PAH REVIEW?

• Review
 QUESTION

• To assess an adult client’s internal ear

canal with an otoscope. What are some of
the actions to be taken by the nurse?
 ANSWER

• Insert the speculum slightly down and

forward
• Use the light to visualize the tympanic
membrane in a cone shape.
• Make sure the speculum does not touch the
ear canal.
 QUESTION

•To identify early jaundice, assess?

 ANSWER

• Sclera and hard palate

 QUESTION

• To test for stereognosis, you would?

 ANSWER

Place a coin in the person’s hand and ask to

identify it.
 QUESTION

• The thickening and yellowing of

the lens due to aging is described
as?
 ANSWER

Senile cataract
 QUESTION

• The sinuses you can assess

through examination are?
 ANSWER

Frontal and maxillary.

 QUESTION

• To elicit the plantar reflex?

 ANSWER

• Stroke the lateral aspect of the sole of

the foot from heel to across the ball.
 QUESTION

• The unpleasant effect that occurs

when use of a drug is stopped is
called?
 ANSWER

• Withdrawal
 QUESTION

• If the tonsils are graded 1+, the tonsils would be:

• Touching the uvula.?
• Touching each other.?
• Visible.?
 ANSWER

• Visible.
 QUESTION

• The most important thing to include on the chart

of the patient who has been the victim of abuse?
A summary of the abused patient’s statements?

Photographic documentation of injuries. ?

 ANSWER

Photographic documentation of
injuries.
 QUESTION

• Routine universal screening for

domestic violence includes?
 ANSWER

• Asking all women each time they

come to the health care system if
they are abused.
 QUESTION

• Which symptoms suggest benign

prostatic hypertrophy (BPH)?
• a. Fever, chills, urinary frequency,
and urgency?
• b. Difficulty initiating urination
and weak stream?
 ANSWER

• Difficulty initiating urination and

weak stream
 QUESTION

• Assessing capillary refill - Abnormal

finding
• - capillary refill time more than …
seconds?
 QUESTION

• For assessment of the spine, ask person to:

-Supinate, evert, and retract ?
-Flex, extend, abduct, and rotate?
 ANSWER

Flex, extend, abduct, and rotate.

 QUESTION

• Best description of an accurate assessment of a

patient’s pulse.
• Count for 30 seconds if the pulse is regular?

• Count for 1 full minute; begin counting with

zero?
 ANSWER

• Count for 30 seconds if the pulse is regular

 QUESTION

• When examining tactile fremitus, it is important

to:
Use the bell of the stethescope.?
Palpate the chest symmetrically?
 ANSWER

• Palpate the chest symmetrically

 QUESTION

• Which older adult is at lowest risk for alteration in

nutritional status?
• 80-year-old widow who lives alone?
• 65-year-old widower who visits a senior center with a
meal program 5 days per week?
 ANSWER

• 65-year-old widower who visits a senior center with a meal

program 5 days per week
 QUESTION

• Concept of communication - verbal and nonverbal

behaviors that do not match.?
 REMINDER!

• Communication is all behaviors, conscious and

unconscious, verbal and nonverbal. All behaviors
have meaning.
 QUESTION

• True statement regarding open-ended

questions?
 ANSWER

• Open-ended questions allow for self-expression,

• build and enhance rapport,
• obtain narrative information.
These features enhance communication during an
interview.
 REMINDER

• Therapeutic response.
• Nontherapeutic response.
• Providing false assurance or reassurance closes
off communication, trivializes pt’s anxiety, and
denies any further talk of the matter.
 QUESTION

• I just don’t know the best way to do it. What should I

do? a patient ask
 ANSWER & REMINDER

• The nurse should answer : “Would you like

some information about …such and such”

• Clarification should be used when the person’s word choice

is ambiguous or confusing. Clarification is also used to
summarize the person’s words or to simplify the words to
make them clearer; the nurse should then ask if he or she is
on the right track.
 QUESTION

• Nurse needs to choose an interpreter.

Which of the following would be the most
appropriate choice?
Trained interpreter?
Male family member?
 ANSWER

• Trained interpreter
 QUESTION

• Purpose of a health history- Best description?

To document the normal and abnormal findings of a physical
assessment?
To provide a database of subjective information about the
patient’s past and current health?
 ANSWER

• The purpose of the health history is to collect

subjective data—what the person says about him
or herself.
 QUESTION

Signs and symptoms -Which of these is an

example of a symptom?
Chest pain
Clammy skin
 ANSWER & REMINDER

• Chest Pain
• A symptom is a subjective sensation (e.g., chest
pain) that a person feels from a disorder.
• A sign is an objective abnormality that the
examiner can detect on physical examination or in
laboratory reports
 QUESTION

• Description of the character or quality of

symptoms – which one describe the quality?
“It is a sharp, burning pain in my stomach.”?
“I also have the sweats and nausea when I feel
this pain?”
 ANSWER & REMINDER

• Describing the pain as “sharp and burning”

reflects the character or quality of the pain;
describing the “sweats and nausea” reflects
associated factors that occur with the pain.
• The setting describes where the person
is or what the person is doing when the
symptom starts.
 QUESTION

• CAGE test indication?

ANSWER
 QUESTION

• Assessment of delirium patient as a result of

fluid and electrolyte imbalance?
• What is delirium?
 ANSWER

• Assess level of consciousness and cognitive

abilities

• Delirium is a disturbance of consciousness (i.e.,

reduced clarity of awareness of the environment)
with reduced ability to focus, sustain, or shift
attention.
 QUESTION

• Mini-Cog test screening in an older adult woman?

ANSWER
 QUESTION

• Symptoms of ETOH withdrawal?

ANSWER
 QUESTION

• Danger assessment (DA) tool?

 ANSWER & REMINDER

• To evaluate the risk of homicide.

• The Danger Assessment helps to determine
the level of danger an abused woman has of
being killed by her intimate partner.
• The higher the number “yes” answers, the more serious the
danger of the woman’s situation.
 QUESTION

If unable to palpate the right radial pulse on a

patient. The best action is:?
Check for the presence of pulsations with a
stethoscope?
Use a Doppler device to check for pulsations
over the area?
 ANSWER

• Use a Doppler device to check for pulsations over

the area.
 QUESTION

• BMI category in adults – Indicative of

obesity?
 ANSWER

• 30 to 39.9 kg/m2
 QUESTION

Findings expectations in a low-protein liquid diet

patient?

-Decreased serum albumin?

-Poor skin turgor?
 ANSWER

• Decreased serum albumin

• Kwashiorkor (protein malnutrition) is due to diets that may be

high in calories but contain little or no protein (e.g., low-protein
liquid diets, fad diets, and long-term use of dextrose-containing
intravenous fluids). The serum albumin would be less than 3.5
g/dL.
 QUESTION

• What gland will you examine in an

Elevated thyroxine (T4) level?
ANSWER
 QUESTION

• The four areas in the body where lymph

nodes are accessible are ?
 ANSWER

• Head and neck, arms, inguinal area,

and axillae.
 QUESTION

• H/A characteristics ?
• Excruciating h/a pain on one side of head, especially around
eye, forehead, and cheek lasting approximately 2 hours,
occurring once or twice each day.

Migraine headaches?
Cluster headaches?
 ANSWER

• Cluster headaches
• produce pain around the eye, temple, forehead, and cheek
and are unilateral and always on the same side of the head.
They are excruciating and occur once or twice per day and
last to 2 hours each.
 QUESTION

• Documentation of 20/30 vision when the

Snellen eye chart is used – Interpretation?
The patient can read from 30 feet what a
person with normal vision can read from 20
feet?
The patient can read at 20 feet what a person
with normal vision can read at 30 feet?
 ANSWER

• The top number indicates the distance the

person is standing from the chart; the
denominator gives the distance at which a
normal eye can see.
• The patient can read at 20 feet what a
person with normal vision can read at
30 feet.
 QUESTION

• A red glow is noticed in the patient’s pupils during eye

examination, what should the nurse do?
Continue with the ophthalmoscopic examination, and
refer the patient for further evaluation?
Consider the red glow a normal reflection of the
ophthalmoscope light off the inner retina?
 ANSWER

• Consider the red glow a normal reflection

of the ophthalmoscope light off the inner
retina
 QUESTION

• Purpose of the cerumen in patient’s

ear?
 ANSWER

• The ear is lined with glands that secrete cerumen, which is a

yellow waxy material that lubricates and protects
the ear.
 QUESTION

• Ear examination of an 80-year-old patient -

normal findings?
High-tone frequency loss?
Increased elasticity of the pinna?
 ANSWER

• A high-tone frequency hearing loss is

apparent for those affected with
presbycusis, the hearing loss that occurs
with aging.
REMINDER
 QUESTION

• Palpation of the sinus areas – normal

findings?
Firm pressure?
No sensation?
 ANSWER

• Firm pressure
 QUESTION

• Assessment of woman’s axillary lymph

system - which nodes to assess?
Central, lateral, pectoral, and subscapular?

Central, axillary, lateral, and sternal?

ANSWER
 REMINDER-
BREAST EXAMINATION

• It is common to have a slight asymmetry in

size; often the left breast is slightly larger
than the right. Always verify that this
change is not new.
 QUESTION

• Position most likely to make significant lumps

more distinct during breast palpation?
ANSWER
 QUESTION
BREATH SOUNDS
• Low-pitched, soft breath sounds over the posterior
lower lobes, with inspiration being longer than
expiration are indicative of ?
Bronchial breath sounds?
Vesicular breath sounds?
ANSWER
 QUESTION

• Long history of chronic obstructive

pulmonary disease (COPD) - Emphysema.
Characteristics?
Atrophied neck and trapezius muscles ?
Barrel chest ?
 ANSWER

• Barrel chest is observed in individuals with

COPD because of hyperinflation of the lungs. The
ribs are more horizontal, and the chest appears as
if held in continuous inspiration
 QUESTION

• Non-modifiable risk factors for CVD?

 ANSWER & REMINDER

- Family history
- Gender

•Nine modifiable risk factors for MI, as identified by a

recent study, include abnormal lipids, smoking,
hypertension, diabetes, abdominal obesity, psychosocial
factors, consumption of fruits and vegetables, alcohol
use, and regular physical activity.
 QUESTION

• a thrill is?
 ANSWER

• Vibration that is palpable

 QUESTION

• The presence of an enlarged right tonsillar

lymph node is noted during assessment? What
is the next step?
• Carefully assess the axillary lymph nodes, and
check for any enlargement?
• Ask additional health history questions regarding
any recent ear infections or sore throats?
 ANSWER

• Ask additional health history

questions regarding any recent ear
infections or sore throats.
 QUESTION

• Intermittent claudication feels like a cramp

and is usually relieved by rest within 2
minutes.
 ANSWER & REMINDER

• When documenting the force, or amplitude, of

pulses, 3+ indicates an increased, full, or
bounding pulse, 2+ indicates a normal pulse, 1+
indicates a weak pulse, and 0 indicates an absent
pulse.
 QUESTION –

• Venous stasis: Observation?

 ANSWER

• Edema, varicosities, weeping ulcers at

ankles
 QUESTION

• Spleen location?
 ANSWER

• LUQ
 REMINDER

• Black stools may be tarry as a result of occult

blood (melena) from gastrointestinal bleeding.
 QUESTION

• Hernia – Definition
 ANSWER

• Hernia is a protrusion of the abdominal

viscera through an abnormal opening in
the muscle wall.
 QUESTION

• a scaphoid contour of the abdomen depicts a

Convex profile?
Concave profile?
 ANSWER

• A scaphoid contour is one that is concave

from a horizontal plane
 REMINDER
LIVER ASSESSMENT
 QUESTION

• sharp pain along the costovertebral angles is

indicative of ?
ANSWER
 REMINDER

• Ascites is free fluid in the peritoneal cavity

and occurs with heart failure, portal
hypertension, cirrhosis, hepatitis,
pancreatitis, and cancer.
 QUESTION

• The appendix is located?

 ANSWER

• In the Right lower quadrant. (RLQ)

 QUESTION

• Appropriate procedure to assess for

appendicitis or a perforated appendix?
 ANSWER

• Testing for the Blumberg sign (rebound

tenderness) - and performing the iliopsoas
muscle test should be used when assessing for
appendicitis.
 QUESTION

• Palpation of the TMJ?

ANSWER
REMINDER
 QUESTION

• Testes? True statement

 ANSWER

• When it is cold, the cremaster muscle contracts,

which raises the scrotal sac and brings the testes
closer to the body to absorb heat necessary for
sperm viability.
 QUESTION
• Name the condition when the urethral
meatus is ventrally positioned
 ANSWER

• Hypospadias
QUESTION
• Name the condition when the foreskin is nonretractable,
forming a pointy tip of the penis with a tiny orifice at the
end of the glans.
 ANSWER

• Phimosis
REMINDER
 REMINDER

• Direct inguinal hernia- Characteristic?

• Painless, round swelling close to the pubis in the
area of the internal inguinal ring that is easily
reduced when the individual is supine.
REMINDER
 REMINDER
PROSTATE GLAND

• The prostate gland secretes a thin milky

alkaline fluid that enhances sperm
viability.
PROSTATE –CHARACTERISTIC?
 REMINDER

• External hemorrhoid, when thrombosed,

contains clotted blood and becomes a painful,
swollen, shiny blue mass that itches and bleeds
with defecation
 FECAL IMPACTION
REMINDER
• A fecal impaction is a collection of hard,
desiccated feces in the rectum. The obstruction
often results from decreased bowel motility, in
which more water is reabsorbed from the stool.
 QUESTION

• What is it found at the end of the vaginal

canal?
 ANSWER

• The cervix projects into the

vagina.
 HRT – SIDE EFFECTS

• Side effects of Hormone Replacement

Therapy include fluid retention, breast
pain, and vaginal bleeding.
 STI - ASSESSMENT

• In reviewing a patient’s risk for STIs, the

nurse should ask in a nonconfrontational
manner whether condoms are being used
during each episode of sexual
intercourse.
 HPV
REMINDER

• HPV is the virus responsible for most

cases of cervical cancer
 HPV LESIONS

• HPV lesions are painless, warty growths that the woman may
not notice.
• Lesions are pink or flesh colored, soft, pointed, moist, warty
papules that occur in single or multiple cauliflower-like
patches around the vulva, introitus, anus, vagina, or cervix
 HPV VACCINE

• The HPV (human papillomavirus) vaccine is

appropriate for girls and women age 9 to 26 and is
given to prevent cervical cancer by preventing
HPV infections before girls become sexually
active.
• However, it cannot protect if an HPV infection
is already present.
 REMINDER

• Facial sensations of pain or touch are mediated by

CN V, which is the trigeminal nerve.
 MEAN ARTERIAL PRESSURE
CALCULATION
• MAP = 2xDBP + SBP/3

• For example: 158/96

• MAP= 116
 QUESTION

• Cerebellar function
assessment?
 ANSWER

• Cerebellar function assesses

Coordination - hopping on one foot
 QUESTION

• Common age-related change in the curvature of the spinal

column?

• Lordosis?
• Kyphosis?
• Scoliosis ?
• Lateral scoliosis ?
 ANSWER

• Kyphosis
 QUESTION

• Pulse deficit?

• For ex : The apical pulse is 118 beats per

minute, and the radial pulse is 105 beats
per minute. What is the pulse deficit
 ANSWER

• 13
• Normally, every beat heard at the apex should perfuse to the
periphery and be palpable. The two counts should be
identical. If they are different, then the nurse should
subtract the radial rate from the apical pulse and record the
remainder as the pulse deficit.
 QUESTION

• Examples of intimate partner

violence?
 ANSWER

• Marital rape
• Hitting a date
• An ex-boyfriend stalks his ex-girlfriend
 REMINDER

• For percussion, percuss two times over

each location.
 TEST YOUR KNOWLEDGE

• Which CN is responsible for hearing and equilibrium?

• Patient had a stroke. The right side of his face is drooping.
You might also suspect which findings? Dysphagia can be
suspected
• When testing the triceps and biceps reflex, what are the
expected responses?
• - The normal response of the triceps reflex is extension
of the forearm. The normal response of the biceps reflex
causes flexion of the forearm.
• Facial sensations of pain or touch are mediated
by CN V, which is the trigeminal nerve. If
unable to differentiate between sharp and dull
stimulation to both sides of her face. Suspect
damage to the trigeminal nerve.
• Cerebellar function is assessed by coordination such as
hopping on one foot
• Global aphasia ( both receptive and expressive).
• - Expressive aphasia - frontal lobe: Broca - can't talk
or can only garble sound, but understands
• - Receptive Aphasia - Temporal lobe: Wernick : hear
sound, but no meaning
• Include in the Care Plan to : Speak at a slower rate - use
cards with pictures -give instructions one step at a time
• It has been such a privilege!
• May God bless your Journey!

• Au revoir!