Brainscape's Knowledge GenomeTM

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


See full index

Nursing > Health Assessment Test 2 > Flashcards

Health Assessment Test 2 Flashcards

1
Q

vascular system

A
  • job is to circulare blood and lymph with arteries, veins, and lymphatics
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

arteries

A
  • deliver freshly oxygenated blood to body, strong, tough vessels that must withstand high pressure demands, expands and recoil with heartbeat/pulse
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

veins

A
  • bring blood back to the heart to go through lungs to be oxygenated, lie closer to the skin surface than arteries, are more elastic/distensible, contain valves so blood cannot flow backwards
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

lymphatics

A
  • made up of vessels, nodes, ducts, some organs
  • brings excess fluid and plasma proteins back to the bloodstream from the interstitial space
  • major part of the immune system
  • absorb lipids from the small instestine
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

superficial veins in the legs

A
  • great and small saphenous
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

cervical nodes

A
  • drain the head and neck
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

axillary nodes

A
  • drain the breast and upper arm
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

epitrochlear node

A
  • drain the hand and lower arm
  • located in the antecubital fossa
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

inguinal nodes

A
  • drain the lower extremities, the external genitalia, and the anterior abdominal wall
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

pregnant female developmental considerations

A
  • increased estrogen levels leads to vasodilation and drop in BP
  • uterus exerts pressure on iliac veins and inferior vena cava which results in edems and varicose veins
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

aging adults developmental consideration

A
  • arteriosclerosis from increased rigidity of the peripheral blood veels
  • increased risk for deep vein thrombosis
  • decreased lymphatic tissue
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

leg pain/cramp assessment subjective data

A
  • note location, type, precipitating factors, caludication distance, relived by rest walking, rubbing, night pain, recent change in exercise, past history of vascular problems
  • note sudden worsening of claudication and pain suddenly relieved with rest
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

skin changes assessment subjective data

A
  • discolorations (redness, pallor, blueness, brownish), varicose veins, coolness, sores, or ulcers
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

arm/leg swelling subjective data

A
  • in one side or both, worse in the morning or evening, constant or intermittent, what makes it better, what makes it worse, associating factors (pain, heat, redness, ulcers, hardened skin)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

lymph node enlargement subjective data

A
  • location, duration, any recent changes, presence of pain or infection
  • if enlarged, it indicates infection, immunologic disease, or malignant disease
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

medications subjective data

A
  • oral contraceptives or hormonal replacement (increased risk for thrombosis)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

full bounding pulse

A
  • 3+
  • indicates hyperkinetic states (exercise, anxiety, fever, and hyperthyroidism)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

weak pulse

A
  • 1+
  • indicates shock and peripheral arterial disease
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

signs of malnutrition

A
  • thiny, shiny, atrophic skin, thick-ridged nails, hair loss, ulcers, gangrene
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

brownish discoloration

A
  • indicated chronic venous stasis
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

venous ulcers

A
  • located on the medial malleolus
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

arterial ulcers

A
  • located on the tips of toes, metatarsal heads, or lateral malleoli
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

bruit

A
  • indicates turbulent blood flow from partial occlusion
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

modified allen test

A
  • evaluates the adequacy of collateral circulation prior to cannulating the radial artery
  • watch for persistant pallor or sluggish return of color
  • indicates occlusion of collateral circulation
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

doppler ultrasound stethoscope

A
  • used to detect a weak peripheral pulse
  • watch for presence of a swishing, whooshing sound which
  • indicates a pulse
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

chronic arterial insufficiency

A
  • deep muscle pain
  • pain with walking claudication
  • coolness, pallor
  • dimished pulse
  • thin, shiny skin
  • absence of hair
  • necrotic ulcers on toes, heels, laterla malleolus
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

chronic venous insufficiency

A
  • dull ache, heaviness in lower leg pain
  • pulses present
  • thick brawney, edematous skin
  • brown pigmintation
  • weeping ulcers on medial malleolus
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

chronic venous stasis

A
  • aching, heaviness, night leg or foot cramps
  • dilated, tortuous veins
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

acutre venous thrombosis

A
  • sudden onset pain
  • increased warmth, swelling, redness
  • watch for homan’s sign (not diagnostic)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

homan sign

A
  • calf pain at dorsiflexion of the foot
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

pitting edema grading

A
  • 1+ mild
  • 2+ moderate
  • 3+ deep pitting
  • 4+ very deep pitting
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

lyphedema

A
  • nonpitting edema, unilateral, overlying skin is indurated and brawy
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

Raynaud’s syndrome

A
  • cause areas of the body like fingers and toes to feel numb and cold in response to cold temperatures
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

derived weight measures include

A
  • body weight as percent of ideal body weight
  • percent of usual body weight
  • recent weight change
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

body mass index

A
  • marker of optimal weight for height and indicator for obesity and protein-calorie malnutrition
  • weight/height(2) * 703
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

hemoglobin and hematocrit

A
  • indicators of iron status
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
37
Q

cholesterol with triglycerides, LDL, and HDL levels

A
  • indicators of cardiovascular risks
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
38
Q

marasmus

A
  • protein-calorie malnutrition
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
39
Q

kwashiorkor

A
  • protein malnutrition
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
40
Q

epidermis

A
  • replaced every 4 weeks
  • outermost layer
  • think but tough
  • houses keratin
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
41
Q

dermis

A
  • inner supportive layer
  • consists of connective tissue
  • contains elastic tissue
  • nerves, sensory receptors, blood vessels, and lymphatics housed here
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
42
Q

subcutaneous

A
  • adipose tissue
  • stores fat for energy
  • provides insulation for temperature control
  • cushions and protects
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
43
Q

functions of the skin

A
  • protects (thermal, physical, chemical, UV, microorganisms)
  • perception (houses sensory end organs for touch, pain, and pressure)
  • temperature regulation (heat dissipation through sweat glands and heat storage through subcutaneous tissue)
  • identification (finger print, hair, skin color)
    communications (blushing, blanching, expressions)
  • wound repair
  • absorption/excretion
  • vitamin D production
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
44
Q

infants developmental care

A
  • languo (fine hair)
  • vernix caseosa (white, cheesy substance)
  • high risk for fluid loss
  • poor thermal regulation
45
Q

pregnancy developmental care

A
  • increased sweat and sebaceous gland
  • increased fat deposits primarily in butt and hips
  • linea nigra - mid-abdominal dark line
  • melasma- increased pigment in the face
  • striae gravidarum - stretch marks
46
Q

older adults developmental care

A
  • thin epidermis (low elasticity, high dryness)
  • less protective mechanisms (functioning decreases)
47
Q

skin conditions more prominent in African Americans

A
  • keloids, pigmentary disorders, pseudofolliculitis, melasma
48
Q

keloid

A
  • scars with increased height and weight
49
Q

pigmentary disorders

A
  • increased incidence of pigment problems
50
Q

pseudofolliculitis

A
  • razor bumps, razor burn, ingrown hairs
51
Q

melasma

A
  • patchy tan to dark brown discoloration of the face
52
Q

xerosis

A
  • excessive dryness
53
Q

seborrhea

A
  • excessive skin moisture
54
Q

nevus

A
  • mole
  • ABCDE
55
Q

pallor

A
  • white
  • anemia, shock, arterial insufficiency, anxiety, fear, exposure to cold, cigarette smoke
56
Q

erythema

A
  • redness
  • fever, local inflammation, blushing
57
Q

cyanosis

A
  • blue
  • lower perfusion, unoxygenated hgb
58
Q

jaundice

A
  • yellow
  • excessive billirubin, sclera, and hard and soft palate of mouth
59
Q

fear/anger

A
  • peripheral vasoconstriction
  • pallor
60
Q

embarrassment

A
  • facial/neck/flushing
  • erythema
61
Q

edema

A
  • accumulation of fluid in intercellular space
62
Q

cardiovascular system

A
  • contains the heart and blood vessels
63
Q

precordium

A
  • region on the anterior chest, over the heart and great vessels
64
Q

medaistinum

A
  • the middle third of the thoracic cavity between the lungs
  • contains the heart and great vessels
65
Q

base

A
  • top of the heart
66
Q

apex

A
  • bottom of the heart
67
Q

great vessels

A
  • superior and inferior vena cava
  • aorta
  • pulmonary veins
68
Q

atrioventricular valves

A
  • tricuspid and bicuspid (mitral)
69
Q

semilunar valves

A
  • pulmonic and aortic
70
Q

P wave

A
  • depolarization of the atria
71
Q

PR interval

A
  • from the start of the P wave to beginning of QRS
72
Q

QRS

A
  • depolarization of ventricles
73
Q

T wave

A
  • repolarization of ventricles
74
Q

QT interval

A
  • electrical systole of the ventricles
75
Q

s1

A
  • closure of the mitral and tricuspid valces
  • indicated beginning of systole
76
Q

s2

A
  • closure of the aortic and pulmonic valves
  • indicated beginning of diastole
77
Q

effect of respiration

A
  • inspriation-> decreased intrathoracic pressure -> increased venous return to the right side of heart -> increased right ventricular stroke volume -> aortic valve closes earlier -> normal split s2
78
Q

s3

A
  • ventricular gallup
  • caused by ventricles being resistant to filling during the rapid filling phase (systolic heart failure)
  • heard right after s2
79
Q

s4

A
  • atrial gallup
  • present at the end of the diastole with resistance of the ventricles to fillling (diastolic heart failure)
80
Q

murmurs

A
  • results from turbulent blood flow caused by increased velocity, decreased viscocity, structural defects
81
Q

heart sounds described by

A
  • frequency or pitch
  • intensity or loudness
  • duration, late
  • timing
82
Q

preload

A
  • venous return
  • the volume of blood in the ventricle at the end of diastole
83
Q

frank-starling law

A
  • the greater the stretch, the stronger the cardiac contraction
84
Q

afterload

A
  • the resistance the heart has to pump against
85
Q

carotid arteries

A
  • lies between the trachea and the sternomastoid muscle
86
Q

jugular venous pulse and pressure

A
  • reflect the filling pressure and volume in the right side of the heart
87
Q

internal jugular

A
  • larger, located deep and medial to the sternomastoid
  • generally not visible
  • diffuse pulsation may be visible in the sternal notch muscle in supine position
88
Q

external jugular

A
  • more superficial
  • located lateral to the sternomastoid muscle
89
Q

foramen ovale

A
  • opening in the atrial septum
  • closes within first hour after birth
90
Q

ducus arteriorosus

A
  • opening between the aorta and pulmonary artery
  • usually closes withing 10-15 hours after birth
91
Q

pregnant female developmental considerations

A
  • increaed blood volume by 30-40%
  • increased stroke volume and cardiac output
  • increased heart rate
  • decreased blood pressure
92
Q

older adult developmental considerations

A
  • increased systolic BP
    left ventricular wall thickens
  • heart rate unchanged at rest
  • cardiac output is unchanged at rest
  • decreased adaptation to exercise
93
Q

chest pain assessment subjective data

A
  • note onset, character, duration, symptoms, radiates, relieved by rest
94
Q

dyspnea symptoms

A
  • shortness of breath, paroxysmal, constant or intermittent, paroxysmal nocturnal dyspnea (sign of heart failure)
95
Q

regional cardiovascular assessment order

A
  1. pulse and BP
  2. extremities
  3. neck vessels
  4. precordium
96
Q

heave

A
  • sustained forceful thrusting of ventricle during systole
  • indicates ventricular hypertrophy from increased workload
97
Q

aortic valve location

A
  • second right interspace
98
Q

pulmonic valve location

A
  • second left interspace
99
Q

tricuspid valve location

A
  • left sternal border
100
Q

mitral valve location

A
  • fifth interspace near the left midclavicular line
101
Q

All Pigs Eat Too Much

A
  1. Aortic
  2. pulmonic
  3. erb’s point
  4. tricuspid
  5. mitral
102
Q

splitting of s2

A
  • normal physiological split that occurs during inspiration only in some peopel
103
Q

fixed split

A
  • a split that occurs in both inhale and exhale
104
Q

parodoxical split

A
  • occurs with exhale but not inhale
105
Q

Patent ductus arteriosus (PDA)

A
  • persistance channel between left pulmonary artery to aorta
106
Q

atrial septal defect (ASD)

A
  • abnormal opening in the atrial septum
107
Q

ventricular septal defect (VSD)

A
  • abnormal opening in the ventricular septum
108
Q

tetrology of fallot

A
  • right ventricular outflow obstruction
  • VSD
  • right ventricular hypertrophy
  • over riding aorta
109
Q

heart failure symptoms

A
  • dilated pupils, skin is pale/cyanotic, dyspnea, orthopnea, crackles, wheeze, cough, lower BP, nausea and vomiting, ascites, pitting edema, anxiety, declining o2sat, confusion, JVD, infarct, fatigue, tachycardia, enlarged spleen, lower urine output, weak pulse

Nursing (4 decks)

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