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NUR 216: Health Assessment > Exam 2 > Flashcards

Exam 2 Flashcards

1
Q

CN I

A

Olfactory
- smell

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2
Q

CN II

A

Optic
- sight

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3
Q

CN III

A

Oculomotor
- eyeball movement: MR, IR, SR, IO
- movement of upper eyelid: LP
- pupillary light reflex

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4
Q

CN IV

A

Trochlear
- eyeball movement: superior oblique

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5
Q

CN V

A

Trigeminal
- Opthalmic: facial sensation/pupillary dilation
- Maxillary: facial sensation
- Mandibular: chewing/facial sensation

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6
Q

CN VI

A

Abducens (6 Abs)
- eyeball movement: lateral rectus

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7
Q

CN VII

A

Facial
- taste: anterior of tongue
- facial expression/eyelid closing
- lacrimation
- salivation

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8
Q

CN VIII

A

Vestibulocochlear
- hearing: cochlea
- balance: vestibular apparatus

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9
Q

CN IX

A

Glossopharyngeal
- sensation from posterior 1/3 of tongue, tonsils middle ear, pharynx
- stylopharyngeus muscle
- salivation

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10
Q

CN X

A

Vagus
- swallowing
- elevation of palate
- talking
- coughing
- gag reflex
- heart rate
- GI peristalsis
- sweating
- vasovagal synope
- peripheral chemoceptors

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11
Q

CN XI

A

Accessory
- head turning: SCM
- shrugging: trapezius

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12
Q

CN XII

A

Hypoglossal
- most muscles of tongue (except palataglasus)
- tongue movement

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13
Q

What to look at when assessing integumentary system?

A

skin
hair
scalp
nails

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14
Q

Integumentary Assessment Equipment

A

penlight
gloves
flexible ruler/tape measure
gown/drape to cover the client

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15
Q

What are you looking for when inspecting the skin?

A

color
odor
integrity

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16
Q

Abnormal findings in skin:

tenderness may indicate….

A

inflammation

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17
Q

Abnormal findings in skin:

increase moisture

A

fever or thyroxitoxicosis

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18
Q

Abnormal findings in skin:

decrease moisture

A

dehydration, myxedema, chronic nepriritis

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19
Q

Abnormal findings in skin:

coarse, thick, dry skin

A

hypothyroidism

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20
Q

Abnormal findings in skin:

skin more fine-texture

A

hyperthyroidism

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21
Q

Abnormal findings in skin:

smooth, thin, shiny skin

A

Arterial Insufficiency

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22
Q

Abnormal findings in skin:

thick, rough skin

A

venous insufficiency

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23
Q

Abnormal findings in skin:

decreased turgor/tenting

A

dehydration or normal aging

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24
Q

Abnormal findings in skin:

increase turgor/tension

A

scleroderma and edema

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25
Q

What are you looking for when inspecting the nails?

A

color
condition
angle of attachment
presence of focal or generalized abnormalities (ridges/clubbing)

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26
Q

Normal nail angle

A

160*

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27
Q

abnormal nail angle

A

> or = 180*

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28
Q

Abnormal findings in nails:

yellow nails

A

cigarette smoking
fungal infection
psoriasis

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29
Q

Abnormal findings in nails:

very distal band of reddish-pink or brown covering <20%

A

cirrhosis
disorder causing hypoalbuminemia

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30
Q

Abnormal findings in nails:

distal band of reddish-pink or brown covering 20% to 60% of the nail

A

renal disease
hypoalbuminemia

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31
Q

Abnormal findings in nails:

green nails (pseudonomas)

A

infection

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32
Q

Abnormal findings in nails:

white nails (leukonychia)

A

trauma
liver
cardiovascular
renal disease

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33
Q

Abnormal findings in nails:

black nails

A

trauma

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34
Q

Abnormal findings in nails:

splinter hemmorhage

A

bacterial endocarditis
trauma

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35
Q

Abnormal findings in nails:

clubbing

A

congenital heart disease
cystic fibrosis
chronic pulmonary disease

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36
Q

Abnormal findings in nails:

spooning/concave nail (koilonychia)

A

severe iron deficiency anemia

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37
Q

Abnormal findings in nails:

separation of nail from the bed (onycholysis)

A

fungal infection
psoriasis
eczema
following trauma
as allergic response to new products

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38
Q

Abnormal findings in nails:

pitting

A

psoriasis

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39
Q

What to look for when examining lesions?

A

size
color
shape
consistency
elevation
location
distribution
configuration
tenderness
fluid
drainage

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40
Q

arise from healthy skin tissue

A

primary lesion

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41
Q

non-palpable
skin color change
< 1cm

freckles, mole melanoma

A

Macule

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42
Q

palpable
circuscribed
solid elevation of the skin
<1cm

elevated nevus
psoriasis

A

Papule

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43
Q

palpable
circumscribed
deep
firm
1-2cm

wart

44
Q

serous fluid-filled
<1cm

blister, herpes simplex, varicella

45
Q

pus-filled
varied in size

acne

46
Q

solid mass
deep
larger than 1-2cm

epithelioma

47
Q

palpable
irregular borders
edematous

insect bite

48
Q

thinning of the skin
w/loss of the skin furrow
skin is shiny and translucent

arterial insufficiency

49
Q

results from change in primary lesion

A

secondary lesion

50
Q

lost epidermis
moist surface
no bleeding

ruptured vesicle

51
Q

dried blood
serum
pus

scab

52
Q

flakes of skin that exfoliate

dandruff, psoriasis, eczema

53
Q

linear crack

tinea pedis

54
Q

loss of epidermis and dermis with possible bleeding and scarring

pressure ulcer, venous stasis ulcer

55
Q

can appear under the fingernails, on the palms and soles of the feet

more common amongst african descent

56
Q

results from aging changes or blood vessel damage in or near the skin

A

Vascular lesions

57
Q

red center radiating with red legs. up to 2cm, possibly raised

A

Spider Angioma

58
Q

red, 1-2cm, round, possibly raised

A

Cherry Angioma

59
Q

bluish, spider shaped or linear, up to several inches in size

A

Spider Vein

60
Q

deep reddish purple, flat

A

Petechiae (1-3mm)
Purpura (larger than 3mm)

61
Q

purple fading to green or yellow over time, varies in size, flat

A

Ecchymosis

62
Q

raised ecchymosis

63
Q

have not yet broken through skin

A

stage 1 pressure ulcers

64
Q

have a break in the top 2 layers of skin

A

stage 2 pressure ulcers

65
Q

affect the top 2 layers of skin as well as fatty tissue

A

stage 3 pressure ulcers

66
Q

are deep wounds that may impact muscle, tendons, ligaments, and bone

A

stage 4 pressure ulcers

67
Q

diaper dermatitis
intertrigo
impetigo
atopic dermatitis (eczema)

A

examples of skin lesions in CHILDREN

68
Q

primary contact dermatitis
tinea pedis (ringworm of the foot)
psoriasis
labial herpes simplex (cold sores)

A

examples of skin lesions in ADULTS

69
Q

lentigines (liver spots)
seborrheic keratosis
dermatosis papulosa nigra (tag-like lesions)
acrochordons (skin tags)
sebaceous hyperplasia

A

examples of skin lesions in OLDER ADULTS

70
Q

AVPU Scale

A

A = Alert
V = Verbal stimulus response
P = Pain stimulus response
U = Unresponsive

71
Q

assigns points according to the client’s degree of alertness and response to verbal and painful stimulation

A

AVPU Scale

72
Q

Hypertrophic scarring caused by excess collage formation

73
Q

coin or oval-shaped

nummular eczema

A

round/oval

74
Q

lesions that remain separate and apart
common to many skin disorders

moles

75
Q

lesions that are grouped or clustered

herpes simplex

76
Q

lesions that run together or are confluent
common in childhood disease

rubella

77
Q

lesions arranged in lines are common with contact dermatitis resulting from poison ivy or herpes zoster

78
Q

ring-shaped lesions

may be ringworm

A

annular/circular

79
Q

lesions arranged in partial rings, or arcs, occur in syphilis

80
Q

a bull’s eye lesion, or round lesion with central clearing

typical of erythema multiforme and lyme disease

81
Q

meshlike pattern as in lichen planus

82
Q

lesions have serpentine configuration
as in gyrate erythema

83
Q

coalesced, concentric circles, such as in urticaria

A

polycyclic

84
Q

lesions distributed over entire body

such as urticaria from allergic reactions

hives, varicella (chicken pox)

A

diffuse/generalized

85
Q

lesions that are sparsely distributed

seborrheic keratosis (non-cancerous, benign skin growth)

86
Q

lesions in a very limited, discrete area
location may indicate contact w/allergen or wheal from insect bite

87
Q

confined to a specific body area

tinea capitis (fungal infection)
pityriasis rosea (skin rash)

A

regional
(head, torso)

88
Q

psoriasis

A

extensor surfaces

89
Q

intertrigo

A

flexor surfaces

90
Q

herpez zoster (shingles)

91
Q

herpes simplex virus type 2
pediculosis pubis

A

dermatome
(hairy areas)

92
Q

contact dermatitis
diaper rash
intertrigo (erythema and scaling of body folds)

A

intertriginous areas

93
Q

actinic keratosis

A

sun-exposed areas

94
Q

indications of PALLOR

A

anemia
shock
lack of blood flow

95
Q

indications of CYANOSIS

A

hypoxia
impaired venous return

96
Q

indications of JAUNDICE

A

liver dysfunction
red blood-cell destruction

97
Q

indications of ERYTHEMA

A

inflammation
localized vasodilation
sun exposure
rash
elevated body temperature

98
Q

accumulation of fluid in the tissues
most often from direct trauma or impaired venous return

99
Q

trace, 2mm, rapid skin response

A

pitting edema 1+

100
Q

mild, 4mm, 10-15 sec skin response

A

pitting edema 2+

101
Q

moderate, 6mm, prolonged skin response

A

pitting edema 3+

102
Q

Crossed eye

A

Strabismus

103
Q

Dancing eyes
Twitching eyes or flutter during field vision test

104
Q

Bulging eyes

A

Exophthalmos

105
Q

Expected findings of neck

A

Muscles of the neck symmetric

Shoulders equal in height and with average muscle mass

ROM:
Flexion
Lateral flexion
Hyperextendion

106
Q

How to maintain skin integrity

A

Adequate nutrition and hydration

Keep clean skin and dry

Apply moisturizer if prescribed

NUR 216: Health Assessment (7 decks)

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