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Exam 3 > Health Assessment > Flashcards

Health Assessment Flashcards

1
Q

What is the single most important neuro assessment component?

A

The LOC or Level of Consciousness

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2
Q

What are the different testing LOC’s?
Select all that apply
- Alert
- Comatose
- Lethargic
- Stuporous
- Obtunded
- Drowsy
- Awake

A

Alert: attentive and follows commands

Comatose: no response to verbal or any stimuli

Lethargic: drowsy but awake, slow to respond

Obtunded: difficult to keep awake

Stuporous: AKA Semi-Comatose only arouses to vigorous stimuli

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3
Q

What is mentation?

A

Cognitive Awareness
- is the patient oriented to person, place, and time?

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4
Q

How do you check for a patients Cognitive awareness?

A

Pt stating their name and DOB (oriented to person)

Pt answering where they are (oriented to place)

Pt answering what year it is (oriented to time)

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5
Q

How many cranial nerves are there?

A

12 pairs

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6
Q

How do you test cranial nerves 3, 4, and 6?

A

Pupil Response and Cardinal Gaze

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7
Q

What is a pupil response?

A

examine the size and shape of pupils and compare it to a scale

start at the ear with a penlight and move towards the nose
Make sure to look at the change in pupil size and speed of reaction

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8
Q

What is the Cardinal Gaze?

A

using the pen, unlit
have the patients eyes follow the pen
9-12 inches away, make the letter H with the pen in the air

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9
Q

How do you test Cranial Nerve 7?

A

ask the patient to smile and show their teeth
then ask the patient to wrinkle their forehead or raise their eyebrows

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10
Q

How do you test Cranial Nerve 12?

A

Ask the patient to open their mouth and stick their tongue out
then ask the patient to move their tongue side to side and to the roof of their mouth

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11
Q

How do you test Cranial Nerve 11?

A

nurse place hands lightly on pt’s shoulders
then ask the pt to shrug their shoulders

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12
Q

What motion will the nurse ask the PT to do in order to complete the Neuro and Musculoskeletal Assessments? Select all that apply

  • Hand grasping and toe wiggling (HGTW)
  • Flexion and extension with resistance
  • Popping the patients hands and toes
  • Placing a pulse ox on the Pt
A

hand grasping and toe wiggling (HGTW)
flexion and extension with resistance

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13
Q

What are all the Neuro Components of Assessment? Select all that apply

  • LOC and orientation
  • pupil response and cardinal gaze
  • smile, showing teeth, and raising eyebrows
  • tongue to roof of mouth, out, side to side
  • shoulder shrug with resistance
  • HGTW
  • flexion/ extension and BUE and BLE
  • auscultation
  • PERRLA
A

LOC and orientation
pupil response and cardinal gaze
smile showing teeth and raising eyebrows
tongue to roof of mouth out and side to side
shoulder shrug with resistance
HGTW
flexion extention and BUE and BLE

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14
Q

Where is the Vesicular located in the lungs?

A

the periphery of the lungs, so pretty much the lungs itself

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15
Q

Where is the Bronchovesicular located?

A

closer to the sternum, the branches that are attached to the lungs near the midline

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16
Q

Where is the Bronchial located?

A

located over the trachea

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17
Q

Which of these are different forms of abnormal sounds? Select all that apply

  • crackles
  • rales
  • ronchi
  • wheezes
  • pleural friction rub
  • fluid noises
  • apnea
  • cheyne-stokes
A

crackles and rales (can be fine or course)
ronchi
wheezes
pleural friction rub

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18
Q

Which one of these are abnormal respiratory patterns? Select all that apply

  • Cheyne-Stokes
  • apnea
  • bradypnea
  • Kussmaul’s
  • crackles
  • wheezes
  • tachypnea
  • hyperpnea
A

bradypnea
apnea
cheyne-stokes
hypernea
kussmaul’s
tachypnea

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19
Q

How many lung sounds do you hear for at the front of the patient?

A

7
starting on the patients left side

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20
Q

How many lung sounds does the nurse hear for at the back of the patient?

A

10
starting at the patients left side
the last 4 the patient needs to take deep breaths in order to hear

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21
Q

How does the nurse check if there is enough oxygen flowing through the patient using the hands?

A

through clubbing,
place the patients finger nails up against each other with the nails touching and if the nail is spread out near the end of the finger, there isn;t enough oxygen going through the patient

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22
Q

What are ways in which the nurse assesses for respiratory components?

A

anterior and posterior lung sounds
clubbing

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23
Q

What is LUB DUB?

A

the way in which the heart sounds,

LUB, S1, is the systolic sound, the sound thats associated with the closing of the mitral or tricuspid valves

DUB, S2, is the diastolic sound, the sound associated with the closing of the aortic or pulmonic valves

There’s natural pauses between S1 and S2 as well as between S2 and S1 but there should be a longer pause between S2 and S1

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24
Q

Where are the heart sounds located?
Select all that apply

  • Aortic
  • SA node
  • Tricuspid
  • AV node
  • Pulmonic
  • Mitral
A

Aortic (right base; second intercostal space to the right of the sternal border)

Pulmonic (left base; second intercostal space to the left of the sternal border)

Tricuspid (left lateral sternal border; fifth intercostal space to the left of the sternal border)

Mitral (apex; midclavicular line at the fifth intercostal space)

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25
Q

Which one of these are pulses of the body?

  • carotid
  • brachial
  • radial
  • ulnar
  • apical
  • femoral
  • popliteal
  • dorsal pedis
  • pedal
  • mitral
  • aortic
A

carotid **
brachial
radial **
ulnar
apical **
femoral
popliteal
dorsal pedis **

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26
Q

How to assess the pulses?

A

Carotid - one at a time, bilaterally
Radial - bilaterally at the same time
Apical - with stethoscope for 2 beats
Dorsal Pedis or Pedal pulses - bilaterally at the same time

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27
Q

Which of these are pulse quality points?

  • 0
  • 1+
  • 2+
  • 3+
  • 4+
  • 1
  • 5+
A

0 - absent. nonpalpable
1+ - diminished, palpable
2+ - strong, normal
3+ - full increased
4+ - bounding

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28
Q

What is a device that’ll help with getting a pt’s pulse?

A

Doppler
- hand held device
- most often used for pedal pulses

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29
Q

How to assess both upper and lower Extremities?

A

Capillary refill (press on the skin of nailbed to make it go white then release the pressure and see how long it takes for the color to return, should be less than 2-3 seconds, BUE and BLE)

Edema (swelling in the extremities)

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30
Q

Which one of these are cardiac components of assessment?

  • heart sounds
  • carotid sounds
  • radial pulses
  • pedal pulses
  • capillary refill
  • assess for edema
  • doppler
  • pulse quality points
A

heart sounds
carotid sounds
radial pulses
pedal pulses
capillary refill
assess for edema

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31
Q

Which of these are Range of Motion (ROM)?
Select all that apply

  • neck
  • shoulders, upper arms and elbows
  • wrists
  • hips
  • knees
  • ankles
  • strength
  • handgrip
A

neck
shoulders, upper arms and elbows
wrists
hips
knees
ankles

32
Q

Neck ROM?

A

move the neck side to side
chin to chest
extended the head back with the face looking at the ceiling

33
Q

Shoulders, Upper Arms & Elbows ROM?

A

arms to the side
arms straight up
touchdown

34
Q

Wrist ROM?

A

wrist circles

35
Q

Hips, Knees, & Ankles ROM?

A

bilateral hip flexion out
bend the knees
ankle circles
make sure to check the skin with the back of your hand

36
Q

How does the nurse test for strength?

A

handgrip
toe wiggle
flexion and extension of BUE and BLE

37
Q

Which are the components of musculoskeletal assessments? Select all that apply

  • Neck ROM
  • BUE ROM
  • BLE ROM
  • HGTW
  • Flexion/ extension BUE and BLE
  • Toe wiggle
A

Neck ROM
BUE ROM
BLE ROM
HGTW
Flexion/ Extension BUE & BLE

38
Q

What does the nurse look for when inspecting the head down to the toes? Select all that apply

  • hydration
  • pallor
  • temperature
  • color
  • texture
  • rashes
  • lesions
  • cracking
  • jaundice
A

hydration
temperature
color
texture
rashes
lesions
cracking

39
Q

Which change in skin color does the nurse look for? Select all that apply

  • pallor
  • erythema
  • jaundice
  • cyanosis
A

pallor (pale or ashen gray)

erythema (redness r/t vasodilation)

jaundice (yellow, impaired liver)

cyanosis (bluish, decreased circulation or oxygenation of blood)

40
Q

What are some skin characteristics?

  • Temp
  • Moisture
  • Texture
  • Turgor
  • Rashes
  • Cracking
A

Temp should be warm consistent with room temp
Moisture from diaphoresis or dry from dehydration
Texture can be dry & course (elbows/knees) or shiny with no hair (impaired peripheral circulation)
Turgor tests elasticity of the skin related to hydration

41
Q

Which of these are factors that effect the skin?
Select all that apply

  • Dampness
  • Dehydration
  • Nutrition
  • Circulation
  • Disease
  • Jaundice
  • Lifestyle
  • Temperature
  • Moisture
A

dampness
dehydration
nutrition
circulation
disease
jaundice
lifestyle

42
Q

Which of these are normal skin changes in older adults? Select all that apply

  • Epidermis
  • Subcutaneous tissue
  • Collagen & elastin fibers
  • Hormones
  • Vascularity
  • Dehydration
  • Hair follicles
  • Melanocytes
  • Nails
  • Skin Growths
A

epidermis
subcutaneous tissue
collagen & elastin fibers
hormones
vascularity
hair follicles
melanocytes
nails
skin growths

43
Q

What is pitting edema?

A

caused by kidney or heart failure
leads to excess fluid collection in tissue

44
Q

4 point scale?

A

1+ (2mm to trace, rapid response)
2+ (4mm to mild, 10-18 seconds)
3+ (6mm to moderate, 1-2 minutes)
4+ (8mm to severe, 2-5 minutes)

45
Q

which of these are Assessment of Bony Prominences?

  • hips, heels, coccyx, shoulders
  • assess for skin integrity
  • blanching red spots
  • edema
  • 4 pt scale
A

hips, heels, coccyx, shoulders
assess for skin integrity

46
Q

what does the nurse observe for when assessing the nails? Select all that apply

  • shape
  • contour
  • cleanliness
  • neatly manicured/ trimmed
  • hygienic
  • convex
A

observe for

shape
contour
cleanliness
neatly manicured/ trimmed

47
Q

What should the nails look like? Select all that apply

  • transparent
  • smooth
  • rounded
  • convex
  • hygienic
  • cleanliness
A

transparent
smooth
rounded
convex
hygienic

48
Q

What is terminal hair?

A

hair on the scalp, axillae (armpits), pubic, and beard

49
Q

What is Vellus hair?

A

soft tiny hairs covering body except on palms and soles

50
Q

what to look for when assessing hair?

A

quantity (alopecia, hirsutism)
distribution
texture
color
parasites

51
Q

What to look for when assessing the ears?

A

inspect for
- symmetry, drainage, shape, hearing defects, lesions, redness, tenderness, odor

52
Q

What to look for when assessing the nose?

A

the position of the nose, symmetry, color, swelling, deformities, discharge, flaring, patency, sinus tenderness

53
Q

What do you inspect in the oral cavity?
Select all that apply

  • Lips
  • Oral Mucosa
  • Teeth
  • Gums/ Tongue
  • Breath Odor
  • Flaring
A

lips
oral mucosa
teeth
gums/ tongue
breath odor

54
Q

What does the nurse inspect the throat for? Select all that apply

  • lumps
  • ulcers
  • edema
  • white spots
  • redness
  • swallowing
  • teeth
  • odor
A

lumps
ulcers
edema
white spots
redness
swallowing

55
Q

What to look for when assessing the neck?

A

contour & symmetry. midline trachea, jugular vein distention

56
Q

Why does the nurse palpate the neck for?

A

inflamed/ enlarged lymph nodes

57
Q

What are the integument components of assessment? Select all that apply

  • inspect hair and scalp
  • inspect ears
  • inspect nose
  • inspect mouth and throat
  • inspect and palpate neck
  • assess skin turgor
  • inspect skin on back and bony prominences
  • inspect skin of BUE and BLE
  • inspect nails
  • inspect armpits
  • inspect eyes
A

inspect hair and scalp
inspect ears
inspect nose
inspect mouth and throat
inspect and palpate neck
inspect nails
assess skin turgor
inspect skin on back and bony prominences
inspect skin of BUE and BLE

58
Q

Bowel Elimination Definitions

  • Elimination
  • Defecation
  • Feces
A

Elimination (excretion of waste products from kidney and intestines)

Defecation (process of elimination of waste)

Feces (semisolid mass of fiber, undigested food, inorganic matter)

59
Q

Urinary Elimination Definitions

  • Incontinence
  • Void
  • Micturate
  • Dysuria
  • Hematuria
  • Nocturia
  • Polyuria
A

Incontinence ( inability to control urine or feces )

Void ( to urinate )

Micturate ( to urinate )

Dysuria ( painful or difficult urination )

Hematuria ( blood in the urine )

Nocturia ( frequent night urination )

Polyuria ( large amounts of urine )

60
Q

Urinary Elimination Definitions Cont.

  • Urinary Frequency
  • Urinary Urgency
  • Proteinuria
  • Dribbling
  • Retention
  • Residual
A

Urinary frequency ( voiding at frequent intervals)

Urinary urgency ( the need to void all at once)

Proteinuria ( presence of large protein in urine)

Dribbling ( leakage of urine despite voluntary control of urination )

Retention ( accumulation of urine in bladder without the ability to complete empty )

Residual ( urine remaining post void >100mL )

61
Q

What structures are part of the Gastrointestinal ( GI ) Tract?

A

Upper GI tract
Small intestine
Large intestine
Rectum
Anus

62
Q

What is the small intestine?

A

folded, twisted, and coiled tube from stomach to large intestine
1 inch in diameter and 20 ft long
Most digestion and absorption happens here
Chyme travels via peristalsis
3 parts - duodenum, jejunem, and ileum

63
Q

What is the large intestine?

A

THE COLON
2.5” in diameter and 5-6 ft long
7 parts - cecum, ascending colon, transverse colon, descending colon, sigmoid colon, rectum, anus

64
Q

What are the functions of the kidney?

A

Filter and regulate
remove waste from blood to form urine

65
Q

what are the functions of the ureters?

A

transport urine from kidneys to bladder

66
Q

What are the functions of the bladder?

A

Reservoir for urine until the urge develops

67
Q

What are the functions of the urethra?

A

urine travels from bladder and exits through urethral meatus

68
Q

Kidney info

A

bilateral, posterior flanks
size of fists
primary regulators of fluid and acid-base balance

69
Q

Which of these are parts of the Kidney?

  • Nephron
  • Glomerulus
  • Bowman’s Capsule
  • Proximal Convoluted Tubule
  • Ureter
  • Loop of Henle
  • Distal Tubule
  • Collecting Duct
A

Nephron ( functional unit of the kidney
Glomerulus
Bowmans capsule
Proximal convoluted tubule
Loop of Henle
Distal tubule
Collecting Duct

70
Q

What are the Ureters?

A

tubule structures that enter the bladder
Urine traveling through ureters is typically sterile
Ureters enter bladder obliquely and posteriorly to prevent reflux
Obstructions cause peristaltic waves severe pain often referred to as renal colic

71
Q

What is the Bladder?

A

A hollow, distensible, muscular organ
In men - bladder lies against anterior wall of rectum
In women - bladder rest against anterior walls of uterus and vagina

when bladder is full, it extends above symphasis pubis
Normal bladder 500 mL
Can extend to 1000mL

72
Q

What is the functions of the Urethra? In men? In woman?

A

Turbulent flow washes urethra free of bacteria
Descends through pelvic floor muscles
Contraction of pelvic floor muscles can prevent flow of urine

In woman - urethra is short (1 1/2 to 2 1/2 inch), leads to prevalence of infection

In men - urethra is long ( 8 in ), serves in both GU ( genito urinary ) and reproductive system, 3 parts: prostatic, membranous, and penile

73
Q

In what order do you examine the abdomen?
Place in order from 1st to last

  • Auscultation
  • Palpation
  • Inspection
A
  1. Inspection
    - observe size, shape, contour, skin integrity
  2. Auscultation
    - listen, bowel sounds, four quadrants
    ( normal hypoactive, hyperactive )
  3. Palpation
    - feel, palpate for tenderness, pain, masses
74
Q

When palpating the abdomen, what kind of questions should the nurse ask?

A

normal bowel and urine patters
appearance
changes
history of problems

75
Q

Assessment of Urethral Meatus and Perineal Area

A

inspect urethral orifice for erythema, discharge, swelling, or odor

Signs of infection, inflammation, or trauma

Perineal area: Odor, condition, presence of urine or stool

76
Q

Components of GI/ GU assessments

A

Examination of abdomen - look, listen, feel
Ask questions about habits
Examination of urethral meatus and perineal area

Exam 3 (2 decks)

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