Nursing Health Assessement Exam Flashcards

Terms Definitions
protein RDA
bronchial obstruction
movement of air
males 14-18 females-12-16
follow-up database
monitors progress
the liver is located
Dr. Davenport Nutrition Lecture:
Protein consists of _____% of the daily diet
Pupils are
Round and
React to
Light and
Accomodation - remember C's and D's
- Pupils constrict when focusing on a close object
- Pupils dilate when focusing on a distant object
linoleic and linolenic acid
Male: 135-146Female: 132-148increased levels mean hydration (a pt in heart failure can be fluid overloaded)
opacities in the lens
absence/closure of ear canal
foreskin is not retracted
Collateral ligaments
Medial & Lateral stability.
Magenta Tongue
Sign of Riboflavin Deficiency
Annular Lesion
Round with central clearing
Kussmaul breathing
Hyperventilation occurs w/ ketoacidosis; very deep & laborious
Excessive sweating assocaiated with shock or other medical emergencies
crackling noise pneumonia, heart failure, asthma, pulmonary disease
what are normal cholesterol levels?
-Complete Blood Count-Evaluates the normal ranges of blood cells-Can be measured any time of day without fasting-measures Hgb, platelets, WBC, and HCT
CN 5
-Trigeminal-massater and temporal muscle strength-pain and sensation, corneal reflex-atrophy, tremors
severe, persistant, psychotic disorder that relapses
how many pair of ribs
lower eyelid loose, rolling outward
normal: muffled 99; abnormal: distinct 99
location of liver
lower right rib cage
Cerebellum (2)
Coordinates skeletal muscle activity, maintains balance & contols fine movement.
Dr. Davenport Nutrition Lecture:
More calories then energy needs =
Weight Gain
Dried drainage or blood; slightly elevated; variable size; colors variable - red, black, tan, or mixed
ex. scab on abrasion
Pupillary dilation greater than 6 mm
High-pitched, musical sound similar to squeak; heard during expiration, may be heard on inspiration; occurs in small airways
Dr. Davenport, Lecture Question
What blood vessels remove blood from the tissue?
Pulmonary Veins
large fissure down tongue
vit. B deficiency
onset, location, duration, characteristics,aggravating and alleviating, related symptoms, treatments and severity
decreased fremitus
________ occurs when anything obstructs transmission of vibrations ex: obstructed bronchus, pleural effusions or thickening, pneumothorax, or emphsyema
Troponin-protein found in the blood and is related to contraction of heart muscle-valuable for detecting heart muscle damage-goal: 0-.10 mcm-test may be done at any time
Cushing Syndrome
prolonged/excessively high exposure to glucocorticcoids
imagining inanimate objects have human characteristics
fissures at corners of the mouth
vesicular breath sounds
longer inspirations, shorter expiration
metabolism of CHO, fats and proteins happens here
topographical markers
suprasternal notch, manubrium, body of sternum, angle of louis, xiphoid process, clavicular lines, axillary lines, POSTERIOR: vertebral line, scapular line
normal: indistinct E; abnormal: "E to A" change
heart murmurs
blood, swooshing sound that occurs with turbulent blood flow in heart or greater vessels
Metacarpophalangeal Joints & Interphalangeal Joints
Finger flexion and extension
Lab Results:
What do increased hemoblogin levels suggest? Decreased Levels?
Increased hemoglobin levels:
Hemoconcentration (Increase amount of cells and solids in blood due to loss of plasma and fluids) due to polycthemia vera (blood disorder in which bone marro wmakes too much RBC's) or dehydration
Diastasis Recti
Midline ridge, separation of abdominal rectus muscles
Ridge is revealed when intraabdominal pressure is increased by raising head while suppine
Occurs because of prolonged distention or a decrease in muscle tone
Not clinically significant
Implementation phase
*the nurse executes the interventions that were devised during the planning phase.*the time frame of the implementation phase varies from pt to pt and from nursing diagnosis to nursing diagnosis.*the nurse simultaneously implements the intervention from multiple nursing diagnoses for a pt at any given time.*it is a dynamic process; the nurse is continually interacting with pt, family, and other health care colleagues, changing the plan of care based on the continuous flow of information
Elevated, firm, & rough lesion with flat top surface greater than 1 cm
Abnormal ocular alignment in which the visual axes do not meet at the desired point
Nonparalytic (muscle weakness) or Paralytic (motor imbalance)
Cranial Nerve VI
Looking laterally, to the side
4 assessment techniques
inspection- observe, listen, smell, hearpalpation-surface or deeppercussion-touching, tappingascultation- hearing
Collapsed section of alveolie or an entire lung; caued by airway, compression of the lungs or lack of surfactant
Mouth, Thyroid
Bleeding gums: vitamin C deficit, gingivitis
Uvula not at midline: nerve damage, occurs with poliomyelitis & diptheria
Bruit occurs with enlarged thyroid gland-hyperthyroidism
What is GMATSO?
General appearance, mood, affect, thought processes, speech patterns, orientation
in infants, _______ are tiny white papules on the cheeks, forehead, and across the nose and chin caused by sebum that occludes the opening of the follicles
Hemoglobin A/C
-reflects average blood sugar levels over the preceding 2-3 months -requires no fasting-normal less than 6%-diabetic less than 7%
CN 2
-Optic-Test for visual acuity, visual fields, opthalmologic examination
peripheral neuropathy
motor/sensory loss in distribution of one or more neurons
peau d'orange
orange-peel appearance of breast due to edema
arcus senilis
gray-white arc around iris, common w/aging
cullen's sign
bluish halo around umbilicus d/t abdominal bleeding, pancreatitis
4 chambers of the heart
R&L atrium, R&L ventricle
tracheal characteristics
high pitched, loud, harsh and tubular, inspiration = expiration (may be break, expiration may be more intense)
cardiac output
stroke volume x heart rate; normal resting CO is 4-6 L/min
Rheumatoid Arthritis
Symmetric joints; pain worse in the morning; and movement relieves pain.
Beefy red colored tongue
(Dr. Davenport stressed in class - may be on exam!!)
Vitamin B Complex Deficiency
Cross Cultural Care
Lactose Intolerant
Lactase: Digestive enzyme necessary for absorption of carbs lactose (milk sugar)
Some racial groups, lactase is high at brith but declines in adulthood (called lactose intolerant)
Lactose intolerant have abdominal pain, bloatin and flaulence when milk is consumed
Polycyclic Lesions
Annular lesions that come in contact with one another as they spread
pt silence
pt silence may indicate feelings of anxiety, confusion, embarrassment, a lack of understanding of the ? asked, or a lack of proficiency in English
Cranial nerve VIII (Acoustic)
Tests auditory functioning; Vestibular function (balance)
4 Types of Assessments
initial, problem focused, emergency, time-lapsed reassessment
Coughing up of blood or blood stained sputum
Unilateral Edema
occlusion of deep vein and lymph obstruction
What is CAGE
Cut down, annoyed, guilty, eye opener
What is the BMI range for "normal" weight?
Normal Lung
When Auscultating this type of lung, you will herea vesicular sounds over the peripheral fields. Bronchvesicular sounds parasternally (anterior) and between scapulae (posterior). Infant and young child-bronchovesicular throughout. There will be no adventitious sounds.
-measures the % of blood that is comprised of RBC's-low could mean dehydration-only give transfusion if below 25%-normal: male 40-52% female 37-47%
Fatty acids
-main source of linoleic acid (omega 7) and alpha linolenic acid (omega 3)-essential for normal growth and developement
What is known as the emotional brain?
Limbic system
assessing the ears
assessment of the ears includes direct inspection and plapation of th external ear, inspection of the remaining parts of teh ear by an OTOSCOPE and determination og auditory acuity
leopold's maneuvers
palpating baby in womb, moving to optimal positioning for labor
4 general survey observations
appearance, body structure, mobility, behavior
the lungs are
elastic and spongy, paired but not symetrical, somewhat concave
located on the right between the right atrium and right ventricle
tricuspid valve
When is S3 abnormal?
after age 35; called ventricular gallop rhythm, S3 gallop, or pathologic S3
Development: Infants and Children:
By age ___, the brain has reached 50% of its adult size; by age __, the brain has reached 100% of its size;
As a result, what type of diet should children have to promote CNS development?
Fatty diets (whole milk, essential fatty acids and calories) - Fats are required for CNS growth and development
Marasmus vs. Kwashiorkor
What is the primary difference between the 2?
Kwashiorkor: Have decreased visceral protein levels and depressed immune function but have appropriate anthropometric measures
Marasmus: Decreased anthropometric measures, normal visceral protein levels
Structure & Function:
Four Quadrants: Right Upper Quadrant (RUQ)
Liver, Gall Bladder, Duodenum, Head of Pancreas, Right Kidney and Adrenal,
evaluation phase
the nurse, in conjunction with the pt and family, evaluates the status of the plan of care
complete health history
a comprehensive history of the pt's past and present health status. it is usually gathered during a pt's initial visit to a health care facility on a nonemergency basis and on admission to a hospital*30-60 min (inform pt of amt of time)if not completed, it may be best to continue later to avoid fatiguing pt
Configurations of the Thorax:
Normal Adult
Elliptical shape with an anteroposterior-to-transverse diameter of 1:2
Industry vs Inferiority
(School Aged)
Peers become more and more important
Approval of those outside of family important
Values independence
Don't push into things where they are likely to fail
Group solidarity
an ulcer occurring in the lower end of the esophagus
A difference in two arms of more than 10-15 mmHg may indicate arterial obstruction on side with lower reading
Epidemic Kaposi's Sarcoma
 what are the skin lesions associated withs AIDS?
Holmes Readjustment Scale – what does it measure for
· Mental health / stress
what is mixed hearing loss
combination of conduction and sesorineural loss
tail of spence
extension of breast tissue into the axilla; most common site of breast tumors
this is the thick muscle tissue of the heart
myocardium muscle
venous hum
due to turbulence of blood flow in the jugular venous system; continuous, low-pitched, soft hum, heard throughout cardiac cycle (loudest in diastole), listen in right subclavicular fossa (medial third of clavical), normal in children
What are methods used to collect current dietary intake?
24-Hour Recall
Food frequency questionnaire
Food Diary
During Hospitalization: Document nutritional intake
Structure & Function:
Four Quadrants: Left Lower Quadrant (LLQ)
Sigmoid Colon, Descending Colon, Left Ovary and Tube and Left Ureter, Spermatic Cord
Cranial Nerve XI (Spinal Accessory)
Shrug shoulders against the resistance of hands pressing down
What does the acinus consist of?
Bronchioles, Alveolar ducts, alveolar sacs and the alveoli
Components of a Health history
biographical data, cc, HPI, PHS(over past 6 months),PHI (medical and surgical), family history-2 generations, psychosocial history, ROS
[(usual wt-current weight)/usual weight]x100
what is the formula for percentage weight loss?
List the risk factors for depression (4/5)
1. Female (2:1)2. Age (adolescents, adults btwx 24-44)3. Genetics4. Psychosocial environment (abuse, alcoholism, losses)5. Personal characteristics (low self esteem, pessimistic
describe different types of primary skin lesions
Macule, patch-unelevated changes in color(freckles, measles, petechia, flat moles.Nodule(tumor)=elevated solid hard mass that extends deeper into the dermis than a papulecyst=fluid filled or semisolid in dermis or subquataneous tissuespapule=circumscribed, solid, elevation of skin, ie warts, acne, pimples elevated molespustule=vesicle or bulla filled with pus. ie acne, vulgaris impetigoplaque=larger than 1cm psoriasis, rubeolawheal-reddened, localized collection of edema fluid, irregular in shape
what does the examination of the neurological system include
*mental status
*level of consciousness
*cranial nerves
*motor function
*sensory function
Check for apical/radial defecit
1. one examiner checks apical and one checks radial for same one minute2. compare rates and check for A/R defecit --> A should be higher (if not, it signals weak ventricular contractions)
Lab Results:
Why is cholesterol measured?
To evalute fat metabolism and to assess risk of CV disease
What are the 3 organs that are palpable in the abdomen?
Liver, Spleen, Kidneys
(Sometimes the Aorta as well)
What is sinus arrhythmia?
a variance but not disease related in child or young adult where the rhythm of the heartrate varies w/inspiration and expiration
CN IX and X
IX = glossopharyngeal, X = vagus; say "ah": symmetrical rise of uvula and palatine arches and uvula stays midline; gag reflex; check voice quality for hoarseness (^ 2 weeks: refer), swallowing
What is the average temperature for an older adult?
36.2 C of 97.2F
What is the description of cerumen for Asians, Native Americans, and Alaskans?
Sparse, flaky, dry, and light
what are the two types of palpation
light and Deeplight-should always precede deep paplaption, becasue heavy pressures on the fingertips can dull the sense of touchdeep paplation-done with two or one hand
what is the plantars reflex
the planter reflex, also teh Babinski reflex is superficial, it may be absent in adults without pathology or overriden in voluntary control, use a moderatley sharp objuect, strock the laterla border of the sole of the clients foot, starting at the hell , observe the response
3 Purposes of nutritional assessments
1. Identify indivdiaus who are or at risk for being malnourished
2. Provide data for designing a nutrition care plan that will prevent or minimize the development of malnutrition
3. Establish baseline data for evaluating the efficacy of nutritional care
working stage of the interview
the working stage of the interview is where the bulk of the pt data is collected. it is a nursing responsibility to keep the interview goal-directed, including refocusing the pt and redefining the goals established in the joining stage. information is summarized and validated in the termination stage. progress toward goals is evaluated in the evaluation stage.
Posterior Thoracic Landmarks:
Vertebra Prominens
C7 and T1 - flex head and feel the bony spur at the base of the neck
In what disease would you see the characteristic "moon face" and "buffalo hump"?
Cushing's Syndrome. Causes endogenous obesity. Caused by excessive ACTH which stimulates adrenal cortex to create cortisol.
what should you do before starting an assignment
prepare the environment, positioning, draping and intrumentation with client
what is the sims position
it is a side lying position with lowering arm behind the body, uppermost leg flexed at hip and knee, upper arm flexed at shoulder and elbow
Is the Spleen palapable? If so, How?
Spleen is usually blocked by the stomach
Locate it by percussing from teh 9-11th intercostal space on the left side
Heart Failure - Its effects on the lung
Left Sided heart failure: Tachypnea (increased rate of breathing) and increased work of breathing; Rales or crackles, heard initially in the lung bases, and when severe, throughout the lung fields suggest the development of pulmonary edema (fluid in the alveoli); Cyanosis which suggests severe hypoxemia, is a late sign of extremely severe pulmonary edema
Bioventricular Failure: Dullnesss of lung fields during percussion and reduced breathing sounds due to pleural effusion (fluid collection in between the lung and the chest wall).
What is the BMI number for a pt who is "extremely obese"?
> 40 BMI
describe steps when assessing a client abdomen
* ask client to urinate, to empty bladder*Inspect the abdomen for skin integrity*inspect the abdomen for contour and symetry*observe ab movements asscoiated with respiration, peristalis, or aortic pressure*observe the vascular patternausculate the abdomen for bowel sounds, vascular sounds, and peritoneal friction rubs*percuss several areas in each quadrants to determine presence of tymphany and dullness*percuss liver to determine size*perform ligh palpations to detect areas of tenderness *perform deep palpations over quadrants, liver and bladder
what is the angle of lois
it is the starting point for locating the ribs anteriorly, the junction b/w the body of the sternum and the manubrium
how do you test for liver disease
hit hand hard with fist, compare right and left lower rib cage posteriorly, tenderness suggests liver disease
If someone tells you they are having pain in their right abdomen before you begin palpation, what should you do?
Start at the location furthest away from the pain and using light palpation at first work in the direction of the pain. Noting where the pain begins.
Give the minimal distance to the area for 2-point discrimination.· Palm of hand· Upper arms· Fingertips· Forearms
·Palm of hand- 8-12 mm or inch· Upper arms – 3 inches· Fingertips – 2-8mm· Forearms – 1 1/2 inches
what are the imaginery lines on the chest
these lines help the nurse identify the position of underlying organs and to record abnormal assessments
Midsternal linevertical line running through the the center pf the sternum
Midclavicular line-vertical lines running midpoint of the clavicle
Anterior axillary line-vertical lines anterior axillary folds
Percussion is used for many reasons! Name 4.
1. It is free. Your hands are portable and with you everywhere. And gives instant feedback.2.Allows you to map out location and size of certain organs.3.Signals the density of a structure by a characteristic tone (air, fluid, solid)4. Detect abnormal mass that is fairly superficial5. Elicit pain if underlying tissue is inflamed.
What is perception and how does it affect mental status?
The perception of a recent life even determines a person’s emotional or psychological reaction to it.
How long should you wait to take an oral temperature after a pt has had ice-cream or chicken broth?
Wait 15 minutes after a pt has taken any hot or cold liquid.
/ 139

Leave a Comment ({[ getComments().length ]})

Comments ({[ getComments().length ]})


{[ comment.comment ]}

View All {[ getComments().length ]} Comments
Ask a homework question - tutors are online