Health Assessment, test Flashcards

Terms Definitions
excessive sweating
Normal rectal temperature
impaired far vision (nearsidedness)condition in which the light rays focus in front of the retina
Tachycardia is:
a faster pulse
elevated, circumscribed, encapsulated lesion; in dermis or subcutaneous layer; filled with liquid or semisolid material...sebaceous cyst, cystic acne
visual actuity
far visionnear visioncolor visionperipheral visiontest of central vision using Snellen chart
enlargement of male breast tissue
Air passing through narrowed bronchioles would produce which of the following adventitious sounds:
the frequency of the vibrations
superficial somewhat round elevation on skin
palpable, may have white center with red periphery accompanied by itching
ex: bug bites, esp mosquito, in a sub dermal inj a wheal is raised as med is injected
problem with chrystalin lens (oldest protein in the bodyu)
unilateral swelling associated with an obstruction in lymph nodes
When assessing the various pulse points bilaterally we are assessing symmetry & how much can the rate shouldn't vary more then __ - __ seconds.
writing an original sentence would test for?
conductive hearing
transmission of sound through external and middle ear.
How long do the symptoms last?
Testing for memory
Long term, short term
After assessing the patient's pulse, the nurse determines it to be "normal". This would be documented as:
disturbance in the circulation of aqueous fluid, which cuases an increase in intraocular pressure
an elevated, firm, circumscribed area less than 1 cm in diameter...wart, elevated moles, lichen planus, cherry angioma, skin tag
Discolored spots on skin. Flat, non-palpable, circumscribed, 1cm in diameter. They may be red, brown or tan, white or purple.
Ex: Measles, Freckles, Moles
enlargement of the skull due to inadequate drainage of the cerebrospinal fluid
ankle-brachial index
assess circulation to the feetankle systolic pressure divided by brachial systolic pressure detects stenosis of 50% or more in major vessels of legs
What age does liver size decrease normally?
External Rotation:
hands together behind head, bending knee and rotating away from body
The smallest structure of the mammary gland is the:
The RN develops a plan that prescribes strategies and alternatives to attain expected outcomes.
Bronchovesicular breath sounds
mid lung, inspiration equals expiration in time
The nurse is reviewing an assessment of a patient's peripheral pulses and notes that the documentation states that the radial pulses are 2+. The nurse recognizes that this reading indicates what type of pulse:
A patient is having difficulty in swallowing her medications and her food. In your charting, you would say that she is experiencing:
Which of the following conditions is an example of visceral pain?
invisible soft film that adheres to the enamel surface of the teeth
thin to thick fibrous tissue that replaces normal skin following injury or laceration to the dermis...healed wound or surgical incision
is an inherited disorder characterized by a complete absence of pigmentation. individuals manifest with a pale white skin tone over the entire body surface
hypopigmentation (albinism)
palpation of thyroid
examiner behind ptplace fingers of both hands on pt's neck with index fingers just below carotidask pt to sip water, feel for glandular tissue rising under your finger padsnote size, contour, consistency of gland
pitting edema +1
slight pitting with about 2-mm depression that usually disappears rapidly. no visible distortion of the extremity
Elderly may not be able to ______ effectively b/c of weaker muscles and increased rigidity of thoracic wall.
In many people the liver extends just below the right _________ margin, where it may be palpated. If palpable it has a soft consistency. The liver functions as an accessory digestive organ and has a variety of metabolic and regulatory functions.
An erythematous areolar halo and a crusted, eczematous retracted nipple are commonly found in:
Paget's disease.
cranial nerves assisting with mouth and throat function?
trigeminal facial glossopharyngealhypoglossal
Name the types of assessment
Complete, episodic or problem-centered, follow-up, and emergency
During an admission assessment, the nurse notices that a male patient has an enlarged and rather thick skull. The nurse suspects acromegaly and would further assess for:
coarse facial features
The muscular wall of the heart is called the:
An elderly patient is noted to have significant edema of the lower extremities. The nurse should review which of the following labs?
When evaluating a patient's pain, the nurse knows that an example of acute pain would be:
kidney stones
an involuntary trembling of a limb or body part
is hair growth in a male distribution pattern with an > of hair on the face, body, and pubic area
elevated and solid lesion; may or may not be clearly demarcated; deeper in dermis; greater than 2 cm in diameter...neoplasms, lipoma, hemangioma
inspection of trachea
trachea midlineask pt to swallow some waterwatch upward movement of thyroid cartilage, cricoid cartilage, and thyroidnote contour and symmetry
venous stasis ulcer
stasis of blood in lower extremities resulting from chronic lower leg edema caused by thrombophlebitis or valvular imcompetenceprominent leg veinslower leg edemaaffected leg hard and leather like to touchpulses normal but difficult to feel with edemagangrene does not occurpain is not severeskin around ulcer pigmented and sometimes fibrotic
What is Kyphoscoliosis?
It is forward bending and lateral bending.
a constant board like hardness of the ab. muscles as a result of inflamation of the peritoneum is
involuntary rigidity
Signs suspicious of breast cancer include:
skin dimpling or retraction.
Risk potential diagnosis
2 parts - Risk of "x"r/t "x"
Tracheal breath sounds
central , loud sounds, 2:5 ratio inspiration to expiration
An elderly woman has come for a health exam. Which of the following is a common age-related change in the curvature of the spinal column?
The precordium is:
the area on the anterior chest overlying the heart and great vessels
Impacted cerumen is a common cause of:
conductive hearing loss.
To the horizontal plane, a scaphoid contour of the abdomen depicts:
a concave profile.
an automatic response of the body to a stimulus
small red or pink spots that often seen on the back of the neck...disappear by age 5
stork bite
Patterns of veins radiating horizontally and toward axilla (transverse) and longitudinally will vary among cultural groups. What is normal?
Both are normal and transverse predominates.
What is abduction? adduction?
abduction=moving AWAY from midline of body. adduction=moving TOWARD the midline of the body.
The number of lobes within the breast ranges between:
15 to 20.
The end result of the nursing assessment is to ?
formulate a nursing diagnosis
Vesicular breath sounds
soft, heard over most of the lung fields, inspiration is longer than expiration 5-2 ratio
Mrs. S complains of pain in her calf muscles which occurs when she walks much of a distance but subsides with rest. The RN suspects:
intermittent claudication.
A patient is described as being cachetic. The RN understands this to mean:
fat and muscle wasting.
what are the main characteristics to be noted when looking at a lesion?
location, distribution, color, pattern, edges, (flat, raised, or sunken), size, characteristics
Describe normal breath sounds in the BRONCHOVESICULAR area. What is the normal pitch, quality, amplitude, duration and location?
Pitch: Moderate, Quality: mixed, Amplitude: moderate, duration: same during inspiration and expiration, location: over all the major bronchi. in posterior: between the scapula. in anterior: around the upper sternum in the first and second intercostal spaces.
Amplitude Scale:
1+ = Thready or Weak, 2+ = Normal, 3+ = Bounding
Rapid Alternating Movements are what tests?
finger to thumb, alternating fingers quickly. Or flip hands back & forth on thighs quickly. For some older clients rapid alternating movements are difficult b/c of decreased reaction time and flexibility.
nasal polyps, what do they indicate
usually from allergies, most r/t cancer
The nurse is aware that tactile fremitus is produced by:
sounds generated from the larynx
A patient is found to have a BMI of 23. This is interpreted as:
normal weight.
Which statement indicates that the health care giver understands the pain experience in the elderly?
"Pain indicates pathology or injury and is not a normal process of aging."
What are the normal percuss tones heard from the posterior thorax?
Resonance should be heard throughout over the healthy lungs, flat over bones (scapula) and dull on liver.
In the left lateral position, what points are you listening at? what for? with what side of stethescope?
Apex: Mitral (apical) and Tricuspid points. Listening for S3 & S4 murmurs. Use the BELL b/c you're listening for low-pitched sounds.
Abdominal percussion techniques are where? What percussion sounds where on abdomen?
there are different patterns. Liver & spleen=dullness (full bladder can be dull too), Tympany (or resonance) in interspace on abdomen.
Assess Place (go specific to general)
specific: where are they currently? What CITY? what STATE? What COUNTRY?
What would an abnormal Uvula look like?
bifid.may be r/t submucous cleft palate
Assessment of 80 yr old, you note following: inability to identify vibrations at ankle, identify position of big toe; slower & more deliberate gait; slightly impaired tactile sensation. All other neurologic findings normal. What's assessment of findings?
Normal changes due to aging
Which of the following is an appropriate health promotion question to ask during a review of symptoms?
"Do you use sunscreen while outside?"
skin temp is best evaluated using the ____ . the skin should be ____
dorsal aspect of your hands.....warm
What are the risk factors for venous PVD?
Surgery, Pregnancy, Obesity, Use of hormone replacement therapy, use of oral contraceptives, job with prolonged standing, limited physical activity or poor fitness, FEMALES, increasing age, genetics (non african american), family history, lack of dietary fiber, wearing constrictive clothing
What is the purpose of the musculoskeletal system and how is it controlled?
the bodies bones, muscles & joints compose the musculoskeletal system. It is controlled and innervated by the nervous system, the musculoskeletal systems overall purpose is to provide structure and movement for body parts.
Variation in BP can be due to:
age, pregnancy, race, time of day, weight
In performing auscultation of heart sounds, which sequence would you use?
Aortic area - pulmonic area - Erb's point - tricuspid area - mitral area
Your newly admitted patient is acutely ill.  Which of the following tactics should you utilize to obtain the patient's health history?
Prioritize the most relevant parts of the history
Which of the following statements is true regarding use of the tympanic thermometer?
There is a reduced risk of cross-contamination when compared to the rectal route.
what are the 8 most important things to remember when describing a lesion?
location, size, color, shape, borders, elevated (flat, raised, sunken), characteristics (hard, soft, fluid filled, etc), pattern
Normal findings for the vascularity of abdomen: Are dilated superficial capillaries without a pattern in older clients normal?
scattered fine veins may be visible. blood in veins over umbilicus flows to head. blood in veins lower then umbilicus flows toward the lower body. Yes, Dilated, random superficial capillaries are normal in older clients.
Orientation is 3 fold. Normal is being oriented to time, place and person. You start with specific! If specific is not known though, move to more general. Use Time as an example...
Going Specific to general with time you may go... Start with time of day, then day of week, the month and then the year.
The physician reports that a patient has a tracheal shift. The nurse is aware that this means that the patient's trachea is:
pushed to the unaffected side with a pneumothorax
When a patient is describing his symptoms, which of the following statements reflects a description of the setting of his symptoms?
"This pain happens every time I sit down to use the computer."
moles tend to be less than ____mm in size and should be ___ in shape
5mm.......round or oval with clear borders
S1 is the sound made by what valves closing?
S1 = tricuspid & mitral valves closing
Who has less vericose veins, blacks or whites?
Blacks - have fewer valves in the external iliac veins but considerably more valves in lower legs compared to Caucasians.
In order to assess cranial nerve VIII, the RN will:
perform a "whisper test" to check for hearing acuity.
The nurse is unable to palpate the right radial pulse on a patient. The best action would be to:
use a Doppler device to check for pulsations over the area.
What position is the head of the bed in for assessing jugular vein distention? Is patient looking at you or away from side assessing?
45 degrees, pt. is turned away from the sd being examined & then you can inspect for jugular vein distention - there should be none.
When testing for the Homan's sign - what can you do to eliminate confusion btwn calf pain and Achilles tendon pain?
flex the knee. A second method calls for putting hand under knee, slightly flex it and sharply dorsiflexing the foot. This is controversial b/c if patient could have DVT and could dislodge a clot with this test. we do not perform in HA anymore.
The electrical stimulus of the cardiac cycle follows which sequence:
SA node - AV node - bundle of His - bundle branches
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