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Health Assesment-RN > Test 2 > Flashcards

Test 2 Flashcards

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1
Q

Test for visual acuity and sharpness of vision 20/20 means you can see 20 feet away covering one eye.

A

Snellen Test

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2
Q

Test where one hits the tuning fork and place it on the mastoid process. when the patient can no longer hear vibrations then move it in front of the ear

A

Hearing-rinne test

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3
Q

What is a bruit and how do you assess for it ??

A

It is a blowing or swishing SOUND during systole- heard over the carotid area while auscultating.

It indicates blow flow turbulence.

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4
Q

What is PERRLA and what does it stand for ??

A

Pupils, equal, round, reactive to light, and accommodation.

It’s what you check the eyes for

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5
Q

How to auscultate over a bruit?

A

Lightly apply BELL of stethoscope to auscultate over carotid artery at 3 levels.

  1. Angle of jaw
  2. mid-cervical area
  3. Base of neck
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6
Q

How to auscultate lungs ?

A

Have patient breath normal with mouth open

Auscultate lungs bilaterally, alternate and compare sides.

Use the diaphragm of the stethoscope, first listen with a quiet respiration, deep breaths

Note the intensity, quality, and pitch of breaths

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7
Q

How to auscultate abdomen?

A

Inspect abdomen

Auscultate from Lower Right Quadrant clockwise to upper right, upper left, lower left.

Palpate sites/any pain?

Ask when was your last BM?

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8
Q

how to do Assessment of moles?

A

Assess ABCDE

Asymmetry, border, color, diameter, envolving or changing appearance

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9
Q

skin lesion type- Confluence, brought on by patient or environmental factors external causes such as scratch, trauma, infections, wound healing, crust, scale, scar, excoriation, ulcer

A

Secondary skin lesion

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10
Q

Pustules, macule, papule, nodule, tumor, plaque, vesicle, bullae,

(elevated superficial lesion greater than 1cm in diameter, formed by a confluence of papules or developed from previously “normal” skin)

A

Primary skin lesion

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11
Q

Lymph nodes and sites

A

Cervical neck <1cm

Axillary armpits

Supraclavicular collar bone

Mediastinal upper body behind sternum/between lung sac

Mesentery-Lower body/abdomen

Inguinal- groin

Femoral- inner/upper thigh

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12
Q

What is normal finding when palpating lymph nodes ?

A

Non tender, non-palpable , soft ,smooth, moveable , bean shaped in subq tissue

1 cm in size , 0.5-2.0 depending on location

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13
Q

Normal breath sounds in :

anterior if lungs ?

Posterior of lungs?

A

Anterior: bronchial- high pitched

Posterior: bronchovesicular and vesicular - low pitched lungs

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14
Q

Lung sounds and what they might mean?

  • continuous low pitched sounds (like wheezes/whistling) with gurgling, snoring
    Sounds like snoring in a stronger an expiration
    Heard in the chest wall where bronco occurs. Air is blocked or flow is rough
A

Rhonchi-

Could mean asthma, chronic obstructive pulmonary disease, foreign body

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15
Q

Lung sounds and what they might mean?

High/fine or low/course popping , clicking, bubbling, when air opens closed air spaces (opening of small airways),

A

Crackles

Could mean inflammation, infection of small bronchi, bronchioles, and alveoli.

May indicate pulmonary edema or fluid in the alveoli due to heart failure, pneumonia, pulmonary Edema, TB, or bronchitis

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16
Q

Lung sounds and what they might mean?

High pitched whistles

A

Wheezing

Airways are narrowing or keeping air from flowing through

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17
Q

Lung sounds and what they might mean?

High pitched, wheeze like sounds heard when breathing due to blockage of airflow in windpipe , trachea , or back of throat

A

Stridor

May indicate croup

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18
Q

Lung sounds and what they might mean?

Low pitched, non musical , many repeated sounds

A

Rub

May indicate inflammation of lungs and lung tremors

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19
Q

Lung sounds and what they might mean?

Short breaths,

can be due to Partial loss all of ventilation tissue, hyper inflated lung tissue, abnormality that reduces transmission, absence of functioning structures

A

Diminished lung sounds

20
Q

Results from valve damage or _________distention

If valve leak occurs, veins become incompetent and blood falls back under gravity as calf muscles relax, increasing _______pressure

A

Venous

Venous

Venous insufficiency

21
Q

Pallor with legs elevated , dusky redness of toes , feet, and calves, dry shiny skin, pulses, delayed cap refill, cool to cold skin, loss of hair over toes, dorsum (top of foot) , thickened nails, pain, intermittent (stoping for some time and then going) claudication (impairment in walking) to sharp, unrelenting(hard), constant.

A

Arterial insufficiency

22
Q

Bdvvc

A

Limb assessment

23
Q

Different stages of edema ?

How long it lasts? mm?? Severity of pitting?
0+
1+
2+
3+
4+
A

0 + none
1+mild pitting 2mm and disappears rapidly
2+ moderate 4mm, 10-15 second pitting
3+ moderately severe, 6mm and lasts more than 1 min
4+ severe pitting edema, 8mm and lasts more than 2 minutes

24
Q

What causes heart sounds?

A

Opening and closing of the valves to blood flow throughout the heart

25
Q

How to heart a patients heart better?

A

Have patient sit up , lean forward, roll to left side , breath out and hold it but not too long

Bell on skin, turn down TV, close door , reduce distractions

26
Q

Heart sound LUB-

Mitral and tricuspid valve closure

A

S1- first heart sound

27
Q

Heart sound DUB

Aortic and pulmonary valve closing

A

S2 - 2nd heart sound

28
Q

Heart sloshing sound at beginning of diastolic after S2. LUB-dub-ta

Indicate?

A

S3

May indicate heart failure or volume overload

29
Q

Pre-systolic gallop or before S1. Occurs after atrial contraction at the end of diastole and right before S1.

A

S4

30
Q

Types of murmurs (whooshing sounds in heart) :

Mitral valve abnormality and aortic valve

A

Regurgitation

31
Q

Types of murmurs (whooshing sounds in heart) :

Aortic valve and mitral valve

A

Stenosis

32
Q

Types of murmurs (whooshing sounds in heart) :

Short high pitches sounds

A

Clicks

33
Q

Types of murmurs (whooshing sounds in heart) :

Inflammation of pericardium, high pitches scratching , creaking sounds from rubbing of inflamed layers

A

Rubs

34
Q

Phases of cardiac cycle (systole and diastole)

A

Atrial systole

Early ventricular systole

Ventricular systole

Early ventricular diastole

Late ventricular diastole

35
Q

The contraction phase of heart where chambers of the heart contract and pump the blood out of the chambers

A

Systole

36
Q

The relaxation phase of heart where the chambers relax. During this phase the chambers are filled with blood.

A

Diastole

37
Q

Area of the heart location:

2nd Rt. intercostal

A

Aortic

38
Q

Area of the heart location:

2nd Lt intercostal space

A

Pulmonic valve

39
Q

Area of the heart location:

3rd Lt intercostal

A

Erbs point

40
Q

Area of the heart location:

4th Lt intercostal

A

Tricuspid valve area

41
Q

Area of the heart location:

5th ICS mid-left clavicular line (further left)

A

Mitral valve area

42
Q

True or false:

Adolescences can have swollen lymph nodes just from growing

A

True

43
Q

What qualities to assess with pulse ?

A

Rate
Rhythm
Elasticity (of vessel wall)
Force (equal on each side)

44
Q

Location of pulses ?

A 
Apical 
Brachial 
Radial 
Carotid 
Dorsalis pedis (above big toe)
Popoliteal- begins knee 
Posterior tibialis-side of back heel/ankle 
Femoral-groin
45
Q

Thoracic deformity where back is protruding, ribs are horizontal instead of downward- due to normal aging. ?

can result in what?

A

Barrel chest

Emphysema and asthma

46
Q

Thoracic deformity where one has sunken chest which is genetic at birth

A

Pectus excavatum

47
Q

Thoracic deformity where one has protruding chest

A

Pectus carinatum

Health Assesment-RN (7 decks)

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