Fundamentals Chap 30 Flashcards
A nurse in orientation is performing an abdominal assessment. Which action would indicate that further practice and study are indicated?
- The bowel is auscultated before being palpated.
- The nurse determines any tenderness before touching the patient.
- Inspection is done before percussion.
- The abdomen is palpated before auscultation is done.
*4
Palpation or percussion of the abdoment can cause bowel sounds to be heard, although peristalsis can be absent. All the other responses are correct
A nurse is performing a neurologic assessment. Which approach is most effective in obtaining accurate data when testing sensory pathways?
- Perform each test quickly
- Have the patient as relaxed as possible.
- compare symmetric areas.
- Use a predictable order of assessment.
*3…
Comparison of areas side to side is extremely important in evaluating a patient’s neurologic system. This prevents omissions between the affected and unaffected areas.
An older adult female patient presents with a history of vomiting and diarrhea. Assessment findings reveal lethargy, decreased skin turgor, a weight loss of 5 lbs in 3 days, and a hematocrit of 51%. Which other assessment data would the nurse expect to find?
- Hypoactive bowel sounds and an elevated urine specific gravity of 1.026
- Concentrated urine and hyperactive bowel sounds.
- Moist mucous membranes and a low urine specific gravity of 1.008
- Increased capillary refill time and brisk reactive pupil
*2…
Diarrhea would be accompanied by hyperactive bowel sounds, and because so much fluid had already been lost, the urine would be darker, therefore concentrated.
During the respiratory assessment the nurse thinks that he hears some crackles in his older adult patient. What should the nurse do to ensure that the assessment is correct?
- Ask patient if he has ever had crackles in his lungs
- Ask patient to breathe in through his nose
- Have patient breathe in deeper when bases are auscultated
- Check patient’s medical record to determine if they are previously heard on auscultation
*3..
Having the patient breathe deeper enables the nurse to fully assess lung sounds in the bases of his or her lungs.
Calculate patient’s intake in milliliters based on the following amounts:
3 ounces of orange juice half carton of milk (240 mL per carton) 3 ounce popsicle 12 ounces of cola an 8 ounce cup of ice.
*
780 mL
In conducting a general survey of a patient, the nurse knows that the survey should include which of the following?
- Appearance
- Obtaining peripheral pulses
- Measuring the chest excursion
- Conducting a detailed history
- Behavior
- Pupillary response
- Posture
*1, 5…
The general survey includes assessment of vital signs, height and weight, general behavior, and appearance
In teaching a patient about skin lesions, the nurse knows that teaching has been successful when the patient identifies which lesion as abnormal?
- a symmetric lesion
- a lesion with regular edges and borders
- one that is blue/black or varied in color
- one that is less than 7 mm in diatmeter
*3…
A lesion colored blue/black or with variegated, nonuniform pigmentation or variations/multiple colors (tan, black) with areas of pink, white, gray, blue or red may indicate melanoma.
On respiratory assessment the nurse notes high pitched, musical sounds on auscultation. The nurse interprets these sounds as:
- Normal; vesicular
- Rhonchi
- Crackles
- Wheezes
*4..
The sounds are abnormal. Crackles sound like crushing cellophane; rhonchi sound like blowing air through fluid with a straw. Wheezes are musical.
The nurse determines that the patient has an audible S2 on auscultation during cardiovascular assessment. After documenting the finding, the nurse should:
- Reposition the patient for comfort
- Report the finding to the health care provider
- Initiate fluid restriction
- Do nothing because this is a normal finding.
*4…
S1 and S2 are normal components of the cardiac cycle and an expected physical assessment finding.
Place the following components of the abdominal assessment in the correct order.
- palpation
- inspection
- auscultation
- percussion
*2, 3, 4, 1….
Percussion and palpation are completed after inspection and auscultation because of the risk for causing increased bowel sounds that could be interpreted as an abnormal finding.
What is the 5 nursing purposes for performing a physical assessment?
- gather baseline data about the pt’s health status
- support or refute subjective data obtained in the nursing history
- identify and confirm nursing diagnoses
- make clinical decisions about a pt’s changing health status and management
- evaluate the outcomes of care
What are the principles related to the nurse performing daily physical examinations?
- a head to toe physical assessment is required daily
- reassessment is performed when the pt’s condition changes as it improves or worsens
- the environment, equipment, and pt are properly prepared
- safety for confused pts should be a priority
What should proper preparation for examination include?
- infection control
- environment
- equipment
- physical preparation of the pt
- psychological preparation of the pt
What is 7 variations in the nurse’s individual style that are appropriate when examining children?
- gather all or part of the histories of infants and children from parents
- perform the examination in a nonthreatening area and provide time for play
- offer support to the parents during the examination and do not pass judgement
- call children by their first names and address their parents as Mr. and Mrs.
- use open ended questions to allow parents to share more information
- treat adolescents as adults
- provide confidentiality for adolescents; speak alone with them
What are 7 variations in the nurse’s individual style that are appropriate when examining older adults?
- do not stereotype about aging pt’s level of cognition
- be sensitive to sensory or physical limitations (more time)
- adequate space is needed
- use patience, allow for pauses, and observe for details
- certain types of information may be stressful to give
- perform the examination near bathroom facilities
- be alert for signs of increasing fatigue
What are the principles to follow to keep an examination well organized?
- compare both sides for symmetry
- if a pt is ill, first assess the systems of the body part most at risk
- offer rest periods if the pt becomes fatigued
- perform painful procedures near the end of the examination
- record assessments in specific terms in the record
- use common and accepted medical terms and abbreviations
- record quick notes during the examination to avoid delays
What are the guidelines to achieve the best results during inspection?
- adequate lighting is available
- use a direct light source
- inspect each area for size, shape, color, symmetry, position, and abnormality
- position and expose body parts as needed, maintaining privacy
- check for side to side symmetry
- validate findings with the pt
What is inspection?
*looking, listening, and smelling to distinguish normal form abnormal findings
What is palpation?
*involves using the hands to touch body parts
What is the difference between light and deep palpation?
*lite involves pressing inward 1 cm (superficial) and deep involves depressing the area 4 cm to assess the conditions of the organs
What is auscultation?
*listening to the internal sounds that the body makes
What is frequency?
*indicates the number of sound wave cycles generated per second by a vibrating object
What is amplitude?
*describes the loudness, soft to loud
What is quality?
*describes sounds of similar frequency and loudness
What are the 12 observations of the pt’s general appearance and behavior that should be reviewed?
- gender and race
- age
- signs of distress
- body type
- posture
- gait
- body movements
- hygiene and grooming
- dress
- body odor
- affect and mood
- speech
What are signs of pt abuse?
- physical injury or neglect are signs of possible abuse (evidence of malnutrition or presence of bruising).
- also watch for fear of the spouse or partner, caregiver, or parent
What are the questions related the to the acronym CAGE?
- C-Have you ever felt the need to cut down on your use?
- A-Have people annoyed you by criticizing your use?
- G-Have you ever felt bad or guilty about your use?*E-Have you ever used or had a drink first thing in the am as an “eye opener” to steady your nerves or feel normal?
What are 3 things that should be taken to ensure accurate weight measurement of a hospitalized pt?
- weigh pts at the same time of the day
- weight pts on the same scale
- weigh pts in the same clothes
Assessment of the skin reveals the pt’s health status related to:
- oxygenation
- circulation
- nutrition
- local tissue damage
- hydration
What is duration?
*describes length of time that sound vibrations last
What are the risks for skin lesions in hospitalized pts?
exposure to pressure during immobilization various medicationsneurologic impairmentchronic illnessorthopedic injurydiminished mental statuspoor tissue oxygenationlow cardiac output*inadequate nutrition
What is pigmentation?
skin colorit is usually uniform over the body
What is cyanosis (blusish)?
increased amount of deoxygenated hemoglobin (associated with hypoxia)heart or lung disease, cold environment*nail beds, lips, mouth, skin (severe cases)
What is pallor (decrease in color)?
reduced amount of oxyhemoglobinreduced visibility of oxyhemoglobin resulting from decreased blood flowanemia-face, conjunctivae, nail beds, palms of handsshock-skin, nail beds, conjunctivae, lips
What is loss of pigmentation?
vitiligocongenital or autoimmune condition causing lack of pigment*patchy areas on skin over face, hands, arms
What is jaundice?
increased deposit of bilirubin in tissuesliver disease, destruction of red blood cells*sclera, mucous membranes, skin
What is erythema (red)?
increased visibility of oxyhemoglobin caused by dilation or increased blood flowfever, direct trauma, blushing, alcohol intake*face, area of trauma, sacrum, shoulders, other common sites for pressure ulcers
What is tan-brown?
increased amount of melaninsuntan, pregnancy*areas exposed to the sun: face, arms, areolas, nipples
What physical findings of the skin are indicative of substance abuse?
diaphoresis (excessive sweating)spider angiomas (small dilated arterioles)burns (especially on fingers)needle markscontusions, abrasions, cuts, scars“homemade” tattoosvasculitis (inflammation of the blood vessels)red, dry skin
What is indurated?
*hardened
What is turgor?
*the skin’s elasticity
What is edema?
*areas of the skin that are swollen or edematous from a buildup of fluid in the tissues
What is senile keratosis?
*thickening of the skin
What is cherry angiomas?
*ruby red papules
What is macule?
*flat, nonpalpable change in skin color; smaller than 1 cm (freckles)
What is papule?
*palpable, circumscribed, solid elevation in skin; smaller than 1 cm (elevated nevus)
What is nodule?
*elevated solid mass, deeper and firmer than papule; 1-2 cm (wart)
What is tumor?
*solid mass that extends deep through subcutaneous tissue; larger than 1-2 cm (epithelioma)
What is wheal?
*irregularly shaped, elevated area or superficial localized edema; varies in size (hive, mosquito bite)
What is vesicle?
*circumscribed elevation of skin filled with serous fluid, smaller than 1 cm (herpes simplex, chickenpox)
What is pustule?
*circumscribed elevation of the skin similar to vesicle but filled with pus; varies in size (acne, staphylococcal infection)
What is ulcer?
*deep loss of skin surface that extends to dermis and frequently bleeds and scars; varies in size (venous stasis ulcer)
What is atrophy?
*thinning of skin with loss of normal skin furrow, with skin appearing shiny and translucent; varies in size (arterial insufficiency)
What is basal cell carcinoma?
.5 to 1 cm crusted lesion that is flat or raised and has a rolled, somewhat scaly borderfrequently appearance of underlying, widely dilated blood vessels within the lesion
What is squamous cell carcinoma?
occurs more often on mucosal surfaces and nonexposed areas of skin than basal cell.5 to 1.5 cm scaly lesion sometimes ulcerated or crusted; appears frequently and grows more rapidly than basal cell
What is melanoma?
.5 to 1 cm brown, flat lesion; appears on sun exposed or nonexposed skin; variegated pigmentation, irregular borders, and indistinct marginsulceration, recent growth, or recent changes in long standing mole are ominous signs
What are the 3 types of lice?
pediculus humanus capitis (head lice)pediculus humanus corporis (body lice)*pediculus pubis (crab lice)
What is clubbing of the nail bed?
*a change in the angle between the nail and nail base, including softening, flattening, and enlargement of the fingertips
What is beau lines?
*transverse depressions in the nails
What is koilonychia?
*concave curves
What are splinter hemorrhages?
*red or brown linear streaks in nail beds
What is paronychia?
*inflammation of the skin at base of the nail
What area of the external eye would you inspect?
position and alignmenteyebrowseyelidslacrimal apparatusconjunctivae and scleracorneas*pupil and irises
What is conjunctivitis?
*the presence of redness, which indicates and allergy or an infection
How does the normal tympanic membrane appear?
*translucent, shiny, and pearly grey
What is excoriation?
*skin breakdown characterized by redness and skin sloughing
What are polyps?
*tumor like growths
What are leukoplakia?
*thick white patches that are often precancerous lesions seen in heavy smokers and people with alcoholism
What are varicosities?
*swollen, tortuous veins that are common in older adults
What structures are examined during assessment of the neck?
neck muscleslymph nodes of the head and neckcarotid arteriesjugular veinsthyroid glandstrachea
What are the key landmarks of the chest?
pt’s nipplesangle of louissuprasternal notchcostal angleclaviclesvertebrae
Chest excursion is normally:
*symmetrical, separating thumbs 3 to 5 cm; reduced chest excursion may be caused by pain, postural deformity, or fatigue
What is vesicular?
*sounds are soft, breezy, and low pitched that are created by air moving through smaller airways
What is bronchovesicular?
*sounds are blowing sounds that are medium pitched and of medium intensity that are created by air moving through large airways
What are bronchial sounds?
*sounds are loud and high pitched with a hollow quality that are created by air moving through trachea close to chest wall
What are crackle sounds?
random, sudden reinflation of groups of alveoli; disruptive passage of air through small airwaysare most common in dependent lobes; right and left lung bases
What are Rhonchi (sonorous wheeze) sounds?
muscular spasm, fluid, or mucus in larger airways; new growth or external pressure causing turbulenceare primarily heard over trachea and bronchi; if loud enough, able to be heard over most lung fields
What are wheezes (sibilant wheeze) sounds?
high velocity airflow through severely narrowed or obstructed airwayheard over all lung fields
What are pleural friction rub sounds?
inflamed pleura, parietal pleura rubbing against visceral pleuraheard over anterior lateral lung field (if pt is sitting upright)
What is the point of maximal impulse?
*where the apex of the heart is touching the anterior chest wall at approximately the fourth to fifth intercostal space just medial to the left midclavicular line
What is the S1?
*mitral and tricuspid valve closure causes the first heart sound
What is the S2?
*aortic and pulmonic valve closure causes the second heart sound
What is the S3?
*when the heart attempts to fill an already distended ventricle, a third heart sound can be heard
What is the S4?
*when the atria contract to enhance ventricular filling, a fourth sound is heard
Where is the Angle of Louis?
*lies between the sternal body and manubrium and feels the ridge in the sternum approximately 5 cm below the sternal notch
Where is the aortic area?
*second intercostal space on the right
Where is the pulmonic area?
*left second intercostal space
Where is the second pulmonic area?
*left third intercostal space
Where is the tricuspid area?
*fourth or fifth intercostal space along the sternum
Where is the mitral area?
*fifth intercostal space just to the left of the sternum; left midclavicular line
Where is the epigastric area?
*tip of the sternum
What is a murmur?
*a sustained swishing or blowing sounds heard at the beginning, middle, or end of the systolic or diastolic phase
What is syncope caused by?
*by the drop in heart rate and blood pressure
What is occlusion?
*blockage of a vessel (artery, vein)
How is atherosclerosis indicated?
*by diminished or unequal carotid pulsations
What is the blowing sound caused by turbulence in a narrowed section of a blood vessel?
*bruit
How would a nurse assess venous pressure?
place pt in a semi Fowler positionexpose neck; align head *lean pt back in a supine position; the level of venous pulsation a begins to rise as the pt reaches 45 degree angle use two rulers to measurerepeat the same measurement on other side
How would you assess for phlebitis (inflammation of a vein)?
*Inspect the calves for localized redness, tenderness, and swelling over vein sites
What is striae?
*stretch marks
What is a hernia?
*a protrusion of abdominal organs through the muscle wall
What is distention?
*swelling by intestinal gas, tumor, or fluid of the abdominal cavity
What is peristalsis?
*movement of contents through the intestines, which is a normal function of the small and large intestine
What are borborygmi?
sounds that the bowel makegrowling sounds, which are hyperactive bowel sounds
What is rebound tenderness?
*pain a pt may experience when the nurse quickly lifts his or her hand away after pressing it deeply into the involved area
What is an aneurysm?
*localized dilation of a vessel wall
What is kyphosis?
*hunchback, an exaggeration of the posterior curvature of the thoracic spine
What is lordosis?
*swayback, an increased lumbar curvature
What is scoliosis?
*lateral spine curvature
What is osteoporosis?
*metabolic bone disease that causes a decrease in quality and quantity of bone
What is hypertonicity?
*increased muscle tone
What is hypotonicity?
*muscle with little tone
What are atrophied muscles?
*reduced in size *they feel soft and boggy
What is the purpose of the mini mental state examination?
*measures orientation and cognitive function
What is delirium characterized by?
*confusion,disorientation, and restlessness
What is the purpose of the Glasgow coma scale?
*objective measurement of consciousness on a numerical scale over time
What is receptive aphasia?
*a person cannot understand written or verbal speech
What is expressive aphasia?
*a person understands written and verbal speech but cannot write or speak appropriately when attempting to communicate
The component that should receive the highest priority before a physical examination is:1. Preparation of equipment2. Preparation of environment3. Physical preparation of pt4. Psychological preparation of pt
*1
The nurse assesses the skin turgid of the pt:1. Inspecting the buccal mucosa with a penlight 2. Palpating the skin with the door sum of the hand3. Grasping a fold of skin on the back of the forearm and releasing 4. Pressing the skin for 5 seconds, releasing, and noting each cm of depth
*3
While examining Mr. Parker, the nurse notes a circumscribed elevation of skin filled with serous fluid on his upper lip. The lesion is .4 cm in diameter. This type of lesion is called a:1. Macule2. Nodule3. Vesicle4. Pustule
*2
When assessing the pt’s thorax, the nurse should:1. Complete the left side and then the right side2. Compare symmetrical areas from side to side3. Begin with the posterior lobes on the right side4. Change position of the stethoscope between inspiration and expiration
*2
In a pt with pneumonia, the nurse hears high pitched continuous musical sounds over the bronchi expiration. These sounds are called:
*wheezes
