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NUR 216: Health Assessment > Exam 4 Study Guide: Q > Flashcards

Exam 4 Study Guide: Q Flashcards

1
Q

which of these are ideal conditions to complete an abdominal assessment? Select all that apply

a. the client should be in a supine position
b. keep the abdomen visible while maintaining client privacy
c. a warm and well-lit environment with minimal environmental noise
d. the nurse should perform the exam prior to the client voiding for optimum bladder palpation

A

a. the client should be in a supine position
b. keep the abdomen visible while maintaining client privacy
c. a warm and well-lit environment with minimal environmental noise

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2
Q

Should the patient go to the restroom (void) before starting abdominal exam?

A

yes, do not want to palpate a full bladder

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3
Q

abdominal shape that is normal, expected

A

flat

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4
Q

abdominal shape that caves inward (concave), malnourished

A

scaphoid

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5
Q

abdominal shape that is convex and expected

A

rounded

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6
Q

abdominal shape that shows abdominal distension

A

protuberant

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7
Q

abdominal shape that is further than protuberant and firm, large protrusion of the abdomen, could be impacted, gas, ovarian cyst, ascites, bowel obstruction (pain and long period since last BM)

A

Distended

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8
Q

a history of any prior abdominal surgery puts a client at higher risk for what?

A

higher risk for bowel obstruction

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9
Q

liver
gallbladder
pylorus
duodenum
head of pancreas
right adrenal
portion of right kidney
hepatic flexion of colon
portion of transverse and ascending colon

A

organs in the RUQ
(right upper quandrant)

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10
Q

spleen
pancreas
left liver lobe
stomach
part of left kidney
left adrenal
splenic flexure of colon
part of transverse and descending colon

A

organs in the LUQ
(left upper quadrant)

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11
Q

lower section left kidney
sigmoid and descending colon
distended bladder
ovaries
salpinx

A

organs in the LLQ
(left lower quadrant)

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12
Q

appendix
cecum
lower portion of right kidney
portion of ascending colon
bladder
ovaries
salpinx

A

organs in the RLQ
(right lower quadrant)

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13
Q

what is a positive Blumberg’s sign and what disease does it indicate?

A

rebound tenderness which signals appendicitis

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14
Q

is tenderness on palpation subjective or objective?

A

subjective

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15
Q

what is the typical cause of ascites?

A

usually caused by liver malfunction
- sodium retention
- fluid retention
- decreased albumin production

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16
Q

when are colorectal screenings recommended?

A
  • regular screening
  • beginning at age 45
  • is the key to preventing colorectal cancer and finding it early
  • the U.S. preventive services task force (USPTF) recommends that adults aged 45 - 75 be screened for colon cancer
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17
Q

T or F:
decreased ambulation causes constipation

A

True
- encourage fluids
- high fiber diet and exercise

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18
Q

when a client is experiencing constipation, what are some questions to ask? (essay question)

A

 Are you passing gas?
 When was your last BM?
 How active have you been lately?
 When is the last time you ate or drank anything?
 What is your regular diet like?
 Have you had any previous abdominal surgery?

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19
Q

what are some questions to ask when a client comes in with abdominal pain? (essay question)

A

PQRST
 Ask about nausea, vomiting, diarrhea?
 When was last BM?
 Any changes in appetite?
 When was last PO intake and what was it?
 Do they still have their appendix?
 Any recent weight changes?
 Belching?
 Gas?
 Blood in vomit or stool?
 LMP?
 Any previous abdominal surgeries?

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20
Q

what are some questions to ask when a client comes in with abdominal issues? (essay question)

A

 When was your last BM?
 What did it look like?
 Are you passing gas?
 Have you had any constipation or diarrhea?
 What is your usual pattern?
 Have you been having any nausea or vomiting?
 Do you have any reflux or heartburn?
 Any family history of stomach cancer?
 Any unintended weight loss or gain recently?
 What is your regular diet?

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21
Q

manifest in RLQ

also positive blumberg test (rebound tenderness)

A

Appendicitis

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22
Q

manifest in LUQ

A

Pancreatitis

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23
Q

Manifest in RUQ

GB pain can radiate to back and shoulder blades

A

Hepatitis & Cholecystitis

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24
Q

what is the correct order of techniques for an abdominal inspection?

A

inspection
auscultation
percussion
palpation

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25
Q

Why do you auscultate right after inspection?

A

percussion and palpation can alter bowel sounds

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26
Q

during an abdominal assessment, where should you inspect from?

A

side and foot of bed
- size, shape, symmetry of abdomen
- flat, scaphoid (concave), rounded, protuberant, distended

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27
Q

what do you need to do before advancing diet?

A

listen for bowel sounds - indicate peristalsis
- halted by anesthesia must make sure they have returned prior to any intake

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28
Q

what is abdominal distention?

A

distention
- rounded
- firm
- enlarged
- painful
- long period since recent BM

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29
Q

what are some causes of abdominal distention?

A
  • adipose tissue
  • flatulence
  • fetus
  • feces
  • free fluid (ascites)
  • tumor
  • hernia
  • ovarian cyst
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30
Q

what are some signs of bowel obstruction?

A
  • pain
  • abdominal distention
  • prolonged period since last BM
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31
Q

What is purple striae?

A
  • indication of recent stretching of the skin
  • pink or bluish in color
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32
Q

what causes purple striae?

A
  • pregnancy
  • fluid weight gain
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33
Q

how long should you auscultate each quadrant before saying bowel sounds are absent?

A

1 minute but if abnormal listen for 5 minutes each quadrant

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34
Q

what is considered hyperactive bowel sounds?

A
  • normal bowel sounds occur every 5 - 15 seconds
  • hyperactive bowel sounds are usually every 3 seconds
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35
Q

what causes hyperactive bowel sounds?

A
  • increased motility
  • can be from diarrhea
  • bowel inflammation
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36
Q

what causes decreased bowel sounds?

A

decreased motility

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37
Q

what is the nursing implication with decreased bowel sounds?

A

must delay diet advancement in post-op patient if noted

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38
Q

what are the functions of the stomach?

A
  • churn food
  • intrinsic factor glycoprotein necessary to absorb B12
  • where digestion begins
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39
Q

what are the functions of the small intestine?

A

primary site for digestion and absorption

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40
Q

what are the functions of the large intestine?

A

sodium and water absorption

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41
Q

what are the functions of the pancreas?

A
  • produces insulin and glucagon
  • pancreatic enzymes
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42
Q

what are the functions of the liver?

A
  • metabolism
  • produces bile
  • clotting factors
  • detoxifies drugs and alcohol
  • converts glucose to glycogen
  • stores vitamins
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43
Q

what are the functions of the gallbladder?

A

stores/concentrate bile

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44
Q

what are the functions of the kidney?

A
  • removes waste
  • control BP
  • produces erythropoietin
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45
Q

what are the functions of the bladder?

A

store urine

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46
Q

what is Abdominal Aortic Aneurysm (AAA)?

A
  • can be life-threatening
  • an out-pouching of the abdominal aorta
  • one of the major blood vessels
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47
Q

how is AAA diagnosed?

A
  • do not palpate abdomen if large
  • diffuse pulsations are present
  • auscultate the area for vascular sounds or bruit using the bell of the stethoscope
  • notify the physician immediately
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48
Q

when is percussion performed during an abdominal assessment?

A

percussion is done before palpation and after auscultation

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49
Q

what is the purpose of palpation during an abdominal assessment?

A
  • light touch to get patient used to touch to make them comfortable and note any surface changes
  • abdomen should be soft and nontender with no masses
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50
Q

CVA (costal vertebral) tenderness indicates what disease?

A

kidney infection

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51
Q

generalized enlarged abdomen may signify what disease?

A

ascites (fluid in the abdominal cavity)
- resulting from liver malfunction
- results from three mechanisms
- - - abnormal movement of protein and water in the abdomen
- - - sodium and fluid retention
- - - decreased albumin production in the liver

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52
Q

which are nursing interventions for constipation? select all that apply

a. encourage fluids
b. high fiber diet
c. offer caffeine
d. assist with ambulation

A

a. encourage fluids
b. high fiber diet
d. assist with amubulation

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53
Q

where should you auscultate for bruits during the abdominal assessment and with what part of the stethoscope?

A
  • auscultate over the aorta
  • heard with the bell of the stethoscope
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54
Q

what part of the stethoscope is used for bowel sounds?

A

diaphragm

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55
Q

how do you perform percussion on the abdomen?

A
  • only the pad of the middle finger against the client’s skin and taps with short quick motions using the tip of the finger of the other hand
  • note areas of:
      • tympany: in all four quadrants and dullness over organs
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56
Q

flexion and extension are movements that occur in what plane?

A

the sagittal plane

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57
Q

what is the movement that decreases the angle between two body parts?

A

flexion decreases the angle

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58
Q

what is the movement that increases the angle between two body parts?

A

extension increases the angle

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59
Q

the hip must flex or extend for a client to sit on a toilet?

A

flex

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60
Q

flexion of the elbow refers to the movement that brings the two proximal bones (closer or further)?

A

closer together
- when the elbow is flex, the angle between the two joined bones is reduced

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61
Q

turning the forearm so palm is down and up is called what?

A

pronation (down)
supination (up)

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62
Q

what is the term for moving the arm in a circle around the shoulder?

A

circumduction

63
Q

inversion and eversion is moving the sole of the foot _________ and _________ at the ankle?

A

inward
outward

64
Q

what is the action of raising the foot upwards towards the shin?

A

dorsiflexion
- - flexion of the foot in the dorsal, or upward direction

65
Q

abduction is the movement of a limb __________ from the body.

A

away
- as the client lifts their leg away from their body, they are performing an abduction exercise

66
Q

adduction is moving the limb of a body ________ the midline.

A

toward
- as the person moves their leg towards their body, they are performing an adduction exercise.

67
Q

muscle strength: 5

A

normal full ROM against gravity and full resistance

68
Q

muscle strength: 4

A

full ROM against gravity with some resistance

69
Q

muscle strength: 3

A

full ROM with gravity

70
Q

muscle strength: 2

A

full ROM without gravity

71
Q

muscle strength: 1

A

visible or palpable contraction with no movement

72
Q

which joint is the most mobile joint in the body?

A

the shoulder
- provides the upper extremity with tremendous ROM such as adduction, abduction, flexion, extension, internal rotation, external rotation, and 360* circumduction in the sagittal plane

73
Q

concave curves

A

cervical and lumbar

74
Q

curves are convex

A

thoracic and sacral

75
Q

accentuated thoracic curve

A

Kyphosis

76
Q

lateral S deviation of the spine

A

Scoliosis

77
Q

accentuated lumbar curve

A

Lordosis

78
Q

what clients can suffer from lordosis?

A

commonly occurs in pregnancy
- due to the spine adjusting itself to the center of gravity as pregnancy weight gain causes abdominal enlargement
- may shift after delivery
- can also be seen in toddlers at the lumbar spine

79
Q

what clients suffer from kyphosis?

A

exaggerated, forward rounding of the back
- most common in older women who are postmenopausal and have a small build
- osteoporosis can also lead to kyphosis over time

80
Q

what is osteoporosis?

A
  • a loss in bone mineral density affects an estimated 10 million Americans
  • increases the risk of fracture, bones become so porous that they fracture spontaneously, from bearing a person’s weight
81
Q

S/S:
tender
warm
swollen joints
stiffness worse in the mornings and after inactivity
fatigue
fever
loss of appetite
also increased the risk of osteoporosis

A

Rheumatoid Arthritis

82
Q

when does a neurological assessment begin?

A
  • when the nurse first enters the room
  • use inspection observe
    • LOC
    • behavior
    • appearance
83
Q

any weakness in an extremity would be an indicator for the nurse to do what?

A

a complete neurological exam
- could be a sign of stroke

84
Q

S/S:
unilateral facial droop
arm drift
weakness on half of the body
expressive aphasia
confusion
loss of balance
blurred vision

A

stroke

85
Q

damage to Broca’s area can cause what symptom?

A
  • expressive aphasia or Broca’s aphasia
  • understand what people say better than they can speak
      • people will struggle to get words out
      • speak in very short sentences and omit words
86
Q

what are some stroke risk factors?

A

HTN
a-fib
smoking
diabetes
high cholesterol
obesity
CAD
ETOH abuse
African American
Hispanic
Elderly
Sleep Apnea
Sickle Cell Anemia
TIAs

87
Q

what is the hypoglossal nerve responsible for?

A

motor nerve that is responsible for tongue movement

88
Q

how can a nurse evaluate hypoglossal nerve?

A

ask client to stick out their tongue to inspect if it is midline and if it moves as expected

89
Q

what is cranial nerve XI responsible for and how can the nurse evaluate it?

A

accessory nerve
- responsible for moving trapezius and sternomastoid muscles

these muscles are responsible for the shoulder shrug and shoulder movement

90
Q

what is cranial nerve V responsible for and how can the nurse evaluate it?

A

trigeminal nerve
- responsible for sensation in the face and motor functions
- - biting and chewing

  • most complex of the cranial nerves

palpate the TMJ while the patient clenches the teeth

91
Q

what are the functions of CN III?

A

Oculomotor
- a motor nerve responsible for eye movement

92
Q

what are the functions of CN VIII?

A

Acoustic Nerve (Vestibulocochlear)
- responsible for hearing and is only a sensory nerve

93
Q

which cranial nerve is responsible for swallowing?

A

CN IX - Gossopharyngeal
- swallowing ability should be assessed prior to anything PO to prevent aspiration

94
Q

what cranial nerve is responsible for gag reflex?

A

CN X - Vagus

95
Q

what is CN II responsible for and how can the nurse evaluate it?

A

Optic Nerve
- vision
- assessed using Snellen Chart

96
Q

what is CN IX responsible for?

A

Glossopharyngeal
- sensory and motor nerve of the tongue

    • taste on the posterior 1/3 of the tongue
    • swallowing
    • speech sounds
    • (gag reflex)
97
Q

what is CN XII responsible for and how can the nurse evaluate it?

A

Hypoglossal
- motor nerve
- - tongue movement

have client stick out their tongue
- should be midline and without atrophy or fasciculations
- tongue deviation to the side may indicate CN XII damage

98
Q

how do you assess facial weakness?

A

ask client:
- raise eyebrows
- close eyes tight
- smile
- frown
- show the teeth
- puff out their cheeks

assess for asymmetric features

99
Q

how many hemispheres and lobes are on the cerebral cortex?

A

two hemispheres and four lobes
- frontal lobe
- occipital lobe
- parietal lobe
- temporal lobe

100
Q

a client with traumatic brain injury with damage to the frontal lobe may present with what symptoms?

A

sudden behavioral, emotional, and personaility changes

101
Q

Frontal lobe is responsible for?

A

personality
behavior
emotions
intellectual function

102
Q

What is controlled by the hypothalamus?

A

body temp
sleep
autonomic system

103
Q

what is controlled by the cerebellum?

A

motor coordination
equilibrium
balance

104
Q

what is controlled by the cerebral cortex?

A

voluntary movement

105
Q

which lobe is responsible for the sensation of touch?

A

parietal lobe

106
Q

how can a nurse assess coordination?

A

finger-thumb opposition
running heel down the shin
finger to finger
finger to nose
toe-tapping
inspecting a client’s gait

107
Q

how do you perform the Romberg test and what is it evaluating?

A

client to stand with their feet together
eyes closed
arms resting to their side while nurse observes for swaying or falls

tests balance

108
Q

PERRLA?

A

P = Pupils
E = Equal
R = Round
R = Reactive to
L = Light and
A = Accommodate

109
Q

how does a nurse evaluate for PERRLA?

A

have clients watch your finger as you bring it closer to their nose for accommodation
- use penlight to assess reactivity

unexpected findings could indicate stroke

110
Q

how does the nurse test for motor function and muscle strength?

A

heel to toe and strength/grip assessment

  • push/pull against hand
111
Q

what are signs of stroke?

A

sudden severe headache
unilateral weakness
expressive aphasia (slurred speech)
blurred vision

112
Q

what is in the LLQ?

A

liver
duodenum
gallbladder
sigmoid colon

113
Q

what can cause hypoactive bowel sounds?

A

Anesthesia

114
Q

what is ascites?

A

fluid in the abdomen
- abdominal distention
- dilated veins

115
Q

what do you call bowel sounds heard every 3 seconds?

A

hyperactive bowel sounds
- increased motility usually from diarrhea

116
Q

should a 60 yo patient get a colonoscopy?

A

yes

117
Q

can you perform abdomen with gown covering stomach?

A

no

118
Q

what does percussion on the abdomen check for?

A

fluid
masses
dullness

119
Q

With stroke patients who are immobile, what could they develop?

A

constipation
- very common in stroke patient
- encourage fluids, fiber, and ambulation

120
Q

what procedure can be performed for decompression of late phase bowel obstruction?

A

NG Tube

121
Q

when using the bell on the abdomen and hear low-pitched swooshing sound is called what?

A

Bruit

122
Q

what is bruit caused by and what condition?

A

AAA
- abdominal aortic aneurism

(fill in the blank question - can put AAA)

123
Q

what should you do if AAA is noted?

A

call the doctor
do not palpate

124
Q

what is osteoporosis?

A

loss of bone mineral density

125
Q

are osteoporosis patients at an increased or decreased risk of fracture?

A

increased

126
Q

how many Americans are affected by Osteoporosis?

A

10 million

127
Q

asking patient to stick out their tongue is testing for which CN?

A

CII - Hypoglossal

128
Q

what is the name of CN I and its functions?

A

Olfactory
- sensory smell

129
Q

what is the name of CN II and its functions?

A

Optic
- sensory sight

130
Q

what is the name of CN III and its functions?

A

Oculomotor
- Pupils
- EOM

131
Q

what is the name of CN IV and its functions?

A

trochlear
- EOM

132
Q

what is the name of CN V and its functions?

A

trigeminal
- facial sensations and motors
- muscles of mastication

133
Q

what is the name of CN VI and its functions?

A

Abducens
- EOM

134
Q

what is the name of CN VII and its functions?

A

facial
- motor
- facial muscles
- sensory
- taste (anterior tongue)

135
Q

what is the name of CN VIII and its functions?

A

Acoustic (vestibulocochlear)
- sensory
- hearing

136
Q

what is the name of CN IX and its functions?

A

glossopharyngeal
- quality of voice
- swallow
- cough
- “ah”
- symmetrical rise of uvula

137
Q

what is the name of CN X and its functions?

A

Vagus
- quality of voice
- gag reflex
- cough
- symmetrical rise of uvula
- “ah”

138
Q

what is the name of CN XI and its functions?

A

spinal accessory
- motor
- strength
- shoulder
- neck

139
Q

what is the name of CN XII and its functions?

A

hypoglossal
- motor
- tongue

140
Q

which CN are motor?

A

CN III
CN IV
CN VI
CN XI
CN XII

141
Q

Which CN are sensory?

A

CN I
CN II
CN VIII

142
Q

which CN are both motor and sensory? (mixed)

A

CN V
CN VII
CN IX
CN X

143
Q

when the nurse puts their hands on patients shoulders and ask them to shrug against resistance, what CN is the nurse testing?

A

CN XI - Spinal Accessory

144
Q

checking for sensation on forehead, cheek, and chin is t esting which CN?

A

CN V - Trigeminal

145
Q

Snellen Chart is used to evaluate which CN?

A

CN II - Optic

146
Q

If noting signs of stroke, what do you need to take note of?

A

the time

147
Q

before giving oral medications, what two CNs must be intact?

A

Glossopharyngeal (CN IX) and Vagus (CNX)
- to swallow

148
Q

when a stroke patient cant transform thoughts into words, suspect damage to which area of the brain?

A

Broca’s area

149
Q

how do you evaluate CN V - trigeminal?

A

ask client to close eyes tight
- clench teeth
- smile
- raise eyebrows

150
Q

what nerve is evaluated by puffing out cheeks?

A

CN VII - Facial

151
Q

patient with Parkinson’s comes in, when checking sensory functions, what are you looking for? How do you check for sensory function?

A

sense sharp from dull
hot from cold

152
Q

when a patient comes in with arm or leg weakness, what should you do?

A

complete neurological exam

153
Q

CN IX is responsible for what?

A

Glossopharyngeal
- tongue movement
- swallowing
- (gag reflex)
- speech sounds
- taste

154
Q

student nurse luring about lobes and knows cerebral cortex contains which lobes? Select all that apply

frontal
parietal
occipital
temporal
optic

A

frontal
parietal
occipital
temporal

NUR 216: Health Assessment (7 decks)

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