Term
| These muscles extend the head and move the shoulders. |
|
Definition
|
|
Term
| The eleventh cranial nerve (XI) is responsible for... |
|
Definition
| ...muscle movement that permits shrugging of the shoulders by the trapezius muscles and turning the head against resistance by the sternomastoid muscles. |
|
|
Term
| The largest endocrine gland in the body is the... |
|
Definition
|
|
Term
|
Definition
| A clear substance composed mostly of excess tissue fluid. |
|
|
Term
|
Definition
| Filter lymph, after the lymphatic vessels collect it but before it returns to the vascular system. |
|
|
Term
| What do lymph nodes filter for? |
|
Definition
| The filtering action of lymph nodes removes bacteria and tumor cells from lymph. |
|
|
Term
| ___________ and __________ are produced in the lymph nodes as a defense against invasion by foreign substances. |
|
Definition
| lymphocytes and antibodies |
|
|
Term
| Normally lymph nodes are either not palpable or they may feel like very small beads. If the nodes are swollen and painful, what could this mean? |
|
Definition
| If the nodes become overwhelmed by microorganisms, as happens with an infection such as mononucleosis, they swell and become painful. |
|
|
Term
| What might nodes that are enlarged but not painful mean? |
|
Definition
| If cancer metastasizes to the lymph nodes, they may enlarge but not be painful. |
|
|
Term
|
Definition
| ...an increase in thyroid hormone production. |
|
|
Term
| Hyperthyroidism can result in... |
|
Definition
| ...insomnia, thinning hair, palpitations, and weight loss. |
|
|
Term
|
Definition
| ...a decrease in thyroid hormone production. |
|
|
Term
| Hypothyroidism can result in... |
|
Definition
| ...insomnia, thickening skin and nails, decreased energy levels, and constipation. |
|
|
Term
| Headaches: Character: What are the symptoms that may be present with a tension headache? |
|
Definition
| Symptoms of anxiety, tension, and depression may be present. |
|
|
Term
| Headaches: Character: may be accompanied by tearing, eyelid drooping, reddened eye, or runny nose |
|
Definition
|
|
Term
| Headaches: Character: Neurologic and mental symptoms and nausea and vomiting may develop. |
|
Definition
|
|
Term
| Headaches: Character: accompanied by nausea, vomiting, and sensitivity to noise or light |
|
Definition
|
|
Term
| Headaches: Onset and Precipitating Factors: No prodromal stage. May be aggrevated by coughing, sneezing, or sudden movement of the head. |
|
Definition
|
|
Term
| Headaches: Onset and Precipitating Factors: May have prodromal stage (visual disturbances, vertigo, tinnitus, numbness or tingling of fingers or toes). Precipitated by emotional disturbances, anxiety, or ingestion of alcohol, cheese, chocolate, or other foods and substances to which client is sensitive. |
|
Definition
|
|
Term
| Headaches: Onset and Precipitating Factors: may be precipitated by ingesting alcohol |
|
Definition
|
|
Term
| Headaches: Onset and Precipitating Factors: No prodromal stage. May occur with stress, anxiety, or depression. |
|
Definition
|
|
Term
| Headaches: Location: located around eyes, temples, cheeks, or forehead |
|
Definition
|
|
Term
| Headaches: Location: varies |
|
Definition
| varies with location of tumor |
|
|
Term
| Headaches: Location: localized in the eye and orbit and radiating to the facial and temporal regions |
|
Definition
|
|
Term
| Headaches: Location: usually located in the frontal, temporal, or occipital region |
|
Definition
|
|
Term
| Headaches: Duration: commonly occurs in the morning and lasts for several hours |
|
Definition
|
|
Term
| Headaches: Duration: lasts days, months, or years |
|
Definition
|
|
Term
| Headaches: Duration: lasts up to 3 days |
|
Definition
|
|
Term
| Headaches: Duration: typically occurs in the late evening or night |
|
Definition
|
|
Term
| Headaches: Severity: throbbing, severe, recurring |
|
Definition
|
|
Term
| Headaches: Severity: dull, aching, tight, diffuse |
|
Definition
|
|
Term
| Headaches: Severity: intense and stabbing |
|
Definition
|
|
Term
| Headaches: Severity: aching, steady, variable in intensity |
|
Definition
|
|
Term
| Headaches: Associated Factors: occur more often in women |
|
Definition
|
|
Term
| Headaches: Associated Factors: occur more in young males |
|
Definition
|
|
Term
| Headaches: Associated Factors: Which gender do tension headaches affect more often? |
|
Definition
| Tension headaches affect women more often than men. |
|
|
Term
| Do migraines commonly have a familial association? |
|
Definition
|
|
Term
| Acromegaly occurs when there is an increased production of which hormone? |
|
Definition
| growth hormone, making bones larger and thicker |
|
|
Term
| Physical Assessment: Aortic insufficiency may cause what abnormality of the head and face? |
|
Definition
| an involuntary nodding movement |
|
|
Term
| Physical Assessment: The head tilted to one side may indicate... |
|
Definition
| ...unilateral vision or hearing deficiency or shortening of the sternomastoid muscle. |
|
|
Term
| Physical Assessment: What facial abnormality may result from a CVA (cerebrovascular accident/sroke) or Bell's palsy (a neurologic condition)? |
|
Definition
| drooping of one side of the face |
|
|
Term
|
Definition
|
|
Term
| Inflammation of the temporal arteries may lead to... |
|
Definition
|
|
Term
| How do you assess the temporomandibular joint (TMJ)? |
|
Definition
| Place your index finger over the front of each ear as you ask the client to open her mouth. |
|
|
Term
| When assessing TMJ (temporomandibular joint) syndrome, be sure to explore the client's history of... |
|
Definition
|
|
Term
| Prominence or swellings other than the __ vertebre may be abnormal. |
|
Definition
|
|
Term
|
Definition
| an abnormal, convex curvature of the spine, with a resultant bulge at the upper back |
|
|
Term
| Normal Finding: Fat may accumulate around the cervical vertebrae (especially in women). This is sometimes called a... |
|
Definition
|
|
Term
| A human neck normally rotates how many degrees? |
|
Definition
|
|
Term
| Normally lymph nodes are what size and shape? |
|
Definition
| Normally lymph nodes are round and smaller than 1 cm and are not palpable. |
|
|
Term
| When lymph node enlargement exceeds 1 cm, the client is said to have _______________. |
|
Definition
|
|
Term
| Lymphadenopathy may be caused by... |
|
Definition
| ...acute or chronic infection, an autoimmune disorder, or metastatic disease. |
|
|
Term
| If one or two lymphatic groups enlarge, the client is said to have ________ _______________. |
|
Definition
|
|
Term
| If three or more lymphatic groups enlarge, it is called ___________ _______________. |
|
Definition
| generalized lymphadenopathy |
|
|
Term
| Generalized lymphadenopathy that persists for more than 3 months may be a sign of... |
|
Definition
| ...human immunodeficiency virus (HIV). |
|
|
Term
| Lymph node delimitation refers to... |
|
Definition
| ...the lymph node's position or boundary. |
|
|
Term
| What is the most accurate method to determine heart rate and rhythm? |
|
Definition
| ascultation of the apical pulse |
|
|
Term
| Why is ascultation of the apical pulse the most accurate method to determine heart rate and rhythm? |
|
Definition
| You are listening directly over the heart, rather than depending on the transmission of the pulse to a distal site, such as the radial pulse site. |
|
|
Term
| The following memory device can be used to assist in obtaining information from the patient who has chest pain: PQRST... P |
|
Definition
| Precipitating Events: What events or activities precipitated the pain (eg, argument, exercise, resting)? |
|
|
Term
|
Definition
| Quality of Pain: What does the pain feel like (eg, pressure, dull, aching, tight, squeezing)? |
|
|
Term
|
Definition
| Radiation of Pain: Where is the pain located? Does the pain radiate to other areas (eg, back, arms, jaw, teeth, shoulder, elbow)? |
|
|
Term
|
Definition
| Severity of Pain: Rate the pain on a scale of 0-10. |
|
|
Term
|
Definition
| Timing: When did the pain begin? Has the pain changed since this time? Have you had pain like this before? |
|
|
Term
| Pericarditis is a condition in which... |
|
Definition
| ...the sac-like covering around the heart (pericardium) becomes inflamed. Symptoms: Chest pain is almost always present. |
|
|
Term
| Assessment of Chest Discomfort: How Various Types of Chest Pain Differ: Onset: SUDDEN, USUALLY IN RESPONSE TO EXERTION, EMOTION, OR EXTREMES IN TEMPERATURE |
|
Definition
|
|
Term
| Assessment of Chest Discomfort: How Various Types of Chest Pain Differ: Onset: SUDDEN, WITHOUT PRECIPITATING FACTORS, OFTEN IN EARLY MORNING |
|
Definition
|
|
Term
| Assessment of Chest Discomfort: How Various Types of Chest Pain Differ: Onset: SUDDEN |
|
Definition
|
|
Term
| Assessment of Chest Discomfort: How Various Types of Chest Pain Differ: Onset: VARIABLE, MAY BE IN RESPONSE TO STRESS OR FATIGUE |
|
Definition
|
|
Term
| Assessment of Chest Discomfort: How Various Types of Chest Pain Differ: Onset: VARIABLE |
|
Definition
| Pleuropulmonay or Esophageal-Gastric |
|
|
Term
| Assessment of Chest Discomfort: How Various Types of Chest Pain Differ: Quality & Severity: SQUEEZING, HEARTBURN, VARIABLE SEVERITY |
|
Definition
|
|
Term
| Assessment of Chest Discomfort: How Various Types of Chest Pain Differ: Quality & Severity: INTENSE STABBING, VISELIKE PAIN OR PRESSURE, SEVERE |
|
Definition
|
|
Term
| Assessment of Chest Discomfort: How Various Types of Chest Pain Differ: Quality & Severity: SQUEEZING, VISE-LIKE PAIN |
|
Definition
|
|
Term
| Assessment of Chest Discomfort: How Various Types of Chest Pain Differ: Quality & Severity: DULL ACHE TO SHARP STABBING; MAY BE ASSOCIATED WITH NUMBNESS IN FINGERS |
|
Definition
|
|
Term
| Assessment of Chest Discomfort: How Various Types of Chest Pain Differ: Quality & Severity: SHARP, STABBING, MODERATE TO SEVERE |
|
Definition
|
|
Term
| Assessment of Chest Discomfort: How Various Types of Chest Pain Differ: Quality & Severity: MODERATE ACHE, WORSE ON INSPIRATION |
|
Definition
|
|
Term
| 5 parts of the sternum from superior to inferior |
|
Definition
| jugular notch, manubrium, sternal angle, body, xiphoid process |
|
|
Term
| Assessment of Chest Discomfort: How Various Types of Chest Pain Differ: Location & Radiation: SUBSTERNAL; MAY SPREAD THROUGHOUT THE ANTERIOR CHEST AND TO THE ARMS, JAW, BACK, OR NECK |
|
Definition
|
|
Term
| Assessment of Chest Discomfort: How Various Types of Chest Pain Differ: Location & Radiation: LUNG FIELDS |
|
Definition
|
|
Term
| Assessment of Chest Discomfort: How Various Types of Chest Pain Differ: Location & Radiation: SUBSTERNAL; MAY SPREAD TO THE SHOULDERS OR THE ABDOMEN |
|
Definition
|
|
Term
| Assessment of Chest Discomfort: How Various Types of Chest Pain Differ: Location & Radiation: USUALLY THE LEFT SIDE OF THE CHEST WITHOUT RADIATION |
|
Definition
|
|
Term
| Assessment of Chest Discomfort: How Various Types of Chest Pain Differ: Location & Radiation: SUBSTERNAL; USUALLY SPREADS TO THE LEFT SIDE OR THE BACK |
|
Definition
|
|
Term
| Assessment of Chest Discomfort: How Various Types of Chest Pain Differ: Location & Radiation: SUBSTERNAL; MAY SPREAD ACROSS THE CHEST AND THE BACK AND/OR DOWN THE ARMS |
|
Definition
|
|
Term
| Assessment of Chest Discomfort: How Various Types of Chest Pain Differ: Duration & Relieving Factors: USUALLY LASTS A FEW MINUTES |
|
Definition
|
|
Term
| Assessment of Chest Discomfort: How Various Types of Chest Pain Differ: Duration & Relieving Factors: USUALLY LASTS <15 MIN; RELIEVED WITH REST, NITRATE ADMINISTRATION, OR OXYGEN THERAPY |
|
Definition
|
|
Term
| Assessment of Chest Discomfort: How Various Types of Chest Pain Differ: Duration & Relieving Factors: USUALLY LASTS 30 MIN OR LONGER OR IS RELIEVED WITH OPIOIDS |
|
Definition
|
|
Term
| Assessment of Chest Discomfort: How Various Types of Chest Pain Differ: Duration & Relieving Factors: INTERMITTENT; RELIEVED WITH SITTING UPRIGHT, ANALGESIA, OR ADMINISTRATION OF ANTI-INFLAMMATORY AGENTS |
|
Definition
|
|
Term
| Assessment of Chest Discomfort: How Various Types of Chest Pain Differ: Duration & Relieving Factors: CONTINUOUS UNTIL THE UNDERLYING CONDITION IS TREATED OR THE CLIENT HAS RESTED |
|
Definition
|
|
Term
| Assessment of Chest Discomfort: How Various Types of Chest Pain Differ: Duration & Relieving Factors: VARIABLE; MAY BE RELIEVED WITH ANTACID ADMINISTRATION, FOOD INTAKE, OR TAKING A SITTING POSITION |
|
Definition
|
|
Term
| Which position provides the best exposure for inspection of the precordium? |
|
Definition
| a supine position with the chest exposed |
|
|
Term
| To assess for a left ventricular heave, the force of the impulse should be observed at which location? |
|
Definition
| left midclavicular line, 5th intercostal space. A left ventricular heave is seen at the apex. This forceful thrusting of the ventricle occurs with hypertrophy of the left ventricle. |
|
|
Term
| To begin palpation at the base of the heart, where should you palpate first? |
|
Definition
| right sternal border, 2nd intercostal space. |
|
|
Term
| The Heart: The right sternal border, 2nd intercostal space is the location of... |
|
Definition
| the aortic site. The aortic and pulmonic sites are found at the base of the heart. |
|
|
Term
| The nurse uses a stethoscope for auscultation of the client's heart, and plans to begin auscultation at the aortic area. How should the nurse plan to continue auscultation from that site? |
|
Definition
| inch the stehoscope across and down in a "Z" pattern |
|
|
Term
| During auscultation, you have difficulty distinguishing S1 from S2 because of the client's irregular heart rhythm. While continuing to listen at the aortic site, what action should you take? |
|
Definition
| Palpate the carotid artery pulse. S1 occurs simultaneously with the carotid artery pulsation. By gently palpating the carotid artery, you can distinguish S1 as the sound that occurs with each pulsation. |
|
|
Term
| What does a murmur sound like? |
|
Definition
| Murmurs are often heard as a swooshing sound. |
|
|
Term
| You hear a swooshing sound that coincides with S1 while listening with the diaphragm of the stethoscope. How should you identify this sound? |
|
Definition
|
|
Term
| Systolic murmurs coincide with which heart sound? |
|
Definition
| Systolic murmurs coincide with the S1 heart sound. |
|
|
Term
| To determine the grade of the murmur, what action should you take? |
|
Definition
| Note how easily the murmur is heard by gradually lifting the stethoscope. Murmurs are graded from 1 to 6. |
|
|
Term
|
Definition
| A soft dull sound heard after S2 is an abnormal heart sound. This S3 heart sound is low pitched and is heard best at the apex with the bell of the stethoscope. |
|
|
Term
| An S3 heart sound may be an early indicator of... |
|
Definition
| ...the onset of heart failure. |
|
|
Term
| After finding an S3 heart sound, what should you check for? |
|
Definition
| Check for jugular vein distention or other signs of heart failure. You would do this because an S3 heart sound may be an early indicator of the onset of heart failure. |
|
|
Term
| The nurse places the client supine in a Semi-Fowler's position. To inspect for jugular vein distention, what action should the nurse take? |
|
Definition
| remove the client's pillow and turn his head away slightly |
|
|
Term
| Which position allow you to measure the height of any jugular vein pulsations? |
|
Definition
| a semi-Flowler's position with the client's head turned slightly away |
|
|
Term
| Are venous pulsations palpable or not palpable? |
|
Definition
|
|
Term
| Is a split S2 a normal finding or an abnormal finding? |
|
Definition
| A split S2 is a normal finding. |
|
|
Term
| A split S2 can be heard in some people as the result of... |
|
Definition
| ...the slightly asynchronous closing of the aortic and pulmonic valves. |
|
|
Term
| A split S2 is heard best... |
|
Definition
| ...during inspiration at the pulmonic site, the left 2nd intercostal space. |
|
|
Term
| Vital signs and oxygen saturation are within normal parameters. Radial pulse rhythm is irregular. Increasingly frequent periods of dyspnea, dizziness and minor chest discomfort. What assessment would you make next? |
|
Definition
| Determine if the client is currently experiencing angina because the client has a history of chest discomfort. Agina should be treated immediately to reduce the risk for myocardial damage. |
|
|
Term
| S1 ("lub") is caused by... |
|
Definition
| ...turbulence caused by the closure of mitral and tricuspid valves at the start of systole. |
|
|
Term
| S2 ("dup") is caused by... |
|
Definition
| ...the closure of the aortic and pulmonic valves, marking the end of systole. |
|
|
Term
| The time between the first heart sound (S1) and the second heart sound (S2) defines... |
|
Definition
| ...systole (ventricular ejection). |
|
|
Term
| The time between the second heart sound (S2) and the following sound defines... |
|
Definition
| ...diastole (ventricular filling). |
|
|
Term
|
Definition
| Situation, Background,Assessment, Recommendations |
|
|
Term
| What are atrioventricular valve flaps anchored to? |
|
Definition
| papillary muscles within the ventricles |
|
|
Term
| What anchors atrioventricular valve flaps to papillary muscles within the ventricles? |
|
Definition
| collagen fibers called chordae tendineae |
|
|
