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NURS 1300 > Unit 1: Ch. 30 > Flashcards

Unit 1: Ch. 30 Flashcards

1
Q

what are the two aspects of assessing a client’s health status

A
  1. ) the nursing health history

2. ) the physical examination

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2
Q

what steps should a nurse take to ease anxiety before an examination?

A
  1. explain when & where the examination will take place
  2. explain why the procedure is important
  3. explain what will happen during the examination
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3
Q

what are the four primary techniques used in a physical examination

A

inspection, palpation, percussion, and auscultation

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4
Q

what characteristics are determined by use of palpation

A
  1. texture
  2. temperature
  3. vibration
  4. position, size, consistency, & mobility of organs or masses
  5. distension
  6. pulsation
  7. tenderness or pain
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5
Q

Back-lying position with legs extended; with or without pillow under the head. Asseses head, neck,axillae, anterior thorax, lungs, breasts, heart, vital signs, abdomen, extremities, peripheral pulses.

A

supine (horizontal recumbent)

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6
Q

A _____ position, back unsupported and legs hanging freely. Asseses head, neck, axillae, posterior and anterior thorax, lungs, breasts, heart, vital signs, upper and lower extremities, and reflexes.

A

sitting

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7
Q

Side-lying position with lowermost arm behind the body. Uppermost leg flexed at hip an knee, upper arm flexed at shoulder and elbow. Assesses the rectum, and vagina

A

Sims’

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8
Q

A position where the client lies on abdomen with head turned to the side, with or without a small pillow. Assesses the posterior thorax, hip joint movement.

A

Prone

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9
Q

Back-lying position with knees flexed and hips externally rotated; small pillow under the head; soles of feet on the surface. Assesses female genitals, rectum, and female reproductive system.

A

Dorsal recumbent

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10
Q

Back-lying position with feet supported in stirrups; the hips should be in line with the edge of the table. Assesses female genitals, rectum, and female reproductive tract

A

Lithotomy

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11
Q

a percussion assessment can elicit what five possible types of sound

A

flatness, dullness, resonance, hyperresonance, and tympany

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12
Q

how are percussion and auscultated sounds described

A

according to pitch, intensity, duration, and quality

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13
Q

the result of inadequate circulating blood or hemoglobin and subsequent reduction in tissue oxygenation and presents as pale skin tone

A

Pallor

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14
Q

a bluish tinge, due to low oxygen supply

A

Cyanosis

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15
Q

a yellowish tinge, due to kidney failure

A

Jaundice

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16
Q

skin redness associated with rashes & other conditions

A

erythema

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17
Q

presence excess of interstitial fluid

A

edema

18
Q

an alteration in the normal appearance of skin

A

skin lesion

19
Q

mild pitting edema, 2mm depression that disappears rapidly

A

+1

20
Q

moderate pitting edema, 4mm depression that disappears after 10-15 secs

A

+2

21
Q

moderately severe pitting edema, 6mm depression that may last more than 1 minute

A

+3

22
Q

severe pitting edema, 8mm depression that can last more than 2 minutes

A

+4

23
Q

when the angle of the nail and nail bed is 180º or greater

A

clubbing

24
Q

clubbing may be caused by what condition

A

long term lack of oxygen

25
Q

what is the blanch test used for

A

to test capillary refill or peripheral circulation

26
Q

an extremely dull sound produced by very dense tissue

A

flatness

27
Q

thud like sound produced by dense tissue, like in liver, spleen, heart

A

dullness

28
Q

hollow sound produced by air filled lungs

A

resonance

29
Q

an abnormal booming sound produced during percussion of the lungs

A

hyperresonance

30
Q

musical/drumlike sound produced from an air filled stomach

A

tympany

31
Q

patches of hypopigmented skin as a result of destruction of melanocytes

A

Vitiligo

32
Q

the degree of detail the eye can discern in an image

A

visual acuity

33
Q

the area an individual can see when looking straight ahead

A

visual fields

34
Q

myopia

A

nearsightedness

35
Q

hyperopia

A

farsightedness

36
Q

loss of elasticity of the lens and thus loss of ability to see close objects

A

presbyopia

37
Q

uneven curvature of the cornea that prevents horizontal and vertical rays from focusing on the retina

A

astigmatism

38
Q

inflammation of the bulbul and palpebral conjunctiva

A

conjunctivitis

39
Q

opacity of the lens which block light rays

A

cataracts

40
Q

disturbance in the circulation of aqueous fluids which cause an increase in intraocular pressure

A

glaucoma

NURS 1300 (11 decks)

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