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NRSG 238- Assessment > Exam 1 > Flashcards

Exam 1 Flashcards

1
Q

complete assessment

A

admission
yields first diagnosis
est. database

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2
Q

focused or problem centered assessment

A

one body system or problem

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3
Q

emergency assessment

A

rapid collection

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4
Q

follow up assessment

A

regular or appropriate intervals

ex. nursing home evals

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5
Q

comprehensive history

A

biog data (name and date of birth)
health and illness patterns
request for care
present health status / problems

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6
Q

request for care (includes)

A

what patient is there for

date of last exam

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7
Q

symptom analysis

A 
PQRSTU
provocative/palliative
quality/quantity
location
region/radiation
severity
timing
understanding/perception
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8
Q

functional assessment

A

health percep/ management
expectations of provider
concerns for own health
hygiene

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9
Q

palpation types

A

light 1-2 cm
temp and moisture
deep >2 cm
organs and masses

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10
Q

percussion purpose

A

determine density, location and size, tenderness

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11
Q

percussion depth

A

3-5 cm

*limited in high fat areas

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12
Q

tympany tone

A

abdom/stomach

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13
Q

resonance tone

A

lungs

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14
Q

dullness tone

A

liver, heart or fluid

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15
Q

flatness tone

A

bone or lrg muscle

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16
Q

hyperresonanace tone and example condition

A

not normal!
excess air
COPD

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17
Q

auscultation digraphmn use

A

high pitched/ bowel sounds

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18
Q

auscultation bell use

A

low pitched

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19
Q

skin cancer signs ABCD

A 
asymm
uneven borders
1+ colors
diameter 
      lrger than 6 mm or 1/4 in (pencil eraser)
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20
Q

pallor

A

white color

dec circulation or shock

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21
Q

erythema

A

red color

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22
Q

cyanosis

A

blue color

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23
Q

hematoma

A

collection of blood (goose egg)

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24
Q

contusion

A

bruise

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25
Q

normal findings for skin

A

good turgor, dry, fair, warm

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26
Q

normal findings for nails

A

no clubbing, cap refill > 2-3 seconds, no white spots

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27
Q

norma findings for hair

A

texture, equal distribution, color

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28
Q

macule

A

< 1cm flat

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29
Q

papule

A

<1 cm elevated

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30
Q

bulla

A

> 1 cm fluid filled

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31
Q

patch

A

> 1 cm flat

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32
Q

Plaque

A

> 1cm elevated

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33
Q

vesicle

A

< 1 cm fluid

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34
Q

pustule

A

any size w/ purulent drainage

35
Q

wheal

A

raised any size, usually allergic rxn

36
Q

scar types

A

keloid- raised

atrophic- bellow dermis

37
Q

lichenificaiton

A

thickening of skin, scaly

38
Q

components braden scale

A 
sens. percep
moisture
act.
mobility
nutrit.
friction and shearing
39
Q

normal ear findings- outer

A

no lesions, edema, redness, pain and skin is intact

40
Q

normal ear alignment

A

10 degrees vertically

equal with eye occipital line

41
Q

purpose of otoscope

A

look at inner canal and tympanic mem

tilt head opposite side, pull ear back and up > 3 yrs

42
Q

light reflections for ear otoscope

A

R- 5 oclock

L- 7 oclock

43
Q

otitis media

A

middle ear infection

tympan mem red and inflammed

44
Q

infant eustachian tube

A

horizontal, prone to ear infections

45
Q

conductive hearing loss

A

outer/ middle

prevention sound waves

46
Q

sensioneural hearing loss

A

inner ear

loud noise damage or ODOTOXINS

47
Q

whisper test tests what

A

high pitch sound

48
Q

accomodation

A

lens alteration to focus on close objects

49
Q

scotoma

A

blind spot in visual field

50
Q

epiphora

A

excessive eye tearing

51
Q

cn nerve for vision

A

2

52
Q

snellen chart

A

distance vision
myopia (nearsightedness)
need correction if 20/30 or worse

53
Q

near vision

A

hyperopia

14/14 normal

54
Q

presbyopia

A

40 yrs old

dec. accommodation (lens stiffens)

55
Q

confrontation test

A

checking inf. sup. nasal and temporal

*peripheral vision

56
Q

EOM

A

cn 3, 4 and 6
positions of gaze (nystagmus)
corneal light reflex (strabismus)
cover and uncover

57
Q

strabismus

A

eyes dont look at same point

58
Q

injections

A

blood vessels

59
Q

corneal blink reflex- cn?

A

cn 5 and 7

should be unconcious

60
Q

PERLA

A 
pupil
equal
round
reactive to light
accommodate
61
Q

opthalmoscope

A

looking for red reflex

can see optic disk or macula lutea

62
Q

cranial nerve 3 4 and 6

A

eom (eyes)

63
Q

cn 2

A

vision, distance and near

64
Q

cn 5

A

facial sensations (temporal motor control)

65
Q

cn 7

A

facial expression

66
Q

cn 8

A

ears

67
Q

cn 9-10

A

gag reflux and phonation (uvula and soft pal)

68
Q

cn 11

A

neck and shoulder mvmnt

69
Q

cn 12

A

tongue control

70
Q

nomocephalic

A

normal skull
measure from frontal to occipital prominence
no tenderness
birth - 2 yrs

71
Q

normal trachea

A

midline

72
Q

normal thyroid

A

no palpable, or tender

73
Q

cn 5

A

facial sensations
1 branch- opthalmic
2- maxillary
3- mandibular

74
Q

lymphadenopathy

A

enlarged nodes

due to allergies, infections or growth/ mass

75
Q

patency

A

unobstructed, open

76
Q

cn 1

A

smell

77
Q

stetsons duct

A

opposite 2nd molar in inner cheek

78
Q

whartons duct

A

underneath tongue on e/ side (ventral)

79
Q

sublingual gland

A

along base tongue

80
Q

teeth for adult inc wisdom

A

32

81
Q

xerostomia

A

dry mouth

82
Q

tonsil rating

A

0-4+
0- not visible
4+ touching
ex. 2+/ 0-4+

83
Q

cn 3

A

constriction of pupils

NRSG 238- Assessment (11 decks)

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