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test-2_ace_review.txt

  1. Define abduction
    • A motion that pulls a structure or part away from the midline of the body
    • (Weber,p.524, 527)
  2. Define adduction.
    • A motion that pulls a structure or part toward the midline of the body
    • (Weber,p.524, 527)
  3. Define dorsiflexion.
    • Dorsiflexion extension of the entire foot superiorly, as if taking one's foot off an automobile pedal.
    • (Weber,p.524, 527)
  4. Define plantarflexion.
    • Plantarflexion is flexion of the entire foot inferiorly, as if pressing an automobile pedal; occurs at ankle.
    • (Weber,p.524, 527)
  5. Define pronation.
    • Pronation is rotation of the forearm that moves the palm from an anterior-facing position to a posterior-facing position, or palm facing down. This is not medial rotation as this must be performed when the arm is half flexed.
    • (http://en.wikipedia.org/wiki/Anatomical_terms_of_motion)
    • (Weber,p.524, 527)
  6. Define supination.
    • Supination is the opposite of pronation, the rotation of the forearm so that the palm faces anteriorly, or palm facing up. The hand is supine (facing anteriorly) in the anatomical position.
    • (http://en.wikipedia.org/wiki/Anatomical_terms_of_motion)
    • (Weber,p.524, 527)
  7. Define flextion
    • Flextion is a bending movement that decreases the angle between two parts.
    • (http://en.wikipedia.org/wiki/Anatomical_terms_of_motion)
    • (Weber,p.524, 527)
  8. Define extension.
    • Extension ending movement that increases the angle between two parts.
    • (http://en.wikipedia.org/wiki/Anatomical_terms_of_motion)
    • (Weber,p.524, 527)
  9. Define eversion
    • Eversion is the movement of the sole of the foot away from the median plane.
    • (http://en.wikipedia.org/wiki/Anatomical_terms_of_motion)
    • (Weber,p.524, 527)
  10. Define inversion.
    • Inversion is the movement of the sole towards the median plane (same as when an ankle is twisted).
    • (http://en.wikipedia.org/wiki/Anatomical_terms_of_motion)
    • (Weber,p.524, 527)
  11. Define kyphosis.
    • kyphosis is rounded thoracic convexity (common in elderly).
    • (Musculoskeletal PPT, 21)
  12. Define scoliosis
    • Scoliosis is lateral curvature with incremental convexity on side with curve.
    • (Musculoskeletal PPT, 21)
  13. Define lumbar lordosis.
    • Lumbar lordosis is exaggerated lumbar curve (pregnancy or obesity).
    • (Musculoskeletal PPT, 21)
  14. What is crepitus in relation to subcutaneous emphysema? Crepitis in bones?
    • Crepitus in relation to subcutaneous emphysema is the course crackling sensation palpated over skin.
    • Crepitus in relation to bones is the sound of bones coming together such as when they are broken.
    • (Musculoskeletal PPT)
  15. Describe the six levels of the Muscular Strength Scale.
    • 0/5: no contraction
    • 1/5: muscle flicker, but no movement
    • 2/5: movement possible, but not against gravity
    • 3/5: movement against gravity, but not against
    • resistance by the examiner
    • 4/5: movement possible against some resistance by the examiner
    • 5/5: normal strength
    • (Musculoskeletal PPT)
  16. In the Muscular Strength Scale describe 0/5.
    • no contraction
    • (Musculoskeletal PPT)
  17. In the Muscular Strength Scale describe 1/5.
    • muscle flicker, but no movement
    • (Musculoskeletal PPT)
  18. In the Muscular Strength Scale describe 2/5.
    • movement possible, but not against gravity
    • (Musculoskeletal PPT)
  19. In the Muscular Strength Scale describe 3/5.
    • movement against gravity, but not against resistance by the examiner
    • (Musculoskeletal PPT)
  20. In the Muscular Strength Scale describe 4/5.
    • movement possible against some resistance by the examiner
    • (Musculoskeletal PPT)
  21. In the Muscular Strength Scale describe 5/5.
    • normal strength
    • (Musculoskeletal PPT)
  22. In the Muscular Strength Scale what level is no contraction?
    • 0/5
    • (Musculoskeletal PPT)
  23. In the Muscular Strength Scale what level is muscle flicker, but no movement?
    • 1/5
    • (Musculoskeletal PPT)
  24. In the Muscular Strength Scale what level is movement possible, but not against gravity?
    • 2/5
    • (Musculoskeletal PPT)
  25. In the Muscular Strength Scale what level is movement against gravity, but not against resistance by the examiner?
    • 3/5
    • (Musculoskeletal PPT)
  26. In the Muscular Strength Scale what level is movement possible against some resistance by the examiner?
    • 4/5
    • (Musculoskeletal PPT)
  27. In the Muscular Strength Scale what level is normal strength?
    • 5/5
    • (Musculoskeletal PPT)
  28. In a in a mental status exam, what areas are assessed?
    • Assess using the Glascow Coma Scale
    • __ While entering the room observe if their eyes are open.
    • __ Best Verbal Response: AAOx3
    • __ Best Motor Response
    • Note general appearance, affect, communication, memory, logic, judgment and speech patterns while conducting the health history.
    • (Musculoskeletal PPT)
  29. What is the Glascow Coma Scale used for and what does it assess?
    • It assesses eye opening, verbal response and motor response to determine if patient is comatose.
    • Eyes 1-4
    • Verbal 1-5
    • Motor 1-6
    • (Musculoskeletal PPT)
  30. In the Glascow Coma Scale, what is the rating for a fully alert and oriented person?
    • 15 (fifteen)
    • Eyes 4
    • verbal 5
    • Motor 6
    • (Musculoskeletal PPT)
  31. Define lethargic.
    • Opens eyes
    • Answers questions
    • Falls back to sleep
    • (Musculoskeletal PPT, 25)
  32. Define obtunded.
    • Opens eyes to loud voice
    • Responds slowly with confusion
    • Seems unaware of environment
    • (Musculoskeletal PPT, 25)
  33. Define stupor.
    • Awakens to vigorous shake or painful stimuli but returns to unresponsive sleep.
    • (Musculoskeletal PPT, 25)
  34. Define coma.
    • Unresponsive to all stimuli
    • Eyes stay closed
    • (Musculoskeletal PPT, 25)
  35. Describe a person with decorticate reflexes.
    • Flexion of elbows, wrists, fingers
    • Foot plantar flexion
    • (Musculoskeletal PPT, 26)
  36. Describe a person with decerebate reflexes.
    • Arms adducted, extended and hyper-pronated
    • Flexed fingers and wrists
    • (Musculoskeletal PPT, 26)
  37. List the twelve cranial nerves by name and number.
    • I Olfactory
    • II Optic
    • III Oculomotor
    • IV Trochlear
    • V Trigeminal
    • VI Abducens
    • VII Facial
    • VIII Vestibularcochlear/Auditory
    • IX Glossopharyngeal
    • X Vagus
    • XI Spinal Accessory
    • XII Hypoglossal
    • (Musculoskeletal PPT, 27)
  38. What is the name of CN I (Cranial Nerve I) and what does it do?
    • Olfactory
    • Sensory: sense of smell
    • Test:
    • __ Sniff test
    • __ Patency
    • __ Smell
  39. What is the name of CN II (Cranial Nerve II ) and what does it do?
    • Optic
    • Sensory: visual information
    • Test:
    • __ Visual aquity
    • __ Visual fields by confrontation
    • __ Fundoscopic exam
  40. What is the name of CN III (Cranial Nerve III ) and what does it do?
    • Oculomotor
    • Motor: most eye movements, constrict pupil, opens eyelid
    • Test:
    • __ PERRLA
    • __ Raise eyelid
    • __ Diagnostic Position Test or Cardinal fields of gaze
  41. What is the name of CN IV (Cranial Nerve IV ) and what does it do?
    • Trochlear
    • Motor:
    • __ Downward and inward movement of the eye
    • __ SO-LID, Superior Oblique: Lateral rotation (Abduction), Intorsion, Depression
    • Test:
    • __ Corneal light reflection
    • __ Diagnostic Position Test or
    • __ Cardinal fields of gaze
  42. What is the name of CN V (Cranial Nerve V ) and what does it do?
    • Trigeminal
    • __ Ophthalmic (V1)
    • ____ Sensory: upper part of face, forehead, scalp, nose
    • __ Maxillary (V2):
    • ____ Sensory: mid part of face, upper jaw
    • __ Mandibular (V3):
    • ____ Sensory: lower part of face, lower jaw. Touch/position and pain/temperature sensation from the mouth
    • ____ Motor: mastication, swallowing
    • Motor Test:
    • __ Masseter/temporal muscle
    • Sensory Test:
    • __ Light touch forehead, checks, jaw
    • __ Corneal reflex (blink)
  43. What is the name of CN VI (Cranial Nerve VI ) and what does it do?
    • Abducens
    • Motor: abducts the eye
    • Test:
    • __ Corneal light reflection
    • __ Lateral movement of eye
    • __ Diagnostic Position Test or Cardinal fields of gaze
  44. What is the name of CN VII (Cranial Nerve VII ) and what does it do?
    • Facial
    • Motor: facial expression
    • __ Test: make faces
    • Sensory: taste on anterior 2/3 tongue
    • Test: anterior tongue; sweet, salty, sour, bitter
  45. What is the name of CN VIII (Cranial Nerve VIII ) and what does it do?
    • Vestibularcochlear/Auditory
    • Sensory: sound, rotation and gravity
    • Test:
    • __ Whisper test
    • __ Rinne, air vs bone condiction
    • __ Rhomberg, stand with feet together, arms at side, and eyes closed
  46. What is the name of CN IX (Cranial Nerve IX ) and what does it do?
    • Glossopharyngeal
    • Sensory: posterior 1/3 tongue
    • ____ Test: posterior 1/3 tongue taste and gag reflex
    • Motor: speech and swallow
  47. What is the name of CN X (Cranial Nerve X ) and what does it do?
    • Vagus
    • Sensory and motor
    • Motor Test:
    • __ Soft palate and uvula rise with yawn or "ahh"
    • __ talking and swallowing
    • __ gag reflex
    • Sensory Test:
    • __ General sensation; carotid body, pharynx, visera
  48. What is the name of CN XI (Cranial Nerve XI ) and what does it do?
    • Spinal Accessory
    • Motor
    • Test:
    • __ Turn head against resistance
    • __ Shoulder shrug
    • __ Movement of trapezius and sternomastoid muscles
  49. What is the name of CN XII (Cranial Nerve XII ) and what does it do?
    • Hypoglossal
    • Motor: swallowing (bolus forming) and speech articulation
    • Test: Say, "light, tight, dynamite"
  50. Define PERRLA and what is it used for?
    • Pupils Equal Round, React to Light and Accomadation
    • Tests some functions of CN III (oculomotor)
  51. Where are the reflex sites for an adult?
    • Biceps
    • Triceps
    • Brachial
    • Patellar
    • Achilles
  52. Where is the triceps reflex assessed?
    • Fold arm across chest or dangle forearm from horizontal upper arm
    • Strike triceps tendon just above elbow.
  53. Where is the biceps reflex assessed?
    • Flex arm at 45 degrees at elbow with palm down.
    • ???????

    • Where is the brachial reflex assessed?
    • Triceps tendon with forearm flexed
    • ????
  54. Where is the achilles reflex assessed?
    Strike achilles tendon above the heel
  55. Where is the patellar reflex assessed?
    Tap patellar tendon just below patella
  56. What is a normal and abnormal Babinski reflex.
    • Stroke lateral side of sole from hell to balls of foot and across to big toe.
    • Normal: planter flextion of all toes
    • Abnormal: Splaying of the toes (this is normal under 2 years old)
  57. What is the rooting reflex in a newborn?
    • Touch upper lip, lower lip, or cheek with gloved finger or nipple.
    • Infant will head toward stimulated area and open mouth.
    • Absence serious CNS disease.
    • Disappears by 2-3 months.
    • (Weber, 659)
  58. What is the sucking reflex in a newborn?
    • Place gloved finger in the infant's mouth.
    • Note strength of sucking response.
    • Absence or weak response may indicate:
    • __ Neurological disorder
    • __ Prematurity
    • __ CNS depression caused by maternal drug use
    • __ CNS depression caused by medication during pregnancy
    • Disappears by 10-12 months
    • (Weber, 659)
  59. What is the palmar grasp reflex in a newborn?
    • Press finger against palmar surface of hand.
    • Grip should be strong.
    • Absense suggests neurologic deficit
    • Diminished response usually indicates prematurity
    • Asymmetric response suggests:
    • __ Fracture of humerous
    • __ Peripheral nerve damage
    • After 4 months may indicate cerebral dysfunction
    • Disappears by 3-4 months
    • (Weber, 660)
  60. What is the reflex scale indicate?
    • O - Absent
    • +1 - present but decreased
    • +2 - normal
    • +3 - increased or brisk
    • +4 - hyperreflexia (abnormal)
  61. What is O on the reflex scale indicate?
    Absent
  62. What is +1 on the reflex scale indicate?
    Present but decreased
  63. What is +2 on the reflex scale indicate?
    Normal
  64. What is +3 on the reflex scale indicate?
    Increased or brisk
  65. What is +4 on the reflex scale indicate?
    Hyperreflexia (abnormal)
  66. How is a reflex that is absent indicated on the reflex scale?
    0 (zero)
  67. How is a reflex that is "present but decreased" indicated on the reflex scale?
    +1
  68. How is a reflex that is normal indicated on the reflex scale?
    +2
  69. How is a reflex that is "increased or brisk" indicated on the reflex scale?
    +3
  70. How is a reflex that is hyperreflexic indicated on the reflex scale?
    +4
  71. What is normal urine color, clarity and odor?
    Yellow, clear, and odorless
  72. What is the normal urinary output per 24 hour period?
    • 1200-1500mL
    • Hourly output should be >= 30mL
  73. What is dysuria?
    Painful or burning urination.
  74. What is urgency?
    The feeling of being unable to delay the urge to void.
  75. What is (urinary) frequency?
    Voiding more often than normal, without a significant increase in fluid intake.
  76. What is hematuria?
    Pink or reddish color to the urine. Urine with blood.
  77. What is urinary retention?
    The inability to empty the bladder.
  78. What is incontinence?
    The involuntary loss of urine from the bladder.
  79. What is Stress Incontinence?
    Leakage of urine with sneezing, coughing or laughing
  80. What is the correct order of assessing the abdomen?
    • Inspection
    • Ascultation
    • Percussion
    • Light palpation
  81. Define absent bowel sounds.
  82. Define normal bowel sounds?
    High pitched gurgles 5 to 30 per minute.
  83. Define hypoactive bowel sounds?
    • Decreased bowel sounds due to:
    • Abdominal surgery
    • Late bowel obstruction
    • Peritonitis (inflammation of the abdominal lining)
    • Paralytic ileus (inability to pass stool or gas due to paralysis of the abdominal smooth muscles)
  84. Define hyperactive bowel sounds?
    Increased bowel sounds, may be due to diarrea.
  85. Where is the aortic valve auscultated?
    2nd intercostal space (ICS), left sternal border.
  86. Where is the pulmonic valve auscultated?
    2nd intercostal space (ICS), right sternal border.
  87. Where is the tricuspid valve auscultated?
    4th/5th intercostal space (ICS), right sternal border.
  88. Where is the mitral valve auscultated?
    5th intercostal space (ICS), right mid clavicular line.
  89. Where is the apex of the heart auscultated?
    5th intercostal space (ICS), right mid clavicular line.
  90. Where and what is the PMI?
    • Point of Maximum Impulse located at the apex of the heart
    • 5th intercostal space (ICS), right mid clavicular line.
  91. Where is erbs point and what is auscultated there?
    • 3nd intercostal space (ICS), right sternal border.
    • Best place to auscultate S2
  92. What are normal S1 heart sounds?
    • Closure of AV valves (mitral and tricuspid)
    • Beginning of systole.
    • Usually one sound, "Lub."
    • If two sounds:
    • __ 1. Mitral valve closure (M1).
    • __ 2. Tricuspid valve closure (T1).
    • (Weber, 354 & 367)
  93. What are normal S2 heart sounds?
    • Closure of semilunar valves (aortic and pulmonic)
    • Beginning of diastole.
    • Usually one sound, "Dub."
    • If two sounds:
    • __ 1. Aortic valve closure (A2).
    • __ 2. Pulmonic valve closure (P2).
    • (Weber, 354 & 367)
  94. What is the systolic pause?
    The the short duration between S1 and S2.
  95. What is the systolic pause?
    The the long duration between S2 and S1.
  96. How are the carotid arteries auscultated and what are normal findings?
    • Place bell of stethoscope over the carotid artery.
    • Ask client to hold breath.
  97. How is capillary refill tested? What is normal?
    • Compress nailbed until it blanches.
    • Normal time for color to return is 2-3 seconds.
  98. What are the characteristics of normal lymph nodes?
    • Drain excess fluid from tissue.
    • Return extra plasma protein to venous system.
    • Absorb lipids (fats) from small intestine.
    • Launching areas for lymphatic cells.
  99. What should be noted when inspecting upper and lower extremities?
    • Varicosities
    • Skin color
    • Nail description & clubbing
    • Hair distribution
    • Rashes
    • Lesions
    • Wounds
    • Ulcers
    • Drainage
    • Size
    • Symmetry (tape measure)
    • Swelling (edema)
  100. What should be noted when palpating upper and lower extremities?
    • you note when palpating upper & lower extremities?
    • Temperature
    • Texture
    • Moistness
    • Turgor
    • Tightness
    • Pain
    • Edema
    • Capillary refill time (2-3 seconds)
    • Pain
  101. What is the range of the Pulse Quality Scale (for N101)?
    0 to +3
  102. What is the pulse quality rating for an absent pulse?
    • 0 (zero)
    • Absent pulse—not palpable and not able to be auscultated by doppler
    • If pulse cannot be palpated, the nurse should try to auscultate the pulse by Doppler. If pulse is heard by Doppler, document, “pulse by doppler”. Don’t use the scale.
  103. What is the pulse quality rating for a thready or weak pulse? How can that be tested?
    • + 1
    • Easily obliterated by slight finger pressure.
  104. What is the pulse quality rating for a pulse that is hard to feel? How can that be tested?
    • + 1
    • Easily obliterated by slight finger pressure.
  105. What is the pulse quality rating for a normal pulse? How can that be tested or recognized?
    • + 2
    • Normal pulse strength—easily palpable
    • Obliterated by strong finger pressure
  106. What is the pulse quality rating for a pulse obliterated by strong finger pressure? How can that be tested?
    • + 2
    • Normal pulse strength—easily palpable
  107. What is the pulse quality rating for a forceful pulse? How can that be tested or recognized?
    • + 3
    • Bounding pulse—readily palpable
    • Not easily obliterated by pressure from the fingers
  108. What is the pulse quality rating for a bounding pulse? How can that be tested or recognized?
    • + 3
    • Readily palpable, forceful
    • Not easily obliterated by pressure from the fingers
  109. Define soft non-pitting edema.
    • Edema can depressed with finger but does not retain an impression
    • Define pitting edema.
    • Edema that when pressed firmly retains the shape of the finger
  110. Define hard non-pitting edema.
    Edema that cannot be depressed.
  111. Describe the Pitting Edema Scale in relation to depth.
    • + 1 = 2 mm deep
    • + 2 = 4 mm deep
    • + 3 = 6 mm deep
    • + 4 = 8 mm deep
    • (number X 2)
Author
digver
ID
44876
Card Set
test-2_ace_review.txt
Description
N101 ACE review for test 2
Updated

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