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HEALTH ASSESSMENT > MIDTERM > Flashcards

MIDTERM Flashcards

1
Q

what the person says about himself or herself during history taking

A

SUBJECTIVE DATA

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2
Q

what you as the healthcare professional observe by inspecting, percussing, palpating, and auscultating during the physical examination

A

OBJECTIVE DATA

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3
Q

HOW TO VALIDATE DATA

A

validating or checking the accuracy and reliability of data

EG. in addictions treatment, a clinician will corroborate data with a family member or friend in order to verify the accuracy of Ellen’s history

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4
Q

NURSING PROCESS

A
  • assessment
    • diagnosis
    • outcome identification
    • planning
    • implementation
    • evaluation
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5
Q

4 TYPES OF DATA

A
  1. COMPLETE DATABASE
  2. EPISODIC OR PROBLEM-CENTRED DATABASE
  3. FOLLOW-UP DATABASE
  4. EMERGENCY DATABASE
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6
Q

THIS KIND OF DATA INCLUDES:

  • includes a complete health history and full physical examination
  • describes the current and past health state and forms a baseline against which all future changes can be measured
  • yields the first diagnoses
A

COMPLETE DATA

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7
Q

THIS KIND OF DATA INCLUDES:

  • collected for limited or short-term problem
  • concerns mainly one problem, one cue complex or one body system
A

EPISODIC OR PROBLEM-CENTRED DATA

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8
Q

THIS KIND OF DATA INCLUDES:

  • status of any identified problems should be evaluated at regular and appropriate intervals:
    • what change has occurred?
    • is the problem getting better or worse?
    • what coping strategies are used?
A

FOLLOW-UP DATA

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9
Q

THIS KIND OF DATA INCLUDES:

  • calls for rapid collection of the data - often compiled concurrently with life-saving measures
  • diagnosis must be swift and sure
  • requires more rapid collection of data than the episodic database
A

EMERGENCY DATA

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10
Q

DISADVANTAGES OF note taking during an interview

A

DISADVANTAGES

  • breaks eye contact too often
  • shifts your attention away from the person - diminishes his/her sense of importance
  • can interrupt patient’s narrative flow
  • impedes your observation of patient’s nonverbal behaviour
  • threatening to the patient
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11
Q

ADVANTAGES OF note taking during an interview

A

ADVANTAGES

  • helps memory
  • increases accuracy
  • provides interview cues
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12
Q

TRUE OR FALSE

interview usually takes longer with older adults

A

TRUE - because they have a longer story to tell

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13
Q

TRUE OR FALSE

adolescents know a lot about health assessment and dont need explanations

A

FALSE

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14
Q

why is building a rapport with adolescents is essential?

A

because otherwise they might not participate

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15
Q

TRUE OR FALSE?

it is important to adjust the pace of the interview to the aging person

A

TRUE -

give them time to remember - do not rush them

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16
Q

WHY IS IT IMPORTANT TO AVOID AN abrupt or awkward closing to an interview?

A

can destroy rapport and leave a negative impression

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17
Q

THESE ARE CHARACTERISTICS OF WHAT AGE GROUP?

  * egocentric - sees the world mostly from his/her own point of view
  * everything revolves around them
  * communication is direct, concrete, literal and set in the present
  * use simple, short sentences with a concrete explanation
A

preschooler (2-6)

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18
Q

THESE ARE CHARACTERISTICS OF WHAT AGE GROUP?

  • can tolerate and understand other perspectives
  • more objective and realistic
  • wants to know functional aspects - how things work & why things are done
  • can verbalize important data to add to history
  • pose questions about school, friends or activities
A

school-age child (7-12)

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19
Q

THESE ARE CHARACTERISTICS OF WHAT AGE GROUP?

  * fluctuate between mature and childlike responses    * value their peers & crave acceptance    * think adults don't understand them
A

adolescent (13-19)

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20
Q

THESE ARE CHARACTERISTICS OF WHAT AGE GROUP?

  • focused on finding out the meaning of life and the purpose of his/her own existence
  • adjusting to inevitability of death
  • be aware that symptoms of illness are even more frightening when they mean physical limitation or threaten independence
  • always address the person by the last name
A

older adult

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21
Q

Reason for seeking care – how to chart

A
  • record the patient’s exact words enclosed in quotations
      • “Want to start jogging and need checkup.”
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22
Q

Questions to ask when someone states they are allergic to a medication

A
  • Note both the allergen (medication, food, or contact agent, cushy as fabric or environmental agent) AND the reaction (rash, itching, runny nose, watery eyes, difficulty breathing)
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23
Q

Purpose of a functional assessment

A
  • functional assessment questions provide data on the lifestyle and type of living environment to which the person is accustomed
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24
Q

subjective sensation that the person feels from the disorder

A

symptom

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25
Q

objective abnormality that you as the examiner could detect on physical examination or lab reports

A

sign

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26
Q

Techniques of physical assessment

A
  1. INSPECTION
  2. PALPATION
  3. PERCUSSION
  4. AUSCULTATION
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27
Q

5 Percussion notes

A 
RESONANT
HYPERRESONNANT
TYMPANY
DULL
FLAT
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28
Q

TYPE OF SOUND HEARD WHEN PERCUSSING:

  • normal lung tissue
A

RESONANT

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29
Q

TYPE OF SOUND HEARD WHEN PERCUSSING:

  • normal over child’s lung
  • abnormal in the adult, over lungs with increased amount of air (emphysema)
A

HYPERESONNANT

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30
Q

TYPE OF SOUND HEARD WHEN PERCUSSING: over air-filled viscus, such as stomach or intestines

A

TYMPANY

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31
Q

TYPE OF SOUND HEARD WHEN PERCUSSING: relatively dense organ, as liver and spleen

A

DULL

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32
Q

TYPE OF SOUND HEARD WHEN PERCUSSING: when no air is present, over thigh muscles, bone or tumour

A

FLAT

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33
Q

TRUE OR FALSE?

STETHOSCOPE MAGNIFIES SOUND

A

FALSE -

* does not magnify sound but does block out extraneous room sounds

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34
Q

PART OF STETHOSCOPE TO USE TO AUSCULTATE: for high-pitched sounds, such as breath, bowel, and normal heart sounds.

A

DIAPHRAGM

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35
Q

PART OF STETHOSCOPE TO USE TO AUSCULTATE: for soft, low-pitched sounds, such as extra heart sounds or murmurs.

A

BELL

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36
Q

DEVELOPMENTAL CARE FOR WHICH AGE GROUP:

  • timing - 1 to 2 hours after feeding when baby is not too drowsy or hungry
  • environment - warm
  • considerations - infant will not object to being nude or being touched, but make sure hands & equipment are warm
  • voice - use soft, crooning voice
  • eye contract - lock eyes from time to time
  • facial expression - baby prefers a smiling face to frowning face
  • movements - smooth and deliberate, not jerky
  • distractions - use pacifier during invasive steps or distract with brightly coloured toys
A

INFANT - developmental stage: establishing trust

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37
Q

WHAT IS THE INFANTS DEVELOPMENTAL STAGE KNOWN AS?

A

ESTABLISHING TRUST

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38
Q

DEVELOPMENTAL CARE FOR WHICH AGE GROUP:

  • need to explore is in conflict with dependency on parent
  • often results in frustration
  • may be difficult to examine
  • may be fearful of invasive procedures and dislike being restrained
A

TODDLER

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39
Q

WHAT IS THE TODDLERS DEVELOPMENTAL STAGE KNOWN AS?

A

developing autonomy

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40
Q

WHAT IS THE General Survey

A
  • overall impression of the patient
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41
Q

WHEN DOES THE GENERAL SURVEY BEGIN?

A
  • begins when you first encounter him or her
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42
Q

4 AREAS COVERED IN GENERAL SURVEY

A
    1. physical appearance
      * 2. body structure
      * 3. mobility
      * 4. behavior
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43
Q

2 THINGS TO NOTE WHEN PERFORMING GENERAL SURVEY OF INFANTS AND CHILDREN

A
  1. PARENTAL BONDING

2. PHYSICAL GROWTH

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44
Q

3 THINGS TO NOTE WHEN PERFORMING GENERAL SURVEY OF OLDER ADULTS

A
  1. PHYSICAL APPEARANCE
  2. POSTURE
  3. GAIT
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45
Q

TRUE OR FALSE?
in terms of blood pressure, there is normally a gradual decline that occurs throughout childhood and into the adult years

A

FALSE. gradual rise is normal

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46
Q

CAUSE OF TRIPOD POSITIONING

A

BREATHING DIFFICULTIES OR LUNG DISEASE

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47
Q

PROPER WAY TO TAKE RADIAL PULSE:

A
  • palpate the radial pulse at the flexor aspect of the wrist laterally along the radial bone
    • push until you feel the strongest pulsation
    • if rhythm is regular, count the number of beats in 30 seconds and multiply by 2
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48
Q

4 THINGS TO NOTE IN RADIAL PULSE

A
  1. RATE
  2. RHYTHM
  3. FORCE
  4. ELASTICITY
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49
Q

THINGS TO REMEMBER WHEN TAKING Blood Pressure

A
  • ARM AT HEART LEVEL
  • FEET ON FLOOR
  • PALPATE RADIAL ARTERY AND NOTE WHEN IT DISAPPEARS WHILE CUFF IS INFLATING
  • ADD 20-30 MM HG
  • DEFLATE CUFF SLOWLY AND GRADUALLY
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50
Q

WHAT ARE THESE SYMPTOMS CHARACTERISTIC OF:

  • irregularity commonly found in children and young adults
  • heart rate varies with the respiratory cycle, speeding up at the peak of inspiration and slowing down to normal with expiration
A

Sinus arrhythmia

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51
Q

the maximum pressure felt on the artery during left ventricular contraction (or systole).

A

systolic blood pressure

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52
Q

is the elastic recoil (or resting) pressure the blood exerts constantly between contractions.

A

diastolic blood pressure

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53
Q

is the difference between the systolic and diastolic pressures and reflects the stroke volume.

A

Pulse pressure

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54
Q

Reason for checking for auscultatory gap before doing BP

A
  • this will avoid missing the auscultatory gap - a period when Korotkoff’s sounds disappear during auscultation
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55
Q

Assessment findings indicating acute pain

A
  • guarding
    • grimacing
    • vocalizations such as moaning
    • agitation
    • restlessness
    • stillness
    • diaphoresis
    • change in vital signs
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56
Q

pain-indicating behaviours

A
  • rocking
    • negative vocalization
    • frowning
    • grimacing
    • noisy breathing
    • irritability
    • agitation
    • rubbing a panful area
    • bracing
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57
Q

__________ PAIN:

  • pain originates from the larger interior organs (kidney, stomach, intestine, gallbladder, pancreas)
  • constant or intermidant
A

visceral

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58
Q

__________ PAIN:

superficial pain derived from skin surface or subcutaneous tissues (joints, tendons, muscles or bone)

A

somatic

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59
Q

__________ PAIN:

  • pain initiated or caused by a primary lesion or dysfunction of the nervous system
  • caused by injury to either peripheral or central nervous system
A

neuropathic

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60
Q

________ PAIN: persistant pain present for 6 months or longer

A

chronic

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61
Q

_________ PAIN:

  • short-term or self-limiting
  • often follows a trajectory
  • dissipates after injury heals
62
Q

possible findings in the Mental Status Assessment of Older Adults

A
  • slower response time
    • decreased recent memory
    • age-related changes in sensory perception can affect mental status
    • confusion
    • cognitive impairment
63
Q

When do you need to perform a complete mental status assessment

A

abnormality in the following:

  • behavioural changes
  • brain lesions (trauma, tumour, stroke)
  • aphasia
  • symptoms of psychiatric mental illness
64
Q

DEFINITION: Drifts off to sleep when not stimulated

65
Q

DEFINITION: slow response, sleeping most of the time, difficult to arouse.

66
Q

DEFINITION: Responds only to persistent or vigorous shake or pain.

67
Q

WHAT KIND OF ASSESSMENT IS CHARACTERIZED BY THE FOLLOWING:

  • simplified scored assessment of cognitive functions
  • includes a brief assessment of memory, orientation to time and place, naming, reading, copying or visual-spatial orientation, writing, and the ability to follow a three-stage command.
  • detect dementia and delirium.
A

MINI-MENTAL

68
Q

SKIN OF INFANT OR OLDER ADULT?

  1. thin, smooth, elastic and relatively permeable
  2. greater fluid loss
  3. temperature regulation is ineffective
  4. sebum is present in first few weeks, producing milia and cradle cap
  5. subcutaneous layer is inefficient
  6. pigment system is inefficient at birth
69
Q

SKIN OF INFANT OR OLDER ADULT?

A
  1. COLOUR OR PIGMENTATION - senile lentigines (liver spots)
  2. MOISTURE: dry skin is common
  3. TEXTURE: acrochordons (skin tags)
  4. THICKNESS: skin becomes thinner as subcutaneous fat diminishes
  5. MOBILITY & TURGOR: turgor is decreased (less elasticity), skin recedes slowly and “tents”
70
Q

Skin provides information about – what?

A

temperature

71
Q

Clubbing of nails is typical in what condition?

A

chronic obstructive pulmonary disease

72
Q

What are small, flat, brown macules known as?

A

liver spots or senile lentigines

73
Q

DEFINITION: something you can feel caused by superficial thickening in the epidermis

74
Q

DEFINITION: soley a colour change, flat and circumscribed, of less that 1 cm. eg. freckle

75
Q

DEFINITION: solid, elevated, hard or soft, larger than 1 cm. deeper than papule

76
Q

DEFINITION: single-chambered, superficial in the epidermis, thin-walled so ruptures easily eg. blister

77
Q

DEFINITION: normal skin feels smooth and firm, with an even surface

78
Q

DEFINITION: an abnormal accumulation of fluid in the interstitial spaces

79
Q

DEFINITION: skin’s ease of rising

80
Q

DEFINITION: skin’s ability to return to place when promptly released - reflects the elasticity of the skin

81
Q

DEFINITION: Of, characterized by, or containing vessels that carry or circulate fluids, such as blood, lymph, or sap, through the body of an animal or plant.

A

vascularity

82
Q

DEFINITION: the time it takes for a nail bed to return to its usual colour after the blood flow has been momentarily occluded. An indicator of peripheral circulation

A

Capillary refill

83
Q

DEFINITION: male pattern baldness

84
Q

DEFINITION: the bluish discolouration of the skin and mucous membranes caused by an excess of deoxygenated hemoglobin in the blood or a structural defect in the hemoglobin molecule

85
Q

DEFINITION: a redness or inflammation of the skin or mucous membranes that is a result of dilation and congestion of superficial capillaries; sunburn is an example

86
Q

DEFINITION: the yellow discolouration of the skin, mucous membranes, and sclera, caused by greater than normal amounts of bilirubin in the blood

87
Q

DEFINITION: any localized, abnormal structural change in the skin

88
Q

DEFINITION: an unnatural paleness or absence of colour in the skin

89
Q

DEFINITION: itching or the uncomfortable sensation leading to the urge to scratch

90
Q

Mole Assessment Mnemonic - ABCDE

A
  • ASYMMETRY - symmetrical circle shape
    • BORDER - no border present
    • COLOUR - light brown
    • DIAMETER - not greater than 6 mm (approx. 3 mm diameter)
    • ELEVATION & ENLARGEMENT - .5 - 1 mm high
91
Q

Salivary glands that are accessible to examination on the face

A

parotid

submandibular

92
Q

WHERE ARE THE parotid SALIVARY GLANDS LOCATED?

A

glands in the cheeks over the mandible, anterior to and below the ear

93
Q

WHERE ARE THE submandibular SALIVARY GLANDS LOCATED?

A

glands beneath the mandible, lie in the angle of the jaw

94
Q

Thyroid gland and tests

A
  • watch person drink glass of water - thyroid moves up with a swallow
    * if the thyroid is enlarged, auscultate it for bruits - presence of bruit is an indication of hyperthyroidism
95
Q

Four areas in body where lymph nodes area accessible

A
  1. head and neck
  2. arms
  3. axillae
  4. inguinal regions
96
Q

DEFINITION: an abnormal blowing or swishing sound or murmur heard while auscultating a carotid artery, the aorta, an organ, or a gland, such as the liver or thyroid, and resulting from blood flowing through a narrow or partially occluded artery

97
Q

Signs of dehydration in infant

A
  • More than six to eight hours without a wet diaper
  • Urine that looks darker in his diaper and smells stronger than usual
  • Lethargy (low energy)
  • A dry, parched mouth and lips
  • No tears while crying
98
Q

Signs of serious dehydration in infants:

A
  • Sunken eyes
  • Hands and feet that feel cold and look splotchy
  • Excessive sleepiness or fussiness
  • Sunken fontanels (the soft spots on your baby’s head)
99
Q

DEFINITION: glaucoma resulting in gradual loss of peripheral vision

A

increased intraocular pressure

100
Q

DEFINITION: adaptation of the eye for near vision accomplished by increasing curvature of lens through movement of ciliary muscles

A

accommodation

101
Q

DEFINITION: different sized pupils

A

anisocoria

102
Q

Meaning of 20/30 from Snellen eye chart

A

meaning they can read letters at a distance of 20 feet that most people can read at a distance of 30 feet

103
Q

Findings of red glow with ophthalmoscope

A

red reflex - reflection of ophthalmoscope light off retina, begin about 25 cm away from person

104
Q

Description of tympanic membrane

A

translucent membrane with pearly grey colour and prominent cone of light in the anteroinferior quadrant

105
Q

Findings in ear drainage from basal skull fracture

A

cerebral spinal fluid (CSF)

106
Q

Voice Test

A
  • done by placing one finger on the tragus and rapidly pushing it in and out of the auditory meatus
    • shield your lips so the person cannot compensate for a hearing loss (consciously or unconsciously) by lip reading or using “good” ear
    • with your head 30 to 60 cm from person’s ear, exhale and whisper slowly some 2-syllable words like “tuesday, armchair, baseball”
107
Q

Response in infant/child when assessing hearing

A

NEWBORN - startle (moro) reflex, acoustic blink reflex
3-4 MONTHS - acoustic blink reflex, infant stops movement and appears to “listen”, halts sucking, quiets if crying, cries if quiet
6-8 MONTHS - infant turns head to localize sound, responds to own name
PRESCHOOL & SCHOOL-AGE - child must be screened with audiometry
* young children may be unaware of hearing loss because child does not known how one “ought” to hear.

108
Q

Weber Test OR Rinne test?

person should hear tone by bone conduction (BC) through the skull and it should sound equally loud in both ears

109
Q

Weber Test OR Rinne test?

normal response in a positive test or “AC>BC”

110
Q

Weber Test OR Rinne test?
place vibrating tuning fork in the midline of person’s skull and ask whether tone sounds the same in both ears or better in one

111
Q

Weber Test OR Rinne test?

  • place the stem of the vibrating tuning fork on the person’s mastoid process and ask him to signal when the sound goes away
  • quickly invert the fork so the vibrating end is near the ear canal; the person should still hear a sound
112
Q

NAME THE ORGAN:

  • Behind the anterior tonsillar pillar are the tonsils
  • mass of lymphoid tissue
  • same colour as the surrounding mucous membrane
  • Look more granular
  • Surface shows deep crypts (indentations)
113
Q

WHAT IS Difficulty swallowing KNOWN AS?

114
Q

Where most breast cancers are found

A

upper outer quadrant of breast

115
Q

How to interview adolescent about breast development

A

Assess each girl’s perception of her own development, provide teaching and reassurance as indicated.
“Have you noticed your breasts changing?”
“How long has this been happening?”

116
Q

6 DIAGNOSTIC CATEGORIES OF Benign breast disease

A
  1. Swelling and tenderness
  2. Mastalgia (severe pain, both cyclical and non cyclical)
  3. Nodularity ((significant lumpiness, both cyclical and non-cyclical)
  4. Dominant lumps (including cysts and fibroadenomas)
  5. Nipple discharge (including intraductal papilloma and duct ectasia)
  6. Infections and inflammations
117
Q

Changes in breasts and nipple that could indicate cancer

A
  • firm/hard irregular axillary nodes
    • Skin dimpling
    • Nipple Retraction
    • Nipple elevation
    • Nipple discharge
118
Q

How to examine breasts

A
  • Place client in supine position with her arm raised over her head
119
Q

Best time to perform breast self examination (BSE)

A

Right after the menstrual period, or the fourth through seventh day of the menstrual cycle, when the breasts are the smallest and least congested.

120
Q

What is the Posterior Thoracic Landmark?

A

Vertebra prominens

121
Q

Where are the vertebra prominens located?

A

the upper one is C7 and lower one is T1

122
Q

Normal assessment findings of adult lungs

A

Resonance is the low pitched, clear, hollow sound that predominates in healthy lung tissue in the adult.

123
Q

What is Tactile fremitus

A
  • Sounds generated from the larynx are transmitted through patent bronchi and through the lung parenchyma to the chest wall, where you feel them as vibrations.
124
Q

Possible percussion notes on the lungs and their indications

A

resonant - normal
dull - abnormal lung density; atelectasis or tumour
stoney dull - pleural effusion

125
Q

Causes of decreased breath sounds

A
  • obstructed bronchial tree by secretions, mucus plug, or a foreign body
  • emphysema
  • pleural thickening, or air in the pleural space
126
Q

Hyperresonant percussion notes indicates what?

A

emphysema or pneumothorax

127
Q

Bronchophony, egophony and whispered pectoriloquy?

Normal voice transmission is soft, muffled, and indistinct; you can hear sound through the stethoscope but cannot distinguish exactly what is being said.

A

Bronchophony

128
Q

Bronchophony, egophony and whispered pectoriloquy?

Normally, you should hear “eeeeeeeee” through your stethoscope while the person phonates “eeeeee”

129
Q

Bronchophony, egophony and whispered pectoriloquy?

The normal response is faint, muffled, and almost inaudible while the person whispers.

A

whispered pectoriloquy

130
Q

Normal breath sounds and their locations

A

Bronchial: Trachea and Larynx

Bronchovesicular: Over major bronchi

Vesicular: Over peripheral lung fields, where air flows through smaller bronchioles and alveoli

131
Q

Abnormal breath sounds:

Discontinuous, high pitched, short crackling, popping sounds heard during inspiration that are not cleared by coughing.

A

Crackles (fine)

132
Q

Abnormal breath sounds:

Loud, low pitched, bubbling and gurgling sounds that start in early inspiration and may be present in expiration.

A

Crackles (coarse)

133
Q

Abnormal breath sounds:

Sounds like fine crackles but do not last and are not pathological

A

Atelectatic crackles

134
Q

Abnormal breath sounds:

superficial sound that is coarse and low pitched; it has a grating quality as if two pieces of leather are being rubbed together

A

Pleural Friction Rub

135
Q

Abnormal breath sounds:

musical squeak predominate in expiration but may occur in both expiration and inspiration

136
Q

Abnormal breath sounds:

High pitched, monophonic, inspiratory, crowing sound, louder in neck than over chest wall.

137
Q

Correct use of stethoscope to auscultate breath sounds

A
  • Hold the flat diaphragm end piece of the stethoscope firmly on the person’s chest wall. Listen to at least one full respiration in each location.
138
Q

Part of brain that helps coordinate movement, maintains equilibrium, and helps maintain posture

A

cerebellum

139
Q

DEFINITION: Ever feel lightheaded, a swimming sensation, like feeling faint?

140
Q

DEFINITION: fainting, sudden loss of strength/consciousness

141
Q

Infant reflexes

A
  • rooting
  • moro/startle
  • sucking
  • palmar
  • babinski
142
Q

In this neurological assessment, the patient is stood up and asked to close his eyes. A loss of balance is interpreted as a positive sign

A

Romberg test

143
Q

when someone can’t identify something in their hand with their eyes closed

A

Astereognosis

144
Q

documentation of normal plantar reflexes

A

plantar flexion of toes and inversion of flexion of forefoot.

145
Q

ability to read a number on a trace of skin

A

graphesthesia

146
Q

ability to distinguish separation between 2 points on skin

A

two point discrimination

147
Q

WHAT IS THE Cremasteric reflex

A

TESTICLE REFLEX

148
Q

is a quantitative tool that is useful in testing consciousness in older adults who may be experiencing confusion. It gives a numerical value to the person’s response in eye-opening, best verbal response, and best motor response.

A

Glasgow coma scale

149
Q

technique to relax muscles and enhance response

A

reinforcement

150
Q

What is the Denver II used to screen for

A

Gross motor skills and coordination in school aged child

151
Q

Ominous sign which indicates brain stem injury

A

unilateral, dilated and nonreactive pupil

152
Q

The Cushing reflex showing signs sudden widening pulse pressure & decreased pulse is an indication of what

A

increased intracranial pressure

HEALTH ASSESSMENT (3 decks)

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