Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

NURSING > Health Assessment > Flashcards

Health Assessment Flashcards

You may prefer our related Brainscape-certified flashcards:
Nursing Pharmacology flashcards NCLEX-RN® flashcards Nursing Mental Health flashcards Nursing Fundamentals flashcards Nursing Safety & Infection flashcards Nursing Adult Health flashcards NCLEX-PN® flashcards Nursing Management of Care flashcards Nursing Pediatrics flashcards Nursing Maternity flashcards
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Ongoing partial assessment

A

conducted at regular intervals

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What is the focus of ongoing partial assessments?

A

concentrates on identified health problems to monitor positive and negative changes

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Focused assessment

A

conducted to assess a specific problem

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What is a health history?

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

How do you assess awareness?

A

Orientation times 3:

1) Time
2) Place
3) Person

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What is consciousness?

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What are the levels of consciousness?

A
  • Awake and alert
  • Lethargic
  • Stuporous
  • Comatose
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

what is a physical assessment?

A

the systematic collection of objective information

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

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

A

low-pitch (heart and vascular system)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

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

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

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

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

What is an ophthalmoscope?

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

What is an otoscope?

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

What are the primary techniques used for assessment?

A
  • inspection
  • palpation
  • percussion
  • auscultation
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

When does inspection of the patient begin?

A

with initial contact

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

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

A

dorsum (back) and fingers

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

What part of the hand is used to assess vibrations?

A

palm

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

What is percussion?

A

the act of striking on object against another to produce sound

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

What is auscultation?

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

What is erythema?

A

redness of the skin

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

what is cyanosis?

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

What is jaundice?

A

yellowing of the skin resulting from liver and gallbladder abnormalities

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions