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Health Assessment > Module 2 > Flashcards

Module 2 Flashcards

1
Q

Describe the decorticate posture

A

Client with lesions of the corticospinal tract and draws hands up to chest

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2
Q

Describe the decerebrate posture

A

Client with lesions of the diencephalon (midbrain) or pons extends arms and legs, arches back, and rotates hands and arms internally

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3
Q

What assessment questionnaire is used to determine if an alcohol assessment is needed

A

CAGE

Cut/Annoyed/Guilt/Eye-opener

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4
Q

What assessment guide is used to assess the likelihood of a suicide attempt

A

SAD PERSONS
(Sex, Age, Depression, Previous attempt, Ethanol abuse, Rational thinking loss, Social supports lacking, Organized plan, No spouse, Sickness)

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5
Q

Questions to ask to assess the patient’s LOC

A

Name, address, phone number, where they are currently, the day, appropriate time of the day

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6
Q

What is the Glasgow Coma Scale (GCS) used for

A

To assess which clients are at a high risk for rapid deterioration of the nervous system
(Scale of 14 indicates an optimal LOC)

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7
Q

In Erikson’s stages of psychological development, describe the infant stage

A

Basic trust vs mistrust

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8
Q

Describe the toddler stage in Erikson’s psychosocial development

A

Autonomy vs shame and doubt

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9
Q

Describe the preschooler stage in Erikson’s psychosocial development

A

Initiative vs guilt

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10
Q

Describe the school-ager stage in Erikson’s psychosocial development

A

Industry vs. inferiority

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11
Q

Define acute pain (2)

A

Rapid onset and a short course

Usually associated with an recent injury

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12
Q

Define chronic (nonmalignant) pain (2)

A

Usually associated with a specific cause of injury

Constant pain that persists for more than 6 months

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13
Q

Define cancer pain (2)

A

Compression of peripheral nerves

Damage to these structures following surgery, chemo, radiation, tumor growth filtration

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14
Q

3 types of cancer pain

A

Somatic
Visceral
Neuropathic

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15
Q

Many clients with cancer experience ___ pain (brief severe pain that occurs in spite of pain meds)

A

Breakthrough

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16
Q

Cancer pain can result from (7)

A 
Blocked blood vessels causing poor circulation 
Bone fracture from metastasis 
Infection 
Inflammation
Psychological/emotional problems 
Side effects from cancer treatments
Tumor exerting pressure of a nerve
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17
Q

What does the sympathetic nervous system do to the body? (4)

A

Heart rate
Constricts blood vessels
Raises the BP
“Fight or flight”

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18
Q

Physiologic response to pain (5)

A 
Anxiety 
Fear
Hopelessness
Sleeplessness
Thoughts of suicide
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19
Q

Patient expresses these when in pain (5)

A 
Reports of pain
Cries
Moans
Frowns
Facial grimaces
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20
Q

What hormones are elevated when the SNS is activated? (5)

A 
Antidiuretic 
Epinephrine 
Norepinephrine
Aldosterone
Glucagons
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21
Q

7 dimensions to pain

A
  • Physical (patients perception of pain)
  • Sensory (quality of the pain)
  • Behavioral (patient demonstrates pain)
  • Sociocultural (cultural background)
  • Cognitive (beliefs, attitudes, intentions, motivating related to pain)
  • Affective (feelings, sentiments, emotions)
  • Spiritual (attributes to pain, self, others, and the divine)
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22
Q

Define COLDSPA

A
  • Character (description in patients words)
  • Onset (when did it start)
  • Location (where is it?/radiate)
  • Duration (how long does it last?)
  • Severity (identify precipitating factors)
  • Pattern (continuous/intermittent)
  • Associated factors (what factors relieve/increase pain)
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23
Q

Describe FLACC pain assessment for children

A 
Face
Legs
Activities
Cry
Consolability
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24
Q

4 abnormal LOC

A
  • Lethargy - client eyes open, answers questions, falls back asleep
  • Obtunded - client opens eyes to loud voice, responds slowly with confusion, seems unaware of environment
  • Stupor - client awakens to vigorous shake or painful stimuli but returns to unresponsive sleep
  • Coma - client remains unresponsive to all stimuli; eyes stay closed
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25
Q

What do you assess using the GCS? (3)

A

Eye opening
Verbal response
Motor response

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26
Q

15 symptoms of depression

A 
Falling asleep frequently 
Ability to sleep through night 
Waking up too early
Sleeping too much
Feeling sad
Decreased appetite
Increased appetite 
Decreased weight 
Increased weight
Concentration/decision making
View of oneself
Thoughts of death/suicide
General interest
Energy level
Feeling slowed down
27
Q

Actual RN Dx with impaired verbal communication R/T….(4)

A
  • international language barrier
  • hearing loss
  • inability to clearly express self or understand others
  • aphasia, psychological impairment, organic brain disorder
28
Q

Actual RN Dx regarding mental status and substance abuse (7)

A
  • Anxiety R/T awareness of increasing memory loss
  • acute or chronic confusion R/T dementia, head injury, stroke, alcohol or drug abuse
  • impaired memory R/T dementia, stroke, head injury, alcohol or drug abuse
  • dressing/grooming self-care deficit R/T confusion and lack of resources/support from caregivers
  • disturbed thought process R/T alcohol or drug abuse, psychotic disorder, or organic dysfunctional
  • social isolation R/T inability to relate/communicate effectively with others
  • complicated grieving R/T suicide of child and increasing isolation from support systems
29
Q

What types of data is included in the RN history (3)

A

Psychosocial
Cognitive
Moral developments

30
Q

What subjective data is included in the RN history (5)

A 
Biographical data
Hx of present health concerns
Personal health Hx 
Family Hx 
Life and health practices
31
Q

8 pain assessment tools

A
  1. Visual analog scale (VAS)
  2. Numeric Rating scale (NRS)
  3. Numeric pain intensity scale (NPI)
  4. Verbal descriptor scale
  5. Simple descriptive pain intensity scale
  6. Graphic rating scale
  7. Verbal rating scale
  8. Faces pain scales (FPS)
32
Q

Barriers to pain assessment with people with cultural background (6)

A
  • Asian and Asian American - pain is honorable
  • African American - God and prayer will help more than medicine
  • Hindu - pain endured in the preparing for the next life in the cycle of reincarnation
  • Native American - metaphors and images from nature are used to describe pain
  • Hispanic - pain is often very expressive
  • Jewish - pain is expressed openly, with much complaining, pain must be shared, recognized, and validated by others so the experience is affirmed
33
Q

What do you inspect when you assess for pain (4)

A

Posture
Facial expressions
Joints and muscles
Skin for scars, lesions, rashes, changes, or discoloration

34
Q

Protocol for pain management (3)

A

Get analgesic ordered
RN observe for changes in self-report
Follow up

35
Q

QUESTT principals for pain in children

A 
Question the child
Use pain rating scales
Evaluate behavior and physiologic changes
Secure parent's involvement 
Take cause of pain into account
Take action and evaluate results
36
Q

Describe melanoma (2)

A

Malignant - most serious skin cancer

Most rapidly increasing form of cancer in US

37
Q

Define macule and 7 examples

A

Small flat nonpalpable skin color change. Less than 1 cm with a circumscribed border

Freckles, flat miles, petechiae, rubella, vitiligo, port wine stains, ecchymosis

38
Q

Mnemonic for assessing suspicious lesions

A 
Asymmetry 
Border 
Color
Diameter
Elevation
39
Q

What tool is used to assess for fungal infections

A

Wood’s light

40
Q

What scale is used to detect pressure sore risk

A

Braden

41
Q

Describe vesicles and 5 examples

A

Circumcised elevated palpable mass containing serious fluid. Less than 0.5 cm

Herpes simplex/zoster, varicella (chicken pox), poison ivy, 2nd degree burn, shingles

42
Q

Describe bulla and give 5 examples

A

Circumcised elevated palpable mass containing serious fluid. Larger than 0.5 cm

Pemphigus, contact dermatitis, large blister burns, poison ivy, billows impetigo

43
Q

Describe papule and give 3 examples

A

Elevated palpable solid mass. Circumscribed border less than 0.5 cm.

Nevi, warts, lichen planus

44
Q

Describe each pressure ulcer stage

A

Stage 1- nonblanchable redness of a localized area, painful
Stage 2- partial thickness loss of dermis, shallow open ulcer, red-pink wound bed without slough
Stage 3- full thickness tissue loss, bone, tendon, or muscle NOT exposed
Stage 4- full thickness tissue loss, exposed bone, tendon, or muscle. Slough or eschar may be present
Unstageable- full thickness tissue loss, covered by slough and/or eschar in the wound bed

45
Q

2 RN Dx with impaired skin integrity R/T…

A
  • Poor nutritional intake and/or bowel/bladder incontinence

- Immobility and deceased circulation

46
Q

RN Dx when analyzing data from a skin, hair and nail assessment (4)

A
  • Ineffective health maintenance R/T lack of hygienic care of the skin, hair, and nails
  • disturbed body image R/T scarring, rash, or other skin condition that alters skin appearance
  • deficient fluid volume R/T excessive diaphoresis secondary to excessive exersise and high environmental temps
  • disturbed sleep pattern R/T persistent itching of the skin
47
Q

What is a useful landmark in the cervical area to determine other vertebrae

A

Cervical vertebrae C7

48
Q

Purpose of lymph nodes

A

Filter lymph before it returns to the vascular system

49
Q

10 lymph nodes

A
  1. Preauricular
  2. Posterior auricular
  3. Occipital
  4. Superficial cervical
  5. Deep cervical chain
  6. Posterior cervical
  7. Supra clavicular
  8. Tonsillar
  9. Submental
  10. Submandibular
50
Q

Leading cause of brain injuries

A

Falling (35.2%)

51
Q

3 risks for a TBI for infants and toddlers

A
  1. Environmental risks for falls
  2. Lack of parental knowledge of shaken baby syndrome
  3. Caregivers risk of shaken baby syndrome
52
Q

2 risks for TBI for children and teens

A
  1. Knowledge and use of protective equipment in sports and bicycle use
  2. Knowledge and use of safety practices when driving
53
Q

3 risks for TBI for adults and older adults

A
  1. Knowledge and use of safety practices when driving
  2. Impairment of physical/mental activity
  3. Potential for maltreatment or domestic violence
54
Q

What kinds of questions would you ask if you were obtaining lifestyle and health practices (5)

A

Do you smoke or chew tobacco?
Do you drink alcohol?
Do you wear a hardhat for hazardous occupations?
What recreational activities do your participate?
What is your typical posture when relaxing, sleeping, and working?

55
Q

How to palpate the thyroid gland

A

Use a posterior approach
Stand behind client
Client lowers chin to chest and turn neck slightly
Place thumbs on nape of neck with other fingers on either side of the trachea below cricoid cartilage
Use fingers to push trachea

56
Q

5 different types of headaches

A 
Sinus 
Cluster 
Tension
Migraine 
Tumor related
57
Q

Characteristics of sinus headache

A

Occurs with or after a cold or acute sinusitis or acute febrile illness with purulent discharge from nose.
Occurs in 1 area of face along eyebrow ridge and below cheek bone.
Lasts until associated condition is improved.
Moderately severe.
Pain is worse with sudden movements of head

58
Q

Characteristics of cluster headache

A

Sudden onset may be precipitated by ingesting alcohol.
In the eye and orbit and radiating to the facial and temporal regions.
Occurs in late evening or night.
Intense pain.
Movement or walking back and forth may relieve the discomfort.

59
Q

Characteristics of tension headache

A

No prodromal stage may occur with stress anxiety or depression.
In the frontal temporal or occipital region.
Lasts days, months, or years.
Aching pain.
Symptomatic relief may be given by local heat, massage, analgesics, antidepressants, and muscle relaxants

60
Q

Characteristics of migraine headache

A

May have prodromal stage (visual disturbances, vertigo, tinnitus, numbness or tingling of fingers or toes) may be precipitated by emotional disturbances, anxiety, or ingestion of alcohol cheese chocolate or other foods.
Around eyes, temples, cheeks, forehead may affect only 1 side of face.
Lasts up to 3 days.
Throbbing severe pain.
Usually subsides later in day.

61
Q

Characteristics of tumor related headaches

A

No prodromal stage may be aggravated by coughing sneezing or sudden movements of the head.
Location depends on tumor.
Occurs in morning and lasts for several hours.
Variable in intensity of pain.
Usually subsides later in day.

62
Q

RN Dx with ineffective health maintenance R/T…(2)

A
  • refusing to wear protective gear during contact sports or seat belt while driving or riding as a passenger
  • disregard for the effects and dangers associated with smoking and using dip
63
Q

RN Dx with imbalanced nutrition R/T…(3)

A
  • less than body’s requirements R/T increased metabolism secondary to hyperthyroidism
  • more than body’s requirements R/T decreased metabolism secondary to hypothyroidism
  • less than body’s requirements R/T difficulty swallowing which limits consumption of food
64
Q

RN Dx with analyzing data from a head and neck assessment (7)

A
  • ineffective tissue perfusion R/T cerebral R/T impaired circulation to brain
  • activity intolerance R/T fatigue and weakness secondary finalized metabolic rate secondary to hypothyroidism or to surgery of head neck or face
  • constipation R/T hyperthyroidism or hypothyroidism
  • chronic pain sinus headache R/T inflammation of sinuses secondary to seasonal allergies
  • disturbed body image R/T head injury
  • impaired swallowing R/T mechanical obstruction of the head and neck secondary to tissue swelling tracheostomy or abnormal growth
  • impaired swallowing R/T lack of gag reflex paralysis of facial muscles or decreased cognition

Health Assessment (2 decks)

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