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Flashcards in 168.123 General questions Deck (137):
1

What is a nursing assessment?

"a process of systematically collecting and analysing data to make judgements about the health and life processes of individuals, families and communities"

2

What are the 4 types of health assessment?

Comprehensive
Focused/problem orientated
Follow up/on going/episodic or partial
Emergency

3

What is the focus of nursing?

Human response to actual and potential health problems

4

What are the nurses responsibilities when abnormalities are detected?

Assess (collect data)
Diagnose (interpret, validate, compare clusters, identify related factors and document)
Outcome identification (realistic, individualised and timeframed)
Implement (review, collaborate, counselling, document)
Evaluate (summarise, identify success/failure, correct where can)

5

What are 5 perceived barriers to health assessment skills?

Lack of:
Resources
Equipment
Time
Patient acceptance
AND
Poor equipment

6

What are the key skills when attaining a health history - hint have to do with communication.

Facilitation - active listening
Silence - patience
Reflection
Empathy - be accepting
Clarification - don't assume-clarify and confirm

7

What are some traps nurses fall into with patients when discussing health histories?

False assurance
Unwanted advice
Using authority
Using professional jargon
Interrupting

8

What four things are the focus of the Complete Health History?

Biographical data (name, DOB, gender etc)
Source of history ( reliable source)
Reason for seeking care (annual exam, acute)
Present and past health history (overall health)

9

What does the acronym COLDSPA mean?

Character
Onset
Location
Duration
Severity
Pattern
Associated factors/how it affects the client

10

What systems are reviewed in a complete health history?

General appearance
Skin
HEENT (Head, Eyes, Ears, Nose, Throat)
Respiratory
Cardiovascular
Gastro Intestinal
Genital urinary
Sexual
Neurological
Musculoskeletal
Gynaecological
Endocrine
Haematological
Lymphatic
Mental

11

What are the five Vital signs?

Temperature
Blood Pressure
Heart Rate
Respiratory rate
Pain

12

Why do we monitor vital signs?

To see if there is any change in a physical condition

13

When would we monitor vital signs?

Pre and/or Post and or During;
Operations
Transfusions
Medications
Patient reports of nonspecific complaints
Frequency

14

What is the normal body temperature range?

35.8-37.5 degrees Celsius

15

What can you expect from a rectal temperature

Can be 0.4 to 0.5 degrees higher

16

At what temperature do we call a patient with mild hypothermia?

< 35 degrees Celsius

17

What temperature is moderate hypothermia?

28 - 32.2 degrees Celsius

18

What temperature is a patient with severe hypothermia?

< 28 degrees celsius

19

What is an elevated temperature range?

37.5 - 38 degrees Celsius

20

AT what temperature does a patient have hyperpyrexia?

> 40 degrees Celsius

21

Where do you place an oral thermometer and for how long?

In the sublingual pocket for 2 minutes

22

How long is a rectal thermometer kept in place?

3 minutes

23

Where does a tympanic thermometer get placed?

In the ear

24

How long do you measure a pulse if it is a regular heart beat?

30 seconds and x 2

25

How long do you take a pulse if the heart beat is irregular?

1 full minutes

26

What are you assessing when you take a pulse - 4 things?

Rate
Rhythm
Force
Elasticity

27

What is the normal range for heart rates?

60 - 100 beats per minute

28

What is bradycardia heart rate?

< 60 beats per minutes

29

What is the tachycardia heart rate?

> 100 beats per minute

30

What are you assessing with the rhythm of pulse rates?

Regular or irregular

31

What are you assessing with the Force of pulse rates

3+ Bounding
2+ Normal
1+ Weak
0 Absent

32

What are some words you can use to describe the elasticity of the pulse?

Normal, springy, straight, resilient

33

Where is the Popliteal pulse located?

Behind the knee

34

Where is the Posterior tibial pulse located?

groove between the medial malleolus and the Achilles tendon

35

Where is the dorsalis pedis pulse located

Dorsal foot, near or lateral to the bony prominence of the navicular bone

36

Where would you located the apical pulse?

4-5 intercostal space, left midclavicular

37

Where would you locate the carotid pulse?

groove between the trachea and sternogleidomastoi muscle

38

Where is the brachial pulse located

Antecubital fossa (anterior elbow)

39

What is the normal rate of respiration for an adult?

12-20 breaths per minutes

40

What are the 4 things you ascertain with regards to respiration?

Rate
Rhythm (regular/irregular)
Quality (deep, effortless)
Ratio (pulse/resp approx. 4.1)

41

What influences the blood pressure?

Blood Volume
Blood Viscosity
Vascular Elasticity
Vascular Resistance
Cardiac output

42

What is the systolic value of blood pressure measuring?

The maximum pressure on the arterial walls during left ventricular contraction

43

What is the diastolic value of blood pressure measuring?

The resting pressure of blood in the vessels between contractions

44

What is the pulse pressure?

The difference between systolic and diastolic

45

What is the normal blood pressure?

120/80 mmHg

46

What is hypertensive?

140/90 mmHg

47

What is hypotensive?

95/60

48

What do you need to ensure about the cuff length and width to get an accurate blood pressure reading?

Width should be 40% of circumference of upper arm
Length (bladder) should be 80% circumference

49

Where do you NOT take blood pressures over - certain anatomical/medical conditions?

Fistulas
Vascular grafts
Affected side post mastectomy/lymphectomy
Vascular access eg IV

50

Is pain subjective or objective?

Subjective

51

What is the purpose of charting?

Communicate information:
Legal record
Information for health team
Record of services
Mandated
Effective patient care

52

What are the 8 principles of charting?

Factual
Signed & dated
Written ASAP
Objective
Done by person who did care
Completed before leaving work
Conforms to requirements
Confidential

53

What do you do if you make a mistake in documentation?

Draw a line through it

54

What are two forms of charting?

Focus charting
SOAPIE (R)

55

What is the principle of focus charting?

Describes patient perspective and focuses on patients current status

56

What are the 5 essential elements to focus charting?

Date & Time
Focus column
Progress notes - data or assessment
Progress notes - action or intervention
Preogress notes - response or evaluation

57

What does the acronym SOAPIE (R) stand for?

Subjective data
Objective data
Assessment findings
Plan of action
Intervention
Evaluation
Revision

58

How many layers to the skin and name them?

3
Epidermis, Dermis and Subcutaneous layer

59

What are you assessing for when you palpate skin?

Moisture/dryness
Temperature
Texture (rough/smooth)
Thickness
Oedema
Mobility and turgor
Vascularity
Lesions

60

What are the 4 point scales of oedema?

1+ Mild oedema/no visble swelling
2+ Moderate oedema/indentation subsides quickly
3+ Deep pitting oedema/ area looks swollen
4+ very deep pitting/lasts long time

61

What is the ABCDE assessment of pigmented lesions

Asymmetry (round/oval/diff shape)
Border (clear/poorly defined)
Colour (variations)
Diameter (>6mm)
Elevation/Enlargement (changes/itching/burning/bleed)

62

What do you describe when assessing recording information about hair?

Colour
Texture
Distribution
Lesions

63

What are you assessing when you examine nails?

Colour
Texture
Shape
Cap refill

64

Name the nine basic lesion patterns

Annular (circular)
Confluent (splotchy - like ink in water)
Discrete ( like pimple dots)
Grouped (lots of small ones in a group - like bacterium)
Gyrate (squiggles - like ebola)
Target (looks like a shooting target)
Linear (line)
Polycyclic ( groups of dots)
Zosteriform (groupings together like a raised rash)

65

What are you assessing when you inspect?

Colour
Patterns
Size
Location
Symmetry
Movement
Behaiour
Sounds
Odours

66

What side of the stethescope listens for low frequency sounds - bell or diaphragm?

Bell

67

What is the purpose of percussion - 4 things

Determine:
Painful areas
Location, size and shape
Density
Abnormal mass detection

68

What are the five sounds you will hear with percussion ?

Resonant (chest/lung)
Hyper resonant (indicates extra air) (abnormal)
Tympany (air filled viscus)
Dull (over dense/solid organs)
Flat (over bone)

69

What is the formula to calculate BMI?

BMI = weight(kg) / height (m's)

70

What is the waist to hip ratio for measuring for obesity?

WHR = waist circum/hip circum.

Ratio of 1 or greater in men OR 0.8 or greater in women = upper body obesity

71

What are you assessing in the mouth?

Oral/buccal mucosa
Hard palate
Lips
Gums
Gum margins
Teeth
Tongue

72

What is epistaxis?

Nose bleed

73

What do you inspect of the nose?

Nares
Nasal mucosa
Nasal septum

74

Name the three pairs of salivary glands?

Parotid
Submandibular
Sublingual

75

How do you palpate the sinuses for tenderness?

Frontal sinuses - press up from under the bony brows
Maxillary sinuses - press up on the front of the cheeks on the bone near the nose

76

What sinuses are not able to be palpated?

Ethmoid and sphenoid

77

What are you feeling for when you palpate the lymph glands

Size
Shape
Delimitation
Mobility
Tenderness

78

What is the average length of the adult ear canal?

2.5cm

79

What are the three levels of the auditory system?

Peripheral
Brain stem
Cerebral cortex

80

What are three forms of hearing loss?

Conductive
Sensorineural (perceptive)
Equilibrium

81

What can cause conductive hearing loss?

Impacted cerumen

82

What do you palpate on the ear for tenderness?

Pinna
Tragus (little bit at front near face)
Mastoid Process

83

When holding the otoscope and inspecting the ears what is an important thing to do for safety?

Make sure that your hand is resting on the face so that the otoscope wont damage ears if patient suddenly moves

84

What is the Weber test?

Putting tuning forks on top of head when 'twanged"

85

What is the Rinne test?

Air and bone conduction test with tuning forks

86

What is the Hirschberg test?

Corneal light reflex

87

What does PERRLA mean?

Pupils Equal Round and React to Light and Accommodation

88

What happens to the pupils if they focus on near vision?

They constrict

89

What are the four posterior thoracic landmarks?

Vertebra prominens
Spinous processes
Inferior border of the scapula
Twelfth rib

90

What is the line called in the lungs that separates the upper from lower lobes?

Oblique fissure

91

What is the symmetrical expansion test?

Using the hand/thumbs s to see if they expand/contract evenly with inhalation/exhalation

92

What do normal healthy lungs sound like?

Resonant

93

What are adventitious sounds?

Added sounds

94

Are vesicular sounds soft or loud?

Soft

95

What are the four landmarks of the anterior thoracic region for respiratory assessment?

Suprasternal notch
Sternum
Manubriosternal angle (angle of Louis)
Costal angle

96

Where is the costal angle located?

Below the xiphoid process of the sternum

97

What is the location of the precordium?

Between the 1st rib and 5th intercostal space (basically the space the heart fills)

98

What are murmurs?

Extra sounds often described as swooshing/blowing

99

What is the cause of murmurs?

Turbulent blood flow

100

What are the palpable arteries of the body?

Temporal
Carotid
Brachial
Radial
Ulnar
Femoral
Popliteal
Dorsalis pedis
Posterior tibial

101

What five factors make up the Neuro structure?

CNS
PNS
Motor pathways
Sensory pathways
Spinal reflexes

102

What are the 12 cranial nerves

Olfactory
Optic
Oculomotor
Trochlear
Trigeminal
Abducens
Facial
Vestibulocochlear
Glossopharyngeal
Vagus
Accessory
Hypoglossal

103

How many pairs of spinal nerves are there?

31

104

What are bursae?

pouches of synovial fluid that cushions movement of tendons and muscles over bone and other structures.

105

The Cerebral Cortex (gray matter) is the center for:

Human's highest functions, governing thought, memory, reasoning, sensation, and voluntary movement.

106


1) The Frontal lobe is the center for:

2) It contains the _____ gyrus which controls:

3) Also contains ___ area which controls:

1) Personality, behavior, emotions, and intellectual function.

2) Precentral gyrus, initiates voluntary movement.

3) Broca's area, which control motor speech. Damage to this = expressive aphasia.

107

The Parietal lobe contains the ____ gyrus which controls:

Postcentral gyrus, controls sensation

108

1. The Temporal lobe is the center for:

2. Contains _____ areas which controls:

1. Auditory reception.

2.Contains Wernicke's area which control language comprehension. Damage to this = receptive aphasia.

109

Paresis:

Partial or incomplete paralysis

110

Dysarthria:

Difficulty forming words

111

Positive Romberg sign:

loss of balance that occurs when closing the eyes.

112

Past-pointing:

Constant deviation to one side.

113

Hemiplegia:

Spastic or flaccid paralysis of one side (right or left) of body and extremities.

114

Paraplegia:

Symmetric paralysis of both lower extremities.

115

Quadriplegia:

Paralysis of all four extremities.

116

Graphesthesia:

The ability to "read" a number by having it traced on the skin.

117

Babinski reflex:

Stroke lateral aspect and across ball of foot.
Abnormal: Extension of great toe, fanning of toes. Indicates corticospinal (pyramidal) tract disease.

118

Kernig reflex:

In flat-lying supine position, raise leg straight or flex thigh on abdomen, then extend knee.
Abnormal: Resistance to straightening, pain down posterior thigh. Indicates meningeal irritation.

119

Brudzinski reflex:

With one hand under the neck and other hand on person's chest, sharply flex chin on chest, watch hips and knees.
Abnormal: Resistance and pain in neck, flexion of hips and knees. Indicates meningeal irritation.

120

Question 1
The two parts of the nervous system are the:
1. motor and sensory.
2. central and peripheral.
3. peripheral and autonomic.
4. hypothalamus and cerebral.

2. central and peripheral.

The nervous system can be divided into two parts central and peripheral. The central nervous system includes the brain and spinal cord. The peripheral nervous system includes the 12 pairs of cranial nerves, the 31 pairs of spinal nerves, and all their branches.

121

Question 3
The area of the nervous system that is responsible for mediating reflexes is the:
1. medulla.
2. cerebellum.
3. spinal cord.
4. cerebral cortex.

3. spinal cord.

The spinal cord is the main highway for ascending and descending fiber tracts that connect the brain to the spinal nerves, and it mediates reflexes.

122

Question 5
A 21-year-old patient has a head injury resulting from trauma and is unconscious. There are no other injuries. During the assessment what would the nurse expect to find when testing the patient s deep tendon reflexes?
1. Reflexes will be normal.
2. Reflexes will not be able to be elicited.
3. All reflexes would be diminished but present.
4. Some would be present depending on the area of injury.

1. Reflexes will be normal.

A reflex is a defense mechanism of the nervous system. It operates below the level of conscious control and permits a quick reaction to potentially painful or damaging situations.

123

Question 6
During the history, a patient tells the nurse that it feels like the room is spinning around me. The nurse would document this as:
1. vertigo.
2. syncope.
3. dizziness.
4. seizure activity.

1. vertigo.

True vertigo is rotational spinning caused by neurologic dysfunction or a problem in the vestibular apparatus or the vestibular nuclei in the brainstem.

124

Question 8
A 50-year-old woman is in the clinic for weakness in my left arm and leg for the past week. The nurse will perform which type of neurologic examination?
1. Glasgow Coma Scale
2. Neurologic recheck examination
3. Screening neurologic examination
4. Complete neurologic examination

4. Complete neurologic examination

Perform a complete neurologic examination on persons who have neurologic concerns (e.g., headache, weakness, loss of coordination) or who have shown signs of neurologic dysfunction.

125

Question 9
During an assessment of the cranial nerves, the nurse finds the following: lack of blink in right eye with corneal reflex; intact ability to sense light touch on face; loss of movement with facial features on right side. This would indicate dysfunction of which of the following cranial nerves?
1. Motor component of IV
2. Motor component of VII
3. Motor and sensory components of XI
4. Motor component of X and sensory component of VII

2. Motor component of VII

The findings listed reflect a dysfunction of the motor component of cranial nerve VII as well as the sensory afferent in cranial nerve V.

126

Question 10 The nurse is testing the function of cranial nerve XI. Which of the following best describes the response the nurse would expect if the nerve is intact?
1. Demonstrates full range of motion of the neck
2. Sticks tongue out midline without tremors or deviation
3. Follows an object with eyes without nystagmus or strabismus
4. Moves the head and shoulders against resistance with equal strength

4. Moves the head and shoulders against resistance with equal strength

Examine the sternomastoid and trapezius muscles for equal size. Check equal strength by asking the person to rotate the head forcibly against resistance applied to the side of the chin. Then ask the person to shrug the shoulders against resistance. These movements should feel equally strong on both sides.

127

Question 11 When the nurse asks a 68-year-old patient to stand with feet together and arms at his side with his eyes closed, he starts to sway and moves his feet further apart. The nurse would document this finding as a(n):
1. ataxia.
2. lack of coordination.
3. negative Homan s sign.
4. positive Romberg s sign.

4. positive Romberg s sign.

Abnormal findings for Romberg s test: patient sways; falls; widens base of feet to avoid falling. Positive Romberg s sign is loss of balance that is increased by closing of the eyes

128

Question 12 The nurse is doing an assessment on a 29-year-old woman who visits the clinic complaining of always dropping things and falling down. While testing rapid alternating movements, the nurse notices that the woman is unable to pat both her knees. Her response is very slow and she misses frequently. What might the nurse suspect?
1. Vestibular disease
2. Lesion of cranial nerve IX
3. Dysfunction of the cerebellum
4. Inability to understand directions

3. Dysfunction of the cerebellum

In rapid, alternating movements, slow, clumsy, and sloppy response occurs with cerebellar disease.

129

Question 14
The nurse is performing a neurologic assessment on a 41-year-old woman with a history of diabetes. When testing her ability to feel the vibrations of a tuning fork, the nurse notes the following: unable to feel vibrations on the great toe or ankle bilaterally; is able to feel vibrations on both patellae. Given this information, what would the nurse suspect?
1. Hyperalgesia
2. Hyperesthesia
3. Peripheral neuropathy
4. Lesion of sensory cortex

3. Peripheral neuropathy

Loss of vibration sense occurs with peripheral neuropathy (e.g., diabetes and alcoholism). Peripheral neuropathy is worse at the feet and gradually improves as you move up leg, as opposed to a specific nerve lesion, which has a clear zone of deficit for its dermatome.

130

Question 15
The nurse is testing the deep tendon reflexes of a 30-year-old woman who is in the clinic for an annual physical examination. When striking the Achilles and quadriceps, the nurse is unable to elicit a reflex. The nurses next response should be to:
1. ask the patient to lock her fingers and pull.
2. complete the examination and then test these reflexes again.
3. refer the patient to a specialist for further testing.
4. document these reflexes as 0 on a scale of 0 to 4+.

1. ask the patient to lock her fingers and pull.

Sometimes the reflex response fails to appear. Try further encouragement of relaxation, varying the person s position or increasing the strength of the blow. Reinforcement is another technique to relax the muscles and enhance the response. Ask the person to perform an isometric exercise in a muscle group somewhat away from the one being tested. For example, to enhance a patellar reflex, ask the person to lock the fingers together and pull.

131

Question 16
The nurse is testing superficial reflexes on an adult patient. When stroking up the lateral side of the sole and across the ball of the foot, the nurse notices the plantar flexion of the toes. How would the nurse document this finding?
1. Positive Babinski sign
2. Plantar reflex abnormal
3. Plantar reflex present
4. Plantar reflex 2+ on a scale from 0 to 4+

3. Plantar reflex present

With the same instrument, draw a light stroke up the lateral side of the sole of the foot and across the ball of the foot, like an upside-down J. The normal response is plantar flexion of the toes and sometimes of the whole foot.

132

Question 20
The nurse knows that which of the following scores would indicate that a patient is in a coma on the basis of the criteria of the Glasgow Coma Scale?
1. 6
2. 12
3. 15
4. 24

1. 6

A fully alert, normal person has a score of 15, whereas a score of 7 or less reflects coma on the Glasgow Coma Scale.

133

3. to test for stereognosis, you would:
a. have the person close his or her eyes, then raise the person's arm and ask the person to describe its location
b. touch the person with a tuning fork
c. place a coin in the person's hand and ask him or her to identify it
d. touch the person with a cold object

c. place a coin in the person's hand and ask him or her to identify it

134

6. cerebellar function is assessed by which of the following tests?
a. muscle size and strength
b. cranial nerve examination
c. coordination-hop on one foot
d. spinothalamic test

c. coordination-hop on one foot

135

8. A positive babinski sign is:
a. dorsiflexion of the big toe and fanning of all toes
b. plantar flexion of the big toe with a fanning of all toes
c. the expected response in healthy adults
d. withdrawal of the stimulated extremity from the stimulus

a. dorsiflexion of the big toe and fanning of all toes

136

The complex motor system that coordinates movement, maintains equilibrium, and helps maintain posture is identified as the:
A. extrapyramidal system.
B. cerebellum.
C. upper and lower motor neurons.
D. basal ganglia.

B. cerebellum.

137

An area of the body that is supplied mainly from one spinal segment through a particular spinal nerve is identified as a:
A. dermatome.
B. dermatomee.
C. dermatophyte.
D. dermoblast.

A. dermatome.