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Health Assessment (NUR 202) > Exam 1 (Chapters 1, 8, 9, 10, 11, 13, 5 (p. 63-76), & 32 (p. 1041 - 1070)) > Flashcards

Exam 1 (Chapters 1, 8, 9, 10, 11, 13, 5 (p. 63-76), & 32 (p. 1041 - 1070)) Flashcards

1
Q

Objective Data

(Ch. 1)

A

Measurable data observed by health professional during an exam

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2
Q

Subjective Data

(Ch. 1)

A

Patient reported data

what the patient says about themselves during history taking

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3
Q

What are the two types of data collection methods and are they objective or subjective?

(Ch. 1)

A
  • History Taking = subjective
  • Physical Exam = objective
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4
Q

6 Phases of the Nursing Process

(Ch. 1)

A
  1. assessment
  2. diagnosis
  3. outcome identificiation
  4. planning
  5. implementation
  6. evaluation
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5
Q

First Level Priorities

(Ch. 1)

A
  • A - airway
  • B - breathing
  • C - circulation
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6
Q

Second Level Priorities

(Ch. 1)

A
  • Acute pain
  • Change in mental status
  • Infection
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7
Q

Third Level Priorities

(Ch. 1)

A
  • Lack of knowledge
  • Family coping
  • Activity
  • Rest
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8
Q

4 Types of Data that are collected

(Ch. 1)

A

1. Complete (Total Health) Database:
* describes current & past health state & forms baseline to measure all future changes

2. Episodic or Problem-Centered Database:
* collect “mini” database, smaller scope & more focused than complete database

3. Follow-Up Database:
* status of all identified problems should be regularly evaluated

4. Emergency Database:
* rapid collection of data often complied concurrently with life-saving measures

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9
Q

What is evidence based practice (EBP)?

(Ch. 1)

A
  • systematic approach
  • emphasizes use of best evidence
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10
Q

5 Steps of Evidence Based Practice (EBP)

(Ch. 1)

A

QESAA
1. Ask clinical question

2. Acquire sources of evidence

3. Appraise & synthesize evidence

4. Apply relevant evidence in practice

5. Assess the outcome

Q: ask a question
E: gather sources of evidence
S: synthesize evidence
A: apply relavent evidence to practice
A: assess the outcome

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11
Q

Validation of data entails

a.) distinguishing normal from abnormal
b.) making inferences
c. using an organized & comprehensive approach
d. checking the accuracy & reliability of data

(Ch. 1)

A

d. checking the accuracy & reliability of data

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12
Q

Which critical thinking skill helps the nurse to see relationships among the data?

a. validation
b. clustering related cues
c. identifying gaps in data
d. distinguishing relevant from irrelevant

(Ch. 1)

A

b. clustering related cues

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13
Q

An example of subjective data is:

a. decreased range of motion
b. crepitation in the left knee joint
c. left knee has been swollen & hot for the past 3 days
d. arthritis

(Ch. 1)

A

c. left knee has been swollen & hot for the past 3 days

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14
Q

Which of the following is considered an example of objective data?

a. alert & oriented
b. dizziness
c. earache
d. sore throat

(Ch. 1)

A

a. alert & oreinted

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15
Q

4 Components of the General Survey

(Ch. 9 & 10)

A

BAMS

1. Physical Appearance
* age, sex, LOC, skin color, facial features

2. Body Structure
* stature, nutrition, symmetry, posture, position, body build & contour

3. Mobility
* gait & ROM

4. Behavior
* facial expression, mood & affect, speech, dress, hygiene

B: behavior
A: appearance
M: mobility
S: structure

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16
Q

Normal Temperature Range

(Ch. 9 & 10)

A
  • 96.4 - 99.1 °F

OR

  • 35.8 - 37.3 °C
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17
Q

What can influence temperature?

(Ch. 9 & 10)

A
  • Age
  • Pain
  • Exercise
  • Smoking
  • Drinking hot or cold fluids
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18
Q

What is pulse?

(Ch. 9 & 10)

A

pressure wave created by stroke volume when the heart is pumping

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19
Q

How long should the apical pulse be taken for?

(Ch. 9 & 10)

A

1 minute

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20
Q

List Pulse Descriptors

(Ch. 9 & 10)

A

Force:
* 0 = no pulse
* +1 = weak, thready
* +2 = normal
* +3 = bounding

Rhythym:
* Regular or irregular

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21
Q

Normal Pulse Rate

(Ch. 9 & 10)

In an Adult

A

60 - 100 BPM

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22
Q

Bradycardia Pulse Rate

(Ch. 9 & 10)

Pulse Rate that constitues bradycardia

A
  • < 50 BPM

(less than)

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23
Q

Tachycardia Pulse Rate

(Ch. 9 & 10)

Pulse rate that constitutes tachycardia

A
  • > 95 - 100 BPM

(greater than)

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24
Q

What are respirations and what does one respiration consist of?

(Ch. 9 & 10)

A
  • breaths per minute
  • 1 breath = 1 inspiration AND 1 expiration
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25
Q

Normal Respiratory Rate (in adults)

(Ch. 9 & 10)

A

10 - 20 / minute

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26
Q

What situations can affect respirations?

(Ch. 9 & 10)

A
  • Narcotis
  • Head injury
  • Anesthesia
  • Exercise
  • Sleep
  • Heart Failure
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27
Q

How can respiratory rate be described / what should be noted when measuring respiratory rate?

(Ch. 9 & 10)

A
  • Sounds: wheezing, grunting, gurgling
  • Effort: accessory muscle use
  • Position: orthopnea, tropod, nocturnal dyspnea, sleeping upright in a chair
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28
Q

What does pulse oximetry measure?

(Ch. 9 & 10)

A

saturation of oxygen (SpO2)

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29
Q

Normal SpO2 Range

(Ch. 9 & 10)

A

97 - 99%

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30
Q

What situations can affect oxygen saturation?

(Ch. 9 & 10)

A
  • Anemia
  • Lung disease
  • Heart disease
  • Inadequate O2 given
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31
Q

What is Blood Pressure?

(Ch. 9 & 10)

A
  • Systolic: blood pushing aginst the vessel wall (CONTRACTION)
  • Diastole: blood resting and no longer pushing against the vessel wall (REST)
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32
Q

What is Pulse Pressure?

(Ch. 9 & 10)

A

difference between systolic & diastolic BP

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33
Q

What can influence BP?

(Ch. 9 & 10)

A
  • age, race, sex, weight, emotions, exercise, stress, medication
  • cardiac output, volume of circulating blood, viscosity, elasticity of vessel walls
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34
Q

Normal Blood Pressure

(Ch. 9 & 10)

A

< 120/80

systolic: < 120
diastolic: < 80

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35
Q

Hypertension Blood Pressure

(Ch. 9 & 10)

What constitutes hypertension?

A

BP > 120 - 129 / 80

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36
Q

What is orthostatic hypotension?

(Ch. 9 & 10)

A

Drop in systolic BP > 20 mmHg

  • increase in pulse > 20 b/min when changing to a standing position

(greater than)

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37
Q

How high should the BP cuff be inflated?

(Ch. 9 & 10)

A

20 - 30 mmHg above pulse cessation point

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38
Q

Common Errors with BP Assessment

(Ch. 9 & 10)

A
  • arm placement
  • crossed legs
  • deflating cuff too fast or slow
  • not waiting 1-2 min between readings
  • failure to palpate for inflation level
  • incorrect cuff size (too big or too small)
  • defective equipment
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39
Q

What are Korotkoff Sounds?

(Ch. 9 & 10)

A
  • Korotkoff I: first clear audible tapping sound (systolic number)
  • Korotkoff V: silence or last audible sound (diastolic number)
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40
Q

Which patient would be most likely to present with a pulse rate that is lower than normal?

a. a 70-year-old telephone salesman presenting with dehydration
b. a 20-year-old runner who had surgery 4 days ago for a fractured leg
c. a 67-year-old who presented with an exacerbation of his COPD

(Ch. 9 & 10)

A

b. a 20-year-old runner who had surgery 4 days ago for a fractured leg

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41
Q

Helpful Temperature Conversions to Memorize

  • 104 °F = ?
  • 98.6 °F = ?
  • 95 °F =?

(Ch. 9 & 10)

A
  • 104 °F = 40 °C
  • 98.6 °F = 37 °C
  • 95 °F = 35 °C
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42
Q

What is an ausculatory gap?

(Ch. 10 - vital signs)

A

** No Sound**

  • silence for 30 - 40 mmHg during deflation; this is an abnormal finding
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43
Q

Common errors in blood pressure measurement include:

a. taking BP in an arm that is at the level of the heart
b. waiting < 1-2 minutes before repeating the BP reading on the same arm
c. waiting 30 minutes if the client has just smoked a cigarette
d. using a BP cuff whose bladder is 80% of the arm circumference

(Ch. 9 & 10)

A

b. waiting < 1-2 minutes before repeating the blood pressure reading on the same arm

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44
Q

What is inspection & what does it require?

(Ch. 8)

A

Inspection: concentrated watching; compares the R & L sides of the body

Requires:
* good lighting
* adequate exposure
* occasional use of certain instruments

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45
Q

What is palpation and what is it used to assess?

(Ch. 8)

A

Palpation: applies sense of touch to assess…

  • texture
  • temperature
  • moisture
  • organ location & size
  • swelling
  • vibration or pulsation
  • rigidity or spasticity
  • crepitation
  • presence of lumps or masses
  • presence of tenderness or pain
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46
Q

What is percussion & what does it depict?

(Ch. 8)

A

Percussion: tapping the patient’s skin with short, sharp strokes that create audible vibration & sounds to assess underlying structures

  • Depicts the size, location, & density of underlying organs
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47
Q

What are the 4 key parts of assessment?

(Ch. 8)

A
  • I: inspection
  • P: palpation
  • P: percussion
  • A: auscultation
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48
Q

What is palpation unable to determine?

(Ch. 8)

A

disease state of an organ

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49
Q

When is light vs deep palpation used?

(Ch. 8)

A
  • Deep Palpation: intermittent pressure to examine abdominal contents
  • Light Palpation: used to detect surface characteristics
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50
Q

Characteristics Assessed by Palpation

(Ch. 8)

A
  • texture
  • temperature & moisture
  • organ location & size
  • swelling
  • vibration & pulsation
  • rigidity or spasticity
  • crepitation (cracking)
  • presence of lumps / masses or tenderness / pain
51
Q

List the characteristics of percussion

(Ch. 8)

A
  • resonant
  • hyperresonant
  • tympany
  • dull
  • flat
  • amplitude
52
Q

What is a resonant sound & where is it located during percussion?

(Ch. 8)

A
  • clear sound
  • over lung fileds, hollow
53
Q

When is a hyperresonant sound heard durring percussion?

(Ch. 8)

A
  • over child lungs
  • in patients with COPD
54
Q

What is a tympany & where is it heard during percussion?

(Ch. 8)

A
  • heard over the abdomen (air filled areas)
  • normal finding
  • sounds like a drum
55
Q

What is a dull sound during percussion & where is it heard?

(Ch. 8)

A
  • sounds like a muffled thud
  • heard over organs (liver, spleen, etc.)
56
Q

What is a flat sound during percussion & where is it heard?

(Ch. 8)

A
  • sound comes to a dead stop
57
Q

What is amplitude in terms of percussion characteristics?

(Ch. 8)

A

can be loud or soft

58
Q

What sounds are detected using the bell vs the diaphragm of the stethoscope?

(Ch. 8)

A
  • Diaphragm: used to detect high pitch sounds (lung, abdoem, heart)
  • Bell: used to detect low pitch sounds (vascular, extra heart sounds, etc.)
59
Q

What sounds is the diaphragm of the stethoscope used to detect?

(Ch. 8)

A

high pitched sounds

  • lungs, abdomen, heart
60
Q

What sounds is the bell of the stethoscope used to detect?

(Ch. 8)

A

**low pitch sounds*

  • vascular sounds, extra heart sounds
61
Q

What is the difference in how you place the diaphragm vs. the bell for effective auscultation?

(Ch. 8)

A
  • Diaphragm = place firmly
  • Bell = place lightly
62
Q

What side should you always examin the patient from?

(Ch. 8)

A

RIGHT side

63
Q

The bell of the stethoscope

a.) is used for soft, low-pitched sounds
b.) is used for high-pitched sounds
c.) is held firmly against the skin
d.) magnifies sound

(Ch. 8)

A

a.) is used for soft, low-pitched sounds

64
Q

Which of the following techniques uses the sense of touch when assessing a patient?

a.) inspection
b.) percussion
c.) palpation
d.) auscultation

(Ch. 8)

A

c.) palpation

65
Q

Is pain subjective or objective?

(Ch. 11)

A

subjective

66
Q

What type of treatment should be considered when treating or managing pain?

(Ch. 11)

A

holistic treatment

67
Q

What are the 4 concepts of nociception?

(Ch 11)

A

1.) Transduction: stimulus occurs in periphery
2.) Transmission: pain moves from spinal cord to brain
3.) Perception: conscious awareness of pain sensation
4.) Modulation: neurons release NTs that block pain impulses

68
Q

What is transduction in regard to nociception?

(Ch. 11)

A

stimulus is felt in the periphery

69
Q

What is transmission in regard to nociception?

(Ch. 11)

A

pain impulse moves from spinal cord to brain

70
Q

What is perception in regard to nociception?

(Ch. 11)

A

conscious awareness of pain sensation

71
Q

What is modulation in regard to nociception?

(Ch. 11)

A

neurons (from the brainstem) release neurotransmitters that block pain impulses

72
Q

What is neuropathic pain?

(Ch. 11)

A

abnormal processing of pain

  • most difficult type of pain to treat
  • pain is perceived long after injury heals
73
Q

Give examples of neuropathic pain

(Ch. 11)

A
  • chronic pain / nerve pain
  • shingles
  • sciatica
  • phantom limb
  • diabetes
  • patients with HIV
74
Q

What are 4 sources of pain?

(Ch. 11)

A
  • visceral pain
  • deep somatic pain
  • cutaneous pain
  • referred pain
75
Q

What is visceral pain?

(Ch. 11)

A

pain in the deep interior organs

stomach, gallbladder, kidneys

76
Q

What is deep somatic pain?

(Ch. 11)

A

pain in the blood vessels, bone, muscle, tendons, etc.

77
Q

What is cutaneous pain?

(Ch. 11)

A

superficial / skin injuries

78
Q

What is referred pain?

(Ch. 11)

A

pain felt from one site, but pain is actually caused by pain or injury in a different location of the body

79
Q

What is acute pain?

(Ch. 11)

A
  • short-term
  • follows a predictable trajectory
  • dissipates after injury heals
  • has protective qualities
  • activates autonomic nervous system
  • elevated BP & respiratory rate
80
Q

What is chronic pain?

(Ch. 11)

A
  • continues beyond expected time
  • has no protective qualities
  • normal vital signs
  • level of pain may not correspond with physical findings
81
Q

What does pain in aging adults indicate?

(Ch. 11)

A

pathology or injury

82
Q

Which type of pain would cholecystitis (gallbladder disease) cause?

a.) somatic
b.) visceral
c.) cutaneous
d.) chronic

A

b.) visceral pain

visceral pain = internal organs

83
Q

What anticipated finding regarding patients with chronic pain should guide a nurse’s care planning?

a.) patients with chronic pain have trouble sleeping
b.) patients with chronic pain show elevated blood pressure
c.) patients with chronic pain need less medication
d.) patients with chronic pain may show few or no outward signs of pain

(Ch. 11)

A

d.) patients with chronic pain may show few or no outward signs

84
Q

What is unique about aging skin?

(Ch. 12)

A
  • drier, flat skin
  • decreased sebum & sweat production, elasticity, functioning melanocytes, elastin, collagen, subcutaneous fat
  • changes in temperature regulation, nails, & hair
  • increased vascular fragility
  • skin lesions are more common
  • increased risk for damage from pressure due to changes in circulation & decreased ability to form new collagen
85
Q

What factors can lead to the development of a pressure ulcer?

(Ch. 12)

A
  • external pressure
  • friction & shearing
  • immobility
  • nutrition & hydration
  • moisture
  • mental status
  • age
86
Q

What is the Braden Scale & explain how it works.

(Ch. 12)

A

assesses risk for developing pressure injury

  • lower score = higher risk for pressure injury development

low score = high risk

high score = less risk of pressure injury

87
Q

What are the 7 factors used in the Braden Scale to assess pressure injury risk?

(Ch. 12)

A
  • sensory perception
  • moisture
  • activity
  • mobility
  • nutrition
  • friction & shear
88
Q

What are the 4 stages of pressure injury?

(Ch. 12)

A

1.) Non-Blanchable Erythema: intact skin with non-blanchable erythrma
2.) Partial-Thickness Skin Loss: loss of dermis, skin is open & presents as an abrasion or blister.
3.) Full-Thicckness Skin Loss: subcutaneous tissue may be visible, presents as a deep crater
4.) Full-Thickness Skin/Tissue Loss: tissue necrosis or damage to muscle, bone, or supporting structures

89
Q

What is a stage I pressure injury?

(Ch. 12)

A

intact skin with non-blanchable erythema

  • localized redness
  • skin is not broken
  • skin does not blanch
90
Q

What is a stage II pressure injury?

(Ch. 12)

A

partial-thickness skin loss

  • skin is open
  • loss of epidermis & exposed dermis
  • appears as an abrasion or blister
91
Q

What is a stage III pressure injury?

(Ch. 12)

A

Full-Thickness Skin Loss

  • subcutaneous tissue may be visible
  • appears as a deep crater
  • may see subcutaneous fat, granulation tissue, & rolled edges
92
Q

What is a stage IV pressure injury?

(Ch. 12)

A

Full-Thickness Skin/Tissue Loss

  • all skin layers are involved
  • extends into supporting tissue exposing muscle, tendon, or bone
  • tissue necrosis
93
Q

What should be included in wound & skin lesion documentation?

(Ch. 12)

A
  • color
  • characteristics of edges & wound bed
  • size & shape
  • depth / tunnles / raised
  • odor
  • clocked method
  • drainage characteristics
  • treatment method, patient tolerance, date, time, signature
94
Q

What is pruritis?

(Ch. 12)

A

itchy skin

95
Q

Explain how capillary refill is measured

(Ch. 12)

A

brisk: 1-2 seconds
- less than 3 seconds

sluggish: 3+ seconds

96
Q

A patient who is admitted for liver failure would be likely to show which of the following skin changes?

a.) cyanosis
b.) flushing
c.) rubor
d.) jaundice

A

d.) jaundice

97
Q

Keloid

(Ch. 12)

A

hypertrophic scar

98
Q

Petechiae

(Ch. 12)

A
  • tiny punctate hemorrhages
  • 1-3 mm
  • round & discrete
  • dark red, purple, or brown in color
99
Q

Nodule

(Ch. 12)

A
  • solid
  • elevated
  • hard or soft
  • larger than 1 cm
100
Q

Vesicle

(Ch. 12)

A
  • elevated cavity containing free fluid
  • up to 1 cm
  • clear serum flows if wall is ruptured
101
Q

Ecchymosis

(Ch. 12)

A

a large patch of capillary bleeding into tissue

102
Q

What is an annular or circular lesion?

(Ch. 12)

A

begins in the center & spreads to periphery

Ex: tinea corporis (ringworm), tinea versicolor, pityriasis rosea

103
Q

What is a grouped skin lesion?

(Ch. 12)

A

clusters of skin lesions

vesicles of contact dermatitis

104
Q

What is a gyrate skin lesion?

(Ch. 12)

A

twisted, coiled spiral, or snake-like lesion

105
Q

What is a linear skin lesion?

(Ch. 12)

A

scratch, streak, line, or stripe

106
Q

5 Levels of Consciousness

(Unit 1 (assessment of whole person) Ch. 5 (mental status))

A

1.) Alert
2.) Lethargic (Somnolent)
3.) Obtunded
4.) Stupor (Semi-Coma)
5.) Coma

107
Q

Explain the first level of consciousness

(Unit 1 (assessment of whole person) Ch. 5 (mental status))

A

Alert:

  • awake or readily aroused
  • oriented
  • fully aware of external & internal stimuli & responds appropriately
  • conducts meaningful interpersonal interactions
108
Q

Explain the second level of consciousness

(Unit 1 (assessment of whole person) Ch. 5 (mental status))

A

Lethargic (Somnolent):

  • not fully alert; drifts off to sleep when not stimulated
  • can be aroused to name when called in normal voice, but looks drowsy
  • responds appropriately to questions or commands but thinking seems slow & fuzzy
  • inattentive, loses train of thought
  • spontaneous movements are decreased
109
Q

Explain the third level of consciousness

(Unit 1 (assessment of whole person) Ch. 5 (mental status))

A

Obtunded:

  • sleeps most of the time
  • difficult to arouse - needs loud shout or vigorous shake
  • acts confused when is aroused
  • converses in monosyllables
  • speech is mumbled & incoherent
  • requires constant stimulation for even marginal cooperation
110
Q

Explain the fourth level of consciousness

(Unit 1 (assessment of whole person) Ch. 5 (mental status))

A

Stupor (Semi-Coma)

  • spontaneously unconscious
  • responds only to persistent & vigorous shake or pain
  • has appropriate motor response; otherwise can only groan, mumble, or move restlessly
  • reflex activity persists
111
Q

Explain the fifth level of consciousness

(Unit 1 (assessment of whole person) Ch. 5 (mental status))

A

Coma

  • completely unconscious
  • no response to pain or any external or internal stimuli
  • light coma has some reflex activity but no purposeful movement
  • deep coma has no motor response
112
Q

Name each of the 5 stages of conscioussness & provide a 1-5 word explanation

(Unit 1 (assessment of whole person) Ch. 5 (mental status))

A

1.) Alert: awake & responsive
2.) Lethargic (Somnolent): sleepy/drowsy (falls asleep between care)
3.) Obtunded: difficult to arouse
4.) Stupor (Semi-Coma): very difficult to arouse
5.) Coma: completely unconscious / unarousable

113
Q

What is delirium?

(Unit 1 (assessment of whole person) Ch. 5 (mental status))

A

clouding of consciousness

  • inattentive, incoherent conversation
  • impaired recent memory & confabulatory for recent events
  • often agitated & having visual hallucinations
  • disoriented with confusion worse at night when environmental stimuli are decreased
114
Q

What are the 3 different types of aphasia?

(Unit 1 (assessment of whole person) Ch. 5 (mental status))

A

1.) Global Aphasia
2.) Broca Aphasia
3.) Wernicke Aphasia

115
Q

What is Global aphasia?

(Unit 1 (assessment of whole person) Ch. 5 (mental status))

A

Patient cannot understand OR express language

116
Q

What is Broca Aphasia?

(Unit 1 (assessment of whole person) Ch. 5 (mental status))

A

individual cannot express themself using words, strugles to form complete sentences

  • uses broken words

Broca = br..oken

117
Q

What is Wernicke Aphasia?

(Unit 1 (assessment of whole person) Ch. 5 (mental status))

A

inability to understand language

  • fluent speech, but it’s a word salad (does not make sense)

Wernicke = what?

118
Q

What are the levels of the Sedation Scale & what do they mean?

(Unit 1 (assessment of whole person) Ch. 5 (mental status))

A
  • S: asleep, easy to arouse
  • 1: awake & alert
  • 2: slgihtly drowsy, easily aroused
  • 3: frequently drowsy, arousable, drifts off to sleep during conversation
  • 4: somnolent, minimal or no response to physical stimulation
119
Q

What does a sedation scale level S mean?

(Unit 1 (assessment of whole person) Ch. 5 (mental status))

A
  • asleep
  • easy to arouse
120
Q

What does a sedation scale level 1 mean?

(Unit 1 (assessment of whole person) Ch. 5 (mental status))

A
  • awake & alert
121
Q

What does a sedation scale level 2 mean?

(Unit 1 (assessment of whole person) Ch. 5 (mental status))

A
  • slightly drowsy
  • easily aroused
122
Q

What does a sedation scale level 3 mean?

(Unit 1 (assessment of whole person) Ch. 5 (mental status))

A
  • frequently drowsy
  • arousable
  • drifts off to sleep during conversation
123
Q

What does a sedation scale level 4 mean?

(Unit 1 (assessment of whole person) Ch. 5 (mental status))

A
  • somnolent
  • minimal or no response to physical stimulation
124
Q

What does a mental status exam consist of?

(Unit 1 (assessment of whole person) Ch. 5 (mental status))

A
  • appearance
  • behavior
  • cognition
  • thought process
  • perception

Health Assessment (NUR 202) (4 decks)

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