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Physical Assessment > Test 1 Study Guide > Flashcards

Test 1 Study Guide Flashcards

1
Q

Attitudes, knowledge, and skills necessary for providing quality care to diverse populations

A

Cultural competence

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2
Q

Verbal responses that promote interview

A

Positive interview

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3
Q

Verbal responses that promote interview
Patient’s or examiners perspective?

-Silence
-Reflection
- empathy
- clarification

A

Patient’s

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4
Q

Verbal responses that promote interview
Patient’s or examiners perspective?

  • confrontation (clarification)
  • interpretation
  • explanation
  • summary
A

Examiners

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5
Q

4 types of data

A

-Complete
- focused or problem- centered
- follow up
-Emergency

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6
Q

Types of data

Complete health history and full physical exam

A

Complete

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7
Q

Types of data

One problem, cue complex, or body system

A

Focused or problem centered

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8
Q

Types of data

Evaluating the identified problems at regular or appropriate intervals

A

Follow-up

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9
Q

Types of data

Urgent rapid collection of information

A

Emergency

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10
Q

Percussion sounds

Low pitched, hollow sounds, medium-loud amp, moderate duration

A

Resonant

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11
Q

Percussion sounds

Low pitched, hollow sound, medium-loud amp, longer duration

A

Hyporresonant

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12
Q

Percussion sounds

High pitch, drumlike, loud amp, longest duration

A

tympany

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13
Q

Percussion sounds

High pitch, muffled thud, soft amp, short duration

A

Dull

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14
Q

Percussion sounds

High pitch, absolute dullness, very soft amp, very short duration

A

Flat (extremely dull )

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15
Q

Stethoscope side best for high pitched sounds

A

Diaphragm

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16
Q

Stethoscope side best for hearing breath, bowel, and normal heart sounds

A

Diaphragm

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17
Q

Stethoscope side best for hearing soft pitched sounds

A

Bell

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18
Q

Stethoscope side best for hearing extra heart sounds or murmurs

A

Bell

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19
Q

Most accurate temperature route

A

Rectal

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20
Q

Normal heart rate

A

60-99

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21
Q

Heart rate under 59 beats/min

A

Bradycardia

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22
Q

Heart rate above 100 beats/min

A

Tachycardia

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23
Q

3 reasons for heartrate to go up

A

-Stress
- Exercise
- sodium

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24
Q

When does blood pressure rise?

A

Late Afternoon

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25
Q

When does blood pressure decline

A

Early morning

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26
Q

How long should you count vitals if abnormal

A

Full 60 seconds

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27
Q

Emotional and cognitive function

A

Mental status

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28
Q

State of well being in which every individual realizes his or her own potential, can cope with normal stress of life, can work productively and able to make contributions to the community

A

Mental health

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29
Q

A patients response is much greater than the expected reaction to a traumatic event

A

Mental disorder

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30
Q

4 ways to assess mental status

A
  • Appearance
  • behavior
  • cognitive function
  • thought process
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31
Q

5 levels of consciousness

A
  • Alert
  • lethargic
  • obtunded
  • stupor/semi coma
  • coma
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32
Q

3 types of aphasia

A
  • broaca’s aphasia
  • wernicke aphasia
  • global
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33
Q

Type of expressive aphasia where

The person knows what he or she wants to say, but cannot produce the correct word Ir statement

A

Broacas aphasia

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34
Q

Type of receptive aphasia where

Severe comprehensive difficulty (word salad)

A

Wernike

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35
Q

Type of wide spread aphasia where

Reduced or absent comprehension

A

Global aphasia

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36
Q

Acute confusional state that is preventable

A

Delirium

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37
Q

Chronic progressive loss of cognitive and intellectual functions

A

Dementia

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38
Q

Long-term depressed mood of at least 2 weeks

A

Depression

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39
Q

Ranges for BMI ( 5 )

A
  • Underweight
  • normal weight
  • Overweight
    -obesity
  • extreme obesity
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40
Q

Range for underweight BMI

A

Anything Under 18. 5

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41
Q

Range for normal BMI

A

18.5 - 24.9

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42
Q

Range for overweight BMI

A

25 - 29.9

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43
Q

Range for obese BMI

A

30-39.9

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44
Q

Range fur extreme obesity BMI

A

40 and up

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45
Q

Lack of proper nutrition

A

Malnutrition

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46
Q

Occurs when nutritional reserves are depleted and/or when nutrient intake 1s inadequate to meet day-to- day needs or added metabolic demands

A

Undernutrition

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47
Q

5 risks for undernutrition

A
  • Impaired growth and development
  • lowered resistance to a disease and infection
  • delayed wound healing
  • longer hospital stays
  • higher healthcare costs
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48
Q

What are these biomarkers for?:

  • waist circumference
  • blood pressure
    -Triglycerides
  • glucose
  • high density lipoproteins
A

Metabolic syndrome

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49
Q

What vitamin deficiency:

Causes dry, flakey skin, foamy plaques on eyes, eye dryness

A

Vitamin A

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50
Q

What vitamin deficiency causes:

  • petechia/ ecchymosis, bleeding, jointpain
A

Vitamin C

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51
Q

What vitamin deficiency causes:

Dry, flaking skin ) glottis (red, swollen tongue ) blepharitis of eyes

A

Vitamin B complex

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52
Q

Nails angled down > 180 degrees

A

Clubbed nails

53
Q

What conditions is clubbed nails prevalent

A
  • congestive heart disease
  • lung cancer
  • pulmonary diseases
54
Q

Now many stages of pressure ulcers are there

A

4

55
Q

At what stage is a pressure ulcer:

Non blanchable erythema

Appears red

A

Stage 1

56
Q

At what stage is a pressure ulcer:

Full thickness skin loss
Full thickness pressure ulcer extending into the subcutaneous tissue and resembling a crater

A

Stage 3

57
Q

At what stage is a pressure ulcer:

Partial thickness skin loss
Partial thickness skin erosion

A

Stage 2

58
Q

At what stage is a pressure ulcer:

Full thickness/tissue loss
Full-thickness pressure ulcer extending into the supportive tissue, muscle, tendon, bone

A

Stage 4

59
Q

Levels of edema gradient (4)

A
  • Trace
  • mild
    -Moderate
  • severe
60
Q

What level Edema gradient is:

Slight indentation

A

Level 1

61
Q

What level Edema gradient is:

4 mm indent, rebounds after a few seconds

A

Level 2

62
Q

What level Edema gradient is:

Deep pitting (6mm), 30 seconds rebound

A

Level 3

63
Q

What level Edema gradient is:

Very deep, 8mm, more than 30 seconds

A

Level 4

64
Q

What is the ABCDE skin assessment used for?

A

suspicious lesions

65
Q

What does the A stand for in the skin assessment

A

Asymmetry

66
Q

What does the B stand for in the skin assessment

A

Border irregularity

67
Q

What does the C stand for in the skin assessment

A

Color

68
Q

What does the D stand for in the skin assessment

A

Diameter

69
Q

What does the E stand for in the skin assessment

A

Elevation and enlargement

70
Q

What does the F stand for in the skin assessment

A

Funny looking

71
Q

Freckles on the dorsal of the hands

A

Senile Lentignes

72
Q

Confluent lesion

A

Running together

73
Q

Gyrate shaped lesion

A

Ring shaped

74
Q

Target shaped lesion

A

Centered

75
Q

Multiple circles (lesions)

A

Polycyclic

76
Q

Vesicle seen in chicken pox

A

Zosterform

77
Q

Herpes zoster known as

A

Shingles

78
Q

A small hole made by a sharp object

A

Puncture

79
Q

4 wound types

A
  • Abrasion
  • laceration
  • puncture
  • avulsion
80
Q

Scrape of the skin due to something abrasive

A

Abrasion

81
Q

A deep cut or tearing of your skin caused by items like knives, tools, machinery

A

Laceration

82
Q

A wound that occurs when tissue is separated from the body

A

Avulsion

83
Q

5 ways to prevent skin breakdown

A

-Nutrition
- repositioning
- Increased mobility/activity
- clean skin
- self assessment

84
Q

Ecchymosis

A

Bruising

85
Q

unstagable pressure ulcer

A

Base of ulcer covered by slough and /or eschar in wound bed

86
Q

What increases skin breakdown? ( 5)

A
  • Poor nutrition
  • pressure
  • moisture (maceration)
    -Immobility
  • age
87
Q

Viral infection affecting peripheral nerves

A

Herpes zoster (shingles)

88
Q

Risk factors for pressure ulcers (4)

A

-Impaired mobility
- Decreased feeling
-Infection
- poor nutrition

89
Q

An unhealthy paleness of the skin

A

Pallor

90
Q

Redness of the skin due to capillary dilation

Fever, infection, inflammation

A

Erythema

91
Q

Which abnormal skin color should a nurse anticipate assessing on a dark skinned patient

A

Ashen gray

92
Q

Lesion that is distinct, individual lesion that remains separate (skin tag)

A

Discrete lesion

93
Q

Lesion: A scratch, streak, time, or stripe.

A

Linear lesion

94
Q

Linear arrangement along a unilateral nerve route

A

Zosteriform lesion

95
Q

Annular lesions that grow together

A

Polycyclic lesion

96
Q

Flat, colored spot on the skin (ex. Freckle)

A

Macula

97
Q

Raised red skin lesson due to interstitial fluid (mosquito bite, allergic reaction)

A

Wheal

98
Q

Solid, elevated mass, less than 1 cm diameter ( mole, wart)

A

Papule

99
Q

Large mass with serous fluid

A

Vesicle /bulla

100
Q

Lesion less than 0.5cm (varicella, herpes simplex,)

A

Vesicle

101
Q

Lesson greater than 0.5 cm ( poison lay, blisters )

A

Bulla

102
Q

Discoloration due to increasing capillary fragility in old people

A

Senile pupura

103
Q

What causes gray hair

A

Functioning melanocytes decrease

104
Q

Why does skin fold and sag in older adults

A

Loss of elasticity

105
Q

Why is wound healing slower in older people

A

Cell replacement is slower

106
Q

Where is generalized pallor found ?

A

Mucous membranes,lips, nail beds

107
Q

Ease of skin to rise

A

Mobility

108
Q

Ability of skin to return to place when released

A

Turgor

109
Q

Freckles, liver spots, hyperpigmentation

Seen on forearms and dorsa of hands

A

Senile lentigines

110
Q

Abnormal dryness of skin

A

xerosis

111
Q

Skin lesion more than 1 cm

A

macule

112
Q

Flat Skin lesion more than 1 cm

A

Patch

113
Q

Secondary skin lesions (2 types)

A

-Debris on skin surface
- break in continuity of skin surface

114
Q

2 types of debris on skin surface

A
  • Crusts
  • scales
115
Q

What causes a false low bp (2)

A

-Cuff too large
- arm above heart

116
Q

What causes a false high bp? (4)

A

-Anxiety
- Cuff too small
- cuff too loose
- arm not supported

117
Q

Where to do the skin turgor test

A

Inferior to the clavicle

118
Q

Pinpoint purple or red spots from small hemorrhages under the skin

A

Petechiae

119
Q

Steps of checking skin turgor

A
  1. Pinch a large fold of skin between your thumb and forefinger
  2. Note the ease with which you were able to move the clients skin
  3. Open the pinch and release skin
  4. Note now quickly the skin returns feat to position on chest
120
Q

What lesion is this

A

Annual (circular)

121
Q

What lesion is this

A

Confluent

122
Q

What lesion of this

A

Discrete

123
Q

What lesion of this

A

Gyrate

124
Q

What lesion is this

A

Grouped

125
Q

What lesion is this

A

Linear

126
Q

What lesion is this

A

Target

127
Q

What lesion is this

A

Zosteriform

128
Q

What lesion is this

A

Polycyclic

Physical Assessment (2 decks)

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