Health Assessment Flashcards
When conducting a general survey of a client, the nurse should address 3 of the following:
-Speech
-Skin Turgor
-Pupils
-Level of Consciousness
-gait
The purpose of the general survey is to obtain information regarding the client’s general health.
-LOC
-Speech
-Gatit
A nurse is conducting a general survey on a client and notes a continuous twitching movement of a muscle in the patient’s left arm. Which of the following terms should the nurse use to describe this involuntary movement?
- Spasticity
- Fasciculation
- Tic
- Myoclonus
Fasciculation
Fasciculation
client who has fasciculation will exhibit a continuous twitching motion of a muscle when the muscle is at rest.
spasticity
A client who has spasticity has an increase in muscle tonicity. Attempting to passively extend a joint will result in increased resistance.
tic
A client who has a tic will exhibit an involuntary, repetitive movement of a muscle group, such as a wink or facial grimace.
myoclonus
A client who has a myoclonus will exhibit a sudden jerking of a muscle, such as with hiccups or the jerk of an arm when falling asleep.
A nurse is documenting information in a client’s medical record. Which of the following information did the nurse collect during the general survey?
Select all that apply.
- Past Medical History
- Current medication list
- behavior and mood
- Use of assistive devices
- height and weight
Use of assistive devices is correct.
The client’s use of assistive devices is information that is collected during the general survey and should be documented in the client’s medical record.
Height and weight is correct. Measuring the client’s height and weight is information that is collected during the general survey and should be documented in the client’s medical record.
Behavior and mood is correct. Observing the client’s behavior and mood is information that is collected during the general survey and should be documented in the client’s medical record.
Fasciculation
Fasciculation is the alteration in muscle movement seen as a continuous, rapid twitching of a muscle at rest.
_____ occurs when the rate and depth of a client’s respirations are increased.
Hyperventilation
During Assessment – Which data do you collect first: Objective or Subjective Data?
Subjective Data
What kind of assessment determines the client’s ability to care for themselves, their lifestyle choices, and the environment in which they live?
functional assessment
Type of questions ask for specific information that can be answered with one or two words and limit the client’s response.
Close-ended
Direct
Type of questions ask a general question about a topic and allow the client to express their thoughts. They encourage the client to provide a thorough and detailed response.
Open-ended
Type of questions suggest an answer for the client and should be avoided during an interview. Instead, the nurse should ask questions that encourage the client to express their thoughts.
Leading
acronym “OLD CARTS
the nurse is gathering information related to the client’s history of present illness.
What stage?
pressure injury presents with intact, reddened skin. There is no loss of skin or drainage associated with this stage of pressure injury.
Stage I
Skin that feels smoother and softer than expected, similar to velvet, is associated with thyroid disorders.
Velvety skin
small, serous, raised, fluid-filled skin lesions. The nurse should identify that they are associated with both chickenpox and shingles infections and should be reported to the provider.
Vesicles
are superficial, raised, discolored areas of the skin that have a slightly irregular shape. Wheals are associated with allergic reactions and insect bites.
Wheals
are small, solid, raised areas caused by a thickening of the epidermis. Papules are associated with warts and moles.
Papules
is larger than 1 cm in diameter and is associated with friction damage to the skin, burns, and contact dermatitis.
Bulla or Blister
Pallor is best observed by inspecting…
inspecting the color of the lips, mucous membranes, and nail beds.
An otoscope with a pneumatic bulb attachment is used to
examine a client’s ears.
A wide-tipped speculum is used to examine
client’s nasal cavity.
A tongue blade is used to examine
client’s mouth, lips, and teeth.
EARS -
Edema around the client’s ear can indicate that the client has…
ear infection.
EARS _-
clear, watery, or bloody drainage can indicate that the client has
skull fracture
EARS -
Yellow drainage from the client’s ear can indicate that the client has
ear infection
EARS -
Crusted skin around the client’s ear can indicate that the client has
ear infection
MOUTH -
Yellowing of the client’s hard palate can indicate
liver disorder and is an unexpected finding.
MOUTH -
Red spots, or petechiae, on the client’s hard palate can indicate
infection and is an unexpected finding
MOUTH -
White patches on the client’s tongue can indicate
candidiasis, an oral infection known as thrush, and is an unexpected finding.
MOUTH -
large vein on the ventral surface of the tongue indicates
Expected Finding
MOUTH -
Petechiae on the client’s hard palate can indicate that the client has
Infection - an unexpected finding
MOUTH -
A beefy red tongue, which can be smooth, dark, or swollen, can indicate that the client has
vitamin B12 insufficiency.
MOUTH -
Overgrowth of gum tissue can indicate
gingival hyperplasia.
MOUTH -
White patches on the client’s tongue can indicate
candidiasis, an oral infection known as thrush
Palpate a client’s sinuses.
what is the sequence?
- Position the thumbs on the supra orbital ridge just below the client’s eyebrows to assess the client’s frontal sinuses is the first step.
- Firmly press upward on the ridge and make sure not to apply pressure to the client’s eyes is the second step.
- Ask the client if they detect tenderness or pain is the third step.
- Position the thumbs below the client’s cheekbones with fingers alongside the client’s head to assess the client’s maxillary sinuses is the fourth step.
- Apply firm, upward pressure and ask the client if they detect tenderness or pain is the fifth step.
SINUSES -
The nurse should identify that a client who has allergies can have
pale mucosa, as well as clear discharge.
SINUSES-
Bright red mucosa is an indication that the client has
upper respiratory infection
SINUSES -
Green discharge is an indication that the client has
infection of the sinuses
SINUSES -
Yellow discharge is an indication that the client has
infection of the sinuses
misalignment of the axes of the eyes.
strabismus
high-pitched ringing in the ears.
tinnitus
weakness of the facial muscles causing asymmetry of facial features.
Bells’ palsy
presence of coarse facial hair on a female client, indicating a hormonal or endocrine disorder.
Hirsutism
anterior lump on the client’s neck can indicate that the client has
thyroid disorder
Is Protrusion of the client’s mastoid bone behind the client’s ear an expected finding or unexpected finding?
Expected finding
Edema of the eyelids can indicate
heart failure
The outer layer of the eyeball is the
sclera
which is the white portion of the eye surrounding the iris.
The mucous membrane that lines the eyeball is
conjunctiva
The nurse should identify that the transparent layer that covers the iris and pupil is
cornea
The colored portion in the center of the eye is the
iris,
which regulates the amount of light entering the lens of the eye.
The nurse should identify that an anterior lump on the client’s neck can indicate
thyroid disorder
