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health assessment > Quiz #3 ( CH.12, 15, & 16 ) > Flashcards

Quiz #3 ( CH.12, 15, & 16 ) Flashcards

1
Q

lifespan considerations in older adults

A
  • bony structures are more pronounced
    ➡️ D/T decreased subcuutaneous fat
  • skin lesions more likely
    ➡️ careful assessments for skin cancers, especially in commonly sun-exposed areas
  • hypothyroidism/hyperthyroidism is more common
    ➡️ hypothyroidism > hyperthyroidism
  • cultural considerations
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2
Q

urgent assessment

A
  • acute head injuries & neurological changes
    ➡️ stabilization of head, neck; trauma essentials
  • neck pain: usually muscle tension, spasm
    ➡️ beware: fever & headache, possibly cardiac
  • lymphatics
    ➡️ more than 1cm, fixed, irregular, hard or rubbery
    ➡️ requires emergency investigation for cancer
  • hyperthyroidism: “ thyroid storm “, “ thyroid crisis “
    ➡️ hypermetabolism in all systems
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3
Q

common head & neck symptoms

A
  • headache, neck pain
  • limited neck movement
  • vision & hearing
  • facial pain
  • lumps/masses
  • hypo/hyperthyroidism
  • sleepiness
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4
Q

thyroid gland

A
  • normally smooth, rubbery, & moveable
  • common to be nonpalpable
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5
Q

abnormal findings

A
  • facial asymmetry
  • unusual distribution of hair patterns
  • nits attached to hair shaft
  • thyroid asymmetry, enlargement, or masses
  • degenerative joint disease ( DJD )
  • temporal arteritis
  • bulging or depression of scalp
  • unilateral bulging may indicate thyroid goiter, cyst, or tumor
  • neck masses
  • tenderness
  • pain or muscle spasms
  • weakness or loss of sensation
  • bruits
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6
Q

nursing diagnoses outcomes & interventions

A
  • activity intolerance
  • fatigue
  • chronic pain
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7
Q

subjective data collection

A
  • multiple systems may influence structure, function
  • assessment of risk factors
    ➡️ personal history
    ➡️ medications
    ➡️ family history
  • risk reduction & health promotion
    ➡️ reducing injury risk
    ➡️ preventing thyroid disorder complications
    ➡️ early detection of masses or malignant lymph nodes
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8
Q

lifespan, cultural, environmental considerations on the nose, sinus, mouth & throat

A

in older adults:
- gustatory rhinitis: runny nose caused by smelling/tasting food
- decreased: olfactory sensory fibers; saliva production; number of taste buds
- loosening/loss of teeth
in cultural aspects:
- oral health: oral disease in children & adults is higher among poor & disadvantaged population groups
- risk factors for oral diseases: an unhealthy diet, tobacco use, harmful alcohol use, poor oral hygiene, & other social determinants
- congenital defects: cleft lip & palate
- head & neck cancers
- sleep-disordered breathing

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9
Q

urgent assessment

A
  • severe nosebleeds
  • ludwig angina: skin infection that is below the tongue which causes rapid edema & may cause a potential airway obstruction ( mostly in the nose, mouth, & throat )
  • aspiration
  • abrupt loss of smell ( possible brain tumor )
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10
Q

subjective data

A

assessment of risk factors:
- personal history/past medical history
- medications, supplements, substance use
- family history
- lifestyle & personal habits
- dental health
- environmental exposure

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11
Q

risk reduction & health promotion

A

healthy people 2030
➡️ risk factors:
- tobacco use
- sleep disorders
- cancer
- oral health
➡️ hereditary hemorrhagic telangiectasia: chronic nose bleeds

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12
Q

common symptoms in nose, sinus, mouth, & throat

A
  • headache
  • facial pressure, pain
  • obstructive breathing: snoring, sleep apnea
  • nasal congestion; epistaxis ( nose bleeds )
  • dysphagia ( swallowing difficulties ); dental pain
  • voice changes, oral lesions
  • cough; pharyngitis ( inflammation of the pharynx )
  • halitosis ( bacteria that normally lives in the throat & on the surface on the tongue ); anosmia ( loss of smell )
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13
Q

objective data collection

A
  • common specialty or advanced techniques
    ➡️ inspection; equipment
  • comprehensive physical assessment
    ➡️ external nose: inspection; palpation
    ➡️ internal nose: inspection
    ➡️ sinuses: inspection; palpation; percussion
    ➡️ mouth: external, internal inspection; palpation
    ➡️ throat: inspection, palpation ( see tonsillar grading scale )
    ➡️ swallowing evaluation
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14
Q

abnormal findings

A
  • asymmetry
  • swelling
  • bruising
  • deviation of nasal septum
  • redness
  • mucosal inflammation
  • polyps
  • anosmia
  • leukoplakia
  • pretechiae
  • tenderness
  • oral candidiasis
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15
Q

nursing diagnoses outcomes & interventions

A
  • impaired definition
  • impaired oral mucous membrane integrity
  • impaired swallowing
  • ineffective breathing
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16
Q

upper respiratory portions

A

warms, moisturizes, transports air to lower

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17
Q

lower respiratory occurs

A

oxygenation, ventilation occurs

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18
Q

how many lobes does the left lung have?

A

two lobes ( due to the location of where the heart is )

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19
Q

how many lobes does the right lung have?

A

three lobes

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20
Q

lifespan considerations

A
  • older adults:
    ➡️ respiratory strength declines
    ➡️ lungs lose elasticity
    ➡️ decreased flexibility
    ➡️ bone density decreases
    ➡️ disease prevalence
  • pregnancy
  • newborns & infants
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21
Q

urgent assessment

A

shortness of breath & lack of adequate ventilation is EMERGENCY
- immediately assess patient & initiate interventions as needed BEFORE continuing data collection
➡️ vital signs ( respiratory rate & effort ) spO2
➡️ lung ascultation
- interventions
➡️ alert rapid response team
➡️ oxygen
➡️ elevate head of the bed
➡️ assess patient anxiety level
➡️ encourage relaxation techniques
➡️ assess for fatigue limits

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22
Q

risk reduction & health promotion

A
  • smoking cessation
  • prevention of occupational exposure
  • prevention of asthma
  • immunizations
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23
Q

common symptoms of the thorax & lung

A
  • chest pain
  • dyspnea ( difficulty breathing )
  • orthopnea ( difficulty breathing, when standing, sitting, etc. )
  • cough; sputum ( fluid in the chest )
  • wheezing
  • functional abilities
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24
Q

adventitious breath sounds

A

crackles, wheezes, rhonchi, pleural friction rub, stridor

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25
Q

nursing diagnosis

A
  • impaired gas exchange
  • ineffective airway clearance
  • ineffective breathing pattern
  • activity intolerance
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26
Q

accessory muscles

A

use of neck & chest muscles to exert more oxygen

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27
Q

apex

A

the top of the lung fields

28
Q

asymmertrical movements

A

abnormal and/or decreased ventilation in one side

29
Q

atelectasis

A

collapse of part or whole of the lung

30
Q

barrel chest

A

deformity in which the chest becomes expanded in size

31
Q

base

A

the bottom of the lung fields

32
Q

bradypnea

A

slow breathing

33
Q

clubbing

A

abnormal nail findings

34
Q

crackles

A

small airways snapping open on inspiration

35
Q

cyanosis

A

bluish discoloration of the skin

36
Q

dyspnea

A

difficulty breathing

37
Q

nasal flaring

A

nostrils flaring wide when breathing

38
Q

orthopnea

A

difficulty breathing in supine position

39
Q

pursed lips

A

technique used to help people living with COPD or asthma when experiencing shortness of breath

40
Q

retractions

A

area between ribs & the neck sinking in when attempting to inhale

41
Q

rhonchi

A

continous, low breathing pitched sounds

42
Q

stridor

A

noisy breathing that occurs due to obstructed airflow through a narrowed airway

43
Q

tachypnea

A

rapid breathing

44
Q

wheezes

A

breathing problems

45
Q

dyspnea on exertion

A

sensation of running out of air of not being able to breath fast enough or deeply enough when doing physical activity

46
Q

nocturia

A

peeing more often during the night

47
Q

REVIEW QUESTION #1: which of the following is part of the upper GI tract?

A

throat

48
Q

REVIEW QUESTION #2: the nurse is assessing the nares to evaluate the site of epistaxis. the most common site of bleeding is which of the following?

A

kiesselbach plexus

49
Q

REVIEW QUESTION #3: the nurse knows that the floor of the mouth is highly vascular & therefore a good location for which of the following?

A

absorption of sublingual medications

50
Q

REVIEW QUESTION #4: acute airway obstruction is a situation that should be?

A

quickly assessed & treated

51
Q

REVIEW QUESTION #5: risk factors for nose, sinus, mouth, & throat problems include?

A

topical decongestant use, smoking, allergies

52
Q

REVIEW QUESTION #6: the nurse has assessed the nose & documents expected findings as?

A

nose symmetrical & midline

53
Q

REVIEW QUESTION #7: the nurse is assessing a patient who has been taking antibiotics for 10 days. oral assessment is important because of the increased risk for which of the following?

A

candida albicans

54
Q

REVIEW QUESTION #8: an adolescent male presents with complaints of nosebleeds. the nurse would further assess for?

A

nasal trauma

55
Q

REVIEW QUESTION #9: the nurse assesses the child with purulent, unilateral nasal change. the nurse knows that most likely causative factor is?

A

foreign body in nose

56
Q

REVIEW QUESTION #10: during routine physical examination of a 20 year old female, the nurse notes a septal perforation. this finding may be significant foe which of the following causes?

A

illicit drug use

57
Q

REVIEW QUESTION #1: when the nurse assesses a 78 year old patient with pneumonia. what is the priority assessment?

A

airway patency

58
Q

REVIEW QUESTION #2: a 45 year old male has been admitted to the hospital with suspicion of PE. which of the following symptoms should be the nurse report to the primary health practitioner immediately?

A

chest pain

59
Q

REVIEW QUESTION #3: a 62 year old female comes to the clinic with an exacerbation of asthma. which of the following findings indicate a diagnosis of asthma? select all that apply

A

increased wheezing & oxygen saturation 90%

60
Q

REVIEW QUESTION #4: a 3 year old child is brought to the ED with stridor, nasal flaring, intercostal & supraclavicular retractions, & respiratory rate of 40 breaths/min. what type of situation is this?

A

emergency

61
Q

REVIEW QUESTION #5: a 92 year old female with a history of COPD presents with increasing shortness of breath, wheezing, no sputum, & 5 lb weight gain in 1 week. what is the most likely problem?

A

impaired breathing

62
Q

REVIEW QUESTION #6: which of the following factors is the most significant risk factor of COPD?

A

tobacco smoking

63
Q

REVIEW QUESTION #7: when the nurse assesses a client with respiratory symptoms, which of the following complaints should be evaluated first?

A

dyspnea

64
Q

REVIEW QUESTION #8: when assessing a patient with atelectasis, what assessment findings are expected? select all that apply

A

shortness of breath, decreased breath sounds, decreased oxygen saturation, increased tactile fremitus

65
Q

REVIEW QUESTION #9: which assessment findings would indicate that inhaled bronchodilators have been effective?

A

vesicular breath sounds, O2 saturation 96%, pink

66
Q

REVIEW QUESTION #10: the nurse auscultates bronchovesicular breath sounds in the second ICS near the sternum. the nurse interprets this as?

A

a normal finding over the bronchi

health assessment (4 decks)

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