Chapter 17 Health Assessment Key Terms

Question 1

accessory muscles

Answer 1

scalene and sternomastoid muscles of the neck and shoulders

Question 2

accommodation

Answer 2

test that engages a patient to look at a close object and then look at a distant object to see whether patient’s pupils constrict to focus on the close object and dilate to see the distant object

Question 3

anterior posterior diameter

Answer 3

distance between the sternum and vertebral column, drawn as a straight line through the thorax

Question 4

ascites

Answer 4

accumulation of serious fluid in the peritoneum

Question 5

audiometer

Answer 5

device in hearing tests that uses headphones capable of transmitting sounds of different frequencies

Question 6

auscultation

Answer 6

technique of listening to body sounds with stethoscope

Question 7

bronchial breath sounds

Answer 7

loud, high pitched sounds, with a hollow quality often compared to the sound of air blowing through a pipe

Question 8

bruits

Answer 8

sounds heard with auscultation; due to turbulent blood flow, such as occurs in partially obstructed blood vessels, tight or floppy heart valves, or dialysis fistulas

Question 9

capillary refill time

Answer 9

simple test of circulatory status that uses nailbeds

Question 10

circulation, motion, sensation

Answer 10

areas evaluated when an acute problem with a limb is possible

Question 11

clubbing

Answer 11

swelling in the nails that flattens the profile angle to 180 degrees or less

Question 12

crepiust

Answer 12

grating feeling and pain that accompany problems with the temporal mandibular joint

Question 13

cyanosis

Answer 13

grayish, blueish or purplish skin tone

Question 14

diaphragmatic excursion

Answer 14

percussion of the posterior diaphragm and measurement of the difference between complete exhalation and full inhalation

Question 15

edema

Answer 15

accumulation of fluid in the interstitial tissues

Question 16

erythema

Answer 16

redness, usually from irritation or inflammation

Question 17

expressive aphasia

Answer 17

communication disorder in which the patient understands and follows directions but cannot verbally and effectively communicate with the nurse

Question 18

focused health assessment

Answer 18

assessment based on the patient’s problems; components include performing a general survey, taking vital signs, and assessing specific areas that related to the problem

Question 19

gallops

Answer 19

auscultation of S3 and S4 heart sounds that is clearest at the apex when the patient is positioned on the left side

Question 20

general survey

Answer 20

apparent state of health, level of consciousness, and signs of distress in a patient

Question 21

glasgow coma scale

Answer 21

standardized assessment tool used when serial assessments are done for high risk patients (e.g. brain tumor, after brain surgery, after a cerebral vascular accident)

Question 22

health history

Answer 22

goal directed conversation between nurse and patient

Question 23

inspection

Answer 23

systematic visual examination of the patient

Question 24

jaundice

Answer 24

yellowish tone to the skin that is also observed in liver disease

Question 25

kyphosis

Answer 25

thoracic abnormality that includes an exaggerated convex curve of the spine

Question 26

lordosis

Answer 26

commonly known as “swayback” in which the lumbar region curves inward and the sacral region curves outward

Question 27

murmur

Answer 27

vibrating sound that results from turbulent blood flow through the heart

Question 28

nystagmus

Answer 28

involuntary, rhythmic oscillations of the eyes

Question 29

objective data

Answer 29

observable, measurable information that can be validated or verified

Question 30

ophthalmoscope

Answer 30

instrument for examining the interior of the eye

Question 31

otoscope

Answer 31

instrument for examining the ear

Question 32

pallor

Answer 32

skin color that may appear pale with hypoxia and anemia

Question 33

palpation

Answer 33

use of the sense of touch to ascertain the size, shape, and configuration of underlying body structures

Question 34

percussion

Answer 34

examination by tapping the body surface with the fingertips and evaluating the sounds obtained

Question 35

point of maximal impulse

Answer 35

visible pulsation with ventricular contraction as the left side of the heart strikes the anterior chest wall

Question 36

primary data

Answer 36

information that includes vital signs, height , and weight gathered directly from the patient during the initial stage of the assessment to obtain a general overview of the patient’s status

Question 37

receptive aphasia

Answer 37

disorder in which patients cannot understand simple directions

Question 38

resonance

Answer 38

echoing of sound through passages

Question 39

respiratory excursion

Answer 39

normal chest expansion during inspiration; usually symmetric, indicating equal expansion of both lungs

Question 40

retraction

Answer 40

backward or inward movement of an organ or part

Question 41

scoliosis

Answer 41

lateral curvature of a portion of the spine

Question 42

secondary data

Answer 42

sources of data other than the patient, such as the chart

Question 43

skin turgor

Answer 43

tension or rigidity of skin

Question 44

stethoscope

Answer 44

device that collects and transmits sound, selects frequencies, and screens out extraneous sound

Question 45

subjective data

Answer 45

symptoms or covert cue that include the patient’s feelings and statements about hsi or her health problems

Question 46

tactile fremitus

Answer 46

sensation felt by a hand placed on a part of the body (ex chest) that vibrates during speech

Question 47

vesicular breath sounds

Answer 47

sounds described as soft and breezy, with inspiration markedly longer than expiration, normally heard over all areas of the lung except over or near the major airways