Chapter 11 - Patient Assessment

Question 1

Differential diagnosis

Answer 1

possible diagnoses based on assessment findings.

Question 2

Working diagnosis

Answer 2

diagnosis you are basing treatment plan on

Question 3

Field Impression

Answer 3

Initial summary of pts condition after findings

Question 4

Delirium

Answer 4

Sudden change in mental status

Question 5

anisocoria

Answer 5

Unequal pupils with a greater than 1-mm difference

Question 6

aphasia

Answer 6

The language impairment that affects the production or understanding of speech and the ability to read or write

Question 7

Ascites

Answer 7

Abnormal accumulation of fluid in the peritoneal cavity; typically signals liver failure.

Question 8

Battle sign

Answer 8

bruising over mastoid bone behind the ear, may indicate a basilar skull fracture, also called retroauricular ecchymosis or raccoon eyes

Question 9

Beck triad

Answer 9

The combination of a narrowed pulse pressure, muffled heart tones, and jugular venous distention associated with cardiac tamponade; usually caused by penetrating chest trauma.

Question 10

Bronchial sounds

Answer 10

Hollow, tubular, lower-pitched sounds heard over the trachea.

Question 11

Bronchophony

Answer 11

A test of decreased breath sounds performed by placing the diaphragm of the stethoscope over the area in question while the patient says “ninety-nine;” a loud, clear sound indicates lung consolidation.

Question 12

Egophony

Answer 12

A test of decreased breath sounds performed by placing the diaphragm of the stethoscope over the area in question while the patient saying a drawn-out “ee;” an “A” sound indicates lung consolidation.

Question 13

Bruit

Answer 13

An abnormal whooshing sound of turbulent blood flow moving through a narrowed artery; usually heard in the carotid arteries.

Question 14

Cerumen

Answer 14

Term for ear wax

Question 15

Crackles

Answer 15

The breath sounds produced as fluid-filled alveoli pop open under increasing inspiratory pressure; can be fine or coarse; formerly called

Question 16

Cushing Reflex

Answer 16

The combination of a slowing pulse, rising blood pressure, and an erratic respiratory pattern; a grave sign for patients with head trauma or cerebrovascular accident.

Question 17

The result of residual pressure in the circulatory system while the left ventricle is relaxing (ie, in diastole)

Answer 17

Diastolic Pressure

Question 18

Double vision

Answer 18

Diplopia

Question 19

Ecchymosis

Answer 19

Localized bruising or collection of blood within or under the skin.

Question 20

Contraction of the abdominal muscles indicating peritoneal irritation.

Answer 20

Guarding

Question 21

Define Heave

Answer 21

The perception that the heart is beating very strongly; felt upon palpation of the chest wall, this finding suggests hypertrophy; also called a lift.

Question 22

Iatrogenic

Answer 22

Related to a side effect or complication of medications or other medical treatment.

Question 23

Sounds related to blood pressure measurement that are heard by stethoscope.

Answer 23

Korotkoff sounds

Question 24

A sensation felt upon palpation of the chest wall, in which the heart beats extremely strongly; suggests hypertrophy; also called a heave.

Answer 24

Lift

Question 25

A sensation felt upon palpation of the chest wall, in which the heart beats extremely strongly; suggests hypertrophy; also called a heave.

Answer 25

Lift

Question 26

Inward curve of the lumbar spine just above the buttocks. An exaggerated form results in the condition known as swayback.

Answer 26

Lordosis

Question 27

whooshing sound heard over the heart that indicates turbulent blood flow around a cardiac valve.

Answer 27

Murmur

Question 28

An instrument used to examine the inside of the ears; consists of a head and a handle. The head contains an electric light source and a low-power magnifying lens.

Answer 28

Otoscope

Question 29

An abnormal sensation such as burning, numbness, or tingling.

Answer 29

Paresthesia

Question 30

A fracture that occurs when normal forces are applied to abnormal bone structures, such as a weakened bone.

Answer 30

Pathologic fracture

Question 31

The drifting of one arm downward toward a patient’s feet while he or she holds out his or her arms, palm side up, with his or her eyes shut; can be a sign of a stroke.

Answer 31

Pronator drift

Question 32

The ability to perceive the position and movement of one’s body or limbs.

Answer 32

Proprioception

Question 33

Rubor

Answer 33

Redness; one of the classic signs of inflammation.

Question 34

Blood pressure created by the left ventricle as it contracts

Answer 34

Systolic pressure

Question 35

A humming vibration that can be palpated through the chest wall, suggesting an underlying bruit or murmur.

Answer 35

Thrill

Question 36

Adventitious breath sounds include:

Answer 36

* Wheezing: High-pitched whistling * Crackles (also called rales): Wet breath sounds * Rhonchi: Congested breath sounds with a lower pitch and rattling * Stridor: Brassy, crowing sound * Pleural friction rubs: Squeaking or grating sounds

Question 37

Calculate MAP

Answer 37

MAP (average arterial pressure throughout one cardiac cycle, systole, and diastole) * MAP = DP + 1/3(SP – DP) or MAP = DP + 1/3(PP)

Question 38

Pulse pressure

Answer 38

The top number (systolic) minus the bottom number (diastolic)