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Health Assesment-RN > Study Guides Test2 > Flashcards

Study Guides Test2 Flashcards

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1
Q

Describe the appearance of Pallor

A

Light pale skin

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2
Q

Erythema in light and dark skin

A

Light skinned: red or pink

Dark skin: purple tinge

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3
Q

Cyanosis

A

Light skin- blue dusky

Dark skin- dark but dull

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4
Q

Jaundice

A

Yellowing of skin, palms , eyes

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5
Q

One color, flat such as freckle

A

Macule

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6
Q

Something you can feel that is solid and elevated such as:

Mole

A

Papule

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7
Q

Plateau like such as Psoriasis

A

Plaque

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8
Q

Nodule:

A

Solid, elevated such as fibroma

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9
Q

Mass in deeper dermis such as lipoma

A

Tumor

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10
Q

Superficial, raised, transient such as mosquito bite

A

Wheal

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11
Q

Elevated cavity with free fluid

Such as a blister

A

Vesicle

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12
Q

Turbid(cloudy) fluid and cavity

Such as acne or impetigo

A

Pustule

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13
Q

Primary skin lesions include?

A

Macule, Papule, plaque, nodule, tumor, wheel, vesicle, pustule

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14
Q

Secondary skin lesions include?

A

Crust, scale, vision, erosion, ulcer

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15
Q

Thick dried out exudate left when vesicles burst or dry up such as impetigo or weeping

A

Crust

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16
Q

Compact desiccated flakes of skin dry or greasy from Shedding of dead excess keratin cells such as eczema

A

Scale

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17
Q

Linear cracks with abrupt edges extend into dermis such as athletes foot

A

Fissure

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18
Q

Scraped out but shallow depression with no scar

A

Erosion

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19
Q

Deep depression into dermis such as pressure sore on body

A

Ulcer

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20
Q

Where to assess for jaundice ?

A

Sclera of eyes and hard palate

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21
Q

Why do we assess skin turgor?

A

To assess for dehydration

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22
Q

How to assess a lesion on a skin assessment?

A

Color, size, location, depth, drainage?

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23
Q

What capillary refill is considered normal?

A

Less than 1 second

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24
Q

What does ABCDE stand for when assessing skin

A

Asymmetry
(Half of mole doesn’t match the other)

Border

Color

Diameter
(Bigger than 6mm)

Evolving
(Changing in shape,color, size)

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25
Q

Characteristics of herpes zoster infection/shingles

A

Lesion on one side of body that does not cross the midline

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26
Q

How are lesions of ringworm described?

A

Annular lesion

Meaning shape of ring

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27
Q

Intense redness of the skin due to excess blood in dilated superficial capillaries

A

Erythema

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28
Q

Blue mottled color

A

Cyanosis

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29
Q

Absence of red pink tones from the oxygenated hemoglobin in blood

A

Pallor

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30
Q

Increase and Bilirubin in the blood causing a yellow color in the skin

A

Jaundice

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31
Q

Name borders of two regions in the neck :

Stemomastoid muscle and midline of body

Behind sternomastoid and trapezius muscles and clavicle

A

Anterior triangle

Posterior triangle

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32
Q

List facial structures that should appear symmetric when inspecting the head

A

Eyebrows , nasofolds, sides of mouth, ears , nose, eyes, palpebral fissures

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33
Q

Describe the characteristics of lymph nodes with associated with acute infection

A

Acute onset and less than 14 days of duration

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34
Q

Characteristics of lymph nodes were associated with chronic inflammation?

A

Nodes are tender and firm, warm, and large

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35
Q

Characteristics of lymph nodes when associated with cancer

A

Hard, Bigger than 3 mm, unilateral , non-tender

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36
Q

Identify the blood vessel that runs diagonally across the sternomastoid muscle

A

External jugular vein

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37
Q

Characteristics of lymph nodes in neck of healthy people

A

Mobile, soft, non tender

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38
Q

What are the characteristics of Bell’s palsy

A

Unilateral paralysis of half of the face

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39
Q

Cranial nerves

A

Oculomotor
Abduces
Trochlear

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40
Q

What does 20/40 vision mean?

A

Number on top is number of feet away from chart

Bottom number is the distance (40ft) that one can see normally where a normal person could see normally at 20 ft

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41
Q

Common age related changes in the eye

A

Loss of skin elasticity which causes wrinkles and drooping

Fat tissues and muscle atrophy

Decrease in acuity, tears, yellow nodules, cloudy cornea

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42
Q

What does it indicate when the examiner records positive consensual light reflex??

A

Construction of other pupil when one eye is exposed to bright light

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43
Q

How is visual acuity assessed

A

Snellen eye chart

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44
Q

What is conjunctivitis associated with?

A

Reddened conjunctiva / pink eye

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45
Q

Cause of red reflex?

A

Light reflecting from retina

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46
Q

Successful PERRLA exam?

A

Pupils are able to follow moving object close up and far away

They respond well to light, equal in size, round, and react to light

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47
Q

One cause of visual impairment?

A

Glaucoma

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48
Q

Whispered voice test of hearing acuity?

A

Test one ear at a time

Stand 2 ft behind

Mask hearing in other ear

Cover lips

Whisper 3 random letters and numbers

Have them repeat it

Passing is 3/6

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49
Q

Tympanic membrane in the ear is what color?

A

Pearly gray

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50
Q

What might the sensation of vertigo mean?

A

Pathology in the semicircular canals

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51
Q

Common cause of conductive hearing loss

A

Impacted cerumen

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52
Q

Functions of nose

A

Smell, respiration, filtration of air, warms and moistens air , sneezing out unwanted particles

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53
Q

Appearance of deviated nasal septum ?

Perforated septum?

A

Deviated? hump
Or shelf in one nasal cavity

Perforated: spot or light from a penlight that is shinning in the other nails

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54
Q

4 point grading scale for the size of tonsils ?

1+
2+
3+
4+

A

1-visible
2-halfway between tonsillar pillars and uvula
3-touching the uvula
4- touching one another

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55
Q

What is the most common reason for dry mouth in the elderly?

A

Medications

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56
Q

What to do if You notice a coin have a deviated septum

A

Document the deviation in the medical record in case the person needs to be suctioned

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57
Q

Where are oral malignancies most likely to develop

A

In the mucosal gutter under the tongue

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58
Q

What sense in the elderly is greatly decreased

A

Ability to identify orders

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59
Q

What abnormal conditions could affect the location of the apical impulse

A

Cardiac enlargement

Left ventricle dilation a.k.a. volume overload

Barrel chest, left ventricular hypertrophy and no dilation or pressure overload

Pulmonary emphysema

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60
Q

Which heart sounds is loudest?

A

1st Lub -at the mitral area at the apex

And softer at the base

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61
Q

Characteristics of the second heart sound and intensity of Apex in the base of the heart

A

Dub - loudest at the base

Closure of semilunar valve and signals end of dyalstole

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62
Q

Major risk factors for heart disease and stroke

A

Hypertension, smoking, high cholesterol, obesity, diabetes, physical inactivity, family history of heart disease, age, gender

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63
Q

Which heart sounds coincides with the carotid artery pulse and R wave if connected to an ECG monitor

A

S1

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64
Q

What are the characteristics of an innocent and functional murmur

A

An innocent murmur has no pathologic cause

A functional murmur Is caused by increased blood flow in the heart

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65
Q

Where to escalate the Pulmonic valve

A

Second left interspace

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66
Q

What is the cause of the second heart sound?

A

Closing of the aortic and pulmonic valves

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67
Q

When auscultating the heart, what is your first step?

A

Identify S1 and S2

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68
Q

Why should the stethoscope bell depressed lightly against the skin?

A

Because the build of the act of a diaphragm

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69
Q

Tough, Fibrous, double walled Sac that surrounds and protects the heart

A

Pericardium

70
Q

Thin layer of endothelial tissue that lines the inner surface of the heart chambers and valves

A

Endocardium

71
Q

Reservoir for holding blood

A

Atrium

72
Q

Ensures smooth, friction free movement of the heart muscle

A

Pericardial fluid

73
Q

Muscular pumping chamber

A

Ventricle

74
Q

Muscular wall of the heart

A

Myocardium

75
Q

Three ways that help return blood to the heart

A

Contracting skeletal muscles which milk blood back toward the heart

The pressure gradient cause breathing

Intraluminal valves and sure flow

76
Q

What are the risk factors for venous status

A

Elderly diabetes, obesity, peripheral vascular disease, pregnancy, smoking, verocrose veins, activity

77
Q

Function of the lymphatic system

A

Transports fluids back to blood

Acts as the body’s defense and resistance to disease

78
Q

What is the function of the lymph nodes

A

Removes toxins from lymph that do not belong there

Acts as a filter

79
Q

Organs of the lymphatic system

A

, tonsils, Thymus , spleen

80
Q

Symptom areas to address during peripheral vascular system history

A

Leg pain or cramps, skin changes and arms or legs, lymph node enlargement, medication

81
Q

Grading scale for assessing force of a pulse, zero, one, two, three, 4+

A

Zero means no pulse

One plus means weak

2+ means normal

3+ means increased

4+ plus means full bounding

82
Q

Skin characteristics with arterial insufficiency in legs

A

Malnutrition, pallor and coolness occur

83
Q

And characteristics with venous insufficiency in the lower legs?

A

Malnutrition, thin, shiny atrophic skin, thick nails, with hair loss,Ulcers, gangrene

84
Q

Raynaud phenomenon associated tricolor changes of the skin tone ???

A

Blue to white to tored

85
Q

What is the function of the venous system

A

It forms a major part of the immune system that defends the body against diseases

86
Q

If it clients Rt hand was red and swollen where would you asses for further infection?

A

Epitrochlear node

87
Q

Would you screan for deep vein thrombosis

A

Measure the widest point with a tape measure

88
Q

What should you do if you are an able to palpate the popilteal pulse

A

Proceed with the examination because it is often impossible to palpate this pulse

89
Q

What is a known risk for venous ulcer development

A

Obesity

90
Q

What is a cause if arteriosclerosis

A

Loss of elasticity of walls of blood vessels

91
Q

What is intermittent claudication

A

Muscular pain relieved by exercise

92
Q

Describe the most important point about the health history for the respiratory system

A

Cough, shortness of breath, chest pain with breathing history or respiratory infection, smoking history, environmental exposure, self-care behaviors

93
Q

With the elements included in the inspection of the respiratory system

A

Posterior and lateral thorax, anterior chest

94
Q

What is barrel chest and what might it signify

A

What is win the ribs or horizontal instead of normally down word

It may be due to normal aging or emphysema or asthma

95
Q

Marked sunken sternum and adjacent cartilages

A

Pectus excavatrum

96
Q

Three types of normal breath sounds, location, name, description of sound

A

Bronchial : trachea/larynx, high pitched/loud

Bronchovesicular: scapulae Rt side , moderate pitch and amplitude

Vesicular sounds : bronchioles and alveoli, low pitch sound, soft

97
Q

How many degrees is the normal costal angle

A

90

98
Q

What is the expected ratio when comparing the anterioposterior diameter of the chest with the transverse diameter

A

The ratio should be 1:2 to 5:7

Ap is lower than transverse

99
Q

What is the tripod position

A

Position where is the patient leans forward with hands on their knees, on chair, or bed helps COPD patient with expiration

100
Q

Description of the left lung

A

Narrower than the right with two lobes

101
Q

Characteristic timing of the cough of chronic bronchitis

A

Productive cough for at least three months of the year for two consecutive years

102
Q

Symmetric chest expansion with assessment

A

Please handsome postorolateral chest wall with thumbs at the level of T9 or T10 And then slide my hands up to pinch a small fold of the skin between the thumbs

103
Q

A client has increased respiratory rate Chest expansion decrease on the left side, for percussion over the left lower lobe, breath sounds louder with fine crackles over the left lower lobe. What might the symptoms resemble?

A

Lobar pneumonia

104
Q

Base of nails angel are greater than 160 degrees and feels spongy when palpating . What does this indicate?

A

COPD

105
Q

What is the best Method to listen to breath sounds on a client

A

Did the diaphragm of the stuff in the chest wall, listen to one for respiration in each location, ensure to do a side to side comparison

106
Q

What do you ask the client to do in order to perform the technique of egophony

A

Say e-e-e each time stethoscope is moved

107
Q

What does pulse oximetry measure

A

Arterial oxygen saturation of hemoglobin

108
Q

What is it important to do when examining for tactile fremitus

A

Palpate the chest symmetrically

109
Q

Exaggerated posterior curvature of the thoracic spine

A

Kyphosis

110
Q

LS shaped curvature of the thoracic and lumbar spine

A

Scoliosis

111
Q

Sunken sternum and adjacent cartilage

A

Pectus excavatum

112
Q

Elliptic shape with an anteroposterior to transverse diameter in the ratio of 1:2

A

Normal chest

113
Q

Forward protruding of the sternum with ribs sloping back at either side

A

Pectus carinatum

114
Q

Inspection of the abdomen findings that should be noted

A

Contour, symmetry, umbilicus skin, pull station, Hair distribution, demeanor

115
Q

Rationale for performing auscultation of the abdomEn Before health palpation or percussion

A

Palpation can increase Movementin the stomach and give a false interpretation of bowel sounds

116
Q

HowTo listen to bowel sounds

A

Use the diaphragm of the stethoscope and press lately on the skin, listen to all four quadrants starting with the right lower and go clockwise, listen for five minutes at a time, note characteristics and frequency of bowel sounds

117
Q

What does a normal abdominal sound like

A

Perched, gurgling, cascading sounds 5 to 30 times per minute

118
Q

How do hyperactive sound in the stomach sound

A

Loud, high-pitched rushing, tingling sounds that signal mobility

119
Q

Hypo active stomach sounds, when would one to have?

A

After surgery or with inflammation of the periitoneum

120
Q

deep Palpation

Abnormalties detected by palpation

A

5 to 8 cm noting location, size, consistency, mobility of organs in the presence of any tenderness

enlarge liver, enlarge spleen, tenderness

121
Q

Light palpation

Abnormalties that may be detected by palpation?

A

Press about 1 cm in to get an overall impression of the skin service and superficial musculature

Muscle guarding, rigidity, Large massive and tenderness

122
Q

Describe a rebound tenderness

A

Person reports abdominal pain, peritoneal inflammation

Old hand at 90° and push down slowly and deeply. Lift handled quickly and a normal responses no pain in the patient

123
Q

Describe the procedure and reason for determining CVA tenderness

A

Please handover the 12th rib at the costoventebral angle on the back

Thump the hand with the owner edge of the other

First pain occurs with inflammation of the kidney or paranephric area

124
Q

In what sequence do you examine the abdomen

A

Inspection, escalation, percussion, palpation

125
Q

What pathalogy might right upper quadrant tenderness indicate

A

Liver, pancreas, or ascending colon issues

126
Q

Listening of the abdomen me review roots of what artery’s

A

Aortic, Renal, iliac, femoral

127
Q

Why is osculating the abdomen beginning in the RLQ

A

Because bm sounds are always normally present here

128
Q

Where is the lower edge of the liver normally located

A

At the right costal margin

129
Q

Does the left upper quadrant contain in stomach

A

Spleen

130
Q

Describe the significance of the inguinal canal and femoral canal

A

They are both potential sites for hernias

131
Q

Teaching points to include when teaching testicular self examination

A

TSE

Time - once a month

Shower- With warm water because it relaxes scrotal sac

Examine- Check for changes, report changes immediately

132
Q

Enlarged and reddened scrotum hard to distinguish from testees, wbc and bacteria in urine

A

Epididymitis

133
Q

When standing feels soft like bag of worms in testes, varicose veins in spermatic cord

A

Varicocele

134
Q

Fluid sac that don’t usually hurt but can if grows too large

A

Spermatocele

135
Q

Lump, swelling, or pain in scrotum/abdomen, firmness in testicle /cancer

A

Testicular tumor

136
Q

Fluid filled sac around a testicle, often first noticed as swelling of the scrotum

A

Hydrocele

137
Q

What is the normal finding on examination of the scrotum

A

Left testicle hangs lower than the right

138
Q

Prostatic hypertrophy is common in older men , what s/s May indicate this problem?

A

Straining , loss of force , and a sense of residual Urine

139
Q

What would be a normal age-related change in the scrotum

A

Pendulous scrotum

140
Q

When teaching about testicular self exam what fact should be shared in regards to age the typical age range for the occurrence of testicular cancer?

A

15-34 years of age

141
Q

What is the congenital displacement of the urethral meatus to the inferior surface of the penis called?

A

Hyposospadias

142
Q

What is a normal finding on palpation of testes

A

Firm, rubbery, smooth

143
Q

Screening measures that are recommended for early detection of colorectal cancer and prostate cancer?

A

Colonoscopy ages 50-75

144
Q

Foods to reduce risk of colon cancer

A

Low in fat

145
Q

Population with highest BPH

A

African Americans

146
Q

How is normal stool described?

A

Brown and soft in consistency

147
Q

How to comfort women while doing vagina exam/pap

A

Empty bladder before exam, Position table so peri area is not exposed to door, elevate head, family or friend present is desired, place stirrups, explain each step before doing it, assure them they can stop at any time , be gentle but firm , communicate

148
Q

How to prepare vaginal speculum?

A

Warm and lubricate it with warm water and gel lubricant

149
Q

Characteristics of vaginal discharge :

White curdy not mal odorous

A

Candidiasis (yeast infection)

150
Q

Characteristics of vaginal discharge :

Pruitus, watery, and often malodorous , thick, white , itchy

A

Trichomoniasis

151
Q

Characteristics of vaginal discharge :

Thin creamy gray-white malodorous

A

Bacterial vaginitis

152
Q

Characteristics of vaginal discharge :

Yellow or green muco purulent discharge

A

Chlamydia

153
Q

Characteristics of vaginal discharge :

Purulent /pus

A

Gonorrhea

154
Q

Normal presence of genitalia of 70 year old lady

A

Thin and sparse pubic hair

155
Q

What is the most common bacterial sexually transmitted STD in the US?

A

Chlamydia

156
Q

What problems are associated with smoking and oral contraceptives?

A

Blood clots and pulmonary clots

157
Q

Hx questions to ask regarding breast exam

A

Any hx of breast disease ? Type?

How was it diagnosed ?

Family hx? Ages?

Pain discharge

Rashes , lesions , swelling ?

158
Q

Components of breast exam

A

Subjective: pain, lumps, discharge , rash, trauma, hx of disease , surgery, meds , radiation

Objective- inspection, appearance, drainage, nipple, teach self exam

159
Q

Self Breast exam teachings

A

Early detection is important

Palpate in shower and lay supine

Perform after period due to decrease congestion

160
Q

Pathological changes that may occur in the breast:

Bilat nodules pain

A

Benign breast disease

161
Q

Pathological changes that may occur in the breast:

Inflammatory mass, red, swollen hard and hot

A

Acute mastitis

162
Q

Pathological changes that may occur in the breast:

Solitary, nontender mass, benign

A

Fibroadenoma

163
Q

Pathological changes that may occur in the breast:

Solitary non tender growing mass

A

Cancer

164
Q

Pathological changes that may occur in the breast:

Early lesion yellow discharge, bloody red nipple

A

Pager disease

165
Q

Characteristics to consider when a mass is noted in the breast?

A

Location, size, shape, moveable , tender, lump

166
Q

Gynecomastia

A

Visible breast tissue , enlargement in males

167
Q

High risk and moderate risk factors for breast cancer

A

Alcohol, decreased activity, obesity,female, over 50 years old, family history, low income, birth control

168
Q

Most common site of breast tumors

A

left Upper outer quadrant

169
Q

What to know about breasts during development ?

A

One may grow faster than the other

170
Q

When should one start getting mammagram and how often?

A

45 - every year

55 years- Every 2 years

171
Q

Malignant versus benign lump in the breast

A

Malignant :fixed, irregular , poorly defined margins

Benign: soft, moveable well defined margins

Health Assesment-RN (7 decks)

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