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Fundamentals of Nursing > Chapter 22: Health Assessment > Flashcards

Chapter 22: Health Assessment Flashcards

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1
Q

Health Assessment is?

A

an assessment that asses the physical, mental, spiritual, socioeconomics, and cultural states.

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2
Q

Nursing Assessment is?

A

Focuses on clients functional abilities and physical responses to illness and other stressors.

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3
Q

Physical Assessment is?

A

Consists of Techniques used to gather (objective data)

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4
Q

What does a complete Health Assessment include?

A
  1. Nursing History

2. Physical Examination

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5
Q

The purpose of the Baseline Data

A

Data about the patients physical status to compare any health changes.

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6
Q

The type of physical examination you perform will depend on clients…

A

Health status, nature of encounters, and settings.

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7
Q

For an Annual Physical perform a…

A

Comprehensive Physical Assessment:

complete head to toe exam, health history interview.

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8
Q

Focused Physical Assessment

A

a particular topic, problem, body part

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9
Q

Systemic Specific Assessment

A

1 body system

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10
Q

What is the order of the Body System approach when preparing to perform a physical examination?

A

Musculoskeleton, Cardiovascular, Neurological

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11
Q

Percussion

A

tapping your fingers on skin.

tapping->produce->vibration= determine location size and density

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12
Q

Auscultation

A

using hearing to gather data

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13
Q

Direct Auscultation

A

listening without using an instrument

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14
Q

Indirect Auscultation

A

listening with the help pf stethoscope

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15
Q

Stethoscope Diaphragm

A

high pitched sounds of the heart, lung, and abdomen

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16
Q

Stethoscope Bell

A

low pitch sounds murmurs, bruits (turbulent blood flow)

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17
Q

Olfaction

A

sense of smell

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18
Q

During olfaction, you notice the client is slurring. You think is was caused by…

A

stroke

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19
Q

Which age group are self conscious, want privacy, and are going through puberty?

A

13-20 adolescence

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20
Q

What type of position is used to measure musculoskeleton, neurological system, asses gait?

A

standing position

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21
Q

If you want to asses vital signs, what position is common to use for patient?

A

Sitting position

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22
Q

When patient is in a supine position and is having a hard time breathing, what passion do you recommend they do next?

A

Fowler’s position: head elevated 60 degree

semi Fowler’s postion: 30 to 50 degrees

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23
Q

What position is used when females get a pelvic exam?

A

Lithotomy

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24
Q

What are the 2 positions use to examine rectal are of the patient

A

sims and knee chest on hands and knees

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25
Q

What is the correct order of physical examination?

A

Inspection, palpation, percussion, Auscultation

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26
Q

When palpating the patient, the nurse uses the dorsum of the hand to…

A

temperature deterimation

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27
Q

When palpating the patient, the nurse uses the palmer surface of the hand to…

A

locate pulsation

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28
Q

When palpating the patient, the nurse uses the fingertips of the hand to…

A

skin texture, swelling, pulsation, masses

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29
Q

In the Integumentary System, you must notice the characteristics of the skin such as…

A

color, temperature, and moisture

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30
Q

If a patient is sweating, this maybe a sign of

A

finished exercising, thyroid problem, overreacted sweating gland

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31
Q

cafe au lait spot is?

A

On infants/ neonates Light brown birthmark: generic disorder/ medical problem

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32
Q

Capillary hemoangiomas

A

small irregular pink areas that can disappear

33
Q

Mangolian Spot

A

blue black birthmark that are found is specific nationality. They usually fade by age 2

34
Q

erythema

A

site of infection

35
Q

If a patients skin temperature feels cooler than usual…then you assume

A

poor peripheral circulation, shock, hypothermia

36
Q

If a patients skin is pale and have a loss of red in their skin tone then…

A

pallor

37
Q

cyanosis

A

blue/green skin color because hypoxia

38
Q

yellow/orange skin color

A

Jaundice

39
Q

Ecchymosis

A

blue green yellow area: sign of abuse/ internal bleeding.

40
Q

Mottling

A

blush

41
Q

What happens when a patient has Edema

A

abnormal fluid in the tissue, common with heart failure, kidney disease, low albumin levels, swollen tissue.

42
Q

Milia is known as

A

white heads

43
Q

Nevi is also known as

A

moles and freckles and birthmarks

44
Q

striae is also know as

A

stretch marks

45
Q

what is the hair type of a patient with hyperthyroidism?

A

very fine and silky

46
Q

what is the hair type of a patient with hypothyroidism?

A

dry

47
Q

Another term for hair loss

A

Alopecia

48
Q

Hirsutism is known as

A

having a lot of facial and trunk hair possibly do to steroid use

49
Q

Bumpy Nail is usual sign of

A

Respiration Problem

50
Q

what is a typical nail plate angle?

A

160 degree and more

51
Q

HEENT

A

Head, eye, ear, nose, teeth

52
Q

Temporomandibular joint syndrom

A

jaw cracks too much

53
Q

Graves disease

A

man looks like women

women look like men

54
Q

myopia

A

far sightness

55
Q

hyperopia

A

near sightness

56
Q

persbyopia

A

diminished near vision (45)

57
Q

cross eye

A

strabismus

58
Q

lazy eye

A

amblyopia

59
Q

what cranial nerves control pupillary reaction to light

A

iii ocululomotor

ii optic

60
Q

how many teeth should adult have

A

28 or 32 including wisdom teeth

61
Q

glossitis

A

inflammation of the tongue

62
Q

What type of test do you use to test color blindness?

A

Itinerary Cards Test

63
Q

When palpating the ear, what do you use?

A

otoscope

64
Q

Webber test

A

use running fork (vibrate) at the center of the head..should have equal vibration in both ears

65
Q

Rinne Test

A

compares air conduction (bone conduction)

66
Q

Romberg Test

A

asses equilibrium…standing with feet together eyes closed. If you see swaying they have vestibular/cerebellar disorder

67
Q

The normal pupil size

A

3mm

68
Q

Cervical lymph nodes have to be what size?

A

1cm

if larger= infection

69
Q

S1

A

lub closure of valve between atria and ventricles

70
Q

S2

A

dub closure for semilunar valve between the ventricles and greater arteries exiting the heart)

71
Q

crepitis

A

popping sound

72
Q

Pulmonary Arteries

A

carry O2 from blood tot he right ventricle->lung

73
Q

Systemic Arteries

A

carry oxygen blood from left ventricle to the body periphery

74
Q

veins carry blood

A

towards the heart

75
Q

arteries carry blood

A

away from the heart

76
Q

peripheral vessels

A

both vein and arteries

77
Q

stereognosis

A

recognize form of object

78
Q

graphesthesia

A

outline number on hand

79
Q

point localization

A

identify if one is being touched

Fundamentals of Nursing (5 decks)

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