Health Assessment Quiz 2 Flashcards
1
Q
What are the primary assessment tools used to examine the hair, skin, and nails?
A
inspection and palpation
2
Q
When palpating the nails the surface should feel:
A
smooth, firm, and uniform
3
Q
A patient has pink nail beds/color. A nurse would say these nails are:
A
normal
4
Q
Yellow nails may indicate
A
psoriasis, fungal infection, chronic respiratory disease, or tobacco use
5
Q
A patient has blue nail beds/color. A nurse may conclude this patient has:
A
acute cyanosis
6
Q
Normal nail plates:
A
should be smooth and slightly convex
7
Q
During an assessment a nurse finds her patient has clubbed finger nails. The nurse will want to test for:
A
chronic hypoxia
8
Q
The laymen’s term for koilonychia is:
A
spoon shaped nails
10
Q
Define paronychia:
A
a bacterial infection of tissue surrounding the nail
11
Q
T or F: If a patient presents with paronychia a nurse may want to suggest a course of antibiotics.
A
TRUE
12
Q
Define Onychomycosis:
A
fungal infection of the nail bed
13
Q
The main point when it comes to hair assessment is watching for changes in:
A
hair texture, quantity, and distribution
14
Q
T or F: Alopecia may be considered normal for some men.
A
TRUE. Alopecia refers to hair loss, which is normal for older men who go bald
15
Q
When assessing the scalp of a 8 year old, what is one important thing to check for?
A
the presence of lice infestation
16
Q
The scalp should be:
A
smooth and nontender
17
Q
The skin has three primary layers which are:
A
Epidermis, dermis, hypodermis
18
Q
The epidermis is:
A
the thick outer layer of the skin
19
Q
This layer of the skin contains blood, lymphatic cells, nerves, base of hair follicles, sebaceous and sweat glands, collagen and reticular fibers
A
the dermis
20
Q
This layer of the skin is connected to underlying organs, contains adipose for cushioning organs
A
hypodermis
21
Q
A nurse bundles a newborn baby in a blanket to keep the child warm. In terms of newborn skin state, why is this important?
A
babies have very little subcutaneous fat
22
Q
During different life stages, what body element is attributed with changing the appearance of skin?
A
hormones
23
Q
When performing a subjective skin assessment, what factor is important to consider?
A
Age of the patient
24
Q
A blister would be an example of a ______________ lesion.
A
vesicular
25
Q
This type of lesion is elevate, solid, and measures less than 0.5 cm
A
papular lesion
26
Freckles, measles, and some drug rashes are examples of this type of lesion:
macular lesion
27
Skin turgor, temperature, and moisture level can be used to asses:
dehydration
28
Circulation of _______ and ________ are most vulnerable.
palms and feet
29
A lesion would be considered primary if:
it is the initial spontaneous eruption of the lesion.
30
A secondary lesion is one that:
often occurs afater primary lesion
31
A nurse sees an essentially flat colored lesion when examining a patient. She would document this as a:
macular lesion
32
A rash that is firm or filled with solid material is:
a papular rash
33
A nurse sees a rash that is a combination of papules and patches of flat colored skin. She would document a:
maculopapular rash
34
A hyperpigmented patch of skin will appear:
dark brown
35
A hypopigmented patch of skin appears:
white
36
A mother states her child was just stung by a bee. A nurse would be looking at the child's skin for:
a wheal rash
37
What is a wheal rash?
an elevated irregular accumulation of subcutaneous edema
38
If a section of skin stays discolored for > 30 minutes after relief of pressure it could be described as a:
stage I pressure ulcer
39
A pressure ulcer that has partial thickness, loss of dermis, open, shallow with a red/pink wound bed would be considered:
Stage II
40
A pressure ulcer which appears as a deep crater, but the nderlying bone is not present would be considered
Stage III
41
A nurse notices a wound that has caused extensive destruction, slough/eschar are present, and bone is visible. She would document this as:
a stage IV pressure ulcer
42
When assessing the head and neck what are the 6 key areas to address?
Head, eyes, ears, nose, mouth and pharynx, neck
43
HEENT stands for:
Head, Eyes, Ears, Nose, Throat
44
What are some common ailments related to the HEENT exam?
headache, rhinitis (common cold), sore throat, swollen lymph nodes
45
T or F: It is normal for babies to have fontanels that are not fused.
TRUE
46
A nurse can tell a lot about a person's _____________ health from looking at their eyes.
Emotional health
47
When assessing the eyes it is important to ask:
any current vision changes, history of visual problems, use of correction lenses?
48
When performing an eye exam, tell patient to report at any time if:
They have blurred vision, double vision, or see flashes of light (scotomata-blind spots)
49
The conjunctiva should be obsered for:
erythema or discharge
50
A nurse is trying to assess a patient for jaundice. How would she do this by looking at the eyes?
looking for yellowing of the sclera
51
The common term for conjuntivitis is:
pink eye
52
Erythema on the conjunctiva could be due to a.virus b. bacteria c. trauma d. allergies/irritants e. all of the above
e-all of the above
53
Eye infections are most common in:
pediatric and elderly
54
A nurse observes that a patient has proptosis (eyes appear to be bulging out of head). She would want to test for:
hyperthyroidism
55
Visual acuity is expressed as a ratio of:
distance from chart/distance at which normal eye can read the line of letters ex: 20/200= patient can read print at 20 ft what normal eye can read @ 200 ft.
56
Legal blindness is described as:
>20/200 with glasses
57
the chart used to measure visual acuity is the:
Snellen eye chart
58
The Snellen eye chart needs to be places ___________ft away from pt.
20
59
The corneal refelction test is looking for:
asymmetry in the reflections from the corneas
60
Asymmetry on the corneal reflection test can indicate:
deviation from normal ocular alignment and muscular problems in eyes
61
When performing a red reflex test, the nurse notes that the reflection is white-ish, not red. This could be due to:
malignancy blocking the reflection of the retina
62
During a physical exam the nurse records "Strabismus" in her notes. This means:
misalignment of the eye
63
Define Esotropia:
eyes look inward
64
Define Exotropia:
eyes look outward
65
When light is shined into the pupils they should:
constrict
66
When a light source is removed from the pupils they should:
revert to non-constricted state
67
Pupilary muscle reactions are a useful assessment of the_______________ system.
neurological system
68
What does PERRLA stand for?
Pupils Equal Round and Reactive to Light and Accommodation
69
When performing an internal ear exam, what is one important safety measure to remember, esp. w/ children?
stabilize the otoscope against their cheek with pinky finger
70
When inspecting the internal ear, one should look for a:
cone of light at 4:00
71
Absence of a cone of light during external ear exam may be due to:
infection or retreaction of tympanic membrane
72
Conductive hearing loss is due to:
wax/fluid build up
73
sensorineural hearing loss is due to:
an inner ear disorder, involves cochlear nerve and neuronal transmission to brain
74
Where should the tuning fork be placed for the Rinne test?
behind ear on mastoid bone
75
T or F: Air conduction is 2x as long as bone conduction.
TRUE
76
During a Rinne test, when patient can no longer hear sound, where do you move the tuning fork?
place fork in front of ear canal
77
A whisper test may not be the greatest assessment for which population?
The elderly-they may be able to hear very soft sounds, but not loud sounds
78
Where should the tuning fork be placed during a Webber test?
base of fork should be on top of patient's head
79
The Webber test is testing:
if the patient can hear out of both ears
80
A normal result for the Webber test would be:
patient stating they can hear out of both sides
81
What is involved in the nail inspection?
Color of nail beds, length, symmetry, shape of nail plate surface, surfase texture
82
What could yellow nails indicate?
psoriasis, fungal infection, chronic respitory disease or tobacco use
83
What could darkened mails indicate?
Trauma
84
What could blue nails indicate?
acute cyanosis
85
What could a deviation for smooth and slightly convex of the nail be?
infection, chronic hypoxia, trauma, or genetic
86
What could clubbing be due to?
chronic hypoxia
87
What could convex nails be due to?
genetic problem
88
What are spoon shaped nails called and what causes them?
Koilonychia, severe chronic iron deficiency anemia and hypothyroidism
89
What is paronychia?
bacterial infection of tissue surrounding the nail
90
What is onychomycosis?
fungal infection of nail bed
91
What do you assess the hair for?
texture, quantity, distribution
92
What is alopecia?
Hair loss could be local or universal
93
What are the three skin layers?
epidermis, dermis, hypodermis
94
Why do newborns have a red look to their skin?
very little subcutaneous fat
95
What causes cyanosis?
Lack of oxygen in the periphery
96
What is involved when you palpate for skin assessment?
Turgor, temperature, moisture, texture, mobility
97
What is a macular lesion and examples?
essentially flat colored lesion: freckles, measles, drug rash
98
What is a papular rash?
elevated above skin surface, firm or filled with solid materials, can also be fluid filled
99
What is a maculopapular rash?
combination of papules and macular rash, red diffuse rash filled with fluid papules and crusts
100
What is a rash with fluid filled lesions <1 cm in diameter that may be clustered or solitary?
vesicular
101
What are two types of patches skin lesions?
psoriasis and vitaligo
102
What is an elevated irregular accumulation of subcutaneous edema?
wheal, insect sting or drug reaction
103
Where do nodules originate?
lower in dermis (elevated and firm)
104
What are elevated encapsulated lesions in dermis or epidermis filled with fluid or semisolid materials?
cysts
105
What is a excoriation lesion?
scratching
106
What is a fissure lesion?
linear cracks
107
What is an erosion lesion?
loss of part of the dermis, may follow rupture of a vesicle or bulla
108
What is an ulcer?
loss of dermis, concave, varies in size
109
What are common sites for pressure ulcers?
sacrum, hip socket, boney prominance of shoulders, heels, posterior region of head
110
What are the characteristics of a stage 1 pressure ulcer?
localized skin intact, redness, non-blanching, discoloration for > 30 minutes after relief of pressure
111
What are the characteristics of a stage II pressure ulcer?
partial thickness, loss of dermis, open and shallow, red, pink wound bed
112
What are the characteristics of a stage III pressure ulcer?
Full thickness, deep crater, damage or necrosis to subcutaneous tissue, undermining may be present, bone/tendon not visible
113
What are the characteristics of a stage IV pressure ulcer?
Full thickness skin loss to muscle/bone, extensive destruction, slough/ eschar present, underminig/ tunneling present, often requires full to heal
114
What is an unstagable pressure ulcer?
involves full thickness skin loss, base of wound obscured by slough or eschar, commonly requires mechanical debridement
115
What is involved in inspecting the external eye structures?
observe: conjuctiva for erythema or discharge, sclera for yellowing, peri-orbital region for edema, lids for symmetry or lid lag, under lower lid for conjuctiva sac, under upper lid for upper conjectiva
116
Why may the lens may appear cloudy?
cataracts
117
What is exopthamos?
Eyes appear to buldge as lids retract, usually due to hyperthyroidism
118
What could an absence of the red reflex mean?
adults: cateracts neonates: retinobtruction or blastoma
119
What is a strabismus?
misalignment of the eyes, can cause visual disturbance: esotropia: inward, exotropia: outward
120
Where should the cone of light be for the internal ear exam?
4:00
121
What is conductive hearing loss?
external or middle ear disorders, impairs sound to inner ear,
122
what could cause conductive hearing loss?
foreign body, otis media, perforated eardrum, may be acute or chronic
123
What is sensorineural hearing loss?
inner ear disorder, involves cochlear nerve and neuronal transmission to brain
124
What can cause sensorineural hearing loss?
loud noise exposure, inner ear infection, trauma, aging, may be congenital
125
Which should be longer in the Rinne test: bone or air conduction?
air conduction should be 2x longer
126
Where do you put the tuning fork for the Rinne test?
first behind the ear on the mastoid bone and then put in front of the ear canal
127
Where do you put the tuning fork for the Weber test?
on top of patient's head- ask then if they can hear it in one, both or neither side
128
Where do you palpate for sinuses?
frontal and maxillary sinuses
129
What could be abnormal findings when palpating the thyroid?
abnormal size, shape consistency, nodules or tenderness
