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NUR101 Health Assessments > Study guide for Final exam > Flashcards

Study guide for Final exam Flashcards

1
Q

Factors affecting detection of Adventitious sounds (sound distortion)

page 200
Box 11.3

A
  • If you bump the stethoscope tubing against something or if the patient touches the tubing, the sound will be distorted
    ** If the patient is cold and shivering
    *** If a patient has excess chest hair, movement of the stethoscope may give a false finding of crackles or pleural friction rub
    ** Extraneous environmental noises such as the rustling of a paper gown might sound like a crackle or pleural friction rub
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2
Q

Nursing process/6 phases

A

1) Assessment
2) Diagnosis
3) Outcome identification
4) Planning
5) Implementation
6) Evaluation

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3
Q

Best time to perform breast self examination

A

1 week after menstruation begins
Lie down and place a towel/pillow under the shoulder of the side of the breast to be examined

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4
Q

Pressure injury/Pressure ulcer

A

A localized defect in the skin of irregular size and shape where epidermis some dermis have been lost
Stage 1
Stage II
Stage III
Stage IV

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5
Q

Stage I Pressure Ulcer

A

Skin is intact but has evolved-so this is still a secondary lesion-Skin is intact and blanchable at this point
(((((Needs intervention/STAT))))

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6
Q

Stage II Pressure Ulcer

A

Loss of epidermis/dermis could look like a shallow abrasion

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7
Q

Stage III Pressure Ulcer

A

Goes all the way into subcutaneous tissue

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8
Q

Stage IV Pressure Ulcer

A

Involves all layers of skin and goes into muscle, bone, tendon

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9
Q

Excoriation
page 120

A

Loss of the epidermis, linear hollowed-out crusted area
Examples: Abrasion/scratch/scabies

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10
Q

OLD CARTS

A

“O” Onset- When did it start?
“L” Location- Be very specific
“D”- Duration- How long its been experienced
‘“C”- Characteristics- Descriptions (stabbing/throbbing/etc)
“A”- Aggravating/Alleviating- What makes it worse/better?
“R” Related Symptoms
“T” Treatment- Any at home/previous treatments/Did they work or not?
“S” Severity- Scale of 1-10/ Does it effect patient’s ADL’s

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11
Q

Novice Nurse

A

Has no experience w/specific pt populations & uses rules to guide performance

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12
Q

Experienced Nurse

A

Understands a patient situation as a whole rather than as a list of task, attends to an assessment data pattern, and acts w/o consciously labeling it

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13
Q

Cultural Diversity
page 51

A

Gender Religion
Age Sexual Orientation
Culture Physical/Mental disabilities
Race Social Status
Ethnicity Economic Status

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14
Q

Ethnicity
page 52

A

Characteristics that a group may share in some combination such as common geographic origin, race, language/dialect, religious beliefs, a shared tradition/symbols, literature, folklore, music, food preferences, settlement and employment patterns and an internal sense of distinctiveness

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15
Q

Culture
page 52

A

Knowledge, belief, art, morals, laws, customs, & any other capability and habits acquired by a person as a member of society

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16
Q

Race
page 52

A

Genetic in origin includes physical characteristics such as skin color, blood type, eye color and hair color

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17
Q

Religion
page 52

A

Organized system of beliefs, rituals, and practices n which individuals participates

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18
Q

Spirituality
page 52

A

“A search for the sacred”

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19
Q

Attaining cultural competence is not an end point
page 51

A

It is a process that evolves over a nurse’s career

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20
Q

Sex
page 52

A

Persons genetic composition & its phenotypic expression

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21
Q

Gender

A

Society’s percepti0n of a person’s sex as male/man or female/woman

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22
Q

Gender identity
page 52

A

Person’s internal sense of self as a man, woman, both, or neither (usually develops around age 3)

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23
Q

Gender expression
page 52

A

Person’s visible expression of social norms, such as mannerisms, dress, speech, or behaviors conventionally regarded as masculine, feminine, both, or neither

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24
Q

Cultural awareness
page 52

A

Nurses begin their cultural awareness through an indepth self examination of their own cultureal/ethnic group

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25
Q

Acute pain
page 60

A

Recent onset (less than 6 months)

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26
Q

Factors that affect B/P

A

Age Emotions
Gender Pain
Pregnancy Personal habits
Race Weight
Diurnal Variations (B/P lower in early AM/peaks in late afternoon/early evening)

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27
Q

V/S Ranges

A

B/P Systolic <120
Diastolic <80
H/R 60-100/bpm
R/R 12-20/bpm
Temp 96.4F-99.0F (35.8C-37.3C)
O2 Sat <90%= abnormal/Requires further evaluation

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28
Q

Cataract
page 181

A

Opacity of the crystalline lens
commonly occurs from denaturation of lens protein caused by aging
can also be congenital or caused by trauma
CLINICAL FINDINGS:
Pt reports cloudy or blurred vision, glare from headlights, lamps or sunlight and diplopia(double vision)
Blurred vision
Poor night vision
Frequent changes in glasses prescription
Cloudy lens can be observed on inspection
Red reflex is absent r/t light can not penetrate opacity of lens

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29
Q

Glaucoma
page 181

A

Group of diseases
Characteristics:
Increase in intraocular pressure
UNTREATED: Causes damage to optic nerve (CN II) leading to blindness
CLOSED ANGLE GLAUCOMA: See halos around lights and sharp eye pain

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30
Q

Rime Test Abnormal Findings
page 168

A

Loss in high frequencies result in difficulty hearing high pitch consonants
Loss in all frequencies causes moderate difficulty in hearing all sounds

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31
Q

Healthy ear drum appearance
(Tympanic Membrane)

A

pearly grey

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32
Q

SA Node

A

Heart’s Natural pacemaker
Sends out electrical signal
Regulates heart beat
LOCATION: Right atrium

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33
Q

S3

A

Heard after S2
Fluid overload
Heart Failure (commonly left sided/but can be right)

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34
Q

S4

A

Heard after S1
Stiff Ventricle
HTN
Hypertrophy

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35
Q

Hypertrophy

A

Enlargement/thickness of organ/tissue

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36
Q

Bruit

A

Low pitch blowing/whooshing sound
Atherosclerosis
HEARD: Carotid artery

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37
Q

Pleura Friction Rub

A

Inflamed pleura rubbing together
SOUND: Rough/Harsh/grating/creaky
Best heard w/deep breath

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38
Q

Headaches
page 179

A

Tension: Tight band around head
Migraine: Photophobia(pain when eyes exposed to sunlight)
N/V
Feeling of depression/restlessness/irritability
Last up to 72hours
Cluster: Most painful/ common in adolescent to middle age
Intense episodes of excruciating unilateral pain
Last 30min to 1hour/May repeat daily for weeks at a
time followed by periods of remission
PAIN: burning/boring/stabbing pain behind 1 eye

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39
Q

Wheezing

A

High pitched musical sound
Asthma/COPD

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40
Q

Stridor

A

Harsh/High pitched sound
Obstruction in upper airway

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41
Q

Question to ask patient on re check/follow up visit

A

What brings you here today?

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42
Q

Bruit

A

Low pitch blowing
Occlusion
HEARD over Carotid artery

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43
Q

Cyanosis

A

Blue due to Low O2(Hypoxia)
Check mucus membranes (mouth/conjunctiva)
Lips
Capillary refill (nail beds/finger & toe tips)

44
Q

Normal heart sounds

A

S1/S2 “LUB/DUB”

45
Q

Normal Abdominal sounds

A

High pitch gurgling and 35 other discreet sounds

46
Q

Normal wound bed color

A

Red/pink

47
Q

Dehisced

A

Wound splits open

48
Q

Wheezing

A

Asthma/COPD-
HEARD in chest/usually lower lobes

49
Q

Crackles (Rales)

A

Crackling/popping/bubbling
Pneumonia/Pulmonary Edema/Heart Failure

50
Q

S3

A

Extra heart sound
HEARD after S2
Volume Overload
Heart Failure
Mitral Regurgitation

51
Q

S4

A

HEARD before S1
Pushes blood up into ventricle
Left Ventricular Hypertrophy

52
Q

Crackles

A

Fluid in small airways

53
Q

Murmur

A

SOUND: Whooshing/swishing/blowing
High and Low pitch
Abnormal turbulent air flow
Occurs during S1/S2
Aortic Valve Stenosis/Mitral Stenosis

54
Q

Primary Prevention
page 6

A

Protection to prevent occurrence of disease
Examples: Immunization
Pollution Control
Nutrition/Exercise

55
Q

Secondary Prevention
page 6

A

Early identification of disease before it becomes symptomatic to halt the progression of pathologic process
Examples: Screening exams
Self exam practices

56
Q

Tertiary Prevention
page 6

A

Minimizes severity & disability from disease through appropriate therapy for chronic disease
Examples: DM Management
HTN Management

57
Q

Preventing Latex Allergy
page 26
Box 3.3

A

Immediately removing latex gloves, wash hands w/mild sap and dry them thoroughly
Use non-latex gloves
Use powder free/ low allergen glove if possible
Do NOT use oil based hand lotion when wearing latex gloves

58
Q

Auscultation/Noises that can alter/interfere w/sound
page 28

A

Stethoscope must be placed directly on skin(gown/clothing can alter/obscure sounds)
Cold and Shivers
Involuntary muscle spasms
Body hairs
Bumping the stethoscope tubing

59
Q

Distance Vision Charts
page 34

A

Snellen/Sloan Chart

60
Q

Near Vision Charts
page 34

A

Rosenbaum chart

61
Q

Tuning Fork
page 37/38

A

Auditory screening and assessment of vibratory sensations
Patients unable to feel vibration have a lower peripheral sensation

62
Q

Ear Obstructions
page 181

A

Any small object, such as a small stone, small part of toy, or even an insect

63
Q

Rinne Test
page 323

A

Air conduction is longer than bone conduction

64
Q

Weber Test
page 323

A

Tone should be equal in both ears

65
Q

Symptoms
page 2

A

Subjective data perceived and reported by patient

66
Q

Signs
page 2

A

Objective data- Data is felt, heard or measured
Measurable data
Collected using the techniques of
Inspection
Palpation
Percussion
Auscultation
Patients: Height Weight
B/P Pulse
Temp Respirations
Pulse O2 Saturation

67
Q

Health Record
page 2

A

Legal permanent record of patient’s health status at the time of the health care encounter
Baseline for the evaluation of subsequent changes
Decisions related to care

68
Q

Electronic Health Record (EHR)

A

Digital version of person health information maintained by provider over time
It is used by all health care professionals involved in an individuals care
-Includes data from the H/x, physical exam, lab/diagnostic test/ surgical procedures/progress notes

69
Q

Documentation

A

Required data to be recorded at the point of care
Accurately & Concise w/o bias or opinion

70
Q

Clinical Manifestations
page 2

A

Used to describe the presenting s/s experienced by a patient

71
Q

Screening Assessment/Exam
page 3

A

Short exam focused on disease detection
Screening exam maybe performed in a hc providers office(as part of comprehensive exam) or at a health fair
Examples: B/P screening
Glucose screening
Cholesterol screening
Colorectal screening

72
Q

Rhonchi

A

Low pitch snoring/gurgling
Sometimes cleared with a cough
Air moving though mucous secretions
Chronic Bronchitis/COPD

73
Q

Wheezing

A

Emphysema/COPD
(Barrell chest)

74
Q

Pneumothorax/Collapsed lunch

A

Diminished/absent breath sounds

75
Q

Systolic

A

When heart contracts

76
Q

Diastolic

A

When heart rest

77
Q

How to understand other’s culture?

A

By knowing your own

78
Q

What type rotation does the knee do?

A

Internal/Medial Rotation
External/Lateral Rotation

79
Q

What position should patient be in when assessing the jugular

A

Semi Fowlers 30-45degrees

80
Q

BMI

A

Normal 19-25
25-30= Overweight
>30= Obese
<19= Underweight

81
Q

Piaget’s o4 Stages of Cognitive Development
Page 397
Box 18.2

A

Stage 1 (0-2yrs)= Sensorimotor- “Out of Sight out of mind”
Thought is dominated by physical manipulation of objects/events

Stage II (2-7yrs)= Preoperational- they see world from their own perspective
Function is symbolic, using language as major tool

Stage III (7-11yrs)= The amount of something doesn’t change even if it’s appearance does
Mental reasoning processes assume logical approaches to solving concrete problems

Stage IV (11-15yrs)= Formal operations- Can reason about hypothetical situations/ think about future/use deductive reasoning
True logical thought and manipulation of abstract concepts emerge

82
Q

Health History

A

Biographical data
Reason for seeking care
H/X of present illness
Pastalth H/X
Family H/X
Personal/Psychosocial H/X
Review of Systems

83
Q

Screening Assessment

A

Short exam focused on disease detection
Maybe performed in Health Care providers office as part of the comprehensive exam
or at a Health Fair
(B/P screening/glucose screening/cholesterol screening/colorectal screening)

84
Q

Health H/X

A

Subjective data collected during interview involving nurse and patient
Obtain important info from patient to develop plan to promote health/prevent disease/ resolve acute health problems/ minimize limitation r/t chronic health problems can be developed

85
Q

Health H/X data

A

Biographic data
Reason for seeking care
H/X of presenting illness
Present health status
Past health H/X
Family H/X
Personal/Psychosocial H/X
Review of Systems

86
Q

Stool Characteristics

A

Bright Red= Hemorrhoid/Lower rectal bleeding
Tarry Black= Upper intestinal tract bleeding/excessive iron/Bismuth indigestion
Light Tan/Grey= Obstruction of biliary tract(obstructive jaundice)
Pale Yellow= Malabsorption Syndrome

87
Q

Bacterial Vaginosis
page 384

A

S/S: Malodorous(fishy odor), vaginal discharge, and vulvar itching and irritation

88
Q

Candida Vaginitis
page 384

A

S/S: Vulvar pruritis associated w/thick, cheesy, white vaginal discharge. Erythema & edema to the labia and vulvar skin may be visible

89
Q

Knee Rotation

A

Internal/Medial Rotation
External/Lateral Rotation

90
Q

Piaget’s 4 Stages

A

S (Smart) Sensorimotor (0-2yrs)
P (People) Preoperational (2-7yrs)
C (Can) Concrete Operations (7-11yrs)
T (Think) Formal operations (11-15yrs)

91
Q

Erikson’s 8 Stages of Human Development
page 397
Box 18.1

Trust
Autonomy
Initiative
Industry
Identity
Intimacy
Generativity
Integrity

A

Infancy (Birth-1yr)= Basic trust -vs- Basic mistrust
Drive/Hope Relationships: Mother

Toddler(2-3yrs)= Autonomy -vs- shame/doubt
Self control/will power Relationships: Parents

Preschool (3-6yrs)= Initiative -vs- Guilt
Direction/Purpose Relationship: Family

Middle Childhood (school age7-12yrs) Industry -vs- Inferiority
Method/Compliance Relationship: Neighborhood/school

Adolescence (12-19yrs)= Identity -vs- Role Confusion
Devotion/Fidelity Relationship: Peer groups/role models

Young Adults (20’s)= Intimacy -vs- Isolation
Affiliation/Love Relationships: Partners/Friends

Middle Adulthood (20’s-50’s)= Generativity -vs- Stagnation
Productive/Care Relationships: Household/Work mates

Older Adult (50’s & beyond)= Ego Integrity -vs- Despair
Renunciation/Wisdom Relationships: Mankind/”My Kind”

92
Q

Motor Development
page 396

A

Gross motor behaviors
Fine motor behaviors

93
Q

Gross-Motor Behaviors
page 396

A

Postural reactions such as head balance, sitting, creeping, standing, and walking

94
Q

Fine Motor Behaviors
page 396

A

Use of hands and fingers in the prehensile approach to grasping and manipulating an object

95
Q

Social Adaptive Behaviors
page 396

A

Interactions of the infant/child w/other people, and the ability to organize stimuli, perceive relationships between objects, dissect a whole into its component parts and solve practical parts
Example: Smiling at other people/learning to feed self

96
Q

Language Behavior
page 396

A

Visible/audible forms of communication w/facial expression, gestures, postural movement, or vocalizations (words/phrases/sentences) language also includes the comprehension of communication by others

97
Q
A
98
Q

Expected Development of Infants
Box 18.3

A

Review Box
too much to remember & copy

99
Q

Nystagmus

A

Involuntary rapid eye movement
involuntary movement of the eyeball in a horizontal/vertical/rotary/mixed direction
involves (CN VIII/Vestibulocochlear)

100
Q

Falls in older Adult

A

Muscle weakness, especially in legs
Problems w/balance/gait
Postural hypotension/dizziness
slower reflexes
Visual problems/poor depth perception
mental status/confusion/disorientation
Adverse effects of medications
Environment: Loose rugs/clutter on floor/stairs/no stair railing or grab bars

101
Q

dementia

A

lossof cognitive functioning such as thinking remembering and reasoning which interferes with daily life

102
Q

what is nutrition

A

the optimal intake and metabolism of nutrients

103
Q

Nutritional Assessment/Health H/X

A

Do you have any chronic illnesses? Special diet restrictions?
Do you take vitamins or supplements?
Do you have any food allergies or intolerances?
What is your activity level/Exercise pattern?
Do you have a specific diet based on preferences or culture/spiritual practices?

104
Q

Obesity Risk factor
Page 88

A

High fat diet
Sedentary lifestyle
Genetics
Ethnicity/race
Female
Low socio-economic status

105
Q

Cancer Risk Factors for Testicular Cancer
page 365-366

A

Age 20-24
Cryptorchidism
Family H/X
Cancer in other testicle
White race

106
Q

Function of bones

A

Support for soft tissue and organs
Protection of organs/brain/spinal cord’
Body movement
Hematopoiesis
Function dictates shape and surface features
Long bones act as levers
Long bones have flat surface for attachment of muscle w/grooves at end for tendon or nerve

107
Q

Risk Factors for Osteoporosis

A

age >50yrs
Female
cauc

NUR101 Health Assessments (10 decks)

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