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Health Assessment > FINAL > Flashcards

FINAL Flashcards

1
Q

what are the different types of lung sounds (3)

A
  1. broncial
  2. bronchialvesicular
  3. vesicular
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2
Q

characteristics of bronchial breath sounds

A

harsh, high pitched, loud

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3
Q

what is an abnormal breath sound

A

adventitious

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4
Q

characteristics of bronchialvesicular sounds

A

blowing, moderate intensity, moderate pitch

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5
Q

which patient has a barrel chest

A

emphysema

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6
Q

what is a more horizontal position of the ribs, costal angle of more than 90*

A

barrel chest

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7
Q

positive sign of the romberg test

A

moving feet apart

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8
Q

characteristics of the soft palate

A

pink, smooth, moist

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9
Q

CN that assesses the gag reflex

A

CN IX and X

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10
Q

4 things to look for when assessing mental status

A
  1. memory
  2. speech
  3. reasoning
  4. judgement
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11
Q

where to percuss the triceps reflex

A

above the olecranon process

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12
Q

suggestive of breast malignancy

A

retraction of the breast

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13
Q

CN that is tested by clenching teeth

A

trigeminal nerve

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14
Q

type of assessment that is performed for a particular problem

A

focused

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15
Q

when should a clinical breast exam be done

A

every 3 years for young adult women

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16
Q

dysfunction of CN VIII

A

vertigo

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17
Q

when objects look blurry up close

A

presbyopia

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18
Q

sound that is heard when auscultating the heart in CHF pt’s

A

S3

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19
Q

slow, less than normal

A

brady

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20
Q

characteristics of vesciular breath sounds

A

sighing, low pitch, soft intensity

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21
Q

4 adventitious lung sounds

A
  1. crackles (rales)
  2. ronchi (gurgles)
  3. friction rub
  4. wheeze
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22
Q

organ that is in the ULQ

A

spleen

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23
Q

where the mitral/apical pulse is located

A

5th ICS, MCL

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24
Q

tests for low back pain

A

straight leg test

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25
Q

what does documentation promote

A

communication between team members

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26
Q

when to use a Doppler

A

if there is a non-palpable pulse where there was not an absent pulse before change

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27
Q

where the apex/apices of the lungs located

A

slightly above the clavicles

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28
Q

orthopnea

A

difficulty breathing when lying supine

*indicative of CHF

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29
Q

tripod position is assoc. with

A

seen in pt’s with COPD

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30
Q

CN for smell

A

CN I (olfactory)

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31
Q

clear watery drainage from the ear

A

CSF

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32
Q

race and gender that has a higher risk for heart failure

A

African American male

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33
Q

when do you palpate the abdomen

A

last

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34
Q

infection of the ear that causes a tender tragus

A

otitis externa

35
Q

pulse that is used to assess for arrhythmias

A

apical

36
Q

foundation of the nursing process

A

assessment

37
Q

when kyphosis is normal

A

in older adult pt’s

  • hunchback
  • overexaggerated curve in the posterior aspect of the spine
38
Q

dimpling or retraction of the breast is usually caused by f

A

malignant tumor

39
Q

pig-skin like or orange-peel appearance results from edema is seen in

A

metastatic breast disease

40
Q

Peau d’orange results from

A

edema

metastatic breast disease

41
Q

tingling, itching, increased sensitivity, burning, discharge, and pain in the nipple are late signs of

A

Paget’s disease

42
Q

where to assess pallor in a dark skinned client

A

buccal mucosa

43
Q

vagus nerve dysfunction

A

drooling

44
Q

when an older pt c/o weakness and fatigue, 1st thing RN should do

A

RULE OUT ANEMIA

45
Q

infection that can cause absent bowel sounds

A

peritonitis

46
Q

ask client to __ when auscultating their thyriod

A

hold breath

47
Q

used to measure angles

A

goniometer

48
Q

used to maintain privacy and confidentiality of pt’s

A

HIPPA

49
Q

characteristics of resonance

A

when percussing loud low pitched hollow sounds

50
Q

5 sounds elicited from percussion of lungs and location

A
  1. flatness (muscle/bone)
  2. dullness (dense tissues)
  3. resonance (lungs filled with air)
  4. hyperresonance (assoc. c. emphysema pt’s)
  5. tympany (air-filled stomach)
51
Q

priority of carotid assessment

A

auscultation

52
Q

characteristics of cluster headache

A

pain to the eye and temple

53
Q

how to percuss the sinuses

A

percuss

54
Q

characteristics of arterial insufficiency

A

deep, cervical, painful ulver

55
Q

consensual response (2)

A

indirect response

other pupil constricts when light is shone into eye

56
Q

part of the brain that controls balance and coordination

A

cerebellum

57
Q

describe petechiae

A

small, flat, reddish, purple macules

58
Q

if a pt has a score of 7 on the GCS, this pt is __

A

in a coma

59
Q

if a pt has a score of 14 on the GCS, this pt is __

A

WNL

60
Q

method of interview process that is exploring and investigating symptoms

A
61
Q

Dr. gives an order over the phone. what should you do before you disconnect the call?

A

read back the order

62
Q

internally rotating the lower extremities

A

decorticate

63
Q

__ can cause pinpoint pupils

A

narcotics

64
Q

visual disturbance in the prodromal stage

A

migraine

65
Q

most common pulse site

A

radial

66
Q

where is referred rebound tenderness located

A

LLQ

67
Q

what test requires the use of a tuning fork to the mastoid process

A

Rinne

68
Q

test to assess knee swelling

A

bulge test

69
Q

if a pt has a hip fx, what will they complain of

A

thigh pain

70
Q

normal degree of lumbar and thoracic extension

A

30*

71
Q

describe macule

A

flat, non-palpable lesions

72
Q

organ that causes RUQ and shoulder pain

A

gallbladder

73
Q

what do you assess for when using bronchophony

A

use phrase “ninety-nine”

74
Q

what do you assess for when using whispered pectiloroquy

A

use phrase “1-2-3”

75
Q

sibilant wheezes are heard in what types of pt’s

A

acute asthma

chronic emphysema

76
Q

fine crackles are heard in what types of pt’s

A

PNA

CHF

77
Q

coarse crackles are heard in what types of pt’s

A

PNA
PE
pulmonary fibrosis

78
Q

sonorous wheezes are heard in what types of pt’s

A

bronchitis
single obstructions
snoring before an episode of sleep apnea

79
Q

what race has a larger thorax and greater lung capacity

A

Caucasians

80
Q

decreased respiratory rate, decreased depth, irregular pattern

A

hypoventilation

81
Q

regular pattern characterized by alternating periods of deep, rapid breathing followed by periods of apnea

A

Cheyene-Stokes respiration

82
Q

irregular pattern characterized by varying depth and rate of respirations followed by periods of apnea

A

Biot’s respirations

83
Q

rapid, deep, labored breathing

A

Kussmaul

84
Q

pectus carinatum AKA…

A

pigeon chest

Health Assessment (2 decks)

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