CARDIOVASCULAR & VASCULAR
What is the name of the area on the anterior chest that overlies the heart and great vessels?
What is the precordium?
What is the correct sequence for assessing the abdomen?
What is Inspection → Auscultation → Percussion → Palpation?
What is the largest joint in the body?
What is the knee?
Which cranial nerve is responsible for the sense of smell?
What is Cranial Nerve I — Olfactory?
The nurse hears an extra heart sound immediately after S2 during early ventricular filling. What heart sound is this?
What is S3?
Where is the apical impulse normally located?
What is the 5th intercostal space at or near the left midclavicular line?
How long must the nurse listen before documenting that bowel sounds are absent (per textbook)?
What is 5 minutes?
What two primary movements occur at the tibiotalar joint of the ankle?
What are dorsiflexion and plantar flexion?
What deep tendon reflex score represents an average, normal response?
What is 2+?
A patient is unable to identify a number or letter traced on the palm while the eyes are closed. What sensory function is being tested?
What is graphesthesia?
Why should the nurse palpate only one carotid artery at a time (two answers)?
To avoid compromising cerebral blood flow. Excessive pressure over the carotid sinus may also stimulate the vagus nerve, slowing the heart rate and lowering blood pressure.
What percussion sound normally predominates over the abdomen because of air within the intestines?
What is tympany?
What are the four muscles of the rotator cuff?
What are the:
Supraspinatus, Infraspinatus, Teres minor, and Subscapularis?
During testing, the patient stands with the feet together and then closes the eyes for approximately 20 seconds. Loss of balance after closing the eyes represents a positive result of what test?
What is the Romberg test?
During rapid alternating movement testing, the patient's movements are slow, clumsy, and sloppy. What is this finding called?
What is dysdiadochokinesia, which may occur with cerebellar disease?
Jugular veins that remain distended when the patient is elevated greater than approximately 45 degrees suggest what abnormal finding?
What is increased central venous pressure, which may occur with heart failure?
Sharp pain produced when assessing the costovertebral angle may indicate inflammation involving what organ?
What is the kidney? This may occur with kidney or perinephric inflammation such as pyelonephritis.
What term describes diminished muscle strength, compared with the term used for complete absence of muscle strength?
Paresis means diminished muscle strength; paralysis/plegia means absent muscle strength.
What cortical sensory test asks the patient to identify a familiar object placed in the hand while the eyes are closed?
What is stereognosis?
A patient has hyperreflexia, sustained clonus, spasticity, weakness, and a positive Babinski response. What type of neurologic involvement should the nurse suspect?
What is upper motor neuron involvement?
A patient's apical heart rate is 94 beats/minute, but the radial pulse is 80 beats/minute. What is this finding called, and what is the value?
What is a pulse deficit of 14 beats/minute? It indicates that some ventricular contractions are too weak to produce a palpable peripheral pulse.
During a prostate examination, the prostate is enlarged, firm, smooth, and the central groove is obliterated. What condition does this finding suggest?
What is benign prostatic hyperplasia (BPH)?
When testing muscle tone, the examiner finds marked spasticity or rigidity rather than the expected mild, even resistance. According to the lecture material, this pattern is associated with what type of weakness?
What is central weakness?
In an adult, dorsiflexion of the great toe with fanning of the other toes indicates what abnormal finding, and what type of neurologic disease may it suggest?
What is a positive Babinski sign, suggesting upper motor neuron/corticospinal tract disease?
During an abdominal assessment, the nurse finds a rigid, boardlike abdominal wall, extreme tenderness, rebound tenderness, and absent bowel sounds. What major condition should these findings raise concern for?
What is an acute abdomen/peritoneal irritation?
A hospitalized patient with a neurologic deficit develops a change in level of consciousness. On reassessment, the nurse finds a sudden unilateral dilated, nonreactive pupil. The patient's blood pressure is increasing with a widening pulse pressure, while the pulse becomes slow and bounding.
Name the major neurologic concern AND the cranial nerve that may be compressed.
What is increasing intracranial pressure (ICP) with compression of Cranial Nerve III — the oculomotor nerve?
The combination of increasing blood pressure/widening pulse pressure with a slow, bounding pulse is described in your material as the Cushing reflex, an ominous sign of increasing ICP. A sudden unilateral dilated, nonreactive pupil can occur when increasing ICP compresses CN III.