health assessment test Flashcards

Peripheral vascular disease
Terms Definitions
superficial veins
assessment of skin
inspectioncolorpigmentationtexturethicknesshair distributionlesions
Physical Exam
objective data
arteries in the arms
responds well and appropriately
skin is normally ___
weber test
tests lateralization (bilateral hearing)place base of vibrating tuning fork firmly on top of patient's head or mid-forheadas where sound is heard (left, right, both)
Nipple discharge is known as
RLQ stands for:
right lower quadrant.
elevated irregular-shaped area of cutaneous edema; solid, transient; variable diameter...insect bites, urticaria, allegic reaction, lupus erythematosus
parkinson's disease
a masklike expression occursethe disease results from a decrease in dopamine, a neurotransmitter
inflammation of eyelids along lid margins
what respiratory pattern has increased rate & depth?
_________________ is extension of a limb or part beyond the normal limit (bending hand backward).
Gynecomastia can accompany:
Cushing's syndrome, hormonal treatment and other medications.cirrhosis of the liver, &
ethnic group
concerned with learned behavior independent of genetics or nationality
Describe self treatment tried before seeking care
The pulse oximeter measures:
arterial oxygen saturation
the result of inadequate circulating blood or hemoglobin and subsequent reduction in tissue oxygenation
redness, swelling and tenderness of the hair follicle and the glands that empty at the edge of the eyelids
is an acquired condition associated with the development of unpigmented patch or patches; it is thought to be an autoimmune disorders
blue, black skin discoloration from bleeding into tissues. changes to greenish brown or yellow as clears
ex bruise
cornea and lens
use penlightinspect cornea for opacities in lens that may be visible through pupil..should be clear
What respiratory pattern has less then 10/min and is regular?
Be CAREFUL WHEN PALPATING the _______! and be sure to palpate with your fingers below the costal margin so you do not miss the lower edge of an enlarged one.
______ AMerican men have highest rate of CVA, twice that of white men.
Abstract thinking is the ability to think
grinding of the teeth r/tstress, tmj, or malocclusion
Aggravating and Alleviating Factors
What affects the symptoms?
When auscultating breath sounds, it is best to use the ____________ of the stethoscope.
The RN is auscultating the heart sounds of a patient with severe chronic obstructive pulmonary disease (COPD). The heart sounds seem "far away." This should be documented as:
During a health history, a patient tells the nurse that he has trouble in starting his urine stream. This problem is known as:
a protrusion of the eyeballs with elevation of the upper eyelids
a protrusion of the intestine through the inguinal wall or canal
an irregular shaped, darkened flat area over the sacral area and buttock...disappear after 1 or 2 years of age....common in AA, Asian, hispanic, native american
mongolian spots
pupil larger than 5mm, occurs in coma, or due to medication
arterial spasm fingers/toes
"do your fingertips/toes ever change color in cold weather or when you handle cold objects?"
Kyphosis is common in elderly. is this normal?
Whether or not abdominal viscera is palpable depends on ____________, structural consistency and _______/
location, size
Mental status assessment documents:
dysfunction and how dysfunction impacts self-care.
this is supplied to blood to enhance energy production
Information provided by clients when asked to describe their current state of health, previous illnesses and surgeries, and their family background.
History (subjective data)
UTI signs in the elderly
frequency, urgency, nocturia, confusion (number 1 sign), may be no dysuria
A woman comes to the clinic and states, "My eyes have gotten so puffy, and my eyebrows and hair have become coarse and dry." The nurse suspects:
The nurse would palpate around the medial malleolus to assess which pulse:
posterior tibial
You are performing a nutritional assessment on an 80-year-old male. You know that physiologic changes that directly affect the nutritional status of the elderly include:
slowed gastrointestinal motility.
conduction hearing loss
the result of interrupted transmission of sound waves through the outer and middle ear structures; possible causes are a tear in the tympanic membrane or an obstruction
benign tumor consisting of a mass of small blood vessels; can vary in size from very small to large...cherry anginoma, hemangioma, cavernous hemangioma, strawberry hemangioma
elevated ___ levels may be a reason for male's hairloss
corneal arcus
thin gray white arc around edges of cornea
amplitude of arterial pulses
0= absent, unable to palpate1+ diminished, weaker than expected2+ brisk, expected3+ increased4+ bounding
Normal abdominal movement is:
respiration (esp. seen in male clients), slight pulsation of abdominal aorta (esp in thin people), normally peristaltic waves are not seen although they may be visible in thin people normally.
The Set Test is a supplemental test specifically used with
aging adults.
Phases of the interview Summary and Closure phase
summarizes informationvalidates problems and goals possible plans to resolve problemsnursing and collabrative problems identifed.ask client if they have any questions.
What is included in body structure?
stature, nutrition, symmetry, posture, position, obvious physical deformities
During an examination of the anterior thorax, the nurse recalls that the trachea bifurcates anteriorly at the:
angle of Louis
Assessment: 29 yr old; always dropping things; falling down. Ask person pat knees w/both hands, lift up, turn hands over, & pat knees w/backs of hands. Instructed to repeat process several times & as rapidly as possible. Notice un
rapid alternating movements.
The thin layer of tissue that lines the inner surface of the heart chambers and valves is called:
the endocardium
Which of the following is the cause of ascites?
A female patient does not speak English well, and the nurse needs to choose an interpreter.  Which of the following would be the most appropriate choice?
A trained interpreter.
visual acuity
the degree of detail the eye can discern in an image
a reddish blue round mass of blood vesssels...freq reassessment should be conducted
cavernous hemanginoma
What are risk factors for lung cancer?
cigarette smoking, genetic predisposition, beta carotene supplements, asbestos & radon exposure, exposure to workplace pollutants like radioactive ores, mining chemicals (arsenic, vinyl chloride, nickel, coal, mustard gas, chloromethyl esters and fuels such as gasoline), other environmental exposure: air pollution, passive tobacco smoke, marijuana smoking, history of previous lung cancer, recurring inflammation that leaves scars (TB, some pneumonias), AFRICAN AMERICAN HERITAGy
Risk Factors for CVA:
older adulthood, risks dbl each decade after 55, MALES, history of stroke or TIA, HTN, smoking chronic alcohol intake, history of cardiovascular disease, sleep apnea, diabetes, high serum levels of fibrinogen, cholesterol, high doses of oral contraceptives, high estrogen levels, postmenopausal women, overweight, African American, newly industrialized environment.
A major characteristic of dementia is
impaired short- and long-term memory.
Symptom Analysis
O - onsetL - locationD - durationC - characteristicsA - aggravating and alleviating factorsR - related symptomsT - treatmentS - severity
Tactile fremitus is assessed by:
instructing the patient to say "ninety-nine" as you palpate over the chest wall
Prior to drawing blood for an arterial blood gas (ABG), the lab tech will perform which assessment?
Modified Allen's test
An aspect (or aspects) of human behavior which is (are) important in all cultures yet can vary significantly between cultures is:
all of the above
clients with situational variations are at risk for ____
pressure ulcers and other skin problems
What scars are normal & abnormal?
normal: pale, smooth, minimally raised old scars. abnormal: nonhealing scars, red, inflammation. deep, irregular scars may result from burns. Keloids (excess scar tissue) are more common in african americans and asians.
What abdominal structures are in the right lower quadrant (RLQ)?
appendix, ascending colon, cecum, right kidney (lower pole), right ovary & tube, right ureter
Language as a social tool coincides with a:
child's readiness to play cooperatively.
When are orthostatic vital signs taken:
when volume depletion, HTN, fainting, or syncope is suspected
The number of each intercostal space corresponds to that of:
the rib immediately above it
Because the physical environment in which an interview takes place is an important consideration for the success of an interview, the interviewer should:
reduce noise by turning off televisions and radios.
hair on an infants lumbosacral area may suggest ___
spina bifida or sinus tract
What are abnormal findings for fremitus?
fluid & masses usually increase the vibration, if it is not equal from R to L that is abnormal. Fluid at base of lung would increase vibration and it would not be symmetrical. Unequal is usually the result of consolidation (which increases vibration) or bronchial obstruction, air trapping in emphysema, pleural effusion, or pneumothorax (which all decrease fremitus). Diminished fremitus even w/ a louder spoke voice may be an obstruction of tracheobronchial tree.
If there is jugular vein distention, what conditions cause it?
increased central venous pressure from RIGHT ventricular failure, pulmonary HTN and pulmonary emboli.
What kind of lifestyle increases risk for osteoporosis?
A sedentary lifestyle. Regular exercise increases bone density.
MI signs in the elderly
may have no chest pain or atypical pain (jaw), tachycardia, hypoxemia, syncope, dysrhytmia
When performing a peripheral vascular assessment on a patient, you are unable to palpate the ulnar pulses. The patient's skin is warm and capillary refill time is normal. You would:
consider this a normal finding and proceed with the peripheral vascular evaluation.
A patient is complaining of severe knee pain after twisting it during a basketball game and is requesting pain medication. Which action by the nurse is appropriate?
Administer pain medication and then proceed with the assessment.
thinning and brittleness of the nail may be secondary to ____ or ____
poor peripheral circulation or poor nutrition
Blood normally flows silently through the heart, but a murmur is from turbulent blood that causes swooshing or blowing sound when ausculated. What are some conditions that cause turbulent blood flow?
1. increased blood velocity 2. valve defects 3. valve malfunction, and 4. abnormal chamber openings. If anemia, the murmur will go away when treated.
What are somet cognitive changes at age 7?
more logical and systematic ablity to reason and understand
When inspecting the anterior chest you should assess for:
the shape and configuration of the chest wall
Which of the following statements is true regarding the apical impulse?
Its location may be indicative of heart size.
Which of the following statements best describes the purpose of a health history?
To provide a database of subjective information about the patient's past and present health
You are preparing to assess a hospitalized patient who is experiencing severe shortness of breath. How should you proceed with the assessment?
Examine body areas appropriate to the problem, then complete the full assessment after the acute problem has resolved.
During exhalation the diaphragm _____ and _____ to the resting position.
rises & recoils. When you exhale, the lungs are decreasing in size so the diaphragm is able to rise back up.
Who has highest rate of HTN... african americans, whites or hispanics?
african americans have higher rates of HTN then whites. Hispanics have lower rates then either group.
Use the ______ of the hammer to elicit receptors in the skin rather than in the muscles.
handle, lateral, bigger/back end of reflex hammer
To assess the dorsalis pedis artery, you would palpate:
lateral to the extensor tendon of the great toe.
A patient with a middle ear infection asks the nurse, "What does the middle ear do?" The nurse responds by telling the patient that the middle ear functions to:
conduct vibrations of sounds to the inner ear.
A 90-year-old patient tells you he can't remember the names of the drugs he is taking or what they are for.  An appropriate response would be:
"Would you have your family bring in your medications?"
signs of cyanosis for a light skin person
grayish-blkue tones (esp in nail beds, earlobes, lips, mucous membranes, palms and soles)
when preparing for the abdominal exam, where should the clients arms be?
by there side. if they are raised behind there head or folded there it will tense the ab muscles.
If patient does not have sensation ability in their feet, what should you do?
move centrally. go up higher & see where sensation stops.
A woman is leaving on a trip to Hawaii and has come in for a checkup. During the examination the nurse notices that she is diabetic and takes oral hypoglycemic agents. She needs to be concerned about which of the following?
the importance of sunscreen and avoiding direct sunlight.
A patient is being seen in the clinic for complaints of "fainting episodes that started last week." How should you proceed with the examination?
Record his blood pressure in the lying, sitting, and standing positions.
What would you think if you heard "lub" "dub" "whish"?
That is a diastlic murmur and they are usually pathologic. They're caused by some abnormality in and around the heart. Usually caused by regurgitated blood through the aortic valve. Ones that occur late in diastole are usually caused by mitral valve stenosis.
The RN instructs the patient to hold their forearm in the position of supination. This would include the following movement:
turning the hand so that the palm is facing upward.
ABCDEF for early signs of melanoma
A- asymmetry (not round or oval) B- border (poorly defined or irregular border) C- color (uneven, variegated) D- diameter (usually greater than 6mm) E- elevation (recent change from flat to raised lesion) F- feeling (sensation of itching, tin
yellow conjuntiva
hair loss
Normal respirations
12-20 RPM
inspect eyebrows: quantity, distribution, scaliness of underlying skinabnormality: seborrhiec dermatitis; sparesness-hypothyroidism
breath sounds
vesicular, bronchovesicular, tracheal
lesion shape: snakelike appearance
palpation of ears
auricle for lumps
what qudrant are the liver/gallbladder located
A flat, non-palpable discolored lesion, which is less than 1 cm is noted. It should be described as a:
booming sound; not normally produced
down syndrome
chromosomal defect causing varying degrees of mental retardation and characteristic facial features such as slanted eyes, a flat nasal bridge, flat nose, a protruding tongue, and short, broad neck
direct reaction
pupil constricts in same eye
varicose veins
irregular, tortuous veins with imcompetent valveslong saphenous veins
________ disease is a vascular disorder caused by vasoconstriction or vasospasm of the fingers or toes and is characterized by rapid changes in color, swelling, pain, throbbing or coldness.
The Set Test specifically screens for:
identifies volume of red blood cells/liter of blood.males 40-53% less than 36%females 36-48% less than 33%
Describe the severity of the symptom
The nurse auscultates bilateral breath sounds on a client two days after surgery and notices absent breath sounds in the bases. The nurse recognizes this is most likely due to which of the following?
Examples of chronic pain behaviors include all of the following EXCEPT:
patches of hypopigmented skin, caused by the destruction of melanocytes
lesion pattern: lesions that are scatteren all over the body (herpes varicella)
Elevated spots on skin. Papable, solid, cicumscribed, less than 1 cm in diameter. May be red, pink, brown, bluish red.
Ex: Elevated moles (Nevi), warts, pimples, drug eruptions
conjunctiva and sclera
inspect sclera and palpebral conjunctivacolor, vascular pattern against scleranodules and swellingpalpate by asking pt to look up while examiner depresses lower lids with thumbs
intermitten pallor and cyanosis of hands/fingers
raynauds phenomenon
Hepatomegaly & Atrophy can account for a different liver span size that is abnormal. T or F?
are variscosities common in an older client + normal?
A Supernumerary nipple is
a normal breast variation
what qudrant are the cecum and appendix located
The RN implements the identified plan through coordination of care, health teaching and health promotion, consultation, and prescriptive authority and treatment.
awakens only to painful stimuli but very briefly, reflexes present
During an assessment, the nurse notes that a patient's left arm is swollen from the shoulder down to the fingers, with nonpitting edema. The right arm is normal. The patient had a mastectomy one year ago. The nurse suspects which problem:
Tenderness on palpation in the right upper quadrant (RUQ) could indicate a disorder of which of the following structures?
Which technique of assessment is used to determine the presence of crepitus, swelling, and pulsations?
intention tremor
becomes more apparent when an individual attempts a voluntary movement
funagl infection commonly on the GI tract, vaagina, skin, and mucous membranes
two pigmentation variation birthmarks
mongolian spots and cafe-au-lait
looks like it has pressure pushing it forward
risk factors for peripheral arterial disease
current/past tobacco usehyperlipidemiadiabetes mellitusCADhypertensioncerebrovascular disease
what breath sound ration is 2:1. Longer inspiration to expiration.
Sequence for examining the abdomen:
Inspect, Ausculate, Percuss, Palpate.
this is a passive process that occurs when the diaphram relaxes and squeezes the lungs
Usually done when client is seeking additional care with a provider after a previous visit. 2 weeks after antibiotics, etc.
Follow-up/Episodic assessment
using the hand and fingers for the act of grasping
A patients incision is noted to be just above the nipple. This location can also be described as:
A 75-year-old male is here for "a routine physical." During the history the patient states he's been having difficulty in sleeping. "I have to get up several times a night to urinate." You should document this as:
A patient presents with complaints of a painful rash. The rash includes small grouped vesicles, some of which are crusted. They are arranged in a linear pattern which extends around the trunk on the right side, just below the axilla. You suspect:
herpes zoster.
eustachian tube
connects the middle ear to the nasopharynx
white, waxy coating, _____ is a misture of sebum and cornified epidermis and covers the newborn's body
vernix caseosa
why may < turgor occur?
dehydration, significant weight loss
is used to describe a variety of superficial inflammatory conditions of the skin that can be acute or chronic
assessment of mouth and phaynx: inspection of lips
color (cyanosis, pallor)moisturelumps, ulcerations, cracking, scaliness
venous peripheral vascular disease
swelling of the feel and legs
A _____ shape chest will make the AP: lateral ratio less than 2:1. The ribs appear horizontal at an angle greater then 45 degrees and there is an increased ratio between the anteroposterior-transverse diameter. This condition is commonly the result of e
Behaviors assessed during the mental status examination include:
consciousness, facial expression, speech, and mood.
The area between the iris and lens is filled with what type of liquid?
Health History Preparation
S - self (build trust, skills, knowledge, appearance)S - setting (privacy, quiet, comfort)
Components of a Physical Exam
Biographical Data, Current Health (chief complaint, oldcarts), past health hx (hospitalizations, surgeries, medications, allergies (meds, other, food), immunizations, childhood illnesses, recent travel, military service.. Family history, review of systems(head to toe approach), psychosocial history.
The RN is assessing a patient's reflexes. The RN supports the patient's upper arm and strikes the tendon just above the elbow. This is done to assess which of the following reflexes?
The triceps reflex.
In cardiovascular assessment a "thrill" is:
a murmur that is palpable.
PERRLA stands for:
Pupils equal, round, reactive to light and accomodation.
The physician comments that a patient has abdominal "borborygmi". The nurse knows that this term refers to:
hyperactive bowel sounds.
resting tremor
more apparent when the client is at rest and diminished activity
is present when the angle of the nail base exceeds 180 degrees...may be caused by proliferation of the connective tissue between the nail matrix and distal phalanx...associated with respiratory or cardovascular problems, but may also be associated with ci
What respiratory pattern is characterized by alternating periods of deep, rapid breathing followed by periods of apnea?
Cheyne-Stokes Respiration. Can be caused by severe congestive heart failure, durg overdose, increased intracranial pressure or renal failure. May be noted in elderly sleep w/o other conditions.
It is difficult or impossible to palpate a pulse in an edematous foot or ankle. what do you do?
use an ultrasound device
Where is the left kidney usually palpable?
right below the ribcage
focused or problem oriented assessment
when a omprehensive assessment exists for the client but the client arives with a specific health care concern. example a client has ear pain, the nurse would focus on the pain.
When assessing a patient's lungs, the nurse recalls that the left lung:
consists of two lobes
The nurse is checking the range of motion in a patient's knee and knows that the knee is capable of the following movements:
Flexion and extension
Which of the following is a cause of hypoactive bowel sounds?
Paralytic ileus
second most common skin cancer and an invasive form
squamous cell carcinoma
Describe normal breath sounds in the VESICULAR area. What is the normal pitch, quality, amplitude, duration and location?
Pitch: Low, Quality: Breezy, Amplitude: Soft, Duration: Long inspiration and short expiration, Location: Peripheral Lung Field.
Do african americans or caucasians have higher HDL levels?
african americans have higher HDL (good cholesterol levels), but also have higher lifestyle risk factors than white americans for coronary heart disease.
Where do the majority of lymph drain?
Into the ipsilateral axillary nodes
phases of the interview working phase
nurse elicits client's comments about mayor biological datareasons for seeking health carehistory of present illnesspast health historyfamily health historyROSlifestyle and health practicesdevelopmental level
Your patient has a long history of chronic obstructive pulmonary disease (COPD). You are most likely to observe:
an anteroposterior: transverse diameter ratio of 1:1
The nurse is listening to bowel sounds. Which of the following is true of bowel sounds?
They are usually high-pitched, gurgling, irregular sounds.
sensorineural hearing loss
the result of damage to the inner ear, the auditory nerve or the hearing center of the brain
Some clinicians prefer to assess the thorax in which order?
inspect the thorax, then palpate anterior & posterior thorax, then percuss and ausculate anter. & post. thorax.
S2 is head as the loudest sound at the _____ & ______ ausculatory point and possibly at Erb's point with both the diaphragm and the bell side of the stethescope in all 3 exam positions.
Aortic & Pulmonic
What happens to bowel sounds post-op?
resume gradually depending on type of surgery. The small intestine functions normally in the first few hours post-op, stomach emptying takes 24-48 hours to recover, and the colon requires 3-5 days to recover post-op.
Reflex Response Scale: (to reflex hammer)
Grade 4+ = hyperactive, very brisk, rhythmic oscillations, abnormal and indicate disorder Grade 3+ = more brisk r active then normal, but not indicative of a disorder 2+ = NORMAL, Usual Response 1+ = Decreased, less active then normal 0+ = No response
What are the 4 things to pay attention do concerning pulse?
rate, rhythm, force, and elasticity
Assessing neurologic status of patient who has late-stage brain tumor. W/reflex hammer, nurse draws light stroke up lateral side of sole of foot; inward across ball of foot; patient's toes fan out; big toe shows dorsiflexion. Nurse recognizes this as:
a positive Babinski's sign, which is abnormal for adults
In response to your question regarding use of alcohol, a patient asks you why you need to know.  What is your reason for needing this information?
Alcohol can interact with medications as well as make some diseases worse.
hypertrophy of the nail is usually secondary to repeated ___, ____, or ____
trauma, fungal infection, or < vascular circulation
Area to ausculate for Mitral (Apical) area is:
5th intercostal spcae near the left midclavicular line-the apex of the heart.
Describe the prevalance of osteoporosis?
30-40% of women and 13% of men. affects more then 28 million americans, 80% if them are women. about 1.5 million actually have it and 15 million have the forerunner of low bone mass.
When auscultating breath sounds in an adult, you would:
use the diaphragm of the stethoscope held firmly against the chest
You note that a patient has a murmur and describe it as Grade III/VI. This signifies that the murmur is:
moderately loud, easy to hear.
A 70-year-old male has a blood pressure of 150/90 in a lying position, 130/80 in a sitting position, and 100/60 in a standing position. Interpret these findings:
The change in blood pressure readings is called orthostatic hypotension.
How & When to perform a breast self exam?
Monthly throughout life beginning in late adolescence. Important for women to feel confident doing a breast self exam... not feeling confident prevents women from doing it. But 90% masses women find themselves. Lie down & put pillow underneath. Use flat pads or 3 fingers to palpate. Palpate using 1 of 3 methods: circular, wedge (out from center) or vertical (up & down). can choose whichever, but have to palpate every square inch of the breast.
Normal findings for color of skin & abnormal findings.
abdominal skin may be paler. abnormal: purple discoloration=indicates bleeding/trauma, Yellow=jaundice, pale+taut skin=ascites, redness=inflammation, bruises=areas of discoloration are abnormal.
WHat is the position sense assessment?
Move fingers on hand up or down (when their eyes are closed) and have them correctly identify which direction.
To test cranial nerve XII, instruct the patient to:
stick out their tongue and move it side to side.
Interpret the findings of a vision examination recorded as 20/20 OU:
The patient has normal vision in both eyes.
The nurse is planning to assess new memory with a patient. The best way to do this would be to:
give him the Four Unrelated Words Test.
When doing a whole body exam, it is convenient to assess the heart and neck vessels immediately following what?
assessment of the thorax & lungs
How do you test the bicep reflex?
ask client to bend arm at elbow with palm up. place your thumb over the biceps tendon and strike your thumb with the reflex hammer. repeat on other side. contraction of bicep muscle is normally seen or felt. Ranges from 1+ - 3+
During the examination of the lower extremities, you are unable to palpate the popliteal pulse. You should:
proceed with the exam. It is often impossible to palpate this pulse.
Which of the following describes the correct technique to use when assessing oral temperature with a mercury thermometer?
Leave the thermometer in place up to 8 minutes if febrile.
What patients is S4 normal in? abnormal in?
An S4 is okay in children & young adults, athletes & some older patients after they exercise. Most of the time it is not normal though. S4 is usually associated with HTN, coronary artery disease, aortic and pulmonic stenosis and acute MI.
Which reflex tests do we use the point part of the hammer?
All the arm tests... So bicep, tricep and brachioradialis reflex tests.
The nurse is bathing a 76 year old man and notices that his skin is wrinkled, thin, lax, and dry. This finding would be related to:
an increased loss of elastin and a decrease in subcutaneous fat in the elderly.
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