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NURSING > Health Assessment > Flashcards

Health Assessment Flashcards

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1
Q

what is done in a comprehensive assessment and when is it performed?

A

health history and complete physical examination

- usually conducted when pt first comes in

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2
Q

Ongoing partial assessment

A

conducted at regular intervals

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3
Q

What is the focus of ongoing partial assessments?

A

concentrates on identified health problems to monitor positive and negative changes

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4
Q

Focused assessment

A

conducted to assess a specific problem

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5
Q

How does a nursing health assessment differ from other types of health assessments?

A

it is a holistic collection of information about factors that affect or are affected by one’s level of health

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6
Q

What is a health history?

A

collection of subjective data that provides a detailed profile of the patient’s health status

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7
Q

What does conducting a health assessment involve?

A

collecting and analyzing subjective and objective data to determine overall level of physical, psychological, sociocultural, developmental, and spiritual health of a pt.

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8
Q

How do you assess awareness?

A

Orientation times 3:

1) Time
2) Place
3) Person

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9
Q

What is consciousness?

A

the degree of wakefulness or the ability of a person to be aroused

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10
Q

What are the levels of consciousness?

A
  • Awake and alert
  • Lethargic
  • Stuporous
  • Comatose
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11
Q

what is a physical assessment?

A

the systematic collection of objective information

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12
Q

What kind of sounds is the bell of a stethoscope used for?

A

low-pitch (heart and vascular system)

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13
Q

What is the sequence of techniques used to assess the abdomen?

A

1st: Inspect
2nd: Auscultate
3rd: Percuss
4th: Palpate

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14
Q

What type of sounds is the diaphragm of the stethoscope used for?

A

High-pitch (normal heart sounds, bowel, breath)

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15
Q

What is an ophthalmoscope?

A

lighted instrument used to visualize the interior structures of the eye.

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16
Q

What is an otoscope?

A

lighted instrument used to examine the external ear canal and the tympanic membrane

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17
Q

What are the primary techniques used for assessment?

A
  • inspection
  • palpation
  • percussion
  • auscultation
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18
Q

When does inspection of the patient begin?

A

with initial contact

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19
Q

What part of the hand is used for gross measurement of temperature?

A

dorsum (back) and fingers

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20
Q

What part of the hand is used to assess texture, shape, fluid, size, consistency and pulsation?

A

palmer (front) surface of the fingers

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21
Q

What part of the hand is used to assess vibrations?

A

palm

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22
Q

What is percussion?

A

the act of striking on object against another to produce sound

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23
Q

What is auscultation?

A

the act of listening with a stethoscope to sounds produced within the body

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24
Q

What is erythema?

A

redness of the skin

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25
Q

what is cyanosis?

A

bluish or grayish discoloration of the skin in response to inadequate oxygenation

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26
Q

What is jaundice?

A

yellowing of the skin resulting from liver and gallbladder abnormalities

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27
Q

what is pallor?

A

paleness of the skin

28
Q

what is Ecchymosis?

A

collection of blood in the subcutaneous tissues causing purplish discoloration

29
Q

what is Petechiae?

A

small hemorraghic spots caused by capillary bleeding

30
Q

what are lesions?

A

areas of diseased or injured tissue i.e….bruises, scratches, cuts, burns, insect bites, and wounds

31
Q

What is the difference between primary and secondary lesion?

A

Primary lesions arise from previously normal skin, but secondary lesions result from changes in primary lesions

32
Q

What is Turgor?

A

the fullness or elasticity of the skin

- usually assessed on the sternum or under the clavicle

33
Q

what is Edema?

A

excess fluid in the tissues

34
Q

How do you assess edema?

A 
use fingers to make indention in the skin and assess depth of indentation that remains
   0 - none
 \+1 - trace, 2 mm
 \+2 -  moderate, 4 mm
 \+3 - deep, 6 mm
 \+4 - very deep, 8 mm
35
Q

How can nits be differentiated from dandruff?

A

they are attached to the hair shaft

36
Q

If a patient smokes what is always included in plan of care?

A

discussion about ways to stop smoking

37
Q

in what position should the head and neck be assessed?

A

sitting position

38
Q

What is used to assess visual acuity?

A

snellen chart

39
Q

how to you assess retinal function and optic nerve function?

A

test for peripheral vision

40
Q

how often do bowel sounds usually occur?

A

every 5 to 34 seconds

41
Q

What is Romberg test?

A

??

42
Q

what is a bruit?

A

abnormal sounds heard over blood vessel as blood passes an obstruction

43
Q

what do high-pitched tinkling or rushing bowel sounds indicate?

A

bowel obstruction

44
Q

what do decreased or absent bowels sounds indicate?

A

peritonitis or paralytic ileus

45
Q

how is Olfactory nerves assessed? Nerve number?

A

test sense of smell

l

46
Q

how is optic nerve assessed? Nerve number?

A

vision acuity and visual fields

ll

47
Q

how are oculomotor nerves assessed? Nerve number?

A

test pupillary reaction to light and ability to open and close eyelids
lll

48
Q

how are trochlear nerves assessed? Nerve number?

A

test downward and inward movement of the eyes

lV

49
Q

how are trigeminal nerves assessed? Nerve number?

A

have pt. open and clench jaws, test face and neck for pain sensation, light touch and temp.
V

50
Q

how are abducen nerves assessed? Nerve number?

A

test lateral movements of the eyes

Vl

51
Q

how are facial nerves assessed? Nerve number?

A

have pt. raise eyebrows, smile, show teeth, puff cheeks, test taste sensations
Vll

52
Q

how are Acoustic nerves assessed? Nerve number?

A

test hearing ability

Vlll

53
Q

how are Glossopharyngeal nerves assessed? Nerve number?

A

ask pt. to say “ah”, elicit gag response, note ability to swallow,
taste sensation on posterior one third of the tongue
lX

54
Q

how are vagus nerves assessed? Nerve number?

A

ask pt. to swallow and speak, note hoarseness

X

55
Q

how are accessory nerves assessed? Nerve number?

A

ask pt. to shrug shoulders against your resistance

Xl

56
Q

What are the risk factors or signs of cancer?

A 
Change in bowel or bladder habits
A sore that doesn't heal
Unusual bleeding or discharge
Thickening or lump in the breast or elsewhere
Indigestion or difficulty in swallowing
Obvious change in wart or mole
Nagging cough or hoarseness
57
Q

How are Hypoglossal nerves assessed? Nerve number?

A

Stick out tongue, push tongue against cheek

Xll

58
Q

What is Crepitus?

A

grating sounds on joint movement

59
Q

What is the minimum score that defines a coma on the Glascow coma scale?

A

7

60
Q

What grade indicates a normal active response for deep tendon reflexes? What is the range of the reflex scale?

A

2+

0 - 4+

61
Q

To assess adult ear canal, how to you manipulate the pinna?

A

pull up and back

62
Q

what does fissured or hairy tongue indicate?

A

dehydration

63
Q

what does bright red tongue indicate?

A

iron, vitamin B12, or niacin deficiency

64
Q

what does black tongue indicate?

A

antibiotic use

65
Q

What is the Glascow coma scale and what parameters are used?

A

Standardized assessment of consciousness level.

Parameters evaluated: eye opening, motor response, verbal response

NURSING (23 decks)

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