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Nursing Assessment > Final Exam Cumulative > Flashcards

Final Exam Cumulative Flashcards

1
Q

subjective data + examples; also known as what?

A

patients’ feelings and statements (“I feel…”) + pain

AKA symptoms

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2
Q

objective data + examples; also known as what?

A

observable, measurable (VS, labs, assessments)

AKA signs

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3
Q

this type of communication technique can be helpful for changes in patient status, communicating needs, updating providers or other healthcare team members about situation

A

SBAR

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4
Q

components of SBAR

A

situation
background
assessment
recommendation

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5
Q

normal adult BP value

A

systolic <120 / diastolic <80

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6
Q

what is hypertension defined as?

A

> or = 140/90

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7
Q

normal adult HR

A

60-100 bpm

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8
Q

normal adult RR

A

12-20 RR

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9
Q

normal adult temperature

A

97-99°F

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10
Q

normal adult O2 saturation

A

> 90%

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11
Q

fever is defined as what value?

A

> 100.4°F

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12
Q

is rectal temp usually higher or lower than oral?

A

slightly HIGHER

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13
Q

normal pulse quality value

A

2+

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14
Q

describe location for apical pulse

A

5th IC space, midclavicular line

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15
Q

when should you check apical pulse?

A

irregular HR, cardiac hx, infant + children, BP meds

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16
Q

word to describe absence of breath sounds for 15 seconds

A

apnea

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17
Q

HYPOtension value

A

<100/60 or 30 mmHg below patient baseline

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18
Q

name 5 ways to prepare for taking a BP to ensure accurate reading

A
  1. no nicotine or caffeine for 30 mins before
  2. choose correct cuff size
  3. rest for 5 minutes before taking
  4. don’t cross legs
  5. arm supported @ heart level
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19
Q

orthostatic hypotension defined as drop of ___ mmHg in systolic and ___ mmHg drop in diastolic

A

20 mmHg drop Systolic

10 mmHg drop diastolic

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20
Q

thorough method to assess pain or new condition (reason for seeking care)

A

OLDCARTS

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21
Q

describe components of OLDCARTS

A 
Onset
Location
Duration
Characteristics 
Aggravating/Alleviating 
Related symptoms 
Treatment
Severity
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22
Q

information in a review of systems (ROS) is obtained how?

A

through PATIENT - subjective !!

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23
Q

the _____ ______ gives us a global impression of the person we’re assessing

A

general survery

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24
Q

the general survey includes which 4 components?

A
  1. physical appearance
  2. body structure
  3. mobility
  4. behavior

“Physical Bodies Move Bashfully”

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25
Q

mood is defined as

A

a person’s emotional state

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26
Q

affect is defined as

A

the expression of that emotion

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27
Q

ataxia

A

defective muscular coordination; walking all over the place; staggering (can resemble ETOH intoxication)

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28
Q

ataxia is cause by dysfunction of what area of the brain?

A

cerebellum

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29
Q

describe decerebrate posture

A

-deep tendon reflexes -exaggerated
-pronated palms
-clenched teeth
=MORE SERIOUS

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30
Q

describe decorticate posure

A
  • clenched fists
  • legs adducted
  • hands come to core
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31
Q

people lose which type of memory last?

A

remote (months or years ago) - think about how a person with dementia can sometimes still remember stories from their childhood…

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32
Q

paresis

A

partial or complete paralysis

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33
Q

paresthesia

A

burning or tingling (r/t nerve injury)

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34
Q

proprioception

A

being aware of where we are and our body movements

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35
Q

orientation is assesing what?

A

level of awareness of reality

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36
Q

what questions would you ask for orientation?

A
  1. person: who are you? DOB?
  2. time: what is the day of the week? –> what season is it? (adjust these questions based on their orientation level)
  3. place: where are you right now?
  4. situation: what brought you in?
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37
Q

level of consciousness is assessing what?

A

responsiveness (overlaps with orientation)

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38
Q

re: LOC, fully conscious =

A

awake/alert

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39
Q

re: LOC, lethargy =

A

drowsy + sluggish but awakens; needs engagement

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40
Q

re: LOC, obtunded =

A

fades in and out; confused when awake; needs CONSTANT stimulation to stay awake

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41
Q

re: LOC, stupor =

A

arouses to vigorous stimulation (usually pain); cannot verbalize or follow commands

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42
Q

re: LOC, coma =

A

no purposeful response to anything you do to them

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43
Q

re: reflex responses, what is a normal/average score?

A

2+

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44
Q

re: reflex responses, what is the score for hyperactive w/clonus and ABNORMAL

A

4+

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45
Q

re: Morse Fall Scale, what is a low risk score?

moderate risk score?

high risk score?

A

0-24

25-45/50?

> 45-50

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46
Q

re: Morse Fall scale, what is a low risk score?

A

0-24

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47
Q

re: Morse Fall Scale, what is a high risk score?

A

> 45/50

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48
Q

describe Romberg Test and what a positive result would be?

A

patient stands with feet together, eyes closed + arms at side

provider gently pushes patient

positive result: patient sways, widens stance or loses balance

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49
Q

term for recognizing an object by touching it with eyes closed

A

stereognosis

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50
Q

term for the ability to recognize numbers or letters written on palm with eyes closed

A

graphesthesia

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51
Q

the glascow coma scale assesses which 3 things?

A
  1. eye opening
  2. verbal response
  3. motor response

= can you open your eyes? can you talk? can you move?

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52
Q

re: Glasgow Coma Scale, which score usually indicates coma?

A

less than 8

the higher the number the better - 15 is highest

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53
Q

Purpose of functional assessment

A

function r/t ADLs - what can you do and how well?

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54
Q

ROM assessment should show what?

A

smooth, painless, movement through motion

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55
Q

describe passive ROM (PROM)

A

nurse anchors joint with one hand and uses other to move body part

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56
Q

two of the most important things to remember with ROM

A
  • keep eyes on patient to indicate pain (nonverbals)

- STOP if resistance or pain is felt!

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57
Q

joint exam findings - snap, crackle, pop =

A

crepitation

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58
Q

ankylosis =

A

stiffness or fixation of joint

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59
Q

subluxation =

A

partial dislocation of joint

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60
Q

atonic =

A

no tone or movement

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61
Q

spasticity =

A

sudden muscle contractions

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62
Q

flaccidity =

A

weakness

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63
Q

atrophy =

A

wasting

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64
Q

hypertrophy =

A

increased muscle mass

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65
Q

contracture =

A

shortened muscle

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66
Q

fasciculation =

A

muscle twitch

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67
Q

re: muscle testing, what score would you give for someone who can move joint with passive ROM

A

2

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68
Q

re: muscle testing, what score would you give for someone who can move against gravity

A

3

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69
Q

re: muscle testing, what score would you give for someone who can move against some resistance

A

4

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70
Q

re: muscle testing, what score would you give for someone who can move against FULL resistance

A

5

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71
Q

difficulty breathing while lying down

A

orthopnea

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72
Q

what valves are closing during S1 (“lub”)?

A

mitral and tricuspid

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73
Q

what valves are closing during S2 (“dub”)?

A

aortic and pulmonic

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74
Q

where can we hear S1 the best?

A

apex

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75
Q

where can we hear S2 the best?

A

base of heart (up top)

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76
Q

what mneumonic can you use for landmarks of the heart?

A

2245 APT M

2nd IC space R of sternum (aortic)
2nd IC space L of sternum (pulmonic)
4th IC space L of sternum (tricuspid)
5th IC space L of sternum (mitral = apex)

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77
Q

what are the AV valves?

A

mitral + tricuspid

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78
Q

what are the semilunar valves?

A

aortic + pulmonic

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79
Q

where can the PMI be felt?

A

5th IC space midclavicular line = apex

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80
Q

where can you find Erb’s Point? why is it a helpful landmark?

A

3rd IC space L sternal border = can hear everything about the same!

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81
Q

term for a high-pitched scratchy/grated sound + what causes it?

A

friction rub r/t pericardial inflammation

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82
Q

describe differences between MI in male + female

A 
men = chest pressure
women = more likely to report N/V, sweating, pain in neck, jaw, abdomen, back; unusual fatigue; sleep disturbance; SOB; impending doom :(
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83
Q

blowing or swishing sound (using bell)

A

bruit

84
Q

what is a normal capillary refill?

A

< 2-3 ish seconds

85
Q

pitting edema

A

leaves indention

86
Q

1+ pitting edema =

A 
depresses 2mm (x2)
disappears rapidly
87
Q

2+ pitting edema =

A

depresses 4mm (x2)

88
Q

3+ pitting edema =

A 
depresses 6mm (x2)
lasts a minute or so

edema becoming visibly obvious at this stage

89
Q

4+ pitting edema =

A 
depresses 8mm (x2)
lasts 2 mins or more
90
Q

S+S of DVT

A

UNILATERAL edema
erythema
warmth
pain, ache, cramps

DON’T MOVE

91
Q

which peripheral disorder is worse with activity?

A

arterial disorder (blood not getting where it needs to go)

92
Q

which peripheral disorder improves with activity?

A

venous disorder (blood can move from pool and get back to heart)

93
Q

what peripheral disorder is characterized by intermittent claudication?

A

arterial (pain after exercise)

94
Q

re: arterial disorder, what movement with feet will reduce pain?

A

lowering feet

95
Q

re: venous disorder, what movement with feet will reduce pain?

A

elevating feet (sends blood back to heart)

96
Q

what will the skin look like with arterial disorder?

A

cool, cold, shiny, hairless, pallor (w/elevation), NO edema

97
Q

what will the skin look like with venous disorder?

A

mottled, warm, edematous

98
Q

pulses present in arterial or venous disorder?

A

venous

99
Q

S+S of acute arterial disorder

A

6 P’s

  1. pain
  2. poikilothermic
  3. pallor
  4. paresthesia
  5. paralysis
  6. pulselessness
100
Q

pallor

A

pale/greyness

101
Q

cyanosis

A

blue-ish purple-ish

can be pale in people with more melanin

102
Q

what could pallor indicate?

A

anemia; reduced blood flow

103
Q

where is a good location to assess for pallor (regardless of melanin levels in skin)

A

conjunctival sacs

104
Q

what can cyanosis indicate?

A

hypoxia

105
Q

acrocyanosis is found where?

A

extremities

106
Q

circumoral cyanosis is found where?

A

around the mouth

107
Q

where does jaundice initially occur before it spreads?

A

mouth + palates + mucous membranes

108
Q

hypopigmentaton is also called what?

A

VITILIGO

109
Q

macule

A

flat, small

110
Q

papule

A

solid, small, elevated

111
Q

pustule

A

raised, pus-filled

112
Q

vesicle

A

elevated, small, serous filled

113
Q

loss of outer layers from itching/rubbing

A

excoriation

114
Q

cleft into the skin, often from drying

A

fissure

115
Q

large, dark, palpable scar w/increased collagen

A

keloid

116
Q

confluent skin issues

A

run together - think confluence of a river

117
Q

arciform skin lesions

A

with arcs, rings; circle within a circle

ex: annular lesion

118
Q

re: skin lesions what is diffuse distribution

A

widespread, generalized, over entire body

119
Q

re: skin lesions, what is localized

A

limited + discrete

120
Q

re: skin lesions, what is one lesion in each area called? (separated from each other)

A

discrete

121
Q

cherry red proliferation of blood vessels

A

hemangioma

122
Q

petechiae

A

tiny, pinpoint hemorrhages

123
Q

purpura

A

flat hemorrhage, larger area

124
Q

hematoma

A

elevated bruise; can be palpated

125
Q

ecchymosis

A

capillary bleeding into tissue; not palpated; will see color progression

126
Q

what method do we use for assessing moles/skin lesions? (skin cx)

A 
ABCDE
asymmetry 
border
color
diameter
elevation/enlargement
127
Q

hirsutism

A

excessive hair growth in unusual places

128
Q

paronychia

A

inflammation/ infection of nail bed

129
Q

clubbing can indicate what?

A

chronic hypoxia

130
Q

define approximated

A

pulled together, matched up, closed wound

131
Q

stage 1 pressure injury

A

non-blanchable redness

132
Q

stage 2 pressure injury

A

epidermis removed; partial thickness

133
Q

stage 3 pressure injury

A

full thickness; into subcutaneous tissue; may see eschar + slough; could see undermining + tunneling

134
Q

stage 4 pressure injury

A

full thickness; into the bone, tendon, muscle

135
Q

unstageable pressure injury

A

cannot visualize bottom of wound bed - don’t know what’s under there

136
Q

6 components of Braden Scale (to predict pressure injury risk)

A
  • sensory perception
  • moisture
  • mobility
  • friction/shear
  • activity
  • nutrition
137
Q

how is Right lung different from left lung?

A

right has 3 lobes (middle lobe), left has 2

138
Q

when auscultating posterior lung fields, which landmark do you start at?

A

C7 - work in ladder-like fashion down

139
Q

what signs might you see with dyspnea?

A
  • nasal flaring
  • retraction
  • pursed lips
  • labored breathing
140
Q

re: thoracic assessment, describe pectus excavatum

A

caved in

141
Q

re: thoracic assessment, describe pectus carinatum

A

bird beak

CARINatum = CANARY bird

142
Q

re: thoracic assessment, describe barrel chest

A

bulging and rounded; AP diameter is equal

143
Q

hyperventilation is what RR?

A

> 24

144
Q

hypoventilation is what RR?

A

<10

145
Q

which type of breathing pattern is this: rate + depth are variable w/periods of apnea; aka “end of life breathing” or “death rattles”

A

cheyne-stokes

146
Q

which type of breathing pattern is this: increased depth + rate with abrupt pauses; associated with head trauma

A

Biot’s

147
Q

which type of breathing pattern is this: abnormally deep w/increased rate; associated with DKA

A

kussmaul

148
Q

what could cause increased tactile fremitus?

A

pneumonia, phlegm, tumor (sound + vibration travels much quicker / easier through liquid)

149
Q

what could decrease tactile fremitus?

A

COPD, emphysema, pleural effusion, pneumothorax

150
Q

what sounds do you hear over lung fields; the majority of the sounds heard?

A

vesicular

151
Q

what sounds do you hear over the trachea?

A

bronchial

152
Q

what sounds do you hear near sternum?

A

broncho-vesicular

153
Q

define this abnormal breath sound:

crackles or popping

A

crackles

154
Q

can crackles be cleared by coughing?

A

no (fluid is too deep)

155
Q

define this abnormal breath sound:

moaning, snoring, gurgles

A

rhonchi

156
Q

can rhonchi be cleared by coughing?

A

yes

157
Q

define this abnormal breath sound:

whistling, musical sound

A

wheezes

158
Q

define this abnormal breath sound:

squeaking or grating sound

A

pleural friction rub

159
Q

define this abnormal breath sound:

crowing (can usually hear w/o a stethoscope)

A

stridor

MEDICAL EMERGENCY!

160
Q

constipation is defined as what?

A

BM < 3 x / week

161
Q

what is the unique order of assessment with the GI system?

A

auscultate before palpation or percussion

162
Q

re: abdomen, describe a scaphoid shape

A

concave

163
Q

re: abdomen, describe a protuberant shape

A

PROTRUDING out

obesity, pregnancy, ascites

164
Q

what should you do if you find a bulging mass on the abdomen during your GI assessment?

A

DON’T PALPATE + GET HELP!

165
Q

for a GI assessment, which quadrant should you start at? and how should you move?

A

RLQ (ileocecal valve)

clockwise direction

166
Q

what conditions could cause hyperactive bowel sounds?

A

diarrhea, just ate (increased peristalsis)

167
Q

what conditions could cause hypoactive bowel sounds?

A

post-op, constipation, decreased peristalsis

168
Q

definition of ABSENT bowel sounds

A

no sounds for 5 minutes TOTAL

169
Q

re: stool assessment, frank red color could indicate what?

A

bleeding close to source (hemorrhoids)

170
Q

re: stool assessment, maroon/dark red color could indicate what?

A

bleeding in upper GI tract (time to hemolyze) - small intestine is possibility?

frank red would be lower GI bleeding

171
Q

re: stool assessment, black/not sticky stool could indicate what?

A
  • iron supps

- Pepto Bismol (bismuth) use

172
Q

re: stool assessment, brown, clay-colored could indicate what?

A

little to no bile

173
Q

re: stool assessment, yellow/greasy could indicate what?

A

increased fat content in diet

174
Q

re: emesis, frank blood could indicate what?

A

esophageal bleeding or bleeding close to source

175
Q

re: emesis, “coffee grounds” could indicate what?

A

GI bleed (blood clots in emesis)

176
Q

describe expected stool consistency from a COLOSTOMY

A

resembling expected/usual stool - more formed since ostomy is lower down in GI tract

177
Q

describe expected stool consistency from an ILEOSTOMY

A

loose stool (ostomy is in small intestine so not as much H2O absorption)

178
Q

what are the assessment findings of a healthy stoma

A

beefy red, healthy periostomal area

NOT retracted, NO edema, NO bleeding

179
Q

at what level of fullness should you empty an ostomy bag?

A

1/3; NO MORE than 1/2!

180
Q

describe the “Fluid Wave” assessment for ascites

A
  • Place ulnar surface of hand firmly on midline of abdomen

- Strike one side of abdomen with fingers and feel impulse of fluid with other hand

181
Q

describe “Shifting Dullness” assessment for ascites

A
  • 1st Patient lying supine
  • find tympany in center of abdomen
  • percuss outward in several directions to denote dullness
  • ask patient to turn to one side then percuss for tympany to dullness (fluid sinks to lowest point)
182
Q

describe rebound tenderness assessment for peritoneal irritation (possible ruptured appendix)

A
  • applies pressure to an area of abdomen

- More painful when pressure is released

183
Q

describe kidney tenderness assessment

A

o Find costovertebral angle
o Place left hand flat in this area on one side; hit hand sharply with fist of other
o If tenderness present, patient will indicate!!!

184
Q

what is minimum volume for voiding per hour?

A

30mL/hr

185
Q

oliguria is defined as what?

A

<20mL/hr or <400mL/day

186
Q

what is anuria?

A

NO URINE

187
Q

polyuria is defined as what? and what condition might we see this in?

A

increased volume; DM

188
Q

what is a bladder scanner assessing for?

A

urinary retention

post void residual

189
Q

at what age do mammograms usually begin?

A

40 yrs old; earlier with risk factors

190
Q

re: breast exam, describe describe Peau D’Orange

A

dimpling, puckering r/t breast cx; resembles skin of an orange

191
Q

describe some abnormal findings in a breast and lymph node exam?

A

hard, non-mobile, cannot feel edges, asymmetrical, not cyclic, located in tal of spence

(expected findings are opposite of this)

192
Q

epistaxis =

A

nose bleeds

193
Q

edentulous =

A

without teeth

194
Q

leukoplakia

A

thick white patches that cannot be scraped off

195
Q

describe the different grades of enlarged tonsils

A
  • 1+ less than 25% (visible tonsils)
  • 2+ less than 50% (enlarged halfway)
  • 3+ less than 75% (tonsils almost touching uvula)
  • 4+ kissing tonsils (tonsils almost touching each other)
196
Q

what is PERRLA assessing?

2 things to look for

A

Pupils Equal Round and Reactive to Light + Accommodation

  • direct pupil rxn
  • consensual pupil rxn
197
Q

what is the expected finding for accomodation w/PERRLA?

A

bilateral pupil contraction as you near nose

198
Q

anisocoria

A

uneven eyes/different size pupils

199
Q

miosis

A

small, tiny, constricted pupils

200
Q

myadrasis

A

dilated, fixed pupils

201
Q

visual acuity is tested with what?

A 
Snellen chart
(20/20) - describe this
202
Q

amblyopia

A

“lazy eye”

203
Q

ptosis

A

droopy eyelid

lacking symmetry

204
Q

where do you place tuning fork with Weber test?

A

on top of head

can they hear equally with both ears?

205
Q

where do you place tuning fork with Rinne test?

A

on mastoid bone

is AC>BC?

206
Q

what tests would we use for depression screening?

A

Patient Health Questionnaire (PHQ) 2 –> PHQ 9 if they are positive for the other 2 questions

207
Q

S+S of agitation

A
  • repetitive motor activity
  • foot tapping
  • hair pulling
  • fiddling
  • repetitive vocalizations
  • irritability
  • heightened response to stimuli
  • aggression

Nursing Assessment (1 decks)

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