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Health Assessment > Final Study Guide > Flashcards

Final Study Guide Flashcards

1
Q

Anatomy of the abdomen

RUQ

A 
Liver
Gallbladder
Bile duct
Transverse colon
Ascending colon
Pancreas
Small intestine
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2
Q

Anatomy of the abdomen

RLQ

A

Cecum
Appendix
Small intestine
Bladder

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3
Q

Anatomy of the abdomen

LLQ

A

Small intestine
Bladder
Descending colon

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4
Q

Anatomy of the abdomen

LUQ

A 
Liver
Stomach
Spleen
Pancreas
Transverse colon
Descending colon 
Small intestine
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5
Q

Anatomical landmarks of the abdomen

A

Umbilicus is center point
Xiphoid process
Ribs
Superior margin of os pubis

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6
Q

Expected findings from inspection of abdomen

A

Smooth, flat contour
No distension
No abdominal aorta peristalsis

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7
Q

Process of auscultating the abdomen

A

Start in RLQ and move clockwise

Bowel sounds should be active in all four quadrants

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8
Q

Order of assessment in abdomen

A

Inspect
Auscultate
Palpate
Percuss

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9
Q

Types of bowel sounds

A

Hypoactive
Normal
Hyperactive
Inactive

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10
Q

Health history questions related to abdomen

A 
Any chronic diseases? (DM, hepatitis, cirrhosis)
Any medications? OTC?
How after are BM?
Any problems with digestive system?
Surgeries?
Any problems with urinary tract?
Any leakage of urine?
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11
Q

GERD

A

Reflux

Heartburn, regurgitation, dysphagia

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12
Q

Peptic Ulcer Disease

A

Ulcer occurring in the lower end of the esophagus, stomach, or duodenum
Complaints of burning after eating

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13
Q

Ulcerative colitis

A

Starts in rectum
Progresses through large intestine
Complaints of severe abdominal pain, fever, chills, anemia, and weight loss
Experiences profuse diarrhea of blood, mucus, and pus

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14
Q

Crohn’s (IBD)

A

Regional enteritis or ileitis

Complaints of severe abdominal pain, cramps, diarrhea, nausea, fever, chills, weakness, anorexia, and weight loss

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15
Q

Diverticulitis

A

Inflammation of the diverticula, herniations through colon wall
Complaints of cramping pain in LLQ, nausea, vomiting, and constipation
Distended and tympanic abdomen, decreased bowel sounds and tenderness

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16
Q

Cirrhosis

A

Chronic degenerative liver disease developed from viral hepatitis, biliary obstruction, or alcohol abuse
Liver becomes palpable and hard
Signs are as it’s, jaundice, spider Angolans, dark urine, clay colored stool, and an enlarged spleen

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17
Q

Cholecystitis

A

Inflammation of the gallbladder
RUQ colicky pain, may radiate to mid torso/right scapula
Causes indigestion and mild jaundice

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18
Q

Pancreatitis

A

Acute or chronic inflammation for auto digestion
Flow is obstructed so digestive enzymes act on pancreas instead
Caused by alcoholism or gallstones
Pain, nausea, vomiting, weight loss, and glucose intolerance
Feels better in fetal position

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19
Q

UTI

A

Frequency, urgency, and dysuria

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20
Q

Esophageal cancer

A 
Age: older than 55
Men more than women
GERD
Barrett’s esophagus
Smoking
Alcohol
Obesity
Diet
Workplace
Injury to esophagus
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21
Q

Stomach cancer

A 
Men more than women
Sharp increase after 50
Less prevalent in Caucasians
More common when living in: japan, China, Europe, south and Central America
Helicobactor pylori infection
Diet
Smoking
Previous stomach surgery
Blood type A
Family history
Work environment
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22
Q

Colon cancer

A 
Diet
Physical activity
Obesity
Smoking
Alcohol use
Over 50
Personal history of polyps 
IBS
Family history
Gene defects
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23
Q

Liver cancer

A 
Men more than women
Asians and Pacific Islanders more so
Previous liver disease
Obesity
Smoking
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24
Q

Pancreatic cancer

A 
Smoking
Obesity
Workplace exposure
After 71
Men more than women
African American more so
Family history
Genetic mutations
Cirrhosis 
Stomach ulcers
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25
Q

Bladder cancer

A 
Smoking
Workplace exposures
Caucasian 2 times more likely
Older than 55
Men more than women
Chronic bladder inflammation
Family history
Low fluid consumption
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26
Q

Structures that are palpated during abdominal assessment

A

Liver - RUQ
Bladder - if distended, midline
Stomach - RLQ
Ribs - found in both upper

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27
Q

Associated symptoms to abdominal pain

A 
Nausea
Vomiting
Diarrhea
Constipation
Gas
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28
Q

Expected motions for a joint

A 
Extension and flexion
Abduction and adduction
Pronation and supination 
Rotation
Inversion and eversion
Circumduction
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29
Q

Assessment for each joint

Neck

A

Flexion
Hyper extension
Lateral bending
Rotation

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30
Q

Assessment for each joint

Shoulder

A 
Extension
Hyper extension
Abduction
Adduction
External and internal rotation
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31
Q

Assessment for each joint

Hip

A 
Abduction
Adduction
Flexion 
Extension
Internal and external rotation
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32
Q

Assessment for each joint

Elbow

A

Flexion
Extension
Supination
Pronation

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33
Q

Assessment for each joint

Knee

A

Flexion

Extension

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34
Q

Assessment for each joint

Ankle

A 
Dorsiflexion
Plantarflexion 
Inversion
Eversion
Abduction
Adduction
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35
Q

Assessment for each joint

Wrist

A

Flexion
Hyperextension
Radial and ulnar deviation

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36
Q

Assessment for each joint

Finger

A

Flexion
Extension
Abduction
Adduction

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37
Q

Six ADL

A 
Toileting
Dressing
Eating
Bathing
Transferring
Continence
38
Q

Scale for evaluating muscle strength?

Considered normal?

A

1-5

5: full ROM against gravity and full resistance

39
Q

Health history questions for musculoskeletal system

A 
Chronic disease?
Medications?
Changes in ability to move/participate in normal activities?
Change in strength?
Accidents or trauma?
Surgeries?
40
Q

Common problems in musculoskeletal system

Fractures

A

A partial or complete break of a bone

Pain caused by muscle spasm, deformity or loss of function is possible

41
Q

Common problems in musculoskeletal system

Osteoporosis

A

Loss in bone density and decreased bone strength associated with age, decline in estrogen, calcium, and exercise
Occurs without SS until loss of height or sudden fracture, or kyphosis

42
Q

Common problems in musculoskeletal system

Rheumatoid arthritis

A

Chronic, autoimmune inflammation or connective tissue
Gradual onset with fatigue, morning stiffness, muscle ache, and weakness
Inflamed synovial linings occur and joints deteriorate
Ligaments and tendons become fibrotic and shorten
Pain, edema, stiffness, fever, fatigue, swan neck and boutonnière deformity May occur

43
Q

Common problems in musculoskeletal system

Osteoarthritis

A

Degenerative change in articulated cartilage
Affects weight bearing joints, hands, and fingers
As cartilage wears, bones hit each other causing joint inflammation
Causes joint edema and aching
Fingers develop heberden’s and bouchard’s nodes

44
Q

Common problems in musculoskeletal system
Herniated nucleus pulposis
Herniated/slipped disk

A

Disk ruptures and compressed spinal nerves
Usually occurs in lumbar region, commonly from improper lifting
Can cause numbness and radiating pain, may lead to paralysis, or DTR may be depressed

45
Q

Common problems in musculoskeletal system

Scoliosis

A

Usually a lateral curvature, spinal rotation, and thoracic kyphosis
Causes may be congenital, neuromuscular diseases, trauma, or unequal leg length
Affects girls more than boys

46
Q

Muscles for strength testing and how to test

A 
Neck: rotate head against resistance
Traps: shoulder shrug against 
Arms: pull push against
Fingers: keep fingers apart against
Grip: hold grip against
Hips: raise legs against
Legs: push pull against
Ankle and feet: walk on heels then toes, then inversion and eversion
47
Q

How do you inspect spine for scoliosis

A

Bend and touch toes

Visual curvature or if one side is raised more than the other

48
Q

Romberg test - a positive

A

Abnormal

Not right

49
Q

Subjective and objective data for musculoskeletal

A

Sub: health history, past surgeries, meds, injuries, chief complaint
Ob: vitals, physical exam, ROM, muscle strength testing

50
Q

anatomical landmarks for heart auscultation

A

APE To Man

51
Q

Heart sound that identifies beginning of systole?

Diastole?

A

S1 - systole

S2 - diastole

52
Q

Orthostatic hypotension technique

A

Take bp while pt is lying down
Take bp when pt stands
Take bp after pt stands for 3 minutes

53
Q

Components of skin assessment included in 10 min assessment

A

IV site check
Abdomen
Skin inspection
Ulcer check using Braden scale

54
Q

Describe skin findings for wound assessments

A

Inspect for: redness, drainage, approximation, and edema

Examine wound: look at edges, granulation tissue, drainage, dressing, measure

55
Q

Skin areas vulnerable to pressure wounds?

A 
Heels
Elbows
Tailbone
Skull
Ears
Scapula
56
Q

PERRLA

A

Pupils are equal and round and reactive to light and accommodation
Check pupils for size, construction with light, change in dilation with accommodation

57
Q

Lung sounds

A

Bronchial are in the neck
Bronchovesicular are midline
Vesicular are throughout the peripheral lung field

58
Q

Skin turgor

A

Pinch clavicle skin
Tests dehydration
Should be elastic with no tenting

59
Q

Health history questions about neurological system

A

Any changes in ability to move or do usual activities?
Any chronic disease? (Hypertension, myasthenia Gravis, multiple sclerosis)?
Meds?
Injury to head or spinal cord?
Stroke? Seizure?
Headaches? Dizziness? Loss of consciousness?

60
Q

Deep tendon reflexes and spinal nerves involved with each

A 
Bicep C5 and C6
Tricep C7
Patellar L4 
Brachioradial C7
Achilles S1
61
Q

What is a reflex arc?

A

A three neuron reflex arc

Tested by observing muscle movement in response to sensory stimuli

62
Q

CN 2

A

Visual acuity

Snellen chart

63
Q

CN 3 4 and 6

A

PERRLA
3 consensual opening and closing
4 smooth diagonal movements
6 smooth lateral movements

64
Q

CN 5

A

Clench teeth

Feel jaw, temple, and open mouth against resistance

65
Q

CN 7

A

Squint, smile, frown, and puff cheeks

66
Q

CN 8

A

Whisper or finger rub test

67
Q

CN 9

A

swallow

68
Q

CN 10

A

Cough

69
Q

CN 11

A

Move head side to side, up and down

Shrug against resistance

70
Q

CN 12

A

Light, tight, and dynamite

Articulation of l, t, d, and n

71
Q

Scoring DTR

Normal?

A

0-4

2 is normal

72
Q

Four ways to assess balance

A

Romberg
Eyes closed standing on 1 foot for 5 sec
Tandem walking
Hopping on one foot

73
Q

Four ways to test upper extremity coordination

A

Rapid pronation-supination on thighs
Alternate nose touch with eyes closed
Touching each finger to thumb quickly
Index finger from nose to examiner finger

74
Q

Test for coordination of lower extremities

A

Heel to shin of opposite leg

75
Q

Test extremities for light touch sensation

A

Cotton tip, touch various extremities with eyes shut and ask them to notify when and where they feel

76
Q

Mini cog

A

Tests cognitive repairment
Give 3 unrelated words to remember, give them a clock, ask them to draw the numbers and a specific time, then ask to repeat back the three words

77
Q

Assessment for domestic violence

A

Get more details:
If abuse is a problem for you, you may talk about It safely here.
Are you in a relationship in which you have been hurt or threatened?
Has your partner destroyed things you care about?
Has your partner forced you to do something you didn’t want to do?
Has your partner prevented you from doing something you wanted to do?
Do you have guns at home?

78
Q

Who is at risk for IPV

A

Women are most at risk, but men are victims too

79
Q

Specific techniques to improve patient’s responding to sensitive topics

A

Privacy
Reassurance that they can trust you
Therapeutic communication
No judging

80
Q

What is the recommended pattern for breast palpation?

A

Supine position, vertical strip method

Lawn mower pattern

81
Q

5 P’s of reproductive health

A 
Partners
Sexual practices
Past STIs 
Pregnancy history and plans
Protection from STIs
82
Q

3 vaccines that may provide protection from reproductive system health problems

A

Hep A
Hep B
HPV

83
Q

What kind of nurse is needed for physical assessment of reproductive system?

A

A specialty nurse

84
Q

Health history questions used for assessing the reproductive system

A

Any chronic illnesses? (Endocrine disorders, diabetes, vascular insufficiency, cardiac disease?)
Meds?
Vaccines?
Sexual relationship? Type of sex? Frequency?
Number of current partners?
Protection? Birth control?

85
Q

Cervical cancer

A 
Persistent HPV infection
Sex at early age
Multiple partners, or partner with multiple partners
Suppressed immune system
Smoking
Multiple childbirths
Long term oral contraceptive use
86
Q

Testicular cancer

A 
Age (highest in 20-34)
Cryptorchidism 
Family history
History of testicular cancer in other testicle
Race (highest in white men)
87
Q

Prostate cancer

A

Age (chance increases after 50 and again after 65)
Race (African American have highest chance)
Family history
Diet
Genes (Lynch syndrome - BRCA1 or BRCA 2)

88
Q

How is physical maturation evaluated in boys and girls

A

Girls: breast development and pubic hair
Boys: pubic hair and testicles dropping

89
Q

What ethnic groups are most at risk for prostate cancer?

A

African Americans

90
Q

What are the 3 functions tested in the Glasgow coma scale?

A

15 point scale to describe consciousness
Eye opening
Motor response
Verbal stimuli
A score of 15 is normal
3-14 isn’t - the lower the score the deeper the coma

91
Q

Describe normal findings for assessing an incision in a hospitalized patient

A

Surrounding skin
Measurement decreases as healing
No redness
No increased temperature

Health Assessment (3 decks)

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