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Nursing School > 💉- Assessment Test > Flashcards

💉- Assessment Test Flashcards

0
Q

What is a sign of pallor in light skinned patients and dark skinned patients

A

Light skinned - extreme paleness, skin appears white loss of pink or yellow tones

Dark skinned - loss of red tones

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1
Q

The integumentary system consists of what 4 parts

A

Skin
Mucous membrane
Hair
Nails

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2
Q

Ashen

A

A blue-gray coloration of the skin also described as cyanosis

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3
Q

What is Ecchymosis

A

Bruised (blue-green-yellow) area

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4
Q

Petechiae

A

Tiny, pinpoint red or reddish-purple spots

Due to extravasation of blood into the skin

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5
Q

Extravasation

A

Leakage from vessels

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6
Q

Mottling

A

Bluish marbling splotchy

Sometimes seen in dying patients

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7
Q

Name a type of embolus associated with petechiae

A

Fat

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8
Q

What does trace mean in relation to pitting edema

A

Minimal depression with pressure

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9
Q

What is the acronym used to assess skin lesions

A 
A - asymmetry 
B - border irregularity 
C - color variation 
D - diameter 
E - elevation 
Patterns
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10
Q

What is central cyanosis

A

Blue-gray coloration in the lips, tongue, mucous membranes and facial features

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11
Q

What are you looking for when inspecting the hair

A

Texture and distribution

Infestation or infection

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12
Q

What are you looking for when assessing the nails

A

Capillary refill
Color and texture
Shape

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13
Q

What is clubbing of the nails and what is it associated with

A

The nail plate angle is 180 degrees or more

Associated with long-term hypoxic states, such as occur with chronic lung disease

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14
Q

What is Hirsutism and what is a possible cause

A

Excess facial or trunk hair

Indicates a possible thyroid issue

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15
Q

What are nits

A

Eggs of head lice and are usually located close to the hair shaft

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16
Q

Which 3 cranial nerves are usually assessed together for eye movement

A

CN 3,4,6

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17
Q

What 5 things do you look for when assessing the head and face

A 
Skin and hair 
Size and shape 
Symmetry 
Facial movements 
Scalp
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18
Q

When assessing the neck name 6 things to look for

A 
Musculature 
Trachea 
Thyroid 
Symmetry 
Contour ROM - shrug CN XI
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19
Q

What are Striae

A

Silver-to-pink stretch marks in pregnant women, women who have had children and anyone who has experienced significant weight fluctuations

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20
Q

What are mees’ lines

A

Transverse white lines in the Nailbeds

Seen in clients who have experienced severe illnesses or nutritional deficiencies

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21
Q

What is acromegaly

A

A large head in an adolescent or adult

Associated with excess growth hormone

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22
Q

Hydrocephalus

A

An accumulation of excessive cerebrospinal fluid

Seen in infants and children, a head that is growing disproportionally

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23
Q

What are some causes of enlarged or tender nodes

A

Infection, malignancy and other diseases

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24
Q

What is enlargement with exophthalmos

A

Associated with a thyroid issues

Is an increase in the volume of the tissue behind the eye, the eyes will appear to bulge out of the face

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25
Q

Goiter

A

Bilateral thyroid enlargement

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26
Q

Name 8 things to look for when assessing the eye

A 
External eye
Sclera and conjunctiva 
Eye position 
Visual acuity 
Visual fields 
Cranial nerve function 
Pupils 
Internal structures
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27
Q

Ectropion

A

An everted eyelid

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28
Q

Entropian

A

An inverted eyelid , can lead to corneal damage

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29
Q

Ptosis

A

Dropping of the lid

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30
Q

What is PERRLA

A

Pupils, equal, round, reactive to light and accommodation

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31
Q

Accommodate

A

When pupils constrict and the eyes converge (cross) as a person attempts to focus on an object moving toward them

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32
Q

Mydriasis

A

Enlarged pupils

May be seen with glaucoma

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33
Q

Miosis

A

Constricted pupils

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34
Q

Anisocoria

A

Unequal pupils

Maybe be seen in stroke, head trauma or could be normal

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35
Q

Myopia

A

Diminished distant vision

“Near sighted”

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36
Q

Presbyopia

A

Diminished near vision

“Far sighted”

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37
Q

Strabismus

A

Crossed eye

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38
Q

Amblyopia

A

Lazy eye

Is a result of constant strabismus of one eye

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39
Q

What is 100% visual efficiency

A

20/20

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40
Q

What does the numerator of the snellen acuity chart represent

A

What the patient can read/see at that distance

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41
Q

What does the denominator of the snellen acuity chart represent

A

What a normal eye can read at that distance

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42
Q

What does it mean to say someone has 20/40 vision

A

Patient can read at 20ft what a normal eye can read at 40ft

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43
Q

What does the corneal light reflex assess

A

Muscle balance of the eye

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44
Q

Which cranial nerve does the confrontation test assess

A

Peripheral vision - CN IV

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45
Q

What is a blown pupil

A

One that is widened out but also not reactive to light

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46
Q

What is the macula

A

The point of central vision

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47
Q

The ophthalmoscope is used to view what 4 things

A

Red reflex (should see red dots)

Optic disk

Retinal vessels

General background

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48
Q

What is the proper technique for examining a patients eye with an ophthalmoscope

A

Examine the patients eye on the same eye you are looking through

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49
Q

Name 4 things you are inspecting for when assessing the ear

A

Alignment
Lesions and trauma
Piercings
Tympanic membrane

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50
Q

What could bruising behind the ear mean

A

Head trauma

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51
Q

What is the tragus

A

The bottom part of the ear

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52
Q

Otitis externa

A

An outer ear infection

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53
Q

Otitis media

A

A middle ear infection

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54
Q

What does the weber test , test for

A

Lateralization of bone conduction

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55
Q

What is considered a positive result in a weber test

A

If vibration is louder in one ear

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56
Q

What does the rinne test , test for

A

Test compares bone conduction and air conduction

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57
Q

What is cerumen

A

Ear wax

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58
Q

What is considered a positive result for a rinne test

A

Air conduction greater (>) bone conduction

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59
Q

What should a normal tympanic membrane look like

A

Pearly, gray, shiny and translucent B

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60
Q

How does the tympanic membrane appear in otitis media

A

Red, inflamed, drainage, bulging tympanic membrane

Cone of light disturbed

61
Q

Cone of light of normal tympanic membrane

A

Right ear - 5 o’clock

Left ear - 7 o’clock

62
Q

To see in an adult ear you pull the ear

A

Up and back

63
Q

To see in a child’s ear you pull the ear

A

Down and back

64
Q

Name 6 things to inspect while assessing the mouth

A 
Lips 
Tongue 
Buccual mucosa 
Hard and soft palate 
Teeth 
Pharyngeal wall
65
Q

Patency

A

Is open, expanded or unobstructed

66
Q

What are 4 factors that affect skin texture

A

Exposure

Age

Hyperthyroidism and other endocrine disorders

Impaired circulation

67
Q

Pediculosis

A

Head lice infestation

68
Q

Name 5 abnormal findings on the eyelids

A 
Crust, scales Or swelling 
Pterygium 
Ectropion 
Entropion 
Ptosis
69
Q

Pterygium

A

A growth or thickening of conjunctiva from the inner can this toward the iris

70
Q

Stomatitis

A

Inflammation of the oral mucosa

71
Q

Leukoplakia

A

Thick elevated white patches that do not scrape off , maybe precancerous lesions

72
Q

Thrush

A

White curdy patches that scrape off and bleed

73
Q

What are the ABCs of documentation

A 
Accurate 
Bias-free
Complete
Detailed
Easy to read
Factual 
Grammatical 
Harmless
74
Q

Name 10 guidelines for documenting care

A
  1. maintain confidentiality
  2. correct form
  3. chart clearly marked
  4. write legibly
  5. use black ink
  6. dont leave blank lines
  7. draw a line through incorrect charting and initial
  8. sign all your paper chatting
  9. no shorthand
  10. only use approved abbreviations
75
Q

Name 8 things included in a change-of-shift report

A
  1. client demographics and diagnoses
  2. relevant medical hx
  3. significant assessment findings
  4. treatments (ex:wound care)
  5. upcoming diagnostics or procedures
  6. restrictions (ex: diet,activity,isolation)
  7. plan of care for the client
  8. concerns
76
Q

What are verbal orders

A

Spoken to you in person, not over the telephone

Should only be used during critical situations or emergencies

77
Q

What are telephone orders

A

Received by phone and transcribed into chart order sheet

78
Q

Name 6 things to remember when documenting telephone orders

A
  1. write the order only if you heard it yourself
  2. ensure the order makes sense sigh the clients status
  3. repeat the order to confirm accuracy
  4. spell unfamiliar names/pronounce digits of numbers separately
  5. directly transcribe the order on the chart (date/time, text, TO with providers signature and your signature)
  6. physicians must countersign within 24hrs
79
Q

What is an occurrence report

A

An organizational record or incident report of an unusual occurrence, accident or error

80
Q

List 8 examples of events requiring an occurrence report

A
  1. fall
  2. medication errors
  3. family incidents/injuries
  4. staff injury
  5. unsafe environments
  6. procedural errors
  7. inadequate response to patient situation
  8. lack of resources or supplies
81
Q

Are occurrence reports apart of a patients health record

82
Q

Should you still complete an occurrence report even if there is no adverse impact on the client

A

Yes .. “Near misses” will lead to actual problems if left unreported

83
Q

Name 5 things to include in an occurrence report

A
  1. patients name,date,time,location
  2. briefly discuss the incident in OBJECTIVE terms
  3. quote if possible
  4. identify any witnesses to the event, equipment involved and environmental conditions
  5. avoid drawing conclusions or placing blame
84
Q

What does SBAR stand for

A

Situation
Background
Assessment
Recommendation

85
Q

Why is the SBAR form of documentation useful

A

Useful for interdisciplinary communication, especially critical situations requiring a clinicians immediate attention and action

86
Q

List 4 situations that the SBAR style of documentation can be used

A

Change of shift
Patient transfers
Critical conversations
Telephone calls

87
Q

SBAR related to the joint commission

A

The joint commission on accreditation of hospitals has added “standardized communication” to the patient safety goals and recommends SBAR as a best practice

88
Q

What does the whisper test , test for

A

High pitched hearing loss

89
Q

What is pulse deficit

A

The difference between the apical pulse and the peripheral pulse

90
Q

What is orthopnea

A

Shortness of breath that occurs while laying flat

Seen a lot in ❤️ patients

91
Q

Name 6 abnormal findings when palpating the posterior thorax and lungs

A

Nodules,lumps and tenderness on back

Chest not expanding symmetrically

Tenderness or curvature of spinous process

Asymmetry of vibrations with “99”

Crepitus

Subcutaneous emphysema

92
Q

What is subcutaneous emphysema

A

Is when gas or air is in the layer under the skin

Looks like rice crispies under the skin

93
Q

Name 4 abnormal findings while percussing the lungs

A
  • tenderness with percussion
  • hyperreasonance with percussion over lung fields
  • dullness with percussion over lung fields
  • tenderness with percussion of costovertebral angle
94
Q

Characteristics of bronchial normal breath sounds

A

Pitch: high, loud

Duration: inspiration < expiration

Normal location: trachea and larynx; sounds harsh, hollow, tubular

95
Q

Characteristics of bronchovesicular normal breath sounds

A

Pitch: moderate

Duration: inspiration = expiration

Normal location: over major bronchi where fewer alveoli are located

Posterior between scapulae, especially on right

Anterior around upper sternum in 1st and 2nd intercostal spaces

96
Q

Characteristics of vesicular normal breath sounds

A

Pitch: low, soft

Duration: inspiration > expiration

Normal location: over peripheral lung fields where air flows through smaller bronchioles and alveoli

Sounds rustling like the sound of wind in the trees

97
Q

Crackles

A

(Rales)

Popping open of alveoli or secretions

Occur with pneumonia and pulmonary edema

98
Q

Wheezes

A

(Rhonchi)

Airway narrowing or obstruction

Occurs with asthma and emphysema

99
Q

What are Cheyenne-stokes respirations

A

A cycle in which respirations gradually increase in rate and depth and then decrease

Caused by severe ❤️ failure, renal failure, meningitis, drug overdose and increased cranial pressure

100
Q

What 2 groups of people are Cheyne-stokes respirations normal in

A

Infants and aging people

101
Q

What is crepitus

A

Clicking or grating at a joint

“Creaking” of bones

102
Q

What is stridor

A

Narrow or obstructed upper airway

103
Q

When are wheezes usually heard

A

On expiration

104
Q

When is stridor usually heard

A

Primarily during inspiration

105
Q

What is grunting

A

Difficulty expelling air

106
Q

What is pectus excavatum

A

“Funnel chest”

A condition in which the breastbone sinks into the chest ; sternum sticks out

107
Q

What is Barrel chest

A

A condition in which the anteroposterior and lateral diameters may be equal 1:1 ratio

Instead of the normal 1:2 ration

108
Q

What is the tail of spence

A

When breast tissue and lymph extend up into the axilla

109
Q

What should you have a patient do if adventitious sounds are heard

110
Q

Where can the aortic ❤️ sound be heard best

A

Second intercostal ; right sternal border

111
Q

Where can the pulmonic ❤️ heart sound best be heard

A

Second intercostal ; left sternal border

112
Q

Where can the tricuspid ❤️ sound best be heard

A

Fourth intercostal ; left sternal border

113
Q

Where can the mitral ❤️ sound best be heard

A

5th intercostal ; midclavicular line

114
Q

Name 3 abnormal ❤️ sounds

A

S3 , S4
Murmurs
Rubs

115
Q

What is systole

A

The contraction , or emptying of the ventricles

116
Q

What is diastole

A

Refers to the relaxation , or filling phase of ventricles

117
Q

What is the proper order for stomach assessment

A

Inspect
Auscultate
Percuss
Palpate

118
Q

Name 4 normal variations in abdominal contour

A

Flat
Rounded
Protuberant
Scaphoid

119
Q

Normal bowel sounds

A

Occur every 5-15 seconds or 5-30 times per minute

120
Q

Hyperactive bowel sounds

A

Loud , rushing sounds occurring every 2 or 3 seconds (more than 30 per minute)

May indicate diarrhea, early bowel obstruction or gastroenteritis (infection of the Gi tract)

121
Q

Hypoactive bowel sounds

A

Very faint and infrequent (fewer than 5 sounds per min)

May occur after abdominal surgery or with bowel obstruction, infection or problems of innervation

122
Q

What is ascites

A

An abnormal accumulation of fluid in the abdomen

123
Q

Cranial Nerve I

A

Olfactory

Function: smell

Testing: smell

124
Q

Cranial Nerve II

A

Optic

Function: sight

Testing: visual fields

125
Q

Cranial Nerve III

A

Ocular motor

Function: extraocular movements

Testing: 6 Cardinal fields of gaze , pupillary reflex , pupillary reaction light and accommodation

126
Q

Cranial Nerve IV

A

Trochlear nerve

Function: downward and inward movements of the eye

Testing: 6 Cardinal fields of gaze

127
Q

Cranial Nerve V

A

Trigeminal

Function: sensory of face and jaw

Testing: sensory - cotton , motor - clench teeth

128
Q

Cranial Nerve VI

A

Abducens

Function: lateral deviation of eye

Testing: 6 Cardinal fields of gaze

129
Q

Cranial Nerve VII

A

Facial

Function: lacrimal gland, lid muscles and tongue (tasting)

Testing: puff cheeks, smile, show teeth, raise eyebrows, taste test

130
Q

Cranial Nerve VIII

A

Acoustic

Function: hearing and balance, eardrum, ear canal

Testing: whisper test, weber, rinne, Romberg

131
Q

Cranial Nerve IX

A

Glossopharyngeal

Function:

Testing: tongue , gag

132
Q

Cranial Nerve X

A

Vagus

Function: palate, pharynx, larynx

Testing: gag , “ah” observe soft palate and uvula

133
Q

Cranial Nerve XI

A

Spinal Accessory

Function: sternocleidomastoid and upper portion of trapezius

Testing: shrug shoulder, rom of neck

134
Q

Cranial Nerve XII

A

Hypoglossal

Function:

Testing: protrude tongue, retract tongue, move tongue to right and left

135
Q

List developmental modifications for infants and children

A
  • have parents present and hold infants
  • offer toddlers choices/praise for cooperation
  • let the preschool child help with the exam; give reassurance
  • support the school aged child’s independence
  • adolescents should provide privacy
136
Q

Developmental modifications for older adults

A
  • observe energy level; provide rest periods and limit position changes
  • allow for extra time to interview and examine
  • can’t assume certain positions
  • be alert for hearing and vision deficits
  • assess the older adults functional status
  • SPICES
137
Q

What does SPICES stand for

A 
Sleep disorders 
Problems eating or feeding 
Incontinence 
Confusion 
Evidence of falls 
Skin breakdown
138
Q

What is hypotonia

A

“Floppy baby syndrome”

Poor muscle tone is a condition usually detected at birth or during infancy

139
Q

ROM of the neck

A 
Flexes 
Extends 
Hyperextend 
Bend laterally 
Rotate side to side
140
Q

ROM of shoulder

A 
Flexion 
Extension 
Hyperextended 
Abduct 
Adduct
Rotate internal and external
141
Q

ROM of the elbow

A

Flexion

Extension

142
Q

ROM of wrist

A 
Supination 
Pronation
Radial deviation 
Ulnar deviation 
Flexion 
Extension 
Hyperextend
143
Q

ROM of fingers

A 
Spread the fingers (abduct) 
Bring them together (adduct)
Make a fist (flex)
Extend the hand (extend) 
Bend fingers back (hyperextend)
Bring thumb to index finger (palmar adduction)
144
Q

ROM of hip

A 
Flexion 
Extension 
Hyperextend 
Abduction 
Adduction 
External/internal rotation
145
Q

ROM of knee

A

Flex

Extend

146
Q

ROM of ankle/foot

A 
Dorsiflex 
Plantar flex 
Evert 
Invert 
Abduct 
Adduct 
Rotate
147
Q

What is ABduction

A

Moving AWAY

148
Q

What is ADDuction

A

Moving toward

149
Q

ROM of spine

A 
Bend at the waist 
Stand upright 
Hyperextend (bend backward) 
Bend laterally
Rotate side to side
150
Q

Soft palate movement is associated with which cranial nerves

A

Cranial nerves IX and X

Saying ah , gag reflex

151
Q

Tongue movement is associated with which cranial nerves

A

Cranial nerves IX and XII

Nursing School (36 decks)

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