Ha Lecture 1 23 Answer Key PDF

Health Assessment (Lecture)
STUDENT ACTIVITY SHEET BS NURSING / FIRST YEAR

Session # 1
Materials:
LESSON TITLE: Introduction to Health Assessment Book, pen and notebook, index card/class list
LEARNING OUTCOMES:
Upon completion of this lesson, the nursing student can:
1. Learn the definition of health and health assessment and

how it is practiced in the field of nursing; References: Bates’ Nursing Guide to Physical
2. Identify the five steps of the nursing process and how they Examination and History Taking (Second Edition)
are applied in all aspects of nursing; by Beth Hogan-Quigley, Mary Louise Palm, and
3. Enumerate and describe the types of health assessment Lynn Bickley.
and to differentiate them from one another.
SUBJECT ORIENTATION (10 minutes)

Your classroom instructor for this subject, Health Assessment (Lecture) ____________________________.
Listed below are the additional information vital in orientation:
1. The calendar of activities for major examinations must be relayed.

2. Classroom rules and regulations will be informed per the instructor’s discretions.
3. Computation of grades specific for this subject must be thoroughly explained to students.
4. The essence and significance in grade computation of these modules must be introduced.
5. If this is the first subject of the class, the instructor must initiate an election for block officers.
6. Any other information that will be deemed necessary by the instructor must be properly coordinated to the class.
MAIN LESSON (50 minutes)

The students will study and read Chapter 1 of their book about this lesson:
Definition of Health
• Health is a relative state in which a person is able to live to his or her potential and includes the “7 facets”:
• Physical health – how the body works and adapts
• Emotional health – positive outlook and emotions channelled in a healthy manner
• Social well-being – supportive relationships with family and friends
• Cultural influences – favorable connections to promote health
• Spiritual influences – living peacefully, morally, and ethically
• Environmental influences – favorable conditions to promote health
• Developmental level – how one thinks, solves problems, and makes decisions
• Health is a sum of these facets and is not solely defined as the absence of disease or eating right, but rather by
the contribution of all dimensions.
Health Assessment
• The nursing health assessment entails both a comprehensive health history and a complete physical examination,
which are used to evaluate the health and status of a person.
• The nursing health assessment involves a systematic data collection that provides information to facilitate a plan
to deliver the best care for the patient.
• The first part of health assessment is the health history, which also incorporates the “7 facets”.
• The nurse asks pertinent questions to gather data from the patient and/or family. Past medical records may also
be used to collect additional information.
• Learning about the patient’s physical and psychological issues, social and cultural associations, environment,
developmental level, and spiritual beliefs contribute to the history.
• The second component of the health assessment is the physical examination.
• The nurse uses a structured head-to-toe examination to identify changes in the patient’s body systems.
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• An unusual or abnormal finding may support the history data or trigger additional questions.
• The purpose of the nursing health assessment is to determine the patient’s health status, risk factors, and need
for education as a basis for developing a nursing plan of care.
• The NURSING PROCESS is the ability of the nurse to extrapolate the findings, prioritize them, and finally
formulate and implement the plan of care is the overall goal.
• The information obtained throughout the health assessment should be documented in a clear, concise manner.
This information is collated in the patient’s medical records.
NURSING PROCESS
• The nurse uses the NURSING PROCESS (a problem-solving process) to identify patient problems; set a goal and
develop an action plan; implement the plan; and evaluate the outcome.
• The NURSING PROCESS steps are:

• Assessment
• Diagnosis
• Planning
• Implementation
• Evaluation
• Assessment – it is the first step of the nursing process. It is the subjective and objective data gathered during the
initial health history and physical examination and collected on each patient encounter.
• Diagnosis has a nursing focus and is based on real or potential health problems or human responses to health
problems. The nurse uses clinical reasoning to formulate diagnoses based on the assessment data and the
patient’s problem list.
• Planning is devising the best course of action to address the patient’s diagnoses. During planning, the nurse and
patient select goals for each diagnosis in order to alleviate, decrease, or prevent the problems addressed in the
nursing diagnosis.
• Implementation of the interventions can be completed by the patient, the family, or members of the health care
team. The interventions should clearly relate to the nursing diagnosis and the planned goals.
• Evaluation is a continuing process to determine if the goals have been attained. The nursing care plan is revised
based on the patient’s condition and whether the goals are realistic or appropriate for the patient.
.
Types of Health Assessment:

• The admission of a new patient to a clinic, hospital, long-term care facility, or visiting nurse agency usually
requires a comprehensive health assessment.
a. A focused or problem-oriented assessment is where the nurse focuses on gathering information about the
patient’s problem.
• A follow-up history is a form of a focused assessment.

• An emergency history is the data collection which focused on the patient’s emergent problem with a systematic
prioritization of need beginning with the ABCs of airway, breathing, and circulation.
CHECK FOR UNDERSTANDING (10 minutes)

You will answer and rationalize this by yourself. This will be recorded as your quiz. One (1) point will be given to correct
answer and another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio is not allowed.
You are given 25 minutes for this activity:
Multiple Choice
1. The phase of the nursing process where the nurse establishes both the short-term and the long-term goals for the
patient
a. Assessment
b. Diagnosis
c. Planning
d. Diagnosis
RATIONALE:
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2. This is the ability of the nurse to extrapolate the findings, prioritize them, and finally formulate and implement the
plan of care is the overall goal
a. Health history
b. Health assessment
c. Physical examination
d. Nursing process
RATIONALE:
3. Which of the following facets of health is demonstrated if the patient feels very much optimistic about the results
of her pregnancy?
a. Spiritual influences
b. Physical health
c. Cultural influences
d. Emotional health
RATIONALE:
4. When the patient is communicative with her friends with regard to his marital problems which facet of health is
being applied here?
b. Environmental influences
d. Social well-being
RATIONALE:
5. When the patient is identifying a solution to financial problems in order to be rid of her financial stresses the
patient is demonstrating which of the following facets of health?
a. Emotional health
b. Developmental level
c. Physical health
RATIONALE:
6. Which of the following is NOT true about the assessment phase of the nursing process?
a. Subjective and objective data are gathered
b. It ends when doing the nursing diagnosis
c. It is the first step of the nursing process
d. It continues throughout the entire patient encounter
RATIONALE:
7. Which of the following is NOT true about the nursing diagnosis?

a. It has a nursing focus
b. It is based on real or potential health problems
c. It determines the medical diagnosis of the patient
d. It sets the stage for the remainder of the care plan
RATIONALE:
8. Which of the following best describes problem-oriented assessment?

a. The nurse focuses on gathering information about the patient’s problem.
b. This allows the nurse to obtain a full picture of the patient’s health status and current problems.
c. The nurse here gathers data to evaluate the outcomes of the plan of care
d. The data collection is focused on the patient’s emergent problem
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RATIONALE:
9. Which of the following best describes follow-up history?

RATIONALE:
10. This is the phase of the nursing process where the nurse determines whether the goals made for the patient have
been attained
a. Nursing diagnosis
b. Planning
c. Implementation
d. Evaluation
RATIONALE:
LESSON WRAP-UP (10 minutes)
You will now mark (encircle) the session you have finished today in the tracker below. This is simply a visual to help you
track how much work you have accomplished and how much work there is left to do.
You are done with the session! Let’s track your progress.
AL Strategy: Turn and talk
(Students turn to talk partner/s to – find out, summarize, clarify, share ideas, point of view or opinions)
(For next session, read on the chapter about the steps on health assessment)
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STUDENT ACTIVITY SHEET
BS NURSING / FIRST YEAR
Session # 2
Materials:
LESSON TITLE: Steps of Health Assessment Book, pen and notebook, index card/class list
LEARNING OUTCOMES:
1. Learn about the phases of the interview and the

description of each phase; References: Bates’ Nursing Guide to Physical
2. Explain the four types of histories and when they are used; Examination and History Taking (Second Edition)
3. Describe the components of a comprehensive health by Beth Hogan-Quigley, Mary Louise Palm, and
history; Lynn Bickley.
4. Obtain a comprehensive health history from a patient.

Interviewing and Communication

Health History Interview
- a conversation with a purpose within three folds using health history format:
• 1. establish a trusting and supportive relationship
• 2. gather information
• 3. Offer information
Health History Format
• - is a structured framework for organizing patient information in written, electronic, and verbal form to
communicate effectively with other health care providers.
• - patient’s information is concisely organized into three categories:
 past
 present
 family history
Phases of Interview
1. Pre-interview: set the stage for a smooth interview
● Self-Reflection
Self-reflection is a continual part of professional development in clinical work. It brings a deepening
personal awareness to our work with patients, which is one of the most rewarding aspects of patient care.
● Review patient record
● Set interview goals
● Review own clinical behavior and appearance
2. Introduction: put the patient at ease and establish trust

● Greet the patient and establish rapport
● Establish the agenda for the interview
3. Working: obtain patient information

● Invite the patient’s story
● Identify and respond to emotional clues
● Expand and clarify the patient’s story
● Generate and test diagnostic hypotheses
● Negotiate a plan, including further evaluation, treatment, education and self-management support and
prevention
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THE SEVEN ATTRIBUTES OF A SYMPTOM
1. Onset. When did (does) it start? Setting in which it occurs, including environmental factors, personal activities,
emotional reactions, or other circumstances that may have contributed to the illness.
2. Location. Where is it? Does it radiate?
3. Duration. How long does it last?
4. Characteristic Symptoms. What is it like? How severe is it? (For pain, ask a rating on a scale of 1 to 10.)
5. Associated Manifestations. Have you noticed anything else that accompanies it?
6. Relieving/Exacerbating Factors. Is there anything that makes it better or worse? 7. Treatment. What have you
done to treat this? Was it effective?
• EXPLORE THE PATIENT ’S PERSPECTIVE (FIFE)
● The patient’s Feelings, including fears or concerns, about the problem
● The patient’s Ideas about the nature and the cause of the problem
● The effect of the problem on the patient’s life and Function
● The patient’s Expectations of the disease, of the clinician, or of health care, often based on prior personal or
family experiences
4. Termination:
● Summarize important points
● Discuss plan of care
“So, you will take the medicine as we discussed, check your blood glucose daily, and make a follow-up
appointment for 4 weeks. Do you have any questions about this?” Address any related concerns or questions that
the patient raises.
Types of data:
 Subjective data are information from the client's point of view (“symptoms”), including feelings, perceptions, and
concerns obtained through interviews.
 Objective data are observable and measurable data (“signs”) obtained through observation, physical
examination, and laboratory and diagnostic testing.
History of Present Illness (HPI). This section of the history is a complete, clear, and chronologic account of the
problems prompting the patient to seek care. The narrative should include the onset of the problem, the setting in which it
has developed, its manifestations, and any treatments. The HPI should reveal the patient’s responses to the symptoms
and the effect the illness has had on daily living.
Key Elements of the History of Present Illness:

 Seven attributes of each principal symptom
 Self-treatment for the symptom by the patient or family
 Past occurrences of the symptom(s)
 Pertinent positives and/or negatives from the review of systems
 Risk factors or other pertinent information related to the symptom
Seven Attributes of a Symptom
OLD CART, or Onset, Location, Duration, Characteristic Symptoms, Associated Manifestations,

Relieving/Exacerbating Factors, and Treatment
1. Onset. When did (does) it start? Setting in which it occurs, including environmental factors, personal activities,
emotional reactions, or other circumstances that may have contributed to the illness.
2. Location. Where is it? Does it radiate?
3. Duration. How long does it last?
4. Characteristic Symptoms. What is it like? How severe is it? (For pain, ask a rating on a scale of 1 to 10.)
5. Associated Manifestations. Have you noticed anything else that accompanies it?
6. Relieving/Exacerbating Factors. Is there anything that makes it better or worse?
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7. Treatment. What have you done to treat this? Was it effective?
Key Elements of the Past History:

Allergies. Allergies, including specific reactions to each medication, such as rash or nausea, must be recorded. Allergies
to foods, insects, or environmental factors along with the patient’s reaction should also be noted.
Medications. Medications, including name, dose/route, and frequency of use, are included. Also list home remedies,
nonprescription drugs, vitamins, mineral or herbal supplements, oral contraceptives, and medicines borrowed from family
members or friends. If the patient is unsure, ask him or her to bring in all medications to see exactly what is taken.
Childhood illnesses. Childhood illnesses, such as measles, rubella, mumps, whooping cough, chickenpox, rheumatic
fever, scarlet fever, and polio, are included in the Past History. Also included are any chronic childhood illnesses, such as
asthma.
Adult Illnesses. Adult Illnesses in each of the following areas:

● Medical: Illnesses such as diabetes, hypertension, hepatitis, asthma, or HIV; hospitalizations
● Surgical: Dates, reasons for surgery, and types of operations or treatments
● Accidents: type, dates, treatment and residual disability of major accidents
● Psychiatric: Illness and time frame, hospitalizations, and treatments
Health Maintenance
● Immunizations: Ask whether the patient has received vaccines for tetanus, pertussis, diphtheria, polio, measles,
mumps influenza, varicella,hepatitis B, Haemophilus influenzae type B, Neisseria meningitidesmeningitis, and
pneumococci. Include the dates of original and booster immunizations.
● Screening Tests: Such as tuberculin tests, cholesterol tests, stool for occult blood, Pap smears, and mammograms.
Include the results and the dates the tests were performed. Alternatively, screening tests maybe asked about during and
documented in the Review of Systems.
● Safety Measures: Seat belts in cars, smoke/carbon monoxide detectors, sports helmets or padding, etc.
● Risk Factors:
Tobacco: Do you use or have you ever used tobacco? At what age did you start? How many packs per
day (ppd) do you smoke? How many ppd in the past?
Environmental Hazards: In home or work environment?
Substance Abuse: Do you use or have you ever used marijuana, cocaine, heroin, or other recreational
drugs?
Alcohol: How much alcohol do you drink per sitting and per week?
Family History. Under Family History, outline or diagram on a genogram the age and health, or age and cause of death,
of each immediate relative, including parents, grandparents, siblings, children, and grandchildren.
Review of Systems. Understanding and using Review of Systems questions are often challenging for beginning
students. Think about asking a series of questions going from “head to toe.” It is helpful to prepare the patient for the
questions to come by saying, “The next part of the history may feel like a hundred questions, but they are important and I
want to be thorough.” Most Review of Systems questions pertain to symptoms, but on occasion some nurses also include
diseases like pneumonia or tuberculosis.
Health Patterns. The Health Patterns section provides a guide for gathering personal/social history from the patient and
daily living routines that may influence health and illness.
The Mental Health History. Cultural constructs of mental and physical illness vary widely, causing marked differences in
acceptance and attitudes. Think how easy it is for patients to talk about diabetes and taking insulin compared with
discussing schizophrenia and using psychotropic medications. Ask open-ended questions initially. “Have you ever had
any problem with emotional or mental illnesses?” Then move to more specific questions such as “Have you ever visited a
counselor or psychotherapist?” “Have you ever been prescribed medication for emotional issues?” “Have you or has
anyone in your family ever been hospitalized for an emotional or mental health problem?”
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Multiple Choice
1. The primary goal in the introduction phase of the interview is for the nurse to
a. Obtain subjective data
b. Make the patient comfortable
c. Greet the patient
d. Establish rapport
RATIONALE:
2. Which of the following is an example of a subjective data?

a. Cyanosis
b. A blood pressure of 140/90 mmHg
c. Blurred vision
d. Heart rate of 89 beats per minute
RATIONALE:
3. This outlines or diagrams age and health, or age and cause of death, of siblings, parents, grandparents
a. History of present illness
b. Past history
c. Family history
d. Health patterns
RATIONALE:
4. This phase of the interview is where the nurse invites the patient’s story, identify and respond to emotional cues,
and expand and clarify the patient’s story
a. Pre-interview
b. Introduction
c. Working
d. Termination
RATIONALE:
5. The primary source of health history would be from which of the following?
a. Parents
b. Patient
c. Spouse
d. Siblings
RATIONALE:
6. Which of the following is an example of an objective information?

a. Dizziness
b. Headache
c. Skin warm to touch
d. Itchiness
RATIONALE:
7. Which of the following component of the adult health history lists childhood illnesses?
a. Family history
b. Past history
c. History of present illness
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d. Review of systems
RATIONALE:
8. This is a component of the adult health history that documents personal/social history
a. Health patterns
b. Chief complaint(s)
c. Identifying data
d. History of present illness
RATIONALE:
9. Which of the following is NOT an identifying data in the adult health history?
a. Age
b. Date of birth
c. Gender
d. Immunization status
RATIONALE:
10. This helps amplify the patient’s chief complaint and describes how each symptom developed
a. Identifying data
b. History of present illness
c. Health patterns
d. Past history
RATIONALE:
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Session # 3
LESSON TITLE: Physical Examination

LEARNING OUTCOMES:
Materials:
1. Describe how to individualize the physical examination
approach based on the patient’s needs and the Book, pen and notebook, index card/class list
environment
2. Select an environment features necessary to ensure
patient safety and comfort during a physical examination
3. Discuss the environmental features necessary to ensure
patient safety and comfort during a physical examination References: Bates’ Nursing Guide to Physical
4. Identify safety precautions when conducting the physical Examination and History Taking (Second Edition)
examination. by Beth Hogan-Quigley, Mary Louise Palm, and
5. Indicate the correct order and how to use the four cardinal Lynn Bickley.
technique

Physical Examination
• Is a process to obtain objective data from the patient

• Each body system connects to another
• The purpose of the physical examination is to determine changes in a patient’s health status and how to respond
to a problem as well as promote healthy lifestyles and wellbeing.
THE COMPREHENSIVE ADULT PHYSICAL EXAMINATION
Beginning the Examination: Setting the Stage
Preparing for the Physical Examination:

• Reflect on your approach to the patient.
• Adjust the lighting and the environment.
• Make the patient comfortable.
• Check your equipment.
• Choose the sequence of examination.
Reflect Your Approach to the Patient:

 Identify yourself as a nursing student.
 Try to appear calm, organized, and competent
 Most patients view the physical examination with some anxiety.
 avoid interpreting your findings - If you find anything that is unusual or disturbing, always talk with your clinical
instructor.
Adjust the Lighting and Environment:

• “set the stage” so that both you and the patient are comfortable
• Good lighting and a quiet environment make important contributions to what you see and hear but may be hard to
arrange
• Tangential lighting optimal for inspecting structures such as the jugular venous pulse, the thyroid gland, and the
apical impulse of the heart
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Make the Patient Comfortable
• Showing concern for privacy and patient modesty must be ingrained in your professional behavior.
Close nearby doors and draw the curtains in the hospital or examining room before the examination begins
• Wash your hands
• draping the patient - goal is to visualize one area of the body at a time keep the patient informed, especially when
you anticipate embarrassment or discomfort checking vital signs, tell the patient the results the examination is
completed, tell the patient your general impressions and what to expect next
Observe Standard and Universal Precautions
STANDARD AND MRSA precautions:

• Based on the principle that all blood, body fluids, secretions, excretions except sweat, non intact skin, and
mucous membranes may contain transmissible infectious agents.
• Hand hygiene, use of protective equipment, safe injection practices, safe handling of contaminated equipment
Universal Precautions
• Set of guidelines designed to prevent transmission of human immunodeficiency virus (HIV), hepatitis B virus
(HBV), and other blood-borne pathogens when providing first aid or health care.
• following fluids are considered potentially infectious:
• all blood and other body fluids containing visible blood, semen, and vaginal secretions; and cerebrospinal,
synovial, pleural, peritoneal, pericardial, and amniotic fluids
Protective barriers include:

• gloves, gowns, aprons, masks, and protective eyewear
• All health care workers should observe the important precautions for safe injections and prevention of injury from
needle sticks, scalpels, and other sharp instruments and devices
Make the Patient Comfortable
PATIENT PRIVACY AND COMFORT:

• Close nearby doors, draw the curtains in the hospital or examining room, wash your hands thoroughly
• During the examination be aware of the patient’s feeling’s and any discomfort.
Draping the Patient:

• GOAL: to visualize one are of the body at a time.
• When patient is sitting, auscultate the lungs with the gown unties in back
• Breast examination, uncover the right breast and keep the left chest draped
• Abdominal examination, only the abdomen should be exposed
Cardinal Techniques of Examination:

• INSPECTION
• PALPATION
• PERCUSSION
• AUSCULTATION
*abdominal examination, the pattern will be inspection, auscultation, percussion, and palpation
Inspection
• Close observation of the details of the patient’s appearance, behavior, and movement such as:
• facial expression, mood, body build and conditioning, skin conditions such as petechiae or ecchymoses, eye
movements, pharyngeal color, symmetry of thorax, height of jugular venous pulsations, abdominal contour, lower
extremity edema, and gait.
Palpation
• Tactile pressure from the palmar fingers or fingerpads to assess areas of skin elevation, depression, warmth, or
tenderness; lymph nodes; pulses; contours and sizes of organs and masses; and crepitus in the joints.
Metacarpal/phalangyeal joint or ulnar surface of the hand is used to detect vibration.
•
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Percussion
 Use of the striking or plexor finger, usually the third, to deliver a rapid tap or blow against the distal pleximeter
finger, usually the distal third finger of the left hand laid against the surface of the chest or abdomen, to evoke a
sound wave such as resonance or dullness from the underlying tissue or organs. This sound wave also generates
a tactile vibration against the pleximeter finger.
Auscultation
• Use of the diaphragm and bell of the stethoscope to detect the characteristics of heart, lung, and bowel sounds,
including location, timing, duration, pitch, and intensity. For the heart this involves sounds from closing of the four
valves and flow into the ventricles as well as murmurs.
• Auscultation also permits detection of bruits, ie, turbulence over arterial vessels.

Instructions: Label and give the function of each instrument used during a physical examination.
1. 2.
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3. 4.
5. 6.
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7. 8.
9. 10.
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Session # 4
LESSON TITLE: Physical Examination of a Pediatric Materials:

Patient Book, pen and notebook, index card/class list
LEARNING OUTCOMES:
1. Identify the sources of subjective and objective data from a

pediatric client; References: Bates’ Nursing Guide to Physical
2. Learn how to do a complete physical examination of a Examination and History Taking (Second Edition)
pediatric patient; by Beth Hogan-Quigley, Mary Louise Palm, and
3. Know the different normal vital signs of each stage of Lynn Bickley.
childhood.

The students will study and read this module for this lesson:
Collecting Subjective Data
Information spoken by the child or family is called subjective data.
Conducting the Client Interview
Most subjective data are collected through interviewing the family caregiver and the child.
 Why interview? The interview helps establish relationships between the nurse, the child, and the family.
 Listen and communicate. Listening and using appropriate communication techniques help promote a good
interview.
 Introduce and explain your purpose. The nurse should be introduced to the child and caregiver and the
purpose of the interview stated.
 Establish rapport. A calm, reassuring manner is important to establish trust and comfort; the caregiver and
the nurse should be comfortably seated, and the child should be included in the interview process.
Interviewing Family Caregivers
The family caregiver provides most of the information needed in caring for the child, especially the infant or toddler.
 Ask questions and note them. Rather than simply asking the caregiver to fill out a form, the nurse may ask
the questions and write down the answers; this process gives the opportunity to observe the reactions of the
child and the caregiver as they interact with each other and answer the questions.
 Avoid being judgmental. The nurse must be non-judgmental, being careful not to indicate disapproval by
verbal or nonverbal responses.
Interviewing the Child
It is important that the preschool child and the older child be included in the interview.
 Be age-appropriate. Use age-appropriate toys and questions when talking with the child.
 Establish rapport. Showing interest in the child and in what he or she says helps both the child and caregiver
to feel comfortable; by being honest when answering the child’s questions, the nurse establishes trust with the
child.
 Listen. The child’s comments should be listened to attentively, and the child should be made to feel important
in the interview.
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Interviewing the Adolescent
Adolescents can provide information about themselves.

 Interview in private. Interviewing them in private often encourages them to share information that they might
not contribute in front of their caregivers.
Obtaining a Client History
When a child is brought to any health care setting, it is important to gather information regarding the child’s current
condition, as well as medical history.
 Biographical data. The nurse obtains identifying information about the child, including the child’s name,
address, and phone number, as well as information about the caregiver; a questionnaire often is used to
gather information, such as the child’s nickname, feeding habits, food likes and dislikes, allergies, sleeping
schedule, and toilet-training status.
 Chief Complaint. The reason for the child’s visit to the healthcare setting is called the chief complaint; to best
care for the child, it is important to get the complete explanation of what brought the child to the healthcare
setting.
 History of present health concern. To help the nurse discover the child’s needs, the nurse elicits information
about the current situation, including the child’s symptoms, when they began, how long the symptoms have
been present, a description of the symptoms, their intensity and frequency, and treatments to this time.
 Health history. Information about the mother’s pregnancy and prenatal history are included in obtaining a
health history for the child; other areas the nurse asks questions about include common childhood, serious, or
chronic illnesses; immunizations and health maintenance; feeding and nutrition; as well as hospitalizations
and injuries.
 Family health history. The caregiver can usually provide information regarding family health history; the
nurse uses this information to do preventive teaching with the child and family.
 Review of systems for current health problem. While the nurse is collecting subjective data, the caregiver
or child is asked questions about each body system; the body system involved in the chief complaint is
reviewed in detail.
 Allergies, medications, and substance abuse. Allergic reactions to any foods, medications, or any other
known allergies should be discussed to prevent the child being given any medications or substances that
might cause an allergic reaction; medications the child is taking or has taken, whether prescribed by a care
provider or over the counter, are recorded; it is important, especially in the adolescent, to assess the use of
substances such as tobacco, alcohol, or illegal drugs.
 Lifestyle. School history includes information regarding the child’s current grade level and academic
performance, as well as behavior seen at school; social history offers information about the environment that
the child lives in, including the home setting, parents’ occupations, siblings, family pets, religious affiliations,
and economic factors; personal history relates to data collected about such things as the child’s hygiene and
sleeping and elimination patterns; nutrition history of the child offers information regarding eating habits and
preferences, as well as nutrition concerns that might indicate illness.
 Developmental level. Gathering information about the child’s developmental level is done by asking
questions directly related to growth and development milestone; knowing normal development patterns will
help the nurse determine if there are concerns that should be further assessed regarding the child’s
development.
Collecting Objective Data
Objective data in nursing is part of the health assessment that involves the collection of information through
observations. The collection of objective data includes the nurse doing a baseline measurement of the child’s height,
weight, blood pressure, temperature, pulse, and respiration.
General Status
The nurse uses knowledge of normal growth and development to note if the child appears to fit the characteristics of the
stated age.
 Observing general appearance. The infant or child’s face should be symmetrical; observe for nutritional
status, hygiene, mental alertness, and body posture and movements; examine the skin for color, lesions,
bruises, scars, and birthmarks; observe hair texture, thickness, and distribution.
 Noting psychological status and behavior. Observation of behavior should include factors that influenced
the behavior and how often the behavior is repeated; physical behavior, as well as emotional and intellectual
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responses, should be noted; also consider the child’s age and developmental level, the abnormal environment
of the healthcare facility, and if the child has been hospitalized previously or otherwise separated from family
caregivers.
Measuring Height and Weight
The child’s height and weight are helpful indicators of growth and development.
 When to measure. Height and weight should be measured and recorded each time the child has a routine
physical examination, as well as at other health care visits.
 How to measure weight. In a hospital setting, the infant or child should be weighed at the same time each
day on the same scales while wearing the same amount of clothing; the infant is weighed nude, lying on an
infant scale, or when the infant is big enough to sit, the child can be weighed while sitting.
 How to measure height. The child who can stand usually is measured for height at the same time; to
measure the height of a child who is not able to stand alone steadily, usually under the age of about 2, place
the child flat, with knees held flat, on an examining table; measure the child’s height by straightening the
child’s body and measuring from the top of the head to the bottom of the foot.
Measuring Head Circumference
The head circumference us measured routinely in children to the age 2 or 3 years or in any child with a neurologic
concern.
 How to measure. A paper or plastic tape measure is placed around the largest part of the head just above the
eyebrows and around the most prominent part of the back of the head.
 Record and plot. This measurement is recorded and plotted on a growth chart to monitor the growth of the
child’s head.
Vital Signs
Vital signs, including temperature, pulse, respirations, and blood pressure, are taken at each visit and compared with the
normal values for children at the same age.
Temperature
 The temperature can be measured by the oral, rectal, axillary, or tympanic method; temperatures are recorded
in Celsius or Fahrenheit, according to the policy of the health care facility.
 A normal oral temperature range is 36.4 degrees Celsius to 37.4 degrees Celsius (97.6 degrees Fahrenheit to
99.3 degrees Fahrenheit.
 A rectal temperature is usually 0.5 to 1.0 degrees higher than the oral measurement.
 An axillary temperature usually measures 0.5 degrees to 1.0 degrees lower than the oral measurement.
Pulse
 The apical pulse should be counted before the child is disturbed for other procedures. The stethoscope is
placed between the child’s left nipple and sternum.
 A radial pulse may be taken on an older child
 A pulse that is unusual in quality, rate, or rhythm should be counted for a full minute and should be compared
on the opposite site.
 Pulse rates vary with age: from 100 to 180 beats per minute for a neonate to 50 to 95 beats per minute for the
14-to 18-year-old adolescent.
Respirations
 The child can be observed while lying or sitting quietly; infants are abdominal breathers; therefore the
movement of the infant’s abdomen is observed to count respirations;
 The older child’s chest can be observed how an adult’s would be.
 The infant’s respirations must be counted for a full minute because of normal irregularity.
 Retractions are noted as substernal, subcostal, intercostal, suprasternal, or supraclavicular.
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Blood pressure
 For children 3 years of age and older, blood pressure monitoring is part of routine and ongoing data collection;
 Taking the blood pressure on a stuffed animal or doll will show the child the procedure is not to be feared.
 The most common sites used to obtain a blood pressure reading in children are the upper arm, lower arm or
forearm, thigh, and calf or ankle;
 The blood pressure is taken by auscultation, palpation, or Doppler or electronic method.
Data are also collected by examining the body systems of the child.
Head and Neck
Symmetry or a balance is noted in the features of the face and in the head.
 Assess the range of motion. Observe the child’s ability to control the head and the range of motion; to see
full range of motion, ask the older child to move her or his head in all directions; in the infant, the nurse gently
moves the head to observe for any stiffness in the neck.
 Assess the fontanels. The nurse feels the skull to determine if the fontanels are open or closed and to check
for any swelling or depression.
 Assess the eyes. Observe the eyes for symmetry and location in relationship to the nose; note any redness,
evidence of rubbing, or drainage; ask the older child to follow a light to observe her or his ability to focus; an
infant will also follow a light with his or her eyes; Observe pupils for equality, roundness, and reaction to light.
 Assess the ears. The alignment of the ears is noted by drawing an imaginary line from the outside corner of
the eye to the prominent part of the child’s skull; the top of the ear, known as the pinna, should cross this line;
note the child’s ability to hear during normal conversation; a child who speaks loudly, responds
inappropriately, or does not speak clearly may have hearing difficulties that should be explored.
 Asses the nose, mouth, and throat. The nose is in the middle of the face; if an imaginary line were drawn
down the middle, both sides of nose should be symmetrical; observe for swelling, drainage, or bleeding; to
observe the mouth and throat, have the older child hold his or her mouth wide open and move the tongue from
side to side; with the infant or toddler, use a tongue blade to see the mouth and throat; observe the mucous
membranes for color, moisture, and any patchy areas that might indicate infection; observe the number and
condition of the child’s teeth.
Chest and Lungs

Chest measurements are done on infants and children to determine normal growth rate.
 How to measure the chest. Take the measurement at the nipple level with a tape measure; observe for chest
size, shape, movement of the chest with breathing, and any retractions.
 Adolescents. In the older school-age child or adolescent, note evidence of breast development.
 Assess respiratory characteristics. Evaluate respiratory rate, rhythm, and depth; report any noisy or
grunting respirations.
 How to assess breath sounds. Using a stethoscope, the nurse listens to breath sounds in each lobe of the
lung, anterior and posterior, while the child inhales and exhales; describe, document, and report absent or
diminished breath sounds, as well as unusual sounds such as crackling or wheezing.
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Heart
In some infants and children, a pulsation can be seen in the chest that indicates the heart beat, which is called the point of
maximum impulse.
 Assessing heart rate and rhythm. The nurse listens for the rhythm of the heart sounds and counts the rate
for 1 full minute.
 Assessing for heart abnormalities. Abnormal or unusual heart sounds might indicate the child has a heart
murmur, heart condition, or other abnormality that should be reported.
 Assess the heart function’s effectiveness. To determine the heart function’s effectiveness, the nurse
assesses the pulses in various parts of the body.
Abdomen
The abdomen may protrude slightly in infants and small children.
 Dividing the abdomen. To describe the abdomen, divide the area into four sections and label sections with
the terms left upper quadrant (LUQ), left lower quadrant (LLQ), right lower quadrant (RLQ), and right upper
quadrant (RUQ).
 Assess bowel sounds. Using a stethoscope, the nurse listens for bowel sounds or evidence of peristalsis in
each section of the abdomen and records what is heard.
Genitalia and Rectum

When inspecting the genitalia and rectum, it is important to respect the child’s privacy and take into account the child’s
age and stage of growth and development.
 Inspect the genitalia and rectum. While wearing gloves, the nurse inspects the genitalia and rectum;
observe the area for any sores or lesions, swelling, or discharge.
 Assess the testes. In male children the testes descend at varying times during childhood; if the testes cannot
be palpated, this information should be reported.
Back and Extremities

The back and extremities should also be assessed for abnormalities.
 Assess the back. The back should be observed for symmetry and for curvature of the spine; in infants the
spine is rounded and flexible; as the child grows and develops motor skills, the spine further develops.
 Assess gait and posture. Note gait and posture when the child enters or is walking in the room.
 Assess the extremities. The extremities should be warm, have good color, and be symmetrical; by observing
the child’s movements during the exam, the nurse notes range of motion, movement of the joints,
and muscle strength.
Neurologic
Assessing the neurologic status of the infant and child is the most complex aspect of the physical exam.
 Neurologic exam. The practitioner in the health care setting assesses the neurologic status of the child by
doing a complete neurologic exam; this exam includes detailed examination of the reflex responses, as well as
the functioning of each of the cranial nerves.
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 Neurologic assessment tools. The nurse uses a neurologic assessment tool such as the Glasgow coma
scale; the use of s standard scale for monitoring permits the comparison of results from one time to another
and from one examiner to another; using this tool, the nurse monitors various aspects of the child’s neurologic
functioning.

Multiple Choice
1. Which of the following is the characteristic of the infant’s spine?

a. Rounded and flexible
b. Straight and rigid
c. Rounded and rigid
d. Straight and flexible
RATIONALE:
2. The head circumference is measured routinely especially for children aged

a. 2 to 3 years old
b. 9 to 12 years old
c. 4 to 8 years old
d. 13 to 18 years old
RATIONALE:
3. Obtaining information about the child’s illness is necessary for physical examination. The parent or a
guardian will be a great source of information for which of the following pediatric clients?
a. Adolescent
b. Infant
c. School-age child
d. None of the above
RATIONALE:
.
4. Which of the following is important for the nurse to do when interviewing the preschool and the older
children EXCEPT?
a. Be age appropriate
b. Establish rapport
c. Interview the parent instead
d. Listen to the child’s comments
RATIONALE:
5. The best way to measure the height of an infant patient is by
a. Letting the infant sit
b. Place the infant flat on an examination table
c. Allow the infant to stand and be held by the guardian
d. Any of the above
RATIONALE:
6. The normal pulse rate for a neonate is at
a. 50-60 beats per minute
b. 60-80 beats per minute
c. 80-100 beats per minute
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d. 100 to 180 beats per minute
RATIONALE:
7. In order to allay the fears of a younger pediatric patient in the measurement of their blood pressure the
nurse must do which of the following?
a. Explain the procedure to the client
b. Tell the mother to hold the child while BP measurement will be done
c. Taking the blood pressure on a stuffed animal or doll will show the child that the procedure is not
to be feared.
d. Inform the child that blood pressure measurement is not painful.
RATIONALE:
8. When measuring the pediatric client’s chest circumference with a tape measure, the nurse must do which
of the following?
a. Measure at the nipple line
b. Measure below the nipple line
c. Measure above the nipple line
d. Any of the above
RATIONALE:
9. Which of the following is true with regard to the infant or younger children’s abdomen?
a. The abdomen is flat
b. The abdomen may protrude slightly
c. The abdomen appears globular
d. The abdomen is retracted
RATIONALE:
10. Which of the following is assessed on the infant’s head in order to assess for further dehydration?
a. Scalp
b. Cheeks
c. Fontanels
d. Temples
RATIONALE:
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Session # 5
LESSON TITLE: Cultural and Spiritual Assessment

LEARNING OUTCOMES: Materials:
Upon completion of this lesson, the nursing student can: Book, pen and notebook, index card/class list
1. Explain why culture is important in the health assessment

process;
2. Define cultural competency and cultural humility;
3. Demonstrate behaviors that show sensitivity to a patient’s References: Bates’ Nursing Guide to Physical
culture during the assessment process; Examination and History Taking (Second Edition)
4. Explain the difference between spirituality and religion; by Beth Hogan-Quigley, Mary Louise Palm, and
5. Explain why the patient’s spiritual needs should be Lynn Bickley.
assessed.

CULTURAL ASSESSMENT
 Refers to a systematic, comprehensive examination of individuals, families, groups and communities regarding
their health-related cultural beliefs, values and practices.
 GLOBAL MIGRATION – increased the challenges of providing health care to patients with health care beliefs,
practices and needs different from health care provider
Culture
 Is the system of shared ideas, rules, meanings that influences how we view the world, experience it emotionally,
and behave in relation to other people.
 ETHNICITY – an ethnic group composed of individual who self-identify membership with or belong to a group with
shared values, ancestry and experiences
 RACE – socially constructed concept of dividing people into populations or groups on the basis of various sets
physical characteristics
Cultural Competence
 Recognizes the need for a set of skills necessary to care for people of different cultures
 Culture as a process, not a state
Cultural Desire
 The motivation the nurse needs to ―want to‖ and not ―need to‖ become culturally aware.
Cultural Humility
 The ―process that requires humility as individuals continually engage in self reflection and self-critique as lifelong
learners and reflective practitioners.‖
 The process that includes ―the difficult work of examining cultural beliefs and cultural systems of both patients and
nurses to locate the points of cultural dissonance or synergy that contribute to patients’ health outcomes.‖
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Begin Self-Reflection by answering the following:
1. Am I aware of my biases? Prejudices? Stereotypes?

2. Am I comfortable interacting with people with different cultures?
3. Do I seek out experiences with other cultures?
4. Do I seek out opportunities to learn about other cultures?
5. Do I respect the beliefs of individuals from other cultures?
6. Do I know how to access language interpreter services for patients?
3 Dimensions of Cultural Humility

 Self-awareness. Learn about your own biases--we all have them.
 Respectful communication. Work to eliminate assumptions about what is ―normal.‖ Learn directly from your
patients—they are the experts on their culture and illness.
 Collaborative partnerships. Build your patient relationships on respect and mutually acceptable plans.
Self-Awareness
 Explore own cultural identity
 Values are the standards we use to measure our own and others’ beliefs and behaviors.
 Biases are the attitudes or feelings that we attach to perceived differences.
Respectful Communication
 Let your patients be the experts on their own unique cultural perspectives.
 Maintain an open, respectful, and inquiring attitude.
 Always be ready to acknowledge your areas of ignorance or bias.
Collaborative Partnerships
 Communication based on trust, respect, and a willingness to reexamine assumptions allows patients to express
concerns that may run counter to the dominant culture.
 You, the nurse, must be willing to listen to and validate these feelings, and not let your own feelings prevent you
from exploring painful areas.
SPIRITUAL ASSESSMENT
Spirituality
 It means that most human of experiences that seeks to transcend self and find meaning and purpose through
connection with others, nature and/or a Supreme Being, which may or may not involve religious structures or
traditions.‖ – Buck
 The North American Nursing Diagnosis Association defined Spirituality as ―A pattern of experiencing and
integrating meaning and purpose in life through connectedness with self, others, art, music, literature, nature and/
or a power greater than oneself.‖
Religion
 System of beliefs or practice of worship.
Spiritual Distress
 When an individual’s sense of purpose or meaning of life is threatened, spiritual distress may result
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 A state of suffering related to the impaired ability to experience meaning I life through connections with self,
others, the world, or a superior being.
 Nursing presence ―is a holistic and reciprocal exchange between the nurse and patient that involves a sincere
connection and sharing of human experience through active listening, attentiveness, intimacy and therapeutic
touch, spiritual exploration, empathy, caring and compassion, and recognition of the patient’s psychological,
psychosocial and physiological needs.
 Questions such as ―Why did I get cancer?‖ ―I’m a burden to my family.‖ and ―I just don’t know what to do,‖ may
arise from the patient who is experiencing spiritual distress.
 Let the patient do the talking
 Nurse should NOT offer solutions
 Nurse should help patient identify the problem and resources utilized in the past to cope with problems
 ―What helps you cope?‖ ―What is your source of strength? Source of hope?‖ ―Who are your support persons?‖

Multiple Choice
1. In order for a nurse to acquire certain skills in order to provide the appropriate nursing care for people of different
cultures, the nurse must first develop
a. Cultural competence
b. Cultural awareness
c. Cultural desire
d. Cultural humility
RATIONALE:
2. Which of the following statements is true about global migration in relation to health care?
a. Patient care has been easier since most nurses can adapt to the different needs of patients.
b. There is globalization of health care therefore creating more ease of work for health care workers.
c. There is an increased challenge of providing health care to patients with health care beliefs, practices and
needs different from the health care provider.
d. Health care workers nowadays are comfortable with the different cultures around the world.
RATIONALE:
3. A patient is taking about the shared values that they have in the Middle East such as strictly conforming to their
religious practices. The patient here is exhibiting which of the following?
a. Culture
b. Ethnicity
c. Race
d. Beliefs
RATIONALE:
4. The nurse has noted the skin color of the patient on the patient’s chart as part of the assessment. The nurse here
is documenting the patient’s
a. Culture
b. Ethnicity
c. Race
d. Values
RATIONALE:
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5. Which of the following self-reflection answers by the nurse would pose a problem later on in rendering health care
to a patient who has a different culture than hers?
a. ―I am aware of my biases, prejudices, stereotypes to other people.‖
b. ―I feel comfortable interacting with people from different cultures.‖
c. ―I learn who to seek experiences with other cultures.‖
d. ―I sometimes have issues with the cultural beliefs of some patients.‖
RATIONALE:
6. Nurses should learn about their own strengths and weaknesses by doing which of the following?
a. Self-awareness
b. Respectful communication
c. Collaborative partnerships
d. Counter transference
RATIONALE:
7. Which of the following is NOT true about respectful communication?

a. Let your patients be the experts on their own unique cultural perspectives
b. Maintain an open, respectful, and inquiring attitude.
c. Try to change the patient’s unconventional cultural practice
d. Always be ready to acknowledge your areas of ignorance or bias
RATIONALE:
8. When the patient diagnosed with stage 4 cancer cries out, ―Why? Why is God punishing me like this?!‖ The
patient here is demonstrating
a. Emotional distress
b. Physiological distress
c. Spiritual distress
d. Psychological distress
RATIONALE:
9. When the patient is suffering from spiritual distress the role of the nurse is to
a. Listen and let the patient do the talking
b. Offer valid solutions
c. Advise the patient that his/her condition is God’s will
d. Refer the patient to their family
RATIONALE:.
10. Which of the following questions is not under sources of hope and strength in Stoll’s guidelines for spiritual
assessment?
a. ―Who is the most important person to you?‖
b. ―To whom do you turn when you need help? Are they available?
c. ―What is your source of strength and hope?‖
d. ―Is religion or God significant to you? If yes, can you describe how?‖
RATIONALE:
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Session # 6
LESSON TITLE: Mental Status Examination

1. Describe the multiple areas assessed in the mental status

examination;
2. Determine the symptoms and behaviors for mental health
screening; References: Bates’ Nursing Guide to Physical
3. Obtain an accurate mental status history for a patient; Examination and History Taking (Second Edition)
4. Perform a mini-mental status examination and; by Beth Hogan-Quigley, Mary Louise Palm, and
5. Identify the screening and health promotion and Lynn Bickley.
counseling tools for depression, suicide, and dementia.

MENTAL STATUS EXAMINATION (MSE)
 Tool for assessing psychological dysfunction and identifying.

 Examines patient’s LOC, general appearance, behavior, speech, mood and affect, intellectual performance,
judgment, insight, perception, and thought content.
Appearance
 Record the patient's sex, age (apparent or stated), race, and ethnic background. Document the patient's
nutritional status by observing the patient's current body weight and appearance. Remember recording the exact
time and date of this interview is important, especially since the mental status can change over time such as in
delirium.
 Recall how the patient first appeared upon entering the office for the interview. Note whether this posture has
changed. Note whether the patient appears more relaxed. Record the patient's posture and motor activity.
 Record the patient's dress and grooming. If nervousness was evident earlier, note whether the patient still seems
nervous. Record notes on grooming and hygiene. Most of these documentations on appearance should be a
mere transfer from mind to paper because mental notes of the actual observations were made when the patient
was first encountered. Record whether the patient has maintained eye contact throughout the interview or if he or
she has avoided eye contact as much as possible, scanning the room or staring at the floor or the ceiling.
Attitude toward the examiner
 Next, record the patient's facial expressions and attitude toward the examiner. Note whether the patient appeared
interested during the interview or, perhaps, if the patient appeared bored.
 Record whether the patient is hostile and defensive or friendly and cooperative. Note whether the patient seems
guarded and whether the patient seems relaxed with the interview process or seems uncomfortable.
Mood
 The mood of the patient is defined as "sustained emotion that the patient is experiencing." Ask questions such as
"How do you feel most days?" to trigger a response.
 Helpful answers include those that specifically describe the patient's mood, such as "depressed," "anxious,"
"good," and "tired." Elicited responses that are less helpful in determining a patient's mood adequately include
"OK," "rough," and "don't know." These responses require further questioning for clarification.
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 Establishing accurate information pertaining to the length of a particular mood, if the mood has been reactive or
not, and if the mood has been stable or unstable also is helpful.
Affect
 A patient's affect is defined in the following terms: expansive (contagious), euthymic (normal), constricted
(limited variation), blunted (minimal variation), and flat (no variation). A patient whose mood could be
defined as expansive may be so cheerful and full of laughter that it is difficult to refrain from smiling while
conducting the interview.
 A patient's affect is determined by the observations made by the interviewer during the course of the interview.
The patient's affect is noted to be inappropriate no connection is clear between what the patient is saying and the
emotion being expressed.
Speech
 Document information on all aspects of the patient's speech, including quality, quantity, rate, and volume of
speech during the interview. Paying attention to patients' responses to determine how to rate their speech is
important.
 Some things to keep in mind during the interview are whether patients raise their voice when responding, whether
the replies to questions are one-word answers or elaborative, and how fast or slow they are speaking. Record the
patient's spontaneous speed in relation to open-ended questions.
Thought process
 Record the patient's thought process information. The process of thoughts can be described with the following
terms: looseness of association (irrelevance), flight of ideas (change topics), racing (rapid thoughts),
tangential (departure from topic with no return), circumstantial (being vague, ie, "beating around the
bush," giving inordinately long responses that only eventually answer the stated question), word salad
(nonsensical responses, ie, jabberwocky), derailment (extreme irrelevance), neologism (creating new
words), clanging (rhyming words), punning (talking in riddles), thought blocking (speech is halted), and
poverty (limited content).
 Throughout the interview, very specific questions will be asked regarding the patient's history. Note whether the
patient responds directly to the questions. Document whether the patient deviates from the subject at hand and
has to be guided back to the topic more than once, or if they are redirectable in the event that they should wander
off-topic. Take all of these things in to account when documenting the patient's thought process.
Thought content
 To determine whether or not a patient is experiencing hallucinations, ask some of the following questions. "Do you
hear voices when no one else is around?" “Do these voices seem to come from outside of your head, so that you
turn to look and see who is talking?” "Can you see things that no one else can see?" "Do you have other
unexplained sensations such as smells, sounds, or feelings?" It should be noted that simple historians may
confuse their own actual thoughts for auditory hallucinations, and this should therefore be carefully scrutinized.
 Importantly, always ask about command-type hallucinations and inquire what the patient will do in response to
these commanding hallucinations. For example, ask "When the voices tell you do something, do you obey their
instructions or ignore them?" Types of hallucinations include auditory (hearing things), visual (seeing things),
gustatory (tasting things), tactile (feeling sensations), and olfactory (smelling things).
 To determine if a patient is having delusions, ask some of the following questions. "Do you have any thoughts that
other people think are strange?" "Do you have any special powers or abilities?" "Does the television or radio give
you special messages?" Types of delusions include grandiose (delusions of grandeur), religious (delusions
of special status with God), persecution (belief that someone wants to cause them harm), erotomanic
(belief that someone famous is in love with them), jealousy (belief that everyone wants what they have),
thought insertion (belief that someone is putting ideas or thoughts into their mind), and ideas of reference
(belief that relatively ordinary or commonplace phenomenon are referring specifically to them). Patient's
perceptions are an important part of this evaluation
 Aspects of thought content are as follows:
 Obsession and compulsions: Ask the following questions to determine if a patient has any obsessions or
compulsions. "Are you afraid of dirt?" "Do you wash your hands often or count things over and over?" "Do
you perform specific acts to reduce certain thoughts?" Signs of ritualistic type behaviors should be explored
further to determine the severity of the obsession or compulsion.
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 Phobias: Determine if patients have any fears that cause them to avoid certain situations. The following are
some possible questions to ask. "Do you have any fears, including fear of animals, needles, heights,
snakes, public speaking, or crowds?"
 Suicidal ideation or intent: Inquiring about suicidal ideation at each visit is always important. In addition,
the interviewer should inquire about past acts of self-harm or violence. Ask the following types of questions
when determining suicidal ideation or intent. "Do you have any thoughts of wanting to harm or kill yourself?"
"Do you have any thoughts that you would be better off dead?" If the reply is positive for these thoughts,
inquire about specific plans, suicide notes, family history (anniversary reaction), and impulse control. Also,
ask how the patient views suicide to determine if a suicidal gesture or act is ego-syntonic or ego-dystonic.
Next, determine if the patient will contract for safety. For homicidal ideation, make similar inquiries.
 Homicidal ideation or intent: Inquiring about homicidal ideation or intent during each patient interview also
is important. Ask the following types of questions to help determine homicidal ideation or intent. "Do you
have any thoughts of wanting to hurt anyone?" "Do you have any feelings or thoughts that you wish
someone were dead?" If the reply to one of these questions is positive, ask the patient if he or she has any
specific plans to injure someone and how he or she plans to control these feelings if they occur again.
 Sensorium and cognition: Perform the Folstein Mini-Mental State Examination.
 Language: Spontaneous speech may be noted. Repetition ("no, Ifs, ands, or buts") should be considered.
 Comprehension: Provide a simple instruction to patient, such as “fold this paper in half” or "squeeze my
fingers."
 Consciousness: Levels of consciousness are determined by the interviewer and are rated as (1) coma,
characterized by unresponsiveness; (2) stuporous, characterized by response to pain; (3) lethargic,
characterized by drowsiness; and (4) alert, characterized by full awareness. If patients exhibit decreased
levels of consciousness note the stimulus required to arouse the patient.
 Orientation: To elicit responses concerning orientation, ask the patient questions, as follows. "What is your
full name?" (ie, person). "Do you know where you are?" (ie, place). "What is the month, date, year, day of
the week, and time?" (ie, time). "Do you know why you are here?" (ie, situation).
 Concentration and attention: Ask the patient to subtract 7 from 100, then to repeat the task from that
response. This is known as "serial 7s." If a patient’s academic abilities are prohibitive or impeding, a
clinician may ask for them to recite the months of the year backwards instead. Next, ask the patient to spell
the word "world" forward and backward. Document the patient's reaction times to particular questions
because this may provide valuable information in the overall evaluation.
 Reading and writing: Ask the patient to write a simple sentence (noun/verb). Then, ask patient to read a
sentence (eg, "Close your eyes."). This part of the MSE evaluates the patient's ability to sequence.
 Visuospatial ability: Have the patient draw interlocking pentagons in order to determine constructional
apraxia. Have the patient "use imaginary scissors" to evaluate motor activity.
 Memory: To evaluate a patient's memory, have them respond to the following prompts. "What was the
name of your first grade teacher?" (ie, for remote memory). "What did you eat for dinner last night?" (ie, for
recent memory). "Repeat these 3 words: 'pen,' 'chair,' 'flag.' " (ie, for immediate recall). Tell the patient to
remember these words. Then, after 5 minutes, have the patient repeat the words. Orientation represents
recent memory.
 Abstract thought: Assess the patient's ability to determine similarities. Ask the patient how 2 items are
alike. For example, an apple and an orange (good response is "fruit"; poor response is "round"), a fly and a
tree (good response is "alive"; poor response is "nothing"), or a train and a car (good response is "modes of
transportation"). Assess the patient's ability to understand proverbs. Ask the patient the meaning of certain
proverbial phrases. Examples include the following. "A bird in the hand is worth 2 in the bush" (good
response is "be grateful for what you already have"; poor response is "one bird in the hand"). "Don't cry
over spilled milk" (good response is "don't get upset over the little things"; poor response is "spilling milk is
bad").
 General fund of knowledge: Test the patient's knowledge by asking a question such as, "How many
nickels are in $1.15?" or asking the patient to list the last 5 presidents of the United States or to list 5 major
US cities. Obviously, a higher number of correct answers is better; however, the interviewer always should
take into consideration the patient's educational background and other training in evaluating answers and
assigning scores.
 Intelligence: Based on the information provided by the patient throughout the interview, estimate the
patient's intelligence quotient (ie, below average, average, above average).
Insight
 Assess the patients' understanding of their condition. To assess patients' insight to their illness, the interviewer
may ask patients if they need help or if they believe their feelings or conditions are normal. A patient's attitude
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toward the clinician and the illness plays an important part to developing insight into their condition and overall
prognosis.
Judgment
 Estimate the patient's judgment based on the history or on an imaginary scenario. To elicit responses that
evaluate a patient's judgment adequately, ask the following question. "What would you do if you smelled smoke in
a crowded theater?" (good response is "call 911" or "get help"; poor response is "do nothing" or "light a
cigarette").
Impulsivity
 Estimate the degree of the patient's impulse control. Ask the patient about doing things without thinking or
planning. Positive responses may result in follow-up questions about the frequency of which impulsive behaviors
occur and whether they appear to impact a patient’s functioning (eg, punching walls in anger, destroying property,
getting into verbal altercations, or experiencing black-out anger).
Reliability
 Estimate the patient's reliability. Determine if the patient seems reliable, unreliable, or if it is difficult to determine.
This determination requires collateral information of an accurate assessment, diagnosis, and treatment.

Multiple Choice
1. The patient has told you, “I want to play basketball. Do you know that my brother loves to play it? However, my
brother is in Europe right now. One place in Europe I want to visit would be Greece. The beaches there are nice. I
have read things about Greek mythology as well…” This is an example of
a. Looseness of association
b. Flight of ideas
c. Clang association
d. Word salad
RATIONALE:
2. When the patient has no variation in his or her affect the nurse must note this as
a. Labile affect
b. Inappropriate affect
c. Blunted affect
d. Flat affect
RATIONALE:
3. The patient talking to you says, “I want to go to Baguio, because it’s hot here in the plains yo! There is always one
thing I am always missing from there. That why I want to my friends there and hangout everywhere.” This type of
thought processing must be noted by the nurse as
a. Neologism
b. Clang association
c. Verbigeration
d. Perseveration
RATIONALE:
4. When the patient says that he is the current president of the Philippines and vows to get rid of China from the
Spratlys, he is demonstrating which of the following types of delusions?
a. Religious delusion
b. Delusion of persecution
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c. Delusion of grandeur
d. Thought insertion
RATIONALE:
5. The patient saw two nurses who were quietly talking to each other at the nurses’ station. The patient then said,
“You two! I know that you are talking about me.” This type of delusion is known as
a. Jealous delusion
c. Thought insertion
d. Ideas of reference
RATIONALE:
6. The most common type of hallucination seen in schizophrenic patients is
a. Auditory
b. Tactile
c. Visual
d. Olfactory
RATIONALE:
th
7. When the nurse is asking, “What would you do if you are on the 4 floor of a building and suddenly a fire broke
out?” The nurse here is testing the patient’s
a. Insight
b. Reliability
c. Judgment
d. Impulsivity
RATIONALE:
8. The nurse is asking the patient, “Do you have anything that extremely frightens you whenever you see that
thing?” The nurse here is determining the patient’s
a. Orientation
b. Anxiety
c. Insight
d. Phobia
RATIONALE:
9. A patient has told the nurse, “Nurse my krizzits are dirty. You need to wash them.” The nurse asked the patient
what krizzits are and the patient was pointing at his soiled clothes. This is an example of
a. Clang association
b. Tangentiality
c. Neologism
d. Verbigeration
RATIONALE:
th
10. The nurse has asked the patient, “What do you recall about your 10 birthday?” The nurse here is testing the
patient’s
a. Memory
b. Orientation
c. Comprehension
d. Consciousness
RATIONALE:
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Session # 7
LESSON TITLE: The Integumentary System Materials:

LEARNING OUTCOMES: Book, pen and notebook, index card/class list
1. Explain the functions of the integumentary system;

2. Identify risk factors for pressure ulcers;
3. Identify risk factors for skin cancer; References: Bates’ Nursing Guide to Physical
4. Obtain an accurate health history of the integumentary Examination and History Taking (Second Edition)
system; by Beth Hogan-Quigley, Mary Louise Palm, and
5. Accurately describe primary, secondary, and vascular Lynn Bickley.
lesions.

Anatomy and Physiology (The students will read their textbook for Health Assessment or their book on Anatomy
& Physiology).
The purpose of the integumentary history is to identify the following:

 Diseases of the skin
 Systematic diseases that have skin manifestations
 Physical abuse
 Risk for pressure ulcer formation
 Risk for skin cancer
 Need for health promotion education regarding the skin
Common or concerning symptoms (use the OLDCART method in obtaining the health history of each symptom):
 Rash
 Non-healing lesions
 Moles
 Lesions
 Bruising (ecchymosis)
 Hair loss
Physical Examination of the Skin

 Color. Skin color will vary according to genetic background and may have fair, olive, tan, brown, or golden hues.
Patients may notice a change in their skin color before the nurse does. Ask about it.
a. Look for increased pigmentation (brownness), lossof pigmentation, or redness of the skin.
b. Assess for cyanosis or pallor. Note the red color of oxyhemoglobin and the pallor (e.g. fingernails, lips,
and the mucous membranes). Inspecting the palms and soles may be useful in dark people.
Cyanosis
 Central cyanosis is best identified in the lips, oral mucosa, and tongue.
 The lips, however, may turn blue in the cold, and melanin in the lips may simulate cyanosis in darker-skinned
people.
 Cyanosis of the nails, hands, and feet may be central or peripheral in origin. Anxiety or a cold examining room
may cause peripheral cyanosis.
 Causes of central cyanosis include advanced lung disease, congenital heart disease, and hemoglobinopathies.
 Cyanosis in congestive heart failure is usually peripheral, reflecting decreased blood flow, but in pulmonary
edema, it may also be central. Venous obstruction may cause peripheral cyanosis.
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 Look for the yellow color of jaundice in the sclera. Do not confuse a normal scleral yellow pigmentation in dark-
skinned individuals with jaundice. Rather, observe the hard palate with a bright light for jaundice.
Jaundice
 Jaundice may also appear in the palpebral conjunctiva, lips, hard palate, undersurface of the tongue, tympanic
membrane, and skin.
 Press the skin over a bony prominence and observe the color when your finger is removed.
 Jaundice suggests liver disease or excessive hemolysis of red blood cells.
 Carotenemia however is the yellow color that accompanies high levels of carotene. The nurse must look at the
palms, soles, and face for this condition.
(Students must refer to their textbook for the description and pictures of the following changes in skin pigmentation:
Cyanosis, erythema, carotenemia, jaundice, café-au-lait spots,vitiligo, tinea versicolor, and acanthosis nigricans)
Moisture
 Note excessive dryness, sweating, and oiliness. Skin should be dry to touch without flaking or cracking.
 Perspiration may appear on the face, hands, axillae, or skin folds in response to a warm environment; increased
metabolic activity, such as fever or exercise; and anxiety or pain.
 Excessive dryness, often accompanied by flaking, or excessive sweating (diaphoresis) may indicate a problem.
Carefully inspect skin folds where moisture may cause skin breakdown.
 Dryness in hypothyroidism; oiliness in acne. Dry skin with parched cracked lips, dry mucous membranes, and lack
of tears indicate dehydration.
Temperature
 Use the backs of your hands to make this assessment. In addition to identifying generalized warmth or coolness
of the skin, note the temperature of any areas with increased pigmentation or erythema.
 Generalized warmth in fever, hyperthyroidism; coolness in hypothyroidism. Local warmth of inflammation or
cellulitis.
Texture
 Note the roughness or smoothness of the skin. Normal skin feels smooth and firm with an even surface.
 Roughness in hypothyroidism; velvety texture in hyperthyroidism
Mobility and Turgor

 Lift a fold of skin and note the ease with which it lifts up (mobility) and the speed with which it returns into place
(turgor). Normally the skin promptly returns into place. Best area to assess for skin turgor would be on the
abdomen.
 Decreased mobility in edema, scleroderma; decreased turgor in dehydration.
Edema
 The presence of excess fluid in the interstitial spaces is edema. It may be localized due to an injury or may be the
result of a systemic problem (e.g., heart failure).
 Systemic edema most often occurs in the dependent portions of the body, the feet, legs, and sacral area.
 The skin appears puffy and feels tight.
 Mobility is decreased and cyanosis or jaundice in the skin is obscured.
 Edema may be pitting or nonpitting. In pitting edema the interstitial water is mobile and can be translocated with
the pressure exerted by a finger. A “pit” or depression is left for 5 to 30 seconds. The degree of pitting is
measured on a 1 to 4 scale.
Skin Lesions - Anatomic Location and Distribution (The student must check chapter 9 of the of their textbook for
the description and illustration of the following skin lesions):
Skin Lesions – Patterns and Shapes (The student must check chapter 9 of the of their textbook for the
description and illustration of the following skin lesions):
Primary Skin Lesions (The student must check chapter 9 of the of their textbook for the description and
illustration of the following skin lesions):
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Multiple Choice
1. Which of the following is NOT a function of the integumentary system?

a. It regulates the body temperature
b. It serves as a protection for the internal organs
c. Excrete waste materials
d. Provide posture and structure to the body
RATIONALE:
2. What type of sweat glands are present in the armpits and groin area?
a. Eccrine
b. Apocrine
c. Sebaceous
RATIONALE:
3. These cells are responsible for the skin color of a person
a. Epithelial cells
b. Melanocytes
c. Dermatocytes
d. Eponychium
RATIONALE:.
4. The layer of the skin that consists of adipose tissue would be the
a. Epidermis
b. Dermis
c. Subcutaneous
d. Any of the above
RATIONALE:
5. Which of the following mechanisms that the skin does in order to regulate the body temperature? Select all that
apply
a. Release of catecholamines
b. Vasodilation
c. Release of pyrogens
d. Vasoconstriction
RATIONALE:
6. Excessive intake of yellow or orange colored fruits and vegetables can lead to which of the following?
a. Pallor
b. Carotenemia
c. Jaundice
d. Redness
RATIONALE:
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7. Loss of oxygen from the skin can lead to which of the following skin colors?
a. Carotenemia
b. Jaundice
c. Flushing
d. Cyanosis
RATIONALE:
8. Which of the following organs will the nurse suspect to have a disorder if she has observed the patient with a
jaundiced skin?
a. Kidneys
b. Stomach
c. Liver
d. Pancreas
RATIONALE:
9. Tinea versicolor is caused by an infection of which of the following microorganisms?
a. Fungi
b. Protozoan
c. Bacteria
d. Virus
RATIONALE:
10. The nurse is tasked to assess the degree of dehydration of a patient who is suffering from acute gastroenteritis.
She is going to assess the patient’s skin turgor. The best site for the assessment of skin turgor would be at the
a. Elbow
b. Forearm
c. Abdomen
d. Thigh
RATIONALE:
AL Strategy: Wrapping Up-Student Reflection

1. The instructor will instruct students to write 3 important things they learned from today’s session.
2. After the students have completed the task, the instructor will call 3-5 students to share and read out loud the things
they have learned from the session.
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Session # 8
Materials:
Book, pen and notebook, index card/class list
LESSON TITLE: The Head and Neck
LEARNING OUTCOMES:
1. Explain the functions of the head and neck; References: Bates’ Nursing Guide to Physical
2. Collect an accurate health history of the head and neck; Examination and History Taking (Second Edition)
3. Perform the physical examination techniques to evaluate by Beth Hogan-Quigley, Mary Louise Palm, and
the head and neck; Lynn Bickley.
4. Identify the measures to prevent traumatic brain injury.

& Physiology).
Common or concerning symptoms of the head:

● Headache
● Head injury
● Head or neck surgery
● Traumatic brain injury
Headache
 It is one of the most common symptoms in clinical practice, with a lifetime prevalence of 30% in the general
population. Migraine headaches are by far the most frequent cause of headaches seen in office practice,
approaching 80% with careful diagnosis. Nevertheless, every headache warrants careful evaluation for life-
threatening causes such as meningitis, subdural or intracranial hemorrhage, or tumor.
 The OLDCART or PQRST methods can be used in order to obtain the health history of the patient’s headache.
History Interview (OLDCART)

 Onset: When did you first notice the headache?
 Location: Where do you feel the headache? Can you point to the area(s)?
 Duration: How long has this been going on? Did the headache begin suddenly (in a few minutes or less than an
hour) or gradually (over a few hours or days)? Is it temporary or constant? When does the pain begin (morning,
evening)? Does it wake you at night? How long do the headaches last? Are they recurring? Is there a pattern?
 Characteristic Symptoms: Describe what it feels like (throbbing, hammering, squeezing). Describe the pain on a
scale of 1 to 10 with 1 being minimal pain and 10 being the worst pain you ever felt.
 Relieving Factors: What have you tried to make the headache go away? (for e.g. Sleep? Dark room? Cool
compresses? Relaxation techniques?) What has worked the best? What has not worked at all? Does
anything make it worse? How have the headaches affected your daily life and activities?
 Treatment: Has anyone treated you for headaches in the past? (eg. physician, nurse practitioner, or massage
therapist). Have you used any medication? If yes, then the name of the medication, dosage, and affect?
Traumatic brain injury (TBI) is a blow to the head or a piercing head injury that interferes with the function of the brain. Not
all injuries to the head result in a TBI, and those that do occur span from mild to severe.
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Head Trauma or Brain Injury:
 Onset: When did this occur? Can you describe what happened? Do you remember when you hurt your head?
Precipitating Factors: What happened to cause the traumatic brain injury? (eg. Lack of protective equipment or
helmet? Environmental)?
 Location: Can you show me where you hurt your head?
 Duration: Did you lose consciousness? If yes, for how long? Did you fall first or lose consciousness first?
 Characteristic Symptoms: Did you experience any symptoms prior to the head injury (headache, shortness of
breath, chest pain, numbness, or tingling)? Do you have any medical issues (cardiac history, diabetes, seizures)?
 Associated Manifestations: Do you experience vision changes; nausea or vomiting; attention span deficits; drainage
from the ears, nose, eyes, or mouth; tremors; seizures; or gait changes?
 Relieving Factors/Strategies: Prevention of further injury
Common or concerning symptoms of the neck

● Swollen lymph nodes or neck lumps
● Enlarged thyroid gland
● Hoarseness
History Interview (OLDCART)

 Onset: When did you first notice the lump?
 Location: Where is the lump? Is there more than one lump?
 Duration: How long have you had the lump?
 Characteristic Symptoms: Has the lump changed (size, tenderness, drainage, shape, consistency)?
 Associated Manifestations: Do you have difficulty swallowing? Have you had any recent infections? Trauma?
Radiation? Surgery? History of smoking? Drinking alcohol? Chewing tobacco?
 Relieving Factors: Does anything make the lump smaller? Less tender? Have you tried compresses on the site?
 Treatment: Have you been to a health care provider?
Physical Assessment
Equipment:
 Tangential light
 Cup of water
 Stethoscope
The Hair
 Note its quantity, distribution, texture, and pattern of loss, if any. You may see loose flakes of dandruff.
The Scalp
 Part the hair in several places and look for scaliness, lumps, nevi, or other lesions.
The Skull
 Observe the general size and contour of the skull. Note any deformities, depressions, lumps, or tenderness. Learn
to recognize the irregularities in a normal skull, such as those near the suture lines between the parietal and
occipital bones.
The Face.
• Note the patient’s facial expression and contours. Observe for asymmetry, involuntary movements, edema, and
masses.
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The Skin.
• Observe the skin, noting its color, pigmentation, texture, thickness, hair distribution, and any lesions.
The Neck.
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• Observe the skin, noting its color, pigmentation, texture, thickness, hair distribution, and any lesions. Inspect the
neck, noting its symmetry and any masses or scars. Look for enlargement of the parotid or submandibular glands,
and note any visible lymph nodes.
The Lymph Nodes.

• Palpate the lymph nodes. Using the pads of your index and middle fingers, move the skin over the underlying
tissues in each area in a circular motion. The patient should be relaxed, with neck flexed slightly forward and, if
needed, slightly toward the side being examined. You can usually examine both sides at once. For the submental
node, however, it is helpful to feel with one hand while bracing the top of the head with the other.
Sequence of following nodes:

1. Preauricular—in front of the ear
2. Posterior auricular—superficial to the mastoid process
3. Occipital—at the base of the skull posteriorly
4. Tonsillar—at the angle of the mandible
5. Submandibular—midway between the angle and the tip of the mandible. These nodes are usually smaller and
smoother than the lobulated submandibular gland against which they lie.
6. Submental—in the midline a few centimeters behind the tip of the mandible
7. Superficial cervical—superficial to the sternomastoid
8. Posterior cervical—along the anterior edge of the trapezius
9. Deep cervical chain—deep to the sternomastoid and often inaccessible to examination. Hook your thumb and fingers
around either side of the sternomastoid muscle to find them.
10. Supraclavicular—deep in the angle formed by the clavicle and the sternomastoid
The trachea and the thyroid gland:

• Inspect the trachea for any deviation from its usual midline position. Then feel for any deviation. Place your finger
along one side of the trachea and note the space between it and the sternomastoid. Compare it with the other
side. The spaces should be symmetric.
• Inspect the neck for the thyroid gland. Tip the patient’s head back a bit. Using tangential lighting directed
downward from the tip of the patient’s chin, inspect the region below the cricoid cartilage for the gland. The lower
shadowed border of each thyroid gland shown here is outlined by arrows.

Multiple Choice
1. What would be the cause of primary headaches?

a. Stroke
b. Meningitis
c. No identifiable underlying cause
d. Seizures
RATIONALE:
2. Which of the following types of headache has an aura and is accompanied by seizures?
a. Tension-type headache
b. Cluster headache
c. Metabolic headache
d. Migraine headache
RATIONALE:
3. When palpating for the lymph nodes on the neck of a patient, the nurse must use which of the following?
a. Thumb and index fingers
b. Index and middle fingers
c. Thumbs only
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d. Index fingers only
RATIONALE:
4. Which of the following is the characteristic of the face of a patient who has hypothyroidism?
a. Swelling of the face
b. Emaciated face
c. Mask-like face
d. Moon face
RATIONALE:
5. The nurse assessing the neck of the patient has observed for an enlargement of the thyroid gland. The nurse
must suspect for which of the following conditions?
a. Goiter
b. Hyperparathyroidism
c. Cushing syndrome
d. Addison’s disease
RATIONALE:
6. Which of the following signs is not seen in a patient who has hyperthyroidism?
a. Palpitations
b. Frequent bowel movements
c. Periorbital puffiness
d. Exophthalmos
RATIONALE:
7. Which of the following must be included in the teaching to prevent motor vehicular head injuries?
a. Always use the seatbelt
b. Wear a helmet when riding motorcycles, all-terrain vehicles, motorized scooters, bicycles, horses or
snowmobiles.
c. Small children should sit in the back seat especially if the car has a passenger airbag
d. All of the above
RATIONALE:
8. In order to decrease the likelihood of falls, the nurse must teach the following precautions EXCEPT
a. Install safety features in the home such as grab bars in the bathroom and nonslip mats in the bathtub.
b. Wear nonslip, well-fitting shoes.
c. Allow babies to use walkers.
d. Install window guards.
RATIONALE:
9. When assessing for the lymph nodes of the head, the very last lymph node that the nurse must palpate would be
the
a. Supraclavicular lymph nodes
b. Preauricular lymph nodes
c. Submental lymph nodes
d. Occipital lymph nodes
RATIONALE:
10. The characteristic face of a patient who has Cushing syndrome would be
a. Emaciated
b. Moon face
c. Puffy and reddish cheeks
d. Reddish cheeks and cyanotic face all over
RATIONALE:
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HEALTH ASSESSMENT SAS LEC #1
CHECK FOR UNDERSTANDING
You will answer and rationalize this by yourself. This will be recorded as your quiz. One (1) point will be
given to correct answer and another one (1) point for the correct ratio. Superimpositions or erasures in
you answer/ratio is not allowed.
Multiple Choice
1. The phase of the nursing process where the nurse establishes both the short-term and the long-
term goals for the patient
a. Assessment
b. Diagnosis
c. Planning
d. Diagnosis
ANSWER: C
RATIONALE: This is where the nurse identifies 2 types of goals for the patient: short-term-goal and the
long-term-goal.
2. This is the ability of the nurse to extrapolate the findings, prioritize them, and finally formulate and
implement the plan of care is the overall goal
a. Health history
b. Health assessment
c. Physical examination
d. Nursing process
ANSWER: D
RATIONALE: The nurse uses the NURSING PROCESS (a problem-solving process) to identify patient
problems; set a goal and develop an action plan; implement the plan; and evaluate the outcome.
3. Which of the following facets of health is demonstrated if the patient feels very much optimistic
about the results of her pregnancy?
b. Physical health
d. Emotional health
ANSWER: D
RATIONALE: Emotional health involves showing positive outlook and emotions channeled in a healthy
manner
4. When the patient is communicative with her friends with regard to his marital problems which
facet of health is being applied here?
b. Environmental influences
ANSWER: D
RATIONALE: Social well-being – supportive relationships with family and friends.
5. When the patient is identifying a solution to financial problems in order to be rid of her financial
stresses the patient is demonstrating which of the following facets of health?
a. Emotional health
b. Developmental level
c. Physical health
ANSWER: B
RATIONALE: Developmental level – how one thinks, solves problems, and makes decisions.
6. Which of the following is NOT true about the assessment phase of the nursing process?
a. Subjective and objective data are gathered
b. It ends when doing the nursing diagnosis
c. It is the first step of the nursing process
d. It continues throughout the entire patient encounter
ANSWER: B
RATIONALE: It does not end with the nursing diagnosis. The final step would be evaluation and the
nursing process can start over if there are goals that are not met.
7. Which of the following is NOT true about the nursing diagnosis?
a. It has a nursing focus
b. It is based on real or potential health problems
c. It determines the medical diagnosis of the patient
d. It sets the stage for the remainder of the care plan
ANSWER: C
RATIONALE: Nursing diagnosis is not used to diagnose the disease of the patient. It is the medical
diagnosis that does that and only doctors are allowed to make a valid medical diagnosis.
8. Which of the following best describes problem-oriented assessment?
ANSWER: A
RATIONALE: This is where the nurse must learn more about the patient’s chief complaint by using the
OLDCART method.
9. Which of the following best describes follow-up history?
ANSWER: C
RATIONALE: Follow-up history is where the nurse reassess the patient’s health history of the patient
comes back to the hospital to have a follow-up check up on the same condition that the patient has.
10. This is the phase of the nursing process where the nurse determines whether the goals made for
the patient have been attained
a. Nursing diagnosis
b. Planning
c. Implementation
d. Evaluation
ANSWER: D
RATIONALE: Evaluation is where to patient reassess the condition of the patient and whether the short
or long-term goals she has made for the patient has been achieved with the nursing interventions.
HEALTH ASSESMENT SAS LEC #2 ANSWER KEY
Multiple Choice
1. The primary goal in the introduction phase of the interview is for the nurse to
a. Obtain subjective data
b. Make the patient comfortable
c. Greet the patient
d. Establish rapport
ANSWER: D
RATIONALE: By establishing rapport, the nurse gains the patient’s trust in order for the patient to
cooperate with the nurse.
2. Which of the following is an example of a subjective data?
a. Cyanosis
b. A blood pressure of 140/90 mmHg
c. Blurred vision
d. Heart rate of 89 beats per minute
ANSWER: C
RATIONALE: Blurred vision can only be experienced by the patient. Subjective data are information from
the client’s point of view.
3. This outlines or diagrams age and health, or age and cause of death, of siblings, parents,
grandparents
a. History of present illness
b. Past history
c. Family history
d. Health patterns
ANSWER: C
RATIONALE: Any genetic condition that the patient’s family members have may be important to the
patient’s current condition since there are diseases or disorders that can be genetic.
4. This phase of the interview is where the nurse invites the patient’s story, identify and respond to
emotional cues, and expand and clarify the patient’s story
a. Pre-interview
b. Introduction
c. Working
d. Termination
ANSWER: C
RATIONALE: The working phase is where the nurse is going to explore more about the patient’s
problems and seek some clarification about it.
5. The primary source of health history would be from which of the following?
a. Parents
b. Patient
c. Spouse
d. Siblings
ANSWER: B
RATIONALE: The patient should be the best source of information regarding the patient’s condition. If
the patient is an infant or unconscious the best source of information would be any of the family
members or friends.
6. Which of the following is an example of an objective information?
a. Dizziness
b. Headache
c. Skin warm to touch
d. Itchiness
ANSWER: C
RATIONALE: This is an information that a nurse can observe, the rest of the choices are under objective
data.
7. Which of the following component of the adult health history lists childhood illnesses?
a. Family history
b. Past history
c. History of present illness
d. Review of systems
ANSWER: B
RATIONALE: Past history of the patient should cover even from when the patient was still a child. The
patient can ask more information from his/her parents about the past illnesses.
8. This is a component of the adult health history that documents personal/social history
a. Health patterns
b. Chief complaint(s)
c. Identifying data
d. History of present illness
ANSWER: A
RATIONALE: The Health Patterns section provides a guide for gathering personal/social history from the
patient and daily living routines that may influence health and illness.
9. Which of the following is NOT an identifying data in the adult health history?
a. Age
b. Date of birth
c. Gender
d. Immunization status
ANSWER: D
RATIONALE: Immunization status is under health maintenance.
10. This helps amplify the patient’s chief complaint and describes how each symptom developed
a. Identifying data
b. History of present illness
c. Health patterns
d. Past history
ANSWER: B
RATIONALE: History of present illness can be better assessed by using the OLDCART mnemonic.
HEALTH ASSESSMENT SAS LEC #3

HEALTH ASSESSMENT SAS LEC # 4 ANSWER KEY
Multiple Choice
1. Which of the following is the characteristic of the infant’s spine?
a. Rounded and flexible
b. Straight and rigid
c. Rounded and rigid
d. Straight and flexible
ANSWER: A
RATIONALE: The back should be observed for symmetry and for curvature of the spine; in infants the
spine is rounded and flexible; as the child grows and develops motor skills, the spine further develops.
2. The head circumference is measured routinely especially for children aged
a. 2 to 3 years old
b. 9 to 12 years old
c. 4 to 8 years old
d. 13 to 18 years old
ANSWER: A
RATIONALE: The head circumference is measured in younger children for the detection of a possible
neurologic condition.
3. Obtaining information about the child’s illness is necessary for physical examination. The parent or
a guardian will be a great source of information for which of the following pediatric clients?
a. Adolescent
b. Infant
c. School-age child
ANSWER: B
RATIONALE: For a pediatric client who cannot communicate especially for infants, the great source of
information would be the infant’s parent or guardian.
4. Which of the following is important for the nurse to do when interviewing the preschool and the
older children EXCEPT?
a. Be age appropriate
b. Establish rapport
c. Interview the parent instead
d. Listen to the child’s comments
ANSWER: C
RATIONALE: The preschool child and older children can already be asked for information about their
illness such as determining the location of pain and how they generally feel.
5. The best way to measure the height of an infant patient is by
a. Letting the infant sit
b. Place the infant flat on an examination table
c. Allow the infant to stand and be held by the guardian
d. Any of the above
ANSWER: B
RATIONALE: The only possible way to measure the height of the infant is by laying the infant flat on the
examination table and using a tape measure for measurement.
6. The normal pulse rate for a neonate is at
a. 50-60 beats per minute
b. 60-80 beats per minute
c. 80-100 beats per minute
d. 100 to 180 beats per minute
ANSWER: D
RATIONALE: The neonate has a higher heart rate. If an infant's heart cannot stretch very much due to
immature muscle fibers, it has to pump at a faster rate to maintain blood flow through the body. As a
result, an infant's heart rate is often faster. It can also be irregular. When an infant gets older, the heart
muscle can stretch and contract more effectively.
7. In order to allay the fears of a younger pediatric patient in the measurement of their blood pressure
the nurse must do which of the following?
a. Explain the procedure to the client
b. Tell the mother to hold the child while BP measurement will be done
c. Taking the blood pressure on a stuffed animal or doll will show the child that the procedure is not
to be feared.
d. Inform the child that blood pressure measurement is not painful.
ANSWER: C
RATIONALE: This is the best method in order to gain cooperation from younger children. The children at
this stage still has the concept of animism and can relate to what the nurse is demonstrating at the
stuffed animal or doll.
8. When measuring the pediatric client’s chest circumference with a tape measure, the nurse must do
which of the following?
a. Measure at the nipple line
b. Measure below the nipple line
c. Measure above the nipple line
d. Any of the above
ANSWER: A
RATIONALE: Chest circumference is measured at the nipple line since this has the greatest chest
circumference size.
9. Which of the following is true with regard to the infant or younger children’s abdomen?
a. The abdomen is flat
b. The abdomen may protrude slightly
c. The abdomen appears globular
d. The abdomen is retracted
ANSWER: B
RATIONALE: Most babies' bellies normally stick out, especially after a large feeding. Between feedings,
however, they should feel quite soft.
10. Which of the following is assessed on the infant’s head in order to assess for further dehydration?
a. Scalp
b. Cheeks
c. Fontanels
d. Temples
ANSWER: C
RATIONALE: Fontanels are soft areas on the infant’s head. The infant is dehydration if the fontanels are
sunken, if they are bulging then they might be having increased intracranial pressure.
HEALTH ASSESSMENT SAS LEC #5 ANSWER KEY
Multiple Choice
1. In order for a nurse to acquire certain skills in order to provide the appropriate nursing care for
people of different cultures, the nurse must first develop
a. Cultural competence
b. Cultural awareness
c. Cultural desire
d. Cultural humility
ANSWER: A
RATIONALE: Cultural competence recognizes the needs for a set of skills necessary to care for people of
different cultures.
2. Which of the following statements is true about global migration in relation to health care?
a. Patient care has been easier since most nurses can adapt to the different needs of patients.
b. There is globalization of health care therefore creating more ease of work for health care workers.
c. There is an increased challenge of providing health care to patients with health care beliefs, practices
and needs different from the health care provider.
d. Health care workers nowadays are comfortable with the different cultures around the world.
ANSWER: C
RATIONALE: Global migration of people from different cultures can cause confusion in rendering health
care to people with different cultural background. It is important for health care workers nowadays to
be knowledgeable about the different cultural practices of patients when it comes to rendering patient
care.
3. A patient is taking about the shared values that they have in the Middle East such as strictly
conforming to their religious practices. The patient here is exhibiting which of the following?
a. Culture
b. Ethnicity
c. Race
d. Beliefs
ANSWER: B
RATIONALE: Ethnicity is an ethnic group composed of individuals who self-identify membership with or
belong to a group with shared, values, ancestry, and experiences.
4. The nurse has noted the skin color of the patient on the patient’s chart as part of the assessment.
The nurse here is documenting the patient’s
a. Culture
b. Ethnicity
c. Race
d. Values
ANSWER: C
RATIONALE: Race is a socially constructed concept of dividing people into populations or groups on the
basis of various sets of physical characteristics.
5. Which of the following self-reflection answers by the nurse would pose a problem later on in
rendering health care to a patient who has a different culture than hers?
a. ―I am aware of my biases, prejudices, stereotypes to other people.
b. ―I feel comfortable interacting with people from different cultures.
c. ―I learn who to seek experiences with other cultures.
d. ―I sometimes have issues with the cultural beliefs of some patients.
ANSWER: D
RATIONALE: The nurse must respect the cultural belief of patients. Not adhering or disrespecting the
patient’s cultural belief would be detrimental to patient care.
6. Nurses should learn about their own strengths and weaknesses by doing which of the following?
a. Self-awareness
b. Respectful communication
c. Collaborative partnerships
d. Counter transference
ANSWER: A
RATIONALE: By doing self-awareness weaknesses such as biases can be avoided when rendering patient
care to patients that has a different cultural belief than that of the nurse’s.
7. Which of the following is NOT true about respectful communication?
a. Let your patients be the experts on their own unique cultural perspectives
b. Maintain an open, respectful, and inquiring attitude.
c. Try to change the patient’s unconventional cultural practice
d. Always be ready to acknowledge your areas of ignorance or bias
ANSWER: C
RATIONALE: We are never going to change the patient’s cultural practices no matter how
unconventional it is. The key to communicating with patients whose culture is different from us is
respect.
8. When the patient diagnosed with stage 4 cancer cries out, ―Why? Why is God punishing me like
this?!‖ The patient here is demonstrating
a. Emotional distress
b. Physiological distress
c. Spiritual distress
d. Psychological distress
ANSWER: C
RATIONALE: When an individual’s sense of purpose or meaning of life is threatened, spiritual distress
may result
9. When the patient is suffering from spiritual distress the role of the nurse is to
a. Listen and let the patient do the talking
b. Offer valid solutions
c. Advise the patient that his/her condition is God’s will
d. Refer the patient to their family
ANSWER: A
RATIONALE: Let the patient do the talking, The nurse should not offer solutions; rather, the nurse
should use the interviewing techniques to help the patient identify the problem and resources utilized in
the past to cope with problems.
10. Which of the following questions is not under sources of hope and strength in Stoll’s guidelines for
spiritual assessment?
a. ―Who is the most important person to you?
b. ―To whom do you turn when you need help? Are they available?
c. ―What is your source of strength and hope?
d. ―Is religion or God significant to you? If yes, can you describe how?
ANSWER: D
RATIONALE: Questions about God is under concept of God or Deity.

Multiple Choice
1. The patient has told you, “I want to play basketball. Do you know that my brother loves to play it?
However, my brother is in Europe right now. One place in Europe I want to visit would be Greece. The
beaches there are nice. I have read things about Greek mythology as well…” This is an example of
a. Looseness of association
b. Flight of ideas
c. Clang association
d. Word salad
ANSWER: B
RATIONALE: Flight of ideas is jumping from one topic to another. However, the topics seem to have a
connection between them. While for looseness of association the patient jumps from one topic to
another without having any connection between them.
2. When the patient has no variation in his or her affect the nurse must note this as
a. Labile affect
b. Inappropriate affect
c. Blunted affect
d. Flat affect
ANSWER: D
RATIONALE: A patient with no variation in his or her tone of voice (affect) is known as flat affect. This is
commonly seen in patients who have autism or who have catatonia.
3. The patient talking to you says, “I want to go to Baguio, because it’s hot here in the plains yo! There
is always one thing I am always missing from there. That why I want to my friends there and hangout
everywhere.” This type of thought processing must be noted by the nurse as
a. Neologism
b. Clang association
c. Verbigeration
d. Perseveration
ANSWER: B
RATIONALE: The patient in the situation is talking in rhymes which is clang association.
4. When the patient says that he is the current president of the Philippines and vows to get rid of
China from the Spratlys, he is demonstrating which of the following types of delusions?
a. Religious delusion
c. Delusion of grandeur
d. Thought insertion
ANSWER: C
RATIONALE: A patient who has a great feeling of importance such as being a president, CEO, or a
celebrity is exhibiting delusions of grandeur.
5. The patient saw two nurses who were quietly talking to each other at the nurses’ station. The
patient then said, “You two! I know that you are talking about me.” This type of delusion is known as
a. Jealous delusion
c. Thought insertion
d. Ideas of reference
ANSWER: D
RATIONALE: Ideas of reference is a belief that relatively ordinary or commonplace phenomenon are
referring specifically
to them.
6. The most common type of hallucination seen in schizophrenic patients is
a. Auditory
b. Tactile
c. Visual
d. Olfactory
ANSWER: A
RATIONALE: Auditory hallucination is one of the classic signs of schizophrenia. Patients who have
schizophrenia seems like they are always talking to someone because voices have been talking to them
(auditory form of hallucination).
7. When the nurse is asking, “What would you do if you are on the 4th floor of a building and suddenly
a fire broke out?” The nurse here is testing the patient’s
a. Insight
b. Reliability
c. Judgment
d. Impulsivity
ANSWER: C
RATIONALE: The nurse is trying to elicit a response that will test the patient’s judgment in dire
situations.
8. The nurse is asking the patient, “Do you have anything that extremely frightens you whenever you
see that thing?” The nurse here is determining the patient’s
a. Orientation
b. Anxiety
c. Insight
d. Phobia
ANSWER: D
RATIONALE: The nurse is assessing for the presence of any phobia (irrational fear) in patients when
asking about anything that extremely frightens them.
9. A patient has told the nurse, “Nurse my krizzits are dirty. You need to wash them.” The nurse asked
the patient what krizzits are and the patient was pointing at his soiled clothes. This is an example of
a. Clang association
b. Tangentiality
c. Neologism
d. Verbigeration
ANSWER: C
RATIONALE: Neologism is coining of new words known only to the patient. This is commonly seen in
patients with autism
and schizophrenia.
10. The nurse has asked the patient, “What do you recall about your 10th birthday?” The nurse here is
testing the patient’s
a. Memory
b. Orientation
c. Comprehension
d. Consciousness
ANSWER: A
RATIONALE: By asking the patient about the events of the past, the nurse is assessing the patient’s long-
term memory. Asking about what he/she did yesterday is assessing the patient’s short-term memory.
Multiple Choice
1. Which of the following is NOT a function of the integumentary system?
a. It regulates the body temperature
b. It serves as a protection for the internal organs
c. Excrete waste materials
d. Provide posture and structure to the body
ANSWER: D
RATIONALE: This is one of the functions of the skeletal system.
2. What type of sweat glands are present in the armpits and groin area?
a. Eccrine
b. Apocrine
c. Sebaceous
ANSWER: B
RATIONALE: Apocrine sweat glands are commonly found on the armpits and the groin area. They
produce sweat that contains organic substances that can be a medium of growth for microorganisms
that can cause body odor.
3. These cells are responsible for the skin color of a person
a. Epithelial cells
b. Melanocytes
c. Dermatocytes
d. Eponychium
ANSWER: B
RATIONALE: Melanocytes produces melanin that is responsible for the skin color. The more melanin
that they produce the darker the skin color becomes.
4. The layer of the skin that consists of adipose tissue would be the
a. Epidermis
b. Dermis
c. Subcutaneous
d. Any of the above
ANSWER: C
RATIONALE: The subcutaneous tissue or also known as the hypodermis contains adipose tissue which
functions as an insulation for the body.
5. Which of the following mechanisms that the skin does in order to regulate the body temperature?
Select all that apply
a. Release of catecholamines
b. Vasodilation
c. Release of pyrogens
d. Vasoconstriction
ANSWER: B and D
RATIONALE: Vasodilation occurs when the person is in a warm environment while vasoconstriction
occurs when the person is in a cold environment. Both mechanisms help release of heat or prevent loss
of heat respectively.
6. Excessive intake of yellow or orange colored fruits and vegetables can lead to which of the
following?
a. Pallor
b. Carotenemia
c. Jaundice
d. Redness
ANSWER: B
RATIONALE: Orange and yellow colored fruits and vegetables are rich in carotene which has a yellow
pigment. Increased consumption of these kinds of food can cause carotenemia.
7. Loss of oxygen from the skin can lead to which of the following skin colors?
a. Carotenemia
b. Jaundice
c. Flushing
d. Cyanosis
ANSWER: D
RATIONALE: Cyanosis is the bluish discoloration of the skin due to the decreased oxygen carrying
capacity of the blood.
8. Which of the following organs will the nurse suspect to have a disorder if she has observed the
patient with a jaundiced skin?
a. Kidneys
b. Stomach
c. Liver
d. Pancreas
ANSWER: C
RATIONALE: The liver is responsible for converting the indirect bilirubin which has a yellow pigment into
direct bilirubin. If the liver is not able to convert bilirubin from the blood due to an underlying disease
such as hepatitis this will cause an abnormal buildup causing jaundice to occur.
9. Tinea versicolor is caused by an infection of which of the following microorganisms?
a. Fungi
b. Protozoan
c. Bacteria
d. Virus
ANSWER: A
RATIONALE: Tinea versicolor is a common fungal infection of the skin. The fungus interferes with the
normal pigmentation of the skin, resulting in small, discolored patches. These patches may be lighter or
darker in color than the surrounding skin and most commonly affect the trunk and shoulders.
10. The nurse is tasked to assess the degree of dehydration of a patient who is suffering from acute
gastroenteritis. She is going to assess the patient’s skin turgor. The best site for the assessment of skin
turgor would be at the
a. Elbow
b. Forearm
c. Abdomen
d. Thigh
ANSWER: C
RATIONALE: The abdomen has a greater surface area for skin turgor than the other body parts.
Multiple Choice
1. What would be the cause of primary headaches?
a. Stroke
b. Meningitis
c. No identifiable underlying cause
d. Seizures
ANSWER: C
RATIONALE: Primary headaches usually don’t have an underlying cause while the rest of the other
choices would fall under secondary headaches.
2. Which of the following types of headache has an aura and is accompanied by seizures?
a. Tension-type headache
b. Cluster headache
c. Metabolic headache
d. Migraine headache
ANSWER: D
RATIONALE: Migraine headaches typically start with an aura such as visual disturbances then proceeds
to headache that will be accompanied with vertigo.
3. When palpating for the lymph nodes on the neck of a patient, the nurse must use which of the
following?
a. Thumb and index fingers
b. Index and middle fingers
c. Thumbs only
d. Index fingers only
ANSWER: B
RATIONALE: In order to properly palpate for the lymph nodes on the neck of the patient, the nurse must
use her index and middle fingers for palpating. The other fingers are not effective in the palpation of the
lymph nodes of the neck.
4. Which of the following is the characteristic of the face of a patient who has hypothyroidism?
a. Swelling of the face
b. Emaciated face
c. Mask-like face
d. Moon face
ANSWER: A
RATIONALE: One of the signs of having hypothyroidism is swelling of the hands, legs, and the face. This
is called anasarca.
5. The nurse assessing the neck of the patient has observed for an enlargement of the thyroid gland.
The nurse must suspect for which of the following conditions?
a. Goiter
b. Hyperparathyroidism
c. Cushing syndrome
d. Addison’s disease
ANSWER: A
RATIONALE: Goiter is an abnormally enlarged thyroid gland. Goiter is a common condition in parts of
the world where there is iodine deficiency.
6. Which of the following signs is not seen in a patient who has hyperthyroidism?
a. Palpitations
b. Frequent bowel movements
c. Periorbital puffiness
d. Exophthalmos
ANSWER: C
RATIONALE: Periorbital puffiness is instead seen in patients who have hypothyroidism.
7. Which of the following must be included in the teaching to prevent motor vehicular head injuries?
a. Always use the seatbelt
b. Wear a helmet when riding motorcycles, all-terrain vehicles, motorized scooters, bicycles, horses or
snowmobiles.
c. Small children should sit in the back seat especially if the car has a passenger airbag
d. All of the above
ANSWER: D
RATIONALE: All choices are appropriate in order to prevent the occurrence of traumatic head injuries.
8. In order to decrease the likelihood of falls, the nurse must teach the following precautions EXCEPT
a. Install safety features in the home such as grab bars in the bathroom and nonslip mats in the bathtub.
b. Wear nonslip, well-fitting shoes.
c. Allow babies to use walkers.
d. Install window guards.
ANSWER: C
RATIONALE: We do not allow babies to use walkers unsupervised. Babies using walkers especially in the
higher floors of the house can cause falls to occur. Babies should be supervised at all times.
9. When assessing for the lymph nodes of the head, the very last lymph node that the nurse must
palpate would be the
a. Supraclavicular lymph nodes
b. Preauricular lymph nodes
c. Submental lymph nodes
d. Occipital lymph nodes
ANSWER: A
RATIONALE: The sequence of assessing the lymph nodes of the head is as follows: 1. Preauricular, 2.
Posterior auricular, 3. Occipital, 4. Tonsillar, 5. Submandibular, 6. Submental, 7. Superficial Cervical, 8.
Posterior cervical, 9. Deep cervical chain, 10. Supraclavicular.
10. The characteristic face of a patient who has Cushing syndrome would be
a. Emaciated
b. Moon face
c. Puffy and reddish cheeks
d. Reddish cheeks and cyanotic face all over
ANSWER: B
RATIONALE: Weight gain and fatty tissue deposits, particularly around the midsection and upper back,
in the face (moon face), and between the shoulders (buffalo hump)
Session # 9
LESSON TITLE: The Eyes Materials:

LEARNING OUTCOMES: Book, pen and notebook, index card/class list
1. Identify the components and function of the eye;

2. Collect an accurate health history of the eye;
3. Describe the physical examination techniques performed References: Bates’ Nursing Guide to Physical
to evaluate the eye; Examination and History Taking (Second Edition)
4. Identify the measures for prevention or early detection of by Beth Hogan-Quigley, Mary Louise Palm, and
eye disease, infections, or vision loss; Lynn Bickley.
5. Perform a complete eye examination.

THE EYES
Common or concerning symptoms:

 Changes in vision:
o Hyperopia- is a refractive error, which means that the eye does not bend or refract light properly to a
single focus to see images clearly. In hyperopia, distant objects look somewhat clear, but close objects
appear more blurred.
o Presbyopia - Presbyopia is when your eyes gradually lose the ability to see things clearly up close. It is a
normal part of aging. In fact, the term ―presbyopia‖ comes from a Greek word which means ―old eye.‖ You
may start to notice presbyopia shortly after age 40.
o Myopia - is a common vision condition in which you can see objects near to you clearly, but objects farther
away are blurry. It occurs when the shape of your eye causes light rays to bend (refract) incorrectly,
focusing images in front of your retina instead of on your retina.
o Scotomas- is an area of partial alteration in the field of vision consisting of a partially diminished or
entirely degenerated visual acuity that is surrounded by a field of normal – or relatively well-preserved –
vision.
 Double vision or diplopia
 Strabismus - is when your eyes are not lined up properly and they point in different directions
 Blurring
 Redness
 Itching
 Discharge
 Pain
 Tearing
 Edema
 Lesions
 Visual disturbances
 Photophobia
Areas of History Interview

• Eye History
• Family History
• Lifestyle Habits
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The components of the eye examination include:
• Vision tests: distal, near, and peripheral Inspection of the eye, eyebrows, lids, conjunctiva and sclera, cornea,
lens, iris, and pupils Inspection and palpation of the lacrimal apparatus.
• Extraocular movements: assessment of cardinal fields, convergence, corneal light test, cover–uncover test.
Equipment for Examination

• Snellen chart or ―E‖ card
• Rosenbaum, near-vision card
• Index card
• Penlight
• Ophthalmoscope
Visual Acuity
• Visual acuity is expressed as two numbers (e.g., 20/30): the numerator indicates the distance of the patient from
the chart and this number should always be 20 unless the patient moved closer to see, and the denominator is
the distance at which a normal eye can read the line of letters.
Near Vision
• Testing near vision with a special hand-held card, the Rosenbaum chart, helps identify the need for reading
glasses or bifocals in patients older than 45 years. This card can be utilized to test visual acuity at the bedside.
Held 14 inches from the patient’s eyes, the card simulates a Snellen chart. However, patients may choose their
own distance.
External Eye Examination

• Position and Alignment of the Eyes. Stand in front of the patient and survey the eyes for position and alignment. If
one or both eyes seem to protrude, assess them from above.
• Eyebrows. Inspect the eyebrows, noting their quantity and distribution and any scaliness of the underlying skin.
• Eyelids. Note the position of the lids in relation to the eyeballs.
Inspect for the following:

• Width of the palpebral fissures—open area between the upper and lower eyelids
• Edema of the lids
• Color of the lids
• Lesions
• Condition and direction of the eyelashes
• Adequacy with which the eyelids close. Look for this especially when the eyes are unusually prominent, when
there is facial paralysis, or when the patient is unconscious.
Internal Eye Examination

• Cornea and Lens. With oblique lighting, inspect the cornea of each eye for opacities and note any opacities in the
lens that may be visible through the pupil.
• Iris. At the same time, inspect each iris. The markings should be clearly deﬁned. With your light shining directly
from the temporal side, look for a crescentic shadow on the medial side of the iris. Because the iris is normally
fairly ﬂat and forms a relatively open angle with the cornea, this lighting casts no shadow.
• Pupils. Inspect the size, shape,and symmetryof the pupils. If the pupils are large (5 mm), small (<3 mm), or
unequal, measure them. A pupil guide with black circles of varying sizes facilitates measurement.
• Test the pupillary reaction to light. Ask the patient to look into the distance, and shine a bright light obliquely into
each pupil in turn.
Ophthalmic Examination
 The nurse would examine the patient’s eyes without dilating the pupils. The view is therefore limited to the
posterior structures of the retina. To see more peripheral structures, to evaluate the macula well, or to investigate
unexplained visual loss, ophthalmologists dilate the pupils with mydriatic drops unless this is contraindicated.
Extraocular Muscles
• Assess the extraocular movements, looking for:
• The normal conjugate movements of the eyes in each direction, or any deviation from normal
• Nystagmus, a fine rhythmic oscillation of the eyes. A few beats of nystagmus on extreme lateral gaze are normal.
If you see it, bring your finger in to within the field of binocular vision and look again.
2 of 5
• Lid lag as the eyes move from up to down.
Special Techniques
• Nasolacrimal Duct Obstruction. This test helps identify the cause of excessive tearing. Ask the patient to look up.
Press on the lower lid close to the medial canthus, just inside the rim of the bony orbit— this compresses the
lacrimal sac. Look for fluid regurgitated out of the puncta into the eye. Avoid this test if the area is inflamed and
tender.
Health Promotion, Disease Prevention and Education

• Vision screening
• Eye protection
• Care of contact lenses
Vision Screening
• Changes in vision shift with age. Amblyopia, also known as ―lazy eye‖, affects approximately 2–4% or preschool
children. This loss of vision is due to an alteration in neural pathways in the developing brain which in turn
decreases use of the affected eye.
• Strabismus is eye misalignment; these are found most frequently in infants and children up to 5 years old.
Screening tests for detecting strabismus and amblyopia include simple inspection, the cover uncover test, corneal
light reflex and visual acuity tests.
Eye protection
• Eye injuries and trauma can occur in the home, during recreational activities, and in the place of employment.
Protective eyewear should be utilized when there is a chance of injury to the eye. Eye injury can result from
numerous causes, for example: chemical splashes from cleaning supplies, metal shards or rocks flying when
mowing the lawn, sports (e.g., lacrosse) injuries, body fluids entering the eye—the list is endless. The activities
and environment in which people work and play should be assessed and precautions taken to avoid eye injury
and promote healthy habits.
Care of Contact Lenses

• Infections can occur and injure the eye if contact lenses are not taken care of properly. Patients should remember
to wash their hands when inserting or removing lenses, to wear and remove them as prescribed by the health
care provider, and to keep them clean and not share contacts. If patients are using solutions, they should discard
unused portions at the expiration date.
Variations and abnormalities of the eyelids (The students must check chapter 11 of their textbook for the description and
illustration of each abnormality).
 Ptosis
 Entropion
 Ectropion
 Lid retraction and exophthalmos
Opacities of the Cornea and Lens (The students must check chapter 11 of their textbook for the description and illustration
of each abnormality).
 Corneal arcus
 Corneal scar
 Pterygium
 Nuclear cataract
 Peripheral cataract
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Multiple Choice
1. Which of the following structures of the eye regulates the amount of light entering the eye?
a. Pupil
b. Iris
c. Cornea
d. Lens
ANSWER:
RATIONALE:
2. Which of the following vitamins is deficient in a patient who is experiencing xerophthalmia?

a. Vitamin C
b. Vitamin K
c. Vitamin D
d. Vitamin A
ANSWER:
RATIONALE:
3. A patient who can see objects that are near but is not able to see objects from afar has which of the following
conditions?
a. Hyperopia
b. Presbycusis
c. Myopia
d. Astigmatism
ANSWER:
RATIONALE:
4. The patient can be declared legally blind if the patient has a visual acuity of
a. 20/150
b. 20/100
c. 20/180
d. 20/200
ANSWER:
RATIONALE:
5. Excessive tearing of the eyes can be commonly caused by which of the following?
a. Nasolacrimal duct obstruction
b. Retinal detachment
c. Cataract
d. Presbyopia
ANSWER:
RATIONALE:
6. A nurse is assessing a patient who has Bell’s Palsy has observed for the drooping of the eyelid of the affected
side. The nurse must note this as
a. Ectropion
b. Entropion
c. Ptosis
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d. Pterygium
ANSWER:
RATIONALE:
.
7. When the nurse is assessing a 4-year old child, she has noticed that the child has an eye misalignment. She
should note this as
a. Strabismus
b. Amblyopia
c. Presbyopia
d. Exophthalmos
ANSWER:
RATIONALE:
8. When teaching a patient who is going to use contact lenses for the first time, the nurse must teach the patient that
prior to the application of the contact lenses the patient must
a. Look at a bright light
b. Do handwashing
c. Clean the contact lenses
d. Ask assistance from a family member in the application of the contact lenses
ANSWER:
RATIONALE:
9. This is the fine rhythmic oscillations of the eyes

a. Amblyopia
b. Presbyopia
c. Nystagmus
d. Exophthalmos
ANSWER:
RATIONALE:
10. A patient who has hyperthyroidism can have which of the following eye conditions?
a. Ptosis
b. Exophthalmos
c. Ectropion
d. Entropion
ANSWER:
RATIONALE:

5 of 5
Session # 10
LESSON TITLE: Ears, Nose, Mouth, and Throat

1. Identify the structures and function of the ear, nose, mouth,

and throat;
2. Collect an accurate health history of the ear, nose, mouth,
and throat; References: Bates’ Nursing Guide to Physical
3. Describe the physical examination techniques performed Examination and History Taking (Second Edition)
to evaluate the ear, nose, mouth, and throat; by Beth Hogan-Quigley, Mary Louise Palm, and
4. Perform a complete ear, nose, mouth, and throat Lynn Bickley.
examination.

& Physiology).
THE HEALTH HISTORY

Common, or Concerning Symptoms of the Ears:
 Hearing loss
 Earache
 Discharge
 Tinnitus
 Vertigo
Ear History
 Try to distinguish between two basic types of hearing impairment: conductive loss, which results from problems in
the external or middle ear, and sensorineural loss, from problems in the inner ear, the cochlear nerve, or itscentral
connections in the brain.
 Hearing loss may also be congenital, from single gene mutations
 People with sensorineural loss have particular trouble understanding speech, often complaining that others
mumble; noisy environments make hearing worse. In conductive loss, noisy environments may help.
 Medications that affect hearing include aminoglycosides, aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs),
quinine, furosemide, and others.
 Symptoms associated with hearing loss, such as earache or vertigo, help you to assess likely causes. In addition,
inquire specifically about medications that might affect hearing and ask about sustained exposure to loud noise.
Earache
 Complaints of earache, or pain in the ear, are especially common. Ask about associated fever, sore throat, cough,
and concurrent upper respiratory infection.
 Pain suggests a problem in the external ear, such as otitis externa, or, if associated with symptoms of respiratory
infection, in the inner ear, as in otitis media.2 It may also be referred from other structures in the mouth, throat, or
neck.
Discharge
 Ask about discharge from the ear, especially if associated with earache or trauma.
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 Unusually soft wax, debris from inflammation or rash in the ear canal, or discharge through a perforated eardrum
may be secondary to acute or chronic otitis media.
Tinnitus
 Tinnitus is a perceived sound that has no external stimulus and commonly is heard as musical ringing or a
rushing or roaring noise. It can involve one or both ears. Tinnitus may accompany hearing loss and often remains
unexplained.
 Occasionally, popping sounds originate in the temporomandibular joint, or vascular noises from the neck may be
audible.
 Tinnitus is a common symptom, increasing in frequency with age. When associated with hearing loss and vertigo,
it suggests Ménière’sdisease.
Vertigo
 Vertigo refers to the perception that the patient or the environment is rotating or spinning. These sensations point
primarily to a problem in the labyrinths of the inner ear, peripheral lesions of cranial nerve (CN) VIII, or lesions in
its central pathways or nuclei in the brain.
Lumps on the ear; Abnormalities of the Eardrum; and Patterns of Hearing Loss (The student will read and check
the illustrations about this topic in chapter 12 of their textbook)
Past History (Ear)

 Congenital hearing loss
 Removal of cerumen
 Ear surgery
 Trauma or injury to your ear(s)
 Infection
 Exposure to hazardous noise levels (work, home, war)
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 History of syphilis, rubella, meningitis
Family History
 Hearing loss
 Otitis media
 Allergies
 Smoking or exposure to cigarette smoke
Common or Concerning Symptoms of the Nose and Sinuses
Rhinorrhea
 Rhinorrhea refers to drainage from the nose and is often associated with nasal congestion, a sense of stuffiness
or obstruction. These symptoms are frequently accompanied by sneezing, watery eyes, and throat discomfort,
and also by itching in the eyes, nose, and throat.
 Causes include viral infections, allergic rhinitis (“hay fever”), and vasomotor rhinitis. Itching favors an allergic
cause.
 Relation to seasons or environmental contacts suggests allergy.
 Excessive use of decongestants can worsen symptoms, causing rhinitismedicamentosa.
Congestion
 The symptoms usually appear after an upper respiratory infection. Together these suggest acute bacterial
sinusitis. Sensitivity and specificityare highest for symptoms appearingafter a URI (90% and 80%).
Epistaxis
 Epistaxis means bleeding from the nose. The blood usually originates from the nose itself, but may come from a
paranasal sinus or the nasopharynx.
 Local causes of epistaxis include trauma (especially nose picking), inflammation, drying and crusting of the nasal
mucosa, tumors, and foreign bodies.
 Bleeding disorders may contribute to epistaxis.
Change in Sense of Smell Ask the patient for the following:

 Trigger
 Illness prior to the symptom
 Any injury to the nose and head
 If the symptom is constant or intermittent
Past History
 Sinus infections
 Upper respiratory infections
 Allergies
 Trauma or injury
 Nasal or sinus surgery
 Polyps
 Dental history
Family History
 Allergies
 Asthma
 Cancer of the nose or sinus
Common or concerning symptoms of the mouth and throat

 Sore throat
 Hoarseness
 Lesions
 Sore tongue
 Bleeding gums
 Toothache
 Dysphagia
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Sore Throat
 Sore throat is a frequent complaint, usually associated with acute upper respiratory symptoms.
 Fever, pharyngeal exudates, and anterior lymphadenopathy, especially in the absence of cough, suggest
streptococcal pharyngitis, or strep throat
Hoarseness
 Hoarseness refers to an altered quality of the voice, often described as husky, rough, or harsh. The pitch may be
lower than before. Hoarseness usually arises from inflammation or infection of the larynx but may also develop as
extralaryngeal lesions press on the laryngeal nerves. Check for overuse of the voice, allergy, smoking or other
inhaled irritants, and any associated symptoms.
Bleeding from the gums

 Bleeding from the gums is a common symptom, especially when brushing teeth. It can also be caused by
gingivitis. Ask what type of toothbrush is used? Hard or soft? Ask about local lesions and any tendency to bleed
or bruise elsewhere.
Dysphagia
 The patient has difficulty of swallowing, whether it be food or fluids.
Abnormalities of the Lips; Findings in the Palate, Pharynx, and the Oral Mucosa; Findings in the Gums and
Teeth; Findings In or Under the Tongue(The student will read and check the illustrations about this topic in
chapter 12 of their textbook)
Past history
 Sore throat
 Loss of voice
 Dental, mouth, or throat surgery
 Trauma or injury to teeth, mouth, or throat
 History of infections
 Oral cancer
 Sexually transmitted disease
Family History
 Allergies
 Smoking or exposure to cigarette smoke
 Stroke
 Tuberculosis

Multiple Choice
1. The labyrinth within the inner ear is responsible for which of the following?
a. Air conduction
b. Bone conduction
c. Equilibrium
d. Hearing
ANSWER:
RATIONALE:
2. In conductive hearing loss the patient will most likely have problems in which of the following ear structures?
a. Auricle
b. Tympanic membrane
c. Ossicles
d. All of the above
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ANSWER:
RATIONALE:
3. Otitis media is common among children below 5 years old since
a. Their immune system is not yet mature
b. The auditory canal is too short
c. Children often insert objects into their ears
d. The eustachian tube is short and more horizontal
ANSWER:
RATIONALE:
4. When tinnitus is present together with hearing loss and vertigo, this may suggest
a. Conductive hearing loss
b. Sensorineural hearing loss
c. Meniere’s disease
d. Otosclerosis
ANSWER:
RATIONALE:
5. Which of the following causes of worsen symptoms of rhinorrhea due to excessive use of decongestants
a. Vasomotor rhinitis
b. Rhinitis medicamentosa
c. Allergic rhinitis
d. Hay fever
ANSWER:
RATIONALE:
6. Which of the following beverages can cause nasal congestion in a patient if taken in excess?
a. Alcohol
b. Coffee
c. Milk
d. Carbonated drinks
ANSWER:
RATIONALE:
7. Fever, pharyngeal exudates, and anterior lymphadenopathy, especially when cough is not present can suggest
an infection of which of the following microorganisms?
a. Corynebacterium diphtheriae
b. Filterable virus
c. Haemophilus influenzae
d. Streptococcus pyogenes
ANSWER:
RATIONALE:
8. Which of the following conditions does NOT cause hoarseness?
a. Smoking
b. Voice abuse
c. Increased intake of high-sodium foods
d. Tuberculosis
ANSWER:
RATIONALE:.
9. The nurse has observed for a sore smooth tongue in a patient while doing a physical examination. The nurse
must suspect for
a. Streptococcal infection
b. Nutritional deficiencies
c. Gingivitis
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d. Hypothyroidism
ANSWER:
RATIONALE:
10. The patient with tumor growing on their larynx has stated to the nurse that she has difficulty in swallowing. The
nurse must note this on her chart as
a. Polydipsia
b. Polyphagia
c. Dysphagia
d. Odynophagia
ANSWER:
RATIONALE:

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Session # 11
LESSON TITLE: The Respiratory System

1. Identify the percussion and auscultation sites for

assessment of the lungs;
2. Describe the normal lung sounds and their location;
3. Describe adventitious sounds and voice sounds and their References: Bates’ Nursing Guide to Physical
origin; Examination and History Taking (Second Edition)
4. Obtain an accurate history of the respiratory system. by Beth Hogan-Quigley, Mary Louise Palm, and
5. Correctly inspect, palpate, percuss, and auscultate the Lynn Bickley.
anterior and posterior thorax.

THE HEALTH HISTORY
Common or Concerning Symptoms:
Dyspnea
 Dyspnea is air hunger, a nonpainful but uncomfortable awareness of breathing that is inappropriate to the level of
exertion, commonly termed shortness of breath. This is a serious symptom that warrants a full explanation and
assessment. It can result from pulmonary or cardiac disease.
 Sudden onset may indicate anaphylaxis or pulmonary embolism (both emergencies), spontaneous
pneumothorax, or anxiety.
Cough
 Cough is typically a reflex response to stimuli that irritate receptors in the larynx, trachea, or large bronchi. These
stimuli include mucus, pus, blood, dust, foreign bodies, and even extremely hot or cold air. Coughing may also be
caused by inflammation of the respiratory mucosa or tension in the air passages from a tumor or enlarged
peribronchial lymph nodes. Patients with asthma may experience a cough without wheezing. The narrowed
airways trigger a cough on expiration as the patient tries to fully exhale the trapped air.
 Cough can be a symptom of left-sided heart failure. Viral upper respiratory infectionsare the most common cause
of acute cough; other causes include acute bronchitis, pneumonia, asthma, or foreign body. Postinfectious cough,
bacterial sinusitis, or asthma in subacutecough; postnasal drip, asthma, gastroesophageal reflux, chronic
bronchitis, bronchiectasis in chroniccough.
 Mucoid sputum is translucent, white or grey; purulent sputum is yellowish or greenish. Foul-smelling sputum in
anaerobic lung abscess; tenacious sputum in cystic fibrosis. Large volumes of purulent sputum in bronchiectasis
or lung abscess.
 An acute cough lasts < 3 weeks, subacute 3 to 8 weeks, and chronic > 8 weeks.
Chest pain may be caused by cardiac, respiratory, gastrointestinal, or musculoskeletal etiologies. Lung tissue itself has
no pain fibers. Pain in lung conditions, such as pneumonia or pulmonary infarction, usually arises from inflammation of the
adjacent parietal pleura. Sources of chest pain are listed below.
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● Trachea and large bronchi due to bronchitis
● Parietal pleura due to pericarditis, pneumonia
● Chest wall, including the musculoskeletal system and skin due to costochondritis, herpes zoster
● Myocardium due to angina pectoris or myocardial infarction
● Pericardium due to pericarditis
● Aorta due to dissecting aortic aneurysm
● Esophagus due to reflux esophagitis or esophageal spasm
● Extrathoracic structures: neck, gallbladder, and stomach due to cervical arthritis, biliary colic, gastritis
● Anxiety (the mechanism of pain remains obscure)
Physical Examinations Key Points:
Percussion
 Learn to identify five percussion notes.
 Train your ear to distinguish these differences
 Healthy lungs are resonant.
 While the patient keeps both arms crossed in front of the chest, percuss the thorax in symmetric locations from
the apex to the base.
 Alternate percussing one side of the chest and then the other at each level in a ladder-like pattern
 Dullness replaces resonance when fluid or solid tissue replaces air- containing lung or occupies the pleural space
beneath your percussing fingers. Examples include lobar pneumonia, in which the pleural accumulations of
serous fluid (pleural effu-sion), blood (hemothorax), pus (empyema), fibrous tissue, or tumor.
 Generalized hyperresonance may be heard over the hyperinflated lungs of COPD or asthma, but is not a reliable
sign. Unilateral hyperresonance suggests a large pneumothorax or possibly a large air-filled bulla in the lung
Breath sounds
Normal Breath Sounds:
 Vesicular, or soft and low pitched. They are heard through inspiration, continue without pause through expiration,
and then fade away about one third of the way through expiration.
 Bronchovesicular, with inspiratory and expiratory sounds about equal in length, at times separated by a silent
interval
 Bronchial, or louder and higher in pitch, with a short silence between inspiratory and expiratory sounds.
Expiratory sounds last longer than inspiratory sounds.
Adventitious Breath Sounds
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 Listen for any extra, or adventitious, sounds that are superimposed on the usual breath sounds. Detection of
adventitious sounds—crackles (sometimes called rales), wheezes, and rhonchi—is an important part of your
examination, often leading to diagnosis of cardiac and pulmonary conditions
 Crackles may be from abnormalities of the lungs (pneumonia, fibrosis, early congestive heart failure) or of the
airways (bronchitis, bronchiectasis). These are intermittent, non-musical, brief crackling sounds (collapsed or
fluid-filled alveoli popping open)
 Wheezes suggest narrowed airways, as in asthma, COPD, or bronchitis. These are high pitched sounds heard
first upon exhalation.
 Rhonchi suggest secretions in large airways. This is a low-pitched, snoring, rattling sounds that occur primarily
during exhalation
 STRIDOR - loud, high pitched crowing sound that is heard upon inhalation.
Deformities of the Chest (Refer to chapter 13 of the textbook for full description and illustration)
Barrel Chest
 There is an increased anteroposterior diameter. This shape is normal during infancy, and often accompanies
aging and chronic obstructive pulmonary disease.
Pigeon Chest (Pectus Carinatum)

 The sternum is displaced anteriorly, increasing the anteroposterior diameter. The costal cartilages adjacent to the
protruding sternum are depressed.
Funnel Chest
 Note depression in the lower portion of the sternum. Compression of the heart and great vessels may cause
murmurs.
Thoracic Kyphoscoliosis
 Abnormal spinal curvatures and vertebral rotation deform the chest. Distortion of the underlying lungs may take
interpretation of lung findings very difficult.

Multiple Choice
1. Nurse Megumi is taking care of a patient who has pulmonary tuberculosis. During the inspection of the patient’s
sputum, she has noticed some blood streaks on it. This is termed as
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a. Rhinitis
b. Rhinorrhea
c. Hematemesis
d. Hemoptysis
ANSWER:
RATIONALE:
2. During the history of present illness, a patient named Subaru is complaining of a dry cough for less than 3 weeks.
He is currently suspected for COVID-19. His cough can be categorized as
a. Acute cough
b. Subacute cough
c. Chronic cough
ANSWER:
RATIONALE:
3. Nurse Alice is currently auscultating a 4-year old patient who is suffering from pneumonia. Upon auscultation
through her stethoscope she has heard a high-pitched inspiratory sound. She must document this as
a. Wheezing
b. Stridor
c. Crackles
d. Rhonchi
ANSWER:
RATIONALE:
4. Nurse Ikumi is currently admitting a patient who is complaining of shortness of breath and cough. The nurse has
noticed that the patient’s chest is barrel-shaped. According to the patient’s health history, he has been a chronic
smoker for the past 20 years and has been smoking 2-3 packs of cigarettes per day. The nurse must suspect for
which of the following diseases?
a. Asthma
b. Chronic obstructive pulmonary disease (COPD)
c. Cystic fibrosis
d. COVID-19
ANSWER:
RATIONALE:
5. Which of the following would best describe tactile fremitus?

a. These are popping sounds heard from the patient’s chest wall
b. It is a harsh and high-pitched inspiratory sound
c. These are palpable vibrations transmitted through the bronchopulmonary tree to the chest wall as the
patient is speaking
d. It is a high-pitched musical sound usually heard during expiration
ANSWER:
RATIONALE:
6. Nurse Hisako is assessing a patient with asthma. Which of the following breath sounds will she expect to hear
from this patient?
a. Stridor
b. Wheezing
c. Rhonchi
d. Vesicular
ANSWER:
RATIONALE:
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7. What type of cardiac disease does the patient have if the patient has the presence of crackles in the lung area
upon auscultation of the nurse?
a. Atherosclerosis
b. Right-sided heart failure
c. Aneurysm
d. Left-sided heart failure
ANSWER:
RATIONALE:
8. This type of deformity of the thorax shows that the sternum is displaced anteriorly, increasing the anteroposterior
diameter. The costal cartilages adjacent to the protruding sternum are depressed.
a. Funnel chest
b. Flail chest
c. Pigeon chest
d. Barrel chest
ANSWER:
RATIONALE:
9. When Nurse Ryoko is percussing the patient’s lungs. A normal percussion note that the nurse must percuss must
be
a. Dull
b. Hyperresonant
c. Flat
d. Resonant
ANSWER:
RATIONALE:
10. Nurse Satoshi has read on the patient’s chart that the patient has pleural effusion. Which of the following is true
with regard to this condition?
a. This is the inflammation of the pleurae
b. This is the air-trapping at the alveoli
c. This is fluid accumulating in the pleural space
d. This is also known as pulmonary edema
ANSWER:
RATIONALE:
MUDDIEST POINT
1. Now, you will write what was least clear to you for this session.
2. Please share your ideas and discuss them with your seatmates.
3. After completing the activity, you will randomly be called to share your inputs to the class.
5 of 5
Session # 12
LESSON TITLE: The Cardiovascular System (Part 1)

LEARNING OUTCOMES:
Upon completion of this lesson, the nursing student can: Materials:
1. Describe the structure and functions of the heart and great Book, pen and notebook, index card/class list
vessels;
2. Identify the landmarks and key auscultation sites of the
precordium;
3. Describe the electrical conduction system of the heart;
4. Inspect, palpate, and auscultate the jugular veins, carotid References: Bates’ Nursing Guide to Physical
arteries, and the precordium to evaluate cardiovascular Examination and History Taking (Second Edition)
status; by Beth Hogan-Quigley, Mary Louise Palm, and
5. Obtain an accurate history of the cardiovascular system; Lynn Bickley.

& Physiology).
THE CARDIOVASCULAR SYSTEM
• The cardiovascular system is made up of the heart and blood vessels.

• The main functions of this system are delivering oxygen and nutrients to the cells of the body, removing waste
products, and maintaining perfusion to the organs and tissues.
• The heart is the pump that drives circulation of the blood and the blood vessels are the pathways to and from the
tissues.
• To assess a patient’s cardiovascular health the nurse gathers a thorough focused health history and uses this
information to perform an appropriate physical examination of the patient’s heart and blood vessels.
Location of the Heart and Great Vessels

• The heart is a hollow muscular organ a little larger than the patient’s fist.
• It lies in the pericardial cavity in the mediastinum under the sternum and between the 2nd and 5th intercostal
spaces.
• About two thirds of the heart lies to the left of the midline of the sternum.
• The area of the exterior chest that overlays the heart and great vessels is called the precordium.
• It is helpful to visualize the underlying structures of the heart as you examine the precordium.
• Note that the heart is rotated so that the right ventricle occupies most of the anterior cardiac surface.
• This chamber and the pulmonary artery form a wedge-shaped structure behind and to the left of the sternum,
outlined in black.
• The inferior border of the right ventricle lies at the junction of the sternum and the xiphoid process.
• The right ventricle narrows as it rises to meet the pulmonary artery just below the sternal angle. This is called the
“base of the heart” and is located at the right and left 2nd intercostal spaces next to the sternum.
• The left ventricle, behind the right ventricle and to the left, outlined below in black, forms the left margin of the
heart.
• Its tapered inferior tip is often termed the cardiac “apex.” It is clinically important because it produces the apical
impulse, identified during palpation of the precordium as the point of maximal impulse, or PMI. This impulse
locates the left border of the heart and is normally found in the 5th intercostal space 7 cm to 9 cm lateral to the
midsternal line, at or just medial to the left midclavicular line.
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• In supine patients the diameter of the PMI may be as large as a quarter, approximately 1 cm to 2.5 cm. A PMI 2.5
cm is evidence of left ventricular hypertrophy (LVH), or enlargement.
• Similarly, displacement of the PMI lateral to the midclavicular line or 10 cm lateral to the midsternal line also
suggests LVH, or enlargement.
Relation of Auscultatory Findings to the Chest Wall

• The locations on the chest wall where heart sounds and murmurs are heard help to identify the valve or chamber
where they originate. The sounds produced by the heart valves travel with the flow of blood.
• Sounds and murmurs arising from the mitral valve are usually heard best at and around the cardiac apex.
• Those originating in the tricuspid valve are heard best at or near the lower left sternal border. Murmurs arising
rd
from the pulmonic valve are usually heard best in the 2nd and 3 left intercostal spaces close to the sternum but
at times may also be heard at higher or lower levels.
• Murmurs originating in the aortic valve may be heard anywhere from the right 2nd intercostal space to the apex.
These areas overlap, as illustrated, and you will need to correlate auscultatory findings with other cardiac
examination findings to identify sounds and murmurs accurately.
The Conduction System

• An electrical conduction system stimulates and coordinates the contraction of cardiac muscle. Each electrical
impulse is initiated in the sinus node, a group of specialized cardiac cells located in the right atrium near the
junction of the vena cava.
• The sinus node acts as the cardiac pacemaker and automatically discharges an impulse about 60 to 100 times a
minute.
• This impulse travels through both atria to the atrioventricular node, a specialized group of cells located low in the
atrial septum.
• Here the impulse is delayed before passing down the bundle of His and its branches to the ventricular
myocardium. Muscular contraction follows: first the atria, then the ventricles.
The Heart as a Pump

• The left and right ventricles pump blood into the systemic and pulmonary arterial trees, respectively. Cardiac
output, the volume of blood ejected from each ventricle during 1 minute, is the product of heart rate and stroke
volume.
• Stroke volume (the volume of blood ejected with each heartbeat) depends in turn on preload, myocardial
contractility, and afterload.
Preload
• Preload refers to the load that stretches the cardiac muscle before contraction. The volume of blood in the right
ventricle at the end of diastole, then, constitutes its preload for the next beat.
Myocardial Contractility
• Myocardial contractility refers to the ability of the cardiac muscle, when given a load, to contract or shorten.
Contractility increases when stimulated by the sympathetic nervous system and decreases when blood flow or
oxygen delivery to the myocardium is impaired.
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Afterload
• Afterload refers to the degree of vascular resistance to ventricular contraction.
• Sources of resistance to left ventricular contraction include the tone in the walls of the aorta, the large arteries,
and the peripheral vascular tree (primarily the small arteries and arterioles), as well as the volume of blood
already in the aorta.
• Increased arterial blood pressure causes increased afterload.
Arterial Pulses and Blood Pressure

• With each contraction, the left ventricle ejects a volume of blood into the aorta and on into the arterial tree. The
ensuing pressure wave moves rapidly through the arterial system, where it is felt as the arterial pulse.
• Blood pressure in the arterial system varies during the cardiac cycle, peaking in systole and falling to its lowest
trough in diastole. These are the levels that are measured with the blood pressure cuff, or sphygmomanometer.
The difference between systolic and diastolic pressures is known as the pulse pressure.
Jugular Vein Undulations
 The oscillations visible in the internal jugular veins, and often in the externals, reflect changing pressures within
the right atrium. Careful observation reveals that the undulating pulsations of the internal jugular veins, and
sometimes the externals, are composed of two quick peaks and two troughs.
Jugular Venous Pressure

• Jugular venous pressure (JVP) reflects right atrial pressure, which in turn equals central venous pressure (CVP)
and right ventricular end-diastolic pressure.
• The JVP is best estimated from the right internal jugular vein, which has a more direct anatomic channel into the
right atrium. Contrary to widely held views, a recent study has reaffirmed inspection of the right external jugular
vein as a useful and accurate method for estimating CVP.
Ask for the patient’s past history and family history on any cardiovascular disease and ask about their lifestyle habits as
well such as:
 Nutrition
 Smoking
 Alcohol
 Exercise: describe their daily or weekly exercise: type and amount
 Medications/drugs

Multiple Choice
1. Which of the following is NOT a main function of the cardiovascular system?
a. Delivering oxygen and nutrients to cells
b. Removing waste products
c. Maintaining perfusion to the organs and tissues
d. Regulate the blood glucose levels
ANSWER:
RATIONALE:
2. This is the area found on the exterior chest where the health worker examines in order to detect the underlying
structures of the heart
a. Precordium
b. Myocardium
c. Endocardium
d. Pericardium
ANSWER:
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RATIONALE:
3. Which of the following statements is true about the point of maximal impulse (PMI)?
a. It is found behind the right ventricle and to the left, outlined below in black, forms the left margin of the heart.
th
b. This is located at the left border of the heart and is found in the 4 intercostal space 7-9 cm lateral to the
midsternal line.
nd
c. Located at the right and left 2 intercostal space next to the sternum.
nd th
d. It is found between the 2 intercostal space and the 5 intercostal space.
ANSWER:
RATIONALE:
4. Which of the following layers of the heart contains cardiac muscle?

a. Pericardium
b. Precordium
c. Myocardium
d. Endocardium
ANSWER:
RATIONALE:.
5. How much is the normal peak pressure of systole?

a. 70 mmHg
b. 80 mmHg
c. 100 mmHg
d. 120 mmHg
ANSWER:
RATIONALE:
6. A nursing student is asking her instructor about the definition of the stroke volume. The nursing instructor is correct
when she says which of the following definitions?
a. It is the amount of blood ejected by the ventricle with each heartbeat.
b. This is the difference between the systolic and diastolic blood pressure.
c. The amount of blood pumped by the heart in a minute.
d. The total number of heart beats in a minute.
ANSWER:
RATIONALE:
7. Cardiac output is the product of (Select all that apply)

a. Heart rate
b. Pulse pressure
c. Myocardial contractions
d. Stroke volume
ANSWER:
RATIONALE:
8. What best describes a preload?

a. This is the degree of vascular resistance to ventricular contraction
b. Sources of resistance to left ventricular contraction include the tone in the walls of the aorta and the peripheral
vascular tree.
c. Refers to the load that stretches the cardiac muscle before contraction.
d. The ability of the cardiac muscle, when given a load, to contract or shorten.
ANSWER:
RATIONALE:
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9. Which of the following equipment are used in measuring the blood pressure? (Select all that apply)
a. Sphygmomanometer
b. Stethoscope
c. Watch
d. Ruler
ANSWER:
RATIOANALE:
10. Which of the following structures can best estimate the jugular venous pressure?
a. Right external jugular vein
b. Right internal jugular vein
c. Left external jugular vein
d. Left internal jugular vein
ANSWER:
RATIONALE:
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Session # 13

LEARNING OUTCOMES:
Materials:
1. Obtain an accurate history of the cardiovascular system;
2. Appropriately prepare and position the patient for
cardiovascular examination;
3. Inspect, palpate, and auscultate the jugular veins, carotid
arteries, and the precordium to evaluate cardiovascular References: Bates’ Nursing Guide to Physical
status; Examination and History Taking (Second Edition)
4. Discuss risk factors for coronary heart disease; by Beth Hogan-Quigley, Mary Louise Palm, and
5. Discuss risk reduction and health promotion strategies to Lynn Bickley.
reduce coronary heart disease.

Preparation of the Patient:

• The patient should be comfortable and calm as anxiety may elevate the blood pressure or change the heart rate
or rhythm.
• Review the examination procedure with the patient before putting on the examination gown. Explain why
visualization of the anterior chest is important for data gathering.
• The examination gown has the opening in the front, which enables the nurse to open the gown only as necessary
during the examination.
• Assist the patient onto the examination table, if necessary, and immediately drape with a sheet. Perform the
examination from the patient’s right side.
Equipment Needed for Examination

• Stethoscope with a bell and diaphragm
• Sphygmomanometer
• Two 15-cm rulers
• Watch with second hand
• Examination light for tangential lighting
The components of the cardiovascular examination include:
Face
 As you are taking the patient’s history inspect the face, noting its color and the presence of any orbital edema.
Look for signs of anxiety. Pallor or cyanosis may indicate poor perfusion of oxygen and orbital edema may
indicate heart failure. Anxiety occurs during heart attacks.
 Infants may exhibit circumoral cyanosis with feeding.
Great Vessels of the Neck

 The Carotid Artery Pulse. The carotid pulse provides valuable information about cardiac function and is
especially useful for detecting stenosis or insufficiency of the aortic valve.
The Amplitude and Contour
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 To assess amplitude and contour of the carotid pulse, the patient should be lying down with the head of the
bed elevated to about 30°.
 First inspect the neck for carotid pulsations. These may be visible just medial to the sternocleidomastoid
muscles.
 Then place your index and middle fingers on the right carotid artery in the lower third of the neck, press
posteriorly, and feel for pulsations.
 A tortuous and kinked carotid artery may produce a unilateral pulsatile bulge.
 Causes of decreased pulsations include decreased stroke volume and local factors in the artery such as
atherosclerotic narrowing or occlusion.
 Press just inside the medial border of a well-relaxed sternocleidomastoid muscle, roughly at the level of the
cricoid cartilage.
 Avoid pressing on the carotid sinus, which lies at the level of the top of the thyroid cartilage.
 For the left carotid artery, use your right fingers. Never press both carotids at the same time.
 This may decrease blood flow to the brain and induce syncope.
 Slowly increase pressure until the maximal pulsation is felt, and then slowly decrease pressure until you best
sense the arterial pressure and contour.
The Amplitude of the Pulse
 The amplitude of the pulse. This correlates reasonably well with the pulse pressure.
 Small, thready, or weak pulse in cardiogenic shock; bounding pulse in aortic insufficiency
Contour of the Pulse Wave
 The contour of the pulse wave, namely, the speed of the upstroke, the duration of its summit, and the speed
of the downstroke.
 The normal upstroke is brisk. It is smooth and rapid and follows S1 almost immediately.
 The summit is smooth, rounded, and roughly midsystolic.
 The downstroke is less abrupt than the upstroke.
Variations in Amplitude
 Any variations in amplitude, either from beat to beat or with respiration.

 The timing of the carotid upstroke in relation to S1 and S2.
 Note that the normal carotid upstroke follows S1 and precedes S2.
 This relationship is very helpful in correctly identifying S1 and S2, especially when the heart rate is increased
and the duration of diastole, normally shorter than systole, is shortened and approaches the duration of
systole.
Thrills and Bruits
 During palpation of the carotid artery, humming vibrations, or thrills, that feel like the throat of a purring cat
may be detected.
 Routinely, but especially in the presence of a thrill, listen over both carotid arteries with the bell of the
stethoscope for a bruit, a murmur-like sound of vascular rather than cardiac origin.
The Brachial Artery
• Use the index and middle fingers to feel for the pulse just medial to the biceps tendon. The patient’s arm should
rest with the elbow extended, palm up. With your free hand, you may need to flex the elbow to a varying degree to
get optimal muscular relaxation.
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Hepatojugular Reflux
• If heart failure is suspected from the patient history or physical examination or if the jugular venous pressure is
elevated, perform the hepatojugular reflux maneuver.
• Position the patient supine with the head of the bed at the same angle used for the jugular venous pressure
examination.
• Place your right hand with fingers pointing toward the patient’s head over the right upper quadrant of the patient’s
abdomen just below the costal margin as seen on the next page.
• Press deeply in and upward and hold the pressure for 30 seconds. This maneuver forces the hepatic venous
blood into the vena cavae, elevating the venous blood volume and pressure.
• While you are applying pressure, watch the patient’s jugular vein level. The healthy person is able to pump the
extra blood through the heart within a few seconds. The jugular vein pressure will rise for a few seconds and then
rapidly diminish to previous levels.
The Heart
• For much of the cardiac examination, the patient should be supine, with the upper body raised by elevating the
head of the bed or table to about 30°.
• Two other positions are also needed: (1) turning to the left side and (2) sitting and leaning forward. These
positions bring the ventricular apex and left ventricular outflow tract closer to the chest wall, enhancing detection
of the PMI and aortic insufficiency. The examiner should stand at the patient’s right side.
• Note the anatomic location of sounds in terms of intercostal spaces and their distance from the midsternal or
midclavicular lines.
• The midsternal line offers the most reliable zero point for measurement, but some feel that the midclavicular line
accommodates the different sizes and shapes of patients.
• Identify the timing of impulses or sounds in relation to the cardiac cycle.
• Timing of sounds is often possible through auscultation alone. In most people with normal or slow heart rates, it is
easy to identify the paired heart sounds by listening through a stethoscope.
• S1 is the first of these sounds, S2 is the second, and the relatively long diastolic interval separates one pair from
the next.
• S1 is sometimes called ―lub‖ and S2 ―dub.‖ Listen for the lub-dub sequence to distinguish the two sounds.
• The relative intensity of these sounds is also helpful. S1 is usually louder than S2 at the apex; S2 is usually louder
than S1 at the base.
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Inspection
• Carefully inspect the anterior chest for the location of the apical impulse or point of maximal impulse or heaves
over the precordium, which indicate increased ventricular movement. Tangential light is useful for making this
observation. Use palpation to confirm the characteristics of the apical impulse.
Palpation
• Begin with general palpation of the chest wall. First palpate for heaves, (lifts), using your fingerpads. Hold them
flat or obliquely on the body surface. Ventricular impulses may heave or lift your finger.
• Check for thrills, formed by the turbulence of underlying murmurs, by pressing the ball of your hand firmly on the
chest. If subsequent auscultation reveals a loud murmur, go back to that area and check for thrills again.
• Thrills may accompany loud, harsh, or rumbling murmurs as in aortic stenosis, patent ductus arteriosus,
ventricular septal defect, and, less commonly, mitral stenosis. They are palpated more easily in patient positions
that accentuate the murmur.
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• On rare occasions, a patient has dextrocardia—a heart situated on the right side. The apical impulse will then be
found on the right. If you cannot find an apical impulse, percuss for the dullness of theheart and liver and for the
tympany of the stomach. In situs inversus, all three of these structures are on opposite sides from normal. A right-
sided heart with a normally placed liver and stomach is usually associated with congenital heart disease.
• Be sure to assess the right ventricle by palpating the right ventricular area at the lower left sternal border and in
nd
the subxiphoid area, the pulmonary artery in the left 2nd intercostal space, and the aortic area in the right 2
intercostal space (see the diagram with palpation areas indicated.
• Palpable pulsations of the right ventricle may indicate an enlarged right ventricle.
The Apical Impulse or Point of Maximal Impulse

• The apical impulse represents the brief early pulsation of the left ventricle as it moves anteriorly during contraction
and touches the chest wall.
• Note that in most examinations the apical impulse is the point of maximal impulse, or PMI; however, some
pathologic conditions may produce a pulsation that is more prominent than the apex beat, such as an enlarged
right ventricle, a dilated pulmonary artery, or an aneurysm of the aorta.
• If you cannot identify the apical impulse with the patient supine, ask the patient to roll partly onto the left side—this
is the left lateral decubitus position.
• Palpate again, using the palmar surfaces of several fingers. If you cannot find the apical impulse, ask the patient
to exhale fully and stop breathing for a few seconds.
• When examining a woman, it may be helpful to displace the left breast upward or laterally as necessary;
alternatively, ask her to do this for you.
• The apex beat is palpable in only 25% to 40% of healthy adults in the supine position and in 50% of healthy adults
in the left lateral decubitus position, especially those who are thin
nd
Pulmonic Area – The Left 2 Intercostal Space
• This intercostal space overlies the pulmonary artery. As the patient holds expiration, look and feel for an impulse
and feel for possible heart sounds. In thin or shallow-chested patients, the pulsation of a pulmonary artery may
sometimes be felt here, especially after exercise or with excitement.
nd
Aortic Area – The Right 2 Intercostal Space
• This intercostal space overlies the aortic outflow tract. Search for pulsations and palpable heart sounds.
• A prominent pulsation here often accompanies dilatation or increased flow in the pulmonary artery. A palpable S2
suggests increased pressure in the pulmonary artery (pulmonary hypertension).
Percussion
• Percussion is rarely used today to estimate cardiac size. X-rays, ECG, and echocardiography provide accurate
measurement. Palpation of the apical impulse can provide a rough size estimate.
Auscultation
• The diaphragm. The diaphragm is better for picking up the relatively high-pitched sounds of S1 and S2, the
murmurs of aortic and mitral regurgitation, and pericardial friction rubs. Listen throughout the precordium with the
diaphragm, pressing it firmly against the chest.
• The bell. The bell is more sensitive to the low-pitched sounds of S3 and S4 and the murmur of mitral stenosis.
Apply the bell lightly, with just enough pressure to produce an air seal with its full rim. Use the bell at the apex,
and then move medially along the lower sternal border. Resting the heel of your hand on the chest like a fulcrum
may help you to maintain light pressure.

Multiple Choice
1. When assessing the amplitude and contour of the patient’s carotid pulse, Nurse Sakura must place the patient in
a
a. High Fowler’s position
b. Supine position
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c. Head of the bed elevated to 30 degrees
d. Left Sim’s Position
ANSWER:
RATIONALE:
2. What will happen if the nurse has accidentally pressed both carotid arteries at the same time while assessing the
patient’s neck?
a. Syncope
b. Hypertension
c. Stroke
d. Myocardial infarction
ANSWER:
RATIONALE:
3. What would be the characteristic of the pulse of a patient who is suffering from aortic insufficiency?
a. Slow, weak, and thready
b. Bounding pulse
c. Fast and bounding
d. Weak and almost unpalpable
ANSWER:
RATIONALE:
4. The hepatojugular reflux is elicited by applying pressure on the patient’s abdomen. Which quadrant will the nurse
apply pressure on?
a. Right upper quadrant
b. Left upper quadrant
c. Right lower quadrant
d. Left lower quadrant
ANSWER:
RATIONALE:
5. When detecting the point of maximal impulse on the patient, the nurse must stand at the
a. Left side of the patient
b. Right side of the patient
c. Head of the patient
ANSWER:
RATIONALE
6. When assessing for any palpable thrills over the heart of the patient, Nurse Ikumi must use her
a. Fingerpads
b. Index and the middle finger
c. Thumb
d. Ball of her hand
ANSWER:
RATIONALE:.
7. Which of the following conditions can exhibit thrills in a patient?

a. Aortic stenosis
b. Patent ductus arteriosus
c. Ventricular septal defect
d. All of the above
ANSWER:
RATIONALE:
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8. This is a condition where the internal organs from the thoracic and abdominal cavity are found on the opposite
sides from what is normal
a. Dextrocardia
b. Situs inversus
c. Congenital heart disease
d. Cardiomegaly
ANSWER:
RATIONALE:
9. The right ventricle of the heart can be palpated at the

nd
a. Left 2 intercostal space
nd
b. Right 2 intercostal space
th
c. Left 5 intercostal space
d. Lower left sternal border in the subxiphoid area
ANSWER:
RATIONALE:
10. When assessing the point of maximal impulse in a female patient, we tell the patient to do which of the following?
a. Let the patient displace her left breast upward and laterally
b. Let the patient displace her left breast downward and medially
c. Let the patient displace her left breast upward
d. Let the patient displace her left breast laterally
ANSWER:
RATIONALE:
7 of 7
Session # 14

LEARNING OUTCOMES:
Materials:
1. Obtain an accurate history of the cardiovascular system;
2. Appropriately prepare and position the patient for
cardiovascular examination;
3. Inspect, palpate, and auscultate the jugular veins, carotid
arteries, and the precordium to evaluate cardiovascular References: Bates’ Nursing Guide to Physical
status; Examination and History Taking (Second Edition)
4. Discuss risk factors for coronary heart disease; by Beth Hogan-Quigley, Mary Louise Palm, and
reduce coronary heart disease.

Auscultatory Sounds
HEART MURMURS
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Midsystolic Murmur
• A midsystolic murmur begins after S1 and stops before S2. Brief gaps are audible between the murmur and the
heart sounds. Listen carefully for the gap just before S2. It is heard more easily and, if present, usually confirms
the murmur as midsystolic, not pansystolic.
Pansystolic Murmur
• A pansystolic (holosystolic) murmur starts with S1 and stops at S2, without a gap between murmur and heart
sounds.
Late Systolic Murmur

• A late systolic murmur usually starts in mid- or late systole and persists up to S2.
Early Diastolic Murmur

• An early diastolic murmur starts immediately after S2, without a discernible gap, and then usually fades into
silence before the next S1.
Middiastolic Murmur
• A middiastolic murmur starts a short time after S2. It may fade away, as illustrated, or merge into a late diastolic
murmur.
Late diastolic (presystolic) murmur

• A late diastolic (presystolic) murmur starts late in diastole and typically continues up to S1.
Shape
• The shape or configuration of a murmur’s shape is the most difficult for a novice to determine. Concentrate on
learning the other characteristics of murmurs first. As your ears become attuned to listening, shape will become
identifiable.
Location of Maximal Intensity

• Find the location where the murmur is heard in terms of the intercostal space and its relation to the sternum, the
apex, or the midsternal, the midclavicular, or one of the axillary lines.
Intensity
• This is usually graded on a 6-point scale and expressed as a fraction.
• The numerator describes the intensity of the murmur wherever it is loudest; the denominator indicates the scale
you are using. Intensity is influenced by the thickness of the chest wall and the presence of intervening tissue.
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*************************************************************
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A client with three or more of these findings may have metabolic syndrome:
● Large waist circumference (abdominal obesity)
Men: waist circumference of 40 inches or more
Women: waist circumference of 35 inches or more
● High blood pressure—130/85 mm Hg or higher
● High fasting blood sugar—fasting glucose of 100 mg/dL or higher
● High triglycerides—150 mg/dL or higher
● Low high-density lipoprotein (HDL; good) cholesterol
Men: 40 mg/dL
Women: 50 mg/dL
• Smoking is also a risk factor for metabolic syndrome.

Multiple Choice
1. This type of murmur starts immediately after S2, without a discernible gap, and then usually fades into silence
before the next S1
a. Midsystolic murmur
b. Early diastolic murmur
c. Late systolic murmur
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d. Pansystolic murmur
ANSWER:
RATIONALE:
2. Which of the following best describes a crescendo-decrescendo murmur?

a. It grows louder
b. It grows softer
c. It first rises in intensity, then falls.
d. It has the same intensity throughout.
ANSWER:
RATIONALE:
3. A nurse has noted that the murmur has a loud with palpable thrill. The nurse should grade this on her chart as
a. Grade 1
b. Grade 2
c. Grade 3
d. Grade 4
ANSWER:
RATIONALE:
4. The shape of a midsystolic murmur is a

a. Crescendo
b. Decrescendo
c. Crescendo-decrescendo
d. Plateau
ANSWER:
RATIONALE:
5. When a patient has a constant blood pressure reading of 150/100, which of the following should be advised to the
patient?
a. No treatment required
b. Lifestyle modifications advised
c. Lifestyle modifications and drug therapy
d. Lifestyle modifications, drug therapy with two-drug combination required
ANSWER:
RATIONALE:
6. The following are modifiable risk factors for coronary heart disease EXCEPT
a. Diabetes
b. History of cardiovascular disease
c. Obesity
d. Physical inactivity
ANSWER:
RATIONALE:
7. Which of the following habits can contribute to the worsening hypertension of the patient?
a. Excessive use of seasonings on food
b. Frequent aerobic exercises
c. Having an average body built
d. Increased intake of potassium-rich foods
ANSWER:
RATIONALE:
8. The optimum body mass index that people should maintain is at
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a. Below 18.5
b. 18.5 to 24.9
c. 25 to 29.9
d. 30 and above
ANSWER:
RATIONALE:
9. Which of the following foods must the nurse recommend to a patient who has hypertension?
a. Carrots
b. Cucumbers
c. Bananas
d. Tomatoes
ANSWER:
RATIONALE:
10. In order to do lifestyle medication on a patient who has a risk for cardiovascular disease the nurse must teach
a. Eating a balanced diet and avoidance of fast food and processed food
b. Having regular aerobic exercises
c. Complete cessation of smoking
d. All of the above
ANSWER:
RATIONALE:
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Session # 15
LESSON TITLE: The Peripheral Vascular System and

Lymphatic System
LEARNING OUTCOMES:
Materials:
1. Identify the locations of the peripheral pulses;
2. Obtain an accurate history of the peripheral vascular Book, pen and notebook, index card/class list
system;
3. Describe the structure and functions of arteries, veins,
lymphatic vessels and lymph nodes;
4. Describe the equipment necessary to perform a peripheral
vascular examination; References: Bates’ Nursing Guide to Physical
5. Evaluate and interpret variations in heart rhythm, rate and Examination and History Taking (Second Edition)
amplitude; by Beth Hogan-Quigley, Mary Louise Palm, and
6. Discuss risk factors for peripheral artery disease, chronic Lynn Bickley.
venous status, and thromboembolic disease.

The Health History

 Pain in the arms or legs
 Intermittent claudication
 Cold, numbness, or pallor in the legs; hair loss
 Swelling in the calves, legs, or feet
 Swelling with redness and tenderness
Because most patients with peripheral vascular diseases report minimal symptoms, asking specifically about the
symptoms below is recommended, especially in patients older than 50 years and those with risk factors, especially
smoking, diabetes, hypertension, elevated cholesterol, or coronary artery disease:
● Do you have pain or cramping in your legs during walking or exertion?

(This is termed intermittent claudication.)
 These symptoms are caused by insufficient arterial supply to the legs, which may be caused by
atherosclerosis.
● Is it relieved by rest within 10 minutes?
● If present, identify the location and the distance the patient walks
before symptoms occur.
● Do you have coldness, numbness, or pallor in the legs or feet?
● Do you have hair on your shins?
● Do you have aching or pain at rest in the lower leg or foot?
● Is pain alleviated by elevating the legs?
● Do you have fatigue or aching in the lower legs with prolonged standing?
● Do you have swelling of the feet or legs? If present, identify:
 Edema, varicose veins, and aching in the legs are symptoms of venous stasis.
● Location
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● Time of day it is present
● Whether it is bilateral or unilateral
● Do you have any varicose veins?
● Where are they located?
● How long have you had them?
● Do you have any discomfort from them?
● Do you have any wounds of the legs or feet that will not heal or heal very
slowly?
 Ulcers may be of venous or arterial origin.
● Where is the wound located?
● How long have you had the wound?
● What precipitated the wound (e.g., an injury)?
● Do your fingertips or toes change color in cold weather?
 May be caused by Raynaud disease: the small arteries spasm in response to cold.
● Have you experienced erectile dysfunction?
 Poor blood supply to the penile arteries can cause erectile dysfunction.
● Do you have abdominal pain after meals?
● Does it prevent you from eating?
 Atherosclerosis of the mesenteric or celiac arteries can cause intestinal ischemia, producing
abdominal pain and “food fear,” where the patient is fearful of eating.
● Do you have tender or swollen lymph nodes (glands)?
 Swollen nodes may indicate an infection or tumor.
PAST HISTORY
● Medications, especially oral contraceptives or hormone replacement

Therapy
 Estrogen use and pregnancy increase one’s risk for blood clots.
● Pregnancy or recent childbirth
● Inflammatory diseases such as lupus, rheumatoid arthritis, or irritable
bowel disease
 Inflammation contributes to clot formation.
● Active cancer
● Coronary artery disease (CAD)
 Coronary artery disease and cerebral artery disease are also caused by atherosclerosis; an
individual with either is at risk for PAD.
● Heart attack
● Congestive heart failure
● Stroke (cerebral arterial disease)
● Clotting disorders
● Hypertension
● Diabetes
● Problems in circulation, such as blood clots, leg ulcers, swelling, or poor
healing of wounds
● Major surgery or fracture of a long bone in the last 4 weeks
Risk factors
● Obesity
● Smoking
● Hyperlipidemia
● Constrictive clothing
● Central venous lines
FAMILY HISTORY
● Peripheral vascular disease
● Varicose veins
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● Abdominal aortic aneurysm
● CAD
● Sudden death younger than 60 years of age
● Diabetes
Lifestyle or Health Patterns

● Job requiring prolonged standing or sitting
● Sedentary lifestyle
● Decreased mobility such as paralysis or cast
Arms
Inspection. Inspect both arms from the fingertips to the shoulders. Note:
1. Their size, symmetry, swelling, and any lesions
 Lymphedema of the arm and hand may follow axillary node dissection and radiation therapy.
2. The venous pattern
 Prominent veins in an edematous arm suggest venous obstruction
3. The color of the skin and nail beds and the texture of the skin
Palpation
1. Palpate the temperature of the arms and hands simultaneously with the backs of your fingers. Compare the
temperature of the arms simultaneously.
 In Raynaud disease, wrist pulses are typically normal, but spasm of more distal arteries causes episodes
of sharpy demarcated pallor of the fingers
2. Palpate the radial pulse with the pads of your fingers on the flexor surface of the wrist laterally. Partially flexing the
patient’s wrist may help you feel this pulse. Compare the pulses in both arms. Pulses may be palpated
simultaneously to facilitate comparison.
There are two common systems for grading the amplitude of the arterial pulses. One system uses a scale of 0 to 3, as
below. The other system uses a scale of 0 to 4. You should check to see what scale your institution uses.
If you suspect arterial insufficiency, feel for the brachial pulse. Flex the patient’s elbow slightly, and palpate the artery just
medial to the biceps tendon at the antecubital crease. The brachial artery can also be felt higher in the arm in the groove
between the biceps and triceps muscles.
Feel for the epitrochlear nodes. With the patient’s elbow flexed to about 90° and the forearm supported by your hand,
reach around behind the arm and feel in the groove between the biceps and triceps muscles, about 3 cm above the
medial epicondyle. If a node is present, note its size, consistency, and tenderness. Epitrochlear nodes are difficult or
impossible to identify in most normal people.
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Legs
The patient should be lying down and draped so that the external genitalia are covered and the legs fully exposed. A good
examination is impossible through stockings or socks!
Inspection. Inspect both legs from the groin and buttocks to the feet.
Note:
1. Their size, symmetry, and edema. Measure leg circumferences in centimeters if discrepancy is suspected.
2. The venous pattern and any venous enlargement or varicosities
3. Pigmentation, rashes, scars, or ulcers
4. The color and texture of the skin and the color of the nail beds
5. The distribution of hair on the lower legs, feet, and toes.
6. Look for brownish areas (or increased pigmentation on dark-skinned clients) near the ankles. The brown
discoloration is caused by hemosiderin released from the red blood cells that seep into the skin with edema and
break down.
7. Note the location, size, and depth of any ulcers in the skin. Are the edges of the wound well demarcated? Is there
bleeding?
Palpation
1. Palpate the temperature of both legs and feet simultaneously with the backs of your hands. Compare the temperature
of the legs. Bilateral coolness is most often caused by a cold environment or anxiety. Coldness, especially when unilateral
or associated with other signs, suggests arterial insufficiency from inadequate arterial circulation.
2. Palpate for edema. Compare one foot and leg with the other, noting their relative size and the prominence of veins,
tendons, and bones. Edema causes swelling that may obscure the veins, tendons, and bony prominences.
Palpate for pitting edema. Press firmly but gently with your thumb for at least 5 seconds (1) over the dorsum of each foot,
(2) behind each medial malleolus, and (3) over the shins. Look for pitting—a depression caused by pressure from your
thumb. Normally there is none. The severity of edema is graded on a four-point scale
Palpate the pulses to assess the arterial circulation.

● The femoral pulse. Press deeply, below the inguinal ligament and about midway between the anterior superior iliac
spine and the symphysis pubis. As in deep abdominal palpation, the use of two hands, one on top of the other, may
facilitate this examination, especially in obese patients.
● The popliteal pulse. The patient’s knee should be somewhat flexed, with the leg relaxed. Place the fingertips of both
hands so that they meet in the midline behind the knee and press deeply into the popliteal fossa. The popliteal pulse is
often more difficult to find than other pulses. It is deeper and feels more diffuse. If you cannot feel the popliteal pulse with
this approach, try with the patient prone. Flex the patient’s knee to about 90°, let the lower leg relax against your shoulder
or upper arm, and press your two thumbs deeply into the popliteal fossa.
● The dorsalis pedis pulse. Feel the dorsum of the foot (not the ankle) just lateral to the extensor tendon of the great
toe. If you cannot feel a pulse, explore the dorsum of the foot more laterally.
● The posterior tibial pulse. Curve your fingers behind and slightly below the medial malleolus of the ankle. (This pulse
may be hard to feel in a fat or edematous ankle.)
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ABNORMALITIES OF THE ARTERIAL PULSE AND PRESSURE WAVES:

Multiple Choice
1. Intermittent claudication is described as

a. Pain felt in the hands during a cold weather
b. Pain that radiates into the left shoulder and arm
c. Pain or cramping in the legs during walking or exertion
d. Pain felt in the feet due to edema
ANSWER:
RATIONALE:
2. Edema, varicose veins, and aching in the legs are symptoms of

a. Arterial stasis
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b. Venous stasis
c. Arterial pooling
d. Atherosclerosis
ANSWER:
RATIONALE:
3. Which of the following findings in the fingertips and toes is usually associated with Raynaud disease?
a. Pallor or cyanosis in the fingertips and toes
b. Redness in the fingertips and toes
c. Clubbing of the fingers and toes
d. Any of the above
ANSWER:
RATIONALE:
4. When asking the female patient about a possible risk for developing blood clots, which of the following
medications that the patient has previous taken should the nurse pay attention to?
a. Aspirin
b. Diphenhydramine
c. Oral contraceptives
d. Warfarin
ANSWER:
RATIONALE:
5. Which of the following type of jobs would increase the risk for the development of a peripheral vascular disease
like varicosities?
a. Truck driver
b. Traffic enforcer
c. Call center agent
d. Any of the above
ANSWER:
RATIONALE:
6. Nurse Mikasa is assessing the patient radial pulse. Upon placing her fingers, she has noted that the patient has a
bounding pulse. The nurse should grade this pulse on her chart as
a. 3+
b. 2+
c. 1+
d. 0
ANSWER:
RATIONALE:
7. Nurse Sasha is assessing the patient bipedal edema. Upon indenting her finger unto the edema she has
measured for at least 6 mm depression that has lasted for more than a minute. Nurse Sasha must grade this on
her chart as
a. 1
b. 2+
c. 3+
d. 4+
ANSWER:
RATIONALE:
8. Which of the following is NOT a risk factor for the development of peripheral vascular disease?
a. Obesity
b. Smoking
c. Hyperlipidemia
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d. Malnutrition
ANSWER:
RATIONALE:
9. Which of the following definitions best describes paradoxical pulse?

a. There is a palpable decrease in the pulse’s amplitude with quiet inspiration.
b. This is caused by a normal beat alternating with a premature contraction
c. The pulse alternates in amplitude from beat to beat even though the rhythm is regular.
d. An increased arterial pulse with a double systolic peak
ANSWER:
RATIONALE
10. When the patient has a pulsus alternans, the nurse must suspect for which of the following in the patient?
a. Aortic stenosis
b. Hyperthyroidism
c. Pericardial tamponade
d. Left ventricular failure
ANSWER:
RATIONALE:
CAT 3-2-1
After the instructor collects all papers, he/she will now summarize the topic. After the lesson, have each student record
three things he or she learned from the lesson. Next, have them record two things that they found interesting and that they
like to learn more about or ask students if they still have something to clarify or clarify about the topic. After answering the
question, station yourself at the door and collect the paper as students depart from the room. Respond to students’
answer during the next class meeting or as soon as possible
*All these must be done giving importance to social distancing, hygienic practices, and wearing of mask at all times.
7 of 7
Session # 16
LESSON TITLE: The Gastrointestinal and Renal Systems

(Part 1)
1. Identify the structures and function of the gastrointestinal

and renal systems;
2. Identify the four quadrants and the organs in each
quadrant; References: Bates’ Nursing Guide to Physical
3. Collect an accurate health history of the GI and renal Examination and History Taking (Second Edition)
systems; by Beth Hogan-Quigley, Mary Louise Palm, and
4. Describe the physical examination techniques and the Lynn Bickley.
order performed to evaluate the GI and renal systems.

THE FOUR QUADRANTS OF THE ABDOMEN
The Right Upper Quadrant:
 In the right upper quadrant, the soft consistency of the liver makes it difficult to feel through the abdominal wall.
The lower margin of the liver, the liver edge, is often palpable at the right costal margin.
 The gallbladder, which rests against the inferior surface of the liver, and the more deeply lying duodenum are
generally not palpable.
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 At a deeper level, the lower pole of the right kidneymay be felt, especially in thin people with relaxed abdominal
muscles. Moving medially, the examiner encounters the rib cage, which protects the stomach; the xiphoid process
lies in the midline.
 The abdominal aortaoften has visible pulsations and is usually palpable in the upper abdomen.
The Left Upper Quadrant:

 In the left upper quadrant, the spleenis lateral to and behind the stomach, just above the left kidney in the left
midaxillary line. Its upper margin rests against the dome of the diaphragm.
 The 9th, 10th, and 11th ribs protect most of the spleen. The tip of the spleen may be palpable below the left costal
margin in a small percentage of adults.
 The pancreasin healthy people escapes detection.
The Left Lower Quadrant:

 In the left lower quadrant, the firm, narrow, tubular sigmoidcolonis often felt and portions of the transverse and
descending colon may also be palpable.
The Right Lower Quadrant
 In the lower midline the bladdermay be palpated. In the right lower quadrantare bowel loops and the appendix
at the tail of the cecum near the junction of the small and large intestines. In healthy people, there will be no
palpable findings.
The Urinary Bladder
 A distended bladdermay be palpable above the symphysis pubis. The bladder accommodates roughly 300 ml of
urine filtered by the kidneys into the renal pelvis and the ureters. Bladder expansion stimulates contraction of
bladder smooth muscle, the detrusor muscle,at relatively low pressures.
 Rising pressure in the bladder triggers the conscious urge to void.
The Kidneys
 The kidneysare posterior organs. The ribs protect their upper portions.
 The costovertebral angle—the angle formed by the lower border of the 12th rib and the transverse processes of
the upper lumbar vertebrae—defines the region to assess for kidney tenderness (flank area).
THE HEALTH HISTORY
Gastrointestinal: Urinary and Renal:

 Suprapubic pain
 Abdominal pain, acute and chronic  Dysuria, urgency, or frequency
 Indigestion, nausea, vomiting including blood,  Hesitancy, decreased stream in males
loss of appetite, early satiety  Polyuria or nocturia
 Dysphagia and/or odynophagia  Urinary incontinence
 Change in bowel function  Hematuria
 Diarrhea, constipation  Kidney or flank pain
 Jaundice  Ureteral colic
Patterns and Mechanisms of Abdominal Pain
Visceral Pain:
 Visceral painoccurs when hollow abdominal organs such as the intestine or biliary tree contract unusually
forcefully or are distended or stretched.
Parietal Pain:
 Parietal painoriginates from inflammation in the parietal peritoneum. It is a steady, aching pain that is usually
more severe than visceral pain and more precisely localized over the involved structure.
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Referred Pain:
 Referred pain is felt in more distant sites, which are innervated at approximately the same spinal levels as the
disordered structures.
 Referred pain often develops as the initial pain becomes more intense and thus seems to radiate or travel from
the initial site. It may be felt superficially or deeply but is usually well localized.
History of Abdominal Pain or Discomfort:

 Onset: First determine the timing of the pain. Is it acute or chronic? Acute abdominal pain has many patterns. Did
the pain start suddenly or gradually? When did it begin?
 Location: Then ask the patient to point to the pain. Patients are not always clear when they try to describe in
words where pain is most intense. The quadrant where the pain is located can be helpful. Often underlying organs
are involved. If clothes interfere, repeat the question during the physical examination.
 Duration: How long does it last? What is its pattern over a 24-hour period? Over weeks or months? Are you
dealing with an acute illness or a chronic and recurring one?
 Characteristic Symptoms: Ask patients to describe the pain in their own words. Pursue important details: “Where
does the pain start?” “Does it radiate or travel anywhere?” “What is the pain like?”
 If the patient has trouble describing the pain, try offering several choices:
 “Is it aching, burning, gnawing . . . ?”

 Ask the patient to rank the severity of the pain on a scale of 1 to 10. Note that severity does not always
help you to identify the cause. Sensitivity to abdominal pain varies widely and tends to diminish in older
patients, masking acute abdominal conditions. Pain threshold and how patients accommodate to pain
during daily activities also affect ratings of severity.
 Associated Manifestations: Ask the patient if he or she is experiencing any other symptoms (e.g., nausea,
vomiting, or indigestion).
 Relieving Factors: As you probe factors that aggravate or relieve the pain, pay special attention to any association
with meals, alcohol, medications (including aspirin and aspirin-like drugs and any over-thecounter medications),
stress, body position, and use of antacids. Ask if indigestion or discomfort is related to exertion and relieved by
rest.
 Treatment: Determine what remedies the patient has tried and the results of each.

Multiple Choice
1. A patient being admitted is complaining of right upper quadrant pain. Upon ultrasonography, the physician has
diagnosed the patient to have cholecystitis. Which of the following best describes this disease?
a. Inflammation of the liver
b. Inflammation of the pancreas
c. Inflammation of the stomach
d. Inflammation of the gallbladder
ANSWER:
RATIONALE:
2. Nurse Mito is admitting a patient who has right lower quadrant pain of the abdomen. Upon palpation of the right
lower quadrant, the nurse has observed for rebound tenderness. This may be an indication of which of the
following conditions?
a. Appendicitis
b. Pancreatitis
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c. Gastritis
d. Gastroenteritis
ANSWER:
RATIONALE:
3. Which of the following is NOT true with regard to visceral pain?

a. It originates from inflammation in the parietal peritoneum
b. It occurs when hollow abdominal organs such as the intestine contract unusually or forcefully
c. It may be difficult to localize
d. It is typically palpable near the midline
ANSWER:
RATIONALE:
4. A patient named Erina is experiencing pain from the stomach brought about by hyperacidity. Which region of the
abdomen will this type of pain be felt at?
a. Hypogastric
b. Umbilical
c. Epigastric
d. Right iliac
ANSWER:
RATIONALE:
5. In early acute appendicitis, the initial complaint of abdominal pain is usually felt at
a. Right hypochondriac
b. Left hypochondriac
c. Epigastric
d. Umbilical
ANSWER:
RATIONALE:
6. A patient named Soma is currently experiencing pain at the costovertebral angle or the flank area. The nurse
must know that the pain is originating from which of the following organs?
a. Uterus
b. Kidneys
c. Stomach
d. Liver
ANSWER:
RATIONALE:
7. The nurse must ask which following questions when the patient is experiencing abdominal pain?
a. “Where does the pain start?”
b. “Does it radiate or travel anywhere?”
c. “Does the pain have an aching, burning, or gnawing quality?”
d. All of the above
ANSWER:
RATIONALE:
8. Which of the following microorganisms can cause the patient to suffer from peptic ulcer disease?
a. Escherichia coli
b. Helicobacter pylori
c. Staphylococcus aureus
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ANSWER:
RATIONALE:.
9. Which of the following diseases does NOT cause the patient to have chronic upper abdominal pain?
a. Dyspepsia
b. Peptic ulcer disease
c. Gastroesophageal reflux disease
d. Acute cholecystitis
ANSWER:
RATIONALE:
10. Which of the following foods can aggravate the occurrence of heartburn?
a. Toast
b. Coffee
c. Rice
d. Apple
ANSWER:
RATIONALE:
CAT 3-2-1
*All these must be done giving importance to social, distancing, hygienic practices, and wearing of mask at all times.
5 of 5
Session # 17
LESSON TITLE: The Gastrointestinal and Renal Systems

(Part 2)
1. Identify the structures and function of the gastrointestinal

and renal systems;
2. Identify the four quadrants and the organs in each
quadrant; References: Bates’ Nursing Guide to Physical
3. Collect an accurate health history of the GI and renal Examination and History Taking (Second Edition)
systems; by Beth Hogan-Quigley, Mary Louise Palm, and
4. Describe the physical examination techniques and the Lynn Bickley.
order performed to evaluate the GI and renal systems.

The Urinary Tract (The students will review about the anatomy and physiologic of the urinary system from their
anatomy book)
Suprapubic Pain
 Disorders in the urinary tract may cause pain in either the abdomen or the back. Bladder disorders may cause
suprapubic pain. In bladder infection, pain in the lower abdomen is typically dull and pressure-like.
 In sudden overdistention of the bladder, pain is often agonizing; in contrast, chronic bladder distention is usually
painless.
 Pain of sudden overdistention accompanies acute urinary retention.
Dysuria, Urgency, or Frequency

 Infection or irritation of either the bladder or urethra often provokes several symptoms. Frequently there is pain on
urination, usually felt as a burning sensation. Some clinicians refer to this as dysuria, whereas others reserve the
term dysuria for difficulty voiding.
 Women may report internal urethral discomfort, sometimes described as a pressure or an external burning from
the flow of urine across irritated or inflamed labia. Men typically feel a burning sensation proximal to the glans
penis. In contrast, prostatic pain is felt in the perineum and occasionally in the rectum.
 Painful urination accompanies cystitis or urethritis.
 If dysuria, consider bladder stones, foreign bodies, tumors; also acute prostatitis. In women, internal burning
occurs in urethritis, and external burning in vulvovaginitis.
 Urinary urgency is an unusually intense and immediate desire to void, sometimes leading to involuntary voiding or
urge incontinence.
 Urinary frequency, or abnormally frequent voiding, may occur. Ask about any related fever or chills, blood in the
urine, or any pain in the abdomen, flank, or back. Men with partial obstruction to urinary outflow often report
hesitancy in starting the urine stream, straining to void, reduced caliber and force of the urinary stream, or
dribbling as voiding is completed.
 Urgency suggests bladder infection or irritation. In men, painful urination without frequency or urgency suggests
urethritis.
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Polyuria and Nocturia
 Polyuria refers to a significant increase in 24-hour urine volume, roughly defined as exceeding 3 liters. It should
be distinguished from urinary frequency, which can involve voiding in high amounts, seen in polyuria, or in small
amounts, as in infection.
 Nocturia refers to urinary frequency at night, sometimes defined as awakening the patient more than once; urine
volumes may be large or small. Clarify the patient’s daily fluid intake.
Urinary Incontinence
 Up to 30% of older patients are concerned about urinary incontinence, an involuntary loss of urine that may
become socially embarrassing or cause problems with hygiene. If the patient reports incontinence, ask:
 When does it happen? How often?
 Do you leak small amounts of urine with increased intra-abdominal
 pressure from coughing, sneezing, laughing, or lifting?
 Is it difficult to hold the urine once there is an urge to void?
 Is a large amount of urine lost?
 Is there a sensation of bladder fullness? Frequent leakage?
 Do you void small amounts of urine but have difficulty emptying the bladder?
Stress Incontinence
 Stress incontinence with increased intra-abdominal pressure suggests decreased contractility of urethral sphincter
or poor support of bladder neck; urge incontinence, if unable to hold the urine, suggests detrusor overactivity;
overflow incontinence, when the bladder cannot be emptied until bladder pressure exceeds urethral pressure,
indicates anatomic obstruction by prostatic hypertrophy or stricture, or neurogenic abnormalities.
Functional Incontinence:
 Functional incontinence may arise from impaired cognition, musculoskeletal problems, or immobility.
Hematuria
 Blood in the urine, or hematuria, is an important cause for concern. When visible to the naked eye, it is called
gross hematuria. The urine may appear frankly bloody.
 Blood may be detected only during microscopic urinalysis, known as microscopic hematuria. Smaller amounts of
blood may tinge the urine with a pinkish or brownish cast.
 In women, be sure to distinguish menstrual blood from hematuria. If the urine is reddish, ask about ingestion of
beets or medications that might discolor the urine.
 Test the urine with a dipstick and microscopic examination before you settle on the term hematuria.
Kidney or Flank Pain; Ureteral Pain

 Disorders of the urinary tract may also cause kidney pain, often reported as flank pain, which is on the side of the
body between the upper abdomen and the back. It may radiate anteriorly toward the umbilicus.
 Kidney pain is a visceral pain usually produced by distention of the renal capsule and typically dull, aching, and
steady. Kidney pain, fever, and chills occur in acute pyelonephritis.
 Ureteral pain is dramatically different. It is usually severe and colicky, originating at the costovertebral angle and
radiating around the trunk into the lower quadrant of the abdomen, or possibly into the upper thigh and testicle or
labium. Ureteral pain results from sudden distention of the ureter and associated distention of the renal pelvis.
Ask about any associated fever, chills, or hematuria.
 Renal or ureteral colic is caused by sudden obstruction of a ureter, for example, from urinary stones or blood
clots.
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Multiple Choice
1. Patients with bladder disorders may cause pain to occur in which of the following areas
a. Left iliac
b. Right iliac
c. Flank area
d. Suprapubic area
ANSWER:
RATIONALE:
2. In men experiencing prostatic pain the pain may be felt

a. Proximal to the glans penis
b. At the perineum
c. At the suprapubic area
d. Distal to the glans penis
ANSWER:
RATIONALE:
3. Pain associated with a urinary tract infection in a patient is often described as

a. Gnawing pain
b. Stabbing pain
c. Burning pain
d. Searing pain
ANSWER:
RATIONALE: .
4. Usually men who have a urinary tract infection is also suspected to have which of the following coexisting
disease?
a. Prostate cancer
b. Kidney stones
c. Sexually transmitted infection
d. Kidney failure
ANSWER:
RATIONALE:
5. Which of the following beverages is related to having urinary frequency in a patient?

a. Milk
b. Orange juice
c. Smoothies
d. Coffee
ANSWER:
RATIONALE:
6. In men, painful urination without frequency or urgency strongly suggests of which of the following urinary
conditions?
a. Nephritis
b. Urethritis
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c. Uteritis
d. Cystitis
ANSWER:
RATIONALE:
7. Polyuria refers to a significant increase in 24-hour urine volume which usually exceeds
a. 3 liters
b. 0.8 liter
c. 1.5 liters
d. 2 liters
ANSWER:
RATIONALE: .
8. Which of the following cardiovascular diseases can cause the patient to suffer from nocturia or increased
urination at night?
a. Angina pectoris
b. Coronary artery disease
c. Hypertension
d. Heart failure
ANSWER:
RATIONALE:
9. Urinary incontinence may be experienced by patients during which of the following situations?
a. Coughing
b. Sneezing
c. Laughing
d. All of the above
ANSWER:
RATIONALE:
10. Which of the following best describes ureteral pain?

a. It is a visceral pain that is typically dull, aching, and steady.
b. It is usually severe and colicky, originating at the costovertebral angle and radiating around the trunk into
the lower quadrant of the abdomen, or possibly into the upper thigh and testicle or labium.
c. It is the pain felt on the side of the body between the upper abdomen and the back. It may radiate
anteriorly toward the umbilicus.
d. It is pain that is felt in the perineum and occasionally in the rectum.
ANSWER:
RATIONALE:
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Wrapping Up- Student Reflection:

1. Using 1 whole sheet of paper, your instructor will ask the you to write some key things they were able to get from this
Session and will explain why.
2. After completion of the task, the instructor will randomly call 3-5 representatives from the class to share their input.
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Session # 18
LESSON TITLE: The Breasts and the Axillae

LEARNING OUTCOMES:
1. Identify the structures and function of the breasts and

Materials:
axillae;
2. Describe the physical examination techniques performed Book, pen and notebook, index card/class list
to evaluate the breasts and axillae;
3. Perform an accurate health history of the breasts and
axillae;
4. Demonstrate how to perform a clinical breast examination;
5. Document a complete breast and axilla assessment References: Bates’ Nursing Guide to Physical
utilizing information from the health history and the Examination and History Taking (Second Edition)
physical examination by Beth Hogan-Quigley, Mary Louise Palm, and
6. Determine the measures for prevention or early detection Lynn Bickley.
of breast cancer.

THE HEALTH HISTORY
Lump or Mass
Have you ever felt a breast or axillary lump?
Below are samples of questions to ask patients if there are positive findings:
Onset: When did you first notice the lump?
Location: In which breast is the lump? Where on the breast?
Duration: Does the lump remain at all times or does it come and go?
If it comes and goes, when is it present and when does it disappear?
Characteristic Symptoms: What does the lump feel like?
Are there multiple lumps or one distinct lump?
Associated Manifestations: What else happens when the lump is present:
Pain?
Discharge?
Menstruation?
Relieving Factors: Does anything make it go away? Hurt less if there is pain?
Treatment: Have you done anything about the lump to make
Pain or Discomfort
Onset: Do you ever have breast pain/discomfort? When do you have pain/discomfort?
Location: Where do you have pain/discomfort?
Duration: Does it come and go or is it constant?
Characteristic Symptoms: Describe the pain/discomfort.
Associated Manifestations: What else happens with the pain/discomfort?
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Relieving Factors: What have you done to make the pain/discomfort feel better?
Treatment: Have you done anything to treat the pain?
There are many questions related to the breast and use of the OLD CART mnemonic ensures all areas of
questioning are covered.
Change in Shape
Have you noticed any change in the shape of your breast?
When did you notice a change in the shape?
Where is the change? Which breast?
When did this occur?
What else happened at this time?
Can you associate anything else with this?
How are you coping with/treating this?
Discharge
Have you ever had nipple discharge?
When does the discharge occur?
In which breast does it occur, or is it both?
How long does the discharge last?
What is the color of the discharge? Consistency? Amount? Is there an odor?
What is associated with the discharge?
How do you deal with this?
Galactorrhea, or the inappropriate discharge of milk-containing fluid, is abnormal if it occurs 6 or more months
after childbirth or cessation of breast-feeding.
Edema
Have you noticed any breast edema?
When does the edema occur?
Where does it occur? Which breast? Which quadrant?
How long does it last?
Is it painful?
What is the color of the breast?
What else occurs?
What do you do to relieve the swelling?
Rashes or Scaling
Have you noticed any rashes? Scaling? (Scaling consists of thin flakes of keratinized epithelium.)
When did this begin?
Where did this begin?
How long has it been going on?
Besides the rash/scaling of the skin, what else is happening?
Does it hurt?
What do you do to relieve the rash/scaling?
Dimpling
Have you noticed dimpling (small indents) of the breast tissue?
When did this begin?
In which breast did this begin?
How long has it been going on? Is it constant?
Are there any other symptoms occurring at this time?
Do you associate anything with this?
Are you treating this?
Retraction
Have you ever had nipple retraction?
When did the retraction occur?
Which nipple is retracted?
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How long does it occur for? Does it evert at any time? When?
What happens when the nipple retracts?
Does anything else occur during the retraction?
Do you do anything to protract the nipple?
Nipple retraction is when the nipple is pulled inward. This is not an issue if the breast has had an inverted nipple
since birth; however, it is noteworthy if this is a change as it could be an indicator of breast cancer or adhesions
below the skin surface.
HEALTH PROMOTION AND COUNSELING
Palpable Masses of the Breast and Breast Symptoms:
 Breast cancer occurs in up to 4% of women with breast complaints, in approximately 5% of women reporting a
nipple discharge, and in up to 11% of women specifically complaining of a breast lump or mass.
 Breast masses show marked variation in etiology, from fibroadenomas and cysts seen in younger women, to
abscess or mastitis, to primary breast cancer.
 On initial assessment, the woman’s age and physical characteristics of the mass provide clues about its etiology.
All breast masses require careful assessment.
 Nurses are the advocates and help navigate the complex health care system. Nurses assist patients to follow up
for accurate diagnosis and treatment.
Assessing Risk of Breast Cancer
 Breast cancer is the second leading cause of cancer death in women, with highest mortality rates in women 35
years or younger and older than 75 years.
 Declines in new cases of invasive breast cancer. The number of new cases of invasive breast cancer has been
falling since 2000, explained by two main factors: decreased mammography screening, which leads to
underdiagnosis or delayed diagnosis rather than a true decrease in disease incidence, and decreased use of
HRT.
 Earlier and more advanced breast cancer in African-American women.
 Breast cancer is the most commonly diagnosed cancer among African American women.
Benign Breast Disorders

 Mammograms are resulting in increasing numbers of breast biopsies, and clinicians should now understand the
effects of benign breast disease on risk for later breast cancer. Within a decade of starting annual screening, 20%
of women have had a breast biopsy.
 Breast lesions are believed to evolve in somewhat linear fashion from usual ductal hyperplasia, or unfolded
lobules, to atypical hyperplasia, to the pathologic stages of ductal carcinoma in situ (DCIS) and invasive cancer.
These disorders are now classified by degree of cellular proliferation on biopsy and degree of risk for breast
cancer.
Breast Density
 Mammographic breast density has been identified as “the most undervalued and underused risk factor” in studies
of breast cancer. It is a strong independent risk factor even after adjusting for the effects of other risk factors, and
it has the important attribute of “being present in the tissue from which the cancer arises.”

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Multiple Choice
1. Cysts can occur in women who are

a. Ages 15-25, usually puberty and young adulthood, but up to age 55
b. Ages 30-50, regress after menopause except with estrogen
c. Ages 30-90, most common over age 50
d. Ages 0-14, during the childhood stage
ANSWER:
RATIONALE:
2. Retractions seen on breasts of females can be present in which of the following conditions?
a. Fibroadenoma
b. Cysts
c. Adenocarcinoma
d. Cancer
ANSWER:
RATIONALE:
3. When palpating for the shape of the breast mass in patients with breast cancer, the nurse must observe for which
of the following?
a. Round, disc-like, or lobular
b. Round only
c. Irregular or stellate
ANSWER:
RATIONALE:
4. The nurse assessing the breast of a patient has observed for peau d’orange on the lower portion of the patient’s
breast. This is indicative of which of the following?
a. Edema
b. Paget disease of the nibble
c. Breast cancer
d. Fibroadenoma
ANSWER:
RATIONALE:
5. Which of the following is NOT a risk for breast cancer?

a. Age of 65 years and above
b. Two or more first-degree relatives with breast cancer diagnosed at an early age
c. High breast tissue density
d. Low breast tissue density
ANSWER:
RATIONALE:
6. In identifying women at risk for BRCA1 or 2 mutation the doctor must establish which of the following risk factors?
a. First-degree relative with a known BRCA1 or 2 mutation
b. 2 or more relatives with a diagnosis of breast cancer before age 50
c. 2 or more relatives with a diagnosis of ovarian cancer
d. All of the above
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ANSWER:
RATIONALE:
7. The histology results of a patient who is suspected to have breast cancer came back as having atypical lobular
hyperplasia. How is the result interpreted?
a. No increased risk
b. Small increased risk
c. Moderate increased risk
d. High increased risk
ANSWER:
RATIONALE:
8. The nurse must teach a female patient to do monthly breast self-examination at around
a. 5-7 days after the onset of menses
b. During the ovulation day
c. 14 days after the onset of menses
d. At the start of menses
ANSWER:
RATIONALE:
9. Which of the following is a modifiable risk factor in the development of breast cancer?
a. Height (tall)
b. Alcohol consumption
c. Jewish heritage
d. Personal history of endometrium, ovary, or colon cancer
ANSWER:
RATIONALE:
10. The recommended age for mammography in order to detect breast cancer in women who are asymptomatic
should be at around
a. 40 to 50 years
b. 30 to 40 years
c. Above 50
d. Below 30
ANSWER:
RATIONALE:
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CAT 3-2-1 / EXIT TICKET/PASS

1. Your instructor will instruct you to record three things you learned from the lesson.
2. You will record two things that you found interesting and that you like to learn more or if you still have something to be
clarified about the topic.
3. After answering the question, your instructor will station himself/herself at the door and collect the “exit pass” as you
depart from the room.
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Session # 19
LESSON TITLE: The Musculoskeletal System (Part 1)

1. Describe the structure and functions of the bones,

muscles, and joint;
2. Identify the key landmarks of each joint;
3. Obtain an accurate history of the musculoskeletal system; References: Bates’ Nursing Guide to Physical
4. Appropriately prepare and position the patient for the Examination and History Taking (Second Edition)
musculoskeletal examination; by Beth Hogan-Quigley, Mary Louise Palm, and
5. Describe the equipment necessary to perform a Lynn Bickley.
musculoskeletal examination.

ASSESSING THE MUSCULOSKELETAL SYSTEM
Overview
Musculoskeletal complaints and disorders are leading causes of health care visits in clinical practice. Since the
musculoskeletal system is enervated by the neurologic system, examinations of the two systems are closely aligned.
Indeed, these systems may be examined at the same time. Careful questioning during the history and acute observations
will help the nurse distinguish the cause of the patient’s symptoms.
Joint Structure and Function

 Articular structures include the joint capsule and articular cartilage, the synovium and synovial fluid, intra-
articular ligaments, and juxta-articular bone.
o Articular disease typically involves swelling and tenderness of the entire joint and limits both active and
passive range of motion.
 Extra-articular structures include periarticular ligaments, tendons, bursae, muscle, fascia, bone, nerve, and
overlying skin.
o Extra-articular disease typically involves selected regions of the joint and types of movement.
 Ligaments are rope-like bundles of collagen fibrils that connect bone to bone.
 Tendons are collagen fibers connecting muscle to bone. Another type of collagen matrix forms the cartilage that
overlies bony surfaces.
 Bursae are pouches of synovial fluid that cushion the movement of tendons and muscles over bone or other joint
structures.
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Types of Joint Articulation
Synovial Joints. The bones do not

touch each other, and the joint articulations
are freely movable. The bones are
covered by articular cartilage and separated
by a synovial cavity that cushions
joint movement, as shown. A synovial
membrane lines the synovial cavity and
secretes a small amount of viscous lubricating
fluid—the synovial fluid. The
membrane is attached at the margins of
the articular cartilage and pouched or
folded to accommodate joint movement.
Surrounding the synovial membrane
is a fibrous joint capsule, which is
strengthened by ligaments extending
from bone to bone.
Cartilaginous Joints. These joints,

such as those between vertebrae and the
symphysis pubis, are slightly movable.
Fibrocartilaginous discs separate the
bony surfaces. At the center of each disc
is the nucleus pulposus, fibrocartilaginous
material that serves as a cushion or shock
absorber between bony surfaces.
Fibrous Joints. In these joints, such as the

sutures of the skull, intervening layers of fibrous
tissue or cartilage hold the bones together. The
bones are almost in direct contact, which allows
no appreciable movement.
Structure of Synovial Joints
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Spheroidal jointshave a ball-and-socket configuration—a rounded, convex surface articulating with a cup-like cavity,
allowing a wide range of rotatory movement, as in the shoulder and hip.
Hinge jointsare flat, planar, or slightly curved, allowing only a gliding motion in a single plane, as in flexion and extension
of the digits.
In condylar joints, such as the knee, the articulating surfaces are convex or concave, termed condyles. One articulating
surface is convex and the matching surface is concave.
Bursae
Easing joint action are bursae, roughly disc-shaped synovial sacs that allow adjacent muscles or muscles and tendons to
glide over each other during movement. They lie between the skin and the convex surface of a bone or joint or in areas
where tendons or muscles rub against bone, ligaments, or other tendons or muscles.
Joint pain is one of the leading complaints of patients seeking health care. Joint pain may also be extra-articular,
involving bones, muscles, and tissues around the joint such as tendons, ligaments, bursae, or overlying skin.
 May be due to sprains from stretching or tearing of ligaments, muscle or tendon strain, bursitis, or tendinitis
 Pain in one joint suggests trauma, monoarticular arthritis, possible tendinitis, or bursitis. Lateral hip pain near the
greater trochanter suggests trochanteric bursitis.
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 Migratory pattern of spread in rheumatic fever or gonococcal arthritis; progressive additive pattern with symmetric
involvement in rheumatoid arthritis
 Extra-articular pain in inflammation of bursae (bursitis), tendons (tendinitis), or tendon sheaths (tenosynovitis);
also sprains from stretching or tearing of ligaments
Low Back Pain. Low back pain is the second most common reason for office visits. Using open-ended questions gives a
clearer picture of the problem, especially the location of the pain.
Elicit any ―red flags‖ for serious underlying systemic disease: age older than 50 years, history of cancer, unexplained
weight loss, pain lasting more than 1 month or not responding to treatment, pain at night or increased by rest, history of
intravenous drug use, or presence of infection.
 Approximately 85% of patients have idiopathic low back pain without a precise underlying cause (this term is
preferred to ―sprain‖ or ―strain‖).
 Midline back pain, suggests musculoligamentous injury, disc herniation, vertebral collapse, spinal cord
metastases, or rarely epiduralabscess. Pain off the midline, suggests sacroiliitis, trochanteric bursitis, sciatica, or
hip arthritis.
 Radicular gluteal and posterior leg pain in the S1 distribution in sciatica that increases with cough or Valsalva
maneuver. Leg pain that resolves with rest and/or lumbar forward flexion suggests spinalstenosis.
 Suspect Cauda equina syndrome from S2–4 midline disc or tumor ifbowel or bladder dysfunction (usuallyurinary
retention and overflowincontinence)
 In cases of low back pain plus a red flag, there is a 10% probability of serious systemic disease.
Neck Pain. Neck pain is also common. Although usually self-limited, it is important to ask about radiation into the
arm, arm or leg weakness or paresthesias, or change in bladder or bowel function. Be sure to elicit symptoms
related to the “red flags” listed above. Persisting pain after blunt trauma or a motor vehicle accident warrants
further evaluation.
 Radicular pain from spinal nerve compression, most commonly C7 followed by C6. Unlike low back pain, usually
from foraminal impingement from degenerative joint changes (70% to 75%) rather than disc herniation (20% to
25%)

Multiple Choice
1. This includes the periarticular ligaments, tendons, bursae, muscle, fascia, bone, nerve, and the overlying skin
a. Articular structures
b. Extra-articular structures
c. Ligaments
d. Tendons
ANSWER:
RATIONALE:
2. Example of fibrous joint are the

a. Knees
b. Shoulders
c. Vertebral bodies of the spine
d. Skull sutures
ANSWER:
RATIONALE:
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3. The extent of movement of cartilaginous joints are
a. Freely movable
b. Slightly moveable
c. Immovable
ANSWER:
RATIONALE:
4. This is the fibrocartilaginous material at the center of each vertebral disc that serves as a cushion or shock
absorber between bony surfaces
a. Vertebral body
b. Ligament
c. Nucleus pulposus
d. Hyaline
ANSWER:
RATIONALE:
5. Which of the following joints is an example of a spheroidal joint?

a. Hip joint
b. Shoulder joint
c. Elbow joint
d. Both a and b
ANSWER:
RATIONALE:
6. The knee is an example of a

a. Spheroidal joint
b. Hinge joint
c. Condylar joint
ANSWER:
RATIONALE: I.
7. Which of the following may have happened if the patient is currently experiencing calf wasting, weak ankle
dorsiflexion, absent ankle jerk, positive crossed straight-leg raise?
a. Osteoarthritis
b. Disc herniation
c. Rheumatoid arthritis
d. Hip joint dislocation
ANSWER:
RATIONALE:
8. Which of the following diseases can cause referred pain to the low back?
a. Peptic ulcer disease
b. Pancreatitis
c. Dissecting aortic aneurysm
d. All of the above
ANSWER:
RATIONALE:
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9. Which of the following is the nurse going to suspect if the client complains of lower back pain with associated
bladder and bowel dysfunction?
a. Bursitis
b. Sciatica
c. Herniated nucleus pulposus
d. Cauda equina syndrome
ANSWER:
RATIONALE:
10. 45% to 60% of cases with cervical radiculopathy have a compressed nerve root which is usually the
a. C7
b. C6
c. C5
d. C4
ANSWER:
RATIONALE: .
CAT 3-2-1
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Session # 20
LESSON TITLE: The Musculoskeletal System (Part 2)

LEARNING OUTCOMES:
Materials:
1. Inspect and palpate the joints, bones, and muscles;
2. Describe the range of motion of the major joints;
3. Assess muscle strength using the muscle strength grading
scale;
4. Correctly document the findings of the musculoskeletal References: Bates’ Nursing Guide to Physical
assessment; Examination and History Taking (Second Edition)
5. Discuss risk factors for osteoporosis and falls; by Beth Hogan-Quigley, Mary Louise Palm, and
reduce musculoskeletal injuries and disease

EXAMINATION OF JOINTS: ANATOMY AND PHYSIOLOGY AND PHYSICAL EXAMINATION
Important Areas of Examination for Each of the Major Joints:

 Inspection for joint symmetry, alignment, bony deformities
 Inspection and palpation of surrounding tissues for skin changes, nodules, muscle atrophy, crepitus
 Range of motion and maneuvers to test joint function and stability, and integrity of ligaments, tendons, bursae,
especially if pain or trauma
 Assessment of inflammation or arthritis, especially swelling, warmth, tenderness, redness
 Assessment of muscle strength
Tips for Successful Examination of the Musculoskeletal System:

 During inspection, look for symmetry of involvement. Is there a symmetric change in joints on both sides of the
body, or is the change only in one or two joints?
o Acute involvement of only one joint suggests trauma, septic arthritis, gout. Rheumatoid arthritis typically
involves several joints, symmetrically distributed.
 Use inspection and palpation to assess the surrounding tissues, noting skin changes, subcutaneous nodules, and
muscle atrophy. Note any crepitus, an audible or palpable crunching during movement of tendons or ligaments
over bone. This may occur in normal joints but is more significant when associated with symptoms or signs.
o Subcutaneous nodules in rheumatoid arthritis or rheumatic fever; effusions in trauma; crepitus over
inflamed joints, in osteoarthritis, or in inflamed tendon sheaths
 Test range of motion and maneuvers (described for each joint) to demonstrate limitations in range of motion or
joint instability from excess mobility of joint ligaments, called ligamentous laxity.
o Decreased range of motion in arthritis, inflammation of tissues around a joint, fibrosis in or around a joint,
or bony fixation (ankylosis). Ligamentous laxity of the anterior cruciate ligament (ACL) in knee trauma.
 Finally, test muscle strength to aid in the assessment of joint function. Be especially alert to signs of inflammation
and arthritis.
o Muscle atrophy or weakness in rheumatoid arthritis.
 Swelling. Palpable swelling may involve (1) the synovial membrane, which can feel boggy or doughy; (2) effusion
from excess synovial fluid within the joint space; or (3) soft-tissue structures such as bursae, tendons, and tendon
sheaths.
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o Palpable bogginess or doughiness of the synovial membrane indicates synovitis, which is often
accompanied by effusion. Palpable joint fluid in effusion, tenderness over the tendon sheaths in tendinitis
 Warmth. Use the backs of your fingers to compare the involved joint with its unaffected contralateral joint, or with
nearby tissues if both joints are involved. (Felt in arthritis, tendinitis, bursitis, and osteomyelitis)
 Tenderness. Try to identify the specific anatomic structure that is tender. Trauma may also cause tenderness.
o Tenderness and warmth over a thickened synovium suggest arthritis or infection.
 Redness. Redness of the overlying
o Redness over a tender joint suggests septic or gouty arthritis, or possible rheumatoid arthritis.
Muscle Bulk
 Begin the exam by inspecting the size and contours of muscles. Do the muscles look flat or concave, suggesting
atrophy? If so, is the process unilateral or bilateral? Is it proximal or distal?
o Muscular atrophy refers to a loss of muscle bulk, or wasting. It results from diseases of the peripheral
nervous system such as diabetic neuropathy, as well as diseases of the muscles themselves.
Hypertrophy is an increase in bulk with proportionate strength, whereas increased bulk with diminished
strength is called pseudohypertrophy (seen in the Duchenne form of musculardystrophy).
 When looking for atrophy, pay particular attention to the hands, shoulders, and thighs. The thenar and hypothenar
eminences should be full and convex, and the spaces between the metacarpals, where the dorsal interosseous
muscles lie, should be full or only slightly depressed. Atrophy of hand muscles may occur with normal aging,
however, as shown on the right below. Be alert for fasciculations in atrophic muscles. If absent tap on the muscle
with a reflex hammer to stimulate them.
o Flattening of the thenar and hypothenar eminences and furrowing between the metacarpals suggest
atrophy. Localized atrophy of the thenar and hypothenar eminences in median and ulnar nerve damage,
respectively.
o Other causes of muscular atrophy include motor neuron diseases, any disease that affects the peripheral
motor system projecting from the spinal cord, rheumatoid arthritis, and protein-calorie malnutrition.
Muscle Tone.
 When a normal muscle with an intact nerve supply is relaxed voluntarily, it maintains a slight residual tension
known as muscle tone. This can be assessed best by feeling the muscle’s resistance to passive
stretch. Persuade the patient to relax. Take one hand with yours and, while supporting the elbow, flex and extend
the patient’s fingers, wrist, and elbow, and put the shoulder through a moderate range of motion. With practice,
these actions can be combined into a single smooth movement. On each side, note muscle tone—the resistance
offered to your movements. Tense patients may show increased resistance. The feel of normal resistance is
learned with repeated practice.
o Decreased resistance suggests disease of the peripheral nervous system, cerebellar disease, or the
acute stages of spinal cord injury.
 If you suspect decreased resistance, hold the forearm and shake the hand loosely back and forth. Normally the
hand moves back and forth freely but is not completely floppy.
o Marked floppiness indicates muscle hypotonia or flaccidity, usually from a disorder of the peripheral motor
system.
 If resistance is increased, determine whether it varies as you move the limb or whether it persists throughout the
range of movement and in both directions, for example, during both flexion and extension. Feel for any jerkiness
in the resistance.
o Spasticity is increased resistance that worsens at the extremes of range. Spasticity, seen in central
corticospinal tract diseases, is rate dependent, increasing with rapid movement. Rigidity is increased
resistance throughout the range of movement and in both directions (not rate dependent).
 To assess muscle tone in the legs, support the patient’s thigh with one hand, grasp the foot with the other, and
flex and extend the patient’s knee and ankle on each side. Note the resistance to your movements.
Muscle Strength.
 People vary widely in their strength, and the assessment should allow for such variables as age, sex, and
muscular training. A person’s dominant side is usually slightly stronger than the other side. Keep this difference in
mind when comparing sides.
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o Impaired strength is called weakness, or paresis. Absence of strength is called paralysis, or plegia.
Hemiparesis refers to weakness of one half of the body; hemiplegia to paralysis of one half of the body.
Paraplegia means paralysis of the legs; quadriplegia, paralysis of all four limbs.
 Test muscle strength by asking the patient to move actively against your resistance or to resist your movement.
Remember that a muscle is strongest when shortest, and weakest when longest.
 If the muscles are too weak to overcome resistance, test them against gravity alone or with gravity eliminated.
When the forearm rests in a pronated position, for example, dorsiflexion at the wrist can be tested against gravity
alone. When the forearm is midway between pronation and supination, extension at the wrist can be tested with
gravity eliminated. Finally, if the patient fails to move the body part, watch or feel for weak muscular contraction.

Multiple Choice
1. Which of the following types of arthritis usually has high uric acid serum levels in the blood?
a. Gouty arthritis
b. Rheumatoid arthritis
c. Osteoarthritis
d. Any of the above
ANSWER:
RATIONALE:
2. Which of the following is the cause of rheumatoid arthritis in a patient?

a. Overweight or obese body
b. Increased intake of purine rich foods
c. Recent infection
d. Unknown
ANSWER:
RATIONALE:
3. Tenderness or warmth above a thickened synovium is indicative of which of the following?

a. Arthritis
b. Infection
c. Tendinitis
d. Both a and b
ANSWER:
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RATIONALE:
4. Which of the following conditions have progressive loss of cartilage within the joints causing damage to underlying
bone, and formation of new bone at the margins of the cartilage?
a. Rheumatoid arthritis
b. Osteoarthritis
c. Gouty arthritis
d. Fibromyalgia syndrome
ANSWER:
RATIONALE
5. Which of the following joints are affected in osteoarthritis?

a. Knees
b. Hips
c. Cervical and lumbar spine
d. All of the above
ANSWER:
RATIONALE:
6. Which of the following best describes the “swan neck” deformity seen in patients with rheumatoid arthritis?
a. Hyperextension of the proximal interphalangeal joints with fixed flexion of the distal interphalangeal joints.
b. Persistent flexion of the proximal interphalangeal joint with hyperextension of the distal interphalangeal
joint.
c. Knobby swellings around the joints ulcerate and contains discharges of white chalk-like urates.
d. It is a thickened plaque overlying the flexor tendon of the ring finger and possibly the little finger at the
level of the distal palmar crease.
ANSWER:
RATIONALE:
7. Which of the following finger abnormalities are seen in patients who have osteoarthritis or degenerative joint
disease?
a. Heberden’s nodes
b. Boutonniere deformity
c. Bouchard’s nodes
d. Both a and c
ANSWER:
RATIONALE:
8. Quadriplegia can occur due to injury to the

a. Cervical spine
b. Thoracic spine
c. Lumbar spine
d. Sacral spine
ANSWER:
RATIONALE:
9. When assessing for the muscle strength of a post-stroke patient, the nurse has noticed paralysis in the right half
of the body. The nurse must note this on her chart as
a. Paraplegia
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b. Quadriplegia
c. Hemiplegia
d. Hemiparesis
ANSWER:
RATIONALE:
10. The nurse is assessing the muscle strength of a patient who is post-stroke. The nurse has noticed a barely
detectable flicker or trace of contraction from the muscle. She must grade the patient’s muscle strength as
a. 0
b. 1
c. 2
d. 3
ANSWER:
RATIONALE:
Wrapping Up-Student Reflection

1. This time you are going to write 3 important things you learned from today’s session.
2. After you have completed the task, I will call 3-5 students to share and read out loud the things you have learned from
the session.
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Session # 21
LESSON TITLE: The Nervous System

LEARNING OUTCOMES:
1. Describe the structure and function of the nervous system; Book, pen and notebook, index card/class list
2. Obtain an accurate history of the neurologic system;
3. Identify the cranial nerves and the motor and sensory
functions;
4. Perform a screening neurologic examination;
5. Assess level of consciousness utilizing the Glasgow Coma References: Bates‟ Nursing Guide to Physical
Scale; Examination and History Taking (Second Edition)
6. Document the finding of the nervous system examination; by Beth Hogan-Quigley, Mary Louise Palm, and
reduce strokes.

THE HEALTH HISTORY
Two of the most common symptoms in neurologic disorders are headache and dizziness. Review the health history
pertinent to headaches.
Headache
 For headache, ask about onset, location, duration, severity and any associated symptoms such as visual
changes, weakness, or loss of sensation.
 Ask if the headache is affected by coughing, sneezing, or sudden movement of the head, which can increase
intracranial pressure.
o Subarachnoid hemorrhage may present as “the worst headache of my life.” Severe headache in
meningitis. Dull headache affected bythe actions listed, especially in thesame location, in mass lesions
suchas brain tumor or abscess
Dizziness or Vertigo.
 The complaint of dizziness can have many meanings. You will need to elicit exactly what the patient has
experienced.
o Light-headedness in palpitations, near syncope from vasovagal stimulation, low blood pressure, febrile
illness, and others. Vertigo in inner ear conditions, brainstem tumor.
o Diplopia, dysarthria, ataxia in vertebrobasilar transient ischemic attack (TIA) or stroke.
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Weakness
 What about any associated weakness, either generalized or in the face or a part of the body? Weakness is
another common symptom and requires careful attention to detail.
 Probe for exactly what it means to the patient. Explore whether there is paralysis, or inability to move a part or
side of the body.
o Weakness or paralysis in transient ischemic attack or stroke.
o Focal weakness may arise from ischemic, vascular, or mass lesions in the central nervous system; also
from peripheral nervous system disorders, neuromuscular disorders, or diseases in the muscles
themselves.
TYPES OF STROKE
 For weakness without light-headedness, try to distinguish between proximal and distal weakness.
o Bilateral proximal weakness in myopathy. Bilateral, predominantly distal weakness in polyneuropathy.

Weakness made worse with repeated effort and improved with rest suggests myasthenia gravis.
Loss of Sensation
 Find out if the patient has had any loss of sensation. Ask if there has been any numbness, but clarify its meaning
and location. Has there been loss of sensation, difficulty moving a limb, or altered sensations such as tingling or
pins and needles?
 There may be peculiar sensations without an obvious stimulus, called paresthesias. These occur commonly when
an arm or leg “goes to sleep” following compression of a nerve, and may be described as tingling, prickling, or
feelings of warmth, coldness, or pressure.
 Dysesthesias are distorted sensations in response to a stimulus and may last longer than the stimulus itself. For
example, a person may perceive a light touch or pinprick as a burning or tingling sensation that is irritating or
unpleasant.
 Pain may arise from neurologic causes but is usually reported with symptoms of other body systems, such as the
head and neck or the musculoskeletal system.
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o Loss of sensation, paresthesias, and dysesthesias in central lesions in the brain and spinal cord, as well
as disorders of peripheral sensory roots and nerves; paresthesias in the hands and around the mouth in
hyperventilation. Burning pain in painful sensory neuropathy.
Loss of Consciousness (Fainting)

 “Have you ever fainted or passed out?” leads the discussion to any loss of consciousness. Begin by exploring
what the patient means by loss of consciousness. Did the patient black out completely, or could voices be heard
throughout the episode, indicating some consciousness?
 Be sure to use descriptive terms carefully and precisely. Syncope is the sudden but temporary loss of
consciousness and postural tone that occurs with decreased blood flow to the brain, commonly described as
fainting.
 Symptoms of feeling faint, light-headed, or weak, but without actual loss of consciousness, are called near
syncope or presyncope.
o Young people with emotional stress and warning symptoms of flushing, warmth, or nausea may have
vasodepressor (or vasovagal) syncope of slow onset, slow offset. Cardiacsyncope from arrhythmias,
more common in older patients, often with sudden onset, sudden offset
Seizures
 A seizure is a paroxysmal disorder caused by sudden excessive electrical discharge in the cerebral cortex or its
underlying structures. Seizures can be of several types. Depending on the type, there may or may not be loss of
consciousness.
 With some types of seizures, there may be abnormal feelings, thought processes, and sensations, including
smells, as well as abnormal movements. Asking “Have you ever had any seizures or „spells‟?” . . . “Any fits or
convulsions?” can open the discussion.
o Tonic–clonic motor activity, bladder or bowel incontinence, and postictal state suggest a generalized
seizure. Unlike syncope, injury such as tongue biting or bruising of limbs may occur.
Tremors
 Tremors and other involuntary movements occur with or without additional neurologic manifestations. Ask about
any trembling, shakiness, or body movements that the patient seems unable to control.
 Distinct from these symptoms is an almost indescribable restlessness of the legs that typically develops at rest
and is accompanied by an urge to move about.Walking gives relief.

Multiple Choice
1. A patient is being admitted at the hospital states, “I am having the worst headache of my life!” The nurse must
report this immediately to the physician since the patient may have which of the following conditions?
a. Seizures
b. Subarachnoid hemorrhage
c. Increased intracranial pressure
d. Aneurysm
ANSWER:
RATIONALE:
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2. A patient at the emergency room is suspected to have stroke is experiencing oculomotor deficits with ataxia and
motor deficits. The knows must know that the area affected is at the
a. Anterior circulation – anterior cerebral artery
b. Anterior circulation – middle cerebral artery
c. Posterior circulation – brainstem, vertebral, or basilar artery branches
d. Posterior circulation – basilar artery
ANSWER:
RATIONALE:
3. A stroke patient is sent to the emergency department experiencing contralateral motor or sensory deficit without
cortical signs. The area affected is in the
a. Anterior circulation – middle cerebral artery
b. Subcortical circulation – lenticulostriate deep penetrating branches of the middle cerebral artery
c. Posterior circulation – posterior cerebral artery
ANSWER:
RATIONALE:
4. The nurse must know that blockage in the anterior circulation – middle cerebral artery can cause which of the
following signs and symptoms in a patient suffering from stroke?
a. Contralateral leg weakness
b. Contralateral field cut
c. Contralateral face, arm, increased leg weakness, sensory loss, vision field cut, aphasia, and apraxia.
d. Dysphagia, dysarthria, tongue/palate deviation and ataxia.
ANSWER:
RATIONALE:
5. A patient is complaining of tingling sensations in her hands and feet as though they are being pricked. The nurse
must note this on her chart as
a. Transient ischemic attack (TIA)
b. Dysesthesias
c. Paresthesias
d. Numbness
ANSWER:
RATIONALE:
6. When the patient faints due to a strong emotion such as fear or pain the nurse must note this on her chart as
having
a. Vasodepressor syncope
b. Postural hypotension
c. Micturition syncope
d. Cough syncope
ANSWER:
RATIONALE:
7. Which of the following best describes absence seizures?

a. The person loses consciousness suddenly and the body stiffens into tonic extensor rigidity. Breathing
stops and the patient becomes cyanotic. A clonic phase of rhythmic muscular contraction follows.
b. A sudden brief lapse of consciousness, with momentary blinking, staring or movements of the lips and
hands but no falling.
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c. Sudden, brief, rapid jerks, involving the trunk or limbs.
d. Sudden loss of consciousness with falling but no movements.
ANSWER:
RATIONALE:
8. A patient is exhibiting tonic and then clonic movements that start unilaterally in the hand, foot or face and spreads
to other parts of the body. The nurse must know that this type of seizure is
a. Complex partial seizure
b. Jacksonian seizure
c. Myoclonic seizure
d. Absent seizure
ANSWER:
RATIONALE:
9. Resting hand tremors and pill rolling are indicative of which of the following neurologic disorders?
a. Myasthenia gravis
b. Multiple sclerosis
c. Parkinson‟s disease
d. Amyotrophic lateral sclerosis
ANSWER:
RATIONALE:
10. This is a disease where weakness is made worse with repeated effort and improved with rest. This is brought
about by the destruction of the receptor sites for acetylcholine. These are describing
c. Muscle dystrophy
d. Guillain-Barre syndrome
ANSWER:
RATIONALE:
You are done with the session! Let‟s track your progress.
CAT 3-2-1
question, station yourself at the door and collect the paper as students depart from the room. Respond to students‟
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Session # 22
LESSON TITLE: The Reproductive System (Part 1)

LEARNING OUTCOMES:
1. Describe the anatomy and physiology of the female and Book, pen and notebook, index card/class list
male reproductive systems;
2. Conduct a focused interview to obtain patient history
pertinent to the reproductive system;
3. Discuss factors related to developmental, psychosocial,
cultural, and environmental areas that affect the References: Bates’ Nursing Guide to Physical
reproductive system; Examination and History Taking (Second Edition)
4. Accurately document subjective and objective data by Beth Hogan-Quigley, Mary Louise Palm, and
findings related to the reproductive system using the Lynn Bickley.
appropriate terminology.

THE HEALTH HISTORY
Common Concerns:
 There are three parts to a woman’s reproductive history: menstrual history, obstetric history, and sexual history. It
is usually more comfortable for the patient if the nurse begins with the menstrual and obstetric history and saves
the sexual history questions for last.
 However, if the woman comes to you relating to the issue. There are five phases of a woman’s reproductive
health: prepuberty (premenstruation), puberty (menarche), childbearing (menstruation), perimenopausal, and
menopausal.
 The nurse must incorporate the needs of each phase into the assessment process as appropriate for the
individual. When a woman reports a problem in the reproductive system, the “OLD CART” mnemonic may be
used to elicit a full history of the problem. If no problem is reported, obtain a baseline reproductive history starting
with the menstrual history.
Menstrual History
Menarche, Menstruation, Menopause
Learn to recognize patterns of menstrual flow, using the terms below.
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 Questions about menarche, menstruation, and menopause often give the nurse an opportunity to explore the
patient’s concerns and attitude toward her body.
 When talking with an adolescent girl, for example, opening questions might include: “How did you first learn about
monthly periods? How did you feel when they started? Many girls worry when their periods aren’t regular or come
late.
 Has anything like that bothered you?” You can explain that girls in the United States usually begin to menstruate
between the ages of 9 and 16 years, and often it takes 1 year or more before periods settle into a regular pattern.
 Age at menarche is variable, depending on genetic endowment, socioeconomic status, and nutrition.
o The dates of previous periods can signal possible pregnancy or menstrual irregularities. Unlike the normal
dark red menstrual discharge, excessive flow tends to be bright red and may include “clots” (not true fibrin
clots).
 Flow can be assessed roughly by the number of pads or tampons used daily. Because women vary in their
practices for sanitary measures, however, ask the patient whether she usually soaks a pad or tampon, spots it
lightly, etc.
 Further, does she use more than one at a time? Does she have any bleeding between periods? Any bleeding
after intercourse?
 Up to 50% of women report dysmenorrhea, or pain with menses.
o Primary dysmenorrhea results from increased prostaglandin production during the luteal phase of the
menstrual cycle, when estrogen and progesterone levels decline.
o Causes of secondary dysmenorrhea include endometriosis, adenomyosis (endometriosis in the muscular
layers of the uterus), pelvic inflammatory disease, and endometrial polyps.
Premenstrual syndrome (PMS) includes emotional and behavioral symptoms such as depression, angry outbursts,
irritability, anxiety, confusion, crying spells, sleep disturbance, poor concentration, and social withdrawal. Ask about signs
such as bloating and weight gain, swelling of the hands and feet, and generalized aches and pains. Criteria for diagnosis
are symptoms and signs in the 5 days prior to menses for at least three consecutive cycles, cessation of symptoms and
signs within 4 days after onset of menses, and interference with daily activities.
Amenorrhea refers to the absence of periods. Failure of periods to initiate is called primary amenorrhea, whereas the
cessation of periods after they have been established is termed secondary amenorrhea. Pregnancy, lactation, and
menopause are physiologic forms of the secondary type.
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o Other causes of secondary amenorrhea include low body weight fromany cause, including
malnutrition,anorexia nervosa, stress, chronicillness, or hypothalamic–pituitary–ovarian dysfunction.
Ask about any abnormal bleeding. The term abnormal uterine bleeding encompasses several patterns:
● Polymenorrhea, or intervals of fewer than 21 days between menses
● Oligomenorrhea, or infrequent bleeding
● Menorrhagia, or excessive flow
● Metrorrhagia, or intermenstrual bleeding
● Postcoital bleeding
o Causes vary by age group and include pregnancy, cervical or vaginal infection, cancer, cervical or
endometrial polyps or hyperplasia, fibroids, bleeding disorders, hormonal contraception or replacement
therapy. Postcoitalbleeding suggests cervical polyps or cancer, or in an older woman, atrophic vaginitis.
Menopause usually occurs between 48 and 55 years, following a period of fluctuation in pituitary secretion of follicle
stimulating hormone (FSH) and luteinizing hormone (LH) and ovarian function. If the patient is perimenopausal, with onset
of variable cycle length, ask about such vasomotor symptoms as hot flashes, flushing, and sweating. Sleep disturbances
are also common. After menopause, there may be vaginal dryness and dyspareunia, or painful intercourse; hair loss; and
mild hirsutism as the androgen-to-estrogen ratio increases. Urinary symptoms may also occur in the absence of infection
because of atrophy of the urethra and urinary trigone.
o Women may ask about many alternative compounds and botanicals for relief of menopause-related
symptoms. Most have not been well studied or proved to be beneficial. Estrogen replacement relieves
symptoms but increases risk of thrombosis.
o Postmenopausal bleeding in endometrial cancer, hormone replacement therapy, uterine and cervical polyps
Contraception. Inquire about methods of contraception used by the patient and her partner. Is the patient satisfied with
the method chosen? Are there any questions about the options available?
Vulvovaginal Symptoms. The most common vulvovaginal symptoms are vaginal discharge and local itching. Use the
“OLD CART” approach to obtain a thorough history. If the patient reports a discharge, inquire about its amount, color,
consistency, and odor. Ask about any local sores or lumps in the vulvar area. Are they painful or not? Because patients
vary in their understanding of anatomic terms, be prepared to try alternative phrasing such as “Any itching (or other
symptoms) near your vagina? . . . between your legs? . . . where you urinate?”
Sexual Preference and Sexual Response. Review the Tips for Taking the Sexual History below. Using neutral and
nonjudgmental questions, ask about your patient’s relationship status. If they are living (or have lived) with someone, ask
what their relationship is to that person, then follow up using the patient’s language. (Loss of a partner can sometimes be
determined by asking about who they have lived with in the past.) Direct questions about sexual orientation may be
difficult to answer. Patients with same-sex partners (or who have been in same-sex relationships) may be more anxious or
fearful during clinical encounters because of past experiences. A reassuring manner will help them express concerns
about their sexual health and activity.
o Sexual dysfunction is classified by the phase of sexual response. A woman may lack desire, she may fail to
become aroused and attain adequate vaginal lubrication, or, despite adequate arousal, she may be unable to
reach orgasm. Causes may include lack of estrogen, medical illness, or psychiatric conditions.
o Ask also about dyspareunia (pain or discomfort during intercourse). If present, try to localize the symptom. Is it
near the outside, occurring at the start of intercourse, or does she feel it farther in, when her partner is pushing
deeper? Vaginismus refers to an involuntary spasm of the muscles surrounding the vaginal orifice that makes
penetration during intercourse painful or impossible.
o Superficial pain suggests local inflammation, atrophic vaginitis, or inadequate lubrication; deeper
pain may be from pelvic disorders or pressure on a normal ovary. The cause of vaginismus may be physical or
psychological.
o In addition to ascertaining the nature of a sexual problem, ask about its onset, severity (persistent or sporadic),
setting, and factors, if any, that make it better or worse. What does the patient think is the cause of the problem,
what has she tried to do about it, and what does she hope for? The setting of sexual dysfunction is an important
but complicated topic, involving the patient’s general health; medications and drugs, including use of alcohol; her
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partner’s and her own knowledge of sexual practices and techniques; her attitudes, values, and fears; the
relationship and communication between partners; and the setting in which sexual activity takes place.
Sexually Transmitted Diseases. Local symptoms or findings on physical examination may raise the possibility of
sexually transmitted diseases (STDs). After establishing the usual attributes of any symptoms, identify sexual preference
(male, female, or both). Inquire about sexual contacts and establish the number of sexual partners in the prior month. Ask
if the patient has concerns about HIV infection, has been tested for HIV previously, desires HIV testing, or has current or
past partners at risk. Also ask about oral and anal sex and, if indicated, about symptoms involving the mouth, throat, anus,
and rectum. Review the past history of venereal disease. “Have you ever had herpes? . . . Any other problems such as
gonorrhea? . . . Syphilis? . . . Pelvic infections?” What does the patient/partner use to prevent STDs?

Multiple Choice
1. Primary dysmenorrhea results from prostaglandin production during which phase of the menstrual cycle?
a. Ischemic phase
b. Proliferative phase
c. Menstrual phase
d. Luteal phase
ANSWER:
RATIONALE:
2. This is known as the abnormal growth of endometrial tissue outside of the uterus
a. Salpingitis
b. Endometrial polyps
c. Endometriosis
d. Pelvic inflammatory disease
ANSWER:
RATIONALE:
3. Which of the following is NOT a sign of premenstrual syndrome?

a. Depression
b. Blurred vision
c. Angry outbursts
d. Sleep disturbances
ANSWER:
RATIONALE:
4. A patient comes to the nurse and complains of having an interval of 18 days between menses. The nurse must
note this her chart as
a. Oligomenorrhea
b. Menorrhagia
c. Polymenorrhea
d. Metrorrhagia
ANSWER:
RATIONALE:
5. Which of the following are the signs and symptoms of perimenopause?

a. Hot flashes
b. Flushing
c. Sleep disturbances
d. All of the above
ANSWER:
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RATIONALE:
6. Estrogen replacement is helpful in relieving the signs and symptoms of menopause but can increase the risk of
a. Thrombosis
b. Varicosities
c. Hypertension
d. Heart failure
ANSWER:
RATIONALE:
7. Certain women can experience sexual dysfunction such as inadequate vaginal lubrication despite adequate
arousal. Some women may not achieve orgasm. This is due to a lack in
a. Progesterone
b. Luteinizing hormone
c. Estrogen
d. Lactogen
ANSWER:
RATIONALE:
.
8. A woman complains of painful sexual intercourse with her husband. The nurse knows that the medical term for
this is known as
a. Vaginismus
b. Dyspareunia
c. Anorgasmia
d. Hypogonadism
ANSWER:
RATIONALE:
9. Which of the following best describes vaginismus?

a. Superficial pain that is suggestive of local inflammation of the vagina
b. Deep vaginal pain from pelvic disorders
c. Infection of the vagina
d. Involuntary spasm of the muscles surrounding the vaginal orifice that makes penetration during
intercourse painful or impossible
ANSWER:
RATIONALE:
.
10. Which of the following cannot cause a(n) sexually transmitted disease?
a. Human immunodeficiency virus
b. Neisseria gonorrheae
c. Treponema pallidum
d. Herpes zoster
ANSWER:
RATIONALE:
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CAT 3-2-1
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Session # 23
LESSON TITLE: The Reproductive System (Part 2)

LEARNING OUTCOMES:
1. Describe the anatomy and physiology of the female and Book, pen and notebook, index card/class list
male reproductive systems;
2. Conduct a focused interview to obtain patient history
pertinent to the reproductive system;
3. Discuss factors related to developmental, psychosocial,
cultural, and environmental areas that affect the References: Bates’ Nursing Guide to Physical
reproductive system; Examination and History Taking (Second Edition)
4. Accurately document subjective and objective data by Beth Hogan-Quigley, Mary Louise Palm, and
findings related to the reproductive system using the Lynn Bickley.
appropriate terminology.

THE HEALTH HISTORY
Sexual Preference and Sexual Response. Use neutral nonjudgmental questions about sexual orientation such as ―Are
you in a relationship?‖ or ―Tell me about your relationship. Do you prefer partners who are women, men, or both women
and men?‖
 Approximately 1 in 10 patients may have same-sex, bisexual, or transgender partner preferences. These patients
often
 experience significant anxiety during clinical encounters, related to fears of clinician acceptance, coexisting
mental health conditions, sparse information about complex issues of hormonal therapy, surgical alterations, or
transitions in gender identity.
 Lack of libido may arise from psychogenic causes such as depression, endocrine dysfunction, or side effects of
medications.
 Erectile dysfunction may be from psychogenic causes, especially if early morning erection is preserved; also from
decreased testosterone, decreased blood flow in the hypogastric arterial system, or impaired neural innervation.
 Premature ejaculation is common, especially in young men. Less common is reduced or absent ejaculation
affecting middle-aged or older men. Possible causes are medications, surgery, neurologic deficits, or lack of
androgen. Lack of orgasm with ejaculation is usually psychogenic.
Penile Discharge or Lesions. To assess the possibility of genital infection from STDs, ask: Have you had any discharge,
leaking, or dripping from your penis or staining on your underwear?
 Penile discharge may accompany gonococcal (usually yellow) and nongonococcal urethritis (may be clear or
white).
Because STDs may involve other parts of the body, additional questions are often indicated. An introductory explanation
may be useful. ―Sexually transmitted diseases can involve any body opening where you have sex. It’s important for you to
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tell me which openings you use.‖ And further, as needed, ―Do you have oral sex? Anal sex?‖ If the patient’s answers are
affirmative, ask about symptoms such as sore throat, diarrhea, rectal bleeding, anal itching or anal pain.
 Infections from oral–penile transmission include gonorrhea, chlamydia, syphilis, and herpes. Symptomatic or
asymptomatic proctitis may follow anal intercourse.
Scrotal Pain or Swelling. If the patient complains of pain or swelling in his scrotum, follow the ―OLD CART‖ mnemonic to
gather thorough information. A sudden onset of scrotal pain may indicate torsion of the testicle, which is an emergency. A
painless lump may be cancer. Ask if he performs self-testicular examination and how often.
Inguinal Pain or Swelling. Inguinal pain or swelling may indicate an inguinal hernia. These hernias may be unilateral or
bilateral. Ask the patient to point to the area of the pain and/or swelling and to describe it. ―When did it begin? Is the pain
continuous or intermittent? Achy or sharp? Does it occur with lifting heavy objects, standing, bending, or bearing down?‖
 Hernia pain and swelling are more likely to occur when internal abdominal pressure increases (e.g., when lifting).
Problems with Urination. The prostate gland wraps around the urethra. If the gland enlarges due to benign prostatic
hyperplasia (BPH) or cancer, the patient may experience urinary symptoms. Men older than 70 years are at greatest risk.
Testicular Self-Examination. The incidence of testicular cancer is low, about 5 per 100,000 men, but it is the most
common cancer of young men between the ages of 15 and 35. When detected early, testicular carcinoma has an
excellent prognosis. Risk factors include cryptorchidism, which confers a high risk for testicular carcinoma in the
undescended testicle; a history of carcinoma in the contralateral testicle; mumps orchitis; an inguinal hernia; or a
hydrocele in childhood. Encourage men, especially young men, to perform monthly testicular self-examinations and to
seek physician evaluation for the following findings: any painless lump, swelling, or enlargement in either testicle; pain or
discomfort in a testicle or the scrotum; a feeling of heaviness or a sudden fluid collection in the scrotum; or a dull ache in
the lower abdomen or the groin.
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Prostate Cancer. Excluding skin cancer prostate cancer is the leading cancer diagnosed in U.S. men, and the second
leading cause of death in men. Although lifetime risk of diagnosis is high (approximately 17%), biologic risk and mortality
are only approximately 3%. Age, ethnicity, and family history are the primary risk factors.
 Age. Risk of prostate cancer increases sharply with each advancing decade after 50 years. Probability of
diagnosis rises by age group, from 2.4% in men 40 to 59 years, to 6.5% in men 60 to 69 years, to 12.5% in men
70 years and older.30
 Ethnicity. For undetermined reasons, incidence rates are significantly higher in African-American men than in
Caucasian men: 232 cases per 100,000 compared with 146 cases per 100,000, even after adjustments for
access to care.30 Prostate cancer occurs at an earlier age and more advanced stage in African-American men.
 Family history. Approximately 15% of men diagnosed with prostate cancer have an affected first-degree
relative.32 One Scandinavian study of twins ascribed 42% of cases to inheritance.33 Rare autosomal dominant
alleles appear to contribute to early-onset prostate cancer, and several X-linked alleles are under investigation in
families with onset at older ages.34
 Diet. A series of studies suggests an association between intake of dietary fat, especially saturated fats and fats
from animal sources, and risk of prostate cancer. However, the evidence remains inconclusive. Other possible
influences include selenium, vitamins E and D, lycopene, and isoflavones.
The optimal approach to prostate cancer screening remains controversial. The U.S. Preventive Services Task Force in
2008 found insufficient evidence to recommend for or against routine screening using prostate-specificantigen (PSA)
testing or digital rectal examination (DRE), primarily because of mixed evidence that early detection improves health
outcomes. The American Cancer Society recommends combining DRE with testing for PSA beginning at 50 years, while
the American Urological Association recommends beginning screening at 40 years. Both recommend beginning screening
at 40 years for African-American men and men with a positive family history.
Men with symptoms of prostate disorders—incomplete emptying of the bladder, urinary frequency or urgency, weak or
intermittent stream or straining to initiate flow, hematuria, nocturia, or even bony pains in the pelvis—should be referred to
a urologist. Men may be reluctant to report such symptoms but should be encouraged to seek evaluation and treatment
early.

Multiple Choice
1. Nurse Sakura is observing for the penis of a male suspected to have a sexually transmitted infection. She has
observed for multiple cauliflower-like lesions on the patient’s penis. The nurse must suspect for which of the
following STDs?
a. Genital warts
b. Genital herpes simplex
c. Primary syphilis
d. Gonorrhea
ANSWER:
RATIONALE:
2. Which of the following best describes cryptorchidism?

a. The testicular length is usually less than or equal to 3.5 cm.
b. The testis is acutely inflamed, painful, tender, and swollen.
c. It usually appears as a painless nodule.
d. The testis is atrophied and may lie in the inguinal canal or the abdomen, resulting in an unfilled scrotum.
ANSWER:
RATIONALE:
.
3. The nurse has noticed an appearance of a small red papule that becomes a chancre or painless erosion on a
patient’s penis. The patient is diagnosed to have syphilis. The causative agent of this is
a. Neisseria gonorrheae
b. Treponema pallidum
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c. Human papilloma virus
d. Haemophilus ducreyi
ANSWER:
RATIONALE:
4. Which of the following best describes epispadias in a male?

a. A congenital displacement of the urethral meatus to the inferior surface of the penis.
b. A nontender, fluid-filled mass within the tunica vaginalis.
c. The urethral meatus is located on the top of the glans penis.
d. An indurated nodule or ulcer that is usually non-tender.
ANSWER:
RATIONALE:
5. Pain felt in the inguinal canal due to inguinal hernia is usually aggravated by
a. Eating
b. Urinating
c. Lifting heavy objects
d. Lying down
ANSWER:
RATIONALE:
6. Which of the following types of food can increase the risk of the development of prostate cancer in men?
a. Processed foods
b. Saturated fat
c. High sugar intake
d. Excessive intake of salt
ANSWER:
RATIONALE:
.
7. In teaching males on how to perform the testicular self-examination, the patient must be taught to do it
a. At night
b. In the morning
c. After a bowel movement
d. After having a warm bath or shower
ANSWER:
RATIONALE:
8. For an African-American male who has a positive family history of prostate cancer, the best time to have a
prostate-specific-antigen (PSA) testing and digital rectal examination (DRE) would be at
a. 30 to 40 years
b. 40 years and above
c. 50 years and above
d. Below 30 years
ANSWER:
RATIONALE:
9. Which of the following are signs and symptoms of prostate disorders?

a. Incomplete emptying of the bladder
b. Urinary frequency or urgency
c. Intermittent stream or straining to initiate flow
d. All of the above
ANSWER:
RATIONALE:
10. Vesicles that are 1-3 mm in size found on the glans or shaft of the penis is usually indicative of
a. Gonorrhea
b. Syphilis
c. Genital herpes
d. Chancroid
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ANSWER:
RATIONALE:
Muddiest Point
1. Each of them will write what was the least clear part on the day’s session.
2. The instructor should encourage each student to share their ideas and discuss them with their partners.
3. After each pair has completed the activity, the instructor will randomly call 3 to 5 pairs to share their inputs in the class.
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Multiple Choice
1. The labyrinth within the inner ear is responsible for which of the following?
a. Air conduction
b. Bone conduction
c. Equilibrium
d. Hearing
ANSWER: C
RATIONALE: The bony labyrinth contains the semicircular canals and the vestibule are responsible for our
equilibrium.
2. In conductive hearing loss the patient will most likely have problems in which of the following ear
structures?
a. Auricle
b. Tympanic membrane
c. Ossicles
d. All of the above
ANSWER: D
RATIONALE: Conductive hearing loss is caused by problems of the external to the middle ear structures.
All of the choices fall into the external and middle ear structures.
3. Otitis media is common among children below 5 years old since
a. Their immune system is not yet mature
b. The auditory canal is too short
c. Children often insert objects into their ears
d. The eustachian tube is short and more horizontal
ANSWER: D
RATIONALE: Children below 5 years old have a shorter and more horizontal eustachian tube. An upper
respiratory tract infection in a child can lead to otitis media since the microorganisms can easily travel
through the eustachian tube.
4. When tinnitus is present together with hearing loss and vertigo, this may suggest
a. Conductive hearing loss
b. Sensorineural hearing loss
c. Meniere’s disease
d. Otosclerosis
ANSWER: C
RATIONALE: These are the common signs and symptoms of Meniere’s Disease: hearing loss, vertigo, and
tinnitus. The cause is unknown but imbalances in sodium and water can precipitate this disease.
5. Which of the following causes of worsen symptoms of rhinorrhea due to excessive use of decongestants
a. Vasomotor rhinitis
b. Rhinitis medicamentosa
c. Allergic rhinitis
d. Hay fever
ANSWER: B
RATIONALE: Excessive usage of decongestants can have a rebound effect on the patient known as rhinitis
medicamentosa. We should advise the patient not to use decongestants for more than 7 days.
6. Which of the following beverages can cause nasal congestion in a patient if taken in excess?
a. Alcohol
b. Coffee
c. Milk
d. Carbonated drinks
ANSWER: A
RATIONALE: Alcohol has a natural vasodilatory effect in the skin (that's why you feel warm when you start
drinking), and that can also lead to short-term nasal congestion as the many blood vessels in your nasal
cavity expand.
7. Fever, pharyngeal exudates, and anterior lymphadenopathy, especially when cough is not present
can suggest an infection of which of the following microorganisms?
a. Corynebacterium diphtheriae
b. Filterable virus
c. Haemophilus influenzae
ANSWER: D
RATIONALE: The signs and symptoms are indicative of strep throat. The causative agent of this is
streptococcus pyogenes or also known as the Group A beta-hemolytic streptococcus which needs to be
treated by antibiotics.
8. Which of the following conditions does NOT cause hoarseness?
a. Smoking
b. Voice abuse
c. Increased intake of high-sodium foods
d. Tuberculosis
ANSWER: C
RATIONALE: The other choices can cause hoarseness but there is no evidence that intake of high-sodium
foods can lead to hoarseness of the voice.
9. The nurse has observed for a sore smooth tongue in a patient while doing a physical examination.
The nurse must suspect for
a. Streptococcal infection
b. Nutritional deficiencies
c. Gingivitis
d. Hypothyroidism
ANSWER: B
RATIONALE: A patient who has a sore smooth tongue has a nutritional deficiency known as iron-deficiency
anemia.
10. The patient with tumor growing on their larynx has stated to the nurse that she has difficulty in
swallowing. The nurse must note this on her chart as
a. Polydipsia
b. Polyphagia
c. Dysphagia
d. Odynophagia
ANSWER: C
RATIONALE: Dysphagia is difficulty of swallowing while polyphagia is intense hunger. Polydipsia is intense
thirst. Odynophagia on the other hand means painful swallowing.
Multiple Choice
1. Nurse Megumi is taking care of a patient who has pulmonary tuberculosis. During the inspection of
the patient’s sputum, she has noticed some blood streaks on it. This is termed as
a. Rhinitis
b. Rhinorrhea
c. Hematemesis
d. Hemoptysis
ANSWER: D
RATIONALE: Hemoptysis is the coughing up of blood or blood-stained mucus from the bronchi, larynx,
trachea, or lungs. In other words, it is the airway bleeding. This can occur with lung cancer, infections such
as tuberculosis, bronchitis, or pneumonia, and certain cardiovascular conditions.
2. During the history of present illness, a patient named Subaru is complaining of a dry cough for less
than 3 weeks. He is currently suspected for COVID-19. His cough can be categorized as
a. Acute cough
b. Subacute cough
c. Chronic cough
ANSWER: A
RATIONALE: An acute cough lasts < 3 weeks, subacute 3 to 8 weeks, and chronic > 8 weeks.
3. Nurse Alice is currently auscultating a 4-year old patient who is suffering from pneumonia. Upon
auscultation through her stethoscope she has heard a high-pitched inspiratory sound. She must
document this as
a. Wheezing
b. Stridor
c. Crackles
d. Rhonchi
ANSWER: B
RATIONALE: Stridor is a high-pitched sound that is usually heard best when a child breathes in
(inspiration). It is usually caused by an obstruction or narrowing in your child's upper airway.
4. Nurse Ikumi is currently admitting a patient who is complaining of shortness of breath and cough.
The nurse has noticed that the patient’s chest is barrel-shaped. According to the patient’s health history,
he has been a chronic smoker for the past 20 years and has been smoking 2-3 packs of cigarettes per
day. The nurse must suspect for which of the following diseases?
a. Asthma
b. Chronic obstructive pulmonary disease (COPD)
c. Cystic fibrosis
d. COVID-19
ANSWER: B
RATIONALE: COPD is a disease that is caused by long-term cigarette smoking. The other choices are not
associated with cigarette smoking.
5. Which of the following would best describe tactile fremitus?
a. These are popping sounds heard from the patient’s chest wall
b. It is a harsh and high-pitched inspiratory sound
c. These are palpable vibrations transmitted through the bronchopulmonary tree to the chest wall as the
patient is speaking
d. It is a high-pitched musical sound usually heard during expiration
ANSWER: C
RATIONALE: Tactile fremitus is an assessment of the low-frequency vibration of a patient's chest, which
is used as an indirect measure of the amount of air and density of tissue present within the lungs.
6. Nurse Hisako is assessing a patient with asthma. Which of the following breath sounds will she expect
to hear from this patient?
a. Stridor
b. Wheezing
c. Rhonchi
d. Vesicular
ANSWER: B
RATIONALE: Wheezing is one of the classic signs of asthma. This sound is heard when the bronchi of the
patient becomes constricted.
7. What type of cardiac disease does the patient have if the patient has the presence of crackles in the
lung area upon auscultation of the nurse?
a. Atherosclerosis
b. Right-sided heart failure
c. Aneurysm
d. Left-sided heart failure
ANSWER: D
RATIONALE: Left-sided heart failure has pulmonary clinical manifestations while right-sided heart failure
has systemic clinical manifestations.
8. This type of deformity of the thorax shows that the sternum is displaced anteriorly, increasing the
anteroposterior diameter. The costal cartilages adjacent to the protruding sternum are depressed.
a. Funnel chest
b. Flail chest
c. Pigeon chest
d. Barrel chest
ANSWER: C
RATIONALE: Pectus carinatum, also called pigeon chest, is a malformation of the chest characterized by a
protrusion of the sternum and ribs.
9. When Nurse Ryoko is percussing the patient’s lungs. A normal percussion note that the nurse must
percuss must be
a. Dull
b. Hyperresonant
c. Flat
d. Resonant
ANSWER: D
RATIONALE: Healthy lungs should sound resonant when the chest is percussed.
10. Nurse Satoshi has read on the patient’s chart that the patient has pleural effusion. Which of the
following is true with regard to this condition?
a. This is the inflammation of the pleurae
b. This is the air-trapping at the alveoli
c. This is fluid accumulating in the pleural space
d. This is also known as pulmonary edema
ANSWER: C
RATIONALE: Pleural effusion, sometimes referred to as “water on the lungs,” is the build-up of excess
fluid between the layers of the pleura outside the lungs. The pleura are thin membranes that line the
lungs and the inside of the chest cavity and act to lubricate and facilitate breathing.
Multiple Choice
1. Which of the following is NOT a main function of the cardiovascular system?
a. Delivering oxygen and nutrients to cells
b. Removing waste products
c. Maintaining perfusion to the organs and tissues
d. Regulate the blood glucose levels
ANSWER: D
RATIONALE: Regulating the blood glucose levels is one of the function of the endocrine system most
specifically the pancreas.
2. This is the area found on the exterior chest where the health worker examines in order to detect the
underlying structures of the heart
a. Precordium
b. Myocardium
c. Endocardium
d. Pericardium
ANSWER: A
RATIONALE: The area of the exterior chest that overlays the heart and great vessels is the precordium. It
is helpful to visualize the underlying structures of the heart as you examine the precordium.
3. Which of the following statements is true about the point of maximal impulse (PMI)?
a. It is found behind the right ventricle and to the left, outlined below in black, forms the left margin of
the heart.
b. This is located at the left border of the heart and is found in the 4th intercostal space 7-9 cm lateral to
the midsternal line.
c. Located at the right and left 2nd intercostal space next to the sternum.
d. It is found between the 2nd intercostal space and the 5th intercostal space.
ANSWER: B
RATIONALE: Letter A is describing the left ventricle of the heart. Letter C is describing the base of the
heart. While letter D is describing the precordium.
4. Which of the following layers of the heart contains cardiac muscle?
a. Pericardium
b. Precordium
c. Myocardium
d. Endocardium
ANSWER: C
RATIONALE: Whenever you see the prefix “myo- “this pertains to a muscle. The myocardium is the heart
muscle that does the pumping within the heart.
5. How much is the normal peak pressure of systole?
a. 70 mmHg
b. 80 mmHg
c. 100 mmHg
d. 120 mmHg
ANSWER: D
RATIONALE: Systole is the period of ventricular contraction. The pressure in the left ventricle rises from
less than 5 mmHg in its resting state to a normal peak of 120 mmHg.
6. A nursing student is asking her instructor about the definition of the stroke volume. The nursing
instructor is correct when she says which of the following definitions?
a. It is the amount of blood ejected by the ventricle with each heartbeat.
b. This is the difference between the systolic and diastolic blood pressure.
c. The amount of blood pumped by the heart in a minute.
d. The total number of heart beats in a minute.
ANSWER: A
RATIONALE: Letter B is defining pulse pressure. Letter C is defining cardiac output. Letter D is defining the
heart rate.
7. Cardiac output is the product of (Select all that apply)
a. Heart rate
b. Pulse pressure
c. Myocardial contractions
d. Stroke volume
ANSWER: A & D
RATIONALE: Cardiac output is the volume of blood ejected from each ventricle during a full minute, it is
the product of the heart rate and the stroke volume.
8. What best describes a preload?
a. This is the degree of vascular resistance to ventricular contraction
b. Sources of resistance to left ventricular contraction include the tone in the walls of the aorta and the
peripheral vascular tree.
c. Refers to the load that stretches the cardiac muscle before contraction.
d. The ability of the cardiac muscle, when given a load, to contract or shorten.
ANSWER: C
RATIONALE: Both A and B are describing after load while letter D is describing myocardial contractility.
9. Which of the following equipment are used in measuring the blood pressure? (Select all that apply)
a. Sphygmomanometer
b. Stethoscope
c. Watch
d. Ruler
ANSWER: A & B
RATIOANALE: The stethoscope is used to detect the Korotkoff sounds while the sphygmomanometer is
used to measure the systolic and diastolic pressures.
10. Which of the following structures can best estimate the jugular venous pressure?
a. Right external jugular vein
b. Right internal jugular vein
c. Left external jugular vein
d. Left internal jugular vein
ANSWER: B
RATIONALE: This structure has a more direct anatomic channel into the right atrium.
Multiple Choice
1. When assessing the amplitude and contour of the patient’s carotid pulse, Nurse Sakura must place
the patient in a
a. High Fowler’s position
b. Supine position
c. Head of the bed elevated to 30 degrees
d. Left Sim’s Position
ANSWER: C
RATIONALE: This is for easy visualization of the amplitude and contour of the carotid pulse. Other
positions will not yield the visibility of the carotid pulse.
2. What will happen if the nurse has accidentally pressed both carotid arteries at the same time while
assessing the patient’s neck?
a. Syncope
b. Hypertension
c. Stroke
d. Myocardial infarction
ANSWER: A
RATIONALE: Pressing both carotid arteries at the same time may decrease blood flow to the brain and
induce syncope or fainting.
3. What would be the characteristic of the pulse of a patient who is suffering from aortic insufficiency?
a. Slow, weak, and thready
b. Bounding pulse
c. Fast and bounding
d. Weak and almost unpalpable
ANSWER: B
RATIONALE: The condition causes widening (dilation) of the left lower chamber of the heart. Larger
amounts of blood leave the heart with each squeeze or contraction. This leads to a strong and forceful
pulse (bounding pulse).
4. The hepatojugular reflux is elicited by applying pressure on the patient’s abdomen. Which quadrant
will the nurse apply pressure on?
a. Right upper quadrant
b. Left upper quadrant
c. Right lower quadrant
d. Left lower quadrant
ANSWER: A
RATIONALE: The pressure is applied on the liver which is in the right upper quadrant to allow hepatic
venous blood into the vena cavae, thus elevating the venous blood volume and pressure.
5. When detecting the point of maximal impulse on the patient, the nurse must stand at the
a. Left side of the patient
b. Right side of the patient
c. Head of the patient
ANSWER: B
RATIONALE: Standing at the right side of the patient will enhance the detection of the PMI. If you turn
the patient to the left side and stand at the left side of the patient, you will be having a hard time
visualizing the PMI.
6. When assessing for any palpable thrills over the heart of the patient, Nurse Ikumi must use her
a. Fingerpads
b. Index and the middle finger
c. Thumb
d. Ball of her hand
ANSWER: D
RATIONALE: The ball of the hand (at the base of the fingers) is the most sensitive at detecting thrills. The
finger pads are more sensitive in detecting pulsations.
7. Which of the following conditions can exhibit thrills in a patient?
a. Aortic stenosis
b. Patent ductus arteriosus
c. Ventricular septal defect
d. All of the above
ANSWER: D
RATIONALE: All conditions can exhibit thrills. Aortic stenosis is the narrowing of the aortic valve, patent
ductus arteriosus is where the ductus arteriosus (fetal blood vessel) remains open, and ventricular septal
defect is a congenital heart disease where an abnormal opening is found in between the ventricles.
8. This is a condition where the internal organs from the thoracic and abdominal cavity are found on
the opposite sides from what is normal
a. Dextrocardia
b. Situs inversus
c. Congenital heart disease
d. Cardiomegaly
ANSWER: B
RATIONALE: Situs inversus (also called situs transversus or oppositus) is a congenital condition in which
the major visceral organs are reversed or mirrored from their normal positions. The normal arrangement
of internal organs is known as situs solitus.
9. The right ventricle of the heart can be palpated at the
a. Left 2nd intercostal space
b. Right 2nd intercostal space
c. Left 5th intercostal space
d. Lower left sternal border in the subxiphoid area
ANSWER: D
RATIONALE: Letter A is describing the location of the pulmonary artery, letter B is describing the location
of the aortic area, letter C is describing the apex of the heart.
10. When assessing the point of maximal impulse in a female patient, we tell the patient to do which of
the following?
a. Let the patient displace her left breast upward and laterally
b. Let the patient displace her left breast downward and medially
c. Let the patient displace her left breast upward
d. Let the patient displace her left breast laterally
ANSWER: A
RATIONALE: By doing this the nurse will have an easier time finding the PMI since the breast can impede
the assessment of the PMI.
Multiple Choice
1. This type of murmur starts immediately after S2, without a discernible gap, and then usually fades
into silence before the next S1
a. Midsystolic murmur
b. Early diastolic murmur
c. Late systolic murmur
d. Pansystolic murmur
ANSWER: B
RATIONALE: A midsystolic murmur begins after S1 and stops before s2, a late diastolic murmur starts late
in diastole and typically continues up to S1, while pansystolic murmur starts with S1 and stops at S2
without a gap between murmur and heart sounds.
2. Which of the following best describes a crescendo-decrescendo murmur?
a. It grows louder
b. It grows softer
c. It first rises in intensity, then falls.
d. It has the same intensity throughout.
ANSWER: C
RATIONALE: Letter A describe a crescendo murmur, letter B describes a decrescendo murmur, while letter
D describes a plateau murmur.
3. A nurse has noted that the murmur has a loud with palpable thrill. The nurse should grade this on
her chart as
a. Grade 1
b. Grade 2
c. Grade 3
d. Grade 4
ANSWER: D
RATIONALE: Grade 1 has very faint murmur, grade 2 has a quiet murmur but can be heard immediately
after placing the stethoscope on the chest, grade 3 is moderately loud.
4. The shape of a midsystolic murmur is a
a. Crescendo
b. Decrescendo
c. Crescendo-decrescendo
d. Plateau
ANSWER: C
RATIONALE: Letter A is seen in late diastolic murmurs, letter B is seen in both early diastolic and
middiastolic murmurs, while letter D is seen in pansystolic murmurs.
5. When a patient has a constant blood pressure reading of 150/100, which of the following should be
advised to the patient?
a. No treatment required
b. Lifestyle modifications advised
c. Lifestyle modifications and drug therapy
d. Lifestyle modifications, drug therapy with two-drug combination required
ANSWER: C
RATIONALE: Based on the BP readings the patient has Stage 1 hypertension so letter C is advised. Letter
A is for people with normal blood pressure, letter B is for people who have prehypertension, while letter
D is for people who have Stage 2 hypertension.
6. The following are modifiable risk factors for coronary heart disease EXCEPT
a. Diabetes
b. History of cardiovascular disease
c. Obesity
d. Physical inactivity
ANSWER: B
RATIONALE: Letter B is under nonmodifiable risk factors including increasing age and a family history of
early heart disease younger than 55 years for males and 65 years for females.
7. Which of the following habits can contribute to the worsening hypertension of the patient?
a. Excessive use of seasonings on food
b. Frequent aerobic exercises
c. Having an average body built
d. Increased intake of potassium-rich foods
ANSWER: A
RATIONALE: Seasoning contain large amounts of sodium, sodium can draw fluid into the blood vessels
which will further increase the blood pressure of the patient.
8. The optimum body mass index that people should maintain is at
a. Below 18.5
b. 18.5 to 24.9
c. 25 to 29.9
d. 30 and above
ANSWER: B
RATIONALE: Letter B is the normal BMI, Letter A has an underweight status, letter C has an overweight
status, while letter D has an obesity status.
9. Which of the following foods must the nurse recommend to a patient who has hypertension?
a. Carrots
b. Cucumbers
c. Bananas
d. Tomatoes
ANSWER: C
RATIONALE: A, B, and D are rich in sodium which is the nutrient that a patient with hypertension should
regulate.
10. In order to do lifestyle medication on a patient who has a risk for cardiovascular disease the nurse
must teach which of the following?
a. Eating a balanced diet and avoidance of fast food and processed food
b. Having regular aerobic exercises
c. Complete cessation of smoking
d. All of the above
ANSWER: D
RATIONALE: All are correct in modifying the lifestyle of a person at risk with CVD together with optimal
blood pressure control, lipid management, optimum weight, and diabetes management.
Multiple Choice
1. Intermittent claudication is described as
a. Pain felt in the hands during a cold weather
b. Pain that radiates into the left shoulder and arm
c. Pain or cramping in the legs during walking or exertion
d. Pain felt in the feet due to edema
ANSWER: C
RATIONALE: Intermittent claudication is caused by insufficient arterial supply to the legs which may be
associated with
atherosclerosis.
2. Edema, varicose veins, and aching in the legs are symptoms of
a. Arterial stasis
b. Venous stasis
c. Arterial pooling
d. Atherosclerosis
ANSWER: B
RATIONALE: Due to venous problems such as varicosities, blood is going to pool in the legs of the patient
causing fluid to be retained leading to edema.
3. Which of the following findings in the fingertips and toes is usually associated with Raynaud disease?
a. Pallor or cyanosis in the fingertips and toes
b. Redness in the fingertips and toes
c. Clubbing of the fingers and toes
d. Any of the above
ANSWER: A
RATIONALE: Raynaud disease is a disease that is associated with a cold weather or during a winter season.
Women are usually affected and their fingers and toes will appear pale or even cyanotic during a cold
weather.
4. When asking the female patient about a possible risk for developing blood clots, which of the
following medications that the patient has previous taken should the nurse pay attention to?
a. Aspirin
b. Diphenhydramine
c. Oral contraceptives
d. Warfarin
ANSWER: C
RATIONALE: Although they do not cause blood clots, most birth control pills do increase a woman's chance
of developing a blood clot by about three to four times
5. Which of the following type of jobs would increase the risk for the development of a peripheral
vascular disease like varicosities?
a. Truck driver
b. Traffic enforcer
c. Call center agent
d. Any of the above
ANSWER: D
RATIONALE: All jobs mentioned are at risk to develop varicose veins since these are jobs that require
either prolonged standing or sitting.
6. Nurse Mikasa is assessing the patient radial pulse. Upon placing her fingers, she has noted that the
patient has a bounding pulse. The nurse should grade this pulse on her chart as
a. 3+
b. 2+
c. 1+
d. 0
ANSWER: A
RATIONALE: We grade 3+ for a bounding pulse, 2+ for brisk, expected (normal) pulse, 1+ for diminished,
weaker than expected, and 0 for absent pulse.
7. Nurse Sasha is assessing the patient bipedal edema. Upon indenting her finger unto the edema she
has
measured for at least 6 mm depression that has lasted for more than a minute. Nurse Sasha must grade
this on her chart as
a. 1
b. 2+
c. 3+
d. 4+
ANSWER: D
RATIONALE: 0 has no pitting edema, 1+ mild pitting edema, 2 mm depression that disappears rapidly, 3+
moderate pitting edema with 4 mm depression that disappears in 10-15 seconds, 3+ moderately severe
edema with 6 mm depression that may last more than a minute and 4+ severe pitting edema with 8 mm
depression that lasts for more than 2 minutes.
8. Which of the following is NOT a risk factor for the development of peripheral vascular disease?
a. Obesity
b. Smoking
c. Hyperlipidemia
d. Malnutrition
ANSWER: D
RATIONALE: Malnutrition is not a risk factor for PVD. The other risk factors are hyperlipidemia and
wearing of constrictive clothing.
9. Which of the following definitions best describes paradoxical pulse?
a. There is a palpable decrease in the pulse’s amplitude with quiet inspiration.
b. This is caused by a normal beat alternating with a premature contraction
c. The pulse alternates in amplitude from beat to beat even though the rhythm is regular.
d. An increased arterial pulse with a double systolic peak
ANSWER: A
RATIONALE: Letter B describes bigeminal pulse, letter C describes pulsus alternans, while letter D
describes Bisferiens.
10. When the patient has a pulsus alternans, the nurse must suspect for which of the following in the
patient?
a. Aortic stenosis
b. Hyperthyroidism
c. Pericardial tamponade
d. Left ventricular failure
ANSWER: D
RATIONALE: The pulse seen in aortic stenosis is bisferiens pulse. Bounding pulse is seen in
hyperthyroidism. Paradoxical pulse is seen in pericardial tamponade.
Multiple Choice
1. A patient being admitted is complaining of right upper quadrant pain. Upon ultrasonography, the
physician has diagnosed the patient to have cholecystitis. Which of the following best describes this
disease?
a. Inflammation of the liver
b. Inflammation of the pancreas
c. Inflammation of the stomach
d. Inflammation of the gallbladder
ANSWER: D
RATIONALE: A is describing hepatits, letter B is describing pancreatitis, while letter C describes gastritis.
2. Nurse Mito is admitting a patient who has right lower quadrant pain of the abdomen. Upon palpation
of the right lower quadrant, the nurse has observed for rebound tenderness. This may be an indication
of which of the following conditions?
a. Appendicitis
b. Pancreatitis
c. Gastritis
d. Gastroenteritis
ANSWER: A
RATIONALE: The origin of pain in appendicitis is at the right lower quadrant. To further assess appendicitis
the doctor is going to observe for rebound tenderness where pain is felt after the palpation of the
McBurney’s point in the RLQ.
3. Which of the following is NOT true with regard to visceral pain?
a. It originates from inflammation in the parietal peritoneum
b. It occurs when hollow abdominal organs such as the intestine contract unusually or forcefully
c. It may be difficult to localize
d. It is typically palpable near the midline
ANSWER: A
RATIONALE: Letter A describes parietal pain. The rest of the choices are true with regard to visceral pain.
4. A patient named Erina is experiencing pain from the stomach brought about by hyperacidity. Which
region of the abdomen will this type of pain be felt at?
a. Hypogastric
b. Umbilical
c. Epigastric
d. Right iliac
ANSWER: C
RATIONALE: Heartburns brought about by hyperacidity is felt at the epigastric region of the abdomen
right where the body of the stomach is located at.
5. In early acute appendicitis, the initial complaint of abdominal pain is usually felt at
a. Right hypochondriac
b. Left hypochondriac
c. Epigastric
d. Umbilical
ANSWER: D
RATIONALE: Periumbilical pain can be an early sign that you have appendicitis. Appendicitis is
inflammation of your appendix. If you have appendicitis, you may feel sharp pain around your navel that
eventually shifts to the lower right side of your abdomen.
6. A patient named Soma is currently experiencing pain at the costovertebral angle or the flank area.
The nurse must know that the pain is originating from which of the following organs?
a. Uterus
b. Kidneys
c. Stomach
d. Liver
ANSWER: B
RATIONALE: Flank pain can be a sign of a kidney problem. But, since many organs are in this area, other
causes are possible. If you have flank pain and fever, chills, blood in the urine, or frequent or urgent
urination, then a kidney problem is the likely cause. It could be a sign of kidney stones.
7. The nurse must ask which following questions when the patient is experiencing abdominal pain?
a. “Where does the pain start?”
b. “Does it radiate or travel anywhere?”
c. “Does the pain have an aching, burning, or gnawing quality?”
d. All of the above
ANSWER: D
RATIONALE: All of the following choices are pertinent to the patient who is experiencing abdominal pain.
Nurses must fully utilize the PQRST method in the assessment of pain from patients.
8. Which of the following microorganisms can cause the patient to suffer from peptic ulcer disease?
a. Escherichia coli
b. Helicobacter pylori
c. Staphylococcus aureus
ANSWER: B
RATIONALE: The H. pylori bacteria weakens the protective mucous coating of the stomach and
duodenum, thus allowing acid to get through to the sensitive lining beneath. Both the acid and the
bacteria irritate the lining and cause a sore, or ulcer.
9. Which of the following diseases does NOT cause the patient to have chronic upper abdominal pain?
a. Dyspepsia
b. Peptic ulcer disease
c. Gastroesophageal reflux disease
d. Acute cholecystitis
ANSWER: D
RATIONALE: Acute cholecystitis from the word itself is under acute upper abdominal pain and this
condition needs emergency medical and surgical treatment.
10. Which of the following foods can aggravate the occurrence of heartburn?
a. Toast
b. Coffee
c. Rice
d. Apple
ANSWER: B
RATIONALE: Coffee is acidic and can further increase the acidity of the stomach of a patient experiencing
a heartburn which can worsen the condition.
Multiple Choice
1. Patients with bladder disorders may cause pain to occur in which of the following areas
a. Left iliac
b. Right iliac
c. Flank area
d. Suprapubic area
ANSWER: D
RATIONALE: Pain associated with the right or left iliac area is associated with hernia. Pain at the flank area
is indicative of a kidney disease.
2. In men experiencing prostatic pain the pain may be felt
a. Proximal to the glans penis
b. At the perineum
c. At the suprapubic area
d. Distal to the glans penis
ANSWER: B
RATIONALE: The pain associated with a prostate disease is either felt at the perineum or in the rectum.
Whereas pain related to urinary tract infection in men is felt proximal to the glans penis.
3. Pain associated with a urinary tract infection in a patient is often described as
a. Gnawing pain
b. Stabbing pain
c. Burning pain
d. Searing pain
ANSWER: C
RATIONALE: Burning pain is felt by patients with a UTI since the urethra are also inflamed due to the
infection. The pain is triggered whenever the patient urinates since the urine will pass through the
inflamed urethra.
4. Usually men who have a urinary tract infection is also suspected to have which of the following
coexisting disease?
a. Prostate cancer
b. Kidney stones
c. Sexually transmitted infection
d. Kidney failure
ANSWER: C
RATIONALE: Men who suffer from UTI is usually suspected to also have an STI. Men rarely have UTI than
women since the urethra of males are 4-5 times longer than that of females.
5. Which of the following beverages is related to having urinary frequency in a patient?
a. Milk
b. Orange juice
c. Smoothies
d. Coffee
ANSWER: D
RATIONALE: Coffee has a diuretic effect causing a person to have urinary frequency than other beverages.
6. In men, painful urination without frequency or urgency strongly suggests of which of the following
urinary conditions?
a. Nephritis
b. Urethritis
c. Uteritis
d. Cystitis
ANSWER: B
RATIONALE: Urinary urgency is usually associated with bladder infection or cystitis. However, if frequency
is not present then the urethra is the one that is initially inflamed.
7. Polyuria refers to a significant increase in 24-hour urine volume which usually exceeds
a. 3 liters
b. 0.8 liter
c. 1.5 liters
d. 2 liters
ANSWER: A
RATIONALE: The patient will be classified as having polyuria if the patient exhibits a urine output of 3 or
more liters of urine per day.
8. Which of the following cardiovascular diseases can cause the patient to suffer from nocturia or
increased urination at night?
a. Angina pectoris
b. Coronary artery disease
c. Hypertension
d. Heart failure
ANSWER: D
RATIONALE: Nocturia is common among patients with heart failure and is often a reported cause of poor
sleep which increases the risk of insomnia.
9. Urinary incontinence may be experienced by patients during which of the following situations?
a. Coughing
b. Sneezing
c. Laughing
d. All of the above
ANSWER: D
RATIONALE: All of the above-mentioned situations can increase the intraabdominal pressure causing
pressure to the urinary bladder leading to an involuntary loss of urine.
10. Which of the following best describes ureteral pain?
a. It is a visceral pain that is typically dull, aching, and steady.
b. It is usually severe and colicky, originating at the costovertebral angle and radiating around the trunk
into the lower quadrant of the abdomen, or possibly into the upper thigh and testicle or labium.
c. It is the pain felt on the side of the body between the upper abdomen and the back. It may radiate
anteriorly toward the umbilicus.
d. It is pain that is felt in the perineum and occasionally in the rectum.
ANSWER: B
RATIONALE: Choice A and C is describing kidney pain. While choice D is describing prostatic pain.
Multiple Choice
1. Cysts can occur in women who are
a. Ages 15-25, usually puberty and young adulthood, but up to age 55
b. Ages 30-50, regress after menopause except with estrogen
c. Ages 30-90, most common over age 50
d. Ages 0-14, during the childhood stage
ANSWER: A
RATIONALE: Cysts are usually seen in Choice B while cancer is seen in Choice C. Choice D is not relevant
to any breast mass.
2. Retractions seen on breasts of females can be present in which of the following conditions?
a. Fibroadenoma
b. Cysts
c. Adenocarcinoma
d. Cancer
ANSWER: D
RATIONALE: Retractions are absent in fibroadenoma, cysts, and adenocarcinoma.

3. When palpating for the shape of the breast mass in patients with breast cancer, the nurse must
observe for which of the following?
a. Round, disc-like, or lobular
b. Round only
c. Irregular or stellate
ANSWER: C
RATIONALE: Choice A is describing the shape of breast masses in fibroadenoma, while choice B describes
the breast mass of cysts.
4. The nurse assessing the breast of a patient has observed for peau d’orange on the lower portion of
the patient’s breast. This is indicative of which of the following?
a. Edema
b. Paget disease of the nibble
c. Breast cancer
d. Fibroadenoma
ANSWER: A
RATIONALE: Edema of the skin is produced by lymphatic blockade which makes the breast appear as
thickened skin with enlarged pores that looks like an orange peel.
5. Which of the following is NOT a risk for breast cancer?
a. Age of 65 years and above
b. Two or more first-degree relatives with breast cancer diagnosed at an early age
c. High breast tissue density
d. Low breast tissue density
ANSWER: D
RATIONALE: Low breast tissue density is not associated with breast cancer. Other risk factors are personal
history of breast cancer, the female sex, biopsy-confirmed atypical hyperplasia.
6. In identifying women at risk for BRCA1 or 2 mutation the doctor must establish which of the following
risk factors?
a. First-degree relative with a known BRCA1 or 2 mutation
b. 2 or more relatives with a diagnosis of breast cancer before age 50
c. 2 or more relatives with a diagnosis of ovarian cancer
d. All of the above
ANSWER: D
RATIONALE: All of the above choices are used as criteria for identifying women at risk for BRCA1 or 2
mutations.
7. The histology results of a patient who is suspected to have breast cancer came back as having atypical
lobular hyperplasia. How is the result interpreted?
a. No increased risk
b. Small increased risk
c. Moderate increased risk
d. High increased risk
ANSWER: C
RATIONALE: Patients who have no increased risk are those with cysts, ductal ectasia, mild hyperplasia,
simple fibroadenoma, mastitis, granuloma, diabetic mastopathy. Moderate risk includes ductal
hyperplasia, complex fibroadenoma, and papilloma. Moderate increased risk includes atypical ductal
hyperplasia and atypical lobular hyperplasia.
8. The nurse must teach a female patient to do monthly breast self-examination at around
a. 5-7 days after the onset of menses
b. During the ovulation day
c. 14 days after the onset of menses
d. At the start of menses
ANSWER: A
RATIONALE: BSE is done when the breasts are least likely to be tender or swollen which is 5-7 days after
the onset of menses.
9. Which of the following is a modifiable risk factor in the development of breast cancer?
a. Height (tall)
b. Alcohol consumption
c. Jewish heritage
d. Personal history of endometrium, ovary, or colon cancer
ANSWER: B
RATIONALE: Choices A, C, and D are modifiable risk factors for breast cancer.
10. The recommended age for mammography in order to detect breast cancer in women who are
asymptomatic should be at around
a. 40 to 50 years
b. 30 to 40 years
c. Above 50
d. Below 30
ANSWER: C
RATIONALE: The United States Preventive Services Task Force (USPSTF) recommends that women who
are 50 and above and are at average risk for breast cancer get a mammogram every two years.
Multiple Choice
1. This includes the periarticular ligaments, tendons, bursae, muscle, fascia, bone, nerve, and the
overlying skin
a. Articular structures
b. Extra-articular structures
c. Ligaments
d. Tendons
ANSWER: B
RATIONALE: Letter A includes the joint capsule and articular cartilage, the synovium and synovial fluid.
Letter C are rope-like bundles of collagen fibrils that connect bone to bone. Letter D are collagen fibers
connecting muscle to bone.
2. Example of fibrous joint are the
a. Knees
b. Shoulders
c. Vertebral bodies of the spine
d. Skull sutures
ANSWER: D
RATIONALE: Knees and shoulders are examples of synovial joints while the vertebrae is an example of
cartilaginous joint.
3. The extent of movement of cartilaginous joints are
a. Freely movable
b. Slightly moveable
c. Immovable
ANSWER: B
RATIONALE: Examples of freely movable joints are the shoulder, hip, and knee joints. Examples of
immovable joints are the skull sutures.
4. This is the fibrocartilaginous material at the center of each vertebral disc that serves as a cushion or
shock absorber between bony surfaces
a. Vertebral body
b. Ligament
c. Nucleus pulposus
d. Hyaline
ANSWER: C
RATIONALE: The nucleus pulposus is found at the center of each disc found between the bones of the
vertebrae.
5. Which of the following joints is an example of a spheroidal joint?
a. Hip joint
b. Shoulder joint
c. Elbow joint
d. Both a and b
ANSWER: D
RATIONALE: Both the hip and shoulder joints have a ball-and-socket configuration known as the
spheroidal joint. The elbow joint is known as a hinge joint.
6. The knee is an example of a
a. Spheroidal joint
b. Hinge joint
c. Condylar joint
ANSWER: C
RATIONALE: In condylar joints like the knee, the articulating surfaces are convex or concave, termed as
condyles. One articulating surface is convex and the matching surface is concave.
7. Which of the following may have happened if the patient is currently experiencing calf wasting, weak
ankle dorsiflexion, absent ankle jerk, positive crossed straight-leg raise?
a. Osteoarthritis
b. Disc herniation
c. Rheumatoid arthritis
d. Hip joint dislocation
ANSWER: B
RATIONALE: The signs and symptoms presented are indicative of disc herniation which is associated with
sciatica which is radicular low back pain.
8. Which of the following diseases can cause referred pain to the low back?
a. Peptic ulcer disease
b. Pancreatitis
c. Dissecting aortic aneurysm
d. All of the above
ANSWER: D
RATIONALE: All of the above-mentioned conditions can cause low-back pain together with pancreatic
cancer, chronic prostatitis, endometriosis, and retroperitoneal tumor.
9. Which of the following is the nurse going to suspect if the client complains of lower back pain with
associated bladder and bowel dysfunction?
a. Bursitis
b. Sciatica
c. Herniated nucleus pulposus
d. Cauda equina syndrome
ANSWER: D
RATIONALE: Cauda equina syndrome (CES) occurs when the nerve roots of the cauda equina are
compressed and disrupt motor and sensory function to the lower extremities and bladder.
10. 45% to 60% of cases with cervical radiculopathy have a compressed nerve root which is usually the
a. C7
b. C6
c. C5
d. C4
ANSWER: A
RATIONALE: The most common site for cervical radiculopathy is the C7 nerve since this is the area that
bears the weight of the head.
Multiple Choice
1. A patient is being admitted at the hospital states, “I am having the worst headache of my life!” The
nurse must report this immediately to the physician since the patient may have which of the following
conditions?
a. Seizures
b. Subarachnoid hemorrhage
c. Increased intracranial pressure
d. Aneurysm
ANSWER: B
RATIONALE: The central feature of classic subarachnoid hemorrhage is sudden onset of severe headache
(thunderclap headache), often described as the "worst headache of my life."
2. A patient at the emergency room is suspected to have stroke is experiencing oculomotor deficits with
ataxia and motor deficits. The knows must know that the area affected is at the
a. Anterior circulation – anterior cerebral artery
b. Anterior circulation – middle cerebral artery
c. Posterior circulation – brainstem, vertebral, or basilar artery branches
ANSWER: D
RATIONALE: There is complete basilar artery occlusion leading to the signs and symptoms presented in
the situation above.
3. A stroke patient is sent to the emergency department experiencing contralateral motor or sensory
deficit without cortical signs. The area affected is in the
a. Anterior circulation – middle cerebral artery
b. Subcortical circulation – lenticulostriate deep penetrating branches of the middle cerebral artery
c. Posterior circulation – posterior cerebral artery
ANSWER: B
RATIONALE: There blockage in the lenticulostriate deep penetrating branches of the middle cerebral
artery causing small vessel subcortical lacunar infarcts in the internal capsule, thalamus, or brainstem.
4. The nurse must know that blockage in the anterior circulation – middle cerebral artery can cause
which of the following signs and symptoms in a patient suffering from stroke?
a. Contralateral leg weakness
b. Contralateral field cut
c. Contralateral face, arm, increased leg weakness, sensory loss, vision field cut, aphasia, and apraxia.
d. Dysphagia, dysarthria, tongue/palate deviation and ataxia.
ANSWER: C
RATIONALE: Letter A are signs of anterior circulation-anterior cerebral artery blockage. Letter B is a sign
of posterior circulation-posterior cerebral artery blockage. Letter D are signs and symptoms of posterior
circulation – brainstem, vertebral, or basilar artery branches blockage.
5. A patient is complaining of tingling sensations in her hands and feet as though they are being pricked.
The nurse must note this on her chart as
a. Transient ischemic attack (TIA)
b. Dysesthesias
c. Paresthesias
d. Numbness
ANSWER: C
RATIONALE: Paresthesia is an abnormal sensation of the skin (tingling, pricking, chilling, burning,
numbness) with no apparent physical cause. Paresthesia may be transient or chronic, and may have any
of dozens of possible underlying causes.
6. When the patient faints due to a strong emotion such as fear or pain the nurse must note this on her
chart as having
a. Vasodepressor syncope
b. Postural hypotension
c. Micturition syncope
d. Cough syncope
ANSWER: A
RATIONALE: Vasodepressor syncope is the most common type of syncope caused by a sudden peripheral
vasodilation, especially in the skeletal muscles, without a compensatory rise in cardiac output. Blood
pressure falls. Often slow onset, slow offset.
7. Which of the following best describes absence seizures?
a. The person loses consciousness suddenly and the body stiffens into tonic extensor rigidity. Breathing
stops and the patient becomes cyanotic. A clonic phase of rhythmic muscular contraction follows.
b. A sudden brief lapse of consciousness, with momentary blinking, staring or movements of the lips and
hands but no falling.
c. Sudden, brief, rapid jerks, involving the trunk or limbs.
d. Sudden loss of consciousness with falling but no movements.
ANSWER: B
RATIONALE: Letter A describes tonic-clonic seizures, letter C describes myoclonus, while letter D describes
atonic seizure.
8. A patient is exhibiting tonic and then clonic movements that start unilaterally in the hand, foot or
face and spreads to other parts of the body. The nurse must know that this type of seizure is
a. Complex partial seizure
b. Jacksonian seizure
c. Myoclonic seizure
d. Absent seizure
ANSWER: B
RATIONALE: Signs and symptoms of complex partial seizures include stare blankly, unable to respond,
swallow, smack
their lips, or move their mouth repetitively, say words repetitively etc. Myoclonic seizures have sudden
brief, rapid jerks, involving the trunk or limbs. Absent seizures have a sudden lapse of consciousness with
blinking, staring or movement of the lips without falling.
9. Resting hand tremors and pill rolling are indicative of which of the following neurologic disorders?
c. Parkinson‟s disease
d. Amyotrophic lateral sclerosis
ANSWER: C
RATIONALE: The signs mentioned above are indicative of Parkinson‟s disease including acute dystonia,
shuffling gait, and ataxia.
10. This is a disease where weakness is made worse with repeated effort and improved with rest. This
is brought about by the destruction of the receptor sites for acetylcholine. These are describing
c. Muscle dystrophy
d. Guillain-Barre syndrome
ANSWER: A
RATIONALE: Myasthenia gravis (MG) is a long-term neuromuscular disease that leads to varying degrees
of skeletal muscle weakness. The most commonly affected muscles are those of the eyes, face, and
swallowing. It can result in double vision, drooping eyelids, trouble talking, and trouble walking.
Multiple Choice
1. Primary dysmenorrhea results from prostaglandin production during which phase of the menstrual
cycle?
a. Ischemic phase
b. Proliferative phase
c. Menstrual phase
d. Luteal phase
ANSWER: D
RATIONALE: Premenstrual syndrome (PMS) is defined as a combination of both physical and psychiatric
symptoms that occur during the luteal phase of your cycle. The luteal phase begins after ovulation and
ends when you get your period — typically lasting about 2 weeks.
2. This is known as the abnormal growth of endometrial tissue outside of the uterus
a. Salpingitis
b. Endometrial polyps
c. Endometriosis
d. Pelvic inflammatory disease
ANSWER: C
RATIONALE: Endometriosis is an often-painful disorder in which tissue similar to the tissue that normally
lines the inside of the uterus — the endometrium — grows outside the uterus. Endometriosis most
commonly involves the ovaries, fallopian tubes and the tissue lining the pelvis.
3. Which of the following is NOT a sign of premenstrual syndrome?
a. Depression
b. Blurred vision
c. Angry outbursts
d. Sleep disturbances
ANSWER: B
RATIONALE: Blurred vision is not included in the signs and symptoms of PMS. Other clinical manifestations
include irritability, anxiety, confusion, crying spells, poor concentration, and social withdrawal.
4. A patient comes to the nurse and complains of having an interval of 18 days between menses. The
nurse must note this her chart as
a. Oligomenorrhea
b. Menorrhagia
c. Polymenorrhea
d. Metrorrhagia
ANSWER: C
RATIONALE: Polymenorrhea is having an interval of fewer than 21 days between menses.
5. Which of the following are the signs and symptoms of perimenopause?
a. Hot flashes
b. Flushing
c. Sleep disturbances
d. All of the above
ANSWER: D
RATIONALE: Perimenopause is the period of years during which the woman transitions to menopause. All
the above signs are indicative of perimenopause.
6. Estrogen replacement is helpful in relieving the signs and symptoms of menopause but can increase
the risk of which of the following?
a. Thrombosis
b. Varicosities
c. Hypertension
d. Heart failure
ANSWER: A
RATIONALE: Estrogen, like many lipophilic hormones, affects the gene transcription of various proteins.
Thus, estrogen increases plasma concentrations of these clotting factors by increasing gene transcription.
Higher doses of estrogen appear to confer a greater risk of venous thrombus formation.
7. Certain women can experience sexual dysfunction such as inadequate vaginal lubrication despite
adequate arousal. Some women may not achieve orgasm. This is due to a lack in
a. Progesterone
b. Luteinizing hormone
c. Estrogen
d. Lactogen
ANSWER: C
RATIONALE: Low levels of estrogen can have a big impact on a female’s sex drive. A female may
experience vaginal dryness that can lead to painful intercourse and she may have unstable mood and
sleep patterns.
8. A woman complains of painful sexual intercourse with her husband. The nurse knows that the
medical term for this is known as
a. Vaginismus
b. Dyspareunia
c. Anorgasmia
d. Hypogonadism
ANSWER: B
RATIONALE: Dyspareunia is the term for recurring pain in the genital area or within the pelvis during
sexual intercourse. The pain can be sharp or intense. It can occur before, during, or after sexual
intercourse. Dyspareunia is more common in women than men. It has many possible causes, but it can be
treated.
9. Which of the following best describes vaginismus?
a. Superficial pain that is suggestive of local inflammation of the vagina
b. Deep vaginal pain from pelvic disorders
c. Infection of the vagina
d. Involuntary spasm of the muscles surrounding the vaginal orifice that makes penetration during
intercourse painful or impossible
ANSWER: D
RATIONALE: Vaginismus is a condition involving a muscle spasm in the pelvic floor muscles. It can make it
painful, difficult, or impossible to have sexual intercourse, to undergo a gynecological exam, and to insert
a tampon.
10. Which of the following cannot cause a(n) sexually transmitted disease?
a. Human immunodeficiency virus
b. Neisseria gonorrheae
c. Treponema pallidum
d. Herpes zoster
ANSWER: D
RATIONALE: Herpes zoster is the causative agent for chickenpox. Herpes simplex type 2 causes herpes
genitalis which is an STD.
Multiple Choice
1. Nurse Sakura is observing for the penis of a male suspected to have a sexually transmitted infection.
She has observed for multiple cauliflower-like lesions on the patient’s penis. The nurse must suspect
for which of the following STDs?
a. Genital warts
b. Genital herpes simplex
c. Primary syphilis
d. Gonorrhea
ANSWER: A
RATIONALE: The appearance of genital warts on the patient is the presence of single or multiple papules
or plaques of variable shapes; may be round, acuminate, or thin and slender. May be raised, flat, or
cauliflower-lie (verrucous).
2. Which of the following best describes cryptorchidism?
a. The testicular length is usually less than or equal to 3.5 cm.
b. The testis is acutely inflamed, painful, tender, and swollen.
c. It usually appears as a painless nodule.
d. The testis is atrophied and may lie in the inguinal canal or the abdomen, resulting in an unfilled scrotum.
ANSWER: D
RATIONALE: Letter A is describing small testis, letter B is describing acute orchitis, while letter D is
describing tumor of the testis.
3. The nurse has noticed an appearance of a small red papule that becomes a chancre or painless erosion
on a patient’s penis. The patient is diagnosed to have syphilis. The causative agent of this is
a. Neisseria gonorrheae
b. Treponema pallidum
c. Human papilloma virus
d. Haemophilus ducreyi
ANSWER: B
RATIONALE: Letter A causes gonorrhea, letter C causes genital warts (condylomata acuminata), while
Letter D causes chancroid.
4. Which of the following best describes epispadias in a male?
a. A congenital displacement of the urethral meatus to the inferior surface of the penis.
b. A nontender, fluid-filled mass within the tunica vaginalis.
c. The urethral meatus is located on the top of the glans penis.
d. An indurated nodule or ulcer that is usually non-tender.
ANSWER: C
RATIONALE: Letter A describes hypospadias, letter B describes hydrocele, while letter D describes
carcinoma of the penis.
5. Pain felt in the inguinal canal due to inguinal hernia is usually aggravated by
a. Eating
b. Urinating
c. Lifting heavy objects
d. Lying down
ANSWER: C
RATIONALE: Lifting heavy objects can cause the intraabdominal pressure to increase pushing the
abdominal organs further into the canal which creates more pain.
6. Which of the following types of food can increase the risk of the development of prostate cancer in
men?
a. Processed foods
b. Saturated fat
c. High sugar intake
d. Excessive intake of salt
ANSWER: B
RATIONALE: Saturated fats have been associated with higher risk of prostate cancer death, while marine
fatty acids and monounsaturated fat have been associated with lower risk of prostate cancer death.
7. In teaching males on how to perform the testicular self-examination, the patient must be taught to
do it
a. At night
b. In the morning
c. After a bowel movement
d. After having a warm bath or shower
ANSWER: D
RATIONALE: The heat from the warm bath or shower relaxes the scrotum and makes it easier to find
anything unusual on the testis.
8. For an African-American male who has a positive family history of prostate cancer, the best time to
have a prostate-specific-antigen (PSA) testing and digital rectal examination (DRE) would be at
a. 30 to 40 years
b. 40 years and above
c. 50 years and above
d. Below 30 years
ANSWER: B
RATIONALE: Both the American Cancer Society and the American Urological Association recommends
testing for PSA and DRE for men above 40 years of age.
9. Which of the following are signs and symptoms of prostate disorders?
a. Incomplete emptying of the bladder
b. Urinary frequency or urgency
c. Intermittent stream or straining to initiate flow
d. All of the above
ANSWER: D
RATIONALE: All above-mentioned choices are indicative of prostate disorders together with hematuria,
nocturia, and bony pain on the pelvis or perineum.
10. Vesicles that are 1-3 mm in size found on the glans or shaft of the penis is usually indicative of
a. Gonorrhea
b. Syphilis
c. Genital herpes
d. Chancroid
ANSWER: C
RATIONALE: The appearance of lesions of genital herpes is scattered or grouped vesicles of 1-3 mm in size
on the shaft or glans penis.

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Health Assessment (Lecture)

STUDENT ACTIVITY SHEET BS NURSING / FIRST YEAR

1. Learn the definition of health and health assessment and

SUBJECT ORIENTATION (10 minutes)

1. The calendar of activities for major examinations must be relayed.

MAIN LESSON (50 minutes)

• The NURSING PROCESS steps are:

Types of Health Assessment:

• A follow-up history is a form of a focused assessment.

CHECK FOR UNDERSTANDING (10 minutes)

7. Which of the following is NOT true about the nursing diagnosis?

8. Which of the following best describes problem-oriented assessment?

9. Which of the following best describes follow-up history?

LESSON WRAP-UP (10 minutes)

AL Strategy: Turn and talk

1. Learn about the phases of the interview and the

MAIN LESSON (60 minutes)

Interviewing and Communication

2. Introduction: put the patient at ease and establish trust

3. Working: obtain patient information

Key Elements of the History of Present Illness:

Seven Attributes of a Symptom

OLD CART, or Onset, Location, Duration, Characteristic Symptoms, Associated Manifestations,

Key Elements of the Past History:

Adult Illnesses. Adult Illnesses in each of the following areas:

2. Which of the following is an example of a subjective data?

6. Which of the following is an example of an objective information?

LESSON WRAP-UP (10 minutes)

AL Strategy: Turn and talk

LESSON TITLE: Physical Examination

MAIN LESSON (60 minutes)

• Is a process to obtain objective data from the patient

THE COMPREHENSIVE ADULT PHYSICAL EXAMINATION

Beginning the Examination: Setting the Stage

Preparing for the Physical Examination:

Reflect Your Approach to the Patient:

Adjust the Lighting and Environment:

Observe Standard and Universal Precautions

STANDARD AND MRSA precautions:

Protective barriers include:

Make the Patient Comfortable

PATIENT PRIVACY AND COMFORT:

Draping the Patient:

Cardinal Techniques of Examination:

CHECK FOR UNDERSTANDING (10 minutes)

LESSON WRAP-UP (10 minutes)

AL Strategy: Turn and talk

LESSON TITLE: Physical Examination of a Pediatric Materials:

1. Identify the sources of subjective and objective data from a

MAIN LESSON (60 minutes)

Collecting Subjective Data

Information spoken by the child or family is called subjective data.

Conducting the Client Interview

Interviewing Family Caregivers

Interviewing the Child

Adolescents can provide information about themselves.

Obtaining a Client History

Collecting Objective Data

Measuring Height and Weight

Measuring Head Circumference

Head and Neck

Chest and Lungs

Genitalia and Rectum