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Accommodation Response
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78 Terms
1
Accommodation Response
measures the eye muscles to focus on an image up close and in the distance
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2
Adventitous Breath Sounds
abnormal breath sounds(crackels, rhonchi, wheezes, pleural friction rub and stridor)
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3
Atelectasis
lack of or decreased excursion on one side of the chest by severe pneumonia or lung collapse
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4
Auscultation
listening to sounds produced by the body
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5
Auscultation anterior
front of body, 3 lines, midsternal line, left and right midclavicular line
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6
Auscultation laterally
from side, 3 lines, midaxillary line, anterior and posterior axillary line
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7
Auscultation posterior
back of body, 3 lines, midspinal line, right and left scapular line
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8
Bronchial breath sounds
heard over bronchi, upper part of sternum, shorter inspiratory phase and longer expiratory phase, louder and more harsh sounds than the others
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9
Bronchovesicular sounds
over middle of chest and sternum, more equal sounding and less harsh
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10
Vesicular sounds
over periphary of lungs, longer inspiratory phase and experiatory phase, softer rustling sounds
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11
Cheilitis
inflammation of lips, as well as dryness and cracking
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12
consensual reflex
optic nerve divides(bifurcates) at the distal end, stimulation of the nerve by shining a light in either eye should cause both pupils to rapidly constrict simultaneously and equally
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13
crackle)
not continuous and usually heard during inspiration, may be fine(softer more high pitched) or coarse (louder and low pitched)
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14
dysphagia
individual having difficulty coordinating and organizing words in sentence correctly
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15
eructation
heard with the naked ear, belching, passing of flatus or rectal gas, loud wheezing or gurgling and loud bowel movements
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16
excursion
equal chest expansion as pt inhales on both sides
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17
guarding
defense mechanism of tightening the abdominal muscles to prevent further compression of tender or inflamed areas
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18
Halitosis
bad breath, poor oral hygiene, sinus infection, gastric upset or high stress
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19
Jaundice
yellow or oranging coloring of skin and mucous membranes, detected in sclera and palm of hands, caused by liver
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20
lethargic
drowsy or mentally sluggish
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21
opthalmoscope
lighted instrument used to assess or examine the internal structure of the eyes
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22
otoscope
lighted instrument used to assess or examine the lining of the nose, tympanic membranes and ear canals
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23
palpation
palpate the 4 quadrants of the abdomen to determine whether it is soft, firm or hard
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24
order of palpating and auscultating bowels
RLQ, RUQ, LUQ, LLQ
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25
paresthesia
numbness or decreased sensation of skin, if present there is a nerve impairment, commonly seen as a complication of diabetes, result of stroke or traumatic event
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26
percussion
striking body parts with tips of fingers, elicits sounds that can help locate and determine the size of structures below the surface, identifies if structure is hollow or solid, detects areas containing air or fluid
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27
peristalsis
wavelike muscular contractions of the intestines that move intestinal content through the alimentary canal, where absorption of nutrients and water takes place, toward the rectum for elimination
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28
normal bowel sounds
5 to 30 clicks or gurgles per minute in each quadrant, high pitched sounds known as active bowel sounds
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29
hypoactive bowel sounds
under 5 gurgles per minute
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30
hyperactive bowel sounds
over 30 gurgles per minute
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31
borborgymus
gurgling bowel sounds heard without stethoscope
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32
PERRLA
Pupils Equal Round Reactive to Light and Accommodating
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33
ptosis
drooping eyelids on one side, usually caused by stroke
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34
retractions
if chest wall appears sunken in between the ribs or under the xiphoid process when patient inhales. indicate respiratory problems that need attention
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35
rhonchi
sounds of lungs snoring, rattling, squeaking, low pitched wheezes. caused by secretions in airway
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36
signs
what the nurse observes
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37
symptoms
what the patient says
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38
solar lenigines
older adults have many spots of yellowish brown discoloration caused by sun exposure. also known as liver spots
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39
sordes
dried mucous or food cakes to lips or teeth. treat with good oral hygiene
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40
stridor
can be heard without stethoscope and is a sign of life threatening upper airway obstruction, caused by a foreign body, tumor, swelling or bronchial spasms
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41
turgor
skin elasticity
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42
wheezes
melodious, musical or whistling sounds in lungs, caused by constriction in airway on inspiratory or expiratory
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43
olfaction
smelling
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44
subjective
interviewing
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45
5 techniques are used to collect objective data in the performance of physical assessment
inspection, palpation, percussion, auscultation and olfaction
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46
when auscultating bowels
inspection, auscultation, palpation, percussion and olfaction
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47
ascites
use palmer surface of hand and palpate for masses below skin surface and accummulation of fluid in the peritoneal cavity
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48
rebound tenderness
reflexive tensing of abdominal muscles or verbalization of pain with the release of deeper pressure. common in appendicitis
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49
which side hands used for temperature
dorsal
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50
assessments start with
height, weight and vitals
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51
HEENT
assessment of Hair, Eyes, Ears Nose Throat
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52
cloudiness of eyes
infection or low vitamin A
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53
opaqueness of lens
cataract
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54
anisocoria
pupils different size, unless born that way it is a neuro impairment
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55
leukemia
reddish purplish or hemorrhagic appearing gums
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56
periodontal disease
receding gums
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57
fungal infection in mouth
black hairy appearing tongue
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58
pernicious anemia
red, beefy tongue caused from lack of B12 used to be considered deadly
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59
glossitis
smooth painful tongue caused by meds or inflammation
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60
anaphlaxis
life threatening allergic response
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61
flexor posturing
arms flexed to chest, hands clenched to fists and rotated internally, feet extended indicates problem above brainstem
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62
extension posturing
arms extended, hands clenched into fists, wrists flexed and forearms severely pronated(internally rotated) indicated problem is mid brain or pons
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63
AAO X 4
Awake Alert and Oriented in all 4 spheres
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64
frothy or pink tinged sputum
pulmonary edema(worsening CHF)
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65
blood tinged sputum
tuberculosis
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66
rust colored sputum
pneumonia
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67
posterior view of spine with curvature to either right or left
scoliosis
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68
midthorax increased lateral view
kyphosis
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69
curve of midthoracic and curve at lumbar
lordosis
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70
eupnea
normal breathing
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71
tachypnea
increased respiratory rate
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72
bradypnea
decreased respiratory rate
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73
kussmaul
deep and rapid breaths
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74
cheyne stokes
gradually increased from shallow breaths to large breaths back to shallow followed by 5 to 60 seconds of apnea
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75
apnea
no breaths
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76
how many mL should kidneys produce per hr
30 mL
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77
pallor
inadequate blood volume
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78
erythema
inflammation or blockage of venous return
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