VETS 280 Applied Primatology full semester lecture notes
In-depth lecture notes covering non-human primate taxonomy, comparative anatomy, biological data, characteristics, normal and abnormal behavior, comparisons of single/pair/group housing, nutrition, biomedical use, quarantine protocols, diseases, TB protocols, information on exposures, hygiene, and disease prevention.
IVY SOCI111 Module 8 Quiz 2018
Gender structures social relationships between people unequally. This is a statement that would be supported by which group?
the general population
Which group argues that sexuality in America is an expression of the unequal power balance between men and women?
John Gray’s book Men Are from Mars, Women Are from Venus was a number-one best seller for more than a decade. Which of the following is one of the reasons his book has been so popular?
It offers the appeal of easy-to-grasp, commonsense generalizations.
People wanted to use information in the book to challenge gender stereotypes.
The book makes academic sociological perspectives easier to grasp.
People had never thought about the differences between men and women before reading the book.
Lou is a man who was raised as a girl. What would Amos Mac predict about how Lou will tell his life narrative? Lou will describe:
an individualized narrative specific only to Lou.
a “before and after” story that shifts from girl to boy.
a childhood sense of living in the “wrong” body.
a narrative missing many episodes due to traumatic memory loss.
Bob and Sue paint their baby’s room pink as soon as they find out they are having a girl. They are beginning to provide the baby with what?
her gendered identity
Which of the following would be considered a positive trait or characteristic for a man within today’s hegemonic masculinity?
a love of sports
Amos Mac is a man who was raised as a girl. Which of the following describes Amos Mac’s self-description? He:
is comfortable in his mind but still struggles to come to terms with his body.
always felt like an adult man, even when he was a child.
is at peace with himself but sometimes worries about how strangers perceive him.
is comfortable in his own skin and doesn’t fully resonate with either “man” or “woman.”
While the notion of sex refers to biological characteristics, the concept of gender refers to ________ characteristics.
By looking at anthropological findings in tribal societies, sociologists can see fluidity in gender, which helps us see that the boundaries within our own system of gender:
are biologically fixed.
are emotionally guided.
may not be stable.
are psychologically established.
Sexuality refers to desire, sexual preference, sexual identity, and behavior. Which of the following is true about sexuality?
There is enormous variation in how humans have sex and what it means to them.
There is little variation in how humans have sex and what it means to them.
Before 1850, people did not engage in homosexual behaviors.
In all societies, homosexual behavior is stigmatized and unaccepted.
Which of the following is one main reason why a Navajo person would identify as nadle? The person:
was bodily altered by sacrificial emasculation.
was born with ambiguous genitalia.
has sexual feelings toward people of the same sex.
was shamed with the stigma of divorce.
In our society, many people take for granted that sex has only two categories and tend to ignore facts that suggest sex itself is socially constructed. Which of the following is an outcome of this sexual dichotomization?
the assumption that gender is fluid
viewing sexual variation as a part of our diversity as a species
the common belief that a person’s genitalia do not always correspond to a person’s gender
the exclusion of those who don’t fit neatly into one category or the other
In the one-sex model, it was believed that both a man’s and a woman’s orgasm were required for conception. When the two-sex model gained momentum, women and men were viewed as radically different creatures, and the female orgasm became viewed as:
crucial for conception.
Judith Lorber believes that gender is a social institution because it is:
an all-encompassing social norm that controls individuals.
a major structure organizing our day-to-day experiences.
within an institution (hospital) that our gender first emerges.
a social construction instead of a biological construction.
Similar to hegemonic masculinity, social problems that exist within a dominant group in a society tend to be:
highly visible and therefore cause for concern.
invisible because they are regarded as the norm.
highly funded and therefore easier to solve.
not cause for questioning for sociologists, as they undermine the social order.
A researcher studies the effects of gender by comparing people’s experiences before undergoing sex changes and then again after their sex changes (e.g., like the Donald to Deirdre case). The researcher uses a statistical technique called individual fixed effects, which involves:
comparing an outcome across time as some factor changes.
comparing an outcome across space, in two different places.
comparing an outcome across time without altering any factors.
comparing outcomes to determine cause and effect.
After a traumatic accident, a male baby is left with a micropenis that is badly damaged. Based on the case of David Reimer, what would likely be most helpful?
The baby should be raised as a boy and should participate in medical decision making in age-appropriate ways.
No predictions can be made because each case is so individual.
The baby should be surgically reassigned as a female and raised as a girl.
Doctors should decide, and even when he’s older, the baby should never be informed.
Sociologist Cynthia Fuchs Epstein argues that deceptive distinctions are those sex differences that arise out of the roles individuals occupy rather than from some innate force. Which of the following is an example of deceptive distinctions?
a man who is a Supreme Court judge and behaves in nurturing and emotive ways
a boy who is a football player and acts fearless and bold
a woman who is a nurse but does not behave in nurturing and emotive ways
a girl who is a cheerleader and acts unanimated and unenthusiastic
When token men enter feminized jobs, they enjoy a quicker rise to leadership positions. This is referred to as the:
Many people believe sex to be an either/or situation (either male or female), but sociologists believe these pure categories are:
more of an ideal than an absolute.
not biologically absolute but socially helpful.
Anthropologist Don Kulick (1998) conducted an ethnography of the transgender prostitutes in Brazil, known as travesti. Which of the following did he find to be true?
The travesti think of themselves as male, even if they allow themselves to be penetrated by other men.
The travesti identify themselves simply as men and are identified by other Brazilians as“normal men.”
The travesti think of themselves as men who emulate women but are not women.
The travesti display stereotypically feminine traits and identify themselves as women.
Use Paula England’s research to predict what incoming college students will find on campus.
a culture of dating
a culture of technology-mediated friendships and romantic partnerships
a culture of hooking up
a norm of alcohol influencing sexual encounters
According to Michelle Rosaldo’s theory, regardless of time or culture, women tend to be associated with ________ and men tend to be associated with ________.
the domestic sphere; the public sphere
being owned; ownership
Alain’s daughter wears dresses, plays with dolls, and likes to pretend she is a princess. Alain does not think society has influenced her preferences or games at all. He views his daughter as evidence that human behavior is determined by genes and hormones. Which term best describes Alain’s views?
the binary system
In the classroom, compared to boys, girls:
are expected to be better at reading.
are expected to be better at math.
are called on more in class.
interrupt the other sex more often.
Which of the following is one of the reasons why sociologists view gender as a social construction rather than a biological given?
Contemporary studies show us that men and women have different personality structures, the innate by-product of existing social structural relations.
Societies in various historical periods have not made any distinction between different genders.
Our understandings of, categorizations of, and behaviors toward what it means to be a man or woman have changed throughout history.
There are no social or biological differences between men and women.
It is 2013, and Isaac is an incoming college student.Sociological research surrounding the data presented in this chart would predict what outcome for Isaac? He will likely:
major in finance or engineering and ultimately out earn his female classmates.
take longer to finish his college degree than most of his female peers.
major in a traditionally female field in order to benefit from minority status.
experience equality with women in prestige and income.
Angie writes a college paper about the origins of patriarchy. Following Gayle Rubin’s theory closely, she argues that:
girls develop subordinate psychologies due to their relationships with their mothers.
trading women as property gave men certain rights over their female kin.
testosterone makes men more dominant.
sex role theory places women in a subordinate position.
Jobs that have been feminized, such as teaching or secretarial work, are also referred to as:
Alfred Kinsey’s 1948 study, Sexual Behavior in the Human Male, is important because:
it viewed the sexual behavior of men as more deviant than what was initially thought, lending support to the psychiatric diagnosis of homosexuality as perverse.
it increased funding to researchers interested in studying the sexual practices of other deviant subcultures.
it viewed sexuality as falling on a continuum, thus challenging the psychiatric claim of homosexuality as abnormal.
sexual topics became taboo for the first time in history.
Literatuur samenvatting artikelen \'Observatie van interacties binnen gezinnen\'
Deze samenvatting bevat de volgende artikelen:
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months. Child: Care, Health, and Development, 42, 1-7.
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parenting behavior prevents social anxiety development in their 4-year-old children: A longitudinal
observational study. Journal of Abnormal Child Psychology, 42, 301-310.
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disturbance: Child, parent, and parent-child relationship. Infant Mental Health Journal, 36, 114-127.
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Mesman, J., & Bakermans-Kranenburg, M. J. (2014). Boys don’t play with dolls: Mothers’ and fathers’
gender talk during picture book reading. Parenting: Science and Practice, 14, 141-161.
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context: Family emotion socialization patterns and children’s emotion regulation in late childhood.
Nonlinear Dynamics, Psychology, and Life Sciences, 16, 269-291.
-Hay, D. et al. (2011). The emergence of gender differences in physical aggression in the context of peer
conflict between young peers. British Journal of Developmental Psychology, 29, 158-175.
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coercion versus warmth in child conduct problems? An observational study. Journal of Child Psychology
and Psychiatry, 52, 1308-1315.
-Pesch, M.H. and Lumeng, J.C. (2017). Methodological considerations for observational coding of eating
and feeding behaviors in children and their families. International Journal of Behavioral Nutrition and
Physical Activity, 14, 170.
-Hodges, E.A., Johnson, S.L., Hughes, S.O., Hopkinson, J.M., Butte, N.F., & Fisher, J.O. (2013).
Development of the responsiveness to child feeding cues scale. Appetite, 65, 210-219.
-Kolak, A. M., & Volling, B. L. (2011). Sibling jealousy in early childhood: Longitudinal links to sibling
relationship quality. Infant and Child Development, 20, 213-226.
- Martins, E. C., Soares, I., Martins, C., & Osorio, A. (2015). Infants’ style of
emotion regulation with their mothers and fathers: Concordance between
parents and the contribution of father-infant interaction quality. Social
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-Ostfeld-Etzion, S., Feldman, R., Hirschler-Guttenberg, Y., Laor, N., &
Golan, O. (2016). Self-regulated compliance in preschoolers with autism
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Autism, 20, 868-878
Walden University NURS 6512 Final Exam Review.docx
NURS 6512 Final Exam Review (Week 7-11)Heart, Lungs, and Peripheral Vascular (Week 7: Ch. 13, 14, & 15)• Examination techniques of the Heart, Lungs, and PV systems (See Notes)• Examination findings of arterial blood flow in infants (339) (345)o At birth the cutting of the umbilical cord, through which oxygen has been provided in utero, requires the infant to begin breathing. The onset of respiration expands the lungs and carries air to the alveoli.o When pulse is weak, expect cardiac output bay be diminished or peripheral vasoconstriction may be present. A bounding pulse is associated with a large left-right shunt produced by a patent ductus arteriosus. In coarctation of the aorta, a difference is noted in pulse amplitude between the upper extremities or between the femoral and radial pulses or the femoral pules are absent capillary refill times in infants and children younger than 2 years of age are raid, less than 1 second. A prolonged capillary refill time, no longer than 2 seconds, indicates dehydration or hypovolemic shock.• Examination findings of the heart and lungs in a patient with illegal drug use (266)o If an adult- especially young- or an adolescent describes severe, acute chest pain, ask about drug use, particularly cocaine. Cocaine can cause tachycardia, hypertension, coronary arterial spasm (with infarction), and pneumothorax (lung collapse) with severe acute chest pain being the common result.• Description: shortness of breath (orthopnea, platypnea. Tachypnea, bradypnea) (265)o Orthopnea- shortness of breath that begins or increases when the patient lies down; ask whether the patient needs to sleep on more than one pillow and whether that helps.o Platypnea- dyspnea increases in the upright posture.o Tachypnea- increased rate of respirations of breath; abnormally rapid breathing.(COPD or Pneumonia)o Bradypnea-breathing more slowly than normal, could mean the body isn’t getting enough oxygen. (sleep apnea, drug overdose, carbon monoxide poisoning)o Paroxysmal nocturnal dyspnea- sudden onset of SOB after a period of sleep; sitting upright is helpful.• Symptoms associated with intrathoracic infectiono The patient may have any combination of the nonspecific symptoms, such as fever, dry or productive cough, blood-streaked sputum, shortness of breath, chest pain, weight loss, fatigue, and anorexia. Physical examination may reveal abnormal breath sounds.• Percussion techniques when examining the lungs (273-275)o Percuss the chest directly or indirectly, comparing sides in three areas. On the posterior chest, percuss with the patient’s head bent forward and arms folded in front. On the lateral chest, percuss with the patient’s arms raised. On the anterior chest, percuss with the patient in the same position.• Examination findings when percussing the lungs (274)o You should hear resonance over all lung areas. Hyperresonance associated with hyperinflation may indicate emphysema, pneumothorax, or asthma. Dullness or flatness suggests pneumonia, atelectasis, pleural effusion, pneumothorax, or asthma. Percuss Tones Heard over the Chest (274)• Cardiac examination findings for a patient with rheumatic fever (330-331)o Systemic connective tissue disease occurring after streptococcal pharyngitis or skin infection. Patho- characterized by a variety of major and minor manifestations (major: carditis, polyarthritis, chorea, erythema marginatum, subcutaneous nodules) (minor: previous rheumatic fever, arthralgia, fever, laboratory, clinical). May result in serious cardiac valvular involvement of mitral or aortic valve; tricuspid and pulmonic are not often affected. Affected valve becomes stenotic and regurgitant. Children between 5 and 15 years of age are most commonly affected. Prevention-adequate treatment for streptococcal pharyngitis or skin infections-is the best therapy. Subjective Data- fever, inflamed swollen joints, flat or slightly raised, painless rash with pink margins with pale centers and a ragged edge (erythema marginatum). Aimless jerky movements (Sydenham chorea or St. Vitus dance). Small, painless nodules beneath the skin. Chest pain, palpations, fatigue, or shortness of breath. Objective Data- characterized by a variety of major and minor manifestations. Murmurs of mitral regurgitation and aortic insufficiency. Cardiomegaly, friction rub of pericarditis, or signs of CHF.• Grading of heart murmurs (311-313)o Diseased valves, a common cause of murmurs, either do not open or close well. When the leaflets are thickened and the passage narrowed, forward blood flow is restricted (stenosis). When valve leaflets, which are intended to fit together snugly, lose competency and leak, blood flows backwards (regurgitation).o Characterization of Heart Murmurs (313)• Evaluation of ECG tracings (298-299)o An electrocardiogram (ECG) is a graphic recoding of electrical activity during the cardiac cycle. The ECG records electrical current generated by the movement of ions in and out of the myocardial cell membranes. The ECG records two basic events: depolarization, which is the spread of a stimulus through the heart muscle, and repolarization, which is the return of the stimulated heart muscle to a resting state. The ECG records electrical activity as specific waves: P-Wave: the spread of a stimulus through the atria (atrial depolarization). PR interval- the time from initial stimulation of the atria to initial stimulation of the ventricles, usually 0.12 to 0.20 seconds. QRS complex- the spread of a stimulus through the ventricles (Ventricular depolarization), less than 0.10 second. ST segment and T wave- the return of stimulated ventricular muscles to a resting state (ventricular repolarization). U wave- a small deflection rarely seen just after the T wave, thought to be related to repolarization of the Purkinje fibers. This is also seen sometimes with electrolyte abnormalities. QT interval- the time elapsed from the onset of ventricular depolarization until the completion of ventricular repolarization. The interval varies with the cardiac rate.• Examination technique for the apical pulseo Feel for the apical impulse and identify its location by the intercostal space and the distance from the midsternal line. The point at which the apical impulse is most readily seen or felt should be described as the point of maximal impulse (PMI). The PMI is typically noted at the left 5th intercostal space, midclavicular line in adults and the 4th intercostal space medial to the nipple in children. If the apical impulse is more vigorous than expected, characterize it as a heave or lift. An apical impulse that is more forceful and widely distributed, fills systole, or is displaced laterally and downward may indicate increased cardiac output or left ventricular hypertrophy.o With warm hands, gently palpate the supine patient’s precordium while moving systematically through five areas. First, palpate at the apex. Second, move to the left sternal border. Third, move to the base. Fourth, go down to the right sternal border. Fifth, move into the epigastrium or axillae, if needed.o Feel for the apical impulse and identify its location, distance from the midsternal line, and width (which is usually no more than 1 centimeter). If the apical impulse is more vigorous than a gentle, brief pulsation, describe it as a heave or lift. Describe the point at which the apical impulse is most readily seen or felt as the point of maximal impulse (or PMI). Feel for a thrill, which is a fine, palpable, rushing vibration that often occurs over the base of the heart at the right or left second intercostal space. You can think of a thrill as a palpable murmur. As you feel the precordium, use your other hand to palpate the carotid artery. The carotid pulse and S1 should occur almost simultaneously.• Examining technique for different cardiac sounds and their names (309-311)o Listen for the four basic heart sounds: S1, S2, S3, and S4. S1 and S2 are the most distinct and should be characterized separately. S3 and S4 normally may or may not be present.o S1 marks at the beginning of systole and is best heard toward the apex, where it is usually louder, lower, and longer than S2. S2 marks at the end of systole and is best heard in the aortic and pulmonic areas. It is louder than S1 at the base of the heart. S3 occurs early in diastole. It normally is quiet, low-pitched, and often difficult to hear. S4 occurs late in diastole. It also normally is quiet and difficult to hear. Splitting of S1 is uncommon, but may be heard in the tricuspid area, particularly on deep inspiration. Splitting of S2 is expected and can be divided into the aortic component (or A2) and the pulmonic component (or P2).o Identify any extra heart sounds because they may indicate pathology. An increased S3 has a galloping rhythm, as in the word Ken-TUCK-y. It is best heard with the bell at the apex and with the patient in the left lateral recumbent position. An increased S4 has the rhythm of the word TEN-nes-see. It is best heard with the bell at the apex and with the patient in the supine or left lateral recumbent position. A gallop is best heard the same way as an increased S4. A mitral valve opening snap is detected with the diaphragm medial to the apex at the second left intercostal space with the patient in any position. An ejection click is auscultated best with the diaphragm in a seated or supine patient. A pericardial friction rub is widely heard, and its grating or rubbing sound is clearest toward the apex.• Varicosity findings in pregnant women (338) (345)o During pregnancy in particular, increased hormonal levels weaken the walls of the vein and result in failure of the valves.o Peripheral edema is a common finding as the pregnancy progresses. Varicose veins can develop during pregnancy and in the postpartum period.• Examination of peripheral arteries(338-339)o The pulses are best palpated over arteries that are close to the surface of the body and lie over bones. These include: carotid, brachial, radial, femoral, popliteal, dorsalis pedis, and posterior tibial arteries. Palpate at least one pulse point in each extremity, usually at the most distal point. When examining the arterial pulses, the thumb may be used, especially if vessels have a tendency to move when probed by fingers. Palpate firmly but not so hard as to occlude the artery. Palpate arterial pulses (radial) to assess the heart rate and rhythm, pulse contour, amplitude, symmetry, and sometimes obstructions to blood flow.• Grading of pulses (340)o The amplitude of the pulse is described on a scale of 0 to 4: 4- bounding, aneurysmal, 3- full, increased, 2- expected, 1- diminished, barely palpable, 0- absent, not palpable.• Examination findings of a child with Kawasaki disease (349)o An acute small vessel vasculitis illness of uncertain cause affecting young males more often than females; the critical concern is cardiac involvement in which coronary artery aneurysms may develop. Patho- the cause of the vasculitis is unknown. Immune-mediated blood vessel damage can result in both vascular stenosis and aneurysm formations. Subjective Data- the symptoms are diffuse and typified by fever lasting 5 days or more. The effects of a systemic vasculitis include weight loss, fatigue, and myalgia, as well as arthritis. Objective Data- findings may include fever, conjunctival injection, strawberry tongue, and edema of the hands and feet. Lymphadenopathy and polymorphous non-vesicular rashes.• Examination findings of a patient with peripheral edema (344)o Inspect the extremities for edema. Press your index finger over the bony prominence of the tibia or medial malleolus for several seconds. A depression that does not rapidly refill and resume its original contour indicates orthostatic pitting edema. The severity of edema may be characterized by grading 1 through 4 . Any concomitant pitting can be mild or severe, as evidenced by: 1 slight pitting, no visible distortion, disappears rapidly, 2 a somewhat deeper pit than in 1 , but again no readily detectable distortion; disappears in 10 to 15 seconds, 3 noticeably deep pit that may last more than a minute; dependent extremity looks fuller and swollen, 4 very deep pit that lasts as long as 2-5 minutes; dependent extremity is grossly distorted.o If edema is unilateral, suspect the occlusion of a major vein. If edema is bilateral, consider CHF. If edema occurs without pitting, suspect arterial insufficiency or lymphedema.• Examination of ammonia in breath odor (274)o Bad breath can be a sign of infection, either acute or chronic, somewhere in the nasal or oral cavity or deep in the lung, can be the source. An especially foul or putrid odor of breath and/or sputum suggests anaerobic respiratory infections, emphysema, bronchiectasis, lung abscess, or a particularly insistent bronchitis. Your nose may provide a significant clue. Ammonia-like: uremia (ammonia)• Miscellaneouso Physical Findings Associated with Common Respiratory Conditions (283-284)o The Sequence of Chest Steps: Inspection, palpation, percussion, and auscultation.o Two common structural findings of the chest: pigeon and funnel chest (267)o Do not tell the patient that you are counting the respirations to prevent the patient from varying the rate. Count the respiratory rate after palpating the pulse, just as if you were counting the pulse rate for a longer time.o Chest Pain Causes/Characteristics (301-302)o Cardiac Disease Risk Factors (303)o Heart: inspection, palpation, percussion, and palpation (304-306).o Heart Sounds after Surgical Procedures: if a cardiac surgical procedure involves placement of a prosthetic mitral valve, listen for a distinct click early in diastole, loudest at the apex and transmitted pre-cordially. A prosthetic aortic valve causes a sound in early systole. The intensity of these sounds depends on the type of material used for the prosthesis. Animal tissue is the quietest and may even be silent. Pacemakers do not cause a sound. (311)o CHF (Ride/Left Side Failure) (321)Assessing Musculoskeletal Pain (Week 8: Ch. 21 & Review 4)• Diagnostic tests for patients with carpal tunnel (524) (536)o The likelihood that a patient will have a positive electro-diagnostic study for carpal tunnel syndrome is increased by the following: weakened thumb abduction; a classic or probable distribution of symptoms on the Katz hand diagram; and hypalgesia (decreased pain sensation along the thumb and median nerve distribution when compared to the little finger on the same hand. The Tinel and Phelan tests are less accurate.o Certain patterns of pain, numbness, and tingling are associated with carpal tunnel syndrome. Ask the patient to make the specific locations of pain, numbness, and tingling on the Katz hand diagram.o Have the patient place the hand palm up and raise the thumb perpendicular to it. Apply downward pressure on the thumb to test muscle strength. Full resistance to pressure is expected. Weakness is associated with carpal tunnel syndrome. To perform the Phalen test, ask the patient to hold both wrists in a fully palmar-flexed positon with the dorsal surface pressed together for 1 minute. Numbness and paresthesia in the distribution of the median nerve are suggestive of carpal tunnel syndrome. The reverse Phalen test is performed by placing the pals and fingers together with full wrist extension. The Tinel sign is tested by striking the patient’s wrist with your index or middle finger where the median nerve passes under the flexor retinaculum and volar carpal ligament. A tingling sensation radiating from the wrist to the hand in the distribution of the median nerve is a positive Tinel sign and is suggestive of carpal tunnel syndrome.o Compression on the median nerve. Patho- compression of the nerve within its flexor tendon sheath due to micro-trauma, local edema, repetitive motion, or vibration of the hands. Associated with rheumatoid arthritis, gout, acromegaly, hypothyroidism, and the hormonal changes of pregnancy. Subjective Data- numbness, burning, and tingling in the hands often occur at night, can also be elicited by rational movements of the wrist. Pain may radiate to the arms. Objective Data- weakness of the thumb and flattening of the thenar eminence of the palm. Reproduction of symptoms with provocations of the Tinel and Phalen maneuvers.• Examination techniques used for muscle and joint pain• Spinal deformities noted during examination (518-519)o Kyphosis may be observed in aging adults. Lordosis is common in patients who are obese or pregnant. A sharp angular deformity, a gibbus, is associated with a collapsed vertebra from osteoporosis.o Ask the patient to bend forward slowly and touch the toes while you observe from behind. Inspect the spine for unexpected curvature, should remain symmetrical.o Reducing the Risk for Lower Back Pain- use appropriate techniques to lift heavy object to reduce the risk for lower back injury. Rather than bend over to pick up a heavy object, keep the back straight and flex the knees to get closer to the object. Keep the object close to the body and lift with knees. Avoid twisting the back during the lift.• Characteristic examination findings for Rheumatoid Arthritis (513) (538)o A chronic systemic inflammatory disorder of the synovial tissue surrounding the joints. Patho- cause is unknown. Within the inflamed synovial tissue and fluid, poly-morphonuclear leukocytes aggregate. Multiple inflammatory cytokines and enzymes are released that can result in subsequent damage to bone, cartilage, and other tissue. Subjective Data- joint pain and stiffness, especially in the morning or after periods of inactivity. Constitutional symptoms of fatigue, myalgia, weight loss, and low-grade fever are common. Objective Data- involved joints include the hands, wrists, feet, and ankles as well as the hips, knees, and cervical spine. Synovitis with soft tissue swelling and effusions is present on examination. Nodules and characteristic deformities can develop.o Deviation of the fingers to the ulnar side and swan neck or boutonniere deformities of the fingers usually indicates rheumatoid arthritis.o Subcutaneous nodules along pressure points of the ulnar surface may indicate rheumatoid arthritis or gouty tophi.• Orthopedic screening evaluation techniques (538-539) (585)o The 14 step screening orthopedic examination- the athlete should be dressed so that the joints and muscle groups included in the exam are easily visible-usually gym shorts for males and gym shorts and a t-shirt for females. Keep in mind that one of the most important points to look for in the exam is SYMMETRY.o The two conditions that are considered absolute contraindications to sport participation are carditis and fever. Carditis (inflammation of the heart) can result in sudden death with exertion and fever is associated with an increased risk of heart-related illness. A good rule: Do not suggest that an athlete “play through” an injury or a problem.• Characteristic examination findings consistent with Osteoarthritis (538)o The deterioration of the articular cartilage covering the ends of bone in synovial joints. Patho- as a result of cartilage abrasion, pitting, and thinning, the bone surfaces are eventually exposed with bone rubbing against bone. Separately there can be remodeling of the bone surface and formation of bone spurs. Subjective Data- pain in hands, feet, hips, knees, and cervical or lumbar spine (most commonly). Onset usually begins after 40 years of age and develops slowly over many years with nearly 100% of people older than 75 years being affected. Objective Data- the joints may be enlarged due to bone growths (osteophytes). May have crepitus and limited, painful, range of motion.o Risk Factors of Osteoarthritis (509)• Characteristic examination findings consistent with Gout (536)o Gout, a form of arthritis, is a disorder of purine metabolism that results from an elevated serum uric acid level. Patho- monosodium urate crystal deposition in joints and surrounding tissues results in acute inflammatory attacks. Subjective Data- sudden onset of a hot, swollen joint; exquisite pain; limited range of motion. Primarily affects men older than 40 years and women of postmenopausal age. Usually affects the proximal phalanx of the great toe, although the wrists, hands, ankles, and knees may be involved. Objective Data- the skin over the swollen joint may be shiny and red or purple. Uric acid crystals may form as tophi under the skin with chronic gout.• Miscellaneous:o Differential Diagnosis Chart: Comparison of Osteoarthritis with Rheumatoid ArthritisAssessment of Cognition and the Neurologic System (Week 9: Ch. 5 & 22)• Significance of the Denver II tool- (Pg. 72) is useful for determining whether the child is developing fine and gross motor skills, language, and personal-social skills as expected.• Examination of the mental status: (Pg. 66-71) the shorter screening exam is commonly used for health visits when no known neurologic problem is apparent. The following areas include: Appearance and Behavior (grooming, emotional status, & body language) Emotional Stability (mood & feelings and thought process) Cognitive Abilities (state of consciousness, memory, attention span, & judgment), and Speech and Language (voice quality, articulation, comprehension, coherence, and aphasia).o Physical Appearance & Behavior- assess grooming, emotional status, and nonverbal communication (body language)o State of Consciousness: patient should be oriented to person, place, time, and make appropriate responses to questions. The Glasgow Coma Scale is used to quantify the level of consciousness after an acute brain injury or medical condition.o Cognitive Abilities- evaluate cognitive functions as the patient responds to questions during the history-taking process (learning, perceiving, decision making, & memory). Analogies- ask the patient to describe simple analogies first and then more complex analogies. Abstract reasoning- ask the patient to tell you the meaning of a fable, proverb, or metaphor (A rolling stone gathers no moss). Arithmetic Calculation- ask the patient to do simple arithmetic, without paper and pencil (50 8). Writing Ability- ask the patient to write his or her name & address or a dictated phrase (letter, syllables, words). Execution of Motor Skills- ask the patient to unbutton a shirt button or to comb their hair. Memory- immediate recall or new learning, recent memory, and remote memory. Attention span- ask the patient to follow a short set of commands. Judgment- determine the judgment and reasoning skills by exploring topicso The Mini-Mental State Examination (MMSE) - is the most studied to date exam to test/assess cognition. It is a standard tool to assess cognitive function changes over time. The 11 items- measuring orientation, registration, attention and calculation, recall, and language take approx. 5-10 min to administer. The maximum score is 30, a score of 20 or less may be associated with dementia, and a score of 26 or higher is not associated with dementia (Pg. 68).o The Mini-Cog- is a brief screening tool for measuring cognitive function that takes up to 5 minutes to administer. Ask the patient to listen carefully to and remember three unrelated words (red, plate, and milk) and then immediately repeat the words. Do not help if a word is not repeated. Next the patient is asked to draw the face of a clock and draw the hands to read a specific time. (Pg. 69).o The importance of validation- if you have concerns about pt. responses/behaviors, it is important to interview a family member, and ask if the patient has had any problems with the following activities remembering important appts. Paying bills, shopping independently for food or clothing, etc.o Common Causes of Unresponsiveness (Pg. 67)o Speech and Language Skills- evaluation of communication skills, both receptive and expressive. Voice Quality- determine if there is any difficulty or discomfort in phonation. Articulation- evaluate spontaneous speech for pronunciation and ease of expression. Comprehension- ask the patient to follow simple one-and two step directions during the examination, such as during the attention span assessment. Coherence- the patient’s intentions or perceptions should be clearly conveyed to you.o Emotional stability- evaluated when the patient does not seem to be coping well or does not have resources to meet personal needs. Mood and Feelings- during the history and physical examination, observe the mood and emotional expression evident from the patient’s verbal and nonverbal behaviors. Thought Process & Content- observe the patient’s thought patterns, especially the appropriateness of sequence, logic, coherence, and relevance to the topics discussed. Perceptual Distortions and Hallucinations- determine whether the patient perceives any sensations that are not caused by external stimuli (hears voices, sees vivid images, or shadowy figures, smells offensive odors, tastes offensive flavors, or feels worms crawling on the skin.o Infants & Children- evaluate an infant’s general behavior and level of consciousness by observing the level of activity and responsiveness to environmental stimuli. Note whether the baby is lethargic, drowsy, stupors, alert, active or irritable.o Expressive Language Milestones for Toddlers and Preschoolers- (Pg. 73)o Pregnant Women- the prevalence of depression during pregnancy and postpartum; risk factors include history of depression, prior postpartum depression, and poor social support.o Older adults- mental function as a whole may be evaluated in about 5 minutes with the Isaac Set Test. Ask the patient to name 10 items in each of four groups: fruits, animals, colors, and towns/cities without prompting or rushing.o Prompting Memory and Cognitive Functioning- encourage patients to engage in a variety of cognitive exercises such as using the computer, various games, reading books, and craft activities such as knitting or sewing, d/t significantly reduced risk of developing mild cognitive impairment.o Functional Assessment- activities of daily living, the ability to perform instrumental activities of daily living or ability to live independently is an important assessment (Pg. 74).• Examination findings associated with Attention Deficit Hyperactivity Disorder (ADHD) - (pg. 77) disorder with genetic component potentially affecting dopamine transport and reception; also may be associated with severe traumatic brain injury or function brain abnormalities. Subjective data- short attention span, easily distracted, fails to complete school assignments or follow instruction. Fidgets and squirms, often moving, running, climbing. Disruptive behavior, talks excessively, temper outbursts, labile moods, poor impulse control. Objective- onset before 7 years of age, increased motor activity, difficulty organizing tasks, difficulty sustaining attention, poor school performance, low self-esteem, and has problems in more than one setting.• Behavior patterns of a patient with Schizophrenia, Depression, Anxiety, and Mania (Pg. 76-77).o Schizophrenia- a severe persistent, psychotic syndrome with impaired reality that relapses throughout life; subjective data- hears voices, unpleasant tastes or odors, sees images, paranoid thoughts, unable to experience emotions, blunted affect, apathy, detached from environment, and poor personal hygiene. Objective data- incoherent speech, loose associations, illogical answers to questions, hallucinations, delusions, repetitive or aimless behavior, and inappropriate affect in response to a situation.o Depression- a mood disorder in which feelings of sadness, loss, anger, or frustration interfere with everyday life for an extended period (weeks or longer). Subjective data- feels sad, hopeless, worthless, no interest or pleasure in what was previously of interest or pleasurable, insomnia or excessive sleeping, or increased or decreased appetite. Objective data- poor concentration, slowed thought process and speech, agitation or restlessness.o Anxiety- a group of disorder with such marked anxiety or fear that it causes significant interference with personal, social, and occupational functioning. (Panic attacks, generalized anxiety disorder, specific phobias, obsessive compulsive disorder, and posttraumatic stress disorder.♣ Subjective data: Panic attacks- palpitations, sweating, shaking. Generalized Anxiety Disorder: chronic worry, restless, irritable, tense, fatigue. OCD: preoccupation with contamination, religion, or sexual themes. PTSD: recurrent intrusive flashbacks, dreams, thoughts, avoidance behavior.♣ Objective Data: Panic attacks- tachycardia, diaphoresis, tremors. Generalized Anxiety Disorders: impaired attention, motor tension, tremors. OCD: Ritualized acts performed compulsively (washing, cleaning, hoarding, counting, organizing). PTSD: anger or rage reactions, impulsive behaviors, hyperarousal, conditions persist more than 4 weeks.• Examination findings of a patient with Diabetic Peripheral Neuropathy- (pg. 578)- a disorder of the peripheral nervous system that results in motor and sensory loss in the distribution of one or more nerves, commonly caused by diabetes mellitus. Subjective data- gradual onset of numbness, tingling, burning, and cramping, most common in the hands and feet, night pain in one or both feet, early signs may be unusual sensations of walking on cotton, floors feeling strange, or inability to distinguish between coins by feel, or sensation of burning accompanied by hyperalgesia (all sensation is painful). Objective data: reduced sensation in the foot with the monofilament; loss of pain or sharp touch sensation to the mid-calf level; distal pulses may be present or diminished; etc.• Examination findings of all Cranial Nerves- cranial nerves are peripheral nerves that arise from the brain rather than the spinal cord. Each nerve has a motor or sensory function, and 4 cranial nerves have parasympathetic functions.o I (Olfactory)- sensory: smell reception and interpretationo II (Optic)- sensory: visual acuity and visual fieldso III- (Oculomotor)- motor: raise eyelids, most extraocular movements; parasympathetic: pupillary constriction, change lens shapeo IV (Trochlear)- motor: downward, inward eye movemento V (Trigeminal)- motor: jaw opening and clenching, chewing, and mastication; sensory: sensation to cornea, iris, lacrimal glands, conjunctiva, eyelids, forehead, nose, nasal, and mouth mucosa, teeth, tongue, ear, facial skino VI (Abducens)- motor: lateral eye movemento VII (Facial)- motor: movement of facial expression muscles except jaw, close eyelids, labial speech sounds (b, m, w, & rounded vowels); sensory: taste- anterior 2/3 of tongue, sensation to pharynx; parasympathetic: secretion of salvia and tearso VIII (Acoustic)- sensory: hearing and equilibriumo IX (Glossopharyngeal)- motor: voluntary muscles for swallowing and phonation; sensory: sensation of nasopharynx, gag reflex, taste-posterior 1/3 of tongue; parasympathetic: secretion of salivary glands, carotid reflex; motor: voluntary muscles of phonation (guttural speech sounds) and swallowingo X (Vagus)- sensory: sensation behind ear & part of external ear canal; parasympathetic: secretion of digestive enzymes; peristalsis; carotid reflex; involuntary action of heart, lungs, and digestive tracto XI (Spinal accessory)- motor: turn head, shrug shoulders, some actions for phonationo XII (Hypoglossal) - motor: tongue movement for speech sound articulation (l, t, d, and n) and swallowing.• Examination techniques of all Cranial NervesEvaluate cranial nerves one through twelve (To examine the cranial nerves, perform the following: Keep in mind that taste and smell usually are tested only if a problem is suspected. No matter which nerves you test, their function should be intact.o For cranial nerve one (the olfactory nerve), test the patient’s ability to identify familiar odors, such as coffee and mint extract, one naris at a time with the eyes closed.o For cranial nerve two (the optic nerve), test visual acuity and the visual fields. Also examine the ocular fundus with an ophthalmoscope, as described in the audio review of the Eyes.o For cranial nerves three, four, and six (the oculomotor, trochlear, and abducens nerves), assess the six cardinal points of gaze, inspect the eyelids for drooping, and observe the pupils for equality of size, shape, and reaction to light and accommodation.o For cranial nerve five (the trigeminal nerve), perform four assessments. First, inspect the face for muscle atrophy, jaw deviation, and tremors. Second, palpate the clenched jaw muscles for tone and strength. Third, test superficial pain and touch sensations in each branch of the nerve. (If the results are unexpected, also test temperature sensation in these areas.) Fourth, test the corneal reflex.o For cranial nerve seven (the facial nerve), observe for facial symmetry while the patient makes a series of facial expressions. Also test the ability to identify tastes on the sides of the tongue.o For cranial nerve eight (the acoustic nerve), test the sense of hearing and bone and air conduction of sound, and note sound lateralization, as described in the audio review of the Ears, Nose, and Throat.o For cranial nerve nine (the glossopharyngeal nerve), test the patient’s ability to identify tastes on the posterior third of the tongue.o For cranial nerve ten (the vagus nerve), inspect the palate and uvula for symmetry with speech sounds. Also check the gag reflex and the ability to swallow, keeping in mind that this also tests part of cranial nerve nine. Evaluate the patient’s speech sounds to detect any hoarseness, nasal quality, or difficulty with guttural sounds.o For cranial nerve eleven (the spinal accessory nerve), evaluate the size, shape, and strength of the trapezius and sternocleidomastoid muscles, as described in the audio review of the Musculoskeletal System.o For cranial nerve twelve (the hypoglossal nerve), perform four assessments. First, inspect the tongue at rest and while protruded, noting symmetry, tremors, and atrophy. Second, observe tongue movement from side to side and toward the nose and chin. Third, test tongue strength by pressing your index finger against the cheek as the tongue presses against it from the inside. Finally, evaluate the quality of lingual speech sounds, such as l, t, d, and n.• Deep Tendon Reflex evaluation- (pg. 564)With the patient relaxed and seated or lying down, test five deep tendon reflexes. When using a reflex hammer, remember to tap briskly, but not too forcefully. And be sure to score each reflex from zero (for no response) to four-plus (for a hyperactive response with clonus).o For the biceps reflex, hold your thumb over the biceps tendon and strike the thumb with the reflex hammer. This should cause elbow flexion.o For the brachioradial reflex, strike the brachioradial tendon (about 1 to 2 inches above the wrist) with the reflex hammer. The expected response is forearm pronation and elbow flexion.o For the triceps reflex, strike the triceps tendon directly, which should produce elbow extension.o For the patellar reflex, strike the patellar tendon just below the patella. Expect to see lower leg extension.o For the Achilles reflex, strike the Achilles tendon at the level of the ankle malleoli. In response, the foot should plantar flex.o Scoring Deep Tendon Reflexes- Grade 0-4 ; normal is 2 active or expected response• Examination technique and findings for nuchal rigidity- (pg. 565-566) a stiff neck or nuchal rigidity, is a sign that may be associated with meningitis and intracranial hemorrhage. Place your patient in a supine position, slip your hand under the head and raise it, flexing the neck. Try to make the patient’s chin touch the sternum, but do not force it. Placing your hand under the shoulder when the patient is supine and raising the shoulders slightly will help relax the neck, making the determination of true stiffness more accurate. Pain and a resistance to neck motion are associated with nuchal rigidity (other causes could be due to painful swollen lymph nodes or superficial trauma can cause neck resistance).o Brudzinski sign- may also be present when neck stiffness is assessed. Involuntary flexion of the hips and knees when flexing the neck is a positive sign and may indicate meningeal irritation.o Kernig sign- evaluated by flexing the leg at the knee and hip when the patient is supine, then attempting to straighten the leg. A positive sign is present when the patient has pain in the lower back and resistance to straightening the leg at the knee, which may indicate meningeal irritationo Vaccines Reduce Meningitis Risk- infants and young children are protected by the Haemophilus influenza type b (Hib) and the pneumococcal vaccine (PCV13) administered as routine immunization, older adolescents and children (MCV4) (pg. 566)• Miscellaneouso Cerebrum of the brain- primarily responsible for person’s mental status.o Two cerebral hemispheres each divided into lobes, comprise the cerebrum. The gray outer layer-the cerebral cortex-houses the higher mental functions and is responsible for perception and behavior.o Frontal lobe- containing the motor cortex is associated with speech formation (in the Broca area). This lobe is responsible for decision making, problem solving, the ability to concentrate, and short-term memory. Associated areas-related to emotions, affect, drive, and awareness of self and the autonomic responses related to emotional states-also originate in the frontal lobe.o Parietal lobe- primarily responsible for receiving and processing sensory data.o Temporal lobe- responsible for perception and interpretation of sounds as well as localizing their source. It contains the Wernicke speech area, while allows a person to understand spoken and written language. The temporal lobe is also involved in the integration of behavior, emotion, and personality as well as long-term memory.o The limbic system- mediates certain patterns of behavior that determine survival (mating, aggression, fear, and affection). Reactions to emotions such as anger, love, hostility, and envy originate here, but the expression of emotion and behavior is mediated by connections between the limbic system and the frontal lobe.o The reticular activating system (RAS) is the brainstem regulates awareness and arousal. Disruption of the ascending RAS can lead to altered mental status (delirium & confusion).o Brain insults- (infection, trauma, or metabolic imbalance) can damage brain cells, which may result in serious permanent dysfunction in mental status.o Infants- all brain neurons are present at birth in a full-term infant, but brain development continues with myelinization of nerve cells over several years.o Adolescents- abstract thinking (ability to develop theories, logical reasoning, making future plans, use generalizations, and consider risks & possibilities) develops during this period. Judgment begins to develop with education, intelligence, and experience.o Older adults- cognitive function should be intact in the healthy older adult, but declines in cognitive abilities occur in some after 60. Speed of information processing and psychomotor speed begin declining at a modest rate after 30, but verbal skills & general knowledge continue to increase into the 60s.o Medications- anticholinergics, benzodiazepines, opioid analgesics, tricyclic antidepressants, levodopa or amantadine, diuretics, digoxin, antiarrhythmic, sedatives, hypnotics, or alternative and complementary therapies such as gingko biloba and St. John’s Wort.o Proprioception and Cerebellar Functions- (pg. 556-559) coordination and fine motor skills, rapid rhythmic alternating movements, accuracy of movements. Balance of equilibrium and gait.o Sensory function- (pg. 559-562) Characteristics of unexpected gait patternso Primary Sensory Functions- superficial touch, superficial pain, temperature and deep pressure, vibration, position of joints (pg. 561)o Cortical Sensory Functions- (pg. 561-562) stereognosis, two-point discrimination, extinction phenomenon, graphesthesia, point location.o Advanced Skills (pg. 565-566)) are performed when problems are detected with routine examination. Protective sensation- use the 5.07 monofilament to test for sensation on several sites of the foot in all patients with diabetes mellitus and peripheral neuropathy. Minegial Signs (nuchal rigidity) stiff neck. Jolt Accentuation of Headache- presenting with fever and headache that leads to a suspected diagnosis of meningitis; move head horizontally at a rate of 2 to 3 rotations per second, positive sign indicated by an increased headache over baseline. Posturing- postures that may be found in unresponsive patients are associated with a severe brain injury. Decorticate or flexor posturing is associated with injury to the corticospinal tracts above the brain stem; associated to injury to brainstem.o Indirect cranial nerve evaluation in newborns and infants- (pg. 567-569)o Abnormalities: Disorders of the neurologic system (pg. 573-580)Assessing the Genitalia and Rectum Case Study (Week 10: Ch. 16, 18, 19, & 20)• Significance of Montgomery tubercleso Tiny sebaceous glands may be apparent on the areola surface (Montgomery tubercles or follicles). The primary function is lubricating and keeping germs away from the breasts. The glands make oily secretions to keep the areola and the nipple lubricated and protected during pregnancy and location, and it is normal to have small bumps on the flat, brown part of the areola called Montgomery glands.• Examination findings of breast changes during menopausalo The breast in postmenopausal women may appear flattened, elongated, and suspended more loosely from the chest wall as the result of glandular tissue atrophy and relaxation of the suspensory ligaments. A finer granular feel on palpation replaces the lobular feel of glandular tissue. The inframammary ridge thickens and can be felt more easily. The nipples become smaller and flatter.• Examination findings consistent with breast cancer in femaleso Screening Recommendations & Breast Cancer Risk Factors (354)o Nipple retraction and dimpling of skin, nipple discharge, painless lump, axilla may be tender if lymph nodes involved, palpable mass usually single; unilateral, irregular, or stellate in shape; poorly delineated borders; fixed; hard or stone-like; and non-tender; breast dimpling, retraction, prominent vasculature; skin may have peau d’ orange or thickened appearance; nipple may be inverted or deviated in position.• Proper technique for using a speculum during the vaginal exam (430-431)o Lubricate the speculum with water or a water-soluble lubricant; warm water if speculum is cold. Select the appropriate size speculum and hold it in your hand with the index finger over the top of the proximal end of the anterior blade and the other fingers around the handle. This position controls the blades as the speculum is inserted into the vagina. Apply downward pressure and ask the woman to breathe slowly and relax the muscles. Use the fingers of that hand to separate the labia minora so that the vaginal opening becomes clearly visible. Then slowly insert the speculum along the path of least resistance, often slightly downward, avoid trauma to the urethra and vaginal walls. Insert the speculum the length of the vaginal canal. While maintaining gentle downward pressure with the speculum, open it by pressing on the thumb piece. Sweep the speculum slowly upward until the cervix comes into view. Gently reposition the speculum, if needed until cervix is in view. Once you visualize the cervix, manipulate the speculum to fully expose the cervix between the anterior and posterior blades. Lock the speculum blades into place to stabilize the distal spread of the blades, and adjust the proximal spread as needed.• Proper technique for the bimanual examinationo Breast: Place one hand, palmar surface facing up, under the patient’s right breast. Position your hand so that it acts as a flat surface against which to compress the breast tissue. With the fingers of the other hand, walk across the breast tissue, feeling for lumps as you compress the tissue between your fingers and your flat hand. Repeat the procedure for the other breast.o Female Genitalia: Inform of examination internally using the fingers; lubricate index and middle fingers and insert into the vaginal opening and press downward. Gently insert fingers the full length into the vagina. Palpate the vaginal wall as you insert your fingers. It should be smooth, homogeneous, and non-tender. Feel for cysts, nodules, masses, or growths. Be careful where you place your thumb during the bimanual exam. You can tuck it into the palm of your hand, but that will cut down on the distance you can insert your fingers. Be aware of where the thumb is and keep it from touching the clitoris, which can produce discomfort.o Examining the woman who has had a hysterectomy (436)• Proper technique for examining the male genitalia, including the prostateo Inspection and Palpation: 1st Inspect- Genital Hair Distribution- coarser than scalp hair. 2nd Penis: the dorsal vein should be apparent on inspection if uncircumcised, retract the foreskin, should retract easily and have a bit of smegma (white cheesy sebaceous matter). 3rd Urethral Meatus- examine the orifice should appear slitlike and be located on the ventral surface from the tip of the glans. Press the glans between the thumb and forefinger to open the urethral orifice, should be glistening and pink, bright erythema or discharge indicates inflammatory disease, and a pinpoint or round opening may result from meatal stenosis. 4th Penile Shaft- palpate the shaft for tenderness and induration. Strip the urethra for any discharge by firmly compressing the base of the penis with your thumb and forefinger and moving them toward the glans. Discharge may indicate an STI, the texture of the flaccid penis should be soft and free of nodularity. 5th Scrotum- inspect, it may appear more deeply pigmented than the body skin, and the surface may be coarse. Lumps in the scrotal skin are commonly caused by sebaceous cyst also called epidermoid cysts. They appear as small lumps on the scrotum but they may enlarged and discharge oily material. 6th Hernia- examine, with the patient standing, ask him to bear down as if having a BM. While he is straining, inspect the area of the inguinal canal and the region of the fossa ovalis. After asking the patient to relax again, insert your examining finger into the lower part of the scrotum and carry it upward along the vas deferens into the inguinal canal. You can auscultate for bowel sounds, which will be present in uncomplicated reducible hernias. It is best to use the middle or index finger in adults, ask the patient to cough. If an inguinal hernia is present, you should feel the sudden presence of a viscus hernia is present, you should feel the sudden presence of a viscus against your finger. The hernia is described as indirect if it lies within the inguinal canal, and suggests the possibility of bilateral herniation, examine both sides thoroughly. If the viscus is felt medial to the external canal, it probably represents a direct inguinal hernia. 7th Testes- palpate the testes using the thumb and first two fingers, should be sensitive to gentle compression but not tender, should feel smooth and rubbery and be free of nodules. Irregularities in texture may indicate infection, cyst, or a tumor. In some diseases, a testis may be totally insensitive to painful stimuli (syphilis and diabetic neuropathy). 8th Cremasteric Reflex- stroke the inner thigh with a blunt instrument such as the handle of the reflex hammer, or a finger if a child. The testicle and scrotum should rise on the stroked side.o Genital Self-Examination for Men (470) - the purpose of GSE is to detect any signs or symptoms that might indicate the presence of an STI. Instruct the patient to hold the penis in his hand and examine the head if uncircumcised, gently pull back the foreskin to expose the glans. Inspection and palpation of the entire head should be performed in a clockwise motion while looking for bumps, sores, or blisters on the skin. Bumps and blisters may be red or light colored or may resemble pimples. Have the patient look for genital warts. The urethral meatus should also be examined for discharge. Next the patient will examine the entire shaft and look for the same signs. Instruct him to separate the pubic hair at the base of the penis and carefully examine the skin underneath. Make sure he includes the underside of the shaft in the exam. Instruct the patient to examine the scrotal skin and contents, he should hold each testicle gently and inspect and palpate the skin, including the underneath of the scrotum, looking for lumps, swelling, or soreness. Gently feel each testicle. Suggest to the patient that self-examination of the scrotum at home be performed while bathing, because the warmth is likely to make the scrotal skin less thick. Lastly, educate the patient regarding symptoms associated with STIs, including, pain, burning on urination, or discharge, including the color, and if any reported, contact health provider.• Proper Technique for examining the prostate (491)o Explain to the patient that the urge to urinate may be felt, but that he will not urinate. In males you can palpate the posterior surface of the prostate gland on the anterior wall. Note the size, contour, consistency, and mobility of the prostate. The gland should feel like a pencil eraser-firm, smooth, and slightly movable-and it should be non-tender. A healthy prostate has a diameter of about 4 cm, with less than 1cm protrusion into the rectum.• Risk factors for testicular and Penile cancer (470)o Testicular Cancer: Undescended testicle (cryptorchidism); risk elevated for both testicles, Personal history of testicular cancer (the opposite testicle is at increased risk), Family history of testicular cancer, abnormal testicle development: Klinefelter syndrome, Age: 20-54 years old, Race: white; 5 times that of black men and more than 3 times that of Asian American and Native American men.o Penile Cancer: lack of circumcision with failure to maintain goo hygiene, Phimosis (occasionally the foreskin is tight and cannot be retracted), Infection with high risk types of HPV, Risk increases with age, smoking, HIV Infection, UV light treatment of psoriasis if genitalia exposed.• Normal vs abnormal bowel findings in newbornso Normal bowel findings- the first meconium stool is ordinarily passed within the first 24 to 48 hours after birth and indicates anal patency. Thereafter, it is common for newborns, especially those breastfed, to have a stool after each feeding (the gastrocolic reflex). Both the internal and external sphincters are under involuntary reflexive control because myelination of the spinal cord in incomplete. Control of bowel is often achieved before control of bladder.o If there is no passage of stool in 24 hours in a newborn, suspect rectal atresia. Hirschsprung disease (congenital megacolon), or cystic fibrosis.• Risk factors for colorectal cancer (498)o Cancer of the large intestine or rectum. Patho- adenocarcinomas comprise the large majority of colorectal cancers. Accumulation of genetic and epigenetic alterations that affect essential cellular and tissue-level functions. Begins with cell proliferation with progression to adenoma and invasive carcinoma. The APC tumor suppressor gene is defective in more than 80% of adenomatous polyps and colon cancers. Subjective Data- bleeding most common symptom, often asymptomatic, may report change in bowel habits or stool characteristics. May report abdominal pain or tenderness. May report personal or family history of colon polyps. May report family history of colon cancer. Objective data- rectal cancer may be felt as a sessile polypoid mass with nodular raised edges and areas of ulcerations; the consistency is often stony, and the contour is irregular. Carcinoma higher in the colon not palpable. Polys or lesions visualized on colonoscopy or flexible sigmoidoscopy.o Risk Factors: overweight/obese, physical inactivity, certain diets (red meats/processed meats), smoking, heavy alcohol use, old age after 50, history of colorectal polyps, history of IBS, family history of colorectal cancer or adenomatous polyps, Lynch Syndrome, Familial adenomatous polyposis, Type 2 DM, and ethnic background of black.• Examination findings consistent with Benign Prostate Hypertrophy (498)o Nonmalignant enlargement of the prostate. Patho- common in men older than 50 years. Gland begins to grow at adolescence, continuing to enlarge with advanced age. Growth of the prostate parallels the increased incidence of BPH. Subjective Data- symptoms of urinary obstruction: hesitancy, decreased force and caliber of stream, dribbling, incomplete emptying of the bladder, frequency, urgency, nocturia, and dysuria. Objective Data- Prostate feels smooth, rubbery, symmetric, and enlarged. Median sulcus may or may not be obliterated.• Examination findings consistent with Prostate Cancero Cancer of the prostate. Patho- Over 99% of prostate cancers are adenocarcinomas, developing from the gland cells in the prostate. In most cases, prostate cancer is a relatively slow-growing cancer; a small percentage is a rapid growing, aggressive form. Incidence increases with age and is less frequent in men younger than 50 years of age. Pathogenesis poorly understood. Following the initial transformation event, further mutations of a multitude of genes lead to tumor progression and metastasis. Subjective Data- early carcinoma asymptomatic, as the malignancy advances, symptoms of urinary obstruction occur. Objective Data- a hard, irregular nodule may be palpable on prostate exam. Prostate feels asymmetric, and the median sulcus may be obliterated. Biopsy required for diagnosis.o Risk Factors of Prostate Cancer (488)o Risk Factors of Anal Cancer (488)• Examination position when assessing anal sphincter toneo Ask pt. to tighten and relax her anal sphincter. Observe sphincter tone. An extremely tight sphincter may be the result of anxiety about the exam; bay be caused by scarring; or indicate spasticity caused by fissures, lesions, or inflammation. A lax sphincter suggests neurologic deficit, whereas an absent sphincter may result from improper repair of a third-degree perineal laceration after childbirth or trauma. Positions: standing position, left lateral decubitus, or knee to chest.• Characteristics of menopausal disordero Menopause is defined as 1 year without menses (amenorrhea). Estrogen levels decrease, causing the labia and clitoris to become smaller. The labia majora becomes flatter as body fat is lost. Pubic hair turns gray and is usually sparser. Both adrenal androgens and ovarian testosterone leaves markedly decrease after menopause, which may account in part for decreases in libido and in muscle mass and strength. The vagina narrows, shortens, and loses its rugae, and the mucosa becomes thin, pale, and dry, which may result in pain with sexual intercourse (dyspareunia). The cervix becomes paler. The uterus decreases in size, and the endometrium thins. The ovaries also decrease, follicles gradually disappear, and the surface of the ovary convolutes. Ovulation usually ceases about 1 to 2 years before menopause. The vaginal walls may lose some of their structural integrity. There may also be an increase in body fat and intraabdominal deposition of body fat, and thermoregulation is altered, which produces the hot flashes associated with menopause.• Characteristics of Pelvic Inflammatory Disease (462)o Infection of the uterus, fallopian tubes, and other reproductive organs; a common and serious complication of some STIs. Often caused by Neisseria gonorrhoeae and chlamydia trachomatis, and may be acute or chronic. Subjective data: symptoms may be mild or absent, unusual vaginal discharge that may have a foul odor, symptoms include painful intercourse, painful urination, irregular menstrual bleeding, and pain in the right upper abdomen. Objective data: acute PID produces very tender, bilateral adnexal areas; the patient guards and usually cannot tolerate bimanual examination; symptoms of chronic PID are bilateral, tender, irregular, and fairly fixed adnexal areas.• Characteristics of Hydrocele, Epididymitis, Epispadias, and Hypospadiaso Hydrocele- when any mass other than the testicle or spermatic cord is palpated in the scrotum, determine whether it is filled with fluid, gas, or solid material. It will most likely be a hernia or hydrocele. Attempt to reduce the size of the mass by pushing it back through the external inguinal canal. If a bright penlight transilluminates the mass, and there is no change in size when reduction is attempted, it most likely contains fluid (hydrocele). Fluid accumulation in the scrotum; as a result of a defect in the tunica vaginalis; this condition is common in infancy; if the tunica vaginalis is not patent, the hydrocele will generally disappear spontaneously in the first 6 months of life; painless enlargement or swelling of the scrotum; non-tender, smooth, firm mass superior and anterior to the testes; transilluminates; confined to the scrotum and does not enter the inguinal canal unless it has been present for a long time and is very large and taut.o Epididymitis- acute painful swelling without discoloration and a thickened or nodular epididymis suggest epididymitis. Often seen in association with a urinary tract infection; can occur from STI, chronic epididymitis may occur from tuberculosis. Subjective data- painful scrotum, urethral discharge, fever, pyuria, recent sexual activity. Objective data- epididymis feels firm and lumpy; is tender, vasa deferentia may be beaded, overlying scrotum may be markedly, (482)o Epispadias- is a rare type of malformation of the penis in which the urethra ends in an opening on the upper aspect of the penis. It can also develop in females when the urethra develops too far anteriorly. Usually diagnosed at birth during exam; can go unnoticed until parent note urine leaks after potty training.o Hypospadias- congenital defect in which the urethral meatus is located on the ventral surface of the glans penile shaft or the base of the penis. Congenital defect that is thought to occur embryological during urethral development, from 8 to 20 weeks of gestation. Presence of this disorder places the infant at greater risk of having undescended testicles. Parents may note penile defect or may be found by health care provider. Diagnosis generally made on exam of newborn infant. Urethral meatus located on ventral surface of the glans penile shaft or the base of the penis. Dorsal hood of foreskin and glandular groove are evident, but prepuce is incomplete ventrally. Penis may have ventral shortening and curvature, called chordee, with more proximal urethral defects.• Cancer of the Male Genitalia (Penile/Testicular) (470)• Miscellaneouso Vaginal Discharges and Infections (Female Genitalia) (457)o ** Unexplained Fever: the search for an unexplained fever should always include the rectal examination- a rectal condition or prostatitis may be the cause.The Ethics Behind Assessment (Week 11: Ch. 23 24) [Review: Ch. 16 & 18]• Ethical considerations when completing adolescent sports physicals with no injuries vs adolescents with previous injuries• Diagnostics tests used to evaluate sports injuries (583, 585-587, 588-589)o Recommended components of the pre-participation physical evaluation (pg. 583)o Sports-Related Concussion/Sport Concussion Assessment Tool (SCAT3) (pg. 588-592)o The 14 Step screening orthopedic examination (pg. 585-587)• Examination of children with heart murmurs when conducting a sports physical (583)o Heart murmur (auscultation should be performed in both supine and standing positions, or with Valsalva maneuver, to identify murmurs of dynamic left ventricular outflow obstruction).• Ethical considerations to be made as Advanced Practice Registered Nurse• Miscellaneouso Hypertension in the pediatric adult (pg. 582)o Atlantoaxial Instability (pg. 582)o The Female Athlete Triad (pg. 593) a trio of problems- disordered eating, amenorrhea, and osteoporosis-define the female athlete triad due to the sport stressors and the need to be lean (gymnastics, figure skating, diving, ballet, etc.)o Classification of Sports According to Contact (587)
Approaches to Psychology – William E. Glassman & Marilyn Hadad. Chapter 1-10 samenvatting
Approaches to Psychology – William E. Glassman & Marilyn Hadad. Chapter 1 Behavior and Psychology, Chapter 2 The Biological Approach, Chapter 3 The Behaviorist Approach, Chapter 4 The Cognitive Approach, Chapter 5 The Psychodynamic Approach, Chapter 6 The Humanistic Approach, Chapter 7 Perspectives on Development, Chapter 8 Perspectives on Social Behavior, Chapter 9 Perspectives on Abnormal Behavior, Chapter 10 Psychology in Perspective
NSG 6020 Midterm Study Guide (Latest): South University (Already graded A)
NSG 6020 Midterm Study Guide
1. For which of the following patients would a comprehensive health history be appropriate?
A) A new patient with the chief complaint of “I sprained my ankle”
B) An established patient with the chief complaint of “I have an upper respiratory infection”
C) A new patient with the chief complaint of “I am here to establish care”
D) A new patient with the chief complaint of “I cut my hand”
2. Is the following information subjective or objective?
Mr. M. has shortness of breath that has persisted for the past 10 days; it is worse with activity and relieved by rest.
3. Is the following information subjective or objective?
Mr. M. has a respiratory rate of 32 and a pulse rate of 120.
4. The following information is recorded in the health history: “Patient denies chest pain, palpitations, orthopnea, and paroxysmal nocturnal dyspnea.”
Which category does it belong to?
A) Chief complaint
B) Present illness
C) Personal and social history
D) Review of systems
5. A patient presents for evaluation of a sharp, aching chest pain which increases with breathing. Which anatomic area would you localize the symptom to?
6. A 22-year-old advertising copywriter presents for evaluation of joint pain. The pain is new, located in the wrists and fingers bilaterally, with some subjective fever. The patient denies a rash; she also denies recent travel or camping activities. She has a family history significant for rheumatoid arthritis. Based on this information, which of the following pathologic processes would be the most correct?
7. A 15-year-old high school sophomore comes to the clinic for evaluation of a 3-week history of sneezing; itchy, watery eyes; clear nasal discharge; ear pain; and nonproductive cough. Which is the most likely pathologic process?
8. You are seeing an elderly man with multiple complaints. He has chronic arthritis, pain from an old war injury, and headaches. Today he complains of these pains, as well as dull chest pain under his sternum. What would the order of priority be for your problem list?
A) Arthritis, war injury pain, headaches, chest pain
B) War injury pain, arthritis, headaches, chest pain
C) Headaches, arthritis, war injury pain, chest pain
D) Chest pain, headaches, arthritis, war injury pain
9. Suzanne, a 25 year old, comes to your clinic to establish care. You are the student preparing to go into the examination room to interview her. Which of the following is the most logical sequence for the patient–provider interview?
A) Establish the agenda, negotiate a plan, establish rapport, and invite the patient's story.
B) Invite the patient's story, negotiate a plan, establish the agenda, and establish rapport.
C) Greet the patient, establish rapport, invite the patient's story, establish the agenda, expand and clarify the patient's story, and negotiate a plan.
D) Negotiate a plan, establish an agenda, invite the patient's story, and establish rapport.
10. Alexandra is a 28-year-old editor who presents to the clinic with abdominal pain. The pain is a dull ache, located in the right upper quadrant, that she rates as a 3 at the least and an 8 at the worst. The pain started a few weeks ago, it lasts for 2 to 3 hours at a time, it comes and goes, and it seems to be worse a couple of hours after eating. She has noticed that it starts after eating greasy foods, so she has cut down on these as much as she can. Initially it occurred once a week, but now it is occurring every other day. Nothing makes it better. From this description, which of the seven attributes of a symptom has been omitted?
A) Setting in which the symptom occurs
B) Associated manifestations
11. A 23-year-old graduate student comes to your clinic for evaluation of a urethral discharge. As the provider, you need to get a sexual history. Which one of the following questions is inappropriate for eliciting the information?
A) Are you sexually active?
B) When was the last time you had intimate physical contact with someone, and did that contact include sexual intercourse?
C) Do you have sex with men, women, or both?
D) How many sexual partners have you had in the last 6 months?
12. On a very busy day in the office, Mrs. Donelan, who is 81 years old, comes for her usual visit for her blood pressure. She is on a low-dose diuretic chronically and denies any side effects. Her blood pressure is 118/78 today, which is well-controlled. As you are writing her script, she mentions that it is hard not having her husband Bill around anymore. What would you do next?
A) Hand her the script and make sure she has a 3-month follow-up appointment.
B) Make sure she understands the script.
C) Ask why Bill is not there.
D) Explain that you will have more time at the next visit to discuss this.
13. When you enter your patient's examination room, his wife is waiting there with him. Which of the following is most appropriate?
A) Ask if it's okay to carry out the visit with both people in the room.
B) Carry on as you would ordinarily. The permission is implied because his wife is in the room with him.
C) Ask his wife to leave the room for reasons of confidentiality.
D) First ask his wife what she thinks is going on.
14. You are performing a young woman's first pelvic examination. You make sure to tell her verbally what is coming next and what to expect. Then you carry out each maneuver of the examination. You let her know at the outset that if she needs a break or wants to stop, this is possible. You ask several times during the examination, “How are you doing, Brittney?” What are you accomplishing with these techniques?
A) Increasing the patient's sense of control
B) Increasing the patient's trust in you as a caregiver
C) Decreasing her sense of vulnerability
D) All of the above
15. A 15-year-old high school sophomore and her mother come to your clinic because the mother is concerned about her daughter's weight. You measure her daughter's height and weight and obtain a BMI of 19.5 kg/m2. Based on this information, which of the following is appropriate?
A) Refer the patient to a nutritionist and a psychologist because the patient is anorexic.
B) Reassure the mother that this is a normal body weight.
C) Give the patient information about exercise because the patient is obese.
D) Give the patient information concerning reduction of fat and cholesterol in her diet because she is obese.
16. A 25-year-old radio announcer comes to the clinic for an annual examination. His BMI is 26.0 kg/m2. He is concerned about his weight. Based on this information, what is appropriate counsel for the patient during the visit?
A) Refer the patient to a nutritionist because he is anorexic.
B) Reassure the patient that he has a normal body weight.
C) Give the patient information about reduction of fat, cholesterol, and calories because he is overweight.
D) Give the patient information about reduction of fat and cholesterol because he is obese.
17. Common or concerning symptoms to inquire about in the General Survey and vital signs include all of the following except:
A) Changes in weight
B) Fatigue and weakness
D) Fever and chills
18. You are beginning the examination of a patient. All of the following areas are important to observe as part of the General Survey except:
A) Level of consciousness
B) Signs of distress
C) Dress, grooming, and personal hygiene
D) Blood pressure
19. Mrs. Lenzo weighs herself every day with a very accurate balance-type scale. She has noticed that over the past 2 days she has gained 4 pounds. How would you best explain this?
A) Attribute this to some overeating at the holidays.
B) Attribute this to wearing different clothing.
C) Attribute this to body fluid.
D) Attribute this to instrument inaccuracy.
20. You are seeing an older patient who has not had medical care for many years. Her vital signs taken by your office staff are: T 37.2, HR 78, BP 118/92, and RR 14, and she denies pain. You notice that she has some hypertensive changes in her retinas and you find mild proteinuria on a urine test in your office. You expected the BP to be higher. She is not on any medications. What do you think is causing this BP reading, which doesn't correlate with the other findings?
A) It is caused by an “auscultatory gap.”
B) It is caused by a cuff size error.
C) It is caused by the patient's emotional state.
D) It is caused by resolution of the process which caused her retinopathy and kidney problems.
21. Mr. Garcia comes to your office for a rash on his chest associated with a burning pain. Even a light touch causes this burning sensation to worsen. On examination, you note a rash with small blisters (vesicles) on a background of reddened skin. The rash overlies an entire rib on his right side. What type of pain is this?
A) Idiopathic pain
B) Neuropathic pain
C) Nociceptive or somatic pain
D) Psychogenic pain
22. A 50-year-old body builder is upset by a letter of denial from his life insurance company. He is very lean but has gained 2 pounds over the past 6 months. You personally performed his health assessment and found no problems whatsoever. He says he is classified as “high risk” because of obesity. What should you do next?
A) Explain that even small amounts of weight gain can classify you as obese.
B) Place him on a high-protein, low-fat diet.
C) Advise him to increase his aerobic exercise for calorie burning.
D) Measure his waist.
23. A 32-year-old white female comes to your clinic, complaining of overwhelming sadness. She says for the past 2 months she has had crying episodes, difficulty sleeping, and problems with overeating. She says she used to go out with her friends from work but now she just wants to go home and be by herself. She also thinks that her work productivity has been dropping because she just is too tired to care or concentrate. She denies any feelings of guilt or any suicidal ideation. She states that she has never felt this way in the past. She denies any recent illness or injuries. Her past medical history consists of an appendectomy when she was a teenager; otherwise, she has been healthy. She is single and works as a clerk in a medical office. She denies tobacco, alcohol, or illegal drug use. Her mother has high blood pressure and her father has had a history of mental illness. On examination you see a woman appearing her stated age who seems quite sad. Her facial expression does not change while you talk to her and she makes little eye contact. She speaks so softly you cannot always understand her. Her thought processes and content seem unremarkable.
What type of mood disorder do you think she has?
A) Dysthymic disorder
B) Manic (bipolar) disorder
C) Major depressive episode
24. A 23-year-old ticket agent is brought in by her husband because he is concerned about her recent behavior. He states that for the last 2 weeks she has been completely out of control. He says that she hasn't showered in days, stays awake most of the night cleaning their apartment, and has run up over $1,000 on their credit cards. While he is talking, the patient interrupts him frequently and declares this is all untrue and she has never been so happy and fulfilled in her whole life. She speaks very quickly, changing the subject often. After a longer than normal interview you find out she has had no recent illnesses or injuries. Her past medical history is unremarkable. Both her parents are healthy but the husband has heard rumors about an aunt with similar symptoms. She and her husband have no children. She smokes one pack of cigarettes a day (although she has been chain-smoking in the last 2 weeks), drinks four to six drinks a week, and smokes marijuana occasionally. On examination she is very loud and outspoken. Her physical examination is unremarkable.
Which mood disorder does she most likely have?
A) Major depressive episode
B) Manic episode
C) Dysthymic disorder
25. Adam is a very successful 15-year-old student and athlete. His mother brings him in today because he no longer studies, works out, or sees his friends. This has gone on for a month and a half. When you speak with him alone in the room, he states it “would be better if he were not here.” What would you do next?
A) Tell him that he has a very promising career in anything he chooses and soon he will feel better.
B) Tell him that he needs an antidepressant and it will take about 4 weeks to work.
C) Speak with his mother about getting him together more with his friends.
D) Assess his suicide risk.
26. You are speaking to an 8th grade class about health prevention and are preparing to discuss the ABCDEs of melanoma. Which of the following descriptions correctly defines the ABCDEs?
A) A = actinic; B = basal cell; C = color changes, especially blue; D = diameter >6 mm; E = evolution
B) A = asymmetry; B = irregular borders; C = color changes, especially blue; D = diameter >6 mm; E = evolution
C) A = actinic; B = irregular borders; C = keratoses; D = dystrophic nails; E = evolution
D) A = asymmetry; B = regular borders; C = color changes, especially orange; D = diameter >6 mm; E = evolution
27. You are beginning the examination of the skin on a 25-year-old teacher. You have previously elicited that she came to the office for evaluation of fatigue, weight gain, and hair loss. You strongly suspect that she has hypothyroidism. What is the expected moisture and texture of the skin of a patient with hypothyroidism?
A) Moist and smooth
B) Moist and rough
C) Dry and smooth
D) Dry and rough
28. A mother brings her 11 month old to you because her mother-in-law and others have told her that her baby is jaundiced. She is eating and growing well and performing the developmental milestones she should for her age. On examination you indeed notice a yellow tone to her skin from head to toe. Her sclerae are white. To which area should your next questions be related?
B) Family history of liver diseases
C) Family history of blood diseases
D) Ethnicity of the child
29. You are examining an unconscious patient from another region and notice Beau's lines, a transverse groove across all of her nails, about 1 cm from the proximal nail fold. What would you do next?
A) Conclude this is caused by a cultural practice.
B) Conclude this finding is most likely secondary to trauma.
C) Look for information from family and records regarding any problems which occurred 3 months ago.
D) Ask about dietary intake.
30. Jacob, a 33-year-old construction worker, complains of a “lump on his back” over his scapula. It has been there for about a year and is getting larger. He says his wife has been able to squeeze out a cheesy-textured substance on occasion. He worries this may be cancer. When gently pinched from the side, a prominent dimple forms in the middle of the mass. What is most likely?
A) An enlarged lymph node
B) A sebaceous cyst
C) An actinic keratosis
D) A malignant lesion
31. A young man comes to you with an extremely pruritic rash over his knees and elbows which has come and gone for several years. It seems to be worse in the winter and improves with some sun exposure. On examination, you notice scabbing and crusting with some silvery scale, and you are observant enough to notice small “pits” in his nails. What would account for these findings?
D) Tinea infection
32. Mrs. Anderson presents with an itchy rash which is raised and appears and disappears in various locations. Each lesion lasts for many minutes. What most likely accounts for this rash?
A) Insect bites
B) Urticaria, or hives
33. Ms. Whiting is a 68 year old who comes in for her usual follow-up visit. You notice a few flat red and purple lesions, about 6 centimeters in diameter, on the ulnar aspect of her forearms but nowhere else. She doesn't mention them. They are tender when you examine them. What should you do?
A) Conclude that these are lesions she has had for a long time.
B) Wait for her to mention them before asking further questions.
C) Ask how she acquired them.
D) Conduct the visit as usual for the patient.
34. Which of the following is a symptom involving the eye?
35. A 29-year-old physical therapist presents for evaluation of an eyelid problem. On observation, the right eyeball appears to be protruding forward. Based on this description, what is the most likely diagnosis?
36. A 12-year-old presents to the clinic with his father for evaluation of a painful lump in the left eye. It started this morning. He denies any trauma or injury. There is no visual disturbance. Upon physical examination, there is a red raised area at the margin of the eyelid that is tender to palpation; no tearing occurs with palpation of the lesion. Based on this description, what is the most likely diagnosis?
37. A 15-year-old high school sophomore presents to the emergency room with his mother for evaluation of an area of blood in the left eye. He denies trauma or injury but has been coughing forcefully with a recent cold. He denies visual disturbances, eye pain, or discharge from the eye. On physical examination, the pupils are equal, round, and reactive to light, with a visual acuity of 20/20 in each eye and 20/20 bilaterally. There is a homogeneous, sharply demarcated area at the lateral aspect of the base of the left eye. The cornea is clear. Based on this description, what is the most likely diagnosis?
B) Acute iritis
C) Corneal abrasion
D) Subconjunctival hemorrhage
38. A sudden, painless unilateral vision loss may be caused by which of the following?
A) Retinal detachment
B) Corneal ulcer
C) Acute glaucoma
39. Sudden, painful unilateral loss of vision may be caused by which of the following conditions?
A) Vitreous hemorrhage
B) Central retinal artery occlusion
C) Macular degeneration
D) Optic neuritis
40. A light is pointed at a patient's pupil, which contracts. It is also noted that the other pupil contracts as well, though it is not exposed to bright light. Which of the following terms describes this latter phenomenon?
A) Direct reaction
B) Consensual reaction
C) Near reaction
41. A patient is assigned a visual acuity of 20/100 in her left eye. Which of the following is true?
A) She obtains a 20% correct score at 100 feet.
B) She can accurately name 20% of the letters at 20 feet.
C) She can see at 20 feet what a normal person could see at 100 feet.
D) She can see at 100 feet what a normal person could see at 20 feet.
42. A patient presents with ear pain. She is an avid swimmer. The history includes pain and drainage from the left ear. On examination, she has pain when the ear is manipulated, including manipulation of the tragus. The canal is narrowed and erythematous, with some white debris in the canal. The rest of the examination is normal. What diagnosis would you assign this patient?
A) Otitis media
B) External otitis
C) Perforation of the tympanum
43. A patient with hearing loss by whisper test is further examined with a tuning fork, using the Weber and Rinne maneuvers. The abnormal results are as follows: bone conduction is greater than air on the left, and the patient hears the sound of the tuning fork better on the left. Which of the following is most likely?
A) Otosclerosis of the left ear
B) Exposure to chronic loud noise of the right ear
C) Otitis media of the right ear
D) Perforation of the right eardrum
44. A college student presents with a sore throat, fever, and fatigue for several days. You notice exudates on her enlarged tonsils. You do a careful lymphatic examination and notice some scattered small, mobile lymph nodes just behind her sternocleidomastoid muscles bilaterally. What group of nodes is this?
D) Posterior cervical
45. A 21-year-old college senior presents to your clinic, complaining of shortness of breath and a nonproductive nocturnal cough. She states she used to feel this way only with extreme exercise, but lately she has felt this way continuously. She denies any other upper respiratory symptoms, chest pain, gastrointestinal symptoms, or urinary tract symptoms. Her past medical history is significant only for seasonal allergies, for which she takes a nasal steroid spray but is otherwise on no other medications. She has had no surgeries. Her mother has allergies and eczema and her father has high blood pressure. She is an only child. She denies smoking and illegal drug use but drinks three to four alcoholic beverages per weekend. She is a junior in finance at a local university and she has recently started a job as a bartender in town. On examination she is in no acute distress and her temperature is 98.6. Her blood pressure is 120/80, her pulse is 80, and her respirations are 20. Her head, eyes, ears, nose, and throat examinations are essentially normal. Inspection of her anterior and posterior chest shows no abnormalities. On auscultation of her chest, there is decreased air movement and a high-pitched whistling on expiration in all lobes. Percussion reveals resonant lungs.
Which disorder of the thorax or lung does this best describe?
A) Spontaneous pneumothorax
B) Chronic obstructive pulmonary disease (COPD)
46. A 62-year-old construction worker presents to your clinic, complaining of almost a year of chronic cough and occasional shortness of breath. Although he has had worsening of symptoms occasionally with a cold, his symptoms have stayed about the same. The cough has occasional mucous drainage but never any blood. He denies any chest pain. He has had no weight gain, weight loss, fever, or night sweats. His past medical history is significant for high blood pressure and arthritis. He has smoked two packs a day for the past 45 years. He drinks occasionally but denies any illegal drug use. He is married and has two children. He denies any foreign travel. His father died of a heart attack and his mother died of Alzheimer's disease. On examination you see a man looking slightly older than his stated age. His blood pressure is 130/80 and his pulse is 88. He is breathing comfortably with respirations of 12. His head, eyes, ears, nose, and throat examinations are unremarkable. His cardiac examination is normal. On examination of his chest, the diameter seems enlarged. Breath sounds are decreased throughout all lobes. Rhonchi are heard over all lung fields. There is no area of dullness and no increased or decreased fremitus.
What thorax or lung disorder is most likely causing his symptoms?
A) Spontaneous pneumothorax
B) Chronic obstructive pulmonary disease (COPD)
47. A 68-year-old retired postman presents to your clinic, complaining of dull, intermittent left-sided chest pain over the last few weeks. The pain occurs after he mows his lawn or chops wood. He says that the pain radiates to the left side of his jaw but nowhere else. He has felt light-headed and nauseated with the pain but has had no other symptoms. He states when he sits down for several minutes the pain goes away. Ibuprofen, Tylenol, and antacids have not improved his symptoms. He reports no recent weight gain, weight loss, fever, or night sweats. He has a past medical history of high blood pressure and arthritis. He quit smoking 10 years ago after smoking one pack a day for 40 years. He denies any recent alcohol use and reports no drug use. He is married and has two healthy children. His mother died of breast cancer and his father died of a stroke. His younger brother has had bypass surgery. On examination you find him healthy-appearing and breathing comfortably. His blood pressure is 140/90 and he has a pulse of 80. His head, eyes, ears, nose, and throat examinations are unremarkable. His lungs have normal breath sounds and there are no abnormalities with percussion and palpation of the chest. His heart has a normal S1 and S2 and no S3 or S4. Further workup is pending.
Which disorder of the chest best describes these symptoms?
A) Angina pectoris
C) Dissecting aortic aneurysm
D) Pleural pain
48. A 36-year-old teacher presents to your clinic, complaining of sharp, knifelike pain on the left side of her chest for the last 2 days. Breathing and lying down make the pain worse, while sitting forward helps her pain. Tylenol and ibuprofen have not helped. Her pain does not radiate to any other area. She denies any upper respiratory or gastrointestinal symptoms. Her past medical history consists of systemic lupus. She is divorced and has one child. She denies any tobacco, alcohol, or drug use. Her mother has hypothyroidism and her father has high blood pressure. On examination you find her to be distressed, leaning over and holding her left arm and hand to her left chest. Her blood pressure is 130/70, her respirations are 12, and her pulse is 90. On auscultation her lung fields have normal breath sounds with no rhonchi, wheezes, or crackles. Percussion and palpation are unremarkable. Auscultation of the heart has an S1 and S2 with no S3 or S4. A scratching noise is heard at the lower left sternal border, coincident with systole; leaning forward relieves some of her pain. She is nontender with palpation of the chest wall.
What disorder of the chest best describes this disorder?
A) Angina pectoris
C) Dissecting aortic aneurysm
D) Pleural pain
49. A grandmother brings her 13-year-old grandson to you for evaluation. She noticed last week when he took off his shirt that his breastbone seemed collapsed. He seems embarrassed and tells you that it has been that way for quite awhile. He states he has no symptoms from it and he just tries not to take off his shirt in front of anyone. He denies any shortness of breath, chest pain, or lightheadedness on exertion. His past medical history is unremarkable. He is in sixth grade and just moved in with his grandmother after his father was deployed to the Middle East. His mother died several years ago in a car accident. He states that he does not smoke and has never touched alcohol. On examination you see a teenage boy appearing his stated age. On visual examination of his chest you see that the lower portion of the sternum is depressed. Auscultation of the lungs and heart are unremarkable.
What disorder of the thorax best describes your findings?
A) Barrel chest
B) Funnel chest (pectus excavatum)
C) Pigeon chest (pectus carinatum)
D) Thoracic kyphoscoliosis
50. A 55–year-old smoker complains of chest pain and gestures with a closed fist over her sternum to describe it. Which of the following diagnoses should you consider because of her gesture?
D) Angina pectoris
51. Which of the following percussion notes would you obtain over the gastric bubble?
52. Which lung sound possesses the characteristics of being louder and higher in pitch, with a short silence between inspiration and expiration and with expiration being longer than inspiration?
53. When crackles, wheezes, or rhonchi clear with a cough, which of the following is a likely etiology?
B) Simple asthma
C) Cystic fibrosis
D) Heart failure
54. What is responsible for the inspiratory splitting of S2?
A) Closure of aortic, then pulmonic valves
B) Closure of mitral, then tricuspid valves
C) Closure of aortic, then tricuspid valves
D) Closure of mitral, then pulmonic valves
55. A 25-year-old optical technician comes to your clinic for evaluation of fatigue. As part of your physical examination, you listen to her heart and hear a murmur only at the cardiac apex. Which valve is most likely to be involved, based on the location of the murmur?
56. You are screening people at the mall as part of a health fair. The first person who comes for screening has a blood pressure of 132/85. How would you categorize this?
C) Stage 1 hypertension
D) Stage 2 hypertension
57. You are conducting a workshop on the measurement of jugular venous pulsation. As part of your instruction, you tell the students to make sure that they can distinguish between the jugular venous pulsation and the carotid pulse. Which one of the following characteristics is typical of the carotid pulse?
B) Soft, rapid, undulating quality
C) Pulsation eliminated by light pressure on the vessel
D) Level of pulsation changes with changes in position
58. You are palpating the apical impulse in a patient with heart disease and find that the amplitude is diffuse and increased. Which of the following conditions could be a potential cause of an increase in the amplitude of the impulse?
B) Aortic stenosis, with pressure overload of the left ventricle
C) Mitral stenosis, with volume overload of the left atrium
59. You are performing a cardiac examination on a patient with shortness of breath and palpitations. You listen to the heart with the patient sitting upright, then have him change to a supine position, and finally have him turn onto his left side in the left lateral decubitus position. Which of the following valvular defects is best heard in this position?
60. You are concerned that a patient has an aortic regurgitation murmur. Which is the best position to accentuate the murmur?
B) Upright, but leaning forward
D) Left lateral decubitus
61. Which of the following events occurs at the start of diastole?
A) Closure of the tricuspid valve
B) Opening of the pulmonic valve
C) Closure of the aortic valve
D) Production of the first heart sound (S1)
62. Which is true of splitting of the second heart sound?
A) It is best heard over the pulmonic area with the bell of the stethoscope.
B) It normally increases with exhalation.
C) It is best heard over the apex.
D) It does not vary with respiration.
63. Which of the following is true of jugular venous pressure (JVP) measurement?
A) It is measured with the patient at a 45-degree angle.
B) The vertical height of the blood column in centimeters, plus 5 cm, is the JVP.
C) A JVP below 9 cm is abnormal.
D) It is measured above the sternal notch.
64. How much does cardiovascular risk increase for each increment of 20 mm Hg systolic and 10 mm Hg diastolic in blood pressure?
65. In measuring the jugular venous pressure (JVP), which of the following is important?
A) Keep the patient's torso at a 45-degree angle.
B) Measure the highest visible pressure, usually at end expiration.
C) Add the vertical height over the sternal notch to a 5-cm constant.
D) Realize that a total value of over 12 cm is abnormal.
66. How should you determine whether a murmur is systolic or diastolic?
A) Palpate the carotid pulse.
B) Palpate the radial pulse.
C) Judge the relative length of systole and diastole by auscultation.
D) Correlate the murmur with a bedside heart monitor.
67. Which of the following correlates with a sustained, high-amplitude PMI?
68. You are listening carefully for S2 splitting. Which of the following will help?
A) Using the diaphragm with light pressure over the 2nd right intercostal space
B) Using the bell with light pressure over the 2nd left intercostal space
C) Using the diaphragm with firm pressure over the apex
D) Using the bell with firm pressure over the lower left sternal border
69. Which of the following is true of a grade 4-intensity murmur?
A) It is moderately loud.
B) It can be heard with the stethoscope off the chest.
C) It can be heard with the stethoscope partially off the chest.
D) It is associated with a “thrill.”
70. A 44-year-old female comes to your clinic, complaining of severe dry skin in the area over her right nipple. She denies any trauma to the area. She noticed the skin change during a self-examination 2 months ago. She also admits that she had felt a lump under the nipple but kept putting off making an appointment. She does admit to 6 months of fatigue but no weight loss, weight gain, fever, or night sweats. Her past medical history is significant for hypothyroidism. She does not have a history of eczema or allergies. She denies any tobacco, alcohol, or drug use. On examination you find a middle-aged woman appearing her stated age. Inspection of her right breast reveals a scaly eczema-like crust around her nipple. Underneath you palpate a nontender 2-cm mass. The axilla contains only soft, moveable nodes. The left breast and axilla examination findings are unremarkable.
What visible skin change of the breast does she have?
A) Nipple retraction
B) Paget's disease
C) Peaud'orange sign
71. A 56-year-old female comes to your clinic, complaining of her left breast looking unusual. She says that for 2 months the angle of the nipple has changed direction. She does not do self-examinations, so she doesn't know if she has a lump. She has no history of weight loss, weight gain, fever, or night sweats. Her past medical history is significant for high blood pressure. She smokes two packs of cigarettes a day and has three to four drinks per weekend night. Her paternal aunt died of breast cancer in her forties. Her mother is healthy but her father died of prostate cancer. On examination you find a middle-aged woman appearing older than her stated age. Inspection of her left breast reveals a flattened nipple deviating toward the lateral side. On palpation the nipple feels thickened. Lateral to the areola you palpate a nontender 4-cm mass. The axilla contains several fixed nodes. The right breast and axilla examinations are unremarkable.
What visible skin change of the breast does she have?
A) Nipple retraction
B) Paget's disease
C) Peaud'orange sign
72. A 23-year-old computer programmer comes to your office for an annual examination. She has recently become sexually active and wants to be placed on birth control. Her only complaint is that the skin in her armpits has become darker. She states it looks like dirt, and she scrubs her skin nightly with soap and water but the color stays. Her past medical symptoms consist of acne and mild obesity. Her periods have been irregular for 3 years. Her mother has type 2 diabetes and her father has high blood pressure. The patient denies using tobacco but has four to five drinks on Friday and Saturday nights. She denies any illegal drug use. On examination you see a mildly obese female who is breathing comfortably. Her vital signs are unremarkable. Looking under her axilla, you see dark, velvet-like skin. Her annual examination is otherwise unremarkable.
What disorder of the breast or axilla is she most likely to have?
B) Acanthosis nigricans
C) Hidradenitis suppurativa
73. A 40-year-old mother of two presents to your office for consultation. She is interested in knowing what her relative risks are for developing breast cancer. She is concerned because her sister had unilateral breast cancer 6 years ago at age 38. The patient reports on her history that she began having periods at age 11 and has been fairly regular ever since, except during her two pregnancies. Her first child arrived when she was 26 and her second at age 28. Otherwise she has had no health problems. Her father has high blood pressure. Her mother had unilateral breast cancer in her 70s. The patient denies tobacco, alcohol, or drug use. She is a family law attorney and is married. Her examination is essentially unremarkable.
Which risk factor of her personal and family history most puts her in danger of getting breast cancer?
A) First-degree relative with premenopausal breast cancer
B) Age at menarche of less than 12
C) First live birth between the ages of 25 and 29
D) First-degree relative with postmenopausal breast cancer
74. How often, according to American Cancer Society recommendations, should a woman undergo a screening breast examination by a skilled clinician?
A) Every year
B) Every 2 years
C) Every 3 years
D) Every 4 years
75. Which of the following is most likely benign on breast examination?
A) Dimpling of the skin resembling that of an orange
B) One breast larger than the other
C) One nipple inverted
D) One breast with dimple when the patient leans forward
76. A 77-year-old retired bus driver comes to your clinic for a physical examination at his wife's request. He has recently been losing weight and has felt very fatigued. He has had no chest pain, shortness of breath, nausea, vomiting, or fever. His past medical history includes colon cancer, for which he had surgery, and arthritis. He has been married for over 40 years. He denies any tobacco or drug use and has not drunk alcohol in over 40 years. His parents both died of cancer in their 60s. On examination his vital signs are normal. His head, cardiac, and pulmonary examinations are unremarkable. On abdominal examination you hear normal bowel sounds, but when you palpate his liver it is abnormal. His rectal examination is positive for occult blood.
What further abnormality of the liver was likely found on examination?
A) Smooth, large, nontender liver
B) Irregular, large liver
C) Smooth, large, tender liver
77. A 27-year-old policewoman comes to your clinic, complaining of severe left-sided back pain radiating down into her groin. It began in the middle of the night and woke her up suddenly. It hurts in her bladder to urinate but she has no burning on the outside. She has had no frequency or urgency with urination but she has seen blood in her urine. She has had nausea with the pain but no vomiting or fever. She denies any other recent illness or injuries. Her past medical history is unremarkable. She denies tobacco or drug use and drinks alcohol rarely. Her mother has high blood pressure and her father is healthy. On examination she looks her stated age and is in obvious pain. She is lying on her left side trying to remain very still. Her cardiac, pulmonary, and abdominal examinations are unremarkable. She has tenderness just inferior to the left costovertebral angle. Her urine pregnancy test is negative and her urine analysis shows red blood cells.
What type of urinary tract pain is she most likely to have?
A) Kidney pain (from pyelonephritis)
B) Ureteral pain (from a kidney stone)
C) Musculoskeletal pain
D) Ischemic bowel pain
78. Chris is a 20-year-old college student who has had abdominal pain for 3 days. It started at his umbilicus and was associated with nausea and vomiting. He was unable to find a comfortable position. Yesterday, the pain became more severe and constant. Now, he hesitates to walk, because any motion makes the pain much worse. It is localized just medial and inferior to his iliac crest on the right. Which of the following is most likely?
A) Peptic ulcer
79. Which is the proper sequence of examination for the abdomen?
A) Auscultation, inspection, palpation, percussion
B) Inspection, percussion, palpation, auscultation
C) Inspection, auscultation, percussion, palpation
D) Auscultation, percussion, inspection, palpation
80. Mr. Patel is a 64-year-old man who was told by another care provider that his liver is enlarged. Although he is a life-long smoker, he has never used drugs or alcohol and has no knowledge of liver disease. Indeed, on examination, a liver edge is palpable 4 centimeters below the costal arch. Which of the following would you do next?
A) Check an ultrasound of the liver
B) Obtain a hepatitis panel
C) Determine liver span by percussion
D) Adopt a “watchful waiting” approach
81. Cody is a teenager with a history of leukemia and an enlarged spleen. Today he presents with fairly significant left upper quadrant pain. On examination of this area a rough grating noise is heard. What is this sound?
A) It is a splenic rub.
B) It is a variant of bowel noise.
C) It represents borborygmi.
D) It is a vascular noise.
82. You are palpating the abdomen and feel a small mass. Which of the following would you do next?
B) Examination with the abdominal muscles tensed
C) Surgery referral
D) Determine size by percussion
83. Mr. Maxwell has noticed that he is gaining weight and has increasing girth. Which of the following would argue for the presence of ascites?
A) Bilateral flank tympany
B) Dullness which remains despite change in position
C) Dullness centrally when the patient is supine
D) Tympany which changes location with patient position
84. Which of the following is consistent with obturator sign?
A) Pain distant from the site used to check rebound tenderness
B) Right hypogastric pain with the right hip and knee flexed and the hip internally rotated
C) Pain with extension of the right thigh while the patient is on her left side or while pressing her knee against your hand with thigh flexion
D) Pain that stops inhalation in the right upper quadrant
85. A 57-year-old maintenance worker comes to your office for evaluation of pain in his legs. He has smoked two packs per day since the age of 16, but he is otherwise healthy. You are concerned that he may have peripheral vascular disease. Which of the following is part of common or concerning symptoms for the peripheral vascular system?
A) Intermittent claudication
B) Chest pressure with exertion
C) Shortness of breath
D) Knee pain
86. You are a student in the vascular surgery clinic. You are asked to perform a physical examination on a patient with known peripheral vascular disease in the legs. Which of the following aspects is important to note when you perform your examination?
A) Size, symmetry, and skin color
B) Muscle bulk and tone
C) Nodules in joints
D) Lower extremity strength
87. You are assessing a patient for peripheral vascular disease in the arms, secondary to a complaint of increased weakness and a history of coronary artery disease and diabetes. You assess the brachial and radial pulses and note that they are bounding. What does that translate to on a scale of 0 to 3?
88. A 77-year-old retired nurse has an ulcer on a lower extremity that you are asked to evaluate when you do your weekly rounds at a local long-term care facility. All of the following are responsible for causing ulcers in the lower extremities except for which condition?
A) Arterial insufficiency
B) Venous insufficiency
C) Diminished sensation in pressure points
89. Asymmetric BPs are seen in which of the following conditions?
A) Coronary artery disease
B) Congenital narrowing of the aorta
C) Diffuse atherosclerosis
D) Vasculitis, as seen in systemic lupus erythematosus
90. When assessing temperature of the skin, which portion of your hand should be used?
C) Backs of fingers
D) Ulnar aspect of the hand
91. A patient presents with claudication symptoms and diminished pulses. Which of the following is consistent with chronic arterial insufficiency?
A) Pallor of the foot when raised to 60 degrees for one minute
B) Return of color to the skin within 5 seconds of allowing legs to dangle
C) Filling of the veins of the ankles within 10 seconds of allowing the legs to dangle
D) Hyperpigmentation of the skin
92. A 32-year-old white male comes to your clinic, complaining of aching on the right side of his testicle. He has felt this aching for several months. He states that as the day progresses the aching increases, but when he wakes up in the morning he is pain-free. He denies any pain with urination and states that the pain doesn't change with sexual activity. He denies any fatigue, weight gain, weight loss, fever, or night sweats. His past medical history is unremarkable. He is a married hospital administrator with two children. He notes that he and his wife have been trying to have another baby this year but have so far been unsuccessful despite frequent intercourse. He denies using tobacco, alcohol, or illegal drugs. His father has high blood pressure but his mother is healthy. On examination you see a young man appearing his stated age with unremarkable vital signs. On visualization of his penis, he is circumcised with no lesions. He has no scars along his inguinal area, and palpation of the area shows no lymphadenopathy. On palpation of his scrotum you feel testes with no discrete masses. Upon placing your finger through the right inguinal ring you feel what seems like a bunch of spaghetti. Asking him to bear down, you feel no bulges. The left inguinal ring is unremarkable, with no bulges on bearing down. His prostate examination is unremarkable.
What abnormality of the scrotum does he most likely have?
B) Scrotal hernia
C) Scrotal edema
93. A 15-year-old high school football player is brought to your office by his mother. He is complaining of severe testicular pain since exactly 8:00 this morning. He denies any sexual activity and states that he hurts so bad he can't even urinate. He is nauseated and is throwing up. He denies any recent illness or fever. His past medical history is unremarkable. He denies any tobacco, alcohol, or drug use. His parents are both in good health. On examination you see a young teenager lying on the bed with an emesis basin. He is very uncomfortable and keeps shifting his position. His blood pressure is 150/100, his pulse is 110, and his respirations are 24. On visualization of the penis he is circumcised and there are no lesions and no discharge from the meatus. His scrotal skin is tense and red. Palpation of the left testicle causes severe pain and the patient begins to cry. His prostate examination is unremarkable. His cremasteric reflex is absent on the left but is normal on the right. By catheter you get a urine sample and the analysis is unremarkable. You send the boy with his mother to the emergency room for further workup.
What is the most likely diagnosis for this young man's symptoms?
A) Acute orchitis
B) Acute epididymitis
C) Torsion of the spermatic cord
94. Which of the following conditions involves a tight prepuce which, once retracted, cannot be returned?
95. You are examining a newborn and note that the right testicle is not in the scrotum. What should you do next?
A) Refer to urology
B) Recheck in 6 months
C) Tell the parent the testicle is absent but that this should not affect fertility
D) Attempt to bring down the testis from the inguinal canal
96. Frank is a 24-year-old man who presents with multiple burning erosions on the shaft of his penis and some tender inguinal adenopathy. Which of the following is most likely?
A) Primary syphilis
B) Herpes simplex
97. A 30-year-old paralegal analyst comes to your clinic, complaining of a bad-smelling vaginal discharge with some mild itching, present for about 3 weeks. She tried douching but it did not help. She has had no pain with urination or with sexual intercourse. She has noticed the smell increased after intercourse and during her period last week. She denies any upper respiratory, gastrointestinal, cardiac, or pulmonary symptoms. Her past medical history consists of one spontaneous vaginal delivery. She is married and has one child. She denies tobacco, alcohol, or drug use. Her mother has high blood pressure and her father died from a heart disease. On examination she appears healthy and has unremarkable vital signs. On examination of the perineum there are no lesions noted. On palpation of the inguinal nodes there is no lymphadenopathy. On speculum examination a thin gray-white discharge is seen in the vault. The pH of the discharge is over 4.5 and there is a fishy odor when potassium hydroxide (KOH) is applied to the vaginal secretions on the slide. Wet prep shows epithelial cells with stippled borders (clue cells).
What type of vaginitis best describes her findings?
A) Trichomonas vaginitis
B) Candida vaginitis
C) Bacterial vaginosis
D) Atrophic vaginitis
98. A 48-year-old high school librarian comes to your clinic, complaining of 1 week of heavy discharge causing severe itching. She is not presently sexually active and has had no burning with urination. The symptoms started several days after her last period. She just finished a course of antibiotics for a sinus infection. Her past medical history consists of type 2 diabetes and high blood pressure. She is widowed and has three children. She denies tobacco, alcohol, or drug use. Her mother has high blood pressure and her father died of diabetes complications. On examination you see a healthy-appearing woman. Her blood pressure is 130/80 and her pulse is 70. Her head, eyes, ears, nose, throat, cardiac, lung, and abdominal examinations are unremarkable. Palpation of the inguinal lymph nodes is unremarkable. On visualization of the vulva, a thick, white, curdy discharge is seen at the introitus. On speculum examination there is a copious amount of this discharge. The pH of the discharge is 4.1 and the KOH whiff test is negative, with no unusual smell. Wet prep shows budding hyphae.
What vaginitis does this patient most likely have?
A) Trichomonas vaginitis
B) Candida vaginitis
C) Bacterial vaginosis
D) Atrophic vaginitis
99. A 55-year-old married homemaker comes to your clinic, complaining of 6 months of vaginal itching and discomfort with intercourse. She has not had a discharge and has had no pain with urination. She has not had a period in over 2 years. She has no other symptoms. Her past medical history consists of removal of her gallbladder. She denies use of tobacco, alcohol, and illegal drugs. Her mother has breast cancer and her father has coronary artery disease, high blood pressure, and Alzheimer's disease. On examination she appears healthy and has unremarkable vital signs. There is no lymphadenopathy with palpation of the inguinal nodes. Visualization of the vulva shows dry skin but no lesions or masses. The labia are somewhat smaller than usual. Speculum examination reveals scant discharge and the vaginal walls are red, dry, and bleed easily. Bimanual examination is unremarkable. The KOH whiff test produces no unusual odor and there are no clue cells on the wet prep.
What form of vaginitis is this patient most likely to have?
A) Trichomonas vaginitis
B) Candida vaginitis
C) Bacterial vaginosis
D) Atrophic vaginitis
100. A 28-year-old married clothing sales clerk comes to your clinic for her annual examination. She requests a refill on her birth control pills. Her only complaint is painless bleeding after intercourse. She denies any other symptoms. Her past medical history consists of two spontaneous vaginal deliveries. Her past six Pap smears have all been normal. She is married and has two children. Her mother is in good health and her father has high blood pressure. On examination you see a young woman appearing healthy and relaxed. Her vital signs are unremarkable and her head, eyes, ears, throat, neck, cardiac, lung, and abdominal examinations are normal. Visualization of the perineum shows no lesions or masses. Speculum examination shows a red mass at the os. On taking a Pap smear the mass bleeds easily. Bimanual examination shows no cervical motion tenderness and both ovaries are palpated and nontender.
What is the most likely diagnosis for the abnormality of her cervix?
A) Carcinoma of the cervix
B) Mucopurulent cervicitis
C) Cervical polyp
D) Retention cyst
101. A 23-year-old waitress comes to your clinic complaining of severe pelvic pain radiating to her right side. The pain began yesterday and is getting much worse. She has had no burning with urination and denies any recent sexual activity. She has no nausea, vomiting, constipation, diarrhea, fever, or vaginal discharge. Her last period was 3 to 4 weeks ago. Her past medical history consists of severe acne, depression, and mild obesity. She has had no surgeries. She broke up with her boyfriend 6 months ago and denies dating anyone else. She smokes one pack of cigarettes a day, drinks three to four beers two to three times a week, and denies any illegal drug use. Her mother is diabetic and her father has coronary artery disease. On examination you see a mildly obese female in moderate distress. Her blood pressure is 130/80 and her pulse is 90. She is afebrile. On auscultation she has active bowel sounds. She has no rebound or guarding in any abdominal quadrant. Speculum examination shows no lesions on the cervix and no discharge or bleeding from the os. During the bimanual examination she has no cervical motion tenderness, but her right adnexal area is swollen and tender. A urine analysis is normal and the urine pregnancy test is pending.
What disorder of the adnexa is most likely the diagnosis?
A) Ovarian cyst
B) Tubal pregnancy
C) Pelvic inflammatory disease
102. Which of the following represents metrorrhagia?
A) Fewer than 21 days between menses
B) Excessive flow
C) Infrequent bleeding
D) Bleeding between periods
103. Abby is a newly married woman who is unable to have intercourse because of vaginismus. Which of the following is true?
A) This is most likely due to lack of lubrication.
B) This is most likely due to atrophic vaginitis.
C) This is most likely due to pressure on an ovary.
D) Psychosocial reasons may cause this condition.
104. Which of the following is true of the HPV vaccine?
A) Ideally it should be administered within 3 years of first intercourse.
B) It covers against almost every HPV type.
C) It can be used as adjuvant therapy in cervical cancer.
D) It can protect against anogenital lesions.
105. A 42-year-old house painter comes to your clinic, complaining of pain with defecation and profuse bleeding in the toilet after a bowel movement. He was in his usual state of health until 2 weeks ago, when he was injured in a car accident. After the accident he began taking prescription narcotics for the pain in his shoulder. Since then he has had very few bowel movements. His stool is hard and pebble-like. He states he has always been “regular” in the past, with easy bowel movements. His diet has not changed but he states that he is exercising less since the accident. His past medical history includes hypertension and he is on a low-dose diuretic. He has had no other chronic illnesses or surgeries. He has a family history of hypertension, coronary heart disease, and diabetes but no cancer. He is divorced and has three children. He smokes two packs of cigarettes per day and quit drinking more than 10 years ago. He has had no recent weight loss, weight gain, fever, or night sweats. On examination he appears muscular and healthy; he is afebrile. His blood pressure is 135/90 with a pulse of 80. His cardiac, lung, and abdominal examinations are normal. He is wearing a sling on his left arm. On observation of his anus you find a swollen bluish ovoid mass that appears to contain a blood clot. Digital rectal examination is extremely painful for the patient. No other mass is palpated within the anus or rectum.
What disorder of the anus is this patient likely to have?
A) Anal fissure
B) External hemorrhoid
C) Anorectal cancer
D) Internal hemorrhoid
106. A 60-year-old coach comes to your clinic, complaining of difficulty starting to urinate for the last several months. He believes the problem is steadily getting worse. When asked he says he has a very weak stream and it feels like it takes 10 minutes to empty his bladder. He also has the urge to go to the bathroom more often than he used to. He denies any blood or sediment in his urine and any pain with urination. He has had no fever, weight gain, weight loss, or night sweats. His medical history includes type 2 diabetes and high blood pressure treated with medications. He does not smoke but drinks a six pack of beer weekly. He has been married for 35 years. His mother died of a myocardial infarction in her 70s and his father is currently in his 80s with high blood pressure and arthritis. On examination you see a mildly obese male who is alert and cooperative. His blood pressure is 130/70 with a heart rate of 80. He is afebrile and his cardiac, lung, and abdominal examinations are normal. On visualization of the anus you see no inflammation, masses, or fissures. Digital rectal examination reveals a smooth, enlarged prostate. No discrete masses are felt. There is no blood on the glove or on guaiac testing. An analysis of the urine shows no red blood cells, white blood cells, or bacteria.
What disorder of the anus, rectum, or prostate is this most likely to be?
A) Benign prostatic hyperplasia (BPH)
C) Prostate cancer
D) Anorectal cancer
107. A 45-year-old African-American minister comes to your clinic for a general physical examination. He has not been feeling very well for about 3 months, including night sweats and a chronic low-grade fever of 100 to 101 degrees. He denies any upper respiratory symptoms, chest pain, nausea, constipation, diarrhea, blood in his stool, or urinary tract symptoms. He has had some lower back pain. He has a past history of difficult-to-control high blood pressure and high cholesterol. He has had no surgeries in the past. His mother has diabetes and high blood pressure. He knows very little about his father because his parents divorced when he was young. He knows his father died in his 50s, but he is unsure of the exact cause. The patient denies smoking, drinking, or drug use. He is married and has three children. On examination he appears his stated age and is generally fit. His temperature is 99.9 degrees and his blood pressure is 160/90. His head, ears, nose, throat, and neck examinations are normal. His cardiac, lung, and abdominal examinations are also normal. On visualization of the anus there is no inflammation, masses, or fissures. Digital rectal examination elicits an irregular, asymmetric, hard nodule on the otherwise normal posterior surface of the prostate. Examination of the scrotum and penis are normal. Laboratory results are pending.
What disorder of the anus, rectum, or prostate is mostly likely in this case?
A) Benign prostatic hyperplasia (BPH)
C) Prostate cancer
D) Anorectal cancer
108. Which is true of the pectinate or dentate line?
A) It is a palpable landmark.
B) It demarcates the areas supplied by the central nervous system from the peripheral nervous system.
C) It is the border between the anal canal and the rectum.
D) It is not visible on proctoscopic examination.
109. Which is a sign of benign prostatic hyperplasia?
A) Weight loss
B) Bone pain
110. Important techniques in performing the rectal examination include which of the following?
B) Waiting for the sphincter to relax
C) Explaining what the patient should expect with each step before it occurs
D) All of the above
111. An elderly woman with dementia is brought in by her daughter for a “rectal mass.” On examination you notice a moist pink mass protruding from the anus, which is nontender. It is soft and does not have any associated bleeding. Which of the following is most likely?
A) Rectal prolapse
B) External hemorrhoid
C) Perianal fistula
D) Prolapsed internal hemorrhoid
Nurse Practitioner 6521. All Answwers Correct
Nurse Practitioner 6521
8. Gender-specific skeletal differences first occur during:
the second stage of fetal development.
7. Fifty percent of an individual’s ideal weight is gained during:
6. During adolescence, the head size normally increases as a result of:
brain mass increase.
evolution of lymphatic tissue.
hypertrophy of myelin.
5. Mrs. Jones has brought her 24-month-old child for a well visit. Which organ(s) completes physical development more quickly than any other body part?
4. By 10 to 12 years of age, lymphatic tissues are about:
25% of adult size.
50% of adult size.
the same as adult size.
twice the size of those in the adult.
3. After 50 years of age, stature:
begins a barely perceptible secondary increase.
increases at a rate of 0.5 cm per year.
2. Developmental changes of puberty are caused mainly by the interaction of the pituitary gland, gonads, and:
1. The gonads begin to secrete estrogen and testosterone during:
2. The perception of pain:
is the same across cultures.
can be easily assessed neonates.
is predictable with the same circumstances.
is impacted by emotions and quality of sleep.
1. The Joint Commission (TJC, formerly The Joint Commission on Accreditation of Healthcare Organizations [JCAHO]) requires that:
pain be assessed on all discharges.
repeated assessment of pain be limited to those patients who complain of pain.
repeated intensity documentation be made of the course of pain relief for all patients.
pain be assessed on surgical patients.
3. A 5-year-old is complaining of nondescriptive “belly pain.” Your next action should be to ask him to:
point a finger to the spot that hurts.
draw a circle around the area that hurts.
use a metaphor to describe the pain.
identify how pain medication affects the pain.
4. Your 85-year-old patient is complaining of right knee pain. She has a history of osteoarthritis for which she is given antiinflammatory medication. To assess her right knee pain, you should ask her if:
the current pain is similar to previous pain.
the left knee hurts as well.
she took pain medication last night.
the pain gets better when she sits.
5. Ms. Green is an 85-year-old female patient with dementia who presents to the emergency department with her daughter because of a change in function. Which pain assessment scale would be the best choice?
Checklist for Nonverbal Pain Indicators
Wong/Baker Rating Scale
6. Body language that leads you to suspect the person is in pain is:
talkative, verbose speech.
fretful hand movements.
focused, fixed eye stares.
7. Mr. Green is a 68-year-old patient who has complained of pain. As the health care provider, you have decided to use a pain scale for documentation of the patient’s pain. The value of the use of scales for patients to rate their pain intensity is that:
the emotional responses are factored in.
correlation with others’ expectations is achieved.
the patient’s response to therapy can be documented.
subjective responses are eliminated.
8. You are caring for a patient with trigeminal neuralgia. During the assessment, the patient would describe the pain as:
throbbing and dull.
burning or shocklike.
tender and deep.
cramping and spasmodic.
1. When is the mental status portion of the neurologic system examination performed?
During the history-taking process
During assessment of cranial nerves and deep tendon reflexes
During the time when questions related to memory are asked
Continually, throughout the entire interaction with a patient
2. A 69-year-old truck driver presents with a sudden loss of the ability to understand spoken language. This indicates a lesion in the:
3. Mr. DeLaurentis is a 58-year-old man who presents to your office with slumped posture and a lack of facial expression, which may indicate depression or:
loss of abstract reasoning.
4. The ability for abstract thinking normally develops during:
Abstract thinking is an intellectual maturation that develops during adolescence.
5. The Mini-Mental State Examination (MMSE) may be used to:
quantitatively estimate cognitive changes.
qualitatively estimate personality disorders.
diagnose neurologic disorders.
determine the cause of memory loss.
6. Assessing orientation to person, place, and time helps determine:
ability to understand analogies.
state of consciousness.
7. “Arousal for short periods to visual, verbal, or painful stimuli” describes which level of consciousness?
8. When you ask the patient to tell you the meaning of a proverb or metaphor, you are assessing which of the following?
Level of consciousness
9. Impairment of arithmetic skills is often due to:
impaired execution of motor skills.
10. Peripheral neuropathy is most likely to be manifested by:
impaired abstract reasoning.
impaired writing ability.
11. Recent memory may be tested by:
asking the patient to name the past four presidents.
asking the patient to listen to and repeat a series of numbers.
showing the patient four items and asking him to list the items about 10 minutes later.
asking the patient about verifiable information, such as his or her mother’s maiden name.
12. Loss of immediate and recent memory with retention of remote memory suggests:
attention-deficit/hyperactivity disorder (ADHD).
13. You ask the patient to follow a series of short commands to assess:
14. Which of these observations would be most significant when assessing the condition of a patient who has judgment impairment?
Repeated failure to complete work obligations
Forgetting family members’ birth dates
Going to church three times a week
Planning for retirement in 20 years
15. Appropriateness of logic, sequence, cohesion, and relevance to topics are markers for assessment of:
mood and feelings.
thought process and content.
16. Which type of hallucination is most commonly associated with alcohol withdrawal?
17. Flight of ideas or loosening of associations is associated with:
18. Facial muscle or tongue weakness may result in:
19. The Glasgow Coma Scale is used to:
determine the cause of decreased consciousness.
diagnose disorders that alter level of consciousness.
predict response to stimulant medications.
20. The Denver II is a tool used to determine:
a child’s IQ.
a child’s mood.
whether a child is educable.
whether a child is developing as expected.
21. When the Goodenough-Harris Drawing Test is administered to a child, the evaluator principally observes the:
presence and form of body parts.
gender and race of the person drawn.
approximate age and posture of the person drawn.
length of time needed to draw a stick man.
22. An older adult is administered the Set Test and scores a 14. The nurse interprets this score as indicative of:
23. Which condition is considered progressive rather than reversible?
24. “A clinical syndrome of failing memory and impairment of other intellectual functions, usually related to obvious structural diseases of the brain” describes:
25. Mrs. Griffiths, a 28-year-old patient, presents to your office to discuss her attention-deficit/hyperactivity disorder (ADHD). Which statement is true in regard to ADHD?
It occurs before 7 years of age.
It is usually related to mental retardation.
It is usually related to dementia.
It is manifested by prolonged periods of catatonic behavior.
26. An aversion to touch or being held, along with delayed or absent language development, is characteristic of:
27. You are interviewing a 20-year-old patient with a new-onset psychotic disorder. The patient is apathetic and has disturbed thoughts and language patterns. The nurse recognizes this behavior pattern as consistent with a diagnosis of:
28. The patient who is delirious usually maintains orientation to:
29. While interviewing a patient, you ask him to explain the “Lion and the Mouse” to assess:
mood and feeling.
30. The Mini-Mental State Examination (MMSE) should be administered for the patient who:
gets lost in her neighborhood.
sleeps an excessive amount of time.
has repetitive ritualistic behaviors.
uses illegal hallucinogenic drugs.
32. George Michaels, a 22-year-old patient, tells the nurse that he is here today to “check his allergies.” He has been having “green nasal discharge” for the last 72 hours. How would the nurse document his reason for seeking care?
A. G. M. is a 22-year-old male here for “allergies.”
B. G. M. came into the clinic complaining of green discharge for the past 72 hours.
C. M., a 22-year-old male, states he has allergies and wants them checked.
D. GM. is a 22-year-old male here for having “green nasal discharge” for the past 72 hours.
Documentation of the chief complaint should always be done by using the patient’s own words in quotation marks.
31. Which of the following formats would be used for visits that address problems not yet identified in the problem-oriented medical record (POMR)?
Brief SOAP note
Comprehensive health history
30. When recording physical findings, which data are recorded first for all systems?
29. The examiner’s evaluation of a patient’s mental status belongs in the:
history of present illness.
review of systems.
28. A SOAP note is used in which type of recording system?
27. Data relevant to the social history of older adults include information on:
family support systems.
previous health care visits.
over-the-counter medication intake.
date of last cancer screening.
26. Eye examination of the newborn does not routinely include assessment of:
. What finding is unique to the documentation of a physical examination of an infant?
24. In which section of the newborn history would you find details of gestational assessment and extrauterine adjustment data?
Personal and social
23. Information recorded about an infant differs from that recorded about an adult, mainly because of the infant’s:
source of information.
22. Ms. G. is being seen for her routine physical examination. She is a college graduate and president of a research firm. Although her exact salary is unknown, she has adequate health insurance. Most of the above information is part of Ms. G.’s _____ history.
personal and social
21. Allergies to drugs and foods are generally listed in which section of the medical record?
History of present illness
Past medical history
20. The review of systems is a component of the:
past medical/surgical history.
19. The patient’s perceived disabilities and functional limitations are recorded in the:
general patient information.
past medical history.
18. The effect of the chief complaint on the patient’s lifestyle is recorded in which section of the medical record?
History of present illness
Past medical history
17. A detailed description of the symptoms related to the chief complaint is presented in the:
history of present illness.
general patient information section.
16. Your patient returns for a blood pressure check 2 weeks after a visit during which you performed a complete history and physical. This visit would be documented by creating a(n):
problem-oriented medical record.
15. Which of the following is not a component of the plan portion of the problem-oriented medical record?
14. When recording assessments during the construction of the problem-oriented medical record, the examiner should:
combine all data into one assessment.
create an assessment for each problem on the problem list.
create an assessment for every abnormal physical finding.
create an assessment for every symptom presented in the history.
13. Differential diagnoses belong in the:
12. A problem may be defined as anything that will require:
11. Which of the following is an example of a problem requiring recording on the patient’s problem list?
Common age variations
Findings of unknown origin
10. Drawing of stick figures is most useful to:
compare findings in extremities.
demonstrate radiation of pain.
indicate consistency of lymph nodes.
indicate mobility of masses.
9. Regardless of the origin, discharge is described by noting:
a grading scale of 0 to 4.
color and consistency.
demographic data and risk factors.
associated symptoms in alphabetic order.
8. The position on a clock, topographic notations, and anatomic landmarks:
are methods for recording locations of findings.
are used for noting disease progression.
are ways for recording laboratory study results.
should not be used in the legal record.
7. Which of the following is an effective adjunct to document location of findings during the recording of physical examinations?
Relationship to anatomic landmarks
Comparison with other patients of same gender and size
Comparison to previous examinations using light pen markings
6. The quality of a symptom, such as pain, is subjective information that should be:
deferred until the cause is determined.
described in the history.
placed in the past medical history section.
placed in the history with objective data.
5. Subjective and symptomatic data are:
documented with the physical examination findings.
not mentioned in the legal chart.
placed in the history section.
recorded with the examination technique.
4. Ms. S. reports that she is concerned about her loss of appetite. During the history, you learn that her last child recently moved out of her house to go to college. Rather than infer the cause of Ms. S.’s loss of appetite, it would be better to:
defer or omit her comments.
have her husband call you.
quote her concerns verbatim.
refer her for psychiatric treatment.
3. During the course of the interview, you should:
take no notes of any kind.
take brief written notes.
take detailed written notes.
repeat pertinent comments into a Dictaphone.
2. Which part of the information contained in the patient’s record may be used in court?
Subjective information only
Objective information only
Diagnostic information only
1. If information is purposefully omitted from the record, you should:
erase the notes that are not pertinent.
accept that sometimes data are omitted.
state in the record why the information was omitted.
use correction fluid to cover the information.