Health Assessment Exam Flashcards

deep tendon reflexes
Terms Definitions
tympanic membrane
Normal Oral Temperature
impaired near vision (farsidedness)light rays focus behind the retina
Where are the symptoms?
inflammation of the tongue
assessment of eyes
inspectionpalpationvisual acuity testsopthalmoscope
Tense posture. Clothing clean;no shoes or coat with temperature in the low 40s describes what?
Normal Blood Pressure
Systolic 110-140/Diastolic 60-90
auricle or pinna
external auditory canal
rough, thickened epidermis secondary to persisten rubbing, itching, or skin irritation; oftern involves flexor surface of extremity...chronic dermatitis
palpation: neck
thyroid gland: consistency, masses, tenderness
lateralization of sound; if present, then suspect conduction loss
Stomach gurgling is hyperactive bowel sounds that are normal and are called:
_________ is straightening of the extremity at the joint and increasing the angle of the joint.
optimal blood pressure
systolic 120 diastolic 80
Data observed, felt, heard, or measured by the nurse. Include fever, rash, enlarged lymph nodes, and swelling.
Three types of physical exam
Health Screen
The patient complains of "seeing double". The RN documents this as:
the period when the ventricles relax
lesion pattern: annular lesion that come into contact with one another as they spread (tinea corporis)
assessment of face: inspection
facial expressions: parkinson's scleradermasymmetry: stroke, cleft lip, bells palsyabnormal movementslesionshairedema of masses
a venous thrombus: blood clot that forms on wall of vein and fully or partially occludes flow of venous blood back to the heart
These abnormal breath sounds can be High or Low pitched. Usually occur during expiration. Hgih pitched heard in acute asthma attacks & emphysema.
Cyanosis or rusty/brown pigment around the ankles is what?
venous insufficiency
The lactiferous sinuses are:
the milk storing reservoirs.
Physical Exam Plan - Skill
KNOW IN ORDER:InspectionPalpationPercussionAuscultation Except abdominal exam, out of order - auscultation before palpation/percussion
Object permanence
Piagets term for concept acquired during infancy that objects and people continue to exist even when thaey are no longer in sight
During the history, a patient tells you that "it feels like the room is spinning around me." You would document this as:
A 59-year-old has been diagnosed with prostatitis and is being seen at the clinic for complaints of burning and pain during urination. He is experiencing:
At what phase during nocieption does the individual become aware of a painful sensation?
the process of listening to sounds produced within the body
posterior cure of the auricle's upper aspect
is a mass of extravasated blood confined to a space caused by a break in a blood vessel
lesion pattern: lesions that form a line (poison ivy, contact dermatitis)
inspection: oropharynx
say "ah" of use tongue blade mid-tongue to visualize pharynxnote rise in soft palate (test of vagus nerve-CN X)test gag reflex
brachial pulse
if there is absent pulse, pallor, pain, or parasthesia of distal upper arm may indicate arterial occlusion
We are told never to listen through the gown. BUT if the client has lots of ____, listening through a thin t-shirt to decrease extraneous sounds that could be mistaken as crackles.
S2 "dubb" is usually heard as one sound, but may be heard as 2 sounds. The first noise is aortic valve closing & the second is the pulmonic valve closing if you hear 2 sounds. This occurs with increased pressure on the left sd of the heart and b/c of th
Hair loss on the lower extremities and is not an absolute sign of arterial insufficiency in an older client. true or false?
The breast is composed of glandular tissue, adipose tissue, and:
fibrous tissue.
A yellow hard/soft palate could be a sign of ?
What is included in mobility?
gait, ROM, involuntary movements
sensory or receptive language problems
pt doesn't understand input
Mrs. A. has had rheumatoid arthritis for years and is starting to notice that her fingers are drifting to the side. This is commonly referred to as:
ulnar deviation.
When the skin is exposed to ultraviolet light, which of the following beneficial substances is produced?
Vitamin D.
Which of the following statements represents subjective data obtained from the patient regarding his skin?
Denies color change
blanch test
tests the capillary refill, that is peripheral circulation
is a finding manifested by white spots observed on the nail plate...minor trauma or manipulation of the cuticle
a funal infection of hte nail plate caused by tinea unuium....plate turns yellow or white as hyperkeratotic debris accumulates
inspection of gums
color of gums, gum margins, swelling, ulceration
pitting edema +4
very deep pitting with about 8-mm depression that lasts 2-3 min. dependent extremity is grossly distorted
What is the most common cancer in women?
Breast Cancer
Blocking best illustrates what?
This best illustrates an abnormality of thought process
Menarche occurs during which stage of breast development?
3 or 4
Diagnosis - Purpose
Direct plan of carePPM - predict, prevent, managedecrease costs, increase efficiency
Abnormal breath sounds
crackles (rales) found in CHF, ronchi (pneumonia), wheezes (asthma), friction (pleural rub), stridor
Upon examination of a patient, you note a coarse, low-pitched sound during both inspiration and expiration. This patient complains of pain with breathing. These findings are consistent with:
pleural friction rub
A patient tells the nurse that she is having a hard time bringing her hand to her mouth when she eats or tries to brush her teeth. The nurse knows that for her to move her hand to her mouth, she must perform the following movement:
The Rinne test has been administered to a patient. A normal response is a positive Rinne test. This should be documented as:
AC > BC.
The patient's lab results indicate an albumin of 2.8 g/dl. The student nurse understands this to represent:
severe protein depletion.
The purpose of percussion is to assess the underlying:
tissue density.
a type of telangiectasia characterized by a small central red area with radiating spider-like legs; this lesion blanches with pressure....causes: may occur in absences of disease, with preg, in liver diseae, or with Vit B def
vascular spider (spider angioma)
What breath sound has a ratio of 1:2? Expiration sounds twice as long as inspiration.
The major causes of abdominal distention are sometimes called the 6 F's. what are they?
fat, feces, fetus, fibroids, flatulence and fluid.
pig-skin, orange peel, and peau d'orange are indicative of what?
Lymphatic obstruction suggestive of cancer
anterior chamber is where?
located between the cornea and the lens.
Move to expertise by ________ not by _____
critical thinking; rote
The RN notes loss of muscle mass and a lack of fullness surrounding the deltoid muscle. This is documented as:
The part of the ear which contains the sensory organs for equilibrium is the:
inner ear.
angle of Louis
the junction between the body of the sternum and the manubrium
What are the 2 lymph node groups on neck, down low by chest really?
Supraclavicular and infraclavicular.
what abdominal structures are in the left upper quadrant?
Pancreas, Spleen, Stomach, left adrenal gland, left kidney, left ureter, transverse descending colon
Except in infancy, anything but a plantar response where the toes curl in is really bad. This is called a Positive ________ Repsonse when the toes fan out or extend (dorsiflexion) at big toe. What conditions might a positive ______ response occur to pla
Babinsky. Unconscious states resulting from drug alcohol toxicity, alcohol intoxication, brain injury, or subsequent to ann epileptic seizure may also cause it.
The depth and scope of the nursing assessment has expanded sigificantly primarily due to ?
technology and biomedical advances
Decorticate (response to painful stimuli)
flesion or arms to chest, cortex damage
The nurse just noted from a patient's medical record that the patient has a lesion that is confluent in nature. On examination, the nurse would expect to find:
lesions that run together.
When would you use a bi-manual palpation technique?
Palpating the kidneys and uterus
Can you percuss the anterior thorax?
Yes, always compare identical spots by moving side-to-side and then moving down no more than 5 cm, percuss in the right and left midclavicular lines, percuss between the ribs, move breast tissue so you aren't percussing through it, be sure to completely percuss lateral surfaces.
If you detect occlusion during ausculation of the carotid artery, can you palpate?
yes, palpate VERY lightly to avoid blocking circulation or triggering vagal stimulation and bradycardia, hypotension or cardiac arrest.
What is a normal gait?
heel should strike the ground first. move to ball of foot and push off from there, go up on the tow and opposite arm swing. Tey should have a fluid start & stop.
What are some common changes for pregnant women?
nodularity, dark areolas with erect nipples, & a superficial, prominent venous pattern.
In order to screen for scoliosis, instruct the patient to:
stand with the feet shoulder-width apart and bend forward slowly to touch the toes.
When examining a patient, the nurse can assess mental status by:
observing the patient and inferring health or dysfunction.
one and two point discrimination
the ability to sense whether one or two areas of the skin are being stimulated by pressure
Normal capillary refill time? causes of delayed capillary refill are...
no longer then 1-2 seconds. Vasoconstriction, decreased cardiac output, shock, arterial occlusion, or hypothermia.
What 2 reinforcement techniques can be used to enhance response when attempting to elicit deep tendon reflexes?
if deep tendon reflexes are diminished or absent-use these reinforcement techniques. When assessing arm reflexes, have client clench their teeth. WHen assessing leg reflexes, have them interlock their hands. Reinforcement techniques may also helo the older client who has difficulty relaxing.
a blue or dark red tympanic membrane is seen with
blood behind the tympanic membrane r/ttrauma
In assessing the carotid arteries of an older patient with cardiovascular disease, you would:
listen with the bell of the stethoscope to assess for bruits.
Which of the following factors is most likely to affect the nutritional status of an 82-year-old male?
Living alone on a fixed income
Select the best description of an accurate assessment of a patient's respirations.
Count for 30 seconds following pulse assessment.
signs of ecchymosis (bruise) of a light skin person
dark red, purple, yellow, or green color, depending on age of bruise
Bilaterally we will assess with pulses:
count the RATE (15 sec's X 4), assess symmetry - rate shouldn't vary more then 2-4 sec.'s, Rhythm: should be regular as opposed to irregular, assess the Amplitude
A 65 year old patient with a history of heart failure comes to the clinic with complaints of "being awakened suddenly from sleep, with shortness of breath." You:
suspect that the patient is experiencing paroxysmal nocturnal dyspnea
Which of the following best describes the test the nurse should use to assess the function of cranial nerve X?
ask the patient to say "ahhh" and watch for movement of the soft palate and uvula.
Which of the following is appropriate for the nurse to say near the end of the interview?
"Is there anything else you would like to talk about?"
In assessing the radial pulse of a patient, you would:
takes time and reveals a surprising amount of information.
A _______ chest/breast is a congenital anomaly where the sternum and the xiphoid stick out. If it's severe it can cause cardiorespiratory problems.
Pigeon. Think of a bird from the side, their chest sticks out.
In class Gale showed a venous stasis ulcer where it is purple & the pressure is coming from where?
Pressure comes from the inside - there is an accumulation of blood
When doing the history on a patient with a seizure disorder, you are assessing whether she has an aura. Which of the following would be the best question for obtaining this information?
"Do you have any warning sign before your seizure starts?"
A patient presents with a complaint of knee pain for several months.  An appropriate statement by the RN would be:
"What has occurred that led you to seek care today?"
How can you tell a client to remember to do their BSE?
Pick a set date they will remember each month! tell older clients to do this, esp. if they don't menstruate.
If an S3 is heard in older adults is this abnormal? What conditions cause this?
Yes, abnormal. Occurs with myocardial failure, congestive heart failure (CHF) or volume overload from valvular disease.
Can the size of the thorax differ by race?
Yes, it does differ by race and this is normal. Adult caucasians have a larger thorax and greater lung capacity then african americans, asians and native americans.
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