Fundamentals: Chapter 30 Flashcards
What does a complete health assessment involve?
nursing history and behavioral and physical examination
When should you perform a reassessment?
when a patient’s condition changes as it improves or worsens
What are the two types of palpation used for a physical examination?
light and deep
What involves tapping the skin with the fingertips to vibrate underlying tissues and organs?
percussion
What involves listening to sounds the body makes to detect variations from normal?
auscultation
What is important to remember when assessing skin pallor on a dark-skinned patient?
normal brown skin appears to be yellow-brown and normal black skin appears to be ashen gray
What is the best site to assess for jaundice?
sclera
What is the term for red discoloration?
erythema
What refers to the character of the skin and how the deeper layers feel?
skin texture
What is induration?
hardening
What refers to the elasticity of the skin?
turgor
What is the term for when pressure from an examiners fingers leave an indentation in the edematous area?
pitting edema
What are the most common neoplasms in patients?
skin (cutaneous) malignancies
What is the most common carcinoma in sun-exposed areas and frequently occurs with a history of sun-damaged skin?
Basal cell carcinoma
Which carcinoma develops on the outer layers of sun-exposed skin?
Squamous cell carcinoma
Which skin cancer develops from melanocytes and often begins as a mole?
malignant melanoma
What does ABCD stand for when assessing the skin for any type of carcinoma?
Asymmetry
Border irregularity
Color
Diameter
What are the two types of hair that cover the body?
soft, fine, vellus hair, which covers the body; and coarse, long, thick terminal hair, which is easily visible on the scalp, axillae, and pubic areas and in the beard on men
What is a change in angle between nail and nail base
clubbing
What are transverse depressions in nails indicating temporary disturbance of nail growth
Beau’s lines
What is a concave curve in a nail?
Koilonychia (spoon nail)
What are red or brown linear streaks in the nail bed?
splinter hemorrhages
What is inflammation of the skin at the base of the nail?
Paronychia
What does an examination of the head and neck include?
assessment of the head, eyes, ears, nose, mouth, pharynx, and neck
What does an examination of the eyes include?
assessment of visual acuity, visual fields, extraocular movements, and external and internal eye structures
What is an involuntary, rhythmical oscillation of the eyes
nystagmus
What is responsible for tear production?
lacrimal gland
What is a thin white ring along the margin of the iris? When is it uncommon?
arcus senilis
under 40 yrs old
What does an observation of the pupils include?
size, shape, equality, accommodation, and reaction to light
What do cloudy pupils indicate?
cataracts
What do dilated pupils result from?
glaucoma, trauma, neuro disorders, eye medication, withdrawal from opioids
What do constricted pupils indicate?
inflammation of the iris, drug use
What does pinpoint pupils indicate?
opioid intoxication
What can alter pupillary reaction?
changes in intracranial pressure, lesions along the nerve pathways, locally applied ophthalmic medications, and direct trauma to the eye
What kind of nurse uses an ophthalmoscope to inspect the internal eye structures?
APRN
What does an ear assessment involve?
the integrity of ear structures and hearing acuity
How does a nurse assess the integrity of the nose and sinuses?
inspection and palpation
What is the purpose of assessing the mouth and pharynx?
detect signs of overall health; determine oral hygiene needs; and determine therapies needed for patients with dehydration, restricted intake, oral trauma, or oral airway obstruction
What does the assessment of the neck include?
assessing the neck muscles, lymph nodes of the head and neck, carotid arteries, jugular veins, thyroid gland, and trachea
What does an abnormality of superficial lymph nodes sometimes reveal?
the presence of an infection or malignancy
What are the vibrations in the chest wall created by sounds waves during speech called?
vocal or tactile fremitus
What are the 3 normal breath sounds?
Vesicular
Bronchovesicular
Bronchial
What are the 4 types of adventitious breath sounds?
crackles
rhonchi
wheezes
pleural friction rub
What is the failure of the heart to beat at regular successive intervals called?
dysrhythmia
What is caused by a premature rush of blood into a ventricle that is stiff or dilated as a result of heart failure and hypertension
ventricular gallop
What are are sustained swishing or blowing sounds heard at the beginning, middle, or end of the systolic or diastolic phase
murmur
What is a murmur that occurs between S1 and S2?
systolic murmur
What is a murmur that occurs between S2 and the next S1?
diastolic murmur
How do you assess for radiation when listening to the heart sounds?
listen over areas in addition to where it is heard best such as over the neck or back
What is a continuous palpable sensation that resembles the purring of a cat?
thrill
What is the term for vascular narrowing?
stenosis
What is the blowing sound that is created by turbulence when blood passes through a narrowed section?
bruit
What are the most accessible veins for examination?
internal and external jugular veins in the neck
When does a nurse assess the lymphatic drainage of the lower extremities?
during examination of the vascular system or during the female or male genital examination
How does a nurse assess the lymphatic drainage of the upper extremities?
gently palpate the epitrochlear nodes, located on the medial aspect of the arms near the antecubital fossa
When is the best time for a breast self exam (BSE)?
the fourth through seventh day of the menstrual cycle or right after the menstrual cycle ends, when the breast is no longer swollen or tender from hormone elevations
What does an abdominal assessment include?
assessment of structures of the lower gastrointestinal (GI) tract in addition to the liver, stomach, uterus, ovaries, kidneys, and bladder
What is used for an objective measurement of consciousness?
Glasgow Coma Scale
What are common pressure points?
Pinna, shoulder blades, elbows, sacrum and coccyx, knees, heels, toes
What can cause increased GI motility?
Inflammation of the bowel, anxiety, diarrhea, bleeding, excessive ingestion of laxatives, and reaction of the intestines to certain foods
What is the term for hyperactive GI sounds that are loud, “growling” sounds?
borborygmi
