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NCLEX-RN® > NCLEX-RN (1) Fundamentals > Health & Physical Assessment > Flashcards

Health & Physical Assessment Flashcards

Review basic assessment techniques and findings for all the systems.

1
Q

Who spends the most time with the client, knows the most about the client, and is able to communicate the client’s needs to the rest of the health care team the most effectively?

A

The nurse

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2
Q

What are the 3 areas of assessment the nurse focuses on in order to get a complete picture of the client?

A
  1. Body: assess the physical systems
  2. Mind: assess mental health
  3. Spirit: assess for religious or spiritual beliefs
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3
Q

What is the ADPIE nursing process?

A
  • Assess: gather data
  • Diagnosis: client problems that are based on medical diagnosis
  • Plan: goals
  • Implement: interventions
  • Evaluate: how the client responded to the intervention

The nursing process is not linear. The nurse will jump back and forth between the steps depending on additional data acquired about the client.

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4
Q

What are nursing clinical judgment skills?

A
  • interpreting sign and symptom data
  • prioritizing what is important
  • generating solutions by making a plan
  • understanding WHY an intervention is done
  • gathering more information if there is not enough to make an informed decision
  • evaluating if inteventions or teaching was effective
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5
Q

What is a clinical pathway or care plan?

A

A plan that the healthcare team agrees to for guiding client care and is based on evidence based practice (EBP).

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6
Q

When does teaching and discharge planning by the nurse begin with a client?

A

During the assessment even while the client is being admitted

During the admission, assessment data is gathered by the nurse such as home environment and available resources so that teaching can begin right away, if there are needs.

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7
Q

How should you identify a client before giving meds, doing a procedure, or performing an assessment?

A

By using 2 client indentifiers:
1. name and
2. date of birth, social security number, phone number or address

Name and date of birth is most typically used.

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8
Q

What are the two purposes of doing a nursing assessment on a client?

A
  1. gather data (especially abnormal data) about the client to heal the client or prevent them from getting sick.
  2. notify the health care provider (HCP) of immediate complications or changes in the client’s condition in order to update the care plan.

The HCP can be a doctor, nurse practitioner or physician assistant.

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9
Q

What is the typical assessment order for most body systems?

A
  1. inspect
  2. palpate
  3. percuss
  4. auscultate
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10
Q

What is the difference between a focused health assessment and a comprehensive health assessment?

A
  • Focused health assessment: Focuses on the immediate concern and is done when the client has a specific complaint or immediate information is needed.
  • Comprehensive health assessment: When the nurse assesses the entire client head to toe.
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11
Q

Which main physical systems are assessed in a comprehensive assessment starting from head to toe?

A
  • neuro
  • respiratory
  • cardiac
  • gastrointestinal
  • kidneys
  • musculoskeletal
  • skin
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12
Q

In addition to the physical assessment of the client, what additional data does the nurse look at to get an overall picture of the client?

A
  • labs
    • CBC, BMP or CMP
    • labs specific to problem
  • imaging diagnostic tests
    • x-rays, CT scan, MRI, etc
  • medical and surgical history and physical from HCP
  • medication administration record (MAR)
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13
Q

How often should a typical nursing physical assessment be done on each of the following units:

  1. Post-operatively
  2. ICU
  3. Progressive or Step-down unit
  4. Medical-surgical unit
A
  1. Post-Op: focused assessments every 5- 15 minutes
  2. ICU: every 1-2 hours
  3. Progressive or Step-down unit: about every 2-4 hours
  4. Medical-surgical unit: about every 4-8 hours
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14
Q

What is subjective and objective data?

A

Subjective data: what the client tells you

Objective data: what anyone can observe

Subjective data example: the client’s stated pain level
Objective data example: a set of vital signs

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15
Q

What conditions cause a higher than normal body temperature?

A
  • dehydration
  • stress
  • ovulation
  • strenuous exercise
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16
Q

Clients with which conditions should avoid rectal temperature measurements?

A

Those at risk of bleeding or infection should avoid rectal temps.

ex: DIC or leukemia

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17
Q

Clients with which conditions should avoid oral temperature measurements?

A

Those that have had oral surgery, because of a risk of trauma to the mouth.

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18
Q

What is placed on the finger to obtain a pulse and oxygen reading?

A

pulse oximeter

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19
Q

Define:

Posterior and Anterior

A
  • Posterior: the back of something
  • Anterior: the front of something
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20
Q

What is a rapid and basic neuro assessment?

A

Assess the level of consciousness by asking the client 4 questions:

  1. Person: “What is your name?”
  2. Place: “Where are you?”
  3. Time: “What year is it?” or “Who is the president?”
  4. Situation: “Do you remember why you are here?”
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21
Q

Define:

Distal and Proximal

A
  • Distal: away from something
  • Proximal: closer to something
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22
Q

What is PERRLA?

A

PERRLA is using a light to check if Pupils are:

  • Equal
  • Round
  • React to Light
  • Accommodate

Remember: pupils constrict as objects get closer.

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23
Q

What is the cranial nerves “saying” in order to remember the names of the 12 cranial nerves?

A

Oh, Oh, Oh! To Touch And Feel A Good Velvet, Such Heaven!

  1. Olfactory
  2. Optic
  3. Oculomotor
  4. Trochlear
  5. Trigeminal
  6. Abducens
  7. Facial
  8. Acoustic/Vestibulocochlear
  9. Glossopharyngeal
  10. Vagus
  11. Spinal Accessory
  12. Hypoglossal
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24
Q

Draw the cranial nerve face.

A

This will help you to remember the function and location of the nerves.

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25
Q

What is the function of cranial nerve I?

A

I. Olfactory: smell

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26
Q

What is the function of cranial nerve II?

A

II. Optic: vision

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27
Q

What is the function of cranial nerve III?

A

III. Oculomotor: movement of pupils and eyelids

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28
Q

What is the function of cranial nerve IV?

A

IV. Trochlear: downward and inward movement of the eyes

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29
Q

What is the function of cranial nerve V?

A

V. Trigeminal: chewing

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30
Q

What is the function of cranial nerve VI?

A

VI. Abducens: eye movement lateral (side to side)

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31
Q

What is the function of cranial nerve VII?

A

VII. Facial: movement of all the facial muscles and taste

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32
Q

What is the function of cranial nerve VIII?

A

VIII. Acoustic/Vestibulocochlear: hearing

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33
Q

What is the function of cranial nerve IX?

A

IX. Glossopharyngeal: swallowing and taste

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34
Q

What is the function of cranial nerve X?

A

X. Vagus: swallowing and speaking

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35
Q

What is the function of cranial nerve XI?

A

XI. Spinal Accessory: shoulder movement

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36
Q

What is the function of cranial nerve XII?

A

XII. Hypoglossal: tongue strength

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37
Q

What is a Romberg test?

A

Used to test a client’s balance.

Have client stand with feet apart with eyes closed to assess balance.

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38
Q

Define:

Ptosis

A

When one eye droops.

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39
Q

What are the 5 areas of the brain?

A
  1. frontal lobe
  2. parietal lobe
  3. temporal lobe
  4. occipital lobe
  5. cerebellum
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40
Q

What is the function of the frontal lobe?

A

Controls:

  • thinking
  • speech
  • personality changes
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41
Q

What is the function of the parietal lobe?

A

Processes information for:

  • temperature
  • taste
  • movement
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42
Q

What is the function of the temporal lobe?

A

Controls:

  • hearing
  • language comprehension
  • memories
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43
Q

What is the function of the occipital lobe?

A

Controls vision.

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44
Q

What is the function of the cerebellum?

Located at the bottom of the brain.

A

Controls:

  • movement
  • gait
  • balance
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45
Q

What are the 4 regions of the spine?

A
  1. Cervical: C1-C8
  2. Thoracic: T1-T12
  3. Lumbar: L1-L5
  4. Sacral and Coccyx: S1-S5
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46
Q

What do the cervical nerves control?

(C1-C8)

A
  • breathing
  • arm and neck movement
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47
Q

What do the thoracic nerves control?

(T1-T12)

A

The strength of the:

  • chest
  • back
  • abdomen
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48
Q

What do the lumbar nerves control?

(L1-L5)

A

The strength of the:

  • lower abdomen
  • buttocks
  • legs
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49
Q

What do the sacral and coccyx nerves control?

(S1-S5)

A

The strength of the:

  • thighs
  • lower leg
  • genitals
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50
Q

What questions are asked during a nursing lung assessment?

A
  1. Have you had any difficulty breathing at rest or with activity?
  2. Have you had a cough?
    • If so, is it dry or a productive cough with mucus?
    • If productive with mucus, what color is it?
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51
Q

What are the normal lung sounds?

A
  • Vesicular
  • Bronchial (tracheal)
  • Bronchovesicular
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52
Q

Where is the stethoscope placed when doing a nursing lung assessment?

A

Place the stethoscope at the top and go progressively down the anterior and posterior thorax.

53
Q

Define:

Adventitious lung sounds

A

Abnormal breath sounds

54
Q

What are diminished or absent breath sounds?

A

An area of the lungs where the movement of air cannot be heard.

55
Q

Define:

dyspnea, tachypnea, and bradypnea

A
  • dyspnea: difficulty breathing
  • tachypnea: rapid respirations > 20
  • bradypnea: slow respirations < 12
56
Q

What is the difference between fine, medium, and coarse lung crackles?

A

Crackles are lung sounds caused by fluid in the lungs.

  • fine crackles: a little bit of fluid in the lungs that sounds like high-pitched popping sounds; click HERE for an audio sample.
  • medium crackles: condition is getting worse and lower-pitched popping sounds.
  • coarse crackles: bubbling sounds from fluids (really bad!); click HERE for an audio sample.
57
Q

What are wheezes?

A

High squeaky lung sounds.

They are caused by the small airways narrowing, usually in asthma. Click HERE for an audio sample.

58
Q

What are rhonchi?

A

Low-pitched lungs sounds that resemble snoring.

It is caused by secretions in the airway. They may clear with cough. Click HERE for an audio sample.

59
Q

What is atelectasis?

A

An incomplete expansion of the lung that causes diminished breath sounds.

It is most common with pneumonia.

60
Q

What are chene-stoke respirations?

A

Apnea lasting 10-60 seconds followed by hyperventilation.

It indicates a dying client but may be normal in babies.

61
Q

What is stridor?

A

A high-pitched, harsh sound from an obstructed airway.

62
Q

What is a pleural friction rub?

A

A low-pitched grating sound from pleurisy (inflammation in the lungs).

Click HERE for an audio sample.

63
Q

What is included in a basic nursing cardiac assessment?

A
  • asking the client about chest pain or chest discomfort
  • listening to heart sounds
  • checking pulses
  • checking capillary refill
  • checking skin temperature and color
  • checking for edema and skin turgor
  • assessing cardiac rhythm strip
64
Q

Define:

Brady and Tachy

A
  • Brady means slow
  • Tachy means fast

Bradycardia means a heart rate < 60
Tachycardia means a heart rate >100

65
Q

Where are the 5 heart sounds located?

  • aortic, pulmonic, Erb’s point, tricuspid, mitral
A

Use the mnemonic: “APE To Man” to remember.

66
Q

Explain how the blood flows through the heart.

A

Blood flow through the heart:
1. from systemic circulation into the vena cavas
2. right atrium > tricuspid valve > right ventricle
3. pulmonary valve > pulmonary artery > lungs
4. pulmonary veins
5. left atrium > mitral valve > left ventricle
6. aortic valve > aorta
7. systemtic circulation (throughout the body)
8. back to the vena cavas

67
Q

What are the heart sounds S1 and S2?

A

S1 and S2 are the normal heart sounds

It is sometimes known as “lub dub”.
Click HERE for an audio sample.

68
Q

What are the heart sounds S3 and S4?

A
  • S3 is usually an abnormal heart sound. Click HERE for an audio sample.
  • S4 is almost always associated with cardiac disease. Click HERE for an audio sample.

S3 and S4 are associated with fluid volume overload.

69
Q

What is a heart murmur?

A

An abnormal heart sound other than “lub-dub”. It can be a whooshing, swishing or clicking noise.

Click HERE for an audio sample.

70
Q

Label the pulses on the diagram from the following choices:

  • brachial, carotid, dorsalis pedis, femoral, posterior tibial, radial, ulna, popliteal
A
71
Q

What are the 4 pulse strengths and what do they indicate?

A
  • 4+: strong and bounding - indicates fluid volume overload
  • 3+: full pulse - less severe fluid volume overload
  • 2+: normal - easily palpable
  • 1+: weak, barely palpable - indicates fluid volume deficit
72
Q

What is edema and pitting edema and how is it assessed?

A

Edema: when there’s too much fluid in the body. It can be localized or throughout the body.

Pitting edema: when the skin remains indented after pressing with a finger.

Assessment criteria:

  • 1+, 2mm: a small pit and rebounds in a few seconds
  • 2+, 4mm: a medium pit and rebounds in a few seconds
  • 3+, 6mm: a deep pit and rebounds in 10-20 seconds
  • 4+, 8mm: very severe edema and rebounds in >30 seconds
73
Q

What is anasarca?

A

Another word for generalized edema.

74
Q

What is skin turgor and how is it assessed?

A

Assessing the client’s fluid status by pinching a fold of skin.

  • If the skin tents up = dehydration or fluid volume deficit.
  • if the skin returns to the normal position = no fluid issue.
75
Q

How is capillary refill assessed?

A

By pressing down on the nail bed.

  • if the pink color comes back in < 3 seconds, that is normal.
  • if the pink color comes back in > 3 seconds, it is abnormal.

Cap refill assesses the client’s blood circulation.

76
Q

Define:

Syncope

A

Loss of consciousness

77
Q

Label the gastrointestinal organs on the diagram from the following choices:

  • appendix, esophagus, gallbladder, large intestine, liver, pancreas, rectum, small intestine, stomach
A
78
Q

What does a basic nursing gastrointestinal assessment include?

A
  • listening to bowel sounds
  • ask when last bowel movement was
  • ask if passing gas
  • ask if patient experiences nausea/vomiting/diarrhea
  • determining appetite
79
Q

Define:

melena

A

Blood in the stool.

Sometimes called “tarry stools”.

80
Q

Define:

hematemesis

A

Blood in the vomit.

81
Q

Define:

Cachexia

A

Malnutrition/wasting away.

82
Q

What is the unique nursing assessment order for the abdomen/GI?

A
  1. inspect
  2. auscultate
  3. percuss
  4. palpate

It is done from least to most invasive in order to not disturb the abdomen and cause inaccurate findings.

83
Q

What are the four areas of the abdomen and how long is each quadrant listened to before deciding if there are bowel sounds?

A

Listen to each quadrant for 5 minutes = a total of 20 minutes.

  • start at upper left, upper right, lower right, lower left
  • go in a counterclockwise direction
84
Q

What are the different types of bowel sounds?

A
  1. absent: no bowel sounds
  2. hypoactive: 1 sound every 3-5 minutes
  3. normal: 5-30 clicks or gurgles per minute
  4. hyperactive: > 30 sounds per minute or an increase from the client’s baseline
85
Q

How is the body mass index (BMI) calculated?

A

BMI = kg ÷ m2

Example: if a client weighs 70 kg and is 1.8 meters tall, the BMI is 70 ÷ 1.82 = 21.6

  • normal weight = 18.5 to < 25
  • overweight = 25 to < 30
  • obese = > 30
86
Q

Define:

NPO

A

Nothing by mouth.

Don’t allow the client to eat or drink anything. This is a common order for preventing aspiration during surgeries and procedures or when having an acute GI issue.

87
Q

What are the 2 main functions of the pancreas?

A
  1. endocrine organ: to release insulin so the body can regulate glucose/sugar
  2. exocrine organ: to release enzymes for food digestion
88
Q

What is the function of the gallbladder?

A

To store bile that’s made by the liver for food digestion.

89
Q

What are the 4 main functions of the liver?

A
  1. to make clotting factors to prevent bleeding
  2. to make proteins so all the organs and cells can function
  3. to metabolize toxins and cholesterol
  4. to make bile for digestion
90
Q

What does a basic renal/urinary assessment include?

A
  1. checking urine: output and color
  2. monitoring: intake and output
  3. checking labs: BUN, creatinine, GFR, electrolytes
  4. urinalysis
91
Q

What is the minimum urine output for an adult and newborn?

A
  • adult: at least 30 mL/hour
  • infant (up to 1 year): at least 2ml/kg/hour
92
Q

What does a basic nursing musculoskeletal assessment include?

A
  1. checking: muscle strength and range of motion
  2. asking about: pain, numbness, and tingling
  3. checking: electrolytes and other labs
  4. imaging tests: spine and head
93
Q

What are the assigned numbers for muscle strength?

A
  • 0 is no muscle strength
  • 5 is normal muscle strength
94
Q

What are the numbers for deep tendon reflex grading?

A
  • 0 = no response; always abnormal
  • 1+ = a slight but present response; may or may not be normal
  • 2+ = a brisk response; normal
  • 3+ = a very brisk response; may or may not be normal
  • 4+ = a tap elicits a repeating reflex called clonus; always abnormal

Deep tendon reflex grading is using a hammer to tap the knee.

95
Q

Label the bones on the diagram from the following:

  • cranium, femur, fibula, humerus, patella, pelvis, radius, ribs, scapula, sternum, talus, tibia, ulna, vertebra
A
96
Q

What is kyphosis?

A

A curved thoracic spine (hunchback).

It is common in the elderly with osteoporosis.

97
Q

What is scoliosis?

A

Lateral spine curvature.

It is tested in teenagers.

98
Q

What does a basic nursing skin assessment include?

A
  • skin color
  • wounds (especially on bony areas)
  • rashes
  • bruising
  • abnormal moles/freckles
  • asking about new meds or exposure to infectious diseases (many cause rashes)
99
Q

Define:

urticaria and pruritis

A
  • urticaria: hives
  • pruritis: itching
100
Q

Define:

Cyanosis

A

When the skin has a blue tint due to a low oxygen reading.

101
Q

How is cyanosis assessed in a dark-skinned client?

A

Look for a bluish color by checking lips, tongue, nail beds, palm soles, and conjunctiva.

102
Q

Define:

erythema

A

Redness of the skin.

It indicates injury, inflammation or infection.

103
Q

Define:

pallor

A

Skin that is lighter than what the client is normally.

It can indicate decreased blood flow.

104
Q

Define:

jaundice

A

Yellowing of the skin, mucous membranes, and whites of the eyes.

It indicates liver failure.

105
Q

Define:

ecchymosis

A

Bruising of the skin.

106
Q

What questions are asked for a nursing pain assessment?

A
  • Location: where is the pain?
  • Severity: how bad is it? Use appropriate pain scale.
  • Character: what does it feel like?
  • Onset: when did it begin?
  • Associated factors: are there other symptoms that occur with it?
  • Pattern: what makes it better? what makes it worse?
  • What pain meds do you take?
  • Do you use alternative therapies to manage pain?
107
Q

What pain scale is used for alert and oriented adults?

A

0 - 10 pain scale

0 is no pain; 10 is the worst pain.

108
Q

What two pain scales can be used for non-verbal adults or young children <10 years old?

A

FLACC pain scale & Wong-Baker faces pain scale:

  • Face
  • Legs
  • Activity
  • Cry
  • Consolability
109
Q

What are some signs/symptoms of pain in an unconscious or non-verbal client?

A
  • ↑ heart rate
  • ↑ respirations
  • shallow respirations
  • facial grimacing
  • gasping
  • stooped
  • moaning
  • rubbing a body part
  • guarding
  • crying
110
Q

Define:

acute pain

A

Has a short duration and identifiable cause such as a surgery.

Vital signs are typically increased with acute pain.

111
Q

Define:

chronic pain

A

Has a long duration such as cancer, fibromyalgia, and back pain.

Vital signs are typically normal with chronic pain.

112
Q

What are basic documentation guidelines for nursing?

A
  • use black ink
  • date/time/name on each entry
  • document right after activity
  • be factual
  • use quotes for subjective data
  • document refusals of treatments and calls to HCP
113
Q

How should an error be documented in a client’s medical chart?

A

Draw one line through the error, initial, and date.

114
Q

What is unacceptable for nursing documentation?

A
  • do NOT document for others
  • do NOT leave blank spaces on forms
  • do NOT use unacceptable abbreviations
115
Q

What are modifiable risk factors?

A

Things the client can change such as diet or exercise.

116
Q

What are non-modifiable risk factors?

A

Things the client can’t change, such as family history/genetics, age, and sex.

117
Q

What are the 3 levels of disease prevention?

A
  1. Primary
  2. Secondary
  3. Tertiary
118
Q

What are some examples of primary disease prevention?

A
  • teaching about a healthy lifestyle (diet and exercise)
  • teeth brusing
  • car seats and seat belts
  • vaccinations
  • sunscreen
  • not smoking
  • preventing falls
  • limiting/eliminating alcohol
  • wearing masks in public
119
Q

What are some examples of secondary disease prevention?

A
  • preventing cancer with mammograms, colonoscopy, pap smear
  • stopping smoking
  • safer sex practices
120
Q

What are some examples of tertiary disease prevention?

A
  • support groups
  • cardiac rehab
  • skin care for diabetics
121
Q

What are some neuro changes in older adults?

A
  • confusion and lethargy with infections
  • hard of hearing
  • unable to see as well
  • decreased sensitivity to pain and temperature
  • taking longer to learn and remember
122
Q

What are some mental health issues older clients are more at risk for?

A
  • older white men that live alone are higher risk for suicide
  • increased risk of being abused
123
Q

What are some immune changes that occur with older adults?

A
  • decreased healing time
  • decreased immune system
  • increased risk of cancer
124
Q

What are some renal changes with older adults?

A
  • decreased kidney function
  • increased risk of incontinence
125
Q

What are some respiratory changes in older adults?

A
  • decreased lung function
  • getting out of breath easier

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126
Q

What are some skin changes in older adults?

A
  • dry skin
  • wrinkles
  • skin tears
  • spider angioma
  • varcose veins
  • bruising (ecchymosis)
127
Q

What are some musculoskeletal changes in older adults?

A
  • osteoporosis
  • decreased muscle mass
  • increased risk of falls
128
Q

What are some gastrointestinal changes in older adults?

A
  • nutritional changes
  • loss of teeth
  • decreased liver function
129
Q

What is a pleural friction rub?

A

A low-pitched grating sound from pleurisy (inflammation in the lungs).

Click HERE for an audio sample.

NCLEX-RN (1) Fundamentals (17 decks)

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