Health Assessments Module 3 Flashcards
In what client situations would a comprehensive assessment be performed?
On initial evaluation by the home health nurse
What type of assessment is complaints of chest pain?
Focused
What type of assessment is “the patient is found lying on the floor and is unresponsive”?
emergency
What type of assessment is “on arrival in the surgery holding area of the operating room”?
10 min or focused
The nurse would place information about the client’s concern that his illness is threatening his job security in which functional health pattern?
Role-relationship
Which situation would require the nurse to obtain a focused assessment?
A previously identified problem needs reassessment
What type of assessment can the nurse perform when a client denies a current health problem?
10 minute
What type of assessment can the nurse perform when a baseline health maintenance examination is required?
comprehensive
What type of assessment can the nurse perform when an emergency problem is identified during physical examination?
emergency
What action should the nurse take to increase the likelihood of obtaining quality data when doing a complete physical examination?
Provide adequate lighting and a comfortably warm room for the interview and physical examination
The nurse selects what equipment to test for a patellar reflex?
percussion hammer
What do you use a stethoscope for?
ausculatation
To perform the proper evaluation of client’s gait, the nurse should place the client in which position?
Standing
To administer a suppository or enema, what position should you place the patient in?
Sim’s
Which of the following would palpation as an assessment technique be used by the nurse to obtain data? SATA
A. Pitting edema B. Cyanosis of the lips C. Hyperactive peristalsis D. Cool, clammy skin E. Normal blood flow to the arteries
A
D
E
The nurse prepares to conduct a general survey on an adult client. Which assessment is performed first while the nurse initiates the nurse-client relationship?
Appearance and behavior
The nurse selects which of the following as the highest priority diagnosis for a 70 y/o male client with an absence of hair on the lower left leg?
A. Imbalanced nutrition: Less than body requirements
B. Risk for infection
C. Deficient fluid volume
D. Impaired peripheral tissue perfusion
D b/c absence of hair is arterial not venous
An inspection of the lower extremities is being performed. The presence of venous return impairment is suspected if the nurse observes what?
A. Cooler skin temperatures
B. Diminished pulses
C. Brown pigmentation
D. Numbness and tingling sensation
C - Brown pigmentation
Cooler skin temperature is an indication of what?
Pallor
Diminished pulses are an indication of what?
Pulselessness
Numbness and tingling sensation is an indication of what?
Paresthesia
What should the nurse use when palpating an edematous area on a client?
A. Dorsal aspect of the hand
B. Palmar surface of the hand
C. Pads of the fingers
D. Fingertips
C - Pads of the fingers
The nurse uses the dorsal aspect of the hand to check for _____________________.
temperature
The nurse uses the palmar surface of the hand to check for ____________________.
vibration in the lungs; called tactile fremitus
The nurse pinches the skin under the clavicle or on the forearm to check for ___________.
skin turgor
In assessing for jaundice, what area should the nurse specifically look on a client with dark skin?
A. Dorsal surface of the hands
B. Buccal mucosa
C. Ear lobe
D. Sclera
D - Sclera (the white outer layer of the eyeball)
In assessing for cyanosis, what area should the nurse specifically look on a client with dark skin?
Buccal mucosa
When the client is unable to detect a wisp of cotton touching his left cheek, the nurse interprets the finding as an abnormality of which cranial nerve?
V - Trigeminal
Which of the following symptoms would occur in a client with a retinal detachment?
Flashing lights and floaters
When the client has ptosis, the nurse interprets the finding as an abnormality of which cranial nerve?
III
What is the disease of the eye when you have loss of central vision?
macular degeneration
What is the disease of the eye when you have blurred vision?
cataracts
Which situation makes the nurse suspect the client has macular degeneration?
A. An automobile accident did not see the car in the next lane
B. The cake tasted funny because the client could not read the recipe
C. The client has been wearing mismatched clothes and socks
D. The client ran a stoplight and hit a pedestrian walking in the crosswalk
D
A is glaucoma
B cataracts
C color blindness
The client’s vision is tested with a Snellen’s chart. The results of the tests are documented as 20/60. The nurses interprets this as:
The client can read only at a distance of 20 ft what a client with a normal vision can read at 60 ft
CN III (Oculomotor) would be assessed using which method?
Check pupil for reaction to light and accommodation
CN II (Optic) would be assessed using which methods?
Inspection with an ophthalmoscope
Testing vision with Snellen chart
Comparing the patient visual fields with nurse’s own
In order to examine the ocular mobility of a client who recently experienced a stroke, the nurse should examine which of the following cranial nerves? SATA
A. CN II (Optic) B. CN III (Oculomotor) C. CN IV (Trochlear) D. CN V (Trigeminal) E. CN VI (Abducens)
B
C
E
The nurse is assessing a client who has a “pinpoint” pupil size and the pupils do not constrict when the light is shown on the eye. Which should the nurse document?
A. Pupillary response poor
B. Pupils one (1 mm) equal and non-reactive to light
C. Pupils two (2 mm) to three (3 mm) and non-constrictive to light
D. Pupils are barely open and don’t constrict to light
B
The student nurse asks the nurse, “Which type of hearing loss involves damage to the cochlea?”
Sensorineural hearing loss
Which statement made by the client indicates an understanding of how the nurse will perform the Romberg test?
A. “You want to bend over so you can inspect my spine for curvature”
B. “I need to touch my toes without bending my knees if possible.”
C. “I am going to walk five to six steps on my toes only, then on my heels only.”
D. “You want me to stand with my feet together and eyes closed for a short time.”
D
Rationale:
A. This is checking for scoliosis
B. Checking for ROM
C. Test for balance or coordination
The nurse is assessing the client’s cranial nerves. Which assessment data indicate cranial nerve I is intact?
A. The client can identify cold and hot on the face
B. The client does not have any tongue tremor
C. The client has not ptosis of the eyelids
D. The client is able to identify a peppermint smell
D
Rationale:
A. CN V
B. CN XII
C. CN III
The nurse is assessing the client’s cranial nerves. Which assessment data indicate cranial nerve I is intact?
A. The client can identify cold and hot on the face
B. The client does not have any tongue tremor
C. The client has not ptosis of the eyelids
D. The client is able to identify a peppermint smell
D
Rationale:
A. CN V
B. CN XII
C. CN III
Which assessment technique should the nurse use to assess the client’s facial nerve?
A. Have the client identify different smells
B. Have the client discriminate between sugar and salt
C. Have the client read the Snellen chart
D. Have the client say “ah” to assess the rise of the uvula
B
Rationale:
A. CN I
C. CN II
D. CN IX-X
During examination of a client’s neck with the bell of the stethoscope, the nurse identifies a carotid bruit. When are bruits audible in the neck?
When the carotid artery is partially occluded
A client with a GCS of 3 is most likely to exhibit what behavior?
No response to verbal or pain stimuli
A student nurse is working with a client who has asthma. The primary nurse tells the student that wheezes can be heard on auscultation. What should the student expect to hear?
High-pitched whistling sounds
What type of normal breath sounds are found at the site of the trachea?
Tubular/Bronchial
Where will the nurse hear bronchovesicular sounds?
Bronchioles
Where will the nurse hear vesicular sounds?
Alveoli
What sounds do crackles make and what area will you hear them?
Coarse crackles and bubbling
Hear them in the vesicular area
What does friction rub sound like when auscultating the lungs?
Dry, grating noises
What does rhonchi sound like?
Loud, low-pitched rumbling
The nurse is auscultating the client’s lungs and notes that bronchovesicular sounds as:
medium-pitched, hollow sounds with inspiration equaling expiration
The nurse is auscultating the client’s lungs and notes that bronchial sounds as:
loud, high-pitched, hollow sounds with expiration longer than inspiration
sounds created by air moving through large upper airways
The nurse is auscultating the client’s lungs and notes that vesicular sounds as:
soft, breezy, low-pitched sounds with longer inspiration
While auscultating the client’s lungs, the nurse hears loud, bubbly sounds during inspiration that did not disappear after the client coughed. Which finding should the nurse document from the lung assessment?
A. Rhonchi
B. Crackles
C. Wheeze
D. Friction Rub
B
Rationale:
Crackles don’t disappear with coughing
The nurse is observing the student nurse perform respiratory assessment on a client. Which action by the student nurse requires the nurse to intervene?
A. The student stands at a midline position behind the client observing for position of the spine and scapula
B. The student palpates the thoracic muscles for masses
C. The student places the bell of the stethoscope on the anterior wall to auscultate for breath sounds
D. The student places the palm of the hand over the intercostal spaces and asks the client to say “99”.
C
Rationale:
You use the diaphragm when you auscultate for breath sounds.
How does the nurses assess the client’s chest expansion?
Place the thumbs at the midline of the lower chest
Rationale:
Respiratory excursion
A nurse is assessing a client’s bilateral pulses for symmetry. Which pulse site should NOT be assessed on both sides of the body at the same time?
Carotid
A nurse is preparing to auscultate a client’s chest. In which area should the nurse listen to evaluate the client’s mitral valve?
Fifth left intercostal space along the midclavicular line
A nurse is preparing to auscultate a client’s chest. In which area should the nurse listen to evaluate the client’s aortic valve?
Second right intercostal space
A nurse is preparing to auscultate a client’s chest. In which area should the nurse listen to evaluate the client’s Erb’s Point?
Third left intercostal space
The student nurse is seeking assistance in hearing the client’s abnormal heart sounds. What should the nurse tell the student to do for a more effective assessment?
Use the bell of the stethoscope with the client leaning forward or on the left side
A nurse must assess for the presence of bowel sounds. Which technique should the nurse employ to obtain accurate results when auscultating the client’s abdomen?
A. Listen for several minutes in each quadrant of the abdomen
B. Place a warmed stethoscope on the surface of the abdomen
C. Perform auscultation before palpation of the abdomen.
D. Start at the left lower quadrant of the abdomen.
C
When grading muscle strength, the nurse records a score of 3/5, which indicates:
Active movement against gravity, but against no resistance
Full range of motion with gravity is Fair
When do you check for lumps on the breasts?
After menstruation
When do you do a testicular check?
After shower
Rationale:
It’s warm so scrotal sac is relaxed
The nurse is teaching a client how to perform a testicular self-examination. Which statement made by the client indicates a need for further teaching:
A. “I’ll recognize abnormal lumps because they are very painful”
B. “I’ll start performing testicular self-examination monthly after I turn 15”
C. “I’ll perform the self-examination in front of a mirror”
D. “I’ll gently roll the testicle between my fingers”
A
What are the 4 types of assessment?
10 minute
Focused
Comprehensive
Emergency
What is a 10 minute assessment?
A BRIEF assessment that is concise, timely and realistic. A head-to-toe assessment that enables the nurse to notice abnormalities quickly.
What is a focused assessment?
An in-depth assessment about an actual or potential problem focusing on 1 or more body systems, classifying the problem as initial or ongoing.
AKA system-specific assessment
What is a comprehensive assessment?
A DETAILED assessment that provides holistic information.
Provides overall information about body systems and functional abilities; emotional status; cultural and spiritual beliefs; psychosocial situation; family and community dynamics
This is typically done during admission, or initial assessment.
What is an emergency assessment?
Focused on ABC (Airway, Breathing, Circulation)
Performed mostly in the acute setting (ED, ICU, etc.)
A patient presents to the ED with abdominal pain. Which assessment will the nurse perform first? Which one second?
A. Comprehensive Assessment using Gordon’s Fxnal Health Pattern
B. 10 minute assessment
C. Focused assessment
D. Emergency
C, followed by A
Describe the best patient environment for an assessment.
Private and adequate covering on the patient
Room temp should be comfortable
Provide warm blankets if needed
What should the nurse do to prepare for a comprehensive assessment?
Soundproof the room and turn on the lights if needed
Use an easy to use exam table
Bring the correct equipment: stethoscope, snellen chart, ophthalmoscope, tuning fork, pen light, gloves
Put the patient in the correct position
What do we use the standing position to assess?
posture, balance, gait
What do we use the sitting position to assess?
vital signs
the head, neck, anterior and posterior thorax, lungs, heart, breasts, and upper extremities
Describe the supine position. What assessments does the nurse perform while the patient is in this position?
The pt lies flat on the back with legs extended and knees slightly flexed.
Asses VS, the head, neck, anterior thorax, lungs, heart, breasts, abdomen, extremities, and peripheral pulses.
Describe the lithotomy position. What assessments are performed with the patient in this position?
The patient is in the dorsal recumbent position with the buttocks at the edge of the examining table and the heels in stirrups.
Assess female genitalia and rectum
Describe the knee-chest position. What assessments are performed with the patient in this position?
The patient kneels, with the body at a 90-degree angle with hips, back straight, and arms above the head.
Assess the anus and rectum
Describe the dorsal recumbent position. What assessments are performed with the patient in this position?
The patient lies on the back with legs separated, knees flexed, and soles of the feet on the bed.
Assess the head, neck, anterior thorax, lungs, heart, breasts, extremities, and peripheral pulses.
Do not use for abdominal assessment b/c it causes contraction of the abdominal muscles
Describe the sims position. What assessments are performed with the patient in this position?
The patient lies on either side with the lower arm below the body and the upper arm flexed at the shoulder and elbow. Both knees are flexed, with the upper leg more acutely flexed.
Assess rectum and vagina
Describe the prone position. What assessments are performed with the patient in this position?
The patient lies flat on the abdomen with the head turned to one side.
Assess the hip joint and the posterior thorax
What are the degrees for each of the following?
High Fowler’s
Fowler’s
Semi Fowler’s
Low Fowlers
80-90
45-60
30-45
15-30
Describe the Trendelenburg Position
Lower extremities higher than the head
Describe the Reverse Position
Lower extremities lower than the head
Describe the Modified Position
Lower extremities and head are above the heart
During the inspection part of assessment, what does the nurse do?
Use the senses of sight, hearing, and smell in gathering data about the patient.
Observe for Color, shape, size, position, symmetry, sounds, odor, abnormalities
During the palpation part of assessment, what does the nurse do?
Use sense of touch
Use the sensitive parts of the hand to detect different characteristics
When do we use the dorsal surface of the hand?
Palpate for temperature, moisture
When do we use the palm of the hand?
Palpate for vibration
When do we use the thumb?
Palpate for pitting edema
When do we use the finger pads and palmar surface?
massess, size, pulses, texture, tenderness, and pain
When do we use the fingertips in a pinching motion?
Assess skin turgor on the forearm, sternum, or under the clavicle (for the elderly)
What is percussion and what are the types of percussion?
Sound is produced by the fingertip tapping through body tissues. Use the sense of hearing to differentiate different sounds.
Direct: Tap using dominant hand and with 2 fingers
Indirect: Tap the other hand into the body
Which organ makes a resonant sound when percussed?
Lung
Which body part makes a flat sound when percussed?
Scapula
Which organ makes a dull sound when percussed?
Liver
Which organ makes a tympanic sound when percussed?
Stomach
What is auscultation and what are the types?
Use sense of hearing, by listening to sounds produced within the body, aided or unaided
Direct: Ex. Ear to chest
Indirect: Use a stethoscope
What does the nurse look for during the general survey of the patient?
General Appearance and Behavior
VS
Ht and Wt
Erythema is a local sign of _____________.
inflammation
What is pallor and what does it indicate in the patient?
Unusual paleness easily observed in the face, buccal mucosa, conjuctivae, and nail beds
For a dark individual, what color does the skin change to if it is showing signs of pallor?
yellowish brown
or
ashen gray
Means that there is less O2 in the blood = hypoxemia
What is cyanosis and what does it indicate in the patient?
Bluish discoloration observed in the lips, nail beds, conjunctivae, palms, soles of the foot
Means that there is increased CO2 in the blood
What is vitiligo?
Loss of pigmentation
What is jaundice?
Yellowish tinge
What is erythema?
redness due to inflammation
What is hyperhidrosis?
excessive perspiration
What is bromhidrosis?
foul-smelling perspiration
How would the nurse assess a pressure ulcer and what would she observe in the case of a stage 1 pressure ulcer?
Put pressure on the redness, it should turn white, or blanch
Stage 1 means it doesn’t turn white, or has no blanching
What will the nurse observe in the case of a hematoma?
A bruise with a bump
What will the nurse observe in the case of a ecchymosis?
Bruise w/out a bump
What will the nurse observe in the case of purpura?
Small breaks in blood vessels/capillaries
What will the nurse observe in the case of petechiae?
Pin-prink size breaks in blood vessels/capillaries
What are the 5 Ps of Peripheral Artery Disease
Pallor Pulselessness Paresthesia Pain Poor vascular circulation
The nurses is doing an assessment of a wound on the patient’s foot and notices that the would is round with smooth edges. The patient also has no leg hair and an absent pulse in the extremities. The nurse would correctly assume that the patient has which vascular disease?
Peripheral Artery Disease
The patient presents to the ED with a would on his shin that has irregular edges and is wet and weeping. The nurse assesses the patient and finds that his skin appears to be brown on his hands and feet and his pain improves when she lifts his foot above his heart. The nurse would correctly assume that the patient has which vascular disease?
Chronic Venous Insufficiency
When assessing for skin turgor, what qualifies as good, poor, and tenting?
Good - Instant Recoil
Poor - 2 sec
Tenting - >2sec
What is edema?
Fluid buildup in the tissues, direct trauma or venous return impairment
What causes edema?
Trauma, CHF, Glomerulus changes, Venus Return Impairment
How can edema lead to kidney failure?
If the edema is due to glomerulus changes, this causes albumin to build up in the kidney, which destroys the kidney tissues
What are the degrees of edema and their corresponding depths?
1+ 2mm
2+ 4mm
3+ 6mm
4+ 8mm
What causes primary lesions and what types are there?
Primary lesions are brought about by disease processes.
Macule Papule Pustule Vesicle Nodule Tumor Wheal
What causes secondary lesions and what types are there?
Secondary lesions are brought about by the primary lesions.
Scar Keloid Crust Fissure Erosion Excoriation
What are the ABCs of Melanoma?
Asymmetry Border Color (black to bluish brown) Diameter (greater than size of a pencil eraser) Evolution (change in size, shape, color)
What are the complete steps to skin assessment?
ELVis is CoMing To Tucson Tonight
Edema Lesion Vascularity Color Moisture Temperature Turgor Texture
When assessing capillary refill, how do we document it?
<3 sec Brisk
>3 sec Sluggish
What is hydrocephalus?
Obstruction in outflow of cerebral spinal fluid that causes a baby to have a very large skull.
What is acromegaly?
Too much growth hormone that causes irregularity in facial features and overgrowth of the bones
What is alopecia?
baldness
Which cranial nerve is #5 and is it motor, sensory or both?
Trigeminal
Both
When the nurse asks the patient to clench her teeth and relax; open her mouth and keep it open against resistance, which cranial nerve is being assessed?
CN V - Trigeminal (Motor part)
When the nurse asks the patient to point out when she feels a cotton ball touch her face, which cranial nerve is being assessed?
CN V - Trigeminal (Sensory)
Which cranial nerve is VII and it is motor, sensory, or both?
Facial
Both
When the nurse asks the patient to smile, frown, show his teeth, puff out checks, raise eyebrows, and resist the force of keeping eyes closed, which cranial nerve is being assessed?
CN VII - Facial (Motor)
When the nurse asks the patient to identify if something is salty or sweet on the front of the tongue, which cranial nerve is being assessed?
CN VII - Facial (Sensory)
What vision change happens as a result of macular degeneration?
Loss of central vision
What vision change happens as a result of glaucoma?
Loss of peripheral vision
What vision change happens as a result of cataracts?
Blurry vision
What vision change happens as a result of retinal detachment?
Floaters in the eyes or a curtain seems to cover vision
What is myopia?
Nearsightedness
What is astigmatism?
The cornea is shaped like a football
Which cranial nerve is II and it is motor, sensory, or both?
Optic
Sensory
When assessing a patient with a Snellen Chart, what does 20/60 mean?
This means that the patient, standing 20 feet from the chart, sees what the person with normal vision sees at 60 feet from the chart.
What does PERRLA stand for?
Pupils are Equally Round, Reactive to Light and Accommodation
Which cranial nerve is III and is it motor, sensory, or both?
Oculomotor
Motor
What is ptosis?
Abnormal drooping of the eyelid over the pupil
What is anisocorla?
pupils unequal in size
What 3 words do we use to describe the reaction of the pupil?
Brisk
Sluggish
Non-reactive
When you apply the tuning fork to the mastoid process, the sound goes directly to the ____________________.
inner ear
When the nurse is conducting the Weber’s Test, will the patient hear the sound on both sides or only one side at a time?
Should be heard on both sides at the same time
Which cranial nerve is VIII and it is motor, sensory, or both?
Auditory
Both - Hearing and Balance
Which cranial nerve is I?
Olfactory
Which cranial nerves are IX and X? Are they sensory, motor, or both?
IX - Glossopharyngeal
X - Vagus
Both
The longest and only cranial nerve that wanders from the brain stem to the organs of the neck, thorax, and abdomen is ____________.
CN X, the Vagus Nerve
Which cranial nerve is XIII and is it sensory, motor, or both?
Hypoglossal
Motor
Which cranial nerve is XI?
Spinal Accessory
Normally lymph nodes are not palpable. Pay close attention to lymph nodes that are __________, ________, ___________ or ________________.
large
fixed
inflamed
tender
What is the Glasgow Coma Scale and what are the highest and lowest scores possible?
The GCS is a measure of the patient’s level of consciousness
3-15 is possible, where anything <8 is comatose
What is aphasia?
Impairment of language ability
What is receptive aphasia? How do we assess for it?
not able to understand written or verbal speech
give the patient a piece of paper and say, “take this in your right hand, fold it in half and put it on the floor”; if they can’t understand, they have receptive aphasia
What is expressive aphasia? How do we assess for it?
understands written or verbal speech but not able to speak
Which area of the brain is affected if receptive aphasia? expressive?
Receptive - Wernicke’s area
Expressive - Broca’s area
These are in the frontal and temporal lobes
Which part of the brain controls intellectual function? How do we assess it?
Frontal lobe
Ask the pt to count backward by seven, beginning with 100
What is proprioception? When is assessing it normally used?
considered the 6th sense, this is the ability to sense position, location, orientation, movement of the body as well as its parts and equilibrium
Used by law enforcement to test drunks
