may reveal variations in contour and symmetryo Steadied with hands pressed against hip with shoulders rolled forward (or alternatively have the patient push her palms together): This contracts the pectoral muscles, which can reveal deviations in contour and symmetryo Seated and leaning forward from the waist: This also causes tension in the suspensory ligaments. The breasts should hang equally. This maneuver can be particularly helpful in assessing the contour and symmetry of large breasts because the breasts fall away from the chest wall and hang freely. As the patient leans forward, support her by the hands. Patient in Seated Position (pg. 360)o Chest Wall Sweep: Have the patient sit with arms handing freely at the sideso Bimanual Digital Palpation: Place on hand, palmar surface facing up, under the patient’s right breasto Lymph Node Palpation: To palpation the axillae, have the patient seated with arm flexed at the elbow. Support the patient’s left lower arm with your left hand while examining the left axilla with your right hand. Patient in Supine Position (pg. 360): Have the patient raise one arm behind her head; then place a small pillow or folded towel under that shoulder to spread the breast tissue more evenly over the chest wall. The ideal position for examination is to have the nipple pointing toward the ceiling.b.) Axillary nodes what position does the patient need to be in? (pg. 360)Lymph Node Palpation: To palpation the axillae, have the patient seated with arm flexed at the elbow. Support the patient’s left lower arm with your left hand while examining the left axilla with your right hand.3. What’s the difference between fibrotic breast tissue and breast cancer? How do you expect each to feel? What are the characteristics of the two?17.Which finding, found on inspection, is related to fibrotic tissue changes that occur with breast carcinoma?ANS: BSkin dimpling or retraction signifies the contraction of fibrotic tissue that occurs with carcinoma. The other choices are normal variations without significance to cancer development.18. Venous patterns on breasts are suggestive of pathology when they areANS: CMalignant tumors require more blood flow. Superficial veins dilate to provide more flow and can be assessed as unilateral venous patterns. Bilateral findings are of no concern and are more commonly seen in pregnant or obese women. Nevi that are long-standing, unchanging, or nontender are of little concern.21.In patients with breast cancer, peau d’orange skin is often first evidenta.Convex or conical shapeb.Skin dimpling or retractionc.Pendulous and loose breastsd.Unequal shape or contoure.Lifelong inverted erally in obese ved during iated with a long-standing unchanging the the upper inner or around the the inframammary the tail of Spence.ANS: CThe areola is the most common initial site to visualize peau d’orange skin.24.Recent unilateral inversion of a previously everted nipple suggestsANS: BRecent unilateral inversion or retraction of a previously everted nipple suggests malignancy rather than a benign condition.41.You are conducting a clinical breast examination for a 30-year-old patient. Her breasts are symmetrical with bilateral, multiple tender masses that are freely moveable with well-defined borders. You recognize that these symptoms and assessment findings are consistent withANS: EFibrocystic changes are tender masses, usually bilateral, with multiple round, mobile, well-delineated borders. Fibroadenoma and cancer are usually nontender; Paget disease is an eczema-like condition of the nipple that signals an underlying cancer. Mammary duct ectasia most commonly occurs in menopausal women. Fibrocystic Changes (pg. 366):o Benign fluid-filled cyst formation caused by duct enlargement o Pathophysiology Usually bilateral and multiple Most common in women 30 to 55 years of age Associated with long follicular or luteal phase of the menstrual cycleo SubjectiveData Tender and painful breasts and/or palpable lumps that fluctuate with menses  Usually worse premenstruallyo ObjectiveData Round, soft to firm, tense, mobile masses with well-delineated borders  Usually tender Usually bilateral Multiple or single Fibroadenoma (pg. 366): n breast adenoma.b.Paget ry duct cystic changes.o Pathophysiology May occur in girls and women of any age during their reproductive years  After menopause, the tumors may regresso SubjectiveData Painless lumps that do not fluctuate with the menstrual cycle May be symptomatic with discovery on clinical breast examination or breast imagingo ObjectiveData Round or discoid, firm, rubbery, mobile masses with well-delineated borders  Usually non-tender Usually bilateral Single; may be multiple Biopsy often performed to rule out carcinoma Malignant Breast Tumors (pg. 366): Ductal carcinoma arises from the epithelial lining of ducts; lobular carcinoma originates in the glandular tissue of the lobuleso Pathophysiology Mutations to normal cells results in uncontrolled cell division and tumor formation; as the tumor grows andinvades surrounding tissue, metastases occurs through the lymph and vascular systems Peak incidence between the ages of 40 and 75 years, with the majority of malignant breast tumors occurring in women older than 50o SubjectiveData Painless lump; change in size, shape, or contour of breast Axilla may be tender if lymph nodes involved May be asymptomatic with discovery on clinical breast examination or breast imagineo ObjectiveData May be palpable mass that is usually single, unilateral, irregular, or stellate in shape; poorly delineatedborders; fixed; hard or stone-like; and non-tender Breast may have dimpling, retraction, prominent vasculature Skin may have peau d’orange or thickened appearance Nipple may be inverted or deviated in position(Differential diagnosis pg. 365)Fibrotic: usually bilateral, multiple or single, round, soft to firm; tense, mobile, absent retraction signs, usually tender, bordersare well delineated, and they vary with menses.Cancer: Usually unilateral, single, irregular or stellate, hard/stonelike, fixed, retraction signs are often present, usually nontender, the borders are poorly delineated; irregular, and they do not vary with menses.4. Breast Exam- What part of the hand do you use? Fingertips, pads, palms, entire hands? Pg. 361Palpate using your finger pads as they are more sensitive than your fingertips. Palpate systematically, pushing gently but firmly toward the chest wall, as you rotate your fingers in a clockwise or counterclockwise pattern. At each point, as you rotate your fingers press inward, using three depths of palpation: light then medium and finally deep. The exact sequence you select for palpation is not critical, but a systematic approach will help ensure that all portions of the breast are examined.26.When palpating breast tissue, the examiner should use the _____ at each r of the surface of the sANS: BThe finger pads are used for breast palpation because they are more sensitive than the fingertips.5. What is Peau d\'orange skin? Look, feel, mean? Pg. 356The skin has an orange peel appearance. This indicates edema of the breast caused by blocked lymph drainage in advanced orinflammatory breast cancer. The skin appears thickened with enlarged pores and accentuated skin markings.6. What is the tail of Spence? Where is it anatomically? Pg. 351The tail of Spence is (extends from) the greatest amount of glandular tissue that lies in the upper outer quadrant and extendsinto the axilla. ??????2.The largest amount of glandular breast tissue lies in theANS: DThe greatest amount of glandular tissue in the breast lies in the upper outer quadrant.31.The tail of Spence extendsANS: DThe tail of Spence extends from the upper outer breast quadrant into the axillae.7. Breast Exam: Certain groups of lymph nodes are enlarge, where would they be for examiner to expect Breast Cancer? Pg. 360The axilla, supraclavicular and infraclavicular areas. Nodes that are detected should be described according to location, size, shape, consistency, tenderness, fixation, and delineation of borders.34.When examining axillary lymph nodes, the patient’s arm inner of S outer the midclavicular d the supraclavicular into the inframammary the the sternal d full above the ded at the ed against the ed over the d at the elbow.ANS: ETo examine the axilla, support the patient’s lower arm with the elbow flexed with one of your hands and use your other hand to palpate the axilla.35.Lymphatic flow of the breast primarily drainsANS: CEach breast contains a lymphatic network that drains the breast radially and deeply to underlying lymphatics.36. The greatest concern for breast cancer is when you palpate _____ nodes.ANS: DThe supraclavicular and infraclavicular nodal areas are sentinel nodes; any enlargement in these areas is especially significant.37.You are performing a clinical breast examination for a 55-year-old woman. While palpating the supraclavicular area, you suspect that you felt a node. To improve your hooked technique, you shouldANS: EHaving the patient turn her head toward the examination side, as well as raising the shoulder on that same side, gives your fingers more room to palpate deeper into the fossa.8. What if you have a 20-30 year-old with freely moveable, well-defined lump, tender with cycle, cancer or more likely fibrotic? Fibrotic (see page 365)iorly toward the ally toward the corresponding lly toward the omedially toward the ior nal lotion to your both hands the patient to press both palms the patient to lower her shoulder on that the patient to turn her head toward that side.1041.You are conducting a clinical breast examination for a 30-year-old patient. Her breasts are symmetrical with bilateral, multiple tender masses that are freely moveable with well-defined borders. You recognize that these symptoms and assessment findings are consistent withANS: EFibrocystic changes are tender masses, usually bilateral, with multiple round, mobile, well-delineated borders. Fibroadenoma and cancer are usually nontender; Paget disease is an eczema-like condition of the nipple that signals an underlying cancer. Mammary duct ectasia most commonly occurs in menopausal women.9. Then you have a 50 year-old-lump firm, fixed, doey-like, cancer or fibrotic? Cancer FEMALE GENITALIA1. Pelvic Exam-anatomy of vagina and location of glands-5 O’clock, 7 O’clock for example, just know the anatomy of the male and female genitals.2. What structures are located at the 5 o’clock and the 7 o’clock positions of the vaginal orifice and open onto the sides of the vestibule in the groove between the labia minora and the hymen?ANS: DBartholin glands are found posteriorly on each side of the vaginal orifice and open onto the sides of the vestibule.2. Cervical Cancer- know patient’s history and what questions to ask patients that put them at high risk for cervical cancer.12. Which factor is associated with an increased risk of cervical cancer?ANS: EWomen who were younger than 17 years when they had their first full-term pregnancy are almost 2 times more likely to get cervical cancer later in life than women who were not pregnant until they were 25 years or adenoma.b.Paget ry duct cystic changes.a.Skene glandsb.Perineal bodiesc.Labia majorad.Bartholin glandse.Labia minoraa.Endometriosisb.Low parityc.HPV vaccinationd.High socioeconomic statuse.Early parity113. What history increases your risk for ovarian cancer? (pg. 425)Risk factors for ovarian cancer (box on p. 425 below cervical risk factors): Age (increases with age), inherited genetic mutation (BRCA1 or BRCA2 gene), family history, obesity, reproductive history (nulliparity increases risk), and the use of fertility drugs, personal history, hormone replacement therapy, and high-fat diet.13.The risk of ovarian cancer is increased by a history ofANS: EThere is a relationship between nulliparity and an increased risk of ovarian cancer. Although the risk increases with age, most ovarian cancers develop after menopause; half are found in women older than 63 years. The other choices have no relationship with ovarian cancer.4. What is a normal cervix and an abnormal cervix? What does an abnormal one look like (not cancerous) what tests might you and what might indicate? Disorder?22. During digital examination of the vagina, the cervix is noted to be positioned posteriorly. Upon bimanual examination of this woman, you would expect to palpate a(n) _____ uterus.ANS: BThe position of the cervix correlates with the position of the uterus. A cervix that is pointing posteriorly indicates an anteverted uterus.23. The presence of cervical motion tenderness may indicateANS: CPainful cervical motion tenderness suggests a pelvic inflammatory disease or a ruptured tubal pregnancy. The cervix is expected to move 1 to 2 cm without discomfort under normal conditions.25.During a routine vaginal examination, you insert the speculum and visualize the cervix. The cervix projection into the vaginal vault -fat ette between 35 and 50 body ally c inflammatory nancy.12approximately 5 cm. Upon bimanual examination, you would expect to find the the midline the retroverted the anteverted ted to the left or the retroflexed position.ANS: DNormally, the cervix protrudes into the vagina 1 to 3 cm. Longer projections suggest a pelvic or uterine mass. A pelvic mass would cause the uterus to be deviated to the right or left, but an anteverted, retroverted, or retroflexed uterus would still be in the midline regardless of its position.26.Small, pale yellow, raised, and rounded areas are visualized on the surface of the cervix. You shouldANS: AThis describes nabothian cysts, which are retention cysts of the endocervical glands and are considered a normal variant. No further testing is this as nabothian this as a friable n a viral the pH of the cervical this as an eroded cervix.a.b.c.Normal cervix: covered with pink squamous epithelium that is uniform in consistency. It should be in an anterior- posterior position that correlates with the position of the uterus. The os is small and round. A small area of ectropion is visible inferior to the os. Cervix should feel firm (during pregnancy will be softer) and be smooth.Abnormal cervix: Bluish color indicates increased, which may indicate pregnancy. A pale cervix is associated with anemia. If the cervix is pointed anteriorly it indicates a retroverted uterus; pointing posteriorly indicated an anteverted uterus. Horizontal indicated a uterus in midposition; deviation indicated a pelvic mass, uterine adhesions, or pregnanacy. Projection greater than 3 cm may indicate a pelvic or uterine mass. Small, white or yellow raised, round areas may indicate nabothian cysts. Friable tissue, red patchy areas, granular areas, and white patches could indicate cervicitis, infection, or carcinoma.Feel for nodules, harness, and roughness. Note the position of the cervix, it should be in the midline and may point anteriorly or posteriorly. Grasp the cervix between your fingers and move it gently from side to side (should move 1-2 cm). There should be no pain or discomfort. Painful cervical movement suggests a pelvic inflammatory disease or a ruptured tubal pregnancy which would require immediate surgery.5. What structure or organs are examined during a Bimanual exam? (pg 436-437). Cervix, Uterus, Adnexa, and Ovaries33.The assessment of which structure is not part of the bimanual examination?a.Cervixb.Bladderc.Uterusd.Ovariese.Adnexa13ANS: BThe bimanual examination consists of assessing the cervix, uterus, adnexa, and ovaries.6. When do PAP smears begin? Age of non-sexually active versus sexually active women? (pg. 437) 21 for non-sexually and sexually active women because cervical cancer is rare for women under age 21.40.When a woman is not sexually active, cervical cancer screening should beginANS: DWomen who are not sexually active should have their first examination by the age of 21 years. Women under age 21 should not be tested.7. Menopausal women- what does the vagina and mucosa of the walls feel like? (pg. 447)The vagina is narrower and shorter. You will see and feel the absence of rugae. The cervix is smaller and paler but the osshould still be palpable and the cervix may be less mobile.43.During a pelvic examination for a postmenopausal woman, you would expect to assessANS: BExpected findings in the pelvic examination for an older woman include a narrower and shorter vagina, absence of rugation, a less mobile cervix, and a palpable cervical os. The ovaries are rarely palpable because of atrophy.MALE GU1. Males-history or what alerts the examiner of the possibility of testicular cancer? (pg. 470).Undescended testicle, personal hx of testicular CA, family hx of testicular CA, abnormal testicle development (klinefelter syn), 20-54 yr male, the most prominent in white race ( 5 times that of black; more than 3 times that of Asian American and Native American men).13.Which of the following is a risk factor for testicular cancer? age 15 age 18 age 21 age 30 years.a.a wider and longer vaginal ce of vaginal wall rugation.c.a nonpalpable cervical os.d.a more mobile ble ovaries.a.Circumcisionb.Condyloma acuminatumc.Cryptorchidism14d.Poor hygienee.Multiple sexual partnersANS: CCryptorchidism (testes that fail to descend by 12 months of age) is a risk factor for testicular cancer.27.The most common cancer in young men age 15 to 30 years isANS: ABecause testicular tumors are the most common cancer occurring in young adults, self-examination is encouraged.37.Self-examination of the male genitaliaANS: BMonthly self-examination is recommended as a screening test for testicular cancer as well as sexually transmitted infections for all young men starting at 15 years of age. It is encouraged during bathing because the scrotal skin is less thick at this time and because the scrotum hangs looser because of the warmth. Inspection is done first followed by palpation.2. What alerts us to do further testing and the need to further and fully assess for testicular cancer? How do we do this?o Irregular, contender mass fixed to the testiso Does not transilluminateo May also have hydrocele(that doesn\'t transilluminate) o InguinalLymphadenopathyo Painless mass in testicleo Scrotalenlargementorswellingo Heavy feel in in scrotumo Dull ache in lower abdomen, back or groino fluid in scrotumThis can be done by performing a Testicular exam ( inspect and palpate), Scrotal US, Lab work including: Chemistry, WBC count, biochemical markers AFP and B-hCg.21.Mr. L. has an unusually thick scrotum with edema and pitting. He has a history of cardiac problems. The appearance of his scrotum is more likely a(n)ANS: BGeneral fluid retention can cause scrotal thickening and pitting edema and is more often seen as a result of cardiac, renal, or hepatic disease. This swelling does not imply a condition of the genitalia but rather a condition of these related d be restricted to adults with prior d be performed while s with palpation and then d be performed t be adequately performed due to poor visualization of the nital defect that has ation of general fluid l consequence of ication to the development of quence of prior STDs.1525.An enlarged, painless testicle in an adolescent or adult may cular torsion.c.a undescended padias.ANS: CA hard, enlarged, painless testicle can indicate a tumor in an adolescent or adult male. Epididymitis and torsion are painful; an undescended testicle is common in infants and is usually resolved by 12 months. Hypospadias is a congenital defect of the urethral opening causing the meatus to be located ventral to its normal position.26.You palpate a soft, slightly tender mass in the right scrotum of a man. You attempt to reduce the size of the mass, and there is no change in the mass size. Your next assessment maneuver is toANS: DA soft mass is either a hernia or hydrocele. If the mass can be reduced, it is probably a hernia; a nonreducible mass should be transilluminated to determine whether it contains fluid and is possibly caused by a hydrocele. Lifting the scrotum should be done when epididymitis is suspected. Urethral cultures are not indicated at this point.29.An adolescent male is being seen for acute onset of left testicular pain. The pain started 3 hours ago. He complains of nausea and denies dysuria and fever. Your prioritized assessment should be toANS: CThe patient is displaying symptoms of testicular torsion. An absent cremasteric reflex is a supporting finding to differentiate torsion from epididymitis.38. A 12-year-old boy says that his left scrotum has a soft swollen mass. The scrotum is not painful upon palpation. The left inguinal canal is without masses. The mass does transilluminate with a penlight. This collection of symptoms is consistent withANS: BA hydrocele is a soft scrotal mass that occurs from fluid accumulation and therefore does transilluminate. Orchitis results in a swollen, tender testis. A rectocele does not result in scrotal swelling. A scrotal hernia would also be palpable along the inguinal canal. Epididymitis is an extremely painful condition.41.A cremasteric reflex should result two fingers to attempt to reduce the te the left scrotum the right testicle, then compare pain illuminate the re the meatus for gonococcal n urine and DNA probe urethral the left scrotum to confirm lish absent cremasteric illuminate the left and right the patient stand and observe the scrotum for a “bag of worms.”al scrotum appear to contain a “bag of worms.”e deviation to the left um to elevate iate erection of the cle and scrotal rise on the stroked side.ANS: EUpon stroking the inner thigh with a blunt instrument or finger, the testicle and scrotum should rise on the stroked side.3. How do you assess for an inguinal hernia? Pg. 472-473Have the pt. stand and bear down. While he is straining inspect the area of the inguinal canal and the region of the fossa ovalis. After the pt. relaxes, insert your examining finger into the lower part of the scrotum and carry it upward along the vas deferens into the inguinal canal. You can also auscultate for bowel sounds, which will be present in uncomplicated reducible hernias.18.Which technique is appropriate to detect an inguinal hernia?ANS: EExamination for inguinal hernias is performed with the patient standing. Inspect the groin while the patient performs a Valsalva maneuver. Insert your examination finger into the lower part of the scrotum and follow upward along the vas deferens to screen for a hernia.19. Which type of hernia lies within the inguinal canal?ANS: CHernias found within the inguinal canal are called indirect hernias.4. What does Vas deferens feel like? Normal? Abnormal? Pg. 473The Vas deferens feels smooth and discrete; abnormal findings are beaded or lumpy feeling. This may indicate diabetes or oldinflammatory changes, especially tuberculosis.2.What structure of the male genitalia travels through the inguinal canal and unites with the seminal vesicle to form the ejaculatory duct?ANS: Da.Conduct percussion while the patient coughs.b.Have the patient strain as you pinch the testes.c.Inspect rectal areas as the patient bears down.d.Conduct the examination only in the supine position.e.Move your finger upward along the vas deferens.a.Umbilicalb.Directc.Indirectd.Femorale.Incisionala.Epididymisb.Corpus cavernosumc.Urethrad.Vas deferense.Ureter17The vas deferens begins at the end of the epididymis, travels the spermatic cord, goes through the inguinal canal, and then unites with the seminal vesicle to form the ejaculatory duct.23.A normal vas deferens should feelANS: BThe vas deferens should normally feel smooth, discrete, and nontender.5. Young man- what is an emergent cause of testicular pain? Pg. 482 Testicular Torsion is twisting of the spermatic cord and is a surgical emergency.29.An adolescent male is being seen for acute onset of left testicular pain. The pain started 3 hours ago. He complains of nausea and denies dysuria and fever. Your prioritized assessment should be toANS: CThe patient is displaying symptoms of testicular torsion. An absent cremasteric reflex is a supporting finding to differentiate torsion from epididymitis.28.The most emergent cause of testicular pain in a young male isANS: ETesticular torsion is a surgical emergency. If surgery is performed within 12 hours after the onset of symptoms, the testis can be saved in about 90% of cases. Delayed treatment results in a much lower salvage rate.6. Understand hernias, where located and how to assess each kind. Pg. 476, 477(see differential diagnosis).Hernia is protrusion of a peritoneal-lined sac through some defect in the abdominal wall. There are indirect, direct and femoral.7. What is the most common type of hernia? Pg. 477 Indirect Inguinal hernias are the most common type.31.The most common type of hernia occurring in young males n urine and DNA probe urethral the left scrotum to confirm lish absent cremasteric illuminate the left and right the patient stand and observe the scrotum for a “bag of worms.”cular cerated ect al.ANS: CThe most common type of hernia in children and young males is an indirect inguinal hernia.MUSCULOSKELETAL1. What is the difference between osteoarthritis versus rheumatoid arthritis?During an assessment what do you expect to see in a patient with osteoarthritis vs. RA? Findings in joints? Describe. OA (pg411)-A progressive disorder associated with age and wear and tear. There is loss of cartilage and progressive erosion of bone. Affects mostly larger bones like hips and knees, but frequently involves small joints of hands, especially distal and proximal interphalangeal joints. Asymmetrical distribution. Pain and stiffness improves with activity, and worsens with rest. Xrays show changes. Sed rate(-), Rheumatoid factor (-) RA (pg410)-If 3 or more metacarpophalangeal joints are swollen is RA. It’s a progressive, inflammatory, and erosive condition that usually affects multiple joints. It’s an autoimmune condition. Affects joints symmetrically. Affects small joints of hands and feet. Joints are tender, swollen with effusion, warm, inflamed. Nodules and deformities are noted. RA associated with: subluxation of metacarpophalgeal joins, hyperextension of joints, but also with changes in eye (scleritis, episcleritis, interstitial lung disease and pericardial disease.1. When does a musculoskeletal exam begin? (text tells you) pg405-The musculoskeletal examination is primarily limited to inspection and palpation. The focused musculoskeletal examination begins withinspection.2. How do you assess the strength of the trapezius muscle? (pg518)The strength of trapezius and sternocleoidomastoid muscle is tested by evaluating the cervical spine and asking patients to do certainmovement. Bend the head forward, chin to chest, and expect flexion of 45 degrees. Bend head to each side, ear to each shoulder and expect lateral bending of 40 degrees. Bend head backward, chin toward ceiling, and expect extension of 45 degrees.3. Patient with scoliosis, bend at waist, what is expected finding? Describe what it looks like (Pg541)When looking form the rear, the spine looks more like an “S” or a “C” than a straight line. There is no known cause. Associated with leg length discrepancy. There’s lateral curvature of spine as patient flexes forward to touch the toes. In severe deformities, patient has uneven shoulder and hip levels, and may have crease on one side of waist.194. Carpal Tunnel-What expect to feel like, how do you assess for? During assessment, particular nerve is tested, what is it? What sensation will the patient have?(pg430,524) The carpal tunnel is a space located on the anterior aspect of the wrist between the carpal bones and a ligamentous band through which the median nerve and several tendons transverse. With overuse and repetitive movements there’s a hypertrophy of tissues, causing a lot of space and impingement on the median nerve. Nighttime pain-early sign. Swelling at wrist related to inactivity of flexion at night, pain can radiate up the forearm to shoulder with numbness and tingling along the median nerve, and paresthesia involves anterior aspects of wrist, medial palm and first three digits of affected nerve. Relief is found by shaking affected hand in downward fashion. To assess, first ask patient to mark specific site using the Katz hand diagram.o Thumb abduction test isolates strength of abductor pollicis brevis muscle, innervated only by median nerve. Pt will place the hand palm up and raise the thumb perpendicular to it. Apply downward pressure on thumb to test muscle strength. Weakness=Carpal tunnel syndromeo Tinel sign: Strike pt’s wrist with your index or middle finger, where median nerve passes under the flexor retinaculum and volar carpal ligament(fig21.42). Tingling, means ( ) tiner sign and ( ) CPT syndrome.o Phalen test: pt holds both wrist in fully palmar-flexed position with dorsal surfaces pressed together for one min. Numbness and paresthesia in the distribution of median nerve is ( ) CPT syndrome.ABDOMINAL1. When conducting an abdominal exam, what position should the patient be in? Examiner? Techniques with rigid abdomen or anxious pt, what are relaxation techniques? (pg377)Need good light source; full exposure of abdomen; warm hands with short fingernails. Have pt empty bladder. Place pt is supine position with arms at sides. Approach pt from right side. Place small pillow under pt’s head and another under slightly flexed knees. Drape a towel or sheet over the patient’s chest for warmth and privacy. Be slow and gentle, avoid sudden movements.Percussion of the abdomen begins with establishinga. liver dullness.b. spleen dullness.c. gastric bubble tympany.d. overall dullness and tympany in all quadrants.e. bladder fullness.ANS: DPercussion begins with a general establishment over all quadrants for areas of dullness and tympany and then proceeds to specific target organs22. Before performing an abdominal examination, the examiner shoulda. ascertain the patient’s HIV status.b. have the patient empty his or her bladder.c. don double gloves.d. completely disrobe the patient.e. uncover only the painful areas of the abdomen.ANS: BThe patient should empty the bladder to ensure an accurate examination of organs as well as to provide comfort for the patient.2024. When examining a patient with tense abdominal musculature, a helpful technique is to have the patienta. hold his or her breath.b. sit upright.c. flex his or her knees.d. raise his or her head off the pillow.e. fully extend the legs.ANS: CTo help relax the abdominal musculature, it is helpful to place a small pillow under the patient’s head and under slightly flexed knees. The other choices increase muscle flexion.28. After thorough inspection of the abdomen, the next assessment step is toa. percuss.b. palpate nonpainful areas.c. auscultate.d. perform a rectal examination.e. palpate painful areas.ANS: CAssessment of the abdomen begins with inspection followed by auscultation. This break from the usual system examination sequence is because palpation and percussion can alter the frequency as well as the intensity of bowel sounds. Therefore, auscultation is done first.2. How long do you auscultate for BS? (pg380)Bowel sounds range from 5-35/min. If you’re unable to hear BS after 5 min of continues listening, associated with abdominal pain andrigidity then is surgical emergency.To correctly document absent bowel sounds, one must listen continuously fora. 30 seconds.b. 1 minute.c. 3 minutes.d. 5 minutes.e. 10 minutes.ANS: DAbsent bowel sounds are confirmed after listening to each quadrant for 5 minutes.3. What is the technique for percussing the liver border? Where to start, how you move, what are you listening for? (pg381)Begin liver percussion at the right midclavicular line over an area of tympany. Always begin with an area of tympany and proceed to area of dullness for easiness. Percuss upward along the midclavicular line to determine lower border of liver. The area of liver dullness is usually heard at the costal margin or slightly below it. Mark with a pen. A lower liver border that is more than 2-3 cm below costal margin may indicate organ enlargement or downward displacement of diaphragm because of emphysema or other pulmonary disease. Upper border of liver, begin percussion on the right midclavicular line at an area of lung resonance around the third intercostal space. Cont downward until the percussion tone changes to one of dullness; this marks upper border of the liver mark with pen. It’s usually in the fifth intercostal space. Measure the distance between the marks, estimates vertical span of liver, usually 6-12cm. If larger=enlargement, if smaller=atrophy.2137. To assess for liver enlargement in an obese person, you shoulda. use the hook method.b. test for cutaneous hypersensitivity.c. auscultate using the scratch technique.d. attempt palpation during deep exhalation.e. have the patient lean over at the waist.ANS: CIf the abdomen is obese or distended or if the abdominal muscles are tight, you should plan on auscultating the liver using the scratch method to estimate the lower border of the liver. Cutaneous hypersensitivity is a sign of peritonitis and does not contribute to determining liver size.Percussion at the right midclavicular line, below the umbilicus, and continuing upward is the correct technique for locating thea. descending aorta.b. lower liver border.c. medial border of the spleen.d. upper right kidney ridge.e. stomach.ANS: BPercussing along the right midclavicular line upward from the umbilicus determines the lower border of the liver. A liver border more than 2 to 3 cm signifies hepatomegaly.When palpating the abdomen, you should note whether the liver is enlarged in thea. left upper quadrant.b. midepigastric region.c. periumbilical area.d. right upper quadrant.e. right lower quadrant.ANS: DAn examiner can recognize a friction rub in the liver by a sound that isa. clicking, gurgling, and irregular.b. high pitched and associated with respirations.c. loud, prolonged, and gurgling.d. soft, low-pitched, and continuous.e. low pitched, tinkling, and unrelated to respirations.ANS: BAn abdominal friction rub is rare and can be identified when high-pitched sounds are auscultated in association with respirations. The liver is located in the right upper quadrant of the abdomen4. CVA tenderness-what might it be a sign of?Costovertebral angle tenderness should be assessed whenever you suspect the patient may havea. cholecystitis.b. pancreatitis.c. pyelonephritis.d. ulcerative colitis.e. intussusception.22ANS: CPyelonephritis is characterized by flank pain and costovertebral angle tendernessNEURO1. Autonomic Nervous System- what are you assessing? Coordinate?(Pg477)The Nervous system with its central and peripheral divisions maintains and controls all body functions by its voluntary and autonomic responses. The evaluation of motor, sensory, autonomic, cognitive and behavioral elements. The CNS is the main network of coordination and control for the body.(PG446) Coordination tests fluidity of movements. Inability to coordinate movements suggests cerebellar dysfunction. Finger to nose testing-ask pt to touch your index finger with his or her index finger, then touch his/her noserepeatedly. Poor coordination of movement indicates dysmetria. Rapid alternating movements-Ask pt to perform rapid pronation and supination of the hand on his/her thigh or on examination table Heel to shin testing-Ask pt to take the heel of one side and repeatedly move up and down the shin of the opposite leg Romberg- Ask pt to stand with feet together, arms abducted outward with palms up, and eyes closed. PostiveRomberg is observed as a swaying motion, or inability to maintain balance, and indicates cerebellar dysfunction.2. Motor Cortex of Brain- What does it control?3. Know EACH Cranial Nerve (several questions)- how to assess each, what testing for, what each do, abnormal findingsvs. expected findings. (pg553) Olfactory (1)- Sensory: smell reception and interpretation. Have available 2-3 vials of aromatic odors. Ensure patient’s nasal passages are patent. Occlude one naris at a time and ask patient to breathe in and out, while closing her eyes. Use different odor to test the other side. Assess the ability of patient to differentiate between diff odors. Sense of smell diminishes with age. Anosmia (loss of sense of smell). Optic (ll)- Sensory: visual acuity and visual field (chapter 11) Oculomotor (lll)-Motor: raise eyelids, most extraocular movements. Parasympathetic: pupillary constriction,change lens shape Trochlear (lV)- Motor: downward, inward eye movement(lll, lV, Vl)- Movement of eyes through the six cardinal points of gaze, pupil size, shape, response, to light and accommodation and opening of the upper eyelids. When assessing pt with severe unremitting headaches, the experienced examiner evaluates movement of the eyes for the presence of absence of lateral gaze. The sixth cranial nerve is commonly one of the first to lose function in the presence of increased intracranial pressure. Trigeminal (V)- Motor: jaw opening and clenching, chewing and mastication. Sensory: sensation to cornea, iris, lacrimal glands, conjunctiva, eyelids, forehead, nose, nasal and mouth mucosa, teeth, tongue, ear, facial skin. Evaluate for muscle atrophy. Have patient clench teeth as you palpate the muscles over the jaw, evaluating tone, which should be symmetric, without fasciculations. The three divisions of the trigeminal nerve are evaluated for the sharp, dull and light sensations. With pt closing eyes, touch each side of face at the scalp, cheek and chin, alternating sharp and smooth edges of a broken23tongue blade or a paper clip. Ask patient to report feeling. Then stroke face with cotton wisp. If sensation is impaired, ask pt to differ btw hot/cold. Abducens (Vl)- Motor: lateral eye movement Facial (Vll)- ask pt to raise eyebrows, squeeze the eyes shut, wrinkle the forehead, frown, smile, show the teeth, purse the lips to whistle, and puff out the cheeks. Observe for ticks, unusual movements and symmetry of expression. Drooping of one side of mouth or sagging of lower eyelid will indicate muscle weakness. Ie: Bells palsyTo evaluate taste, a sensory fx of cranial nerves Vll and lX: have patient have tongue protruded and have 4 solutions with Bitter, sour,

NURS 6512 Final Exam (Latest 2019 Version) Already Graded A+ Walden University Course NURS-6512D-1/NURS-6512N-1-NURS-6512D- 1/NURS-6512N-1- Advanced Health Assessment and Diagnostic ReasoningTest Final Exam
Started 8/1/19 11:30 AM Submitted 8/1/19 1:20 PMDue Date 8/12/19 1:59 AMStatus Completed
Attempt Score 93 out of 100 pointsTime Elapsed 1 hour, 34 minutes out of 1 hour and 50 minutes1. Costovertebral angle tenderness should be assessed whenever you suspect the patient may have: - Polynephritis2. In older adults, overflow fecal incontinence is commonly due to: -Fecal impaction3. A 1 month old boy has been vomiting for 2 weeks. How is this symptom of GERD and pyloric stenosis further differentiated in this child’s assessment? – The infant has regurgitation with pyloric stenosis4. Auscultation of borborygmi is associated with: - Gastroenteritis, early intestinal obstruction, or hunger5. When auscultating the abdomen, which finding would indicate collateral circulation between the portal and systemic venous systems? – Venous hum6. Conversion of fat-soluble wastes to water-soluble material for renal excretion is a function of the: - Liver7. The major function of the large intestine is: -Water absorption8. Which structure is located in the hypogastric region of the abdomen? –Ileum, bladder, andpregnant uterus9. A 45 year old man relates a several week history of severe intermittent abdominal burning sensations. He relates that the pain is relieved with small amounts of food. Before starting the physical examination, you review his laboratory work, anticipating a (n): -Positive Helicobacter pylori result10. You are caring for a patient with trigeminal neuralgia. During the assessment, the patient would describe the pain as: - Burning or shocklike11. Your 85 year old patient is complaining of right knee pain. She has a history of osteoarthritis for which she is given anti-inflammatory medication. To assess her right knee pain, you should ask her if: - The pain gets better when she sits12. A 5 year old is complaining of nondescriptive “belly pain.” Your next action should be to ask him to: - Point to the area of pain13. The perception of pain: - Is variable and is affected by emotions, and cultural background14. Patients presenting with ascites, jaundice, cutaneous spider veins, and nonpalpable liver exhibit signs of: - Cirrhosis15. A patient presents to the emergency department after a motor vehicle accident. The patient sustained blunt trauma to the abdomen and complains of pain in the upper left quadrant that radiates to the left shoulder. What organ is most likely injured? – Spleen16. Imaging studies reveal that a patient has dilation of the renal pelvis from an obstruction in the ureter, what condition will be documented in this patient’s health record? – Hydronephrosis17. Visible intestinal peristalsis may indicate: - Intestinal obstruction18. Infants born weighing less than 1500g are at higher risk for: - Necrotizing enterocolitis19. Which of the following factors is not known to affect patient compliance with his or her treatment regimen? – The patient’s age and social status20. One of the most important aspects to consider in the orthopedic screening examination is: -Symmetry21. The sequence of the physical examination should be individualized to: -22. As you greet the patient, which examination technique is first implemented? - Inspection23. Which of the following is most likely to enhance examiner reliability? – The examiner attempts to qualify data24. A 7 year old boy is brought to your office with a chief complaint of possible fracture to his left third finger. He jammed it while playing basketball 2 days ago. The mother states that she really does not think it is broken because he can move it. What is your best response? – This is common misconception, and the finger may be broken. An x-ray is indicated.25. A patient presenting for the first time with typical low back pain should receive which of the following diagnostic tests?26. Skeletal changes in older adults are the result of: -Increased bone resorption 27. A positive straight leg raise test usually indicates: - Lumbar nerve root irritation28. What technique is performed at every infant examination during the first year of life to detect hip dislocation? – Barlow-Ortolani maneuvers29. Expected normal findings during inspection of spinal alignment include: - Convex lumbar curvenumber of times the patient has to change positions to conserve the patient’s energyMinimize theusually musculoskeletal etiology.– None of the above. X-ray is not indicated because lumbar pain is30. Temporalis and masseter muscles are evaluated by: - Having the patient clench his or her teeth31. When palpating joints, crepitus may be caused when: - Irregular bony surfaces rub together32. A 3 year old is brought to the clinic complaining of a painful right elbow. He is holding the right arm slightly flexed and pronated and refuses to move it. the mother states that symptoms started right after his older brother had been swinging him around by his arms. This presentation supports a diagnosis of: - Radial head subluxation33. Light skin and thin body habitus are risk factors for: - Osteoporosis34. Risk factors for sports-related injuries include: - Failure to warm up before activity35. Injuries to long bones and joints are more likely to result in fractures than in sprains until: -Adolescence36. Ligaments are stronger than bone until: - Adolescence37. The family history for a patient with joint pain should include information about siblings with: -Genetic disorders38. The Thomas test is used to detect: - Flexion contractures of the hip39. A goniometer is used to assess: - Range of motion40. During a football game, a player was struck on the lateral side of the left leg while his feet were firmly planted. He is complaining of left knee pain. To examine the left knee you should initially perform the ________ test. – Valgus stress41. You note that a child has a positive Gower Sign. You know that this indicates generalized: -Muscle weakness42. The dowager hump is: - The hallmark of osteoporosis43. What temporary disorder may be experienced by pregnant women during the third trimester because of fluid retention? –Carpal tunnel syndrome44. A common finding in markedly obese and pregnant women is: - Lordosis45. A 45 year old laborer presents with low back pain, stating that the pain comes from the right buttock and shoots down and across the right anterior thigh, down the shin to the ankle. Which examination finding is considered more indicative of nerve root compression? – Positive straight leg raise result46. Mrs. Bower is a 57 year old patient who comes in for an office visit. Which of the following disorders is known to be hereditary? – Huntington chorea47. Testing of cranial nerve ________ is not routinely performed unless a problem is suspected.–I48. The patient is able to rapidly touch each finger to his thumb in rapid sequence. What does this finding mean? – The patient has appropriate cerebellar function49. Which question asked by the examiner may hellp to determine prevention strategies for seizures that a patient is experiencing? – “Are there any factors or activities that seem to start the seizures?”50. A patient has a complaint of dizziness. The patient makes the following statement: “I sometimes feel as if the whole room is spinning.” What type of neurologic dysfunction should the examiner suspect? – Inner ear dysfunction affecting the acoustic nerve51. The examiner asks the patient to close her eyes, then places a vibrating tuning fork on the patient’s ankle and asks her to indicate what is felt. What is being assessed? – Peripheral nerve sensory function52. Which of the following findings should an examiner consider a normal finding if associated with pregnancy? – Acroparesthesia52. Jack is a 52 year old obese man with a history of poorly controlled diabetes. He also smokes. Based on the above data, the examiner should recognize that Jack has several risk factors for: - Cerebrovascular accident53. Mrs. Jones is a 24 year old patient who presents to your office 2 days postpartum. She complains that she is experiencing foot drop. Which of the following problems should the examiner consider? – Lumbosacral plexopathy54. The examiner is assessing deep tendon reflex response in a 12 year old boy. The response is an expected reflex response. Which of the following scores should be documented? – 2 55. A 68 year old patient presents to your office for follow-up. He tells you, “I have a hard time finding the right words when I am talking;” he also is experiencing numbness. On examination, you note postural instability. This symptom may be: - A late symptom of Parkinson’s disease56. Motor maturation proceeds in an orderly progression from: - Head to toe 57. The thalamus is the major integration center for perception of: - Pain58. The examiner should be concerned about neurologic competence if a social smile cannot be elicited by the time a child is ________old. – 3 months59. Normal changes of the aging brain include: -60. When interviewing a 70 year old female clinic patient, she tells you that she takes ginkgo biloba and St. John’s Wort. You make a short note to check for results of the: -Mini-mental state examination61. The area of body surface innervated by a particular spinal nerve is called a: - Dermatome 62. If a patient cannot shrug the shoulders against resistance, which cranial nerve (CN) requiresfurther evaluation? – CN XI, spinal accessory63. The finger-to-nose test allows assessment of: - Coordination and fine motor function64. You ask the patient to follow a series of short commands to assess: - Attention span65. As Mr. B. enters the room, you observe that his gait is wide based and he staggers from side to side while swaying his trunk. You would document Mr. B.’s pattern as: - Cerebellar ataxia66. When is the mental status portion of the neurologic system examination performed? –Constantly throughout the entire interaction with a client67. An aversion to touch or being held, along with delayed or absent language development, is a characteristic of: -Autism68. The autonomic nervous system coordinates which of the following? – Internal environment of the body69. The major function of the sympathetic nervous system is to: - Orchestrate the stress response70. The parasympathetic nervous system maintains the day-to-day function of: - Digestion 71. Cerebrospinal fluid serves as a: - Shock absorber72. You are performing a two-point discrimination test as part of a well physical examination. The area with the ability to discern two points in the shortest distance is the: -Finger tips73. Which type of hallucination is most commonly associated with alcohol withdrawal? – Visual- bugs, pink elephantsDiminished perception of touch. -- this is byprocess of elimination/educated guess. I could not find direct information addressing this inSeidel74. On a scale of 0 to 4 , which deep tendon reflex score is appropriate for a finding of clonus in a patient? –3 75. Which statement is true regarding mental status changes in older adults? – There is an increased risk of delirium with acute illness or metabolic derangement.76. A characteristic related to syphilis or diabetic neuropathy is testicular: -Insensitivity to painful stimulation77. When collecting personal and social history data from a woman complaining of breast discomfort, you should question her regarding: - Alcohol, tobacco, and caffeine use78. What risk factor is associated with cervical cancer? – HPV79. A 23 year old female presents with severe right lower quadrant tenderness. All of thefollowing should be considered in the differential except: - Classis diverticulitis80. What is the initial diagnostic radiology test that should be ordered if you suspect a rupturedovarian cyst? – Abdominal and transvaginal ultrasound81. A 17 year old male was brought into the emergency room with testicular/scrotal pain. Thedifferential diagnosis should include all except: - Inguinal herniation82. The nursing mother complains that her breasts are tender. You assess hard, shiny, and erythremic breasts bilaterally. You should advise the patient to: - Massage gently and continue nursing83. A normal vas deferens should feel: - Smooth84. In a woman complaining of a breast lump, it is most important to ask about: - Itsrelationship to menses85. The finding of a painless indurated lesion on the glans penis is most consistent with: -Chancre86. Thrombosed hemorrhoids are: - Blue, shiny, painful masses87. Pregnancy-related cervical changes include: - Softening and bluish coloring88. You are inspecting the genitalia of an uncircumcised adult male. The foreskin is tight and cannot be easily retracted. You should: - Inquire about previous penile infections89. An adolescent male is being seen for acute onset of left testicular pain. The pain started 3 hours ago. He complains of nausea and denies dysuria or fever. Your prioritized assessment should be to: - Establish absent cremasteric reflex90. A 23 year old white woman has come to the clinic because she has missed two menstrual periods. She states that her breasts have enlarged and that her nipples have turned a darker color. Your further response to this finding is: - Suggest pregnancy testing91. What accommodations should be used in the position of a hearing-impaired woman for a pelvic examination? – The head of the table should be elevated92. Sexual differentiation in the fetus has occurred by _______weeks gestation. - 1293. You are performing a clinical breast examination for a 55 year old woman. While palpating the supraclavicular area, you suspect that you felt a node. In order to improve your hooked technique, you should: -Ask the patient to turn her head toward that side94. If a firm, transverse ridge of compressed tissue is felt bilaterally along the lower edge of a 40 year old patient’s breast, you should: -Record the finding in the patient’s record95. A therapeutic technique for dealing with grieving individuals is to: - Tell them that is good to cry and to share feelings96. The examination of the newborn should begin with: - Inspection noting skin color, flaccidity, tension, gross deformities, or distortions of facies97. Which one of the following patient characteristics is most likely to limit patient reliability during history taking? – Patient is sleep and sensory deprived98. In crying infants, it is often difficult to: - Auscultate heart sounds99. Which of the following statements accurately reflects the sensitivity and specificity oflaboratory tests? – No test has 100% sensitivity and specificity100. Which medical condition would exclude one from sports participation? – Fever101. Your 15 year old patient is athletic and thin. Radiography of an ankle injury reveals a stress fracture. You question this patient about her: - Menstrual cycles102. Which of the following are examined with the patient in a reclining 45 degree position? –Jugular venous pulsation and pressure103. Functional assessment is most important during the examination of a(n): -Older adult104. The best way to ease the apprehension of a 3 year old child before a physical examination is to: - Encourage child’s participation105. An ophthalmoscopic eye examination involves: - Lens inspection106. When conducting a geriatric assessment, basic activities of daily living (ADLs) include: -Bathing107. The checkout station for preparticipation physical evaluation (PPE) is critical because at this point: - The coordination of follow-ups is reviewed108. Which of the following is true regarding the relationship between the examiner and the patient? – The patient is a full partner with the examiner109. Which of the following factors is not known to affect patient compliance with his or her treatment regimen? – The patient’s age and social status110. One of the most important aspects to consider in the orthopedic screening examination is:- To look for symmetry of muscle, stature, and joint movement111. As you greet the patient, which examination technique is first implemented? – Inspection 112. Which portion of the physical examination is best done with the patient standing? –Spinal 113. Which patient position facilitates inspection of the chest and shoulders? – Sitting114. The least reliable indicator of newborn distress is: - Color115. Proprioception should be assessed while the patient is: - Standing116. Part of the screening orthopedic component of the examination includes evaluating the person while: - Duck walkingHealth Assessment Final Review ExamMust have 78% to pass between both exams Always go with the text bookMENTAL ASSESSMENT (Ch 5 pgs 64-78)1. What does orientation to person, place, and time assess? When you perform assessment, what exactly are you looking for? Pg. 67Person, place and time assess state of consciousness. When performing this assessment you are looking for cognitive function. Person disorientation is a result of cerebral trauma, seizures, or amnesia; Place disorientation occurs with psychiatric disorders, delirium, and cognitive impairment; Time disorientation is associated with anxiety, delirium, depression, and cognitive impairment.8. Assessing orientation to person, place, and time helps determineANS: DOrientation to person, place, and time are measures of states of consciousness and awareness, not degrees of attention span. Analogies and abstract reasoning are higher functions than orientation. Emotional status can be better evaluated by observing behaviors.2. How many serial numbers should most people be able to repeat? For example: counting backwards. How many should the average person be able to repeat? Pg. 70Five to eight numbers forward or four to six backward can usually be repeated.10.Under most conditions, adult patients should be able to repeat a series of _____ numbers.ANS: BMost adults should be able to recall immediately a series of five to eight numbers forward and four to six numbers backward.3. How do you assess recent memory if you’ve had a patient your worried about memory? What technique and how would you assess recent memory? Pg. 70Give the patient a short time to view four or five test objects, telling them you will ask them about them in a few minutes. Ten minutes later, ask the patient to list the objects.14.Recent memory may be tested ability to understand act tion of onal to to eightc.10 to 15d.15 to than g the patient to do simple g the patient to listen to and repeat a series of ng the patient four items and asking him or her to list the items about 10 minutes g the patient about verifiable past events, such as his or her mother’s maiden g the patient to name the past four presidents.ANS: CShowing the patient four or five objects, saying you will ask about them in a few minutes, and then 10 minutes later asking the patient to list the objects is a technique to measure recent memory. The other choices are not tests of recent memory. Asking the patient to listen and then repeat tests immediate recall.4. What pysch or mental condition is considered progressive and not reversible? Pg. 76, 78 Dementia (see differential diagnosis).27. Which condition is considered progressive rather than reversible?ANS: BDementia is considered progressive and irreversible, delirium and coma have the potential for reversal, and depression and anxiety are reversible.26. An older adult is administered the Set Test and scores a 14. The nurse interprets this score as indicative ofANS: EScores of less than 15 on this mental function test indicate dementia.28.Which of the following is usually related to structural diseases of the brain?ANS: BOne of the distinguishing characteristics that distinguishes dementia from the others is that it is usually related to structural diseases of the brain such as abnormal deposits, or recurrent strokes.5. If patient is delirious do they maintain orientation and attention span? Look up delirium and see what you expect patient to maintain. Pg. 75,76a.Deliriumb.Dementiac.Depressiond.Anxietye.Ctive tia.a.Deliriumb.Dementiac.Depressiond.Anxietye.Psychosis2Patient suffering from delirium is usually disoriented (usually oriented to person only) and have an impaired attentiveness. (pg 461 in Adv. Assessment) In spite of the confusion, the patient’s sensorium (consciousness) is usually intact although some condition (intoxication and severe metabolic derangements) result in altered level of consciousness.9.A state of impaired cognition, consciousness, mood and behavioral dysfunction of acute onset refers toANS: BDelirium is a state of impaired cognition, consciousness, mood and behavioral dysfunction of acute onset. Stupor describes arousals for short periods of time after a stimulus for arousal (e.g., visual, verbal, or painful). Lethargy relates to sleepiness with ease of arousal; coma is nonarousal and nonawareness. Confusion relates to inappropriate responses to questions with decreased attention span and memory.6. Who should you give a mini mental exam to? Everyone or certain patients? Pg. 67,68The mini mental exam should be given to elderly patients when there is a concern about their cognitive function. This testdetects probable dementia.34.The Mini-Mental State Examination should be administered for a patient whoANS: AThe MMSE is a tool used to estimate cognitive function quantitatively or document cognitive changes serially. Getting lost in a familiar territory is a sign of possible cognitive impairment.6. The Mini-Mental State Examination (MMSE)ANS: AThe MMSE is a standard tool that functions to estimate cognitive function quantitatively7.While interviewing a 70-year-old female clinic patient, she tells you that she takes ginkgo biloba and St. John’s wort. You make a short note to check for results of lost in her or his s an excessive amount of repetitive ritualistic illegal hallucinogenic a fear of leaving the be used to estimate cognitive changes be used to estimate personality disorders s do not vary with regard to age or determine the cause of memory a good tool to diagnose neurologic disorders.a.Denver II.b.Mini-Mental State Examination.3c.Glasgow Coma Scale.d.Goodenough-Harris Drawing Test.e.CAGE Questionnaire.ANS: BGinkgo biloba and St. John’s wort are herbal remedies used to improve mental alertness and elevate mood. As side effects, they can also result in disorientation and confusion that can be monitored with the Mini-Mental State Examination. The Denver and Goodenough- Harris tests are used for childhood development, and the Glasgow Coma Scale is used to rate coma depth. The CAGE Questionnaire is a useful tool for approaching a discussion of the use of alcohol.BREAST EXAM1. With documenting breast exams, how do you divide the breasts? If you want a radiologist to concentrate on one particular area of the breast, how do you divide to communicate findings? Pg. 351The breast is divided into five segments, four quadrants and a tail (upper inner, upper outer, lower inner, and lower outer).Either the right or left breast should be communicated. The terms: upper inner, upper outer, lower inner, lower outer, and tail of Spence should be communicated to the radiologist in terms of how to communicate findings.3.For purposes of examination and communication of physical findings, the breast is divided intoANS: CThe breast is referenced according to five segments: four quadrants and a tail.11. When conducting a clinical breast examination, the examiner shouldANS: DInspection with simultaneous observation of both breasts is essential in order to detect differences between the breast size, symmetry, contour, and skin color.2. If you have a pt c/o breast lump, what questions do you ask? For example you have a 50 year-old with breast lump, how do you begin exam compared to a 30 year-old pt?(just arbitrary ages) What assessment do you do and what questions would you ask based on age? Pg.9. Which breast change is typical after menopause?s (upper and lower).s (left, middle, and right). quadrants plus a es (six consecutive rings, each 1 inch farther away from nipple).l portions 1 through the examination if the patient has had a recent the patient covered to respect the lights to minimize ct both breasts with palpation of the breasts.a.Thickening of the inframammary ridgeb.Hypertrophy of glandular tissuec.Increase in number of lactiferous ductsd.Reduction of fat deposits4e.Shortening of Cooper’s ligamentsANS: A. After menopause, the breast tissue atrophies and is replaced by fat deposit, the inframammary ridge at the lower edge of the breast thickens, and the breast hangs more loosely as Cooper’s ligaments relax.10. In a woman complaining of a breast lump, it is most important to ask aboutANS: AHormonal changes of menstruation can result in breast tenderness, swelling, and enlarged nodes that can be felt on palpation.12. A 50-year-old woman presents as a new patient. Which finding in her personal and social history would increase her risk profile for developing breast cancer?ANS: CNulliparity or late age at birth of first child (after 30 years old) is a risk factor for breast cancer. Other risk factors include late menopause, early menarche, and drinking more than one alcoholic drink daily.1. What position do you put a patient in for a breast exam? What position is the examiner standing in? Axillary nodes what position does the patient need to be in? Pg. 355-3622. 14. To begin the clinical breast examination (CBE) for a man, ask him toANS: B Inspection begins the CBE. Ask the patient to sit with his arms hanging loosely at his sides. The technique is the same for both men and women.15.Inspection of the breasts usually begins with the patient in which position?ANS: BInspection begins with the patient in a sitting position with arms hanging loosely at the sides. Inspection (pg. 355): As the patient sits with arms hanging loosely at the sides, inspect each breast and compare it with the other for size, symmetry, contour, skin color, and texture, venous pattern, and lesions. Re-inspect the woman’s breasts with the patient in the following positions (pg. 357-358): relationship to t ization ol consumption.a.Drinking three glasses of wine per weekb.Early menopausec.Nulliparityd.Late menarchee.Young age at birth of first ne on the table with his arms with his arms hanging at his with his hands on his with his arms clasped behind his leaning forward.a.Lateralb.Sittingc.Standingd.Supinee.Proneo Seated with arms over the head or flexed behind the neck. This adds tension to the suspensory ligaments, accentuates dimpling, and may reveal variations in contour and symmetryo Steadied with hands pressed against hip with shoulders rolled forward (or alternatively have the patient push her palms together): This contracts the pectoral muscles, which can reveal deviations in contour and symmetryo Seated and leaning forward from the waist: This also causes tension in the suspensory ligaments. The breasts should hang equally. This maneuver can be particularly helpful in assessing the contour and symmetry of large breasts because the breasts fall away from the chest wall and hang freely. As the patient leans forward, support her by the hands. Patient in Seated Position (pg. 360)o Chest Wall Sweep: Have the patient sit with arms handing freely at the sideso Bimanual Digital Palpation: Place on hand, palmar surface facing up, under the patient’s right breasto Lymph Node Palpation: To palpation the axillae, have the patient seated with arm flexed at the elbow. Support the patient’s left lower arm with your left hand while examining the left axilla with your right hand. Patient in Supine Position (pg. 360): Have the patient raise one arm behind her head; then place a small pillow or folded towel under that shoulder to spread the breast tissue more evenly over the chest wall. The ideal position for examination is to have the nipple pointing toward the ceiling.b.) Axillary nodes what position does the patient need to be in? (pg. 360)Lymph Node Palpation: To palpation the axillae, have the patient seated with arm flexed at the elbow. Support the patient’s left lower arm with your left hand while examining the left axilla with your right hand.3. What’s the difference between fibrotic breast tissue and breast cancer? How do you expect each to feel? What are the characteristics of the two?17.Which finding, found on inspection, is related to fibrotic tissue changes that occur with breast carcinoma?ANS: BSkin dimpling or retraction signifies the contraction of fibrotic tissue that occurs with carcinoma. The other choices are normal variations without significance to cancer development.18. Venous patterns on breasts are suggestive of pathology when they areANS: CMalignant tumors require more blood flow. Superficial veins dilate to provide more flow and can be assessed as unilateral venous patterns. Bilateral findings are of no concern and are more commonly seen in pregnant or obese women. Nevi that are long-standing, unchanging, or nontender are of little concern.21.In patients with breast cancer, peau d’orange skin is often first evidenta.Convex or conical shapeb.Skin dimpling or retractionc.Pendulous and loose breastsd.Unequal shape or contoure.Lifelong inverted erally in obese ved during iated with a long-standing unchanging the the upper inner or around the the inframammary the tail of Spence.ANS: CThe areola is the most common initial site to visualize peau d’orange skin.24.Recent unilateral inversion of a previously everted nipple suggestsANS: BRecent unilateral inversion or retraction of a previously everted nipple suggests malignancy rather than a benign condition.41.You are conducting a clinical breast examination for a 30-year-old patient. Her breasts are symmetrical with bilateral, multiple tender masses that are freely moveable with well-defined borders. You recognize that these symptoms and assessment findings are consistent withANS: EFibrocystic changes are tender masses, usually bilateral, with multiple round, mobile, well-delineated borders. Fibroadenoma and cancer are usually nontender; Paget disease is an eczema-like condition of the nipple that signals an underlying cancer. Mammary duct ectasia most commonly occurs in menopausal women. Fibrocystic Changes (pg. 366):o Benign fluid-filled cyst formation caused by duct enlargement o Pathophysiology Usually bilateral and multiple Most common in women 30 to 55 years of age Associated with long follicular or luteal phase of the menstrual cycleo SubjectiveData Tender and painful breasts and/or palpable lumps that fluctuate with menses  Usually worse premenstruallyo ObjectiveData Round, soft to firm, tense, mobile masses with well-delineated borders  Usually tender Usually bilateral Multiple or single Fibroadenoma (pg. 366): n breast adenoma.b.Paget ry duct cystic changes.o Pathophysiology May occur in girls and women of any age during their reproductive years  After menopause, the tumors may regresso SubjectiveData Painless lumps that do not fluctuate with the menstrual cycle May be symptomatic with discovery on clinical breast examination or breast imagingo ObjectiveData Round or discoid, firm, rubbery, mobile masses with well-delineated borders  Usually non-tender Usually bilateral Single; may be multiple Biopsy often performed to rule out carcinoma Malignant Breast Tumors (pg. 366): Ductal carcinoma arises from the epithelial lining of ducts; lobular carcinoma originates in the glandular tissue of the lobuleso Pathophysiology Mutations to normal cells results in uncontrolled cell division and tumor formation; as the tumor grows andinvades surrounding tissue, metastases occurs through the lymph and vascular systems Peak incidence between the ages of 40 and 75 years, with the majority of malignant breast tumors occurring in women older than 50o SubjectiveData Painless lump; change in size, shape, or contour of breast Axilla may be tender if lymph nodes involved May be asymptomatic with discovery on clinical breast examination or breast imagineo ObjectiveData May be palpable mass that is usually single, unilateral, irregular, or stellate in shape; poorly delineatedborders; fixed; hard or stone-like; and non-tender Breast may have dimpling, retraction, prominent vasculature Skin may have peau d’orange or thickened appearance Nipple may be inverted or deviated in position(Differential diagnosis pg. 365)Fibrotic: usually bilateral, multiple or single, round, soft to firm; tense, mobile, absent retraction signs, usually tender, bordersare well delineated, and they vary with menses.Cancer: Usually unilateral, single, irregular or stellate, hard/stonelike, fixed, retraction signs are often present, usually nontender, the borders are poorly delineated; irregular, and they do not vary with menses.4. Breast Exam- What part of the hand do you use? Fingertips, pads, palms, entire hands? Pg. 361Palpate using your finger pads as they are more sensitive than your fingertips. Palpate systematically, pushing gently but firmly toward the chest wall, as you rotate your fingers in a clockwise or counterclockwise pattern. At each point, as you rotate your fingers press inward, using three depths of palpation: light then medium and finally deep. The exact sequence you select for palpation is not critical, but a systematic approach will help ensure that all portions of the breast are examined.26.When palpating breast tissue, the examiner should use the _____ at each r of the surface of the sANS: BThe finger pads are used for breast palpation because they are more sensitive than the fingertips.5. What is Peau d\'orange skin? Look, feel, mean? Pg. 356The skin has an orange peel appearance. This indicates edema of the breast caused by blocked lymph drainage in advanced orinflammatory breast cancer. The skin appears thickened with enlarged pores and accentuated skin markings.6. What is the tail of Spence? Where is it anatomically? Pg. 351The tail of Spence is (extends from) the greatest amount of glandular tissue that lies in the upper outer quadrant and extendsinto the axilla. ??????2.The largest amount of glandular breast tissue lies in theANS: DThe greatest amount of glandular tissue in the breast lies in the upper outer quadrant.31.The tail of Spence extendsANS: DThe tail of Spence extends from the upper outer breast quadrant into the axillae.7. Breast Exam: Certain groups of lymph nodes are enlarge, where would they be for examiner to expect Breast Cancer? Pg. 360The axilla, supraclavicular and infraclavicular areas. Nodes that are detected should be described according to location, size, shape, consistency, tenderness, fixation, and delineation of borders.34.When examining axillary lymph nodes, the patient’s arm inner of S outer the midclavicular d the supraclavicular into the inframammary the the sternal d full above the ded at the ed against the ed over the d at the elbow.ANS: ETo examine the axilla, support the patient’s lower arm with the elbow flexed with one of your hands and use your other hand to palpate the axilla.35.Lymphatic flow of the breast primarily drainsANS: CEach breast contains a lymphatic network that drains the breast radially and deeply to underlying lymphatics.36. The greatest concern for breast cancer is when you palpate _____ nodes.ANS: DThe supraclavicular and infraclavicular nodal areas are sentinel nodes; any enlargement in these areas is especially significant.37.You are performing a clinical breast examination for a 55-year-old woman. While palpating the supraclavicular area, you suspect that you felt a node. To improve your hooked technique, you shouldANS: EHaving the patient turn her head toward the examination side, as well as raising the shoulder on that same side, gives your fingers more room to palpate deeper into the fossa.8. What if you have a 20-30 year-old with freely moveable, well-defined lump, tender with cycle, cancer or more likely fibrotic? Fibrotic (see page 365)iorly toward the ally toward the corresponding lly toward the omedially toward the ior nal lotion to your both hands the patient to press both palms the patient to lower her shoulder on that the patient to turn her head toward that side.1041.You are conducting a clinical breast examination for a 30-year-old patient. Her breasts are symmetrical with bilateral, multiple tender masses that are freely moveable with well-defined borders. You recognize that these symptoms and assessment findings are consistent withANS: EFibrocystic changes are tender masses, usually bilateral, with multiple round, mobile, well-delineated borders. Fibroadenoma and cancer are usually nontender; Paget disease is an eczema-like condition of the nipple that signals an underlying cancer. Mammary duct ectasia most commonly occurs in menopausal women.9. Then you have a 50 year-old-lump firm, fixed, doey-like, cancer or fibrotic? Cancer FEMALE GENITALIA1. Pelvic Exam-anatomy of vagina and location of glands-5 O’clock, 7 O’clock for example, just know the anatomy of the male and female genitals.2. What structures are located at the 5 o’clock and the 7 o’clock positions of the vaginal orifice and open onto the sides of the vestibule in the groove between the labia minora and the hymen?ANS: DBartholin glands are found posteriorly on each side of the vaginal orifice and open onto the sides of the vestibule.2. Cervical Cancer- know patient’s history and what questions to ask patients that put them at high risk for cervical cancer.12. Which factor is associated with an increased risk of cervical cancer?ANS: EWomen who were younger than 17 years when they had their first full-term pregnancy are almost 2 times more likely to get cervical cancer later in life than women who were not pregnant until they were 25 years or adenoma.b.Paget ry duct cystic changes.a.Skene glandsb.Perineal bodiesc.Labia majorad.Bartholin glandse.Labia minoraa.Endometriosisb.Low parityc.HPV vaccinationd.High socioeconomic statuse.Early parity113. What history increases your risk for ovarian cancer? (pg. 425)Risk factors for ovarian cancer (box on p. 425 below cervical risk factors): Age (increases with age), inherited genetic mutation (BRCA1 or BRCA2 gene), family history, obesity, reproductive history (nulliparity increases risk), and the use of fertility drugs, personal history, hormone replacement therapy, and high-fat diet.13.The risk of ovarian cancer is increased by a history ofANS: EThere is a relationship between nulliparity and an increased risk of ovarian cancer. Although the risk increases with age, most ovarian cancers develop after menopause; half are found in women older than 63 years. The other choices have no relationship with ovarian cancer.4. What is a normal cervix and an abnormal cervix? What does an abnormal one look like (not cancerous) what tests might you and what might indicate? Disorder?22. During digital examination of the vagina, the cervix is noted to be positioned posteriorly. Upon bimanual examination of this woman, you would expect to palpate a(n) _____ uterus.ANS: BThe position of the cervix correlates with the position of the uterus. A cervix that is pointing posteriorly indicates an anteverted uterus.23. The presence of cervical motion tenderness may indicateANS: CPainful cervical motion tenderness suggests a pelvic inflammatory disease or a ruptured tubal pregnancy. The cervix is expected to move 1 to 2 cm without discomfort under normal conditions.25.During a routine vaginal examination, you insert the speculum and visualize the cervix. The cervix projection into the vaginal vault -fat ette between 35 and 50 body ally c inflammatory nancy.12approximately 5 cm. Upon bimanual examination, you would expect to find the the midline the retroverted the anteverted ted to the left or the retroflexed position.ANS: DNormally, the cervix protrudes into the vagina 1 to 3 cm. Longer projections suggest a pelvic or uterine mass. A pelvic mass would cause the uterus to be deviated to the right or left, but an anteverted, retroverted, or retroflexed uterus would still be in the midline regardless of its position.26.Small, pale yellow, raised, and rounded areas are visualized on the surface of the cervix. You shouldANS: AThis describes nabothian cysts, which are retention cysts of the endocervical glands and are considered a normal variant. No further testing is this as nabothian this as a friable n a viral the pH of the cervical this as an eroded cervix.a.b.c.Normal cervix: covered with pink squamous epithelium that is uniform in consistency. It should be in an anterior- posterior position that correlates with the position of the uterus. The os is small and round. A small area of ectropion is visible inferior to the os. Cervix should feel firm (during pregnancy will be softer) and be smooth.Abnormal cervix: Bluish color indicates increased, which may indicate pregnancy. A pale cervix is associated with anemia. If the cervix is pointed anteriorly it indicates a retroverted uterus; pointing posteriorly indicated an anteverted uterus. Horizontal indicated a uterus in midposition; deviation indicated a pelvic mass, uterine adhesions, or pregnanacy. Projection greater than 3 cm may indicate a pelvic or uterine mass. Small, white or yellow raised, round areas may indicate nabothian cysts. Friable tissue, red patchy areas, granular areas, and white patches could indicate cervicitis, infection, or carcinoma.Feel for nodules, harness, and roughness. Note the position of the cervix, it should be in the midline and may point anteriorly or posteriorly. Grasp the cervix between your fingers and move it gently from side to side (should move 1-2 cm). There should be no pain or discomfort. Painful cervical movement suggests a pelvic inflammatory disease or a ruptured tubal pregnancy which would require immediate surgery.5. What structure or organs are examined during a Bimanual exam? (pg 436-437). Cervix, Uterus, Adnexa, and Ovaries33.The assessment of which structure is not part of the bimanual examination?a.Cervixb.Bladderc.Uterusd.Ovariese.Adnexa13ANS: BThe bimanual examination consists of assessing the cervix, uterus, adnexa, and ovaries.6. When do PAP smears begin? Age of non-sexually active versus sexually active women? (pg. 437) 21 for non-sexually and sexually active women because cervical cancer is rare for women under age 21.40.When a woman is not sexually active, cervical cancer screening should beginANS: DWomen who are not sexually active should have their first examination by the age of 21 years. Women under age 21 should not be tested.7. Menopausal women- what does the vagina and mucosa of the walls feel like? (pg. 447)The vagina is narrower and shorter. You will see and feel the absence of rugae. The cervix is smaller and paler but the osshould still be palpable and the cervix may be less mobile.43.During a pelvic examination for a postmenopausal woman, you would expect to assessANS: BExpected findings in the pelvic examination for an older woman include a narrower and shorter vagina, absence of rugation, a less mobile cervix, and a palpable cervical os. The ovaries are rarely palpable because of atrophy.MALE GU1. Males-history or what alerts the examiner of the possibility of testicular cancer? (pg. 470).Undescended testicle, personal hx of testicular CA, family hx of testicular CA, abnormal testicle development (klinefelter syn), 20-54 yr male, the most prominent in white race ( 5 times that of black; more than 3 times that of Asian American and Native American men).13.Which of the following is a risk factor for testicular cancer? age 15 age 18 age 21 age 30 years.a.a wider and longer vaginal ce of vaginal wall rugation.c.a nonpalpable cervical os.d.a more mobile ble ovaries.a.Circumcisionb.Condyloma acuminatumc.Cryptorchidism14d.Poor hygienee.Multiple sexual partnersANS: CCryptorchidism (testes that fail to descend by 12 months of age) is a risk factor for testicular cancer.27.The most common cancer in young men age 15 to 30 years isANS: ABecause testicular tumors are the most common cancer occurring in young adults, self-examination is encouraged.37.Self-examination of the male genitaliaANS: BMonthly self-examination is recommended as a screening test for testicular cancer as well as sexually transmitted infections for all young men starting at 15 years of age. It is encouraged during bathing because the scrotal skin is less thick at this time and because the scrotum hangs looser because of the warmth. Inspection is done first followed by palpation.2. What alerts us to do further testing and the need to further and fully assess for testicular cancer? How do we do this?o Irregular, contender mass fixed to the testiso Does not transilluminateo May also have hydrocele(that doesn\'t transilluminate) o InguinalLymphadenopathyo Painless mass in testicleo Scrotalenlargementorswellingo Heavy feel in in scrotumo Dull ache in lower abdomen, back or groino fluid in scrotumThis can be done by performing a Testicular exam ( inspect and palpate), Scrotal US, Lab work including: Chemistry, WBC count, biochemical markers AFP and B-hCg.21.Mr. L. has an unusually thick scrotum with edema and pitting. He has a history of cardiac problems. The appearance of his scrotum is more likely a(n)ANS: BGeneral fluid retention can cause scrotal thickening and pitting edema and is more often seen as a result of cardiac, renal, or hepatic disease. This swelling does not imply a condition of the genitalia but rather a condition of these related d be restricted to adults with prior d be performed while s with palpation and then d be performed t be adequately performed due to poor visualization of the nital defect that has ation of general fluid l consequence of ication to the development of quence of prior STDs.1525.An enlarged, painless testicle in an adolescent or adult may cular torsion.c.a undescended padias.ANS: CA hard, enlarged, painless testicle can indicate a tumor in an adolescent or adult male. Epididymitis and torsion are painful; an undescended testicle is common in infants and is usually resolved by 12 months. Hypospadias is a congenital defect of the urethral opening causing the meatus to be located ventral to its normal position.26.You palpate a soft, slightly tender mass in the right scrotum of a man. You attempt to reduce the size of the mass, and there is no change in the mass size. Your next assessment maneuver is toANS: DA soft mass is either a hernia or hydrocele. If the mass can be reduced, it is probably a hernia; a nonreducible mass should be transilluminated to determine whether it contains fluid and is possibly caused by a hydrocele. Lifting the scrotum should be done when epididymitis is suspected. Urethral cultures are not indicated at this point.29.An adolescent male is being seen for acute onset of left testicular pain. The pain started 3 hours ago. He complains of nausea and denies dysuria and fever. Your prioritized assessment should be toANS: CThe patient is displaying symptoms of testicular torsion. An absent cremasteric reflex is a supporting finding to differentiate torsion from epididymitis.38. A 12-year-old boy says that his left scrotum has a soft swollen mass. The scrotum is not painful upon palpation. The left inguinal canal is without masses. The mass does transilluminate with a penlight. This collection of symptoms is consistent withANS: BA hydrocele is a soft scrotal mass that occurs from fluid accumulation and therefore does transilluminate. Orchitis results in a swollen, tender testis. A rectocele does not result in scrotal swelling. A scrotal hernia would also be palpable along the inguinal canal. Epididymitis is an extremely painful condition.41.A cremasteric reflex should result two fingers to attempt to reduce the te the left scrotum the right testicle, then compare pain illuminate the re the meatus for gonococcal n urine and DNA probe urethral the left scrotum to confirm lish absent cremasteric illuminate the left and right the patient stand and observe the scrotum for a “bag of worms.”al scrotum appear to contain a “bag of worms.”e deviation to the left um to elevate iate erection of the cle and scrotal rise on the stroked side.ANS: EUpon stroking the inner thigh with a blunt instrument or finger, the testicle and scrotum should rise on the stroked side.3. How do you assess for an inguinal hernia? Pg. 472-473Have the pt. stand and bear down. While he is straining inspect the area of the inguinal canal and the region of the fossa ovalis. After the pt. relaxes, insert your examining finger into the lower part of the scrotum and carry it upward along the vas deferens into the inguinal canal. You can also auscultate for bowel sounds, which will be present in uncomplicated reducible hernias.18.Which technique is appropriate to detect an inguinal hernia?ANS: EExamination for inguinal hernias is performed with the patient standing. Inspect the groin while the patient performs a Valsalva maneuver. Insert your examination finger into the lower part of the scrotum and follow upward along the vas deferens to screen for a hernia.19. Which type of hernia lies within the inguinal canal?ANS: CHernias found within the inguinal canal are called indirect hernias.4. What does Vas deferens feel like? Normal? Abnormal? Pg. 473The Vas deferens feels smooth and discrete; abnormal findings are beaded or lumpy feeling. This may indicate diabetes or oldinflammatory changes, especially tuberculosis.2.What structure of the male genitalia travels through the inguinal canal and unites with the seminal vesicle to form the ejaculatory duct?ANS: Da.Conduct percussion while the patient coughs.b.Have the patient strain as you pinch the testes.c.Inspect rectal areas as the patient bears down.d.Conduct the examination only in the supine position.e.Move your finger upward along the vas deferens.a.Umbilicalb.Directc.Indirectd.Femorale.Incisionala.Epididymisb.Corpus cavernosumc.Urethrad.Vas deferense.Ureter17The vas deferens begins at the end of the epididymis, travels the spermatic cord, goes through the inguinal canal, and then unites with the seminal vesicle to form the ejaculatory duct.23.A normal vas deferens should feelANS: BThe vas deferens should normally feel smooth, discrete, and nontender.5. Young man- what is an emergent cause of testicular pain? Pg. 482 Testicular Torsion is twisting of the spermatic cord and is a surgical emergency.29.An adolescent male is being seen for acute onset of left testicular pain. The pain started 3 hours ago. He complains of nausea and denies dysuria and fever. Your prioritized assessment should be toANS: CThe patient is displaying symptoms of testicular torsion. An absent cremasteric reflex is a supporting finding to differentiate torsion from epididymitis.28.The most emergent cause of testicular pain in a young male isANS: ETesticular torsion is a surgical emergency. If surgery is performed within 12 hours after the onset of symptoms, the testis can be saved in about 90% of cases. Delayed treatment results in a much lower salvage rate.6. Understand hernias, where located and how to assess each kind. Pg. 476, 477(see differential diagnosis).Hernia is protrusion of a peritoneal-lined sac through some defect in the abdominal wall. There are indirect, direct and femoral.7. What is the most common type of hernia? Pg. 477 Indirect Inguinal hernias are the most common type.31.The most common type of hernia occurring in young males n urine and DNA probe urethral the left scrotum to confirm lish absent cremasteric illuminate the left and right the patient stand and observe the scrotum for a “bag of worms.”cular cerated ect al.ANS: CThe most common type of hernia in children and young males is an indirect inguinal hernia.MUSCULOSKELETAL1. What is the difference between osteoarthritis versus rheumatoid arthritis?During an assessment what do you expect to see in a patient with osteoarthritis vs. RA? Findings in joints? Describe. OA (pg411)-A progressive disorder associated with age and wear and tear. There is loss of cartilage and progressive erosion of bone. Affects mostly larger bones like hips and knees, but frequently involves small joints of hands, especially distal and proximal interphalangeal joints. Asymmetrical distribution. Pain and stiffness improves with activity, and worsens with rest. Xrays show changes. Sed rate(-), Rheumatoid factor (-) RA (pg410)-If 3 or more metacarpophalangeal joints are swollen is RA. It’s a progressive, inflammatory, and erosive condition that usually affects multiple joints. It’s an autoimmune condition. Affects joints symmetrically. Affects small joints of hands and feet. Joints are tender, swollen with effusion, warm, inflamed. Nodules and deformities are noted. RA associated with: subluxation of metacarpophalgeal joins, hyperextension of joints, but also with changes in eye (scleritis, episcleritis, interstitial lung disease and pericardial disease.1. When does a musculoskeletal exam begin? (text tells you) pg405-The musculoskeletal examination is primarily limited to inspection and palpation. The focused musculoskeletal examination begins withinspection.2. How do you assess the strength of the trapezius muscle? (pg518)The strength of trapezius and sternocleoidomastoid muscle is tested by evaluating the cervical spine and asking patients to do certainmovement. Bend the head forward, chin to chest, and expect flexion of 45 degrees. Bend head to each side, ear to each shoulder and expect lateral bending of 40 degrees. Bend head backward, chin toward ceiling, and expect extension of 45 degrees.3. Patient with scoliosis, bend at waist, what is expected finding? Describe what it looks like (Pg541)When looking form the rear, the spine looks more like an “S” or a “C” than a straight line. There is no known cause. Associated with leg length discrepancy. There’s lateral curvature of spine as patient flexes forward to touch the toes. In severe deformities, patient has uneven shoulder and hip levels, and may have crease on one side of waist.194. Carpal Tunnel-What expect to feel like, how do you assess for? During assessment, particular nerve is tested, what is it? What sensation will the patient have?(pg430,524) The carpal tunnel is a space located on the anterior aspect of the wrist between the carpal bones and a ligamentous band through which the median nerve and several tendons transverse. With overuse and repetitive movements there’s a hypertrophy of tissues, causing a lot of space and impingement on the median nerve. Nighttime pain-early sign. Swelling at wrist related to inactivity of flexion at night, pain can radiate up the forearm to shoulder with numbness and tingling along the median nerve, and paresthesia involves anterior aspects of wrist, medial palm and first three digits of affected nerve. Relief is found by shaking affected hand in downward fashion. To assess, first ask patient to mark specific site using the Katz hand diagram.o Thumb abduction test isolates strength of abductor pollicis brevis muscle, innervated only by median nerve. Pt will place the hand palm up and raise the thumb perpendicular to it. Apply downward pressure on thumb to test muscle strength. Weakness=Carpal tunnel syndromeo Tinel sign: Strike pt’s wrist with your index or middle finger, where median nerve passes under the flexor retinaculum and volar carpal ligament(fig21.42). Tingling, means ( ) tiner sign and ( ) CPT syndrome.o Phalen test: pt holds both wrist in fully palmar-flexed position with dorsal surfaces pressed together for one min. Numbness and paresthesia in the distribution of median nerve is ( ) CPT syndrome.ABDOMINAL1. When conducting an abdominal exam, what position should the patient be in? Examiner? Techniques with rigid abdomen or anxious pt, what are relaxation techniques? (pg377)Need good light source; full exposure of abdomen; warm hands with short fingernails. Have pt empty bladder. Place pt is supine position with arms at sides. Approach pt from right side. Place small pillow under pt’s head and another under slightly flexed knees. Drape a towel or sheet over the patient’s chest for warmth and privacy. Be slow and gentle, avoid sudden movements.Percussion of the abdomen begins with establishinga. liver dullness.b. spleen dullness.c. gastric bubble tympany.d. overall dullness and tympany in all quadrants.e. bladder fullness.ANS: DPercussion begins with a general establishment over all quadrants for areas of dullness and tympany and then proceeds to specific target organs22. Before performing an abdominal examination, the examiner shoulda. ascertain the patient’s HIV status.b. have the patient empty his or her bladder.c. don double gloves.d. completely disrobe the patient.e. uncover only the painful areas of the abdomen.ANS: BThe patient should empty the bladder to ensure an accurate examination of organs as well as to provide comfort for the patient.2024. When examining a patient with tense abdominal musculature, a helpful technique is to have the patienta. hold his or her breath.b. sit upright.c. flex his or her knees.d. raise his or her head off the pillow.e. fully extend the legs.ANS: CTo help relax the abdominal musculature, it is helpful to place a small pillow under the patient’s head and under slightly flexed knees. The other choices increase muscle flexion.28. After thorough inspection of the abdomen, the next assessment step is toa. percuss.b. palpate nonpainful areas.c. auscultate.d. perform a rectal examination.e. palpate painful areas.ANS: CAssessment of the abdomen begins with inspection followed by auscultation. This break from the usual system examination sequence is because palpation and percussion can alter the frequency as well as the intensity of bowel sounds. Therefore, auscultation is done first.2. How long do you auscultate for BS? (pg380)Bowel sounds range from 5-35/min. If you’re unable to hear BS after 5 min of continues listening, associated with abdominal pain andrigidity then is surgical emergency.To correctly document absent bowel sounds, one must listen continuously fora. 30 seconds.b. 1 minute.c. 3 minutes.d. 5 minutes.e. 10 minutes.ANS: DAbsent bowel sounds are confirmed after listening to each quadrant for 5 minutes.3. What is the technique for percussing the liver border? Where to start, how you move, what are you listening for? (pg381)Begin liver percussion at the right midclavicular line over an area of tympany. Always begin with an area of tympany and proceed to area of dullness for easiness. Percuss upward along the midclavicular line to determine lower border of liver. The area of liver dullness is usually heard at the costal margin or slightly below it. Mark with a pen. A lower liver border that is more than 2-3 cm below costal margin may indicate organ enlargement or downward displacement of diaphragm because of emphysema or other pulmonary disease. Upper border of liver, begin percussion on the right midclavicular line at an area of lung resonance around the third intercostal space. Cont downward until the percussion tone changes to one of dullness; this marks upper border of the liver mark with pen. It’s usually in the fifth intercostal space. Measure the distance between the marks, estimates vertical span of liver, usually 6-12cm. If larger=enlargement, if smaller=atrophy.2137. To assess for liver enlargement in an obese person, you shoulda. use the hook method.b. test for cutaneous hypersensitivity.c. auscultate using the scratch technique.d. attempt palpation during deep exhalation.e. have the patient lean over at the waist.ANS: CIf the abdomen is obese or distended or if the abdominal muscles are tight, you should plan on auscultating the liver using the scratch method to estimate the lower border of the liver. Cutaneous hypersensitivity is a sign of peritonitis and does not contribute to determining liver size.Percussion at the right midclavicular line, below the umbilicus, and continuing upward is the correct technique for locating thea. descending aorta.b. lower liver border.c. medial border of the spleen.d. upper right kidney ridge.e. stomach.ANS: BPercussing along the right midclavicular line upward from the umbilicus determines the lower border of the liver. A liver border more than 2 to 3 cm signifies hepatomegaly.When palpating the abdomen, you should note whether the liver is enlarged in thea. left upper quadrant.b. midepigastric region.c. periumbilical area.d. right upper quadrant.e. right lower quadrant.ANS: DAn examiner can recognize a friction rub in the liver by a sound that isa. clicking, gurgling, and irregular.b. high pitched and associated with respirations.c. loud, prolonged, and gurgling.d. soft, low-pitched, and continuous.e. low pitched, tinkling, and unrelated to respirations.ANS: BAn abdominal friction rub is rare and can be identified when high-pitched sounds are auscultated in association with respirations. The liver is located in the right upper quadrant of the abdomen4. CVA tenderness-what might it be a sign of?Costovertebral angle tenderness should be assessed whenever you suspect the patient may havea. cholecystitis.b. pancreatitis.c. pyelonephritis.d. ulcerative colitis.e. intussusception.22ANS: CPyelonephritis is characterized by flank pain and costovertebral angle tendernessNEURO1. Autonomic Nervous System- what are you assessing? Coordinate?(Pg477)The Nervous system with its central and peripheral divisions maintains and controls all body functions by its voluntary and autonomic responses. The evaluation of motor, sensory, autonomic, cognitive and behavioral elements. The CNS is the main network of coordination and control for the body.(PG446) Coordination tests fluidity of movements. Inability to coordinate movements suggests cerebellar dysfunction. Finger to nose testing-ask pt to touch your index finger with his or her index finger, then touch his/her noserepeatedly. Poor coordination of movement indicates dysmetria. Rapid alternating movements-Ask pt to perform rapid pronation and supination of the hand on his/her thigh or on examination table Heel to shin testing-Ask pt to take the heel of one side and repeatedly move up and down the shin of the opposite leg Romberg- Ask pt to stand with feet together, arms abducted outward with palms up, and eyes closed. PostiveRomberg is observed as a swaying motion, or inability to maintain balance, and indicates cerebellar dysfunction.2. Motor Cortex of Brain- What does it control?3. Know EACH Cranial Nerve (several questions)- how to assess each, what testing for, what each do, abnormal findingsvs. expected findings. (pg553) Olfactory (1)- Sensory: smell reception and interpretation. Have available 2-3 vials of aromatic odors. Ensure patient’s nasal passages are patent. Occlude one naris at a time and ask patient to breathe in and out, while closing her eyes. Use different odor to test the other side. Assess the ability of patient to differentiate between diff odors. Sense of smell diminishes with age. Anosmia (loss of sense of smell). Optic (ll)- Sensory: visual acuity and visual field (chapter 11) Oculomotor (lll)-Motor: raise eyelids, most extraocular movements. Parasympathetic: pupillary constriction,change lens shape Trochlear (lV)- Motor: downward, inward eye movement(lll, lV, Vl)- Movement of eyes through the six cardinal points of gaze, pupil size, shape, response, to light and accommodation and opening of the upper eyelids. When assessing pt with severe unremitting headaches, the experienced examiner evaluates movement of the eyes for the presence of absence of lateral gaze. The sixth cranial nerve is commonly one of the first to lose function in the presence of increased intracranial pressure. Trigeminal (V)- Motor: jaw opening and clenching, chewing and mastication. Sensory: sensation to cornea, iris, lacrimal glands, conjunctiva, eyelids, forehead, nose, nasal and mouth mucosa, teeth, tongue, ear, facial skin. Evaluate for muscle atrophy. Have patient clench teeth as you palpate the muscles over the jaw, evaluating tone, which should be symmetric, without fasciculations. The three divisions of the trigeminal nerve are evaluated for the sharp, dull and light sensations. With pt closing eyes, touch each side of face at the scalp, cheek and chin, alternating sharp and smooth edges of a broken23tongue blade or a paper clip. Ask patient to report feeling. Then stroke face with cotton wisp. If sensation is impaired, ask pt to differ btw hot/cold. Abducens (Vl)- Motor: lateral eye movement Facial (Vll)- ask pt to raise eyebrows, squeeze the eyes shut, wrinkle the forehead, frown, smile, show the teeth, purse the lips to whistle, and puff out the cheeks. Observe for ticks, unusual movements and symmetry of expression. Drooping of one side of mouth or sagging of lower eyelid will indicate muscle weakness. Ie: Bells palsyTo evaluate taste, a sensory fx of cranial nerves Vll and lX: have patient have tongue protruded and have 4 solutions with Bitter, sour, salty, sweet solutions on them. With applicator apply them on lateral side of

NURS 6512 Final Exam 2019 NURS 6512 Final Exam 2019 Course NURS-6512D-1/NURS-6512N-1-NURS-6512D- 1/NURS-6512N-1- Advanced Health Assessment and Diagnostic ReasoningTest Final Exam
Started 8/1/19 11:30 AM Submitted 8/1/19 1:20 PMDue Date 8/12/19 1:59 AMStatus Completed
Attempt Score 93 out of 100 pointsTime Elapsed 1 hour, 34 minutes out of 1 hour and 50 minutes1. Costovertebral angle tenderness should be assessed whenever you suspect the patient may have: - Polynephritis2. In older adults, overflow fecal incontinence is commonly due to: -Fecal impaction3. A 1 month old boy has been vomiting for 2 weeks. How is this symptom of GERD and pyloric stenosis further differentiated in this child’s assessment? – The infant has regurgitation with pyloric stenosis4. Auscultation of borborygmi is associated with: - Gastroenteritis, early intestinal obstruction, or hunger5. When auscultating the abdomen, which finding would indicate collateral circulation between the portal and systemic venous systems? – Venous hum6. Conversion of fat-soluble wastes to water-soluble material for renal excretion is a function of the: - Liver7. The major function of the large intestine is: -Water absorption8. Which structure is located in the hypogastric region of the abdomen? –Ileum, bladder, andpregnant uterus9. A 45 year old man relates a several week history of severe intermittent abdominal burning sensations. He relates that the pain is relieved with small amounts of food. Before starting the physical examination, you review his laboratory work, anticipating a (n): -Positive Helicobacter pylori result10. You are caring for a patient with trigeminal neuralgia. During the assessment, the patient would describe the pain as: - Burning or shocklike11. Your 85 year old patient is complaining of right knee pain. She has a history of osteoarthritis for which she is given anti-inflammatory medication. To assess her right knee pain, you should ask her if: - The pain gets better when she sits12. A 5 year old is complaining of nondescriptive “belly pain.” Your next action should be to ask him to: - Point to the area of pain13. The perception of pain: - Is variable and is affected by emotions, and cultural background14. Patients presenting with ascites, jaundice, cutaneous spider veins, and nonpalpable liver exhibit signs of: - Cirrhosis15. A patient presents to the emergency department after a motor vehicle accident. The patient sustained blunt trauma to the abdomen and complains of pain in the upper left quadrant that radiates to the left shoulder. What organ is most likely injured? – Spleen16. Imaging studies reveal that a patient has dilation of the renal pelvis from an obstruction in the ureter, what condition will be documented in this patient’s health record? – Hydronephrosis17. Visible intestinal peristalsis may indicate: - Intestinal obstruction18. Infants born weighing less than 1500g are at higher risk for: - Necrotizing enterocolitis19. Which of the following factors is not known to affect patient compliance with his or her treatment regimen? – The patient’s age and social status20. One of the most important aspects to consider in the orthopedic screening examination is: -Symmetry21. The sequence of the physical examination should be individualized to: -22. As you greet the patient, which examination technique is first implemented? - Inspection23. Which of the following is most likely to enhance examiner reliability? – The examiner attempts to qualify data24. A 7 year old boy is brought to your office with a chief complaint of possible fracture to his left third finger. He jammed it while playing basketball 2 days ago. The mother states that she really does not think it is broken because he can move it. What is your best response? – This is common misconception, and the finger may be broken. An x-ray is indicated.25. A patient presenting for the first time with typical low back pain should receive which of the following diagnostic tests?26. Skeletal changes in older adults are the result of: -Increased bone resorption 27. A positive straight leg raise test usually indicates: - Lumbar nerve root irritation28. What technique is performed at every infant examination during the first year of life to detect hip dislocation? – Barlow-Ortolani maneuvers29. Expected normal findings during inspection of spinal alignment include: - Convex lumbar curvenumber of times the patient has to change positions to conserve the patient’s energyMinimize theusually musculoskeletal etiology.– None of the above. X-ray is not indicated because lumbar pain is30. Temporalis and masseter muscles are evaluated by: - Having the patient clench his or her teeth31. When palpating joints, crepitus may be caused when: - Irregular bony surfaces rub together32. A 3 year old is brought to the clinic complaining of a painful right elbow. He is holding the right arm slightly flexed and pronated and refuses to move it. the mother states that symptoms started right after his older brother had been swinging him around by his arms. This presentation supports a diagnosis of: - Radial head subluxation33. Light skin and thin body habitus are risk factors for: - Osteoporosis34. Risk factors for sports-related injuries include: - Failure to warm up before activity35. Injuries to long bones and joints are more likely to result in fractures than in sprains until: -Adolescence36. Ligaments are stronger than bone until: - Adolescence37. The family history for a patient with joint pain should include information about siblings with: -Genetic disorders38. The Thomas test is used to detect: - Flexion contractures of the hip39. A goniometer is used to assess: - Range of motion40. During a football game, a player was struck on the lateral side of the left leg while his feet were firmly planted. He is complaining of left knee pain. To examine the left knee you should initially perform the ________ test. – Valgus stress41. You note that a child has a positive Gower Sign. You know that this indicates generalized: -Muscle weakness42. The dowager hump is: - The hallmark of osteoporosis43. What temporary disorder may be experienced by pregnant women during the third trimester because of fluid retention? –Carpal tunnel syndrome44. A common finding in markedly obese and pregnant women is: - Lordosis45. A 45 year old laborer presents with low back pain, stating that the pain comes from the right buttock and shoots down and across the right anterior thigh, down the shin to the ankle. Which examination finding is considered more indicative of nerve root compression? – Positive straight leg raise result46. Mrs. Bower is a 57 year old patient who comes in for an office visit. Which of the following disorders is known to be hereditary? – Huntington chorea47. Testing of cranial nerve ________ is not routinely performed unless a problem is suspected.–I48. The patient is able to rapidly touch each finger to his thumb in rapid sequence. What does this finding mean? – The patient has appropriate cerebellar function49. Which question asked by the examiner may hellp to determine prevention strategies for seizures that a patient is experiencing? – “Are there any factors or activities that seem to start the seizures?”50. A patient has a complaint of dizziness. The patient makes the following statement: “I sometimes feel as if the whole room is spinning.” What type of neurologic dysfunction should the examiner suspect? – Inner ear dysfunction affecting the acoustic nerve51. The examiner asks the patient to close her eyes, then places a vibrating tuning fork on the patient’s ankle and asks her to indicate what is felt. What is being assessed? – Peripheral nerve sensory function52. Which of the following findings should an examiner consider a normal finding if associated with pregnancy? – Acroparesthesia52. Jack is a 52 year old obese man with a history of poorly controlled diabetes. He also smokes. Based on the above data, the examiner should recognize that Jack has several risk factors for: - Cerebrovascular accident53. Mrs. Jones is a 24 year old patient who presents to your office 2 days postpartum. She complains that she is experiencing foot drop. Which of the following problems should the examiner consider? – Lumbosacral plexopathy54. The examiner is assessing deep tendon reflex response in a 12 year old boy. The response is an expected reflex response. Which of the following scores should be documented? – 2 55. A 68 year old patient presents to your office for follow-up. He tells you, “I have a hard time finding the right words when I am talking;” he also is experiencing numbness. On examination, you note postural instability. This symptom may be: - A late symptom of Parkinson’s disease56. Motor maturation proceeds in an orderly progression from: - Head to toe 57. The thalamus is the major integration center for perception of: - Pain58. The examiner should be concerned about neurologic competence if a social smile cannot be elicited by the time a child is ________old. – 3 months59. Normal changes of the aging brain include: -60. When interviewing a 70 year old female clinic patient, she tells you that she takes ginkgo biloba and St. John’s Wort. You make a short note to check for results of the: -Mini-mental state examination61. The area of body surface innervated by a particular spinal nerve is called a: - Dermatome 62. If a patient cannot shrug the shoulders against resistance, which cranial nerve (CN) requiresfurther evaluation? – CN XI, spinal accessory63. The finger-to-nose test allows assessment of: - Coordination and fine motor function64. You ask the patient to follow a series of short commands to assess: - Attention span65. As Mr. B. enters the room, you observe that his gait is wide based and he staggers from side to side while swaying his trunk. You would document Mr. B.’s pattern as: - Cerebellar ataxia66. When is the mental status portion of the neurologic system examination performed? –Constantly throughout the entire interaction with a client67. An aversion to touch or being held, along with delayed or absent language development, is a characteristic of: -Autism68. The autonomic nervous system coordinates which of the following? – Internal environment of the body69. The major function of the sympathetic nervous system is to: - Orchestrate the stress response70. The parasympathetic nervous system maintains the day-to-day function of: - Digestion 71. Cerebrospinal fluid serves as a: - Shock absorber72. You are performing a two-point discrimination test as part of a well physical examination. The area with the ability to discern two points in the shortest distance is the: -Finger tips73. Which type of hallucination is most commonly associated with alcohol withdrawal? – Visual- bugs, pink elephantsDiminished perception of touch. -- this is byprocess of elimination/educated guess. I could not find direct information addressing this inSeidel74. On a scale of 0 to 4 , which deep tendon reflex score is appropriate for a finding of clonus in a patient? –3 75. Which statement is true regarding mental status changes in older adults? – There is an increased risk of delirium with acute illness or metabolic derangement.76. A characteristic related to syphilis or diabetic neuropathy is testicular: -Insensitivity to painful stimulation77. When collecting personal and social history data from a woman complaining of breast discomfort, you should question her regarding: - Alcohol, tobacco, and caffeine use78. What risk factor is associated with cervical cancer? – HPV79. A 23 year old female presents with severe right lower quadrant tenderness. All of thefollowing should be considered in the differential except: - Classis diverticulitis80. What is the initial diagnostic radiology test that should be ordered if you suspect a rupturedovarian cyst? – Abdominal and transvaginal ultrasound81. A 17 year old male was brought into the emergency room with testicular/scrotal pain. Thedifferential diagnosis should include all except: - Inguinal herniation82. The nursing mother complains that her breasts are tender. You assess hard, shiny, and erythremic breasts bilaterally. You should advise the patient to: - Massage gently and continue nursing83. A normal vas deferens should feel: - Smooth84. In a woman complaining of a breast lump, it is most important to ask about: - Itsrelationship to menses85. The finding of a painless indurated lesion on the glans penis is most consistent with: -Chancre86. Thrombosed hemorrhoids are: - Blue, shiny, painful masses87. Pregnancy-related cervical changes include: - Softening and bluish coloring88. You are inspecting the genitalia of an uncircumcised adult male. The foreskin is tight and cannot be easily retracted. You should: - Inquire about previous penile infections89. An adolescent male is being seen for acute onset of left testicular pain. The pain started 3 hours ago. He complains of nausea and denies dysuria or fever. Your prioritized assessment should be to: - Establish absent cremasteric reflex90. A 23 year old white woman has come to the clinic because she has missed two menstrual periods. She states that her breasts have enlarged and that her nipples have turned a darker color. Your further response to this finding is: - Suggest pregnancy testing91. What accommodations should be used in the position of a hearing-impaired woman for a pelvic examination? – The head of the table should be elevated92. Sexual differentiation in the fetus has occurred by _______weeks gestation. - 1293. You are performing a clinical breast examination for a 55 year old woman. While palpating the supraclavicular area, you suspect that you felt a node. In order to improve your hooked technique, you should: -Ask the patient to turn her head toward that side94. If a firm, transverse ridge of compressed tissue is felt bilaterally along the lower edge of a 40 year old patient’s breast, you should: -Record the finding in the patient’s record95. A therapeutic technique for dealing with grieving individuals is to: - Tell them that is good to cry and to share feelings96. The examination of the newborn should begin with: - Inspection noting skin color, flaccidity, tension, gross deformities, or distortions of facies97. Which one of the following patient characteristics is most likely to limit patient reliability during history taking? – Patient is sleep and sensory deprived98. In crying infants, it is often difficult to: - Auscultate heart sounds99. Which of the following statements accurately reflects the sensitivity and specificity oflaboratory tests? – No test has 100% sensitivity and specificity100. Which medical condition would exclude one from sports participation? – Fever101. Your 15 year old patient is athletic and thin. Radiography of an ankle injury reveals a stress fracture. You question this patient about her: - Menstrual cycles102. Which of the following are examined with the patient in a reclining 45 degree position? –Jugular venous pulsation and pressure103. Functional assessment is most important during the examination of a(n): -Older adult104. The best way to ease the apprehension of a 3 year old child before a physical examination is to: - Encourage child’s participation105. An ophthalmoscopic eye examination involves: - Lens inspection106. When conducting a geriatric assessment, basic activities of daily living (ADLs) include: -Bathing107. The checkout station for preparticipation physical evaluation (PPE) is critical because at this point: - The coordination of follow-ups is reviewed108. Which of the following is true regarding the relationship between the examiner and the patient? – The patient is a full partner with the examiner109. Which of the following factors is not known to affect patient compliance with his or her treatment regimen? – The patient’s age and social status110. One of the most important aspects to consider in the orthopedic screening examination is:- To look for symmetry of muscle, stature, and joint movement111. As you greet the patient, which examination technique is first implemented? – Inspection 112. Which portion of the physical examination is best done with the patient standing? –Spinal 113. Which patient position facilitates inspection of the chest and shoulders? – Sitting114. The least reliable indicator of newborn distress is: - Color115. Proprioception should be assessed while the patient is: - Standing116. Part of the screening orthopedic component of the examination includes evaluating the person while: - Duck walkingHealth Assessment Final Review ExamMust have 78% to pass between both exams Always go with the text bookMENTAL ASSESSMENT (Ch 5 pgs 64-78)1. What does orientation to person, place, and time assess? When you perform assessment, what exactly are you looking for? Pg. 67Person, place and time assess state of consciousness. When performing this assessment you are looking for cognitive function. Person disorientation is a result of cerebral trauma, seizures, or amnesia; Place disorientation occurs with psychiatric disorders, delirium, and cognitive impairment; Time disorientation is associated with anxiety, delirium, depression, and cognitive impairment.8. Assessing orientation to person, place, and time helps determineANS: DOrientation to person, place, and time are measures of states of consciousness and awareness, not degrees of attention span. Analogies and abstract reasoning are higher functions than orientation. Emotional status can be better evaluated by observing behaviors.2. How many serial numbers should most people be able to repeat? For example: counting backwards. How many should the average person be able to repeat? Pg. 70Five to eight numbers forward or four to six backward can usually be repeated.10.Under most conditions, adult patients should be able to repeat a series of _____ numbers.ANS: BMost adults should be able to recall immediately a series of five to eight numbers forward and four to six numbers backward.3. How do you assess recent memory if you’ve had a patient your worried about memory? What technique and how would you assess recent memory? Pg. 70Give the patient a short time to view four or five test objects, telling them you will ask them about them in a few minutes. Ten minutes later, ask the patient to list the objects.14.Recent memory may be tested ability to understand act tion of onal to to eightc.10 to 15d.15 to than g the patient to do simple g the patient to listen to and repeat a series of ng the patient four items and asking him or her to list the items about 10 minutes g the patient about verifiable past events, such as his or her mother’s maiden g the patient to name the past four presidents.ANS: CShowing the patient four or five objects, saying you will ask about them in a few minutes, and then 10 minutes later asking the patient to list the objects is a technique to measure recent memory. The other choices are not tests of recent memory. Asking the patient to listen and then repeat tests immediate recall.4. What pysch or mental condition is considered progressive and not reversible? Pg. 76, 78 Dementia (see differential diagnosis).27. Which condition is considered progressive rather than reversible?ANS: BDementia is considered progressive and irreversible, delirium and coma have the potential for reversal, and depression and anxiety are reversible.26. An older adult is administered the Set Test and scores a 14. The nurse interprets this score as indicative ofANS: EScores of less than 15 on this mental function test indicate dementia.28.Which of the following is usually related to structural diseases of the brain?ANS: BOne of the distinguishing characteristics that distinguishes dementia from the others is that it is usually related to structural diseases of the brain such as abnormal deposits, or recurrent strokes.5. If patient is delirious do they maintain orientation and attention span? Look up delirium and see what you expect patient to maintain. Pg. 75,76a.Deliriumb.Dementiac.Depressiond.Anxietye.Ctive tia.a.Deliriumb.Dementiac.Depressiond.Anxietye.Psychosis2Patient suffering from delirium is usually disoriented (usually oriented to person only) and have an impaired attentiveness. (pg 461 in Adv. Assessment) In spite of the confusion, the patient’s sensorium (consciousness) is usually intact although some condition (intoxication and severe metabolic derangements) result in altered level of consciousness.9.A state of impaired cognition, consciousness, mood and behavioral dysfunction of acute onset refers toANS: BDelirium is a state of impaired cognition, consciousness, mood and behavioral dysfunction of acute onset. Stupor describes arousals for short periods of time after a stimulus for arousal (e.g., visual, verbal, or painful). Lethargy relates to sleepiness with ease of arousal; coma is nonarousal and nonawareness. Confusion relates to inappropriate responses to questions with decreased attention span and memory.6. Who should you give a mini mental exam to? Everyone or certain patients? Pg. 67,68The mini mental exam should be given to elderly patients when there is a concern about their cognitive function. This testdetects probable dementia.34.The Mini-Mental State Examination should be administered for a patient whoANS: AThe MMSE is a tool used to estimate cognitive function quantitatively or document cognitive changes serially. Getting lost in a familiar territory is a sign of possible cognitive impairment.6. The Mini-Mental State Examination (MMSE)ANS: AThe MMSE is a standard tool that functions to estimate cognitive function quantitatively7.While interviewing a 70-year-old female clinic patient, she tells you that she takes ginkgo biloba and St. John’s wort. You make a short note to check for results of lost in her or his s an excessive amount of repetitive ritualistic illegal hallucinogenic a fear of leaving the be used to estimate cognitive changes be used to estimate personality disorders s do not vary with regard to age or determine the cause of memory a good tool to diagnose neurologic disorders.a.Denver II.b.Mini-Mental State Examination.3c.Glasgow Coma Scale.d.Goodenough-Harris Drawing Test.e.CAGE Questionnaire.ANS: BGinkgo biloba and St. John’s wort are herbal remedies used to improve mental alertness and elevate mood. As side effects, they can also result in disorientation and confusion that can be monitored with the Mini-Mental State Examination. The Denver and Goodenough- Harris tests are used for childhood development, and the Glasgow Coma Scale is used to rate coma depth. The CAGE Questionnaire is a useful tool for approaching a discussion of the use of alcohol.BREAST EXAM1. With documenting breast exams, how do you divide the breasts? If you want a radiologist to concentrate on one particular area of the breast, how do you divide to communicate findings? Pg. 351The breast is divided into five segments, four quadrants and a tail (upper inner, upper outer, lower inner, and lower outer).Either the right or left breast should be communicated. The terms: upper inner, upper outer, lower inner, lower outer, and tail of Spence should be communicated to the radiologist in terms of how to communicate findings.3.For purposes of examination and communication of physical findings, the breast is divided intoANS: CThe breast is referenced according to five segments: four quadrants and a tail.11. When conducting a clinical breast examination, the examiner shouldANS: DInspection with simultaneous observation of both breasts is essential in order to detect differences between the breast size, symmetry, contour, and skin color.2. If you have a pt c/o breast lump, what questions do you ask? For example you have a 50 year-old with breast lump, how do you begin exam compared to a 30 year-old pt?(just arbitrary ages) What assessment do you do and what questions would you ask based on age? Pg.9. Which breast change is typical after menopause?s (upper and lower).s (left, middle, and right). quadrants plus a es (six consecutive rings, each 1 inch farther away from nipple).l portions 1 through the examination if the patient has had a recent the patient covered to respect the lights to minimize ct both breasts with palpation of the breasts.a.Thickening of the inframammary ridgeb.Hypertrophy of glandular tissuec.Increase in number of lactiferous ductsd.Reduction of fat deposits4e.Shortening of Cooper’s ligamentsANS: A. After menopause, the breast tissue atrophies and is replaced by fat deposit, the inframammary ridge at the lower edge of the breast thickens, and the breast hangs more loosely as Cooper’s ligaments relax.10. In a woman complaining of a breast lump, it is most important to ask aboutANS: AHormonal changes of menstruation can result in breast tenderness, swelling, and enlarged nodes that can be felt on palpation.12. A 50-year-old woman presents as a new patient. Which finding in her personal and social history would increase her risk profile for developing breast cancer?ANS: CNulliparity or late age at birth of first child (after 30 years old) is a risk factor for breast cancer. Other risk factors include late menopause, early menarche, and drinking more than one alcoholic drink daily.1. What position do you put a patient in for a breast exam? What position is the examiner standing in? Axillary nodes what position does the patient need to be in? Pg. 355-3622. 14. To begin the clinical breast examination (CBE) for a man, ask him toANS: B Inspection begins the CBE. Ask the patient to sit with his arms hanging loosely at his sides. The technique is the same for both men and women.15.Inspection of the breasts usually begins with the patient in which position?ANS: BInspection begins with the patient in a sitting position with arms hanging loosely at the sides. Inspection (pg. 355): As the patient sits with arms hanging loosely at the sides, inspect each breast and compare it with the other for size, symmetry, contour, skin color, and texture, venous pattern, and lesions. Re-inspect the woman’s breasts with the patient in the following positions (pg. 357-358): relationship to t ization ol consumption.a.Drinking three glasses of wine per weekb.Early menopausec.Nulliparityd.Late menarchee.Young age at birth of first ne on the table with his arms with his arms hanging at his with his hands on his with his arms clasped behind his leaning forward.a.Lateralb.Sittingc.Standingd.Supinee.Proneo Seated with arms over the head or flexed behind the neck. This adds tension to the suspensory ligaments, accentuates dimpling, and may reveal variations in contour and symmetryo Steadied with hands pressed against hip with shoulders rolled forward (or alternatively have the patient push her palms together): This contracts the pectoral muscles, which can reveal deviations in contour and symmetryo Seated and leaning forward from the waist: This also causes tension in the suspensory ligaments. The breasts should hang equally. This maneuver can be particularly helpful in assessing the contour and symmetry of large breasts because the breasts fall away from the chest wall and hang freely. As the patient leans forward, support her by the hands. Patient in Seated Position (pg. 360)o Chest Wall Sweep: Have the patient sit with arms handing freely at the sideso Bimanual Digital Palpation: Place on hand, palmar surface facing up, under the patient’s right breasto Lymph Node Palpation: To palpation the axillae, have the patient seated with arm flexed at the elbow. Support the patient’s left lower arm with your left hand while examining the left axilla with your right hand. Patient in Supine Position (pg. 360): Have the patient raise one arm behind her head; then place a small pillow or folded towel under that shoulder to spread the breast tissue more evenly over the chest wall. The ideal position for examination is to have the nipple pointing toward the ceiling.b.) Axillary nodes what position does the patient need to be in? (pg. 360)Lymph Node Palpation: To palpation the axillae, have the patient seated with arm flexed at the elbow. Support the patient’s left lower arm with your left hand while examining the left axilla with your right hand.3. What’s the difference between fibrotic breast tissue and breast cancer? How do you expect each to feel? What are the characteristics of the two?17.Which finding, found on inspection, is related to fibrotic tissue changes that occur with breast carcinoma?ANS: BSkin dimpling or retraction signifies the contraction of fibrotic tissue that occurs with carcinoma. The other choices are normal variations without significance to cancer development.18. Venous patterns on breasts are suggestive of pathology when they areANS: CMalignant tumors require more blood flow. Superficial veins dilate to provide more flow and can be assessed as unilateral venous patterns. Bilateral findings are of no concern and are more commonly seen in pregnant or obese women. Nevi that are long-standing, unchanging, or nontender are of little concern.21.In patients with breast cancer, peau d’orange skin is often first evidenta.Convex or conical shapeb.Skin dimpling or retractionc.Pendulous and loose breastsd.Unequal shape or contoure.Lifelong inverted erally in obese ved during iated with a long-standing unchanging the the upper inner or around the the inframammary the tail of Spence.ANS: CThe areola is the most common initial site to visualize peau d’orange skin.24.Recent unilateral inversion of a previously everted nipple suggestsANS: BRecent unilateral inversion or retraction of a previously everted nipple suggests malignancy rather than a benign condition.41.You are conducting a clinical breast examination for a 30-year-old patient. Her breasts are symmetrical with bilateral, multiple tender masses that are freely moveable with well-defined borders. You recognize that these symptoms and assessment findings are consistent withANS: EFibrocystic changes are tender masses, usually bilateral, with multiple round, mobile, well-delineated borders. Fibroadenoma and cancer are usually nontender; Paget disease is an eczema-like condition of the nipple that signals an underlying cancer. Mammary duct ectasia most commonly occurs in menopausal women. Fibrocystic Changes (pg. 366):o Benign fluid-filled cyst formation caused by duct enlargement o Pathophysiology Usually bilateral and multiple Most common in women 30 to 55 years of age Associated with long follicular or luteal phase of the menstrual cycleo SubjectiveData Tender and painful breasts and/or palpable lumps that fluctuate with menses  Usually worse premenstruallyo ObjectiveData Round, soft to firm, tense, mobile masses with well-delineated borders  Usually tender Usually bilateral Multiple or single Fibroadenoma (pg. 366): n breast adenoma.b.Paget ry duct cystic changes.o Pathophysiology May occur in girls and women of any age during their reproductive years  After menopause, the tumors may regresso SubjectiveData Painless lumps that do not fluctuate with the menstrual cycle May be symptomatic with discovery on clinical breast examination or breast imagingo ObjectiveData Round or discoid, firm, rubbery, mobile masses with well-delineated borders  Usually non-tender Usually bilateral Single; may be multiple Biopsy often performed to rule out carcinoma Malignant Breast Tumors (pg. 366): Ductal carcinoma arises from the epithelial lining of ducts; lobular carcinoma originates in the glandular tissue of the lobuleso Pathophysiology Mutations to normal cells results in uncontrolled cell division and tumor formation; as the tumor grows andinvades surrounding tissue, metastases occurs through the lymph and vascular systems Peak incidence between the ages of 40 and 75 years, with the majority of malignant breast tumors occurring in women older than 50o SubjectiveData Painless lump; change in size, shape, or contour of breast Axilla may be tender if lymph nodes involved May be asymptomatic with discovery on clinical breast examination or breast imagineo ObjectiveData May be palpable mass that is usually single, unilateral, irregular, or stellate in shape; poorly delineatedborders; fixed; hard or stone-like; and non-tender Breast may have dimpling, retraction, prominent vasculature Skin may have peau d’orange or thickened appearance Nipple may be inverted or deviated in position(Differential diagnosis pg. 365)Fibrotic: usually bilateral, multiple or single, round, soft to firm; tense, mobile, absent retraction signs, usually tender, bordersare well delineated, and they vary with menses.Cancer: Usually unilateral, single, irregular or stellate, hard/stonelike, fixed, retraction signs are often present, usually nontender, the borders are poorly delineated; irregular, and they do not vary with menses.4. Breast Exam- What part of the hand do you use? Fingertips, pads, palms, entire hands? Pg. 361Palpate using your finger pads as they are more sensitive than your fingertips. Palpate systematically, pushing gently but firmly toward the chest wall, as you rotate your fingers in a clockwise or counterclockwise pattern. At each point, as you rotate your fingers press inward, using three depths of palpation: light then medium and finally deep. The exact sequence you select for palpation is not critical, but a systematic approach will help ensure that all portions of the breast are examined.26.When palpating breast tissue, the examiner should use the _____ at each r of the surface of the sANS: BThe finger pads are used for breast palpation because they are more sensitive than the fingertips.5. What is Peau d'orange skin? Look, feel, mean? Pg. 356The skin has an orange peel appearance. This indicates edema of the breast caused by blocked lymph drainage in advanced orinflammatory breast cancer. The skin appears thickened with enlarged pores and accentuated skin markings.6. What is the tail of Spence? Where is it anatomically? Pg. 351The tail of Spence is (extends from) the greatest amount of glandular tissue that lies in the upper outer quadrant and extendsinto the axilla. ??????2.The largest amount of glandular breast tissue lies in theANS: DThe greatest amount of glandular tissue in the breast lies in the upper outer quadrant.31.The tail of Spence extendsANS: DThe tail of Spence extends from the upper outer breast quadrant into the axillae.7. Breast Exam: Certain groups of lymph nodes are enlarge, where would they be for examiner to expect Breast Cancer? Pg. 360The axilla, supraclavicular and infraclavicular areas. Nodes that are detected should be described according to location, size, shape, consistency, tenderness, fixation, and delineation of borders.34.When examining axillary lymph nodes, the patient’s arm inner of S outer the midclavicular d the supraclavicular into the inframammary the the sternal d full above the ded at the ed against the ed over the d at the elbow.ANS: ETo examine the axilla, support the patient’s lower arm with the elbow flexed with one of your hands and use your other hand to palpate the axilla.35.Lymphatic flow of the breast primarily drainsANS: CEach breast contains a lymphatic network that drains the breast radially and deeply to underlying lymphatics.36. The greatest concern for breast cancer is when you palpate _____ nodes.ANS: DThe supraclavicular and infraclavicular nodal areas are sentinel nodes; any enlargement in these areas is especially significant.37.You are performing a clinical breast examination for a 55-year-old woman. While palpating the supraclavicular area, you suspect that you felt a node. To improve your hooked technique, you shouldANS: EHaving the patient turn her head toward the examination side, as well as raising the shoulder on that same side, gives your fingers more room to palpate deeper into the fossa.8. What if you have a 20-30 year-old with freely moveable, well-defined lump, tender with cycle, cancer or more likely fibrotic? Fibrotic (see page 365)iorly toward the ally toward the corresponding lly toward the omedially toward the ior nal lotion to your both hands the patient to press both palms the patient to lower her shoulder on that the patient to turn her head toward that side.1041.You are conducting a clinical breast examination for a 30-year-old patient. Her breasts are symmetrical with bilateral, multiple tender masses that are freely moveable with well-defined borders. You recognize that these symptoms and assessment findings are consistent withANS: EFibrocystic changes are tender masses, usually bilateral, with multiple round, mobile, well-delineated borders. Fibroadenoma and cancer are usually nontender; Paget disease is an eczema-like condition of the nipple that signals an underlying cancer. Mammary duct ectasia most commonly occurs in menopausal women.9. Then you have a 50 year-old-lump firm, fixed, doey-like, cancer or fibrotic? Cancer FEMALE GENITALIA1. Pelvic Exam-anatomy of vagina and location of glands-5 O’clock, 7 O’clock for example, just know the anatomy of the male and female genitals.2. What structures are located at the 5 o’clock and the 7 o’clock positions of the vaginal orifice and open onto the sides of the vestibule in the groove between the labia minora and the hymen?ANS: DBartholin glands are found posteriorly on each side of the vaginal orifice and open onto the sides of the vestibule.2. Cervical Cancer- know patient’s history and what questions to ask patients that put them at high risk for cervical cancer.12. Which factor is associated with an increased risk of cervical cancer?ANS: EWomen who were younger than 17 years when they had their first full-term pregnancy are almost 2 times more likely to get cervical cancer later in life than women who were not pregnant until they were 25 years or adenoma.b.Paget ry duct cystic changes.a.Skene glandsb.Perineal bodiesc.Labia majorad.Bartholin glandse.Labia minoraa.Endometriosisb.Low parityc.HPV vaccinationd.High socioeconomic statuse.Early parity113. What history increases your risk for ovarian cancer? (pg. 425)Risk factors for ovarian cancer (box on p. 425 below cervical risk factors): Age (increases with age), inherited genetic mutation (BRCA1 or BRCA2 gene), family history, obesity, reproductive history (nulliparity increases risk), and the use of fertility drugs, personal history, hormone replacement therapy, and high-fat diet.13.The risk of ovarian cancer is increased by a history ofANS: EThere is a relationship between nulliparity and an increased risk of ovarian cancer. Although the risk increases with age, most ovarian cancers develop after menopause; half are found in women older than 63 years. The other choices have no relationship with ovarian cancer.4. What is a normal cervix and an abnormal cervix? What does an abnormal one look like (not cancerous) what tests might you and what might indicate? Disorder?22. During digital examination of the vagina, the cervix is noted to be positioned posteriorly. Upon bimanual examination of this woman, you would expect to palpate a(n) _____ uterus.ANS: BThe position of the cervix correlates with the position of the uterus. A cervix that is pointing posteriorly indicates an anteverted uterus.23. The presence of cervical motion tenderness may indicateANS: CPainful cervical motion tenderness suggests a pelvic inflammatory disease or a ruptured tubal pregnancy. The cervix is expected to move 1 to 2 cm without discomfort under normal conditions.25.During a routine vaginal examination, you insert the speculum and visualize the cervix. The cervix projection into the vaginal vault -fat ette between 35 and 50 body ally c inflammatory nancy.12approximately 5 cm. Upon bimanual examination, you would expect to find the the midline the retroverted the anteverted ted to the left or the retroflexed position.ANS: DNormally, the cervix protrudes into the vagina 1 to 3 cm. Longer projections suggest a pelvic or uterine mass. A pelvic mass would cause the uterus to be deviated to the right or left, but an anteverted, retroverted, or retroflexed uterus would still be in the midline regardless of its position.26.Small, pale yellow, raised, and rounded areas are visualized on the surface of the cervix. You shouldANS: AThis describes nabothian cysts, which are retention cysts of the endocervical glands and are considered a normal variant. No further testing is this as nabothian this as a friable n a viral the pH of the cervical this as an eroded cervix.a.b.c.Normal cervix: covered with pink squamous epithelium that is uniform in consistency. It should be in an anterior- posterior position that correlates with the position of the uterus. The os is small and round. A small area of ectropion is visible inferior to the os. Cervix should feel firm (during pregnancy will be softer) and be smooth.Abnormal cervix: Bluish color indicates increased, which may indicate pregnancy. A pale cervix is associated with anemia. If the cervix is pointed anteriorly it indicates a retroverted uterus; pointing posteriorly indicated an anteverted uterus. Horizontal indicated a uterus in midposition; deviation indicated a pelvic mass, uterine adhesions, or pregnanacy. Projection greater than 3 cm may indicate a pelvic or uterine mass. Small, white or yellow raised, round areas may indicate nabothian cysts. Friable tissue, red patchy areas, granular areas, and white patches could indicate cervicitis, infection, or carcinoma.Feel for nodules, harness, and roughness. Note the position of the cervix, it should be in the midline and may point anteriorly or posteriorly. Grasp the cervix between your fingers and move it gently from side to side (should move 1-2 cm). There should be no pain or discomfort. Painful cervical movement suggests a pelvic inflammatory disease or a ruptured tubal pregnancy which would require immediate surgery.5. What structure or organs are examined during a Bimanual exam? (pg 436-437). Cervix, Uterus, Adnexa, and Ovaries33.The assessment of which structure is not part of the bimanual examination?a.Cervixb.Bladderc.Uterusd.Ovariese.Adnexa13ANS: BThe bimanual examination consists of assessing the cervix, uterus, adnexa, and ovaries.6. When do PAP smears begin? Age of non-sexually active versus sexually active women? (pg. 437) 21 for non-sexually and sexually active women because cervical cancer is rare for women under age 21.40.When a woman is not sexually active, cervical cancer screening should beginANS: DWomen who are not sexually active should have their first examination by the age of 21 years. Women under age 21 should not be tested.7. Menopausal women- what does the vagina and mucosa of the walls feel like? (pg. 447)The vagina is narrower and shorter. You will see and feel the absence of rugae. The cervix is smaller and paler but the osshould still be palpable and the cervix may be less mobile.43.During a pelvic examination for a postmenopausal woman, you would expect to assessANS: BExpected findings in the pelvic examination for an older woman include a narrower and shorter vagina, absence of rugation, a less mobile cervix, and a palpable cervical os. The ovaries are rarely palpable because of atrophy.MALE GU1. Males-history or what alerts the examiner of the possibility of testicular cancer? (pg. 470).Undescended testicle, personal hx of testicular CA, family hx of testicular CA, abnormal testicle development (klinefelter syn), 20-54 yr male, the most prominent in white race ( 5 times that of black; more than 3 times that of Asian American and Native American men).13.Which of the following is a risk factor for testicular cancer? age 15 age 18 age 21 age 30 years.a.a wider and longer vaginal ce of vaginal wall rugation.c.a nonpalpable cervical os.d.a more mobile ble ovaries.a.Circumcisionb.Condyloma acuminatumc.Cryptorchidism14d.Poor hygienee.Multiple sexual partnersANS: CCryptorchidism (testes that fail to descend by 12 months of age) is a risk factor for testicular cancer.27.The most common cancer in young men age 15 to 30 years isANS: ABecause testicular tumors are the most common cancer occurring in young adults, self-examination is encouraged.37.Self-examination of the male genitaliaANS: BMonthly self-examination is recommended as a screening test for testicular cancer as well as sexually transmitted infections for all young men starting at 15 years of age. It is encouraged during bathing because the scrotal skin is less thick at this time and because the scrotum hangs looser because of the warmth. Inspection is done first followed by palpation.2. What alerts us to do further testing and the need to further and fully assess for testicular cancer? How do we do this?o Irregular, contender mass fixed to the testiso Does not transilluminateo May also have hydrocele(that doesn't transilluminate) o InguinalLymphadenopathyo Painless mass in testicleo Scrotalenlargementorswellingo Heavy feel in in scrotumo Dull ache in lower abdomen, back or groino fluid in scrotumThis can be done by performing a Testicular exam ( inspect and palpate), Scrotal US, Lab work including: Chemistry, WBC count, biochemical markers AFP and B-hCg.21.Mr. L. has an unusually thick scrotum with edema and pitting. He has a history of cardiac problems. The appearance of his scrotum is more likely a(n)ANS: BGeneral fluid retention can cause scrotal thickening and pitting edema and is more often seen as a result of cardiac, renal, or hepatic disease. This swelling does not imply a condition of the genitalia but rather a condition of these related d be restricted to adults with prior d be performed while s with palpation and then d be performed t be adequately performed due to poor visualization of the nital defect that has ation of general fluid l consequence of ication to the development of quence of prior STDs.1525.An enlarged, painless testicle in an adolescent or adult may cular torsion.c.a undescended padias.ANS: CA hard, enlarged, painless testicle can indicate a tumor in an adolescent or adult male. Epididymitis and torsion are painful; an undescended testicle is common in infants and is usually resolved by 12 months. Hypospadias is a congenital defect of the urethral opening causing the meatus to be located ventral to its normal position.26.You palpate a soft, slightly tender mass in the right scrotum of a man. You attempt to reduce the size of the mass, and there is no change in the mass size. Your next assessment maneuver is toANS: DA soft mass is either a hernia or hydrocele. If the mass can be reduced, it is probably a hernia; a nonreducible mass should be transilluminated to determine whether it contains fluid and is possibly caused by a hydrocele. Lifting the scrotum should be done when epididymitis is suspected. Urethral cultures are not indicated at this point.29.An adolescent male is being seen for acute onset of left testicular pain. The pain started 3 hours ago. He complains of nausea and denies dysuria and fever. Your prioritized assessment should be toANS: CThe patient is displaying symptoms of testicular torsion. An absent cremasteric reflex is a supporting finding to differentiate torsion from epididymitis.38. A 12-year-old boy says that his left scrotum has a soft swollen mass. The scrotum is not painful upon palpation. The left inguinal canal is without masses. The mass does transilluminate with a penlight. This collection of symptoms is consistent withANS: BA hydrocele is a soft scrotal mass that occurs from fluid accumulation and therefore does transilluminate. Orchitis results in a swollen, tender testis. A rectocele does not result in scrotal swelling. A scrotal hernia would also be palpable along the inguinal canal. Epididymitis is an extremely painful condition.41.A cremasteric reflex should result two fingers to attempt to reduce the te the left scrotum the right testicle, then compare pain illuminate the re the meatus for gonococcal n urine and DNA probe urethral the left scrotum to confirm lish absent cremasteric illuminate the left and right the patient stand and observe the scrotum for a “bag of worms.”al scrotum appear to contain a “bag of worms.”e deviation to the left um to elevate iate erection of the cle and scrotal rise on the stroked side.ANS: EUpon stroking the inner thigh with a blunt instrument or finger, the testicle and scrotum should rise on the stroked side.3. How do you assess for an inguinal hernia? Pg. 472-473Have the pt. stand and bear down. While he is straining inspect the area of the inguinal canal and the region of the fossa ovalis. After the pt. relaxes, insert your examining finger into the lower part of the scrotum and carry it upward along the vas deferens into the inguinal canal. You can also auscultate for bowel sounds, which will be present in uncomplicated reducible hernias.18.Which technique is appropriate to detect an inguinal hernia?ANS: EExamination for inguinal hernias is performed with the patient standing. Inspect the groin while the patient performs a Valsalva maneuver. Insert your examination finger into the lower part of the scrotum and follow upward along the vas deferens to screen for a hernia.19. Which type of hernia lies within the inguinal canal?ANS: CHernias found within the inguinal canal are called indirect hernias.4. What does Vas deferens feel like? Normal? Abnormal? Pg. 473The Vas deferens feels smooth and discrete; abnormal findings are beaded or lumpy feeling. This may indicate diabetes or oldinflammatory changes, especially tuberculosis.2.What structure of the male genitalia travels through the inguinal canal and unites with the seminal vesicle to form the ejaculatory duct?ANS: Da.Conduct percussion while the patient coughs.b.Have the patient strain as you pinch the testes.c.Inspect rectal areas as the patient bears down.d.Conduct the examination only in the supine position.e.Move your finger upward along the vas deferens.a.Umbilicalb.Directc.Indirectd.Femorale.Incisionala.Epididymisb.Corpus cavernosumc.Urethrad.Vas deferense.Ureter17The vas deferens begins at the end of the epididymis, travels the spermatic cord, goes through the inguinal canal, and then unites with the seminal vesicle to form the ejaculatory duct.23.A normal vas deferens should feelANS: BThe vas deferens should normally feel smooth, discrete, and nontender.5. Young man- what is an emergent cause of testicular pain? Pg. 482 Testicular Torsion is twisting of the spermatic cord and is a surgical emergency.29.An adolescent male is being seen for acute onset of left testicular pain. The pain started 3 hours ago. He complains of nausea and denies dysuria and fever. Your prioritized assessment should be toANS: CThe patient is displaying symptoms of testicular torsion. An absent cremasteric reflex is a supporting finding to differentiate torsion from epididymitis.28.The most emergent cause of testicular pain in a young male isANS: ETesticular torsion is a surgical emergency. If surgery is performed within 12 hours after the onset of symptoms, the testis can be saved in about 90% of cases. Delayed treatment results in a much lower salvage rate.6. Understand hernias, where located and how to assess each kind. Pg. 476, 477(see differential diagnosis).Hernia is protrusion of a peritoneal-lined sac through some defect in the abdominal wall. There are indirect, direct and femoral.7. What is the most common type of hernia? Pg. 477 Indirect Inguinal hernias are the most common type.31.The most common type of hernia occurring in young males n urine and DNA probe urethral the left scrotum to confirm lish absent cremasteric illuminate the left and right the patient stand and observe the scrotum for a “bag of worms.”cular cerated ect al.ANS: CThe most common type of hernia in children and young males is an indirect inguinal hernia.MUSCULOSKELETAL1. What is the difference between osteoarthritis versus rheumatoid arthritis?During an assessment what do you expect to see in a patient with osteoarthritis vs. RA? Findings in joints? Describe. OA (pg411)-A progressive disorder associated with age and wear and tear. There is loss of cartilage and progressive erosion of bone. Affects mostly larger bones like hips and knees, but frequently involves small joints of hands, especially distal and proximal interphalangeal joints. Asymmetrical distribution. Pain and stiffness improves with activity, and worsens with rest. Xrays show changes. Sed rate(-), Rheumatoid factor (-) RA (pg410)-If 3 or more metacarpophalangeal joints are swollen is RA. It’s a progressive, inflammatory, and erosive condition that usually affects multiple joints. It’s an autoimmune condition. Affects joints symmetrically. Affects small joints of hands and feet. Joints are tender, swollen with effusion, warm, inflamed. Nodules and deformities are noted. RA associated with: subluxation of metacarpophalgeal joins, hyperextension of joints, but also with changes in eye (scleritis, episcleritis, interstitial lung disease and pericardial disease.1. When does a musculoskeletal exam begin? (text tells you) pg405-The musculoskeletal examination is primarily limited to inspection and palpation. The focused musculoskeletal examination begins withinspection.2. How do you assess the strength of the trapezius muscle? (pg518)The strength of trapezius and sternocleoidomastoid muscle is tested by evaluating the cervical spine and asking patients to do certainmovement. Bend the head forward, chin to chest, and expect flexion of 45 degrees. Bend head to each side, ear to each shoulder and expect lateral bending of 40 degrees. Bend head backward, chin toward ceiling, and expect extension of 45 degrees.3. Patient with scoliosis, bend at waist, what is expected finding? Describe what it looks like (Pg541)When looking form the rear, the spine looks more like an “S” or a “C” than a straight line. There is no known cause. Associated with leg length discrepancy. There’s lateral curvature of spine as patient flexes forward to touch the toes. In severe deformities, patient has uneven shoulder and hip levels, and may have crease on one side of waist.194. Carpal Tunnel-What expect to feel like, how do you assess for? During assessment, particular nerve is tested, what is it? What sensation will the patient have?(pg430,524) The carpal tunnel is a space located on the anterior aspect of the wrist between the carpal bones and a ligamentous band through which the median nerve and several tendons transverse. With overuse and repetitive movements there’s a hypertrophy of tissues, causing a lot of space and impingement on the median nerve. Nighttime pain-early sign. Swelling at wrist related to inactivity of flexion at night, pain can radiate up the forearm to shoulder with numbness and tingling along the median nerve, and paresthesia involves anterior aspects of wrist, medial palm and first three digits of affected nerve. Relief is found by shaking affected hand in downward fashion. To assess, first ask patient to mark specific site using the Katz hand diagram.o Thumb abduction test isolates strength of abductor pollicis brevis muscle, innervated only by median nerve. Pt will place the hand palm up and raise the thumb perpendicular to it. Apply downward pressure on thumb to test muscle strength. Weakness=Carpal tunnel syndromeo Tinel sign: Strike pt’s wrist with your index or middle finger, where median nerve passes under the flexor retinaculum and volar carpal ligament(fig21.42). Tingling, means ( ) tiner sign and ( ) CPT syndrome.o Phalen test: pt holds both wrist in fully palmar-flexed position with dorsal surfaces pressed together for one min. Numbness and paresthesia in the distribution of median nerve is ( ) CPT syndrome.ABDOMINAL1. When conducting an abdominal exam, what position should the patient be in? Examiner? Techniques with rigid abdomen or anxious pt, what are relaxation techniques? (pg377)Need good light source; full exposure of abdomen; warm hands with short fingernails. Have pt empty bladder. Place pt is supine position with arms at sides. Approach pt from right side. Place small pillow under pt’s head and another under slightly flexed knees. Drape a towel or sheet over the patient’s chest for warmth and privacy. Be slow and gentle, avoid sudden movements.Percussion of the abdomen begins with establishinga. liver dullness.b. spleen dullness.c. gastric bubble tympany.d. overall dullness and tympany in all quadrants.e. bladder fullness.ANS: DPercussion begins with a general establishment over all quadrants for areas of dullness and tympany and then proceeds to specific target organs22. Before performing an abdominal examination, the examiner shoulda. ascertain the patient’s HIV status.b. have the patient empty his or her bladder.c. don double gloves.d. completely disrobe the patient.e. uncover only the painful areas of the abdomen.ANS: BThe patient should empty the bladder to ensure an accurate examination of organs as well as to provide comfort for the patient.2024. When examining a patient with tense abdominal musculature, a helpful technique is to have the patienta. hold his or her breath.b. sit upright.c. flex his or her knees.d. raise his or her head off the pillow.e. fully extend the legs.ANS: CTo help relax the abdominal musculature, it is helpful to place a small pillow under the patient’s head and under slightly flexed knees. The other choices increase muscle flexion.28. After thorough inspection of the abdomen, the next assessment step is toa. percuss.b. palpate nonpainful areas.c. auscultate.d. perform a rectal examination.e. palpate painful areas.ANS: CAssessment of the abdomen begins with inspection followed by auscultation. This break from the usual system examination sequence is because palpation and percussion can alter the frequency as well as the intensity of bowel sounds. Therefore, auscultation is done first.2. How long do you auscultate for BS? (pg380)Bowel sounds range from 5-35/min. If you’re unable to hear BS after 5 min of continues listening, associated with abdominal pain andrigidity then is surgical emergency.To correctly document absent bowel sounds, one must listen continuously fora. 30 seconds.b. 1 minute.c. 3 minutes.d. 5 minutes.e. 10 minutes.ANS: DAbsent bowel sounds are confirmed after listening to each quadrant for 5 minutes.3. What is the technique for percussing the liver border? Where to start, how you move, what are you listening for? (pg381)Begin liver percussion at the right midclavicular line over an area of tympany. Always begin with an area of tympany and proceed to area of dullness for easiness. Percuss upward along the midclavicular line to determine lower border of liver. The area of liver dullness is usually heard at the costal margin or slightly below it. Mark with a pen. A lower liver border that is more than 2-3 cm below costal margin may indicate organ enlargement or downward displacement of diaphragm because of emphysema or other pulmonary disease. Upper border of liver, begin percussion on the right midclavicular line at an area of lung resonance around the third intercostal space. Cont downward until the percussion tone changes to one of dullness; this marks upper border of the liver mark with pen. It’s usually in the fifth intercostal space. Measure the distance between the marks, estimates vertical span of liver, usually 6-12cm. If larger=enlargement, if smaller=atrophy.2137. To assess for liver enlargement in an obese person, you shoulda. use the hook method.b. test for cutaneous hypersensitivity.c. auscultate using the scratch technique.d. attempt palpation during deep exhalation.e. have the patient lean over at the waist.ANS: CIf the abdomen is obese or distended or if the abdominal muscles are tight, you should plan on auscultating the liver using the scratch method to estimate the lower border of the liver. Cutaneous hypersensitivity is a sign of peritonitis and does not contribute to determining liver size.Percussion at the right midclavicular line, below the umbilicus, and continuing upward is the correct technique for locating thea. descending aorta.b. lower liver border.c. medial border of the spleen.d. upper right kidney ridge.e. stomach.ANS: BPercussing along the right midclavicular line upward from the umbilicus determines the lower border of the liver. A liver border more than 2 to 3 cm signifies hepatomegaly.When palpating the abdomen, you should note whether the liver is enlarged in thea. left upper quadrant.b. midepigastric region.c. periumbilical area.d. right upper quadrant.e. right lower quadrant.ANS: DAn examiner can recognize a friction rub in the liver by a sound that isa. clicking, gurgling, and irregular.b. high pitched and associated with respirations.c. loud, prolonged, and gurgling.d. soft, low-pitched, and continuous.e. low pitched, tinkling, and unrelated to respirations.ANS: BAn abdominal friction rub is rare and can be identified when high-pitched sounds are auscultated in association with respirations. The liver is located in the right upper quadrant of the abdomen4. CVA tenderness-what might it be a sign of?Costovertebral angle tenderness should be assessed whenever you suspect the patient may havea. cholecystitis.b. pancreatitis.c. pyelonephritis.d. ulcerative colitis.e. intussusception.22ANS: CPyelonephritis is characterized by flank pain and costovertebral angle tendernessNEURO1. Autonomic Nervous System- what are you assessing? Coordinate?(Pg477)The Nervous system with its central and peripheral divisions maintains and controls all body functions by its voluntary and autonomic responses. The evaluation of motor, sensory, autonomic, cognitive and behavioral elements. The CNS is the main network of coordination and control for the body.(PG446) Coordination tests fluidity of movements. Inability to coordinate movements suggests cerebellar dysfunction. Finger to nose testing-ask pt to touch your index finger with his or her index finger, then touch his/her noserepeatedly. Poor coordination of movement indicates dysmetria. Rapid alternating movements-Ask pt to perform rapid pronation and supination of the hand on his/her thigh or on examination table Heel to shin testing-Ask pt to take the heel of one side and repeatedly move up and down the shin of the opposite leg Romberg- Ask pt to stand with feet together, arms abducted outward with palms up, and eyes closed. PostiveRomberg is observed as a swaying motion, or inability to maintain balance, and indicates cerebellar dysfunction.2. Motor Cortex of Brain- What does it control?3. Know EACH Cranial Nerve (several questions)- how to assess each, what testing for, what each do, abnormal findingsvs. expected findings. (pg553) Olfactory (1)- Sensory: smell reception and interpretation. Have available 2-3 vials of aromatic odors. Ensure patient’s nasal passages are patent. Occlude one naris at a time and ask patient to breathe in and out, while closing her eyes. Use different odor to test the other side. Assess the ability of patient to differentiate between diff odors. Sense of smell diminishes with age. Anosmia (loss of sense of smell). Optic (ll)- Sensory: visual acuity and visual field (chapter 11) Oculomotor (lll)-Motor: raise eyelids, most extraocular movements. Parasympathetic: pupillary constriction,change lens shape Trochlear (lV)- Motor: downward, inward eye movement(lll, lV, Vl)- Movement of eyes through the six cardinal points of gaze, pupil size, shape, response, to light and accommodation and opening of the upper eyelids. When assessing pt with severe unremitting headaches, the experienced examiner evaluates movement of the eyes for the presence of absence of lateral gaze. The sixth cranial nerve is commonly one of the first to lose function in the presence of increased intracranial pressure. Trigeminal (V)- Motor: jaw opening and clenching, chewing and mastication. Sensory: sensation to cornea, iris, lacrimal glands, conjunctiva, eyelids, forehead, nose, nasal and mouth mucosa, teeth, tongue, ear, facial skin. Evaluate for muscle atrophy. Have patient clench teeth as you palpate the muscles over the jaw, evaluating tone, which should be symmetric, without fasciculations. The three divisions of the trigeminal nerve are evaluated for the sharp, dull and light sensations. With pt closing eyes, touch each side of face at the scalp, cheek and chin, alternating sharp and smooth edges of a broken23tongue blade or a paper clip. Ask patient to report feeling. Then stroke face with cotton wisp. If sensation is impaired, ask pt to differ btw hot/cold. Abducens (Vl)- Motor: lateral eye movement Facial (Vll)- ask pt to raise eyebrows, squeeze the eyes shut, wrinkle the forehead, frown, smile, show the teeth, purse the lips to whistle, and puff out the cheeks. Observe for ticks, unusual movements and symmetry of expression. Drooping of one side of mouth or sagging of lower eyelid will indicate muscle weakness. Ie: Bells palsyTo evaluate taste, a sensory fx of cranial nerves Vll and lX: have patient have tongue protruded and have 4 solutions with Bitter, sour, salty, sweet solutions on them. With applicator appl