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Health Assessment (NURS 3309) > Test 2 > Flashcards

Test 2 Flashcards

1
Q

What quadrant is the liver located in?

A
  • RUQ (majority of liver)

- LUQ

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2
Q

What quadrant is the spleen located in?

A

LUQ

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3
Q

What quadrant is the small intestine located in?

A

All 4 quadrants

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4
Q

Hematemesis

A

Vomiting blood - bright red

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5
Q

What are some common causes of hematemesis?

A

Upper GI problems

E.g., esophageal varices rupture, stomach cancer, blood thinners, NSAIDs, stomach ulcer

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6
Q

Coffee-Ground Emesis

A
  • Dark brown, coffee-ground appearing vomit

- Color comes from oxidation of blood in stomach - not as urgent as others

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7
Q

What is coffee ground emesis associated with?

A

Upper GI bleeding

E.g., stomach ulcer, gastritis, esophageal varices rupturing

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8
Q

Which is more of an emergency? Bright red vomit, coffee-ground vomit, or bright green vomit?

A

Green & bright red vomit are biggest emergencies

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9
Q

Feculent emesis definition & Cause

A
  • Vomiting feces

- Indicates intestinal obstruction

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10
Q

What quadrant is the large intestine found in?

A

All 4 quadrants

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11
Q

Acute abdomen signs & symptoms of exam (subjective & objective)

A
  • Severe pain
  • Fever
  • Bilious or bloody vomit
  • Diarrhea or constipation
  • Distended abdomen
  • Hyper resonance
  • Mass
  • Rigid abdomen
  • Hyperactive bowel sounds
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12
Q

Linea alba

A

Midline seam joining abdominal muscle

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13
Q

OLDCARTS

A

Onset
Location
Duration

Characteristics 
Aggravating/Alleviating factors 
Radiation 
Timing
Severity
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14
Q

What are some things you should do to prepare for an abdominal exam?

A
  • Ensure good lighting
  • Drape for privacy
  • Enhance relaxation by having pt lie supine, do breathing exercise, etc
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15
Q

What are the steps in order of the abdominal exam?

A
  1. Inspection
  2. Auscultation
  3. Percussion
  4. Palpation
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16
Q

What do you look at on inspection of the abdomen?

A 
Contour 
Symmetry 
Umbilicus
Skin
Pulsations
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17
Q

Hypoactive bowel sounds suggest…

A

Peritonitis or recent surgery

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18
Q

Hyperactive bowel sounds suggest…

A

Intestinal obstruction, diarrhea, intestinal infection

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19
Q

How long do you listen to bowel sounds to deem them absent?

A

5 min

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20
Q

Hyper-resonance during percussion of the abdomen suggests…

A

A gas-filled distension

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21
Q

If percussion causes pain, the pt likely has _______.

A

Peritonitis (inflammation of peritoneum)

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22
Q

What is the purpose for light palpation?

A

Determines musculature & forms impression of skin surface

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23
Q

When are some situations that bimanual palpation of abdomen may be necessary?

A
  • Obese pt

- Overcome resistance

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24
Q

T/F: In normal circumstances, the liver is often not palpable

A

T

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25
Q

T/F: In normal circumstances, the spleen is often palpable.

A

F (not normally palpable)

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26
Q

When palpating aorta, a width of >4cm could suggest…

A

Aneurysm

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27
Q

Why would you percuss for a fluid wave in pt?

A

To differentiate btw gaseous & fluid distension

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28
Q

Blumberg Sign

A

Palpating for rebound tenderness to test for peritoneal inflammation or appendicitis

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29
Q

Murphy’s Sign tests for…

A

Cholecystitis - should be painless

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30
Q

What are some differences in abdominal assessment in infants & children?

A
  • Liver takes up more space
  • Bladder higher up
  • Protuberance
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31
Q

What is the normal sound you’d hear in percussion on the abdomen over air-filled structures?

A

Tympany

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32
Q

What is the normal sound you’d hear in percussion on the abdomen over a fluid-filled structure?

A

Dullness

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33
Q

What is the normal sound you’d hear in percussion of the abdomen over a solid viscera?

A

Dullness

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34
Q

When would you do a test for Murphy’s Sign?

A

If you suspect gallbladder inflammation

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35
Q

What is the normal sound you’d hear in percussion of the abdomen over a gas-filled distension?

A

Hyper-resonance

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36
Q

What do you listen for in auscultation of the abdomen?

A
  • Bowel sounds (hypoactive, hyperactive, normal)

- Vascular sounds (bruits)

37
Q

T/F: Upon palpation, you should be able to feel both smooth, round kidneys on left & right.

A

False; Can usually only feel right kidney

38
Q

Cholecystitis

A
  • Inflammation of gallbladder

- Tested w/ Murphy Sign Test

39
Q

Wernicke’s Aphasia

A

Inability to understand speech

40
Q

Brocha’s Aphasia

A

Inability to produce fluent speech

41
Q

Global Aphasia

A
  • Both production of language & understanding of language impaired
  • Most common & most severe aphasia
42
Q

If spleen is palpable during abdominal exam, what are some possible causes?

A 
Mononucleosis
Lymphoma 
Leukemia 
HIV
Trauma
43
Q

for pt w/aphasia, what are some cognitive tests we would do?

A

Word comprehension
Reading
Writing

44
Q

In what part of a mental status exam would a nurse typically pick-up on a pt hallucinations?

A

Thought processes & perceptions

45
Q

If you are going to administer the MMSE test, what are you testing & what must the pt be able to do in order to participate?

A
  • Assesses cognitive function

- Pt must be able to read, write, & see

46
Q

The MMSE is a good screening tool for detecting…

A

Dementia & delirium

47
Q

T/F: The MMSE doesn’t assess mood or thought processes

A

True! Only cognitive function

48
Q

Delirium vs. Dementia

A

Delirium: acute onset, reversible
Dementia: gradual, progressive, not reversible

49
Q

CIWA

A

Assessment tool for alcohol withdrawal

50
Q

GAD-7

A

Screens for generalized anxiety disorder

51
Q

PHQ-9

A

Screens for depression

52
Q

MMSE

A

Mini cognitive function screening identifying dementia & delirium

53
Q

Denver II

A

Screens children for developmental delays

54
Q

Behavioral Checklist

A

Given to parents for children age 7-11 to assess development

55
Q

Mini-Cog Test

A

Screens for dementia using clock drawing & 3 word recall

56
Q

What are some things to ensure before performing a Mini-Cog test on a pt?

A
  • Ensure pt doesn’t have hearing or vision impairment

- Ensure environment is quiet

57
Q

First 7 ribs attach to?

A

Sternum by costal cartilages

58
Q

Floating ribs

A
  • Ribs 11 & 12

- Free palpable tips

59
Q

Costochondral Junctions

A
  • Points which ribs join cartilages

- Not palpable

60
Q

Vertebral prominence location

A

C7 or T1

61
Q

Spinous process location

A

T10 to T12

62
Q

Mediastinum

A
  • MIddle section of thoracic cavity

- Contains: esophagus, trachea, heart, & great vessels

63
Q

Which lung is shorter and why?

A
  • Right lung

- Underlying liver

64
Q

Which lung is narrower and why?

A
  • Left lung

- Heart bulges left

65
Q

How many lobes does each lung have?

A
  • R: 3

- L: 2

66
Q

Visceral Pleura

A

Lines outside of lungs, dipping down into fissures

67
Q

Parietal Pleura

A

Lines inside of chest wall & diaphragm

68
Q

Pleural Cavity

A

Potential space filled/few mL of lubricating fluid

69
Q

Functions of Respiratory Stystem

A
  1. Supply O to body for energy production
  2. Remove CO2 as waste product
  3. Maintain homeostasis (acid-base balance)
  4. Maintaining heat exchange
70
Q

Steps of Respiratory Assessment

A
  1. Inspection
  2. Palpation
  3. Percussion
  4. Auscultation
71
Q

Crepitus

A
  • Collection of air in subcutaneous tissue

- Tender when palpated

72
Q

Where should you place your hands for posterior chest expansion for symmetry? Steps?

A
  • Posterolateral chest wall w/thumbs at 79 or T10
  • Slide hands together medially to pinch small fold
  • Ask pt to take deep breath
73
Q

Tactile Fremitus

A
  • Sound generated from larynx; vibration

- Transmitted through pt bronchi & lung parenchyma to chest wall

74
Q

How to test for Tactile Fremitus?

A
  1. Palmar base of fingers or ulnar edge both hands, touch pt chest while pt repeats “99”
  2. Start over lung apices & palpate bilaterally through lung fields
75
Q

What are some factors affecting normal intensity of Tactile Fremitus?

A
  • Relative location of brochi to chest wall
  • Decreases as progressing down
  • Thickness of chest wall (fat or muscular)
76
Q

Percussion of lung fields of posterior chest

A
  1. Determine predominant note over lung fields (start at apices)
  2. Percuss in intercostal spaces
  3. Percuss at 5cm intervals
  4. Resonance low-pitched, clear, hollow sound in healthy lung tissue of adult
77
Q

Purpose of Diaphragmatic Excursion?

A

Mapping out lower lung border in expiration & inspiration

78
Q

The 3 types of breath sounds?

A
  1. Bronchial (tracheal or tubular): expiration > inspiration
  2. Broncho-vesicular: inspiration = expiration
  3. Vesicular: inspiration > expiration
79
Q

Crackles - Fine

A
  • Discontinuous, high-pitched, short crackling, popping
  • During inspiration
  • Not cleared by coughing
  • Mech: inhaled air collides w/previously deflated airways
80
Q

Crackles - Coarse

A
  • Loud, low pitched bubbling & gurgling sounds
  • Start in inspiration & may be present expiration
  • May decrease w/cough; will reappear
  • Mech: inhaled air collides w/secretions in trachea & large bronchi
81
Q

Atelectatic crackles

A
  • Sound like fine crackles but don’t last
  • Not pathologic
  • Disappear after first few breaths
82
Q

Pleural Friction Rub

A
  • Coarse & low pitched
  • Sounds like crackles but close to ear
  • Louder if push stethoscope harder
  • Inspiratory & expiratory
  • Mech: Pleurae inflamed & lose normal lubricating fluid
83
Q

Wheeze - High Pitched (Sibilant)

A
  • High-pitched, squeaking sounds sounding polyphonic
  • Predominate in expiration; may occur in both
  • Mech: air squeezed or compressed though passageways narrowed almost to closure (collapsing, swelling, secretions, or tumors)
84
Q

Wheeze - Low Pitched (Sonorous rhonchi)

A
  • Low-pitched
  • Monophonic, single note, moaning sounds
  • More prominent on expiration
  • May clear by coughing
  • Mech: Airflow obstruction
85
Q

Stridor

A
  • High-pitched
  • Monophonic, inspiratory, crowing sound
  • Louder in neck than over chest wall
  • Mech: upper airway obstruction from swollen, inflamed tissues
86
Q

When id voice resonance testing performed?

A

If any adventitious sound is heard during auscultation

87
Q

Bronchophony

A

“99”

Normal = soft, muffled, indistinct

88
Q

Egophony

A

“eeee”

Normal: audible “eee” doesn’t change to “aaa”

89
Q

Whispered pectoriloquy

A

“1, 2, 3”

Normal: faint, muffled, almost inaudible

Health Assessment (NURS 3309) (1 decks)

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