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Health Assessment > Health Assessment Exam 1 > Flashcards

Health Assessment Exam 1 Flashcards

1
Q

Describe the use of the four physical examination techniques: inspection, palpation, percussion, auscultation.

A
  1. Inspection: use of sense of vision, smell, and hearing to look & observe characteristics and components of body.
  2. Palpation: examination of body using fingers/hands to determine texture, location, size, & consistency of organs and masses.
  3. Percussion: Striking (or) tapping a body part by listening o sound produced.
  4. Auscultation: using a stethoscope to listen to sounds of body
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2
Q

Blood pressure definition

A

force that blood exerts AGAINST vessel wall

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3
Q

systolic pressure definition

A

ventricles contract (top number of blood pressure)

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4
Q

diastolic pressure defintion

A

ventricles relax with minimal pressure (bottom number)

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5
Q

pulse pressure is the difference between…

A

the difference between systolic & diastolic pressure

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6
Q

Relate the use of a blood pressure cuff of improper size to the possible findings that may be obtained

A
  • Wider cuffs = false low reading
  • Narrow cuffs = false high reading
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7
Q

what are collaborative problems?

A
  • Actual or potential PHYSIOLOGICAL PROBLEMS
  • health care team monitors client conditions
  • uses clinical judgment to minimize interventions
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8
Q

what is a nursing diagnosis?

A
  • prescribed by nurse
  • focused on patient goals
  • interventions within scope of nursing
  • uses NANDA-international
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9
Q

The following is an example of WHAT type of diagnosis?
- Ineffective airway clearance
- Disturbed body image
- Risk for unstable blood glucose
- Impaired urinary elimination
- Self-care deficit: dressing

A

Nursing Diagnosis

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10
Q

The following is an example of WHAT type of diagnosis?
- pneumonia
- amputation
- type 2 DM
- post-op prostatectomy
- CVA

A

medical diagnosis

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11
Q

The following is an example of WHAT type of diagnosis?
- potential complication of head injury: increased intracranial pressure
- potential complication of myocardial infarction - congestive heart failure

A

collaborative problems diagnosis

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12
Q

Described parts of the health history & associated interview data

A
  1. Biographical data (name, address, gender, provider, education,etc)
  2. Reason for seeking care & history of current health concern
  3. Personal health history (birth, development, childhood diseases, immunizations, allergies, rx use, surgeries, etc)
  4. Family health history
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13
Q

Discuss assessment of nails

A
  1. Inspect for grooming and cleanliness
  2. Inspect color and markings
  3. Inspect shape
  4. Palpate texture and consistency
  5. Test for capillary refill
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14
Q

Light palpation

A
  • fingertips
  • fine discriminations (PULSE, SURFACE SKIN TEXTURE)
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15
Q

deep palpation

A
  • Nondominant hand over dominant hand
  • Ulnar/Palmar Surface
  • Vibrations, thrills, fremitus
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16
Q

bimanual palpation

A
  • 2 hands
  • One hand on each side of body part to palpate
  • Bimanual like bilateral mammogram
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17
Q

Describe direct and indirect percussion, and the names and origins for the five different percussion notes.

A

Direct:
- Tapping with 1-2 fingertips
- Tenderness

Indirect/Mediate:
- Most common
- tapping to produce sound of density underlying structures
- density increase > sound gets quieter

5 Percussion notes:
1. Resonance = normal lungs

  1. Hyper resonance = abnormal lungs
  2. Tympany =
    - abdomen
    - gastric bubble, puffed out cheek (normal)
  3. Dullness =
    - large dense organs
    - diapgrahm, pleural effusion, liver
  4. Flatness
    - Bones
    - Muscle, sternum, thigh
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18
Q

physical appearance data

A
  • Facial features (symmetry)
  • Hygiene
  • Grooming
  • Consciousness
  • Skin
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19
Q

body structure data

A
  • posture
  • body build
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20
Q

mobility data

A
  • Range of motion
  • Gait
  • Involuntary movements
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21
Q

behavior data

A
  • behavior
  • speech
  • mood
  • facial expressions
  • grooming
  • personal + dental hygeine
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22
Q

list all 4 data areas of a general survey

A

physical appearance, body structure, mobility, and behavior

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23
Q

Discuss measurements of weight and height.

A

Height
- measured in feet + inches OR centimeters
- uses studio meter to measure
- measures from top of head to bottom of heel of foot

Weight
- measured in pounds or kilograms
- uses balance scale or electronic scale

BMI is used to assess healthy weight and height for clients based on age.
- less than 18.5 is underweight
- healthy weight 18.5 - 24.9
- overweight 25- 29.9
- obesity 30+

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24
Q

Describe various routes of temperature measurement and special considerations for each route.

A

Oral - wait 10-15 minutes before taking if client has smoked/or had any oral intake

  • Rectal - most accurate, core temp, not preferred if rectal bleeding/complications
  • Temporal - forehead + behind the ear
  • Axillary - less accurate
  • Tympanic - accuracy impacted by infection in ear canal
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25
Q

Describe the four qualities considered when one assesses the pulse.

A
  1. rate - beats per minute
  2. rhythm - consistent intervals between pulsations
  3. amplitude - strength of pulse
    - 0 = absent, 1 = weak, 2 = normal, 3 = bounding
  4. elasticity & contour - waveform analysis + stroke volume
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26
Q

Describe the appropriate procedure for assessing normal respirations.

A
  1. Provide privacy
  2. Introduce self to client, hand hygiene, client identification
  3. Position patient sitting/lying 45 to 60 degrees
  4. Place clients arm across abdomen or lower chest
  5. Place fingers to measure pulse, but observe the rise & fall of chest for a 30 seconds and multiply by 2 or a full minute
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27
Q

List the factors that affect blood pressure.

A
  • Age
  • Ethnicity
  • Sex
  • Position changes
  • Exercise
  • Weight
  • Anxiety
  • Medications
  • Time of day
  • Nicotine use
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28
Q

Describe the use of the pain symptom analysis acronyms: OPQRSTUAA and/or COLDSPA and/or OLDCARTS

A

OPQRSTUAA: onset, provocative/palliative, quality, radiates, severity, timing, aggrivating factors, alleviating factors

COLDSPA: character, onset, location, duration, severity, pattern, associated factors

OLDCARTS: onset, location, duration, character, aggravating factors, relieving factors, timing, severity

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29
Q

what does the acronym OPQRSTUAA stand for?

A

Onset, provocative/palliative, quality, radiates, severity, timing, understanding, aggravating factors, alleviating factors

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30
Q

what does the acronym COLDSPA stand for?

A

character, onset, location, duration, severity, pattern, associated factors

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31
Q

what does the acronym OLDCARTS stand for?

A

onset, location, duration, character, aggravating factors, relieving factors, timing, severity

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32
Q

what is a medical diagnosis?

A
  • made by physician or advanced health care practitioner
  • specific and precise for cause of illness
  • examples: DM, TB, chronic kidney disease
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33
Q

Discuss assessment of skin and proper equipment used

A

Discuss assessment of skin and proper equipment used
Skin Physical assessment (gloves, exam light, penlight, magnifying glass, centimeter ruler, wood lamp)

  1. Note any distinct odor
  2. Inspect for generalize color variation on skin
  3. Inspect for skin breakdown
  4. Inspect for primary, secondary, or vascular lesions
  5. Palpate lesions
  6. Palpate texture (rough/smooth) of skin using palmar surface of 3 middle fingers
  7. Palpate temperature (using dorsal side of hand) and moisture
  8. Palpate mobility of skin by pinching over sternum
  9. Palpate for thickness, texture, oiliness, lesions, or parasites
34
Q

Discuss assessment of hair and proper equipement

A

Hair physical assessment (gloves, exam light, penlight, magnifying glass, centimeter ruler, wood lamp)

  1. Inspect color of hair
  2. inspect amount and distrubtion of hair
  3. Inspect and palpate for thickness, texture, oiliness, lesions, and parasites with 1-inch intervals
35
Q

Describe selected observable skin lesions

A
  1. Color
  2. Height (flat/raised)
  3. Shape of lesion
  4. Size (centimeters, less or greater than 6cm)
  5. Location (area)
  6. Presence of drainage (color and odor)
36
Q

Discuss assessment findings for the 4 stages of pressure ulcers

A

Stage one:
1. Red area, does not blanch
2. Texture difference than surrounding tissue
3. Temperature difference than surrounding tissue

Stage two:
1. Partial loss of dermis
2. Shiny/dry ulcer with pink wound bed
3. Intact or ruptured blister

Stage three:
1. full thickness skin loss (necrosis) in subq tissue
2. subq tissue visible
3. dead skin present

Stage four:
1. full thickness loss
2. exposed bones, tendons, muscle
3. dead tissue exposed

37
Q

what stage of pressure ulcer is the following (1-4)?

  1. Red area, does not blanch
  2. Texture difference than surrounding tissue
  3. Temperature difference than surrounding tissue
A

Stage one pressure ulcer

38
Q

which stage pressure ulcer is the following (1-4)?

  1. Partial loss of dermis
  2. Shiny/dry ulcer with pink wound bed
  3. Intact or ruptured blister
  4. broken skin
A

stage two pressure ulcer

39
Q

which stage pressure ulcer is the following (1-4)?

  1. full thickness skin loss (necrosis) in subq tissue
  2. subq tissue visible
  3. dead skin present
A

stage three pressure ulcer

40
Q

which stage pressure ulcer is the following (1-4)?

  1. full thickness loss
  2. exposed bones, tendons, muscle
  3. dead tissue exposed
A

stage 4 pressure ulcer

41
Q

Discuss health screening instructions for patients with suspected melanoma using the ABCDEF acronym

A

A - asymmetry
B - border
C - color
D - diameter (cm, less or more than 6cm)
E - evolving
F - feel

42
Q

what are expect findings of a capillary refill?

A

return of the blood to the nail in 2 seconds or less.

43
Q

which type of cancer is most dangerous?

A

malignant melanoma

44
Q

where is hyperresonance heard during percussion? is this normal or abnormal?

A

heard over the lungs, ABNORMAL sound

45
Q

where is dullness heard during percussion?

A

over large dense organs (this is NORMAL)

46
Q

where is flatness heard during percussion?

A

the bones (this is normal)

47
Q

there are 3 types of percussion methods, it is listed as

A
  1. direct - tapping with 1-2 fingertips for tenderness
  2. blunt - uses two hands to strike back of the hand flat on the surface for tenderness over organs
  3. indirect/mediate - tapping to produce sound of underlying structures
48
Q

the IPPA order is a sequence used to perform what actions in which order?

A
  1. Inspection
  2. Palpation
  3. Percussion
  4. Auscultation
49
Q

during a skin assessment, the nurse demonstrates to the patient to perform the “profile sign” using their fingers and knuckles. What is the nurse detecting for in this patient?

A

chronic hypoxia. The profile sign checks for clubbing of the fingertips.

50
Q

when using the stethoscope…which side is preferred to listen to low pitched sounds?

A

bell

51
Q

when using the stethoscope…which side is preferred to listen to high pitched sounds?

A

diaphragm

52
Q

what is skin turgor?

A

elasticity of the skin

53
Q

how is skin turgor assessed? what are the normal expectations for a young healthy adult?

A

skin turgor is assessed by pinching the skin under the clavicle. the normal expectations for a young healthy adult is a brisk response within a matter of 1-2 seconds.

54
Q

what is “tenting” of the skin? when is it used?

A

tenting of the skin refers to the skin recoiling during the skin turgor assessment. tenting means the skin is SLOWLY recoiling in shape of a tent, a lot slower than expected. This is found often in elderly/older clients.

55
Q

A patient who is at risk for pressure ulcers and is bed-ridden will have to continuously do what in order to prevent ulcer injuries?

A

reposition/turn every 2 hours

56
Q

Patients who are at risk for pressure ulcers should recognize what risk factors?

A
  • decreased mobility
  • increased moisture
  • nutrition
  • friction
  • tissue and age
57
Q

in which order is a full skin assessment performed?

A
  1. . Inspect Skin
  2. Palpate skin
  3. Inspect scalp and hair
  4. Inspect nails
58
Q

True or false, Inspecting the fingernails and toenails is not priority in respiratory system assessment?

A

False. The nails give vital information about the condition of respiratory like cyanosis, hypoxia, spoon shaped (cancer)

59
Q

What is arm span/wing span? Why is it important?

A

arm span: stretching both arms wing out should measure to persons size/height.

  • if not, patient could have marfan syndrome (arms longer than actual patients height) and would need to see a cardiologist
60
Q

The braden scale measures what?

A

Pressure ulcer RISK

61
Q

the PUSH scale measures what?

A

Pressure ulcer HEALING (H at the end of PUSH = think of healing)

62
Q

A high number on the PUSH scale most likely indicates that the pressure injury is….

A

pressure injury that scores high, indicates it is less healed

63
Q

Patients at risk, or who have pressure injuries should incorporate what kind of nutrition?

A

high protein diets

64
Q

Bruising in the skin is known as

A

ecchymosis

65
Q

A fissure is known as a…

A

STRAIGHT tear/crack in the skin that extends into the dermis

66
Q

What are apocrine glands and where are they found?

A

Large sweat glands. They are found in dermis, armpits, forehead, chest, low back

67
Q

What is the MAIN concern when it comes to skin cancer risk factors?

A

UV Radiation, chemical exposure, abesto

68
Q

bleeding in the skin is known as what?

A

petechiae

69
Q

what are signs/symptoms of dehydration?

A
  • slowed skin turgor
  • dry oral mucosa
  • elevated temperature
  • tachypnea
  • low blood pressure
70
Q

What is a wood lamp used for?

A

detects fungus

71
Q

What is a goniometer?

A

instrument used to measure joint angles

72
Q

what are the layers of the skin (IN ORDER)

A
  1. Epidermis
  2. Dermis
  3. Subcutaneous fat
  4. Soft tissue
  5. Bone
73
Q

Which gender is most at risk for skin cancer?

A

male gender

74
Q

Which patient is at most risk for pressure injuries?
1. A patient who has diabetes (type 2)
2. A patient who is is the ER for chest pain
3. A patient who is in the ER for an acute laceration on their finger

A
  1. A patient who has diabetes (type 2) is most at risk for pressure injuries
75
Q

A client visits the clinic for a routine exam. The nurse prepares to assess the clients skin. The nurse asks the client if there is a family history of skin cancer, and should explain to the client that there is a genetic component with skin cancer, especially…

A

malignant melanoma

76
Q

A client recovering from a stroke complains of pain. The nurse suspects this client is most likely experiencing which type of pain?
1. somatic
2. neuropathic
3. Idiopathic

A

neuropathic. neuropathic pain occurs from CNS brain injury, in this case - a stroke.

77
Q

where do you hear tympany?

A

abdomen (all 4 quadrants)

78
Q

how do you define spirituality?

A

a search of meaning and PURPOSE in life that seeks to understand life’s ultimate questions

79
Q

how do you define religion?

A

rituals, practices, and experiences shared within a GROUP that involve a search for the SACRED.

80
Q

Which assessment would you use to conduct a spiritual history assessment?

A

FICA assessment (faith, importance, community, address in care)

81
Q

which assessment would you use to conduct a religious assessment?

A

RCOPE (religious coping questionnaire)

82
Q

how would a darker skinned client present with pallor?

A

ashen gray skin tone

Health Assessment (1 decks)

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