Brainscape's Knowledge GenomeTM


Top Flashcards (Certified)
All Flashcards

NUR3120 HEALTH ASSESSMENT > Exam 2 > Flashcards

Exam 2 Flashcards

(66 cards)

Start Studying
1
Q

Chronic Obstructive Breathing

A

Shortness of breath due to inability to fully exhale air

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Measure Edema

A
  • Scale is subjective
  • 1+ = mild pitting, slight indentation w/ no perceptible swelling
  • 2+ = moderate pitting & indentation subsides rapidly
  • 3+ = deep pitting, indention remains for short time, limb appears swollen
  • 4+ = very deep pitting, indention persists for long time, limb very swollen
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Expected Findings for Head, Neck, & Face

A
  • Head should be midline & centered
  • Bruit over thyroid gland & carotids
  • Lymph nodes movable, discrete, soft, & nontender
  • Trachea straight & midline
  • Thyroid usually nonpalpable
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Hyperventilation

A

Rapid, deep breathing

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Properties of Veins

A
  • Thin-walled, elastic
  • Carry deoxygenated blood to heart
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Cheyne-Stokes Respiration

A

A period of fast, shallow breathing followed by slow, heavier breathing and moments without breathing at all

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

How Does Diastole Occur

A

Heart muscle relaxes, fill with blood

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

S2

A
  • Short, high-pitched
  • Loudest at base
  • Closure of semilunar valves (pulm & aortic)
  • End of systole (dub)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Risk Factors for Breast Disease (nonmodifiable)

A
  • 2+ 1st degree relatives
  • Previous breast irradiation
  • Menstruation before 12
  • Menopause after 55
  • History: endometrial, ovarain, or colon CA
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Low Pitched Wheeze

A
  • Low pitched
  • Monophonic, single note
  • More prominent on expiration
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Abnormal Findings of Breast Exam

A
  • Sudden increase in size
  • Redness, bulging, dimpling, lesions, incrd pigmentation, heat, unilateral/dilated superficial veins, edema
  • “orange-peel”
  • Lymphatic drainage
  • Discharge
  • New nipple retraction/inversion
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Abdominal Exam Sequence

A

Inspect > Auscultate > Percuss > Palpate (light then deep)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Key Subjective Data for Respiratory Health

A
  • Cough
  • SOB/SOA
  • Chest pain while breathing (inspiration or expiration)
  • Past hx of resp infections or allergies
  • Hx of smoking
  • Previous chest surgery
  • Environmental exposures
  • Self-care behaviors
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Promoting Relaxation of Abdominal Muscles

A
  • Empty bladder
  • Warm room
  • Supine w/ knees bent
  • Hands on chest or at sides
  • Warm hands & steth
  • Distraction
  • Save painful for last
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Inspection of Anterior Eye Structures

A
  • Cornea should be clear
  • Iris & pupil flat & equal
  • Direct & consensual
  • PERRLA: pupils equal, round, reactive to light & accommodation
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Sounds of Abdominal Exam

A
  • Auscultation: gurging for 5-30 secs (not heard listen for 5 mins)
  • Percussion: dull over solid organs (liver), tympany over gas filled (intestines)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Scoliosis

A
  • Sideways “S” shaped
  • Potential Causes/Associated Factors: cerebral palsy, muscular dystrophy, birth defects, injuries
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Breast Exam Data & Health Hx

A
  • Any pain, lumps, discharge, rashes, swelling, or trauma
  • Hx of breat disease
  • Surgery/radiation
  • Medications: female hormones
  • Self care: mammograms, BSE
  • Axilla: tender, lump, swelling, rash
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Hypothyroidism

A
  • Intolerance to cold
  • Receding hairline
  • Facial & eyelid edema
  • Dull expression
  • Extreme fatigue
  • Thick tongue, slow speech
  • Anorexia
  • Brittle nail & hair
  • Hair loss
  • Dry skin
  • Muscle aches & weakness
  • Constipation
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Breast Exam Techniques

A
  • For inspection hands: at side, above head, on hips, palms together, leaning forward
  • For palpation: vertical strip pattern, Spokes of a wheel, concentric circles pattern, palpating axilla, nipple squeeze for discharge
  • Bimanual Palpation: for large pendulous breast; lean forward, support lower part
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Barrel Chest

A
  • Front & back of chest (anterior to posterior) is bigger than normal
  • 1:1 anterior to posterior
  • Potential Causes/Associated Factors: COPD, Emphysema, cystic fibrosis, arthritis
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Modifiable Risk Factors for Breast Disease

A
  • Heavy alcohol consumption
  • Lack of physical activity
  • Never breastfed
  • Late age 1st pregnancy
  • Fatty diet
  • Obesity
  • Long term use of hormone therapy
  • Recent oral contraceptive use
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Adventitious

A

Abnormal breath sounds

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Palpate Anterior Chest

A
  • Symmetrical chest expansion
  • Tactile fremitus
  • Tenderness, masses, skin turgor, temp, & moisture
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Inspection of External Eye Structures
- Nonverbal signs of vision loss - Eyebrow, eyelid, & lash symmetry - Conjunctiva
26
Wheezes
- Rhonchi - Means restricted airflow
27
Changes in Aging Adult for Head, Neck, & Face
- Facial bones & orbits more prominent - Facial skin sagging - Dizziness - Neck pain
28
Promotion of Cardiovascular Health
- Screening for HTN - No smoking - Health BMI - No illicit drug use - Heart healthy diet; low Na, low fat, low chol, limit trans-fat - Healthy blood sugar (65-100) - Early screenings for family hx - Aerobic exercise
29
Tachypnea
Rapid, shallow breathing rate
30
Signs of Respiratory Distress
- Use of accessory muscles - Pursed lip breathing - Excessive chest movement
31
Changes in Aging Adult for Abdominal
- Incrd abdom fat - Reduced salivation: dry mouth, dcrd taste - Incrd risk for aspiration - Dcrd gastric acid secretion: reduced vit D, iron, & calcium absorption - Incrd risk of gallstones - Liver size dcrs: impaired drug metabolism - Constipation due to reduced GI motility
32
S1
- Long, low-pitched - Loudest at apex - Closure of AV valves (tri & mi) - Beginning of systole (lub)
33
Hyperthyroidism
- Intolerance to heat - Bulging eyes - Enlarged thyroid - Tachycardia - Incrd systolic BP - Weight loss - Muscle wasting - Localized edema - Tremors - Clubbing - Incrd diarrhea - Menstrual changes
34
Considerations for Aging Adult with Cardiac System
- Widening pulse pressure - Check for orthostatic hypotension - Caution when palpating & auscultation carotid arteries - Incr murmurs - Incrd anteroposterior diameter
35
Pleural Friction Rub
- Low pitched - Leather rubbing together - Sound intensifies if stethoscope is pressed - Inspiratory & expiratory sounds
36
Expected Findings of Breast Exam
- Symmetric in size or shape, unless asymmetry is not new - Skin smooth w/ even color - Striae w/ pregnancy - Symmetric nipples; inversion normal if not new
37
Palpate Posterior Chest
- Symmetric expansion - Spinal alignment - Tactile fremitus
38
Stridor
- High pitched, monophonic inspiration crowing loudest in neck - Originates in larynx or trachea - Signifies an upper airway obstruction - Swelling or lodged foreign body - Frequently life threatening - ex: croup, epiglottitis
39
Auscultation of Posterior Chest
- Bronchial: expiration louder & longer - Bronchovesicular: inspiration & expiration abt equal - Vesicular: inspiration louder & longer
40
Health Promotion & Education for Breast Health
- Maintain healthy weigh & diet: fruits, veggies, whole grains, vit d and stress management & adequate sleep - Avoid red meats, sat fats, tobacco products & 2nd hand smoke - Minimize alcohol intake - Exercise - Breast feed infants - Annual CBE & Mammogram - Monthly SBE
41
Percussion of Posterior & Anterior Chest
Normal percussion sound is RESONANCE over lungs
42
Bruit
A soft blowing swishing sound that indicates blood flow turbulence
43
Eye Assessment Data
- Difficulty with vision: reduced acuity, blurring, blind spots - Pain of itching - Strabismus, diplopia - Redness or swelling - Use of glasses or contacts - Hx of ocular problems, glaucoma, or eye surgery - Watering or dishcarge - Hygiene practices - Date of last exam - Night vision problems, dcr in ADLs, difficulty climbing stairs or driving
44
Pulse Rating System
- 0 = absent - 1+ = weak - 2+ = normal - 3+ = incrd, full bounding
45
Crackles
- Rales - Means fluid
46
Appearance (inspection) of Abdominal Exam
- Flat, scaphoid (inverted), rounded, protuberant - Symmetry of contour, midline & inverted umbilicus - Skin color; striae, piercings, demeanor
47
Inspecting Anterior Chest
- Shape & configuration - Facial expression - Quality & RR - Skin color (any cyanosis; could mean dcrd oxygen, reduces LOC) - Resp effort: normal 10-20/min, even
48
Biot Respiration
Regular deep respirations with periods of apnea
49
Signs of Arterial Insufficiency
- Deep muscle pain, pain w/ walking (claudication) - Cold, pale extremity - Dependent rubor - Reduced pulse intensity - Bruits - Thin shiny skin - Absence of hair - Distal gangrene
50
Abdominal Assessment Data
- Appetite - Dysphagia - Food intolerances - Pain - N/V - Bowel habits - Bloating or indigestion - Past surgeries or GI illnesses - Medications - Screening for colon CA - Nutrition
51
Kyphosis
- Curvature of spine towards top, "humpback" - Due to low activity and stretching - Common in older adults - Potential Causes/Associated Factors: osteoporosis, fractures, disk degeneration
52
Properties of Arteries
- Delivers oxygen & other nutrients in tissues - High pressure system - Thick walls
53
Breast Exam Preparation - Mammogram
- No deodorant, lotions, or powders - Schedule exam when not menstruating - Avoid excessive caffeine
54
Auscultation of Anterior Chest
- Work downward while comparing sides - Listen to full sounds - Bronchial: expiration louder & longer - Bronchovesicular: inspiration & expiration abt equal - Vesicular: inspiration louder & longer
55
Inspecting Posterior Chest
- Note configuration of thoracic cage - Pt's basic body position - Pt's color - Use of accessory muscles
56
Bradypnea
Slow breathing rate; >12 breaths/min
57
Hypoventilation
Shallow, slow breathing
58
Auscultation of Heart Tones
- Aortic Valve: 2nd ICS R sternal border (S2>S1) - Pulmonic Valve: 2nd INC L sternal border (S2>S1) - Erb's Point: 3rd ICS L sternal border (S2=S1) - Tricuspid Valve: 4th or 5th ICS L sternal border (S1>S2) - Mitral Valve: 5th ICS mid-clavicular line (S1>S2)
59
APE to Man
Aortic Pulmonic Erb's Point Tricuspid Mitral
60
Expected Changes in Aging Adults with Peripheral Vascular System
- Dorsalis pedis & posterior tibial pulses difficult to find - Trophic skin changes w/ arterial insufficiency: thin shiny skin, thick-ridged nails, loss of hair
61
How Does Systole Occur
Heart muscle contracts, ejects blood
62
Head, Neck, & Face Assessment Data
- Headaches - Hx of head injury, cosmetic, or cranial surgery - Dizziness (affecting ADLs?) - Neck pain (limiting ADLs or reduced ROM?) - Lumps or swelling - Hx of neck injury or surgery
63
High Pitched Wheeze
- High pitched, musical squeaking - Predominate in expiration, may occur in inspiration
64
Signs of Venous Insufficiency
- Pain worsens when standing - Dull aching - Tingling sensation - Varicose veins
65
Pulmonary Complications in Aging Adult
- Less mobile thorax - Dcrd resp muscle strength - Dcrd lung elasticity; dcrd vital capacity, incrd residual vol - Loss of intra-alveolar septa - Dcrd # of alveoli; less surface area for gas exhange - Incrd risk for dyspnea on exertion (DOE) - Incrd risk for postoperative pulm comps; atelectasis, infection
66
Blood Flow Through Heart to Systemic Circ
SVC/IVC > RA > Tri Valve > RV > Pulm Valve > Pulm Artery > Lungs > Pulm Vein > LA > Mitral Valve > LV > Aortic Valve > Aorta > Systemic Circulation

NUR3120 HEALTH ASSESSMENT (3 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2025 Bold Learning Solutions. Terms and Conditions