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MODULE 1 > Health Assessment And Physical Examination > Flashcards

Health Assessment And Physical Examination Flashcards

1
Q

two types of data

A

subjective and objective

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2
Q

what the patient tells us about their world is what type of data

A

subjective

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3
Q

where nurse has results and data/vital signs is what type of data ____

A

objective

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4
Q

what are the methods of data collection?

A

interview, nursing health history, physical examination, and diagnostics/lab results

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5
Q

interview has 3 phases

A

orientation phase, working phase, and termination phase

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6
Q

types of physical assessment are ___

A

comprehensive, focused, system specific, and ongoing

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7
Q

head to toe, normal assessment is ___

A

comprehensive

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8
Q

if you have already done comprehensive, and going back to check on one area

A

focused

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9
Q

system specific

A

similar to focused

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10
Q

patient comes in often, do head to toe but assess the ongoing issues

A

ongoing

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11
Q

what’s been going on is the ____

A

baseline history

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12
Q

vital signs, inspection (looking), ausculation (listening), and palpation (feel) is what part of the assessment

A

examination

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13
Q

how do you assess a patient?

A

look, listen, feel

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14
Q

nursing process and physical assessment is done in what order?

A

assessment, outcome identification, planning, implementation, and evaluation

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15
Q

good lighting, expose all of part to be examined, use penlight for ears, eyes, and mouth. observe for color, shape/symmetry, position and movement is what technique of the assessment?

A

inspection

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16
Q

touch is what technique of assessment?

A

palpation

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17
Q

light palpation is how many cm or inch in depth?

A

1 cm or 0.5 inch

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18
Q

deep palpation is how many cm or inch in depth?

A

4 cm or 2 inch

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19
Q

listen, frequency (# of oscillations/sound waves) per second generated by vibrating object, loudness (amplitude of a sound wave), quality (descriptive), duration (length of time that sounds last- short, medium, long)

A

auscultation

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20
Q

smell, abnormal or normal

A

olfaction

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21
Q

_____ typically taken prior to exam and begin with general survey

A

health history

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22
Q

_____ is the single most important assessment component and often first clue of deteriorating conditon

A

level of conciousness

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23
Q

how do you test level of consciousness?

A

alert, lethargic, obtunded, stuporous/semi-comatose, and comatose

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24
Q

attentive, follows commands, if asleep-wakes up promptly and remains attentive

A

alert (LOC)

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25
Q

drowsy but awakens, slow to respond

A

lethargic

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26
Q

difficult to arouse, needs constant stimulation

A

obtunded

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27
Q

arouses only to vigorous/noxious stimuli, may only withdraw from pain

A

stuporous/semi-comatose

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28
Q

no response to verbal or noxious stimuli, no movement

A

comatose

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29
Q

pt oriented to person, place, and town, also known as mentation

A

cognitive awareness

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29
Q

how do you test cognitive awareness?

A

name, DOB, where are they right now, what year/day it is, and what brought you in

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29
Q

PERLA is testing on what cranial nerves?

A

cranial nerves III, IV, and VI

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30
Q

examine size and shape of pupils and compare to scale

A

pupil response

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31
Q

PERLA stands for _____

A

pupils, equal, react to, light, and accommodation

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32
Q

using the tip of unlit penlight and have pt follow with eyes only and about 9-12 inches from face in “H” motion is called ____

A

cardinal gaze

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33
Q

ask patient to smile and show teeth, wrinkle forehead or raise eyebrows, looking for symmetry is testing what cranial nerves

A

cranial nerve VII

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34
Q

ask patient to touch roof of mouth with tongue, protrude tongue out of mouth and side to side is testing what cranial nerve?

A

cranial nerve XII

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35
Q

place hands on patient shoulders lightly and ask pt to shrug shoulders is testing what cranial nerve?

A

cranial nerve XI

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36
Q

BUE means

A

bilateral upper extremities

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37
Q

BLE means

A

bilateral lower extremities

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38
Q

crackles or rales, rhonchi, wheezes, and pleural friction rub are what?

A

abnormal or adventitious sounds of lungs

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39
Q

can be fine or course at the base of the lungs-high pitching popping sounds

A

crackles or rales

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40
Q

can be cleared with coughing typically, over the trachea and bronchial area (wet sounds ,roaring)

A

rhonchi

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41
Q

airways get restricted/narrowed, air passing through the tube fast

A

wheezes

42
Q

lining around lungs and has fluid here, if lining gets dry, it is rubbing tissue on tissue

A

pleural friction rub

43
Q

abnormally slow, under 12 RR

A

bradypnea

44
Q

greater than 20

A

tachypnea

45
Q

absence of respirations, no respirations or period of apnea

A

apnea

46
Q

high respirations

A

hyperpnea

47
Q

rapid, deep breathing at a constant rate

A

kussmaul’s

48
Q

depth and rate are irregular with periods of apnea

A

cheyne-stokes

49
Q

anterior and posterior lung sounds and clubbing of fingers

A

respiratory components of assessment

50
Q

systole or S1 and is the sound associated with the closing of the mitral/tricuspid valves

A

“LUB” sound

51
Q

diastole or S2 and is the sound associated with the closing of the aortic/pulmonic valves

A

“DUB” sound

52
Q

when is there a longer pause between what heart sounds?

A

S2 and S1

53
Q

location of the heart sounds

A

aortic, pulmonic, tricuspid, and mitral

54
Q

aortic location

A

right base, second intercostal space to the right of the sternal border

55
Q

pulmonic location

A

left base, second intercostal space to the left of the sternal border

56
Q

tricuspid location

A

left lateral sternal border, 5th intercostal space to the left of the sternal border

57
Q

mitral location

A

midclavicular line at the 5th intercostal space

58
Q

swelling in the extremities is ____

A

edema

59
Q

most often on feet and ankles, older adults and standing

A

dependent edema

60
Q

venous insufficiency or heart failure; fluid in tissues

A

pitting edema

61
Q

heart sounds, cartoid pulses, radial pulses, pedal pulse, capillary refill, assess for edema

A

cardiac components of assessment

62
Q

neck ROM, BUE ROM, BLE ROM, HGTW, flexion/extension BUE/BLE are ____

A

musculoskeletal components of assessment

63
Q

hydration, temperature, color, texture, rashes, lesions and cracking are assessment of ___

A

skin

64
Q

pale or ashen gray

A

pallor

65
Q

redness r/t vasodilation (a lot of blood flow to area)

A

erythemea

66
Q

yellow, impaired liver (can see in sclera of eye)

A

juandice

67
Q

bluish, decreased circulation or oxygenation of blood

A

cyanosis

68
Q

____ test is elasticity of skin related to hydration

A

turgor

69
Q

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

A

pitting edema

70
Q

nails should be ____

A

transparent, smooth, rounded, convex, and hygienic

71
Q

patent nares means:

A

the nostrils are open

72
Q

excretion of waste products from kidneys and intestines

A

elimination

73
Q

process of elimination waste

A

defecation

74
Q

semisolid mass of fiber, undigested food, inorganic matter

A

feces

75
Q

observe size, shape, contour, skin integrity of abdomen

A

inspection

76
Q

bowel size, four quadrants, normal hypoactive, hyperactive- start in RLQ, RUQ, LUQ, LLQ

A

auscultation

77
Q

palpate for tenderness, pain, and masses of the abdomen

A

palpation

78
Q

inability to control urine or feces

A

incontinence

79
Q

to urinate

A

void

80
Q

to urinate

A

micturate

81
Q

painful or difficult urinating

A

dysuria

82
Q

blood in the urine

A

hematuria

83
Q

frequent night urination

A

nocturia

84
Q

large amounts of urine

A

polyuria

85
Q

voiding at intervals

A

urine frequency

86
Q

the need to void all at once

A

urinary urgency

87
Q

presence of large protein in urine

A

proteinuria

88
Q

leakage of urine despite voluntary control of urination

A

dribbling

89
Q

accumulation of urine in bladder without the ability to completely empty

A

retention

90
Q

urine remaining post void >100 mL

A

residual

91
Q

primary regulators of fluid and acid-base balance

A

kidneys

92
Q

tubule structures that enter into the bladder

A

ureters

93
Q

urine traveling through ureters is typically _____

A

sterile

94
Q

ureters enter bladder ____ & ______ to prevent reflux

A

obliquely and posteriorly

95
Q

in women the uretha is short, ___ to ____ inches

A

1.5 inches to 2.5 inches

96
Q

in men, the uretha is ___ inches, serves in both the GI and reproductive systems

A

8 inches

97
Q

in men, the ____ lies against the anterior wall of rectum

A

bladder

98
Q

in women, the ___ rest against anterior walls of uterus and vagina

A

bladder

99
Q

normal bladder is ____ mL

A

500

100
Q

bladder can extend to ____ mL

A

1000

101
Q

What are normal sounds of the lungs?

A

Vesicular, bronchovesicular, and bronchial

102
Q

Filter and regulate, remove waste from blood to form urine

A

Kidneys

103
Q

Transport urine from kidneys to bladder

A

Ureters

104
Q

Reservoir for urine until the urge develops

A

Bladder

105
Q

Urine travels from bladder and exits through urethral meats

A

Urethra

MODULE 1 (27 decks)

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