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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
Q

The general survey consists of four distinct areas…they are

A

Physical appearance
Body structure
Mobility
Behavior

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26
Q

What should the width and length be on a blood pressure cuff?

A

Width: 40% of the arm circumference
Lenth: 80% of the arm circumference

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27
Q

What rate should the cuff be deflated at while taking a blood pressure?

A

Rate of 2 mm Hg per heart beat

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28
Q

A cuff that is too narrow or too wide yields what kind of reading?

A

Narrow: falsely high pressure
Wide: falsely low pressure

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29
Q

Does the Doppler technique more easily identify systolic or diastolic pressure?

A

systolic blood pressure

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30
Q

Endogenous obesity is caused by

A

administration/excessive production of adrenocorticorticotropin ACTH by the pituitary

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31
Q

Acromegaly is caused by

A

an excessive secretion of growth hormone in adulthood

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32
Q

Bradycardia

A

HR less than 50 bpm in an adult

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33
Q

Tachycardia

A

HR greater than 90 bpm in an adult

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34
Q

A full, bounding pulse (3+) reflects…

A

increased stroke volume, as with anxiety and exercise

35
Q

The ratio of the pulse rate to respiratory rate commonly is

A

4 to 1

36
Q

5 Factors Blood pressure level is determined by…

A 
Cardiac output
Peripheral vascular resistance
Blood volume
Blood viscosity
Vessel wall elasticity
37
Q

Tympanic Membrane Thermometer

A
  • 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
Q

Neuropathic pain implies an abnormal

A

processing of the pain message

39
Q

On a 2000 calorie, a person should consume…

A 
2 cups of fruit
2½ cups of vegetables per day
20-35% fat
60% complex carbs
less than 300 mg of cholesterol
40
Q

Serum albumin

A

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
Q

Obese persons with more fat in the upper body, especially the abdomen, have…

A

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
Q

Cephalhematoma

A

Subperiosteal hemorrhage resulting from birth trauma

43
Q

Craniosynostosis

A

Asymmetry caused by a severe deformity caused by premature closure of the sutures resulted in a long, narrow head.

44
Q

Caput Succedaneum

A

edematous swelling and ecchymosis of the presenting part of the head caused by birth trauma

45
Q

Paget disease (osteitis deformans)

A

Localized bone disease of unknown etiology that softens, thickens, and deforms bone

46
Q

Facial characteristics of fetal alcohol syndrome include…

A

Narrow palpebral fissures
Epicanthal folds
Midfacial hypoplasia

47
Q

Facial characteristics of Down syndrome include…

A 
Upslanting eyes with inner epicanthal folds
Flat nasal bridge
Small broad flat nose
Protruding thick tongue 
Ear dysplasia
48
Q

Facial characteristics of chronic allergies include…

A

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
Q

Facial characteristics of congenital hypothyroidism include …

A 
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
Q

Congenital hypothyroidism

A

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
Q

The trachea is normally midline; the trachea will deviated to the unaffected side (left) with a …

A

right pneumothorax

52
Q 
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
A

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
Q

The thoracic cage is defined by the …

A

sternum, ribs, vertebrae, and diaphragm

54
Q

The major muscle responsible for inspiration is the

A

Diaphragm & Intercostal muscles.
Intercostal muscles lift the sternum and elevate the ribs, making them more horizontal; this increases the anteroposterior diameter

55
Q

The gradual loss of intraalveolar septa and a decreased number of alveoli in the lungs of the elderly cause

A

decreased surface area for gas exchange

56
Q

The function of the trachea and bronchi is to…

A

transport gases between the environment and the lung parenchyma

57
Q

Stridor is a high-pitched, inspiratory crowing sound commonly associated with

A

upper airway obstruction

58
Q 
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
A

Lower lobes - posterior chest

The posterior chest is almost all lower lobe

59
Q

An increase in the transverse diameter of the chest cage in a pregnant female is due to a(n)

A

increase in estrogen

60
Q

Base of the fingers or ulnar surface detects…

A

Vibration

61
Q

When inspecting the ear canal, the examiner chooses what type of speculum for the otoscope?

A

The Largest that will fit

62
Q

Normal Gait is how wide?

A

Shoulder-width

63
Q 
Pulses 3 point scale
3+
2+
1+
0
A

3+ Full, Bounding
2+ Normal
1+ Weak, Thready
0 Absent

64
Q

Pulse rate to Respiratory rate ratio is…

A

4:1

65
Q

During BP, a cuff size that is too narrow yields what kind of reading?

A

Falsely High BP

66
Q

The Wong-Baker Scale

A

Faces Pain Scale

67
Q

Simple Descriptor Scale

A 
List words that describe different levels of pain. 
no pain
mild pain
moderate pain
severe pain
68
Q

3 types of Normal Breath sounds

A

Bronchial
Bronchovesicular
Vesicular

69
Q

Bronchial is heard over

A

Trachea & Larynx

70
Q

Bronchovesicular

A

Major bronchi, between scapulae, upper sternum, 1st & 2nd intercostal spaces

71
Q

Vesicular

A

Peripheral Lungs - Rustling sound

72
Q

Apgar Scoring Scale

A

Newborns 1st respiratory assessment.

Scored at 1 min & 5 min after birth

73
Q

Unequal chest expansion occurs with…

A

Atelectasis
Lobar pneumonia
Pleural Effusion (fluid in lungs)
Thoracic Trauma

74
Q

Pallor

A

Absence of red-pink tones from the oxygenated hemoglobin in blood

75
Q

Tension Headache

A

All over
non-throbbing
dull, aching pain
stress, anxiety, depression brings it on

76
Q

Migraine Headaches

A

Pain often behind the eyes (usually just on 1 side)
Throbbing/pulsating
Hormones, certain foods, changes in sleep can bring it on

77
Q

Cluster Headaches

A

Always 1 sided
continuous/burning/piercing pain
Need to move/pace to feel better

78
Q

Blood Vessel that runs diagonally across the sternomastoid muscle

A

External Jugular Vein

79
Q

Cephalhematoma is associated with

A

Subperiosteal Hemorrhage

80
Q

What size are normal cervical lymph nodes?

A

smaller then 1 cm

81
Q

Manubriosternal angle is

A

The articulation of the manubrium & the body of the sternum

82
Q

How many lobes does the L lung have?

A

2 lobes

narrower then the R lung

83
Q

Absence of diaphragmatic excursion occurs with…

A

pleural effusion or atelectasis of the lower lobes

Nursing Second Semester (5 decks)

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