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Health Assesment-RN > Final Exam Review > Flashcards

Final Exam Review Flashcards

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NCLEX-RN® flashcards
1
Q

What are some examples of communication barriers?

Ten trap questions

A

list 10 traps for interviewing?
1) providing false assurance or reassurance

2) Giving unwanted advice
3) Using authority
4) Using avoidance
5) Engaging in distancing
6) Using professional jargon
7) using leading or biased questions
8) Talking too much
9) Interupting
10) Using “why” questions.

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2
Q

Components of health hx?

Family health hx ?

A

Specific to patient: Past health such as vaccines, diseases, injuries, hospitalizations, medical hx ,surgeries, illness

Health info on close relatives

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3
Q

Subjective vs objective data

A

Subjective is what the patient tells you

Objective is data observed and what you see

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4
Q

Open ended vs close ended ?

Which would give the most info?

A

Closed - yes or no answers

Open- detailed answers - most info

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5
Q

What order would you conduct assessment of the abdomen

A

Inspect
Auscultate
Palpate
Percussion

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6
Q

Normal lung sounds ?

Bronchial ?

Bronchovestibular?

Vestibular ?

Where would you hear each on anterior and posterior ?

A

Bronchial- pitch is high, ampliflitude is loud - trachea and larynx

Bronchovestibular- pitch is moderate and amplitude is moderate - major bronchi and right scapula and upper sternum

Vestibular- pitch is low and amplitude is soft. Like wind in trees, over peripheral lung fields

Found by the sternum

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7
Q

Mole/lesion assessment:

How to assess ?

What might cancer look like?

A

ABCDE

Asymmetry- both side look the same?

Border irregularities

Color variations

Diameter greater than 6mm

Elevation or evolution

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8
Q

Inspection findings r/t

Scoliosis

Lordosis

Kyphosis

A

Scoliosis- shoulders are uneven, spine is uneven when bending over -curve is greater than 10 degrees

Lordosis- arched lower back (lumbar/cervical region)

Kyphosis- arches upper back -(thoracic region)

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9
Q

Define functional ability

A

Ones ability to perform activities necessary to live in modern society and include driving, using the phone, or performing personal tasks such as bathing and toileting

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10
Q

Define instrumental ADLs

A

Tasks such as shopping , meal
Preparation, house keeping, laundry, managing finances , taking meds , transportation.

Yard work, home maintenance, cooking

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11
Q

Importance of cuff size when taking bp?

A

If too big - false low

If too small- false high

?? How big to be

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12
Q

What does clubbing look like? Causes??

A

Protruding nails (bulbous)

Low oxygen in blood can cause (hypoxia)

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13
Q

Heart auscultation areas?

A

Aorta- 2nd Rt intercostal

Pulmonary- 2nd Lt

Erbs-3rd

Tricuspid 4th

Mitral/apical-5th

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14
Q

APEToman

Location of apical pulse

A

Mitral 5th- loudest at S1 here

Abnormality would be stenosis or regurgitation

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15
Q

Location of pulses ?

A

Radial wrist

Brachial - other side of elbow

Dorsal pedis - between big toe and second

Posterior tibial - back ankle

Popilital - behind knee

Apical- Lower left

Carotid - neck

Femoral - crotch

Temporal- behind eye on head

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16
Q

Glasgow coma scale?

What are the components?

A

Based on eye opening response, verbal response, and motor responses

13-15 points=minor brain injury

9-12 points=moderate brain injury

3-8 points =severe brain injury

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17
Q

Jendrassik maneuver

A

Have patient hook fingers together and clench their teeth to allow them to relax enough to elicit a patellar reflex

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18
Q

Cerebellum function tests

A

Rapid alternating movements - palm and back of hand knee pats

Finger to finger

Finger to nose **

Heel to shin - rub opposite heel along shin bone

Romberg test- standing with eyes closed and arms out holding the position

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19
Q

Test for each cranial nerves?

A

1-smell , plug one nostril

2-test visual acuity

3,4,6-tracking the finger and ocular movements

5- test clenching of teeth , push down on chin

7- smile, frown, lift eyebrows, show teeth, facial symmetry

8 hearing whispered voice test

9 and 10 depress tounge with blade and say ah , see uvula and tounge at midline

11-shrugging shoulders

12- to tremors, no protruding tounge , Normal clear speech

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20
Q

Deep tendon reflexes?

A

5 components :

An intact sensory nerve (afferent) 
A functional synapse in the cord 
An intact motor nerve fiber (efferent)
The neuromuscular junction 
A competent muscle
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21
Q

Location of organs by quadrant

RUQ

RLQ

LLQ

LUQ

Midline

A

RUQ- liver, right kidney, gallbladder, colon, pancreas

LUQ- stomach left kidney, spleen, colon, pancreas

RLQ- appendix, colon, small intestine, ureter,major vein and artery to right leg

LLQ- colon, small intestine, ureter , major vein and artery to left leg

Midline- aorta, pancreas, small intestine, bladder, spine

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22
Q

Signs of arterial/venous insufficiency in extremities ?

A

Arterial- arteriosclerosis is stiffening or hardening of artery walls,
Atherosclerosis is narrowing of the artery because of plaque build up.

Symptoms -pain-worse with activity
Intermittent claudication 
Rest pain- increased occlusion 
Worse with legs in elevated position
Varcrose vein- worse in dependent position 
Signs- coldness 
Pallor (pale)
Hair loss
Skin tight, shiny , hard 
Decreased/absent pedal pulse 
Sores-round, minimal drainage , no odor
23
Q

Bowel sounds?

A

?? What do normal sound like??

Assess LRQ first, click wise

4 quadrants for 5 min each

24
Q

What does PERRLA stand for?

What does accommodation mean?

A

Pupils, equal, round, reactive to light, accommodation

Accommodation means pupils get bigger with distance and constrict when close up

25
Q

Staging of pressure ulcers ?

A

Stage 1- red but unbroken

Stage 2- partial thickness skin erosion with loss of epidermis or dermis. Superficial

Stage 3-full thickness into the subcutaneous tissue. May see fat but no bone or tendon

Stage 4- full thickness and involves all skin layers including bone muscle and tendon. Maybe have eschar and slough

Unstageable- Black Eschar

26
Q

Pectus escavatum vs Pectus carinatum

A

Pectus escavatum-sunken in

Pectus carnatum- protruding

27
Q

Concentrated observation of the client

A

Inspection

28
Q

Purposeful touch on the client

A

Percussion

29
Q

Tapping with short, sharp strokes to assess underlying structures

A

Percussion

30
Q

Listening

A

Auscultation

31
Q

Purposeful touch on the client

A

Palpation

32
Q

Edema scale

1-4 +

How long each resolve ?

A

0 + none
1+mild pitting 2mm and disappears rapidly
2+ moderate 4mm, 10-15 second pitting
3+ moderately severe, 6mm and lasts more than 1 min
4+ severe pitting edema, 8mm and lasts more than 2 minutes

33
Q

Headache table page 271

A

?
Exacerbated by alcohol, stress, Day time napping , wind, heat.

Ipsilateral autonomic signs: Nasal congestion or runny nose , watery or reddened eye, eyelid, drooping, miosis

Feelings of agitation

34
Q

Infant reflexes

A

Babinski

Moro

Grasp

Tonic neck

Root

Step

Suck

35
Q

Neurological recheck exam?

A

Pupil response - size 2-6mm

Level of consciousness

Motor function

Vital signs

36
Q

Lymph nodes names?

What’s normal?

What’s abnormal?

A

Submental -below jaw

Submandibular

Tonsillar

Preauricular

Postauricular

Anterior cervical

Posterior cervical

Occipital

Supraclavicular

Normal is non tender and non palpable

37
Q

Components of general survey?

A

A study of the whole person, covering the general health state and any obvious physical characteristics.

Into to physical exam

Whole person not just one body system

38
Q

What does the finger to nose test evaluate

A

Coordination

39
Q

Touch toes - what does this evaluate

A

Scoliosis

ROM

40
Q

Jaundice in a dark skin- where to assess

A

Palms

Scleras

41
Q

Characteristics of psoriasis

A

Scaly , erthyematous patch with silvery scales on top

Usually on elbows, knees , low back, genital area

42
Q

Doris flexion

A

Drawing the foot up

43
Q

Active vrs passive ROM

A

Active is when patient can do it their self

Passive - staff helps

44
Q

The ability to perceive and recognize the form of an object when unable to see or hear info about it by using texture, size , temp, etc

A

Stereognosis

45
Q

The ability to recognize writing on the skin purely by the sense of touch

A

Graphesthesia

46
Q

Increased loudness of whispering noted during auscultation with stethoscope on a patients torso

A

Whispered pectoriloguy

47
Q

Increased voice sounds heard when listening to lungs , open caused by lung consolidation and fibrosis

A

Egophony

48
Q

Abnormal transition of sounds from the lungs or bronchi

A

Bronchoscopy

49
Q

Bababinski reflex , when does it disappear?

A

Stoke finger at bottom of foot , birth- 24 months

50
Q

Good , normal , unlabored breathing

12-20

A

Eupneic

51
Q

Slow breathing

Fast

A

Bradypneic

Less than 10 /min

Tachypneic greater than 24

52
Q

SOB / dyspnea when lying flat

Prop up HOB

A

Orthopnea

53
Q

Linear arrangement along with unilateral nerve route (one side of body)

A

Zosteriform

54
Q

Blowing / swooshing sound heard through bell side of stethoscope when arerty is partially occluded

A

Bruit

Health Assesment-RN (7 decks)

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