NR 509 Final Exam-with 100% verified solutions-2024-2025-tutor verified.docx, Exams of Nursing

Download NR 509 Final Exam-with 100% verified solutions-2024-2025-tutor verified.docx and more Exams Nursing in PDF only on Docsity! NR 509 Final Exam-with 100% verified solutions-2024-2025-tutor verified Appendicitis 1. McBurney point tenderness 2. Rovsing sign 3. the psoas sign 4. the obturator sign --Appendicitis is twice as likely in the presence of RLQ tenderness, Rovsing sign, and the psoas sign --The pain of appendicitis classically begins near the umbilicus, then migrates to the RLQ. Older adults are less likely to report this pattern. --Localized tenderness anywhere in the RLQ, even in the right flank, suggests appendicitis. McBurney Point 1. McBurney point lies 2 inches from the anterior superior spinous process of ilium on a line drawn from that process to the umbilicus 2. Appendicitis is three times more likely if there is McBurney point tenderness. Rovsing sign Press deeply and evenly in the LLQ. Then quickly withdraw your fingers. Pain in the RLQ during left-sided pressure is a positive Rovsing sign. Psoas Sign --Place your hand just above the patient's right knee and ask the patient to raise that thigh against your hand. Alternatively, ask the patient to turn onto the left side. Then extend the patient's right leg at the hip. Flexion of the leg at the hip makes the psoas muscle contract; extension stretches it. --Increased abdominal pain on either maneuver is a positive psoas sign, sug-gesting irritation of the psoas muscle by an inflamed appendix. Obturator Sign --Less helpful --Flex the patient's right thigh at the hip, with the knee bent, and rotate the leg internally at the hip. This maneuver stretches the internal obturator muscle. --Right hypogastric pain is a positive obturator sign, from irritation of the obturator muscle by an inflamed appendix. This sign has very low sensitivity. Acute Cholecystits RUQ pain Murphy Sign Murphy Sign Hook your left thumb or the fingers of your right hand under the costal margin at the point where the lateral border of the rectus muscle intersects with the costal margin. Alternatively, palpate the RUQ with the fingers of your right hand near the costal margin. If the liver is enlarged, hook your thumb or fingers under the liver edge at a comparable point. Ask the patient to take a deep breath, which forces the liver and gallbladder down toward the examining fingers. Watch the patient's breathing and note the degree of tenderness. --A sharp increase in tenderness with inspiratory effort is a positive Murphy sign. When positive, Murphy sign triples the likelihood of acute cholecystitis. Acute Pancreatitis Process Intrapancreatic trypsinogen activation to trypsin and other enzymes, result-ing in autodigestion and inflammation of the pancreas Acute Pancreatitis Location Epigastric, may radiate straight to the back or other areas of the abdomen; 20% with severe sequelae of organ failure Acute Pancreatitis Quality Usually steady Acute PancreatitisTiming Acute onset, persistent pain Acute Pancreatitis Aggrevating Factors Lying supine; dyspnea if pleural effusions from capillary leak syn-drome; selected medications, high triglycerides may exacerbate Acute Pancreatitis Relieving factors Leaning forward with trunk flexed Acute Pancreatitis Associated Symptoms and Setting Nausea, vomiting, abdominal dis-tention, fever; often recurrent; 80% with history of alcohol abuse or gallstones Fever, constipation. Also nausea, vomiting, abdominal mass with rebound tenderness Hepatitis -Tenderness over liver (liver inflammation) --Hep A and B prevention: Vaccination Hep A: spread through fecal matter and asymptomatic children Hep B: 1% fatality, 15-25% of chronic infection die from cirrhosis or liver cancer (usually asymptomatic until onset of advanced liver disease). Hep C: Mainly percutaneous exposure. Hepatitis B high risk -Sexual contact: w/ partners infected, more than one parter in prior 6 mos, people seeing eval of treatment for STD, men with men -Perc and Mucosal exposure to blod: drugs, household contacts, residents and staff of facilties of DD, Health care, dialysis -Others: Travel to endemic areas, chronic liver disease and HIV, people seeking protection from Hep B. --All adults in high risk-settings: STD clinics, HIV programs, Drug programs, correctional facilities, programs for gay men, chronic hemodialysis facilities, facilities for people with Developmental Delays. IBS patterns 1. diarrhea—predominant 2. constipation—predominant 3. mixed. --Symptoms present ≥6 mo and abdominal pain for ≥3 mo plus at least 2 of 3 features (improvement with defecation; onset with change in stool frequency; onset with change in stool form and appearance) IBS: process Altered motility or secretion from luminal and mucosal irritants that change mucosal permeability, immune activation, and colonic transit, including maldigested carbohydrates, fats, excess bile acids, gluten intolerance, entero-endocrine signaling, and changes in microbiomes IBS characteristics of stool Loose; ∼50% with mucus; small to mod-erate volume. Small, hard stools with constipation. May be mixed pattern. IBS timing Worse in the morning; rarely at night. IBS associated symptoms Crampy lower ab-dominal pain, ab-dominal disten-tion, flatulence, nausea; urgency, pain relieved with defecation IBS setting, persons at risk Young and middle-aged adults, especially women Stress Incontinence problem The urethral sphincter is weakened so that transient increases in intra-abdominal pressure raise the bladder pressure to levels that exceed urethral resistance. Stress Incontinence mechanisms In women, pelvic floor weakness and inadequate muscular and ligamentous support of the bladder neck and proximal urethra change the angle between the bladder and the urethra (see Chapter 14, pp. 592-593). Causes include childbirth and surgery. Local conditions affecting the internal urethral sphincter, such as postmenopausal atrophy of the mucosa and urethral infection, may also contribute. In men, stress incontinence may follow prostate surgery. Stress Incontinence symptoms Momentary leakage of small amounts of urine with coughing, laughing, and sneezing while the person is in an upright position. Urine loss is unrelated to a conscious urge to urinate. Stress Incontinence Physical signs Stress incontinence may be demonstrable, especially if the patient is examined before voiding and in a standing position. Atrophic vaginitis may be evident. Bladder distention is absent. Urge incontinence problem Detrusor contractions are stronger than normal and overcome the normal urethral resistance. The bladder is typically small. Urge incontinence mechanism Decreased cortical inhibition of detrusor contractions from stroke, brain tumor, dementia, and lesions of the spinal cord above the sacral level. Hyperexcitability of sensory pathways, as in bladder infections, tumors, and fecal impaction. Deconditioning of voiding reflexes, as in frequent voluntary voiding at low bladder volumes. Urge incontinence symptoms Involuntary urine loss preceded by an urge to void. The volume tends to be moderate. Urgency, frequency, and nocturia with small to moderate volumes. If acute inflammation is present, pain on urination. Possibly "pseudo-stress incontinence"—voiding 10-20 sec after stresses such as a change of position, going up-or downstairs, and possibly coughing, laughing, or sneezing. Urge incontinence physical signs The small bladder is not detectable on abdominal examination. When cortical inhibition is decreased, mental deficits or motor signs of central nervous system disease are often present. When sensory pathways are hyperexcitable, signs of local pelvic problems or a fecal impaction may be present. Overflow incontinence problem Detrusor contractions are insufficient to overcome urethral resistance, causing urinary retention. The bladder is typically flaccid and large, even after an effort to void. Overflow incontinence mechanisms Obstruction of the bladder outlet, as in benign prostatic hyperplasia or tumor. Weakness of the detrusor muscle associated with peripheral nerve disease at S2-4 level. Impaired bladder sensation that interrupts the reflex arc, as in diabetic neuropathy. Overflow incontinence symptoms When intravesicular pressure overcomes urethral resistance, continuous dripping or dribbling incontinence ensues. Decreased force of the urinary stream. Prior symptoms of partial urinary obstruction or other symptoms of peripheral nerve disease may be present. Overflow incontinence physical signs Examination often reveals an enlarged, sometimes tender, bladder. Other signs include prostatic enlargement, motor signs of peripheral nerve disease, a decrease in sensation (including perineal sensation), and diminished to absent reflexes. Functional incontinence problem The patient is functionally unable to reach the toilet in time because of impaired health or environmental conditions. Protuberant abdomen: 1. Hernia (umbilica, incisional, epigastric, 2. Diastasis Recti, 3. Lipoma, 4. Fat, 5. Gas, 6. Tumor, 7. Pregnancy, 8. Ascites Abdominal Auscultation 1. Bowel sounds 2. Bruits: hepatic (Cirrhosis), Arterial with systolic and diastolic component (occlusion of aorta or large artery (ex. epigastric--renal artery stenosis/renovascular hypertension) 3. Venous Hum: rare soft humming w/ sys/dias.= increase collateral circ btwn portal and systemic systems (hepatic cirrhosis) 4. Friction Rub over liver or spleen: Rare grating sounds w/ respiratory variation=inflammation (liver cancer, chlamydial/gonococcal perihepatitis, liver bx, splenic infarct) Abdomen percussion --Tympany dominates d/t gas --Dull areas: fluid, feces, mass, enlarged organ --Protuberant abdomen: note where tympany changes to dullness (solid posterior structures) --Percuss lower anterior chest above costal margins: normal= right dullness over liver, left tympany over gastric air bubble and spelnic flexure of colon. Abdomen palpation gently palpate over 4 quadrants: abnormal: involuntary rigidity=peritoneal inflammation Deep palpation to feel for masses: physiologic (pregnancy), inflammatory (diverticulitis), vascular (AAA), neoplastic (colon cancer), or obstructive (distended bladder or dilated loop of bowel) Liver assessment Percussion: liver span should be about 4-8cm in midsternal line and 6-12cm in right midclavicular line. Palpation ("hooking technique" may be helpful): 1. start below line of dullness of lower liver border and press gently in and up. 2. Have pt take deep breath in and feel liver edge (soft, sharp, and regular with smooth surface, non-tender). 3. Inspiration: liver is palpable 3cm below right costal margin in midclavicular line. (gallbladder may merge with liver causing firm oval mass below liver edge) Percussion tenderness in nonpalpable liver: strike right side with ulnar surface of hand and compare to sensation felt on left side: tenderness suggests inflammation (hepatitis or congestion from heart failure). Spleen assessment Enlargement: expands anteriorly, downward, and medially, replacing tympany of stomach and colon with dullness of solid organ. Percussion: 1. Percuss the left lower anterior chest wall roughly from the border of cardiac dullness at the 6th rib to the anterior axillary line and down to the costal margin, an area termed Traube space. As you percuss along the route, note the lateral extent of tympany. Percussion is moderately accurate in detecting splenomegaly (80% of the time) 2. If tympany is prominent, splenomegaly is unlikely. 3. Check for a splenic percussion sign. Percuss the lowest interspace in the left anterior axillary line (usually tympanic). Have patient to take a deep breath, and percuss again. When spleen size is normal, the percussion note usually remains tympanitic. Palpation (supine and on right side): Splenomegaly is eight times more likely when the spleen is palpable (portal hypertension, hematologic malignancies, HIV infection, infiltrative diseases like amyloidosis, and splenic infarct or hematoma). In 5% of normal adults: Spleen tip, is just palpable deep to the left costal margin. Kidney assessment LEFT Retroperitoneal and nonpalpable. Palpation: lay on left side. Place R hand behind the pt, just below and parallel to the 12th rib, with fingertips just reaching the CVA. Lift, trying to displace the kidney anteriorly. Place your left hand gently in the LUQ, lateral and parallel to the rectus muscle. Ask the patient to take a deep breath. At the peak of inspiration, press your left hand firmly and deeply into the LUQ, just below the costal margin. Try to "capture" the kidney between your two hands. Ask the patient to breathe out and then to stop breathing briefly. Slowly release the pressure of your left hand, feel-ing at the same time for the kidney to slide back into its expiratory position. If the kidney is palpable, describe its size, contour, and any tenderness. OR Deep palpation: Stand on pt right side, use left hand, reach over and around pt to lift up beneath the left kidney, and with right hand, feel deep in the LUQ. Have pt to take deep breath, feel for a mass. Abnormal: Splenomegaly (if palpable notch on medial border, edge extends beyond midline, percussion is dull, and fingers can prode deep to the medial and lateral borders but NOT btwn mass and costal margin) Large kidney if: normal tympany in LUQ and can probe with fingers between mass and costal margin but not deep to its medial and lower borders. Kidney assessment: RIGHT A normal right kidney may be palpable, especially when the patient is thin and the abdominal muscles are relaxed. To capture the right kidney, return to the patient's right side. Use your left hand to lift up from the back, and your right hand to feel deep in the RUQ. Proceed as before. The kidney may be slightly tender. The patient is usually aware of a capture and release. Causes of kidney enlargement include hydronephrosis, cysts, and tumors. Bilateral enlargement suggests poly-cystic kidney disease. Kidney Percussion assess percussion tenderness over the CVAs. Pressure from your fingertips may be enough to elicit tenderness; if not, use fist percussion. Place the ball of one hand in the CVA and strike it with the ulnar surface of your fist (Fig. 11-29). Use enough force to cause a perceptible but painless jar or thud. Pain with pressure or fist percussion supports pyelonephritis if associated with fever and dysuria, but may also be musculoskeletal. Bladder assessment Percussion dullness: bladder must be 400-600ml full for dullness to appear. Palpation: dome of distended bladder feels smooth, round, nontender. Causes of bladder distention: outlet obstruction from a urethral stricture or prostatic hyperplasia, medication side effects, and neurologic disorders such as stroke or multiple sclerosis. Suprapubic tenderness is common in bladder infection. Aorta assessment Press firmly deep in the epigastrium, slightly to the left of the midline, and identify the aortic pulsations Adults over age 50 years, assess the width of the aorta by pressing deeply in the upper abdomen with one hand on each side of the aorta (normally no more than 3cm wide). Aorta abnormalities A periumbilical or upper abdominal mass with expansile pulsations that is ≥3 cm in diameter suggests an AAA. Sensitivity of palpation increases as AAAs enlarge. Risk factors for AAA 1. Age ≥65 years 2. history of smoking 3. male gender 4. first-degree relative with a history of AAA repair Ascites assessment A protuberant abdomen with bulging flanks is suspicious for ascites dullness appears in the dependent areas of the abdomen. Test for shifting dullness: site of dullness shifts when pt turns to one side. Test for fluid wave: have someone hold both sides of abdomen and sharply tap top part of abdomen and feel for fluid to shift to lower part. A positive fluid wave, shifting dullness, and peripheral edema makes the presence of ascites to three to six times more likely Examining the lateral portion of the breast. To examine the lateral portion of the breast, ask the patient to roll onto the opposite hip, placing her hand on her forehead but keeping the shoulders pressed against the bed the medial portion of the breast, ask the patient to lie with her shoulders flat against the bed or exam-ining table, placing her hand at her neck and lifting up her elbow until it is even with her shoulder Axilla Exam Enlarged axillary nodes may result from infection of the hand or arm, recent immunizations or skin tests, or generalized lymphadenopathy. Check the epitrochlear nodes medial to the elbow and other groups of lymph nodes. Nodes that are large (≥1 to 2 cm) and firm or hard, matted together, or fixed to the skin or underlying tissues sug-gest malignancy. Breast Self-Exam best timed 5 to 7 days after menses, when hormonal stimulation of breast tissue is low. Supine with pillow under one shoulder-->finger pads of the three middle fingers-- >Make overlapping, dime-sized circular motions to feel the breast tissue-->Apply three levels of pressure in each spot-->up-and-down or "strip" pat-tern Standing: 1. hands pressing firmly down on your hips, look at your breasts for any changes of size, shape, contour, or dimpling, or redness or scaliness of the nipple or breast skin. 2. Examine each underarm while sitting up or standing and with your arm only slightly raised Erectile Dysfunction 1. Psychogenic causes, especially if early morning erection is preserved 2. Decreased testosterone 3. decreased blood flow in the hypogastric arterial system 4. impaired neural innervation 5. diabetes Penile Discharge/rash yellow penile discharge in gonorrhea white discharge in non-gonococcal urethritis from Chlamydia. Rash, tenosynovitis, monoarticular arthritis, even meningitis, not always with urogenital symptoms, occur in disseminated gonorrhea. Look for an ulcer in syphilitic chancre and herpes; warts from human papillomavirus (HPV); swelling in mumps orchitis, scrotal edema, and testicular cancer; pain in testicular torsion, epididymitis, and orchitis. Testicular Cancer Cryptorchidism, present in 7% to 10% of men with testicular cancer, con-fers a 3-to 17- fold increased risk for testicular cancer. Seek clinical attention if: a painless lump, swelling, or enlargement in either testicle; pain or discomfort in a testicle or the scrotum; a feeling of heaviness or a sud-den fluid collection in the scrotum; or a dull ache in the lower abdomen or the groin. Urethral Stricture 1. Inspect for induration along the ventral surface of the penis 2. May have tenderness in the indurated area d/t periurethral inflammation Prepuce and glans abnormalities 1. Phimosis is a tight prepuce that cannot be retracted over the glans. 2. Paraphimosis is a tight prepuce that, once retracted, cannot be returned. Edema ensues. 2. Balanitis is inflammation of the glans 3. balanoposthitis is inflammation of the glans and prepuce. Check for varicocele Patient standing 1. palpate the spermatic cord about 2 cm above the testis. 2. Have the patient hold his breath and "bear down" against a closed glottis for about 4 seconds (the Valsalva maneuver). 3. During this maneuver, a temporary increase in the diameter of the spermatic cord indicates filling of abnormally dilated spermatic veins draining the testis. Swellings containing serous fluid, such as hydroceles, light up with a red glow, or transilluminate. Those containing blood or tissue, such as a normal testis, a tumor, or most hernias, do not. 4. feels like soft bag of worms. 5. appears to distort contours of scrotal skin.