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Nursing Second Semester > Assessment > Flashcards

Assessment Flashcards

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1
Q

Amplitude is

A

the intensity (soft or loud) of sound

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2
Q

Duration is

A

the length of time the note lingers

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3
Q

Pitch is

A

the number of vibrations per second (high or low)

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4
Q

Quality is

or timbre

A

the subjective difference due to a sound’s distinctive overtones

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5
Q

Deep palpation is used to identify

A

abdominal contents

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6
Q

Light palpation is used to evaluate

A

surface characteristics

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7
Q

Percussion with a reflex hammer is used to elicit

A

deep tendon reflexes

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8
Q

Percussion is used to determine

A

the density (air, fluid, or solid) of a structure by a characteristic note

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9
Q

The base of the fingers or ulnar surface of the hand is best for

A

vibration

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10
Q

What isused for detecting fine tactile discrimination such as skin texture, swelling, pulsation, and presence of lumps

A

The fingertips

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11
Q

The otoscope is used to visualize the

A

ear canal and tympanic membrane

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12
Q

The pharynx is best examined with a…

A

A flashlight or penlight and tongue depressor

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13
Q

A funduscopic examination is an examination of the…

A

internal structures of the eye

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14
Q

An otoscope may also be used with a short, broad speculum to view the…

A

nasal turbinates and nares

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15
Q

Use physical touch (if it is not a cultural contraindication) to offset the disadvantages of…

A

diminishing vision and hearing.

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16
Q

To perform percussion, the examiner strikes the stationary finger at the…

A

distal interphalangeal joint (just behind the nail bed)

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17
Q

When should the examiner use hand washing instead of an alcohol-based hand rub?
A. if the pt has Mycobacterium tuberculosis
B. if the pt has Clostridium difficile
C. if the pt has hepatitis B virus
D. if the pt is HIV positive

A

The examiner should use the mechanical action of soap-and-water hand washing when hands are visibly soiled and when patients are infected with spore-forming organisms (e.g., Clostridium difficile or Bacillus anthracis)

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18
Q

The stethoscope’s diaphragm is used for what type of sounds…

A

high-pitched sounds

Ex: breath, bowel, and normal heart sounds.

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19
Q

The stethoscope’s bell is used for what type of sounds…

A

soft, low-pitched sounds

Ex: extra heart sounds or murmurs

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20
Q

Resonant

A

Over Normal Lung Tissue

Low-pitched, clear, hallow sound

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21
Q

Hyperresonant

A

Normal Over Child’s Lung.
Abnormal over adults lung = too much air is present (emphysema)

amplitude: Louder
pitch: Lower
quality: Booming
duration: Longer

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22
Q

Tympany

A

Air-Filled Stomach / Intestine

amplitude: Loud
pitch: High
quality: Drumlike
duration: Sustained Longest

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23
Q

Dull

A

Dense Organ (live/spleen)

amplitude: Soft
pitch: High
quality: Muffled Thud
duration: Short

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24
Q

Flat

A

No air is present, over thigh muscle, bone, tumor

amplitude: Very Soft
pitch: High
quality: No Sound
duration: Very Short

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25
The general survey consists of four distinct areas...they are
Physical appearance Body structure Mobility Behavior
26
What should the width and length be on a blood pressure cuff?
Width: 40% of the arm circumference Lenth: 80% of the arm circumference
27
What rate should the cuff be deflated at while taking a blood pressure?
Rate of 2 mm Hg per heart beat
28
A cuff that is too narrow or too wide yields what kind of reading?
Narrow: falsely high pressure Wide: falsely low pressure
29
Does the Doppler technique more easily identify systolic or diastolic pressure?
systolic blood pressure
30
Endogenous obesity is caused by
administration/excessive production of adrenocorticorticotropin ACTH by the pituitary
31
Acromegaly is caused by
an excessive secretion of growth hormone in adulthood
32
Bradycardia
HR less than 50 bpm in an adult
33
Tachycardia
HR greater than 90 bpm in an adult
34
A full, bounding pulse (3+) reflects...
increased stroke volume, as with anxiety and exercise
35
The ratio of the pulse rate to respiratory rate commonly is
4 to 1
36
5 Factors Blood pressure level is determined by...
``` Cardiac output Peripheral vascular resistance Blood volume Blood viscosity Vessel wall elasticity ```
37
Tympanic Membrane Thermometer
- Accurately measure of core body temperature - Senses the infrared emissions of the tympanic membrane - Temperature is displayed in 2 to 3 seconds - Used with unconscious patients or those in the emergency department, recovery areas, and labor and delivery units
38
Neuropathic pain implies an abnormal
processing of the pain message
39
On a 2000 calorie, a person should consume...
``` 2 cups of fruit 2½ cups of vegetables per day 20-35% fat 60% complex carbs less than 300 mg of cholesterol ```
40
Serum albumin
Common measurement of visceral protein status. Low serum albumin levels occur w/ protein-calorie malnutrition, altered hydration status, and decreased liver function. A serum albumin level of 2.8 to 3.5 g/dl represents moderate visceral protein depletion, and less than 2.8 g/dl denotes severe depletion
41
Obese persons with more fat in the upper body, especially the abdomen, have...
android obesity | A waist to hip ratio of 1.0 or greater in men or 0.8 or greater in women is indicative of android obesity
42
Cephalhematoma
Subperiosteal hemorrhage resulting from birth trauma
43
Craniosynostosis
Asymmetry caused by a severe deformity caused by premature closure of the sutures resulted in a long, narrow head.
44
Caput Succedaneum
edematous swelling and ecchymosis of the presenting part of the head caused by birth trauma
45
Paget disease (osteitis deformans)
Localized bone disease of unknown etiology that softens, thickens, and deforms bone
46
Facial characteristics of fetal alcohol syndrome include...
Narrow palpebral fissures Epicanthal folds Midfacial hypoplasia
47
Facial characteristics of Down syndrome include...
``` Upslanting eyes with inner epicanthal folds Flat nasal bridge Small broad flat nose Protruding thick tongue Ear dysplasia ```
48
Facial characteristics of chronic allergies include...
Exhausted face Blue shadows below the eyes Double or single crease on the lower eyelids Central facial pallor Open mouth breathing (malocclusion of the teeth and malformed jaw) Transverse line on the nose
49
Facial characteristics of congenital hypothyroidism include ...
``` Low hairline Hirsute forehead Swollen eyelids Narrow palpebral fissures Widely spaced eyes Depressed nasal bridge Puffy face Thick tongue protruding through an open mouth Dull expression ```
50
Congenital hypothyroidism
Thyroid deficiency - occurs at an early age (low hairline, hirsute forehead, swollen eyelids, narrow palpebral fissures, widely spaced eyes, depressed nasal bridge, puffy face, thick tongue protruding through an open mouth, and a dull expression.)
51
The trachea is normally midline; the trachea will deviated to the unaffected side (left) with a ...
right pneumothorax
52
``` A clinical manifestation common in an individual with chronic obstructive pulmonary disease (COPD) is A. periodic breathing patterns B. pursed-lip breathing C. unequal chest expansion D. hyperventilation ```
pursed-lip breathing An individual with COPD may purse the lips in a whistling position. By exhaling slowly and against a narrow opening, the pressure in the bronchial tree remains positive, and fewer airways collapse
53
The thoracic cage is defined by the ...
sternum, ribs, vertebrae, and diaphragm
54
The major muscle responsible for inspiration is the
Diaphragm & Intercostal muscles. Intercostal muscles lift the sternum and elevate the ribs, making them more horizontal; this increases the anteroposterior diameter
55
The gradual loss of intraalveolar septa and a decreased number of alveoli in the lungs of the elderly cause
decreased surface area for gas exchange
56
The function of the trachea and bronchi is to...
transport gases between the environment and the lung parenchyma
57
Stridor is a high-pitched, inspiratory crowing sound commonly associated with
upper airway obstruction
58
``` Which of the following correctly expresses the relationship to the lobes of the lungs and their anatomic position? A. Upper lobes—lateral chest B. Upper lobes—posterior chest C. Lower lobes—posterior chest D. Lower lobes—anterior chest ```
Lower lobes - posterior chest The posterior chest is almost all lower lobe
59
An increase in the transverse diameter of the chest cage in a pregnant female is due to a(n)
increase in estrogen
60
Base of the fingers or ulnar surface detects...
Vibration
61
When inspecting the ear canal, the examiner chooses what type of speculum for the otoscope?
The Largest that will fit
62
Normal Gait is how wide?
Shoulder-width
63
``` Pulses 3 point scale 3+ 2+ 1+ 0 ```
3+ Full, Bounding 2+ Normal 1+ Weak, Thready 0 Absent
64
Pulse rate to Respiratory rate ratio is...
4:1
65
During BP, a cuff size that is too narrow yields what kind of reading?
Falsely High BP
66
The Wong-Baker Scale
Faces Pain Scale
67
Simple Descriptor Scale
``` List words that describe different levels of pain. no pain mild pain moderate pain severe pain ```
68
3 types of Normal Breath sounds
Bronchial Bronchovesicular Vesicular
69
Bronchial is heard over
Trachea & Larynx
70
Bronchovesicular
Major bronchi, between scapulae, upper sternum, 1st & 2nd intercostal spaces
71
Vesicular
Peripheral Lungs - Rustling sound
72
Apgar Scoring Scale
Newborns 1st respiratory assessment. | Scored at 1 min & 5 min after birth
73
Unequal chest expansion occurs with...
Atelectasis Lobar pneumonia Pleural Effusion (fluid in lungs) Thoracic Trauma
74
Pallor
Absence of red-pink tones from the oxygenated hemoglobin in blood
75
Tension Headache
All over non-throbbing dull, aching pain stress, anxiety, depression brings it on
76
Migraine Headaches
Pain often behind the eyes (usually just on 1 side) Throbbing/pulsating Hormones, certain foods, changes in sleep can bring it on
77
Cluster Headaches
Always 1 sided continuous/burning/piercing pain Need to move/pace to feel better
78
Blood Vessel that runs diagonally across the sternomastoid muscle
External Jugular Vein
79
Cephalhematoma is associated with
Subperiosteal Hemorrhage
80
What size are normal cervical lymph nodes?
smaller then 1 cm
81
Manubriosternal angle is
The articulation of the manubrium & the body of the sternum
82
How many lobes does the L lung have?
2 lobes | narrower then the R lung
83
Absence of diaphragmatic excursion occurs with...
pleural effusion or atelectasis of the lower lobes

Nursing Second Semester (5 decks)

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