Ch 26 Health Assessment

Question 1

Activities of daily living (ADLs)

Answer 1

Self care activities such as eating, bathing, dressing and toileting

Question 2

Adventitious breath sounds

Answer 2

Abnormal breath sounds over the lungs

Question 3

Auscultation

Answer 3

Listening for sounds in the body

Question 4

Body mass index (BMI)

Answer 4

Ratio of height to weight

Question 5

Bronchial breath sounds

Answer 5

Those heard over the larynx and trachea are high pitched, harsh blowing sounds, with sound on expiration being longer than inspiration

Question 6

Comprehensive health assessment

Answer 6

Broad health assessment that includes a complete health history and physical assessment; it is usually conducted when a patient first enters a health care setting, with information providing a baseline for comparing later assessment

Question 7

Cyanosis

Answer 7

Bluish coloring of the skin and mucous membranes

Question 8

Diaphoresis

Answer 8

An excessive amount of perspiration, such as when the entire skin is moist

Question 9

Ecchymosis

Answer 9

Collection of blood in subcutaneous tissues that cause a purplish discoloration

Question 10

Edema

Answer 10

Accumulation of fluid in extra cellular spaces

Question 11

Emergency health assessment

Answer 11

Type of rapid focused assessment conducted in when addressing a life threatening or unstable situation

Question 12

Erythema

Answer 12

Redness of the skin

Question 13

Focused health assessment

Answer 13

Assessment is conducted to assess a specific problem; focuses on pertinent history and body regions but may also be used to address the immediate and highest priority concerns for an individual patient

Question 14

Health history

Answer 14

A collection of subjective information that provides information about the patient’s health status

Question 15

Inspection

Answer 15

Purposeful and systematic observation

Question 16

Instrumental activities of daily living (IADLs)

Answer 16

The activities of daily living needed for independent living

Question 17

Jaundice

Answer 17

Yellow appearance of the skin

Question 18

Ongoing partial health assessment

Answer 18

Also known as follow up assessment, is one that is conducted at regular intervals during care of the patient; concentrate on identified health problems to monitor positive or negative changes and evaluate the effectiveness of interventions

Question 19

Pallor

Answer 19

Paleness of the skin

Question 20

Palpation

Answer 20

Method of examining by feeling a part of the body with fingers or hand

Question 21

Percussion

Answer 21

Act of striking one object against another for the purpose of producing a sound; used to access the location, shape, size and density of body tissues

Question 22

Petechiae

Answer 22

Small, purplish hemorrhagic spots on the skin that do not blanch with applied pressure

Question 23

Physical assessment

Answer 23

Systematic examination of the patient for objective data to better define the patient’s condition and to help the nurse in planning care, usually preformed in a head to toe format; a collection of objective data about changes in the patient’s body systems

Question 24

Precordium

Answer 24

Anterior surface of the chest wall overlying the heart and it’s related structures

Question 25

Review of systems

Answer 25

Physical examination of all body systems in a systematic manner as part of a nursing assessment

Question 26

Turgor

Answer 26

Tension of the skin determined by its hydration

Question 27

Vesicular breath sounds

Answer 27

Normal sound of respirations heard on auscultation over peripheral lung areas

Question 28

Waist circumference

Answer 28

A numerical measurement of the waist, used to assess an individual’s’ abdominal fat and establish ideal body weight

Question 29

Right upper quadrant

Answer 29

``` Pylorous Duodenum Liver Right kidney and adrenal gland Hepatic flexure of colon Head of pancreas ```

Question 30

Left upper quadrant

Answer 30

``` Stomach Spleen Left kidney and adrenal gland Splenic flexure of colon Body of pancreas ```

Question 31

Left lower quadrant

Answer 31

Sigmoid colon Left ovary and Fallopian tube Left ureter and lower kidney pole Left spermatic cord

Question 32

Right lower quadrant

Answer 32

``` Cecum Appendix Right ovary and Fallopian tube Right ureter and lower kidney pole Right spermatic cord ```

Question 33

Midline

Answer 33

Urinary bladder Urethra female 

Question 34

Cranial nerve I

Answer 34

Name: olfactory Function: sense of smell Test: ask patient to smell substance with eyes closed Type: sensory

Question 35

Cranial Nerve II

Answer 35

Name: optic Function: vision Test: Snellen chart, ophthalmoscopic exam, confrontation to check peripheral vision Type: sensory

Question 36

Cranial Nerve III

Answer 36

Name: oculomotor Function: eye movement, controls most eye-movement, pupil constriction and upper eyelid rise Test: look up down and inward, ask the patient to follow your finger as you move it towards their face Type: memory

Question 37

Cranial Nerve IV

Answer 37

Name: Trochlear Function: controls downward and inward Eye movement Test: look up and down and inward, ask the client to follow your finger as you move it towards their face Type: memory

Question 38

Cranial Nerve V

Answer 38

Name: trigeminal Function: motor mastication, sensory facial sensation Test: pressure on the forehead cheek and jaw with a cotton swab to check sensation, ask patient to open mouth and then bite down Type: both

Question 39

Cranial Nerve VI

Answer 39

Name: abducens Function: controls parallel eye-movement, abduction, moving laterally away from the midline Test: look up down and Inward, ask the patient to follow your finger as you move it towards their face Type: memory

Question 40

Cranial Nerve VII

Answer 40

Name: facial Function: motor facial expression, sensory taste sweet and salty Test ask client to do different facial expression frown, smile, raise eyebrows, close eyes, blow, test tongue by giving clients sweet bitter and salty substances Type: both 

Question 41

Cranial Nerve VIII

Answer 41

Name: vestibulocochlear/acoustic Function: balance and hearing Test: stand with eyes closed, otoscopic exam, Rhine and Weber Test Type: sensory

Question 42

Cranial Nerve IX

Answer 42

Name: glossopharyngeal Function: motor tongue movement and swallowing, sensory taste sour and bitter Test: test tongue by giving client sour bitter and salty substances Type both

Question 43

Cranial Nerve X

Answer 43

Name: Vagus Function: motor swallowing, speaking and cough, sensory facial sensation Test: sensation coming from skin and around the ear Type: both

Question 44

Cranial Nerve XI

Answer 44

Name: spinal accessory Function: control strength of neck and shoulder muscles Test: ask the client to rotate their head and shrug their shoulders Type: memory

Question 45

Cranial Nerve XIi

Answer 45

Name: hypoglossal Function: tongue movement, swallowing and speech Test: inspect tongue and ask patient to stick their tongue out Type: memory

Question 46

Comprehensive assessment

Answer 46

Conducted upon admission to healthcare facility

Question 47

Ongoing partial assessment

Answer 47

Conducted at regular intervals

Question 48

Focused assessment

Answer 48

Conducted to assess a specific problem

Question 49

Emergency assessment

Answer 49

Conducted to determine life-threatening or unstable conditions

Question 50

Techniques used during a physical assessment

Answer 50

IPPA | Inspection, palpitation, percussion and auscultation

Question 51

Inspection

Answer 51

Assessing size, color, shape, position and symmetry

Question 52

Palpitation

Answer 52

Assessing temperature, tyrgor, texture, moisture, vibrations and shape

Question 53

Percussion

Answer 53

Assessing location, shape, size, and density of tissues

Question 54

Auscultation

Answer 54

Assessing the forecast eristics of sound that is pitch, loudness, quality, and duration

Question 55

PERRLA

Answer 55

Pupils are equal round reactive to light and accommodation