Health Assessment 2 Flashcards

Health Care
Terms Definitions
myopia
nearsightedness
alopecia
hair loss
Health History Plan
InterpersonalCommunication
red eye
conjunctivitis (pink eye)
Health History Physical Examination
PurposePreparationPlan-Skills
ossicles
bones of sound transmission
stye
horeolum-infected hair follicle on margin
predominate percussive sound heard over a gasseous distended abdomen:
hyper-ressonance
Auscultation sites
heart, lung, bowel, vascular
dacryocystitis
inflammation of the lacrimal sac
flat, reddish purple, nonblanchable discoloration in the skin greater than .5 cm in diameter...causes: infection or bleeding disorder resulting in hemorrhage of blood into the skin...senile, actinic purpura, progressive pigmented purpura, thrombocytopenic
purpura
pterygium
triangular thickness from nasal to cornea (occurs in farmers)
communicating veins
connect superficial (saphenous) system with deep system
If you are having difficulty differentiating S1 from S2 palpate the _________ pulse, this harsh sound that occurs with this pulse is S1.
carotid
Spontaneous, unilateral serous or serosanguinous discharge from a single duct is most likely due to an:
intraductal papilloma.
Race
a breeding population that mates largely with it group
Characteristics
Describe the characteristics of the symptom
Percussion Sounds
Resonance (lung tissue), hyper resonance, dullness, flat, tympany (abdominal tissue)
The term hepatomegaly refers to:
enlarged liver.
jaundice
yellowish tinge; noticable in the sclera of the eyes, then the mucous membrance and skin
lesion pattern: lesions following a nerve (herpes zoster)
zosteriform
decreased ____ production leads to gray hair
melanin
occipital lymph
at the base of the skull
epitrochlear nodes
flex elbow 90 degrees support forearmfeel in groove b/w biceps and triceps muscle3cm above medial epicondyle
Tenderness or pain at the __________ junction of ribs is seen with fractures, especially with osteoporosis.
costochondral
Can we assume that checking for vibratory sense distally means that vibratory sense proximally is intact?
Yes
Grooming and hygiene fall under the category of:
appearance.
shallow form of breathing that leads to CO2 build up in blood
hypoventilation
Hooking is the technique common in palpating the...
liver
Actual diagnosis
3 parts -diagnosisr/t "x"AEB (as evidenced by) "x"
Health History
Subjective data about the client condition given by the client.
Which of the following scores would indicate that a patient is in a coma, based on the criteria of the Glasgow Coma Scale?
6
Deep palpation is used to determine:
enlarged organs.
Which of the following vital sign changes occur with aging?
inspection
mixed hearing loss
combination of conduction and sensorineural loss
malignant neoplasm that affects those with AIDS and drug-induced immunosupression
kaposi's sacroma
loss of part of the epidermis; depressed, moist, glistening; follows rupture of a vesicle or bulla....varicella, variola after rupture, candidiasis, herpes simplex
erosion
undermining and sinus tract may also be associated tieh stage ___ pressure ulcer
IV
inspection: roof of mouth
colorarchitecture or hard palate (cleft palate)
pitting edema +2
deeper pitting with about 4mm depression that disappears in 10-15 seconds no visible distortion of extremity
What breath sounds is 1:1? equal inspire to expire?
bronchovesicular
Ausculating for vascular sounds in the abdomen is esp imp if the client has ___ or you suspect _________ insufficiency in the legs.
HTN, arterial
What test uses a blunt instrument to write a number, on client's hand & hope they can correctly id?
Graphesthesia
a shallow dimple or skin tether apparent at rest or with arm lifting is
Skin retraction
open ended questions usually beging with?
"How" or "What"
Diastolic BP is:
the pressure that exists btwn contractions
A patient is assessed and found to have shallow respirations at a rate of 10 breaths per minute. This should be documented as:
hypoventilation
67 yr old patient states that he recently began to develop cramp-like pain in calves when climbing 10 stairs to apartment. This pain is relieved by sitting for a few minutes; then he's able to resume activities. This patient is most likely experiencing:
claudication
Accommodation refers to:
pupillary constriction when looking at a near object.
Irregular areas of darkened pigment of the back and buttocks of babies and small children may be:
Mongolian spots.
extinction
the failure to perceive touch on one side of the body
___ of the nail is common;y associated with psoriasis
pitting
assessment: paranasal sinuses: palpation
for sinus tendernesspress up on frontal sinuses from under bony browsacoid pressure on eyespress up on maxillary sinuses
pitting edema +3
depression of about 6mm lasting more than a minute. dependent extremity looks swollen
WHat lymph nodes are below the armpit Central Midaxillary and are more lateral then towards the breast?
Posterior Subscapular
A 3 cm firm, fixed, irregular mass L tail of Spence would be suspicious of what?
cancer
Physical Exam Purpose
V - validate subjective dataC - collect objective dataE - establish a baseline
Hyperthyroid symptoms in the elderly
lethargy, weakness, afib, Congestive heart failure.
A patient is complaining of pain in his joints that is worse in the morning, is better after he has moved around for awhile, and then gets worse again if he sits for long periods of time. The nurse suspects that he may have:
rheumatoid arthritis
The nurse is explaining to a patient that there are "shock absorbers" in his back to cushion the spine and to help it move. The nurse is referring to his:
Intervertebral discs
70 yr old w/history of hypertension & coronary artery disease; presence of pitting edema in lower legs bilaterally. Skin puffy, tight, normal color. No increased redness or tenderness over lower legs & peripheral pulses = & strong. Likely cause of edema?
Heart failure.
In performing an assessment on a 49-year-old woman who has imbalanced nutrition as a result of dysphagia, which of the following data would the nurse expect to find?
Inadequate food intake.
A patient's blood pressure is obtained at 140/95. This falls into which of the blood pressure classifications?
Stage I hypertension
caused by a number of dermophte fungal infections involving the skin, hair, and nails that affect childrenand adults
tinea infections
What lymph node is on the arm above armpit?
Lateral Brachial
Jaw muscle's ability to clench is what CN?
5 - trigemenal
Drainage from the central axillary nodes flow:
into the infraclavicular and supraclavicular nodes.
perceptive/ sensorineural hearing ?
transmission of sound waves in the inner ear.
Decerebrate (response to painful stimuli)
outward rotation and extension of arms, brain damage
A patient has been diagnosed with osteoporosis and asks the nurse, "What is osteoporosis?" The nurse knows that osteoporosis can be defined as:
Loss of bone density
The main reason auscultation precedes percussion and palpation of the abdomen is:
to prevent stimulating peristalsis which might occur after percussion and palpation.
is an inflammation of the skin on teh lower legs most commonly seen in the older adult---areas of erythema and pruritis followed by scaling, petechiae, and brown pigmentation
stasis dermatitis
How long do you listen in each ausculated spot?
one full respiratory cycle
A split S1 is OK if heard in who?
healthy, young adults
Modifiable risk factors for osteoporosis:
little or no physical exercise, low calcium intake, for women: low estrogen levels, postmenopausal women not on estrogen replacement therapy, smoking
The purpose of a comphrensive assessment is ?
arrive at conclusions about the clients health
Non-purposeful (response to painful stimuli)
movement to painful stimuli but no relation to the pain
68 yr old woman; having trouble w/reading paper, sewing, & even seeing faces of her grandchildren. On examination, you note that she has some loss of central vision but her peripheral vision is normal. These findings suggest that:
she may have macular degeneration.
Your patient states that the pain medication is "not working" and rates his postoperative pain at a 10 on a 0 to 10 scale. Which of the following objective assessment findings indicates an acute pain response to poorly controlled pain?
Increased blood pressure and pulse
When should women have mammograms?
Baseline at 35-40 yrs old and then every 2 years between 40-49. Annually after 50. If risk factors are present, mammography is recommended earlier & more often. Mammography detects masses less then 1/2 cm. They DO NOT detect all masses.
Diastole is the time between S_ and the next S_.
S2 and the next S1
What is the best method for prevention of CHD?
a population based approach, especially educating young children to adopt and maintain healthy lifestyles.
Which CN is used resisting and ROM of shoulders?
11 - spinal accessory
After proposing a possible nursing diagnosis the nurse would then ?
check for the presence of defining characteristics
The temporomandibular joint can be palpated by placing the fingers in the depression:
anterior to the tragus of the ear.
When taking a patient's history, you are asked questions about your personal life. What is the best response to facilitate the interviewing process?
Answer briefly, if appropriate, and then refocus to the patient's history.
what do you palpate the skin for? (6)
texture, temp, moisture, mobility, turgor, and thickness
If edema in the ankles makes it impossible to assess posterior tibial pulse, what do you do?
Doppler Ultrasound helps to assess pulse
How do you assess brachioradialis reflex?
ask client to flex elbow with palm down and hand resing on abdomen or lap. tap the tendon at the radius about 2 inches above wrist. THe forearm will flex and supinate. ranges from 1+ - 3+
If the pupils are "Mydriasis" they are
both pupils will be dilated and fixed.caused by central nerve system injury,circulatory collapse,deep anesthesia
Which of the following is a normal physiologic change associated with the aging process?
Peripheral blood vessels growing more rigid with age, producing a rise in systolic blood pressure
A 52-year-old patient states that when she sneezes or coughs she "wets herself a little." She is very concerned that something may be wrong with her. The nurse knows that the problem is:
stress incontinence and is usually due to muscle weakness.
Your patient's blood pressure is 118/82. He asks you to explain "what the numbers mean." You reply:
"The top number is the systolic blood pressure and reflects the pressure on the arteries when the heart contracts."
signs of jaundice for a dark skin person
yellowish green color most obviously seen in sclera of eye, palms, and soles
what abdominal structures are in the left lower quadrant (LLQ)?
left kidney (lower pole), left ovary & tube, left ureter, descending and sigmoid colon
Normal reflex reactions range where on the deep tendon reflex scale?
1+ - 3+. 1+=diminshed, present but decreased. 2+=normal. 3+=slightly increased but not pathologic.
If the thyroid gland is enlarged, which of the following maneuvers is appropriate?
Listen for a bruit over the thyroid lobes.
In performing a voice test to assess hearing, which of the following would you do?
Whisper two-syllable words and ask the patient to repeat them.
17-year-old single mother is describing how difficult it's to raise 2 yr old boy by herself. During course of interview she states, I can't believe my boyfriend left me! What a terrible thing to do to me! Which of following responses uses empathy?
"It must be so hard to face this all alone."
signs of cyanosis for a dark skin person
ashen-gray color most easily seen in the conjuctiva of the eye, oral mucous membrane, and nail beds
What is the 1st leading cause of death in African American women?
Breast Cancer. The incidence of breast cancer rates continue to rise.
Older clients are at particular risk for potential complications with diarrhea, F & E imbalance. Why?
Because they have a higher fat to lean muscle ratio
You suspect that a patient has carpal tunnel syndrome, and so you ask her to perform Phalen's test. To perform this test, she would:
hold both hands back to back while flexing the wrists 90 degrees for 60 seconds.
The nurse is assessing a new patient who has recently immigrated to the United States.  Which question is appropriate to add to the health history?
"When did you come to the United States, and from what country?"
What position should the pt. be in to best feel & count the apical pulse?
left lateral position. to bring the apex closer to the chest wall.
The Romberg test checks Fx of what CN? What is this test performed?
CN VII (8). Person stands with feet together, arms at sd, eyes open and test for swaying. close eyes and test for any swaying. Be sure to stand right behind elderly patients b/c you will need to catch them if they fall over.
Which reflex tests do we use the back of the hammer?
On the leg reflex tests. So the patellar refelx and the achilles reflex.
Pulse
1-rate2-rhythm3-force5-elasticity
skin
nervous system
SECONDARY LESION
changes overtimescratching/infection
mydriasis
enlarged pupils (587)
HAIR
geneticblacks: fragile, dry, thickasians: silky/straight
average BP
120/80 mm Hg
GROUPED
lesions that appear in clusterspurpural lesion
HYPERTHYROIDISM
excessive production of thyroid hormones; enlargement of the gland, exophthalmos (bulging eyes), fine hair, weight loss, diarrhea
dysmenorrhea
Primary dysmenorrhea refers to menstrual pain that occurs in otherwise healthy women (Wright et al. 2003). This type of pain is not related to any specific problems with the uterus or other pelvic organs.Secondary dysmenorrhea is menstrual pain that is attributed to some underlying disease process or structural abnormality either within or outside the uterus
Resonant percussion notes
AMPLITUDE: medium-loudPITCH: low(vibrations)QUALITY: clean, hollowDURATION: moderateEX: over normal lung tissue
umbilicus
imbilicus is invertedmidlineno signs or protrusion or inflammation
exophthalos
- caused by hyperthyroidism- protrusion of the eyeballs w/ elevation of the upper eyelids, resulting in a startled/staring expression (584)
EROSION
wearing away of the superficial epidermis causing a moist, shallow depression; heal w/o scarring;stratch marks, ruptured vesicles
DEVELOPMENTAL CONSIDERATIONS
fontanels, thryoid enlargement, older adults-nose & ears continue to grow
HIRSUTISM
excessive hair growth in unusual places, especially in women; could be a side effect of hormone therapy or medication
GYRATE
lesions that are coiled or twisted
visceral pain
originates from larger interior organs. can stem for direct injury to the organ, or from stretching of the organ from tumor, ischemia, distention, or severe contraction. ex: appendicitis, ulcer pain, ureteral colic
fingertips
best for fine tactile dicrimination, as of skin texture, swelling, pulsation, lumps.
bulla
larger than 1cm; usually single chambered; superficial in epidermis; it is thin walled, so it ruptures easily. ex: friction blister, pemphigus, burns, contact dermatitis
nocturia
Nocturia (derived from Latin nox, night, and Greek [τα] ούρα, urine), also called nycturia (Greek νυκτουρία), is the need to get up during the night in order to urinate, thus interrupting sleep. Its occurrence is more frequent in the elderly. Nocturia could result simply from too much liquid intake before going to bed, or it could be a symptom of a larger problem, such as urinary incontinence, Interstitial Cystitis, diabetes, benign prostatic hyperplasia or prostate cancer.
acrochordons
normal variation in aginig adult. "skin tags" overgrowths of normal skin
cn 3, 4, 6
oculomotor, trochlear, abducensextraocular movement, PERRLA
Depressed nasal bridge, epicanthal folds, mongoloid slant of eyes, low set ears, and a large tongue are seen in:
Downs syndrome
A rounded, elongated mass projecting into the nasal cavity from boggy mucosa may be a:
polyp
dysuria
dysuria refers to any difficulty in urination. It is sometimes accompanied by pain. It is most often a result of an infection of the urinary tract.
conductive hearing loss
mechanical dysfunction that blocksex: impacted cerumen, otoscerosis
elderly: vision
-visual acuity may diminish gradulally after 50yrs, even more after 70.-near vision is commonly affected due to decreased power of accommodation int eh lens (presbyopia)-as early as 4th decade, blurred vision and diff. reading.-decreased adaption to darkness
test for CNVII
expression, affect, symmetry and movement. smile.
stensen's duct
in buccal mucosa:opening of the parotid salivary gland. it looks like a small dimple opposite the upper second molar.
grip/ strength
could you please grab my fingers?please resist my pusharms: in, out, up, downthighs: in out up downlegs: up downfeet: plantar, dorsimotor strength is 5 out of 5
normocephalic
reference to a normal head size (584)
Coarsening of features with broadening of the nasal alae and prominence of the zygomatic arches is seen in :
early acromegaly
______ is associated with diffuse thyroid enlargement and often presents with exophthalmos and nonpitting edema (pretibial myxedema).
Graves disease
See table 11-1 for chronology of visual development
 
Secretions that accumulate in the newborn's mouth requiring frequent suctioning may indicate:
esophageal atresia
Presbycusis is:
some degree of sensorineural hearing deterioration with advancing  age.
HYPOTHYROIDISM
occurs when there is a decrease in production of thyroid hormones; results in lowered basal metabolism; mostly in females b/t ages 30-50; fatigue, weakness, weight gain, constipation, memorm impairment
NORMAL FINDINGS FOR NAILS
smooth, round edges; curvature-slighty flat&curved; smooth surface; nml. angle of nail base; uniform thickness; firm nail base; clubbing?
lacrimal apparatus
(a) the lacrimal gland, which secretes the tears, and its excretory ducts, which convey the fluid to the surface of the eye;(b) the lacrimal canaliculi, the lacrimal sac, and the nasolacrimal duct, by which the fluid is conveyed into the cavity of the nose.
otoscope
funnels light into the ear canal and onto the tympanic membrane
sebaceous hyperplasia
normal finding in aging adult. raised yellow papules with a central depression. more in men, over the forehead, nose, or cheeks. have pebbly loook
test of CN XI
ROM-- controlled movement, strength against resistance, head back and side-to-side, shoulder shrug
4) percussion
please lean forward slightly and cross arms over chest to expand the thoracic areanormal tone is resonant throughout
Butterfly rash over malar surfaces and the bridge of the nose is seen with what condition:
Lupus erythematosus
The ____ is composed of skin, striated muscle, the tarsal plate, and conjunctivae,and contains meibomian gland that provide oils to the tear film.
eyelid
The ____ drains into the posterior aspect of the inferior turbinate of the nose.
Eustachian tube
NECK: STRUCTURE AND FUNCTION
neck muscles, thyroid gland*, trachea, bones, and neck vessels*
test for CNV
facial response to sharp and dull touch. movement and sensory.
tumor
larger than a few cms. firm or soft, deeper into the dermis; maybe benign or malignant.ex: lipoma, hemangioma
stereognosis
im going to place an object in your hand please identify what it is
_____  is a long, narrow head seen often with preterm infants. ____ is any skull asymmetry or a particularly flattened spot on the back or one side of the head which can result from premature fusion of one of the sutures (craniosynostosis)or from externa
Brachiocephaly, Plagiocephaly
Lipemia Retinalis occurs when the serum triglycerides levels exceed:
2000mg/dl-seen in diabetic ketoacidosis and hyperlipidemic states, improves with return of triglicerides to normal levels.
The lacrimal glands are rarely enlarged by may become so in some conditions such as:
tumors, lymphoid infiltrations, sarcoid disease, and Sjogren syndrome.
The ____ sinuses are air-filled, paired extensions of te nasal cavities withing the bones of th skull. Their openings into the medial meatus of the nasal cavity are easily obstructed.
Paranasal
 
Only the maxillary sinus (along the lateral wall of the nasal cavity of the maxillary bone) and the frontal sinus (in the frontal bones superior to the nasal cavities) are accessible for physical exam.
 
The ethmoid sinus (behind the frontal sinus near the superior portion of the nasal cavity) and the sphenoid sinus (deep in the skull behind the ethmoid sinus) are difficult to access for physical exam. 
INSPECT & PALPATE HAIR FOR....
color, texture; fine, thick, straight, kinky; distribution, lesions or pests;
referred pain
pain that is felt at a particular site but originates from another location. both sites are innervated by the same spinal nerve. can originate from visceral or somatic.
edema
no edema presentif so rate it 1+ for mild pitting, 2+ moderate pitting, 3+ deep, 4+ very deep pitting
The thyroid gland produces 2 hormones:
Thyroxine (T4) and triiodothyronine (T3)
Involutary rhythmic movements of the eyes that can occur in a horizontal, vertical, rotary, or mixed pattern are called:
Nystagmus
 
If the eye moves rapidly to the right and then slowly drifts leftward, the patient is said to have nystagmus to the right.
A disruption of the corneal epithelium and stroma is:
Corneal Ulcer-associated with connective tissue diseases like RA, Sjogren syndrome, or a systemic vasculitic disorder, bacterial infection or desiccation because of incomplete lid closure or poor lacrimal duct function.
The ____ (parallel curved bony structures covered by vascular mucous membranes) form the lateral walls of the nose and protrude into the nasal cavity.
Turbinates
 
A meatus below each turbinate is named for the turbinate above it.
 
The Inferior meatus drains the nasolacrimal duct.
The Medial meatus drains the paranasal sinuses.
The Superior meatus drains the posterior ethmoid sinus.
NODES ARE PALPABLE WHEN INFECTED/ENLARGED
MUST KNOW ALL LYMPHATIC NODES; USE CIRCULAR MOTION TO PALPATE
please take a deep breath
no pulsations or masses are present that protrude or can be seen
Bossing (bulging of the skull) of the frontal areas of infants is associated with:
Prematurity, Thalassemia, and Rickets
abscence of red reflex may indicate:
cataract or hemorrhage into the vitreous humor
Risk factors for oral cancer include:
 
older than 40
gender-men twice the rate of women
ethinicity-black
excessive alcohol use
Ill-fitting dentures, prior oral lesions
Tobacco use-risk increases with freq and durating of use/smoking hx of more than 20pk-year
Occupation-textile industry, leather manufacturing
Systemic disease-pernicious or iron deficiency anemia, HIV Infection, lichen planus, previous malignancy, human papilloma virus.
Marked edema of the neck may be associated with ____ whereas a mass fillilng the base of the neck or visible thyroid tissue that glides upward when the patien swallows may indicate_____.
1.local infection ex cervical lymphadenitis
2. enlarged thyroid
T or F
Thyroid enlargement may be seen during pregnancy in areas of iodine deficiency.
True
As long as adequeate iodine intake is maintained between 225 and 375mcg per day the size of the thyroid will not change on physical exam.
A hemorrhage at the optic disc margin often indicates:
poorly controlled glaucoma or undiagnosed glaucoma
A saddleshaped nose with a low bridge and broad base, a short small nose, or a large nose may suggest a:
chromosomal disorder or congenital anomaly
The ___ test helps distinguish wheter the patient hears better by air or bone conduction.
Rinne
 
Vibrate fork and place on mastoid bone have pt tell you when the can no longer hear quickly remove and place 1-2cm from auditory canal and have them tell you when sound no longer heard. Record the time mastoid conduction and auditory conduction. Air conduction should be twice as long as bone conduction.
The eye has four ___ and two ____ muscles attached to the eye, and the eye itself is connected to the brain by CN __ the optic nerve.
Rectus (superior, inferior, medial, lateral), Oblique (superior and inferior), CN II
 
The muscles are innervated by CN's:
III-occulomotor controls the levator papebra suerioris (that elevates and retracts the upper eyelid) and all extraocular muscles except for the superior oblique and lateral rectus muscle.
 
IV-troclear-superior oblique muscle
 
VI-abducens-lateral rectus muscle
T or F
One half of adults older than 65 have hearing loss.
False
One third have hearing loss
 
Sensorineural loss occurs first wit high-frequency sounds and then progresses to tones of lower frequency.
 
The ability to localize sound also diminishes with age.
 
Conductive hearing loss may result form excess deposition of bone celss along the ossicle chain, causing fixation of the stapes in the oval window, cerumen impaction, or a sclerotic tempanic membrane.
T or F
The presence of wt loss, tachycardia, and bruit over the thyroid are normal in pregnancy.
False they are highly suggestive of hyperthyroidism comfirmed with TSH and free T4 levels.
When examining the a normal thyroid all of the following should be present:
1. If felt it should be small smooth, and free of nodules, with a consistency that is firm yet pliable. Coarse tissue or a gritty sensation suggests an inflammatory process.
 
2. The gland should rise freely with swallowing
 
3. at its broadest dimensions it should be approximately 4cm with a right lobe that is often 25% larger than the left. An enlarged, tender thyroid may indicate thyroiditis.
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Term:
Definition:
Definition:

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