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SH P&P 32

P&P Ch 32

QuestionAnswer
The first technique the nurse employs when conducting a client's physical examination is: Inspection
The main reason that auscultation proceeds palpation of the abdomen is to: Prevent distortion of bowel sounds.
To correctly palpate the client's skin for temperature, the nurse will use the: Dorsal surface of the hands.
To assess a client's superficial lymph nodes, the nurse would: Gently palpate using the pads of the index & middle fingers.
The nurse is teaching the client to inspect all skin surfaces & to resport pigmented skin lesions that: Have irregular borders.
The client is being assessed for range-of-joint movement. You ask the client to move the arm away from the body, evaluating the movement of: Abduction.
When inspecting the adult cleint's thorax, the nurse observes for: Symmetry of chest excursion.
The nurse is auscultating the client's lung fields. The systematic pattern used for comparison is: Side to side.
The nurse asks the client to interpret the saying "Don't count your chickens before they're hatched." The client response reveals: Association.
The nurse is conducting a general survey on an adult client. The general survey includes: Conducting a detailed health history.
Acromegaly Disorder caused by excessive secretion of growth hormones.
Adventitious Sounds Abnormal breath sounds (ie. crackles, rhonchi, wheezes, pleural friction rub)
Allen's Test Assess collateral circulation. Client makes a fist as the ulnar & radial arteries are compressed simultaneously.
Alopecia Hair loss or thinning of the hair.
Aneurysm Localized dilation of the vessel wall, pulsation expands laterally.
Aphasia Communication is clearly ineffective.
Apical Impulse & PMI Apex actually touches the anterior chest wall at approximately the 4th or 5th intercostal space just medial to the left midclavicular line.
Arcus Senilis Thin white ring along the margin of the iris, abnormal in anyone under age of 40.
Atherosclerosis Diminished or unequal carotid pulsations or aortic arch disease.
Atrophied Reduction of size in muscle.
Basal Cell Carcinomas Commonly seen in sun-exposed areas & frequently occur in background of sundamaged skin.
Borborygmi Hyperactive sounds that are loud, "growling" sounds; indicate increased GI mortility.
Bronchophony Vibrations from the client's voice are transmitted to the chest wall & the sounds become clear.
Bruit Blowing sounds.
Capillary Refill Measured by blanching the nail bed with a substantial pressure of several seconds.
Caries Cavities; Tartar along the base of the teeth.
Cerumen Yellow, waxy substance.
Chancres Syphilitic lesions; small open ulcers that drain serous material.
Cherry Angiomas Ruby red papules; Atrophic warts.
Cholecystitis Appendicitis cause this.
Cirrhosis Causes liver enlargement.
Clubbing Insufficient oxygenation at the perphery resulting from conditions such as chronic emphysema & congenital heart disease.
Conjunctivitis Presence of redness; usually indicates subconjunctival hemorrhage.
Cyanosis Bluish discoloration; observed in nail beds, lips, papebral conjunctive, & palms.
Cystocele Portion of the vaginal wall & bladder may prolapse or fall into the orifice anteriorly.
Dermatitis Excessive dryness.
Distention Swelling; when generalized the entire abdomen protrudes.
Dysrhythmia Failure of the heart to beat at regular successive intervals
Ectropion Lid margins that turn out
Entropion Lid margins that turn in
Excoriation Local skin breakdown of the naris; redness & sloughing of the skin.
Exophthalmos Bulging of eye usually caused by hyperthyroidism when both eyes are involved.
Exostosis Bony growth.
Goniometer Measures the precise degree of motion in a particular joint; mainly for pts. w/ suspected reduction in joint movement.
Hirsutism Woman with hair growth on upper lip, chin & cheeks.
Hypertonicity Muscle has increased tone.
Hypotonicity Muscle has decreased tone.
Kyphosis Hunchback; exaggeration of the posterior curvature of the thoracic spine.
Leukoplakia Thick white patches; can be seen in heavy smokers 7 alcoholics.
Lordosis Swayback; increase lumbar curvature
Metastasize Cancerous lesions that spread & nodes are commonly involved.
Nystagmus Involuntary, rhythmical oscillation of the eyes.
Occlusion Blockage.
Osteoporosis Metabolic bone disease that causes a decrease in quality & quanity of bone.
Pancreatitis Peritoneal injury which causes bile, blood, or enzymes to enter the peritoneal cavity.
Papaniolaou (Pap) Smear Collection to test for cervical & vaginal cancer.
Paralytic Ileus or Peritonitis Absent bowel sounds-->late stage bowel obstruction.
Peristalsis Intestinal motility; normal function of the small & large intestines.
Petechiae Pinpoint-sized, red or purple spots on the skin caused by small hemorrhages in the skin layer.
Phlebitis Inflammation of a vein that occurs commonly after trauma to the vessel wall, infection, prolonged immobilization, & prolonged insertion of IV's.
Polyps Tumorlike growths or purulent drainage.
Ptosis Abnormal drooping of the lid over the pupil; caused by edema or impairment of the 3rd cranial nerve.
Pulse deficit Radial pulse is slower than the apical pulse b/c ineffective contractions fail to send pulse waves tot he periphery.
Rectocele Bulging of the posterior wall may be caused by prolapse of the rectum.
Scoliosis Lateral spinal curvature.
Senile keratosis Thickening of the skin.
Striae Stretch marks.
Syncope Circulatory arrest.
Thrill Continuous palpable sensation like the purring of a cat.
Ventricular gallop Occurs just after S2 @ the end of ventricular diastole.
Psychological preparation of the client The component that should receive the highest priority before a physical examination.
The nurse assesses the skin turgor of the client Grasping a fold of skin on the back of the forearm & releasing.
Vesicle While examining Mr. Parker, the nurse notes a circumscribed elevation of skin filled with serous fluid on his upper lip. The lesion is 0.4 cm in diameter. This type of lesion is?
When assess the client's thorax, the nurse should: Compare symmetrical areas from side to side.
Wheezes In a client with pneumonia, the nurse hears high-pitched, continuous musical sounds over the bronchi on expiration. These sounds are called what?
The second heart sound (S2) occurs when: The aortic & pulmonic valves close.
Created by: SHeim79
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