Chapter 22: Health Assessment

Question 1

Health Assessment is?

Answer 1

an assessment that asses the physical, mental, spiritual, socioeconomics, and cultural states.

Question 2

Nursing Assessment is?

Answer 2

Focuses on clients functional abilities and physical responses to illness and other stressors.

Question 3

Physical Assessment is?

Answer 3

Consists of Techniques used to gather (objective data)

Question 4

What does a complete Health Assessment include?

Answer 4

1. Nursing History

2. Physical Examination

Question 5

The purpose of the Baseline Data

Answer 5

Data about the patients physical status to compare any health changes.

Question 6

The type of physical examination you perform will depend on clients…

Answer 6

Health status, nature of encounters, and settings.

Question 7

For an Annual Physical perform a…

Answer 7

Comprehensive Physical Assessment:

complete head to toe exam, health history interview.

Question 8

Focused Physical Assessment

Answer 8

a particular topic, problem, body part

Question 9

Systemic Specific Assessment

Answer 9

1 body system

Question 10

What is the order of the Body System approach when preparing to perform a physical examination?

Answer 10

Musculoskeleton, Cardiovascular, Neurological

Question 11

Percussion

Answer 11

tapping your fingers on skin.

tapping->produce->vibration= determine location size and density

Question 12

Auscultation

Answer 12

using hearing to gather data

Question 13

Direct Auscultation

Answer 13

listening without using an instrument

Question 14

Indirect Auscultation

Answer 14

listening with the help pf stethoscope

Question 15

Stethoscope Diaphragm

Answer 15

high pitched sounds of the heart, lung, and abdomen

Question 16

Stethoscope Bell

Answer 16

low pitch sounds murmurs, bruits (turbulent blood flow)

Question 17

Olfaction

Answer 17

sense of smell

Question 18

During olfaction, you notice the client is slurring. You think is was caused by…

Answer 18

stroke

Question 19

Which age group are self conscious, want privacy, and are going through puberty?

Answer 19

13-20 adolescence

Question 20

What type of position is used to measure musculoskeleton, neurological system, asses gait?

Answer 20

standing position

Question 21

If you want to asses vital signs, what position is common to use for patient?

Answer 21

Sitting position

Question 22

When patient is in a supine position and is having a hard time breathing, what passion do you recommend they do next?

Answer 22

Fowler’s position: head elevated 60 degree

semi Fowler’s postion: 30 to 50 degrees

Question 23

What position is used when females get a pelvic exam?

Answer 23

Lithotomy

Question 24

What are the 2 positions use to examine rectal are of the patient

Answer 24

sims and knee chest on hands and knees

Question 25

What is the correct order of physical examination?

Answer 25

Inspection, palpation, percussion, Auscultation

Question 26

When palpating the patient, the nurse uses the dorsum of the hand to...

Answer 26

temperature deterimation

Question 27

When palpating the patient, the nurse uses the palmer surface of the hand to...

Answer 27

locate pulsation

Question 28

When palpating the patient, the nurse uses the fingertips of the hand to...

Answer 28

skin texture, swelling, pulsation, masses

Question 29

In the Integumentary System, you must notice the characteristics of the skin such as...

Answer 29

color, temperature, and moisture

Question 30

If a patient is sweating, this maybe a sign of

Answer 30

finished exercising, thyroid problem, overreacted sweating gland

Question 31

cafe au lait spot is?

Answer 31

On infants/ neonates Light brown birthmark: generic disorder/ medical problem

Question 32

Capillary hemoangiomas

Answer 32

small irregular pink areas that can disappear

Question 33

Mangolian Spot

Answer 33

blue black birthmark that are found is specific nationality. They usually fade by age 2

Question 34

erythema

Answer 34

site of infection

Question 35

If a patients skin temperature feels cooler than usual...then you assume

Answer 35

poor peripheral circulation, shock, hypothermia

Question 36

If a patients skin is pale and have a loss of red in their skin tone then...

Answer 36

pallor

Question 37

cyanosis

Answer 37

blue/green skin color because hypoxia

Question 38

yellow/orange skin color

Answer 38

Jaundice

Question 39

Ecchymosis

Answer 39

blue green yellow area: sign of abuse/ internal bleeding.

Question 40

Mottling

Answer 40

blush

Question 41

What happens when a patient has Edema

Answer 41

abnormal fluid in the tissue, common with heart failure, kidney disease, low albumin levels, swollen tissue.

Question 42

Milia is known as

Answer 42

white heads

Question 43

Nevi is also known as

Answer 43

moles and freckles and birthmarks

Question 44

striae is also know as

Answer 44

stretch marks

Question 45

what is the hair type of a patient with hyperthyroidism?

Answer 45

very fine and silky

Question 46

what is the hair type of a patient with hypothyroidism?

Answer 46

dry

Question 47

Another term for hair loss

Answer 47

Alopecia

Question 48

Hirsutism is known as

Answer 48

having a lot of facial and trunk hair possibly do to steroid use

Question 49

Bumpy Nail is usual sign of

Answer 49

Respiration Problem

Question 50

what is a typical nail plate angle?

Answer 50

160 degree and more

Question 51

HEENT

Answer 51

Head, eye, ear, nose, teeth

Question 52

Temporomandibular joint syndrom

Answer 52

jaw cracks too much

Question 53

Graves disease

Answer 53

man looks like women | women look like men

Question 54

myopia

Answer 54

far sightness

Question 55

hyperopia

Answer 55

near sightness

Question 56

persbyopia

Answer 56

diminished near vision (45)

Question 57

cross eye

Answer 57

strabismus

Question 58

lazy eye

Answer 58

amblyopia

Question 59

what cranial nerves control pupillary reaction to light

Answer 59

iii ocululomotor | ii optic

Question 60

how many teeth should adult have

Answer 60

28 or 32 including wisdom teeth

Question 61

glossitis

Answer 61

inflammation of the tongue

Question 62

What type of test do you use to test color blindness?

Answer 62

Itinerary Cards Test

Question 63

When palpating the ear, what do you use?

Answer 63

otoscope

Question 64

Webber test

Answer 64

use running fork (vibrate) at the center of the head..should have equal vibration in both ears

Question 65

Rinne Test

Answer 65

compares air conduction (bone conduction)

Question 66

Romberg Test

Answer 66

asses equilibrium...standing with feet together eyes closed. If you see swaying they have vestibular/cerebellar disorder

Question 67

The normal pupil size

Answer 67

3mm

Question 68

Cervical lymph nodes have to be what size?

Answer 68

1cm | if larger= infection

Question 69

S1

Answer 69

lub closure of valve between atria and ventricles

Question 70

S2

Answer 70

dub closure for semilunar valve between the ventricles and greater arteries exiting the heart)

Question 71

crepitis

Answer 71

popping sound

Question 72

Pulmonary Arteries

Answer 72

carry O2 from blood tot he right ventricle->lung

Question 73

Systemic Arteries

Answer 73

carry oxygen blood from left ventricle to the body periphery

Question 74

veins carry blood

Answer 74

towards the heart

Question 75

arteries carry blood

Answer 75

away from the heart

Question 76

peripheral vessels

Answer 76

both vein and arteries

Question 77

stereognosis

Answer 77

recognize form of object

Question 78

graphesthesia

Answer 78

outline number on hand

Question 79

point localization

Answer 79

identify if one is being touched