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NUR 216: Health Assessment > Final Exam Study Guide > Flashcards

Final Exam Study Guide Flashcards

1
Q

when palpating pulses, what system is being evaluated?

A

cardiovascular

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2
Q

when moving a patient with a BMI of 32, what tool should you use?

A

hoyer lift

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3
Q

which patient should you see first?

  • an older client with decreased upper extremity muscle loss
  • one with stiff fingers and joints in the morning
  • someone who slumps forward when standing
  • a patient who can’t grip one of their hands
A

a patient who can’t grip with one hand

  • could be a stroke finding
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4
Q

what stage pressure ulcer is broken skin?

A

stage 2

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5
Q

what stage pressure ulcer is when the sub-cutaneous is exposed?

A

stage 3

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6
Q

what stage pressure ulcer is when the bone is exposed?

A

stage 4

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7
Q

where can you hear vesicular lung sounds?

A

lung fields
- mostly what we listen to

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8
Q

where can you hear bronchovesicular lung sounds?

A

near sternal notch

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9
Q

where can you hear bronchial lung sounds?

A

up by clavicle

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10
Q

how do you classify a patient who has a blood pressure of 138/88?

A

stage 1

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11
Q

how do you classify a patient who has a blood pressure of 142/96?

A

stage 2

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12
Q

how do you know if a patient who has cognitive impairment is in pain?

A
  • nonverbal signs
  • wong-baker pain scale
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13
Q

after giving pain medications and coming back 30 min later to see how a patient is doing, falls under what part of the nursing process?

A

evaluation

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14
Q

an older male experiencing nocturia and unable to fully empty bladder likely has what condition?

A

BPH

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15
Q

what is phimosis?

A

can’t retract the foreskin

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16
Q

which finding on an abdominal assessment is abnormal?

  • soft
  • active bowel sound
  • convex shape
  • ecchymosis
A
  • convex shape
  • ecchymosis
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17
Q

right after you put a wound dressing on a patient’s upper arm, a CNA takes BP on that same arm,

is that ok?

A

no

  • needs to be done on a healthy arm
  • cuff 80% arm circumference and 40% of width
  • not on same side as mastectomy, PICC, bandage, etc.
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18
Q

a testicle feels rubber y and smooth,

is that normal?

A

yes

  • do not need to go to the doctor
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19
Q

which part of the stethoscope is used to listen for S1, S2 heart sounds?

A

diaphragm

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20
Q

which joints can perform rotation?

  • neck
  • wrist
  • thumb
  • jaw
  • finger
A
  • neck
  • wrist
  • thumb
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21
Q

which sinus is located under the cheekbones?

A

maxillary

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22
Q

a patient with rectal itching and blood in their stool likely has what condition?

A

hemorrhoids

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23
Q

who is at the greatest risk for skin breakdown?

  • patient with a fracture clavicle
  • patient with a broken arm
  • patient with femur fracture
  • patient with hip fracture
A

femur or hip fracture

  • differentiate based on age
  • older client less likely to move as much and at higher risk for skin breakdown
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24
Q

what are important points for proper body mechanics?

A
  • push don’t pull
  • bend at the knee
  • use legs not back to lift
  • wide stance
  • raise bed to working height
  • carry object close to the body
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25
Q

which findings are subject?

  • dizziness
  • skin color
  • skin turgor
  • pain
  • vitals
  • lab results
A
  • dizziness
  • pain
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26
Q

which findings are objective?

  • dizziness
  • skin color
  • skin turgor
  • pain
  • vitals
  • lab results
A
  • skin color
  • skin turgor
  • vitals
  • lab results
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27
Q

how do you assess CN X (vagus)?

A
  • ask the patient to swallow and say ahh
  • check the gag reflex
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28
Q

how do you assess CN XI (spinal accessory)?

A
  • ask patient to shrug shoulders against resistance
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29
Q

how do you assess CN XII (hypoglossal)?

A
  • stick out tongue
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30
Q

how do you assess CN VII (facial)?

A
  • have client puff out their cheeks
  • make faces
  • test taste on anterior tongue
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31
Q

how do you assess CN VIII?

A
  • Romberg test
  • Whisper test
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32
Q

how can you increase safety for a patient with impairment of CN II?

A

vision

  • adequate lighting
  • make clear path
  • no cords
  • keep glasses close by
  • do not put up all 4 bedrails
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33
Q

which cranial nerves are responsible for EOM?

A

III
IV
VI

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34
Q

where can you assess a client with dark skin for cyanosis?

A
  • MM
  • conjunctiva
  • palms
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35
Q

what is circumoral cyanosis?

A
  • purple/blue color around the mouth
  • indicates respiratory distress and needs to be addressed immediately
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36
Q

how do you evaluate the effectiveness of respiratory medicatiions?

A

listen to lungs shortly after administering the treatment

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37
Q

what should you do when you palpate an irregular pulse?

A

use stethoscope and listen to apical pulse for 60 seconds

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38
Q

how do you assess the carotid?

A
  • palpate unilaterally (never bilaterally)
  • auscultate using the bell of the stethoscope
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39
Q

where is the mitral valve located?

A

between left aria and ventricle

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40
Q

what are the auscultation points for a cardiac assessment?

A
  • aortic: 2nd ICS R of the sternum
  • pulmonic: 2nd ICS L of the sternum
  • erbs point: 3rd ICS L of the sternum
  • tricuspid: 4th ICS L of the sternum
  • mitral (apical): 5th ICS midclavicular L of the sternum
41
Q

when should you use standard precautions?

  • when obtaining vitals
  • palpating sinuses
  • shining penlight in their eyes
  • palpating the tongue/gums
A

palpating tongue/mouth
- contact with body fluids

42
Q

what equipment is required to assess for PERRLA?

A
  • penlight
43
Q

what are crackles and what causes them?

A
  • caused by air passing through fluid
  • sounds like bubbling/crackling like rice crispy
  • soft, high-pitched, very brief
  • usually on inspiration
  • pulmonary edema, atelectasis, fibrosis, and pneumonia
44
Q

what are wheezes and what causes them?

A
  • narrowing of airway passages by spasm, inflammation, mucus, or tumor
  • if hearing, ask them to do a few deep breaths and cough
  • high-pitched musical, whistling, or squeaking sounds
  • MAY CLEAR WITH COUGHING
  • can be heard on inspiration or expiration
45
Q

what tasks can AP perform?

  • nursing process
  • ADL car
  • document assessment
  • evaluate effectiveness of an intervention such as oxygen
A

ADL care

  • cannot perform the other tasks
46
Q

which intervention for dyspnea should be performed first?

  • call the doctor
  • raise the head of the bed
  • put on oxygen
  • get an ABG
A
  • raise the head of the bed first
47
Q

what is the term used for yellow sclera?

A

jaundice

48
Q

what is erythema?

A

red in color

49
Q

what is pallor?

A

white/pale in color

50
Q

what is cyanosis?

A

blue in color

51
Q

what should you do before inserting the otoscope into an adult client’s ear?

A

pull pinna UP and BACK

52
Q

which patient should you see first?

  • patient with HR 90
  • patient with temperature 99.2
  • patient with RR 30 bpm
A

patient with RR 30 bpm

53
Q

what is included in a cardiovascular assessment?

A
  • focuses history: chest pain, edema, palpitations, dyspnea, cough, syncope, fatigue
  • general survey/inspection: signs of JVD
  • palpate pulses: carotid unilaterally, radial and pedal bilaterally
  • palpate chest for vibrations
  • percussion
  • auscultate: carotids for bruit with bell, use diaphragm for 5 pulse points - apical for 60 seconds
54
Q

what are signs of right sided heart failure?

A
  • JVD
  • lower limb edema
  • ascites
  • sudden weight gain
  • fatigue
  • hepatosplenomegaly
    anorexia
55
Q

what are signs of left heart failure?

A
  • pulmonary congestion
  • crackles
  • cough
  • wheezes
  • blood-tinges sputum
  • dyspnea
  • tachypnea
  • cyanosis
  • fatigue
56
Q

how long should you auscultate the lungs at each point?

A

one full inspiration and expiration
- move from right to left to compare sounds

57
Q

what are components of general survey?

A
  • general health state and any obvious physical characteristics
  • overall first impression about physical appearance
  • body structure
  • hygiene
  • mobility and behavior
  • not vital signs
58
Q

what are the ABCDE signs of melanoma when considering a suspicious skin change?

A

A = asymmetry
B = irregular borders/bleeding
C = color change/multicolored
D = diameter greater than 0.5 cm
E = enlarging in size

in addition:
- individuals may report a change in size
- the development of itching
- burning
- bleeding
- a new-pigmented lesion
- any one of these signs raises the suggestion of melanoma and warrants immediate referral

59
Q

what are expected changes in the older adult?

A
  • hard, thick nails
  • loss muscle tone
  • BP higher
  • decreased motility
  • decreased vision
  • sky dryness
  • thin and translucent skin
60
Q

non-blanchable erythema of intact skin

A

stage 1 pressure ulcer

61
Q

partial thickness skin loss with exposed dermis

A

stage 2 pressure ulcer

62
Q

full-thickness skin loss visible adipose tissue with possible granulation tissue

A

stage 3 pressure ulcer

63
Q

full-thickness skin and tissue loss with exposed bone muscle or ligaments

A

stage 4 pressure ulcer

64
Q

normal BP

A

< 120/80

65
Q

elevated BP

A

120-129/<80

66
Q

stage 1 hypertension

A

130-139/80-89

67
Q

stage 2 hypertension

A

> or equal to 140/90

68
Q

what is referred pain?

A

originates in one location but can be felt in others

heart attack -> pain in jaw, back, shoulders

69
Q

what questions would you ask when assessing a patient with a headache?

A
  • when did it start
  • where is it located specifically
  • have you taken anything and did it help
  • anything make it worse, light/sound
  • don’t need family history
70
Q

what are the stages of the nursing process? (ADPIE)

A

A = assessment
D = diagnosis
P = planning
I = implementation
E = evaluation

71
Q

what is BPH?

A

benign prostatic hypertrophy

72
Q

signs/symptoms of BPH?

A
  • common in aging males
  • nocturia
  • increased urgency and frequency
  • inability to completely empty the bladder
73
Q

what are normal findings of an abdominal assessment?

A
  • abdomen flat
  • no vibrations or bruit over the abdominal aorta
  • normal bowel sounds every 5 - 15 seconds in all 4 quadrants
  • tympany with dullness over organs on percussion
  • soft with no tenderness or masses on palpation
74
Q

what should you do if the client is not fluent in english?

A
  • use a trained interpreter
  • speak directly to the client
  • avoid medical jargon
  • use interpreter for entire assessment
  • legally cannot use the patient’s children to translate
75
Q

what are causes of high blood pressure?

A
  • high salt diet
  • stress
76
Q

what are important points about a self-testicular exam?

A
  • testicles should feel rubbery and smooth
  • if client notices a firm, painless lump, hard area, or enlarged testicle, they should call their provider
77
Q

what are important points about a self- breast exam?

A
  • performing exam 4-7 days after cycle starts
  • place hands on hips and look in mirror
  • then palpate entire breast tissue axilla to sternum
  • use 3 middle fingers
78
Q

what are the 4 main functions of skin?

A
  • temp regulation: skin allows heat dissipation through sweat glands and heat storage with SQ tissue
  • protection: minimizes injury, no opening for infection
  • first line of defense: when skin integrity is impaired client is at risk for pathogens entering
79
Q

how do you palpate the frontal sinuses?

A

press firmly upward just under the eyebrows

80
Q

who is likely to develop lordosis?

A

pregnant women

81
Q

what part of orientation is the first to go in older adults?

A

time

82
Q

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

A
  • client to stand with their feel together
  • eyes closed
  • arms resting at their side while nurse observes for swaying or falls
  • tests balance
83
Q

what is abduction?

A

movement away from the body

84
Q

what is adduction?

A

movement towards the body

85
Q

what is fidelity?

A

fulfill a promise to the patient

86
Q

what is beneficence?

A

provide best quality care to patient

87
Q

what is non-maleficence?

A

commitment to do no harm

88
Q

what is autonomy?

A

nurse who acts within scope of practice

89
Q

what are some causes of tachycardia?

A
  • fever
  • medication
  • changing position
  • hyperthyroidism
  • not marathon runner
90
Q

what is scoliosis?

A

S-shaped lateral curvature of the spine

91
Q

describe wound drainage SERIOUS exudate?

A
  • straw colored
  • watery consistency: contains little cellular matter
92
Q

describe wound drainage sanguineous?

A

bloody drainage

93
Q

describe wound drainage serosanguineous?

A
  • mix of bloody and straw-colored fluid
  • most common in fresh wounds
94
Q

describe wound drainage purulent?

A
  • yellow
  • contains pus-infection
95
Q

what are you assessing when percussing the CVA?

A
  • kidney infection/tenderness
96
Q

which part of the hand will the nurse use to palpate the skin temperature?

A

dorsal

97
Q

which part of the hand will the nurse use to palpate skin moisture?

A

palmar

98
Q

when testing the brachioradialis reflex, the nurse should expect which response?

A

pronation of the forearm and flexion of the elbow

NUR 216: Health Assessment (7 decks)

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