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Exam 3 > Health Assessment > Flashcards

Health Assessment Flashcards

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1
Q

What is the single most important neuro assessment component?

A

The LOC or Level of Consciousness

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2
Q

What are the different testing LOC’s?
Select all that apply
- Alert
- Comatose
- Lethargic
- Stuporous
- Obtunded
- Drowsy
- Awake

A

Alert: attentive and follows commands

Comatose: no response to verbal or any stimuli

Lethargic: drowsy but awake, slow to respond

Obtunded: difficult to keep awake

Stuporous: AKA Semi-Comatose only arouses to vigorous stimuli

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3
Q

What is mentation?

A

Cognitive Awareness
- is the patient oriented to person, place, and time?

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4
Q

How do you check for a patients Cognitive awareness?

A

Pt stating their name and DOB (oriented to person)

Pt answering where they are (oriented to place)

Pt answering what year it is (oriented to time)

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5
Q

How many cranial nerves are there?

A

12 pairs

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6
Q

How do you test cranial nerves 3, 4, and 6?

A

Pupil Response and Cardinal Gaze

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7
Q

What is a pupil response?

A

examine the size and shape of pupils and compare it to a scale

start at the ear with a penlight and move towards the nose
Make sure to look at the change in pupil size and speed of reaction

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8
Q

What is the Cardinal Gaze?

A

using the pen, unlit
have the patients eyes follow the pen
9-12 inches away, make the letter H with the pen in the air

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9
Q

How do you test Cranial Nerve 7?

A

ask the patient to smile and show their teeth
then ask the patient to wrinkle their forehead or raise their eyebrows

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10
Q

How do you test Cranial Nerve 12?

A

Ask the patient to open their mouth and stick their tongue out
then ask the patient to move their tongue side to side and to the roof of their mouth

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11
Q

How do you test Cranial Nerve 11?

A

nurse place hands lightly on pt’s shoulders
then ask the pt to shrug their shoulders

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12
Q

What motion will the nurse ask the PT to do in order to complete the Neuro and Musculoskeletal Assessments? Select all that apply

  • Hand grasping and toe wiggling (HGTW)
  • Flexion and extension with resistance
  • Popping the patients hands and toes
  • Placing a pulse ox on the Pt
A

hand grasping and toe wiggling (HGTW)
flexion and extension with resistance

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13
Q

What are all the Neuro Components of Assessment? Select all that apply

  • LOC and orientation
  • pupil response and cardinal gaze
  • smile, showing teeth, and raising eyebrows
  • tongue to roof of mouth, out, side to side
  • shoulder shrug with resistance
  • HGTW
  • flexion/ extension and BUE and BLE
  • auscultation
  • PERRLA
A

LOC and orientation
pupil response and cardinal gaze
smile showing teeth and raising eyebrows
tongue to roof of mouth out and side to side
shoulder shrug with resistance
HGTW
flexion extention and BUE and BLE

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14
Q

Where is the Vesicular located in the lungs?

A

the periphery of the lungs, so pretty much the lungs itself

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15
Q

Where is the Bronchovesicular located?

A

closer to the sternum, the branches that are attached to the lungs near the midline

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16
Q

Where is the Bronchial located?

A

located over the trachea

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17
Q

Which of these are different forms of abnormal sounds? Select all that apply

  • crackles
  • rales
  • ronchi
  • wheezes
  • pleural friction rub
  • fluid noises
  • apnea
  • cheyne-stokes
A

crackles and rales (can be fine or course)
ronchi
wheezes
pleural friction rub

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18
Q

Which one of these are abnormal respiratory patterns? Select all that apply

  • Cheyne-Stokes
  • apnea
  • bradypnea
  • Kussmaul’s
  • crackles
  • wheezes
  • tachypnea
  • hyperpnea
A

bradypnea
apnea
cheyne-stokes
hypernea
kussmaul’s
tachypnea

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19
Q

How many lung sounds do you hear for at the front of the patient?

A

7
starting on the patients left side

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20
Q

How many lung sounds does the nurse hear for at the back of the patient?

A

10
starting at the patients left side
the last 4 the patient needs to take deep breaths in order to hear

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21
Q

How does the nurse check if there is enough oxygen flowing through the patient using the hands?

A

through clubbing,
place the patients finger nails up against each other with the nails touching and if the nail is spread out near the end of the finger, there isn;t enough oxygen going through the patient

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22
Q

What are ways in which the nurse assesses for respiratory components?

A

anterior and posterior lung sounds
clubbing

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23
Q

What is LUB DUB?

A

the way in which the heart sounds,

LUB, S1, is the systolic sound, the sound thats associated with the closing of the mitral or tricuspid valves

DUB, S2, is the diastolic sound, the sound associated with the closing of the aortic or pulmonic valves

There’s natural pauses between S1 and S2 as well as between S2 and S1 but there should be a longer pause between S2 and S1

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24
Q

Where are the heart sounds located?
Select all that apply

  • Aortic
  • SA node
  • Tricuspid
  • AV node
  • Pulmonic
  • Mitral
A

Aortic (right base; second intercostal space to the right of the sternal border)

Pulmonic (left base; second intercostal space to the left of the sternal border)

Tricuspid (left lateral sternal border; fifth intercostal space to the left of the sternal border)

Mitral (apex; midclavicular line at the fifth intercostal space)

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25
Which one of these are pulses of the body? - carotid - brachial - radial - ulnar - apical - femoral - popliteal - dorsal pedis - pedal - mitral - aortic
carotid *** brachial radial *** ulnar apical *** femoral popliteal dorsal pedis ***
26
How to assess the pulses?
Carotid - one at a time, bilaterally Radial - bilaterally at the same time Apical - with stethoscope for 2 beats Dorsal Pedis or Pedal pulses - bilaterally at the same time
27
Which of these are pulse quality points? - 0 - 1+ - 2+ - 3+ - 4+ - 1 - 5+
0 - absent. nonpalpable 1+ - diminished, palpable 2+ - strong, normal 3+ - full increased 4+ - bounding
28
What is a device that'll help with getting a pt's pulse?
Doppler - hand held device - most often used for pedal pulses
29
How to assess both upper and lower Extremities?
Capillary refill (press on the skin of nailbed to make it go white then release the pressure and see how long it takes for the color to return, should be less than 2-3 seconds, BUE and BLE) Edema (swelling in the extremities)
30
Which one of these are cardiac components of assessment? - heart sounds - carotid sounds - radial pulses - pedal pulses - capillary refill - assess for edema - doppler - pulse quality points
heart sounds carotid sounds radial pulses pedal pulses capillary refill assess for edema
31
Which of these are Range of Motion (ROM)? Select all that apply - neck - shoulders, upper arms and elbows - wrists - hips - knees - ankles - strength - handgrip
neck shoulders, upper arms and elbows wrists hips knees ankles
32
Neck ROM?
move the neck side to side chin to chest extended the head back with the face looking at the ceiling
33
Shoulders, Upper Arms & Elbows ROM?
arms to the side arms straight up touchdown
34
Wrist ROM?
wrist circles
35
Hips, Knees, & Ankles ROM?
bilateral hip flexion out bend the knees ankle circles make sure to check the skin with the back of your hand
36
How does the nurse test for strength?
handgrip toe wiggle flexion and extension of BUE and BLE
37
Which are the components of musculoskeletal assessments? Select all that apply - Neck ROM - BUE ROM - BLE ROM - HGTW - Flexion/ extension BUE and BLE - Toe wiggle
Neck ROM BUE ROM BLE ROM HGTW Flexion/ Extension BUE & BLE
38
What does the nurse look for when inspecting the head down to the toes? Select all that apply - hydration - pallor - temperature - color - texture - rashes - lesions - cracking - jaundice
hydration temperature color texture rashes lesions cracking
39
Which change in skin color does the nurse look for? Select all that apply - pallor - erythema - jaundice - cyanosis
pallor (pale or ashen gray) erythema (redness r/t vasodilation) jaundice (yellow, impaired liver) cyanosis (bluish, decreased circulation or oxygenation of blood)
40
What are some skin characteristics? - Temp - Moisture - Texture - Turgor - Rashes - Cracking
Temp should be warm consistent with room temp Moisture from diaphoresis or dry from dehydration Texture can be dry & course (elbows/knees) or shiny with no hair (impaired peripheral circulation) Turgor tests elasticity of the skin related to hydration
41
Which of these are factors that effect the skin? Select all that apply - Dampness - Dehydration - Nutrition - Circulation - Disease - Jaundice - Lifestyle - Temperature - Moisture
dampness dehydration nutrition circulation disease jaundice lifestyle
42
Which of these are normal skin changes in older adults? Select all that apply - Epidermis - Subcutaneous tissue - Collagen & elastin fibers - Hormones - Vascularity - Dehydration - Hair follicles - Melanocytes - Nails - Skin Growths
epidermis subcutaneous tissue collagen & elastin fibers hormones vascularity hair follicles melanocytes nails skin growths
43
What is pitting edema?
caused by kidney or heart failure leads to excess fluid collection in tissue
44
4 point scale?
1+ (2mm to trace, rapid response) 2+ (4mm to mild, 10-18 seconds) 3+ (6mm to moderate, 1-2 minutes) 4+ (8mm to severe, 2-5 minutes)
45
which of these are Assessment of Bony Prominences? - hips, heels, coccyx, shoulders - assess for skin integrity - blanching red spots - edema - 4 pt scale
hips, heels, coccyx, shoulders assess for skin integrity
46
what does the nurse observe for when assessing the nails? Select all that apply - shape - contour - cleanliness - neatly manicured/ trimmed - hygienic - convex
observe for shape contour cleanliness neatly manicured/ trimmed
47
What should the nails look like? Select all that apply - transparent - smooth - rounded - convex - hygienic - cleanliness
transparent smooth rounded convex hygienic
48
What is terminal hair?
hair on the scalp, axillae (armpits), pubic, and beard
49
What is Vellus hair?
soft tiny hairs covering body except on palms and soles
50
what to look for when assessing hair?
quantity (alopecia, hirsutism) distribution texture color parasites
51
What to look for when assessing the ears?
inspect for - symmetry, drainage, shape, hearing defects, lesions, redness, tenderness, odor
52
What to look for when assessing the nose?
the position of the nose, symmetry, color, swelling, deformities, discharge, flaring, patency, sinus tenderness
53
What do you inspect in the oral cavity? Select all that apply - Lips - Oral Mucosa - Teeth - Gums/ Tongue - Breath Odor - Flaring
lips oral mucosa teeth gums/ tongue breath odor
54
What does the nurse inspect the throat for? Select all that apply - lumps - ulcers - edema - white spots - redness - swallowing - teeth - odor
lumps ulcers edema white spots redness swallowing
55
What to look for when assessing the neck?
contour & symmetry. midline trachea, jugular vein distention
56
Why does the nurse palpate the neck for?
inflamed/ enlarged lymph nodes
57
What are the integument components of assessment? Select all that apply - inspect hair and scalp - inspect ears - inspect nose - inspect mouth and throat - inspect and palpate neck - assess skin turgor - inspect skin on back and bony prominences - inspect skin of BUE and BLE - inspect nails - inspect armpits - inspect eyes
inspect hair and scalp inspect ears inspect nose inspect mouth and throat inspect and palpate neck inspect nails assess skin turgor inspect skin on back and bony prominences inspect skin of BUE and BLE
58
Bowel Elimination Definitions - Elimination - Defecation - Feces
Elimination (excretion of waste products from kidney and intestines) Defecation (process of elimination of waste) Feces (semisolid mass of fiber, undigested food, inorganic matter)
59
Urinary Elimination Definitions - Incontinence - Void - Micturate - Dysuria - Hematuria - Nocturia - Polyuria
Incontinence ( inability to control urine or feces ) Void ( to urinate ) Micturate ( to urinate ) Dysuria ( painful or difficult urination ) Hematuria ( blood in the urine ) Nocturia ( frequent night urination ) Polyuria ( large amounts of urine )
60
Urinary Elimination Definitions Cont. - Urinary Frequency - Urinary Urgency - Proteinuria - Dribbling - Retention - Residual
Urinary frequency ( voiding at frequent intervals) Urinary urgency ( the need to void all at once) Proteinuria ( presence of large protein in urine) Dribbling ( leakage of urine despite voluntary control of urination ) Retention ( accumulation of urine in bladder without the ability to complete empty ) Residual ( urine remaining post void >100mL )
61
What structures are part of the Gastrointestinal ( GI ) Tract?
Upper GI tract Small intestine Large intestine Rectum Anus
62
What is the small intestine?
folded, twisted, and coiled tube from stomach to large intestine 1 inch in diameter and 20 ft long Most digestion and absorption happens here Chyme travels via peristalsis 3 parts - duodenum, jejunem, and ileum
63
What is the large intestine?
THE COLON 2.5" in diameter and 5-6 ft long 7 parts - cecum, ascending colon, transverse colon, descending colon, sigmoid colon, rectum, anus
64
What are the functions of the kidney?
Filter and regulate remove waste from blood to form urine
65
what are the functions of the ureters?
transport urine from kidneys to bladder
66
What are the functions of the bladder?
Reservoir for urine until the urge develops
67
What are the functions of the urethra?
urine travels from bladder and exits through urethral meatus
68
Kidney info
bilateral, posterior flanks size of fists primary regulators of fluid and acid-base balance
69
Which of these are parts of the Kidney? - Nephron - Glomerulus - Bowman's Capsule - Proximal Convoluted Tubule - Ureter - Loop of Henle - Distal Tubule - Collecting Duct
Nephron ( functional unit of the kidney Glomerulus Bowmans capsule Proximal convoluted tubule Loop of Henle Distal tubule Collecting Duct
70
What are the Ureters?
tubule structures that enter the bladder Urine traveling through ureters is typically sterile Ureters enter bladder obliquely and posteriorly to prevent reflux Obstructions cause peristaltic waves severe pain often referred to as renal colic
71
What is the Bladder?
A hollow, distensible, muscular organ In men - bladder lies against anterior wall of rectum In women - bladder rest against anterior walls of uterus and vagina when bladder is full, it extends above symphasis pubis Normal bladder 500 mL Can extend to 1000mL
72
What is the functions of the Urethra? In men? In woman?
Turbulent flow washes urethra free of bacteria Descends through pelvic floor muscles Contraction of pelvic floor muscles can prevent flow of urine In woman - urethra is short (1 1/2 to 2 1/2 inch), leads to prevalence of infection In men - urethra is long ( 8 in ), serves in both GU ( genito urinary ) and reproductive system, 3 parts: prostatic, membranous, and penile
73
In what order do you examine the abdomen? Place in order from 1st to last - Auscultation - Palpation - Inspection
1. Inspection - observe size, shape, contour, skin integrity 2. Auscultation - listen, bowel sounds, four quadrants ( normal hypoactive, hyperactive ) 3. Palpation - feel, palpate for tenderness, pain, masses
74
When palpating the abdomen, what kind of questions should the nurse ask?
normal bowel and urine patters appearance changes history of problems
75
Assessment of Urethral Meatus and Perineal Area
inspect urethral orifice for erythema, discharge, swelling, or odor Signs of infection, inflammation, or trauma Perineal area: Odor, condition, presence of urine or stool
76
Components of GI/ GU assessments
Examination of abdomen - look, listen, feel Ask questions about habits Examination of urethral meatus and perineal area

Exam 3 (2 decks)

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