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Nursing 1 > Health Assessment > Flashcards

Health Assessment Flashcards

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1
Q

What is a health assessment?

A

assessment of physical, mental, spiritual, socioeconomic and cultural status

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2
Q

What does a nursing assessment focus on?

A

the clients’ functional abilities and physical responses

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3
Q

What is the purpose of physical exams?

A

baseline data, monitors problems, screen, ID diagnoses

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4
Q

What are types of physical exams?

A

comprehensive PE
focused PE
system-specific assessment
ongoing assessment

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5
Q

How do you prepare for an exam?

A

prepare yourself, environment, client, position client

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6
Q

How do you prepare the environment for an exam?

A

privacy, noise, light, temp, equipment

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7
Q

Order of physical exam techniques to follow

A

-inspection
-palpation
-percussion
-auscultation
-olfaction

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8
Q

What body system has an exception to the assessment order and what is the order?

A

the abdomen

-inspection
-auscultation
-percussion
-palpation

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8
Q

what happens during the inspection phase?

A

use of sight to gather data & eval each system of body

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9
Q

what happens during the palpation phase?

A

use of touch to gather data

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9
Q

what happens during the percussion phase?

A

tapping of fingers on skin using short strokes- produces vibrations

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9
Q

what happens during the auscultation phase?

A

use of hearing to gather data
direct- no equipment
indirect- equipment

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10
Q

what happens during the olfaction phase?

A

use of smell to gather data

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11
Q

What are component of the general survey?

A

personal Identity, appearance and behavior, body type, speech, mental state, hygiene, vitals, height and weight

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12
Q

What do we observe the skin for?

A

Tone
Temperature
Moisture
Texture
Turgor

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13
Q

what is ecchymosis?

A

bruising

14
Q

what is petechiae?

A

Tiny pinpoint red or reddish-purple spots

15
Q

what it mottling?

A

Bluish marbling

16
Q

what are skin lesions?

A

Variation in pigment or a break in continuous tissue
- always be suspicious of malignancies
ABCDE:
Asymmetry
Border irregularity
Color variation
Diameter >0.5 cm
Elevation above the skin surface

17
Q

What to assess the hair for?

A

inspect and palpate for
Color
Texture
Distribution
Alopecia
Hirsutism
Scalp
Pediculosis
is it free of debris?

18
Q

What to assess the nails for

A

color, shape, texture

19
Q

how to assess eyes

A

Inspect and palpate external eye structures
Assess vision
Examine the internal eye structures

20
Q

what is visual acuity?

A

A measure of the eye’s ability to detect the details of an image

Assess distant, near, peripheral, and color vision

21
Q

How to assess the neck

A

palpate the tracheal rings, the cricoid, and the thyroid cartilage, cervical lymph nodes, thyroid

22
Q

how to assess the lungs

A

Respiratory rate
Rhythm
Depth
Symmetry
Palpate:
Trachea
Chest
Chest excursion (expandability)

23
Q

what is rhonchi?

A

snoring during inspiration and expiration

24
Q

what is friction rub?

A

high-pitched grating or rubbing sound that may be heard through the resp cycle. loudest over lower lateral anterior field

25
Q

The female client admitted for an unrelated diagnosis asks the nurse to check her back because “it itches all the time in that one spot.” When the nurse assesses the client’s back, the nurse notes an irregular-shaped lesion with some scabbed-over areas surrounding the lesion. Which action should the nurse implement first?

  1. Notify the HCP to check the lesion on
    rounds.
  2. Measure the lesion and note the color.
  3. Apply lotion to the lesion.
  4. Instruct the client to make sure the HCP checks the lesion.
A

2.

26
Q

The nurse assesses a clients capillary refill. The nurse notes that the capillary refill was > 3 seconds. Is this finding normal or abnormal?

A

Abnormal

27
Q

What is the nurse assessing?
Ask the patient to sit or stand about 2 feet away, facing you sitting or standing at eye level with the patient. Ask the patient to hold the head still and follow the movement of your forefinger or a penlight with the eyes. Keeping your finger or light about 1 foot from the patient’s face, move it slowly through the cardinal positions: up and down, left and right, diagonally up and down to the left, diagonally up and down to the right

A

extra ocular muscles

28
Q

what test as the PT maintain balance with the eyes closed?

A

romberg test

29
Q

what is the first cranial nerve associated with?

A

olfaction

30
Q

During the assessment the nurse notes a small lesion on the patients lower gum line. What would be an appropriate follow up question for the client?
Is the area of the lesion painful?

What does your diet consist of?

Do you smoke or use tobacco products?

A

Do you smoke or use tobacco products?

Nursing 1 (10 decks)

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