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Health Assessment > Final Exam > Flashcards

Final Exam Flashcards

1
Q

What does COLDSPA mean?

A

Character
Onset
Location
Duration
Pattern
Associated Factors

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2
Q

What does PQRST

A

Provactive; What provokes or relieves the pain

Quality; Character of the pain

Radiates; is pain local or radiates

Severity; Scale of 1-10

Timing; When does pain occur or how long does it last

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3
Q

What is the Nursing Process

A

Assessment
Diagnosis
Planning
Interventions
Evaluation

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4
Q

What are the developmental stages (Erikson)

A

Infant: Trust vs Mistrust

Toddler: Autonomy vs Shame/Doubt

Pre-schooler: Initiative vs Guilt

Grade-schooler: Industry vs Inferiority

Teenager: Identity vs Role Confusion

Young adult: Intimacy vs Isolation

Middle-age adult: Generatively vs Stagnation

Older adult: Integrity vs Despair

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5
Q

Special Considerations for Skin, Hair, & Nails (infants)

A

Lanugo; Fine hair

Vernix Caseosa; biofilm

Unregulated temperature

Underdeveloped eccrine glands

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6
Q

Special Considerations for Skin, Hair, & Nails (Pregnant Women)

A

Linea nigra: Line on stomach

Chloasma: brown spot on face

Stria gravidarum: stretch marks

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7
Q

Special Considerations for Skin, Hair, & Nails (Older adults)

A

Decreased sweat

Decreased flexibility & mobility

May have dryer skin

Decreased skin turgor resulting in sagging skin

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8
Q

How to assess skin turgor?

A

Using two fingers gently pinch skin over clavicle

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9
Q

What does decreased skin turgor indicate?

A

Dehydration

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10
Q

Definition of Pallor

A

Loss of color related to arterial insufficiency, decreased blood flow, or anemia

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11
Q

Definition of Cyanosis

A

Blue-tinged

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12
Q

Definition of Jaundice

A

Yellow skin tone usually in sclera, oral mucosa, palms or soles

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13
Q

Definition of Erythema

A

Skin redness/warmth related to inflammation, allergic reactions, or trauma

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14
Q

Skin Assessment (ABCDE)

A

Asymmetry
Border
Color
Diameter
Elevation/Enlargement

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15
Q

Pressure Ulcer Staging

A

STAGE I: Nonblanchable, skin is intact & red

STAGE II: Partial-thickness loss epidermis & some dermis

STAGE III: Full-thickness loss & necrosis of subQ tissue, tendon/bone are not exposed

STAGE IV: Full-thickness loss with muscle, bone or tendon visible

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16
Q

Special Consideration of Eyes (Older adults)

A

Pupil size decreases

Visual acuity may diminish

Lens loses elasticity resulting in decreased accommodation (Presbyopia)

Arcus senilis: White arc around limbus

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17
Q

How to test peripheral vision?

A

Perform confrontation test; Stand 2ft away and move finger into 3 visual fields

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18
Q

How to test pupillary reaction?

A

TURN LIGHTS OFF

Use penlight to check for bilateral consensual reflex

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19
Q

What CN are the eyes?

A

CN III, IV, VI

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20
Q

Describe a Sinus Headache

A

Constant throbbing pain that occurs w/ or after a cold. Worsens with sudden movements of the head & associated w/fevers, sinusitis, nasal drainage

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21
Q

Describe a Cluster Headache

A

Stabbing pain usually caused by ingesting alcohol and relieved by movement or walking back & forth.

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22
Q

Describe a Tension Headache

A

Dull or tight occurs with stress, anxiety or depression. Can last days, months, or years & relieved by message, heat or antidepressants.

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23
Q

Describe a Migraine Headache

A

Accompanied by nausea, vomiting & sensitivity to light. Can lasts up to 3 days and described as throbbing or severe pain. Rest may bring relief.

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24
Q

Describe crackles (fine) & associated

A

High pitched, short popping sounds cleared w/ coughing

Associated w/ asthma COPD conditions

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25
Q

Describe crackles (coarse) & associated

A

Low pitched, moist bubbling sounds

Associated w/pneumonia, pulmonary edema & pulmonary fibrosis

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26
Q

Describe Pleural friction rub

A

Low pitched grating sound occurs during inspiration and expiration

Associated w/pleuritis

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27
Q

Describe Wheeze

A

High pitched musical sounds

Associated w asthma & emphysema

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28
Q

Describe wheeze (sonorous)

A

Low pitched snoring or moaning sounds

Associated w/bronchitis, obstruction or stridor

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29
Q

Smoking Cessation Mneumonic

A

Ask, advise, Assess, Assist, Arrange

30
Q

Special Considerations for Cardio (Infants)

A

Heart beat begins 3 weeks gestation

Oxygenation occurs via placenta

Formen ovale closes within first hour (Ductus arterioles closes within 10-15 hours)

31
Q

Special Considerations for Cardio (Pregnant women)

A

Increased blood volume 30-40%

Increased SV & CO (pulse 10-15 bpm higher)

Decreased arterial blood pressure

Decreased BP drops during 2nd trimester, then increases back to normal

32
Q

Special Considerations for Cardio (Older adults)

A

Systole BP (20 mm Hg) due to stiffening of large arteries

Increased LV wall thickness

Increased risk for arrhythmia & coronary artery disease

Ectopic beats (extra heart beats) are common

33
Q

Definition of Murmur

A

Blowing, swishing sounds over valve area or intercostal space

(Described as musical, harsh, or rumbling)

34
Q

Electrical Pathways of the heart

A

1.) SA node (sinus node) generates impulses & contracts to send blood to ventricles

2.) Impulse conducted to atria to AV node

3.) AV node relays impulse to AV bundle (bundle of His)

4.) Electrical impulses travel to right and left bundle branch & purkinje fibers in myocardium to both ventricles

35
Q

Normal Heart Sounds & Where are they heard the best

A

S1 (“lub”)-Best at apex
M1-mitral valve closure
T1-Tricupsid valve closure

S2 (“dub”)-Best at base
A2-aortic valves closure
P2-pulmonic valve closure

36
Q

Why is systole split into two?

A

S1- Beginning of systole, closing of AV valves (tricuspid & mitral)

S2-Ventricular emptying, decreased pressure & closing of semilunar valves (aortic & pulmonic)

37
Q

Lays of the Heart & Function

A

Pericardium- Fibroserous sac that attache to great vessels & surround heart

Myocardium-Thickest layer, contracts muscle cells

Endocardium-Thin endothelial tissue & lines inner surface of heart

38
Q

S/S of Arterial Insufficiency

A

Cold, pale (pallor), clammy skin, thin skin on extremities

39
Q

S/S of Venous Insufficiency

A

Warm skin, edema, brown hyperpigmentation

40
Q

S/S of Peripheral Venous Disease and Indicates

A

Heaviness of legs, aching aggravated by standing/sitting. leg edema

Associated with delayed wound healing

41
Q

What does Peripheral Venous Disease Cause?

A

Blood clots, DVT, swelling, narrowing/blockage of vessels

42
Q

Assessment order for Abdomen

A

Inspection
Auscultate
Percuss
Palpation

43
Q

Organs in RUQ

A

Liver (majority)

Gallbladder*

Right kidney

Pancreas (small portion)

Transverse/ascending

44
Q

Organs in LUQ

A

Liver (small portion)

Spleen*

Left kidney

Pancreas (majority)

Transverse/descending

45
Q

Organs in RLQ

A

Appendix*

Right ovary/fallopian tube

Ascending colon

46
Q

Organs in LLQ

A

Left ovary/fallopian tube

Left ureter

Sigmoid colon

47
Q

Special Considerations for Musculoskeletal (Older adults)

A

Lost of bone density

Joint stiffening conditions

Osteoporosis; bones break down & become fragile

48
Q

Why is the CAGE assessments & what do the questions include?

A

Four questions to assess alcohol dependence

1.) Cut down on your drinking

2.) Annoyed by people asking about your drinking

3.) Guilty about drinking

4.) Eye-opener in the morning to relieve shakes

49
Q

Dementia vs Delirium

A

Dementia is a gradual progression w/changes in the brain & irreversible; Alzheimers. LOC unchanged & normal behavior

Delirium is a sudden onset but temporary & reversible. LOC changed & disturbed behavior

50
Q

In what order do adolescents develop? (female)

A

1.) Breast enlargement

2.) Hair growth

3.) Menstrual period

51
Q

In what order do adolescents develop? (Males)

A

1.) Testicle enlargement

2.) Hair growth

3.) Height

52
Q

How to perform Testicular Self-examination

A

1.) Palpate the testis

2.) Index & middle fingers to roll testis in horizontal plane to feel for lumps

3.) Begin to palpate upward

4.) Locate epididymis

53
Q

How to perform Breast Self-examination

A

Use the pads of three fingers to palpate in a circular movement

54
Q

How to grade Tonsils

A

1+: Tonsils are visible

2+ Tonsils are midway between pillar & uvula

3+ Tonsils touch uvula

4+ Tonsils touch each other

55
Q

Name & Function of CN I

A

Olfactory; sense of smell

56
Q

Name & Function of CN II

A

Optic; Visual impulses to brain

57
Q

Name & Function of CN III

A

Oculomotor; Eye movement (Constriction of pupils)

58
Q

Name & Function of CN IV

A

Trochlear; Extraoccular eye movements

59
Q

Name & Function of CN V

A

Trigeminal; Controls impulses of pain, temperature, & pain to the brain

-Controls jaw movements (chewing, biting)

60
Q

Name & Function of CN VI

A

Abducens; Controls lateral eye movements

61
Q

Name & Function of CN VII

A

Facial; Stimulates salvia & tears

62
Q

Name & Function of CN VIII

A

Acoustic, vestibulocochlea; Hearing & balance

63
Q

Name & Function of CN IX

A

Glossopharyngeal; Gag reflex

64
Q

Name & Function of CN X

A

Vagus; Swallowing, talking, production of digestive juices

65
Q

Name & Function of CN XI

A

Spinal accessory; Promotes movement of shoulder & head rotation

66
Q

Name & Function of CN XII

A

Hypoglossal; Controls tongue movements

67
Q

Define Kussmaul respirations

A

Rapid, deep or labored breathing, caused by diabetic ketoacidosis

68
Q

Define Cheyne-Stokes respirations

A

Periods of deep rapid breathing followed by periods of apnea

69
Q

Define Biot respirations

A

Irregular pattern characterized by varying rate of respirations followed by periods of apnea

70
Q

Define Bronchial breath sounds (Normal)

A

Loud high pitched sound w/harsh or hollow quality. Short during inspiration & long during expirations located over the trachea & thorax

71
Q

Define Bronchovesicular breath sounds (Normal)

A

Moderate pitch w/moderate quality. Same sound during inspiration & expiration located over bronchi-posterior & sternum

72
Q

Define Vesicular breath sounds (Normal)

A

Soft low sound w/breezy quality. Long in inspiration short in expiration heard over peripheral lung fields

Health Assessment (5 decks)

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