Skin, Hair, & Nails
Documentation of lesions
discribe color and how it differs from rest of the body,
What is the pattern of the lesion
What are the edges like, regular or irregular
Assessment techniques for cerebellar function
Romberg test
Tandem Walking
Knee bending
A 60 year old client undergoing chemotherapy presents to the clinic for a routine follow up exam. Upon removal of a cap, the nurse notes no hair present on the scalp. The nurse correctly documents this as:
Alopecia
What is found in the RUQ, LUQ, RLQ, LLQ
RUQ: Liver, Gallbladder
LUQ: Spleen, Stomach
RLQ: Appendix, right ureter
LLQ: Left ureter, sigmoid colon
Chlamydia if not caught in time
Can cause epididymitis and PID
Types of lesions caused by abuse
Bites
Burns
Bruises
Four lobes
Occipital
Temporal
Parietal
Frontal
When documenting the palpation of a pulse, the nurse is correct in making what notation about the rhythm?
irregular rhythm
Order of abdominal assessment
Inspect
Auscultate
Palpate
Percuss
Spermatocele
Sperm back up that turns into a mass, can be tranilluminated
Skin lesions common to infants
Milia
Erythema Toxicum
Diaper rash
Allergen rashes
Deep tendon reflex scoring
0 = absent reflex
1 = sluggish/slow reflex
2 = normal
3 = slightly hyperreactive
4 = Hyperreactive
A client admitted to the emergency department with a tracheal obstruction. What sound does the nurse expect to hear as the client breathes?
High pitched sounds on inspiration and expiration
Important question to ask a patient who complains of nausea and vomiting but doesn't know why?
chance of pregnancy?
Types of noninvasive breast cancer
DCIS: Precursor (more important)
LCIS: Risk factor
Early signs of melanoma pnemonic
A - ASYMMETERY
B - BORDER
C - COLOR
D - DIAMETER
E - ELEVATION
F - FEELING
Cranial nerve XII
Hypoglossal, tests swallowing and articulation. Have patient say AHHH
A nurse is assessing a client’s peripheral circulation. Which finding indicates venous insufficiency of this client’s legs?
Edema that is worse at the end of the day
A change in bowel habits may be considered what?
A warning sign of cancer
What breath sounds should be heard over the lateral and posterior thorax?
Vesicular and broncho vesicular
Define macule, papule, pustule, and vesicle
Macule: Flat, superficial, circumscribed lesion less then 1cm in diameter
Papule: solid, elevated, circumscribed lesion, less then 1cm in diameter
Pustule: elevated skin lesion with pus in it
Vesicle: fluid filled superficial lesion, less than 1 cm in diameter
When completing a skin assessment of a client the nurse notes a circular lesion with a clearing center. The nurse correctly documents this as a/an:
Annular lesion
How would the nurse distinguish the source of an auscultated pleural friction rub? (is it from the heart or the lung)
Would distinguish by having the patient hold their breath. If the rub is no longer heard while patient holds their breath, source is the kung. If the sounds continues while patient holds breath, source is the heart.