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HESI Health Assessment Practice (1)
Get Quizlet's official HESI A2 - 1 term, 1 practice question, 1 full practice test
Terms in this set (78)
Measures O2 saturation
think Abe Lincoln
Hyperpituitarism- occurs during adulthood.
wasting syndrome (cancer patients)
Normal BMI for adults
Weight around middle.
Body temp regulated by-
Heat is lost through:
Radiation, convection, conduction and evaporation.
Point of Maximum Impulse= Apical Impulse
Same pulse as carotid artery. Measure this if you find irregularity.
Normal Respiratory Rate
12-20 breathes per minute
volume of blood ejected from heart each minute.
Peripheral Vascular Resistance
force that opposes flow of blood through vessels.
Bps standing, lying, sitting (fainting/syncope)
Narrow PP: decrease in ventricular output, dehydration or bleeding out.
Wide PP: physical activity.
Cuff too small:
Cuff too loose:
Arm above heart:
Arm below heart:
Deflate too fast:
Deflate too slow:
Cuff too small: falsely high
Cuff too loose: falsely high
Arm above heart: falsely high
Arm below heart: falsely low
Deflate too fast: falsely low systolic
Deflate too slow: falsely high diastolic
Excess cortisol secreted (buffalo hump), moon face
Acute vs Chronic Pain
Where can gallbladder pain be felt?
Lower chest and neck (referred pain)
difficulty speaking or writing
disorders of voice (hoarseness)
difficulty saying words due to muscles
Making up new words
unnecessarily wordy language
Hallucination vs Illusion
Hallucination- seeing something that isn't there.
Illusion- seeing things that are there but with unreal characteristics.
Delirium vs Dementia
Delirium- temporary & reversible
Dementia- progressive & irreversible
Alcohol Screening Tool
CAGE C:cut down? A:anyone annoyed you? G:feeling guilty? E:eyeopener?
Alcohol Assessment for pregnant women
How often should you screen for domestic violence?
At every visit
Jaundice due to high levels of bilirubin (babies)
During an examination, the nurse can assess mental status by which activity?
Observing the patient and inferring health or dysfunction
To test for a pt's judgment-
Ask about daily or long-term goals.
Order of assessment for abdomen-
Inspection, Auscultation, Palpation, Percussion
The nurse is preparing to assess a patient's abdomen by palpation. How should the nurse proceed?
Start with light palpation to detect surface characteristics and to accustom the patient to being touched.
The nurse would use bimanual palpation technique in which situation?
Kidneys & unterus
The nurse is unable to palpate the right radial pulse on a patient. The best action would be to:
use a Doppler device to check for pulsations over the area.
When assessing the force, or strength, of a pulse, the nurse recalls that it:
is a reflection of the heart's stroke volume.
When assessing the quality of a patient's pain, the nurse should ask which question?
"What does your pain feel like?"
ABCDEs of suspicious lesions
A-asymmetry, B-border, C-color, D-diameter (pencil eraser), E-elevation
Pressure Ulcer Stages
Stage I- red, unbroken skin
Stage II- shallow, open pink ulcer
Stage III- damage to subcutaneous tissue
Stage IV- exposed bone, muscle or tendon
absence of melanin pigment in patchy areas of white skin
intense redness of skin from excess blood
Normal pulse rates
60-100 beats per minute
Normal blood pressure
90-139 mmHg/60-89 mmHg
6 Steps of the Nursing Process
3) Outcome Identification
The largest and fastest growing population in the US-
Prevention in describing health is essential because:
prevention places emphasis on the link between health and personal behavior.
A physician in clinic is frequently bothered when patients arrive late 4 appointments. He's so irritated by this behavior that he often finds it hard to provide appropriate care. What should he do first in trying to overcome his difficulty?
Examine his own culturally based values, beliefs, attitudes, and practices.
Who has the highest risk of suicide?
The patient with a plan.
Flight of Ideas
Continuous flow of rapid speech that jumps topics but based on association.
"Pill is red. Red velvet. Velvet is smooth"
Mini Mental State Examination
It is a good tool to detect delirium and dementia and to differentiate these from psychiatric mental illnesses.
Chronic Alcohol use associated with-
Diaphragm vs bell
diaphragm- high pitched sounds
bell- low pitched sounds (murmurs)
Normal less than 120 and less than 80
Prehypertension 120 - 139/80 - 89
(Hypertension) Stage 1 140 - 159 /90 - 99
(Hypertension) Stage 2 160 or higher/100 or higher
(Emergency care needed) Higher than 180/Higher than 110
showing symptoms of fever
red, blunt tipped, lubricated thermometer about 1 inch in for 2.5 min.
Rate (60-100 bpm)
Rhythm (Regular, Irregular regular, Irregular irregular)
Force (0-3+, 2+ normal)
Pulse/hr varies with respiratory cycle.
inflammation of the gall bladder.
The nurse knows that which statement is true regarding the pain experienced by infants?
A procedure that induces pain in adults will also induce pain in the infant.
Hyperthyroidism vs Hypothyroidism
Hyperthyroidism- skin feels smooth & soft, tachycardia
Hypothyroidism- skin feels rough & dry
Primary vs Secondary lesions
Primary- develops on previously unaltered skin
Secondary- lesion changes (scratching or infection)
excess body hair
ringworm of the scalp
symptoms: scaling, hair breaks off in patches
180 degrees or more. Occurs with congenital cyanotic, pulmonary and neoplastic diseases
Brown linear streaks
Brown linear streaks: melanoma
Beau's lines: transverse ridges due to infection/trauma
Splinter hemorrhages: red/brown streaks due to bacterial endocarditis
Increased serum carotene from ingestion of large amounts of carotene-rich foods.
Appearance: yellow-orange in forehead, palms, soles and nasolabial folds but no yellowing in the sclera or mucous membranes.
Lesion Shapes & Configurations-
Confluent: run together
Discrete: remain separate
Target/Iris: concentric rings
Zosteriform: follow nerve route
Polycyclic: circular lesions grow together
Primary Skin Lesions-
Macule: flat color change; freckle (large- patch)
Papule: you can feel, <1 cm; mole (large- plaque)
Nodule: deep, >1 cm (large- tumor)
Wheal: raised, irregular shaped edema; mosquito bite (multiple- urticaria/hives)
Vesicle: blister (large- bula)
Cyst: encapsulated, fluid filled; cyst
Pustule: pus in cavity; acne
Secondary Skin Lesions'
Crust: dried out exudate
Scale: desiccated flakes of skin
Fissure: crack in skin
Erosion: shallow depression
Ulcer: deep depression
Lichenification: prolonged scratching
Keloid: hypertrophic scar
Contusion vs Bruise
Contusion is a bruise
Hematoma is a bruise you can feel.
Progression of bruise:
1) red-blue or purple
2) blue to purple
Petechiae: tiny point hemorrhages
Ecchymosis: purplish patch
Purpura: patch of petechiae and ecchymosis
Paget's disease occurs more often in males and is characterized by bowed long bones, sudden fractures, and enlarging skull bones that press on cranial nerves causing symptoms of headache, vertigo, tinnitus, and progressive deafness.
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