144 terms

health assessment final exam

from the blueprint/study guide
The nurse is caring for patients on the surgical floor and has just received report from the previous shift. Which of the following patients should the nurse see FIRST?

A. A 35-year-old admitted three hours ago with a gunshot would; 1.5 cm area of dark drainage noted on the dressing

B. A 43-year-old who had a masectomy tow days ago; 23 cc of serosanguinous fluid noted in the Jackson-Pratt drain

C. A 59-year-old with a collapsed lung due to an accident; no drainage noted in the previous eight hours

D. A 62-year-old who had an abdominal-perineal resection three days ago; patient complains of chills
The nurse is caring for patients in the outpatient clinic. Which of the following phone calls should the nurse return first?

A. A client with hepatitis A who states "My arms and legs are itching."

B. A client with a cast on the right leg who states, " I have a funny feeling in my right leg."

C. A client with osteomylitis of the spine who states, " I am so nauseous that I can't eat."

D. A client with rheumatoid arthritis who states, " I am having trouble sleeping."
high priority
Vital Signs
Second priority
mental status change
untreated medical problem
acute pain
acute urinary elimination problem
abnormal lab value
risk of infection
cultural consideration hispanic
Curanderos use herbs, aromas, and rituals to treat the ills of the body, mind and spirit.
have a higher rate of diabetes
cultural consideration chinese
eldest son holds responsibility for family
Control of emotions, restraint, obedience to authority, conforming and "face" are highly valued and important
balance between hot foods and cold foods
lung (worry), gallbladder/liver (anger), heart (happy), kidney (fear), spleen (desire)
considerations japanese
diabetes, cancer, dementia
muslim consideration
female/female or male/male for nursing care as they place high value on modesty
left hand=dirty
what distance should you be from patient when you are conducting interview
4-5 feet
ten traps of interviewing
false assurances
giving unwanted advice
using authority
using avoidance language
engaging in distancing
using professional jargon
using leading or biased questions
talking too much
using why questions
this age uses telegraphic speech so it is best to keep explainations simple
this age can tolerate and understand others viewpoints, more objective and realistic, able to reason very curious
school age
value peers, crave acceptance, think that no adult can understand them
broca's aphsia
can understand language but cannot express it himself nonfluent, dysarthic, effortful speech
wernickes aphasia
can hear sounds but cannot relate them to previous experiences speech is fluent, effortless and well articulated but has many paraphasias and made up words
subjective data
"Lately I just don't feel like myself"
objective data
HR=80 BP=125/80 T=38 RR=18
skin feels cool, & clammy etc
dont use family member
must use trained medical interpreter
nonverbal cross cultural
vocal cues
action cues
object cues
use of personal and territorial space
physical appearance
facial expression
eye contact
standard based precautions
designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources, and they apply to (1) blood; (2) all body fluids, secretions, and excretions except sweat, whether or not they contain visible blood; (3) nonintact skin; and (4) mucous membranes
transmission based precaution
i`ntended for use with patients with documented or suspected transmissible infections. They are designed in addition to Standard Precautions to interrupt transmission in hospitals. There are three types of transmission-based precautions: airborne, droplet, and contact
infant examination considerations
nonverbal communication is key
firm gentle handling quiet calm voice
keep parent in view
aging adult considerations
biggest fear is losing independence
avoid elder speak
allow more time for interview
collect most important data first, allow for multiple meetings
adjust pace; allow time to answer questions fully
head/chest circumference infant
Newborn's chest grows at a faster rate than the cranium; @ some point btw 6mths & 2 yrs, both measurements are about the same, & after 2 yrs of age the chest circumference is greater than the head circumference. Enlarged head circumference occurs w/ increased ICP
radial pulse
0 absent
1+ weak( as with shock and peripheral arterial disease)
2+ normal
3+ increased/full/bounding (as with anxiety, exercise, fever, anemia, hyperthyroidism)
atopic dermatitis erythematous papules and vesicles with weeping oozing and crusts lesiosn usually on scalp forehead cheeks forearms and wrists elbows backs on knees family history of allergie
moist thin roofed vesciles with thin erythemous base. rupture to form HONEY COLORED CRUST contagious bacterial infection of the skin most common in infants and children
an inflammation of the skin characterized by redness, pruitus (itching), and various lesions
herpes zoster
small grouped vesicles emerge along route of a cutaneous sensory nerve, then pustules then crusts. caused by the varicella zoster virus acute appearance UNILATERAL DOES NOT CROSS MIDLINE
traumatic self induced hair loss usually the result of compulsive teisting or plucking
forms irregularly shaped patch, with broken off stublike hairs of varying lengths; person is never completely bald
occurs as child rubs or twists area absently while falling asleep reading or watching tv
in adults it is a sign of a serious personality disorder
superficial infection of hair follicles
multiple pustules whiteheads with hair visible at the center and erythematous base
usually on arms legs face and buttocks
traumatic alopecia
linear or oval patch of hair loss along hair line, a part of scattered distribution; caused by trauma from hair rollers tight braiding tight ponytail or barrettes
tina capitis
scalp ringworm; rounded patchy hair loss on scalp leaving broken off hairs pustules and scales of skin. caused by fungal infection; lesions may fluoresce blue green under woods light usually seen in children and farmers; highly contagious may be transmitted to another person by domoestic animals or from soil
shock white patient
shock black patient
pallor=ashen gray
basal cell carcinoma
usually starts as a skin colored papule (may be deeply pigmented with a pearly translucent top and overly telangiectasia. then develops rounded, pearly borders with central red ulcer, or looks like large open pore with central yellowing. most common form of skin cancer slow but inexorable growth. basal cell cancers occur on sun exposed areas of face ears scalp and shoulders
cluster headache
repeated headaches that can occur for weeks to months at a time, followed by periods of remission; characterized by attacks of intense unilateral pain that occurs most often over the eye and forehead.
severe vascular headache preceded by auras that may include nausea and vomiting
meningeal inflammation
acute onset of stiffness with headache and fever shows this inflammation
condition of hypersecretion of the thyroid gland characterized by exophthalmia, tachycardia, goiter, and tumor
condition of hyposecretion of the thyroid gland causing low thyroid levels in the blood that result in sluggishness, slow pulse, and often obesity
CVA tenderness
costovertebral angle; firmly tapping over the kidneys - + if it produces pain (suggests renal pain)
Bell's palsy
temporary paralysis of the seventh cranial nerve that causes drooping only on the affected side of the face
tympanostomy tube
..., ear tubes inserted to relieve middle ear pressure n allow drainage from repeated middle ear infection
position of ear for adult
up and back
position of ear for child
down and back
the process of the teeth pushing their way through the gums ~6-7 months
most common site for nosebleed is kiesselbach plexus in anterior septum
may be spontaneous or a sign of underlying illness
posterior hemorrhage is less common more profuse and harder to manage
facial pain after upper respiratory infection signs include red swollen nasal mucosa swollen turbinates and purulent discharge. person also has fever chills malaise. with maxillary sinusitis dull throbbing pain occurs in cheeks and teeth on same side and pain with palpation is present. with frontal sinuitis pain is supraorbital
when to perform BSE
right after menstral period or the 4th or 7th day of menstral cycle breasts are smallest and least congested
breast abnormalities
mammory duct ectasia
intraductal papilloma
pagets disease
breast absess
characteristic of a lump(10)
nipple(displaced or retracted)
note skin over lump
beginning of breast development precedes menarche by ___ years
apices of lung
3-4 cm above the clavicle
base of lung
lower border of lung; rests on the diaphragm at about the sixth rib in the midclavicular line (T 10 posteriorly)
normal= soft muffled indistinct
abnormal= more distinct
Increase in intensity and clarity of the vocal resonance that may result from an increase in the lung tissue density, such as in the consolidation of PNEUMONIA
a change in the voice sound of a patient with PLEURAL EFFUSION or PNEUMONIA as heard on auscultation. When the patient is asked to make /ē-ē-ē/ sounds, they are heard over the peripheral chest wall as /ä-ä-ä/, particularly over an area of consolidated or compressed lung above the effusion.
significance of unequal chest expansion
abnormal wide costal angel with little inspiratory variation occurs with atelectasis, pneumothroax, lobar pneumonia, pneumonia
__ weeks primitive lung emerges
___ weeks conducting airways reach same # as in adults
___ weeks surfactant is present in adequate amounts
aortic pulse
pulse located at the right 2nd intercostal space
pulmonic pulse
pulse located at the left 2nd intercostal space
erbs point
auscultatory area 3rd left intercostal space
triscuspid is located
4-5 intercostal left
mitral is located
fifth interspace left midclavicular
beginning of systole, closing of AV valves
loudest at APEX
coincides with carotid artery pulse
coincides with R segment of QRS complex if patient is on an ECG monitor
Loudest at BASE
end of systole
closing of semilunar( aortic and pulmonic valves)
abnormal heart sound
Usual cause is myocardial failure.
Occurs immediately after S2 (early diastole).
Heard best at apex
listen with bell. Low pitch.
an abnormal heart sound
detected late in diastole as resistance is met to blood entering either ventricle during atrial contraction;
most often caused by hypertrophy of the ventricle
aortic stenosis
allen test
Determining the patency of the radial and ulnar arteries by compressing one artery site and observing return of skin color as evidence of patency of the other artery
CVA tenderness
Pain felt when gently tapping the area of the back overlying the kidney(~12 rib). Sign of inflammation, infection of the kidney eg pyleonephritis
black tarry stools significance?
occult blood upper GI
Right Upper Quadrant
Head of pancreas
Right kidney
Hepatic flexure of colon
Top of ascending and part of transverse colon
Right Lower Quadrant
Right ovary and tube
Right ureter
Right spermatic cord
Left Upper Quadrant
Left lobe of liver
Body of pancreas
Splenic flexure of colon
Transverse and top of descending colon
Left Lower Quadrant
Part of descending colon
Sigmoid colon
Left ovary and tube
Left ureter
Left spermatic cord
umbilical hernia
soft skin covered mass which is the protrusion of the omentum or intestine through a weakness or incomplete closure in the umbilical ring
crying coughing vomiting straining
tennis elbow
Inflammation of the common tendon of origin for all posterior forearm muscles. Patient has pain around lateral epicondyle with radiation down lateral forearm. AKA: lateral epicondylitis
phalens test
Ask the person to hold both hands back to back while flexing the wrists 90 degrees. Acute flexion of the wrist for 60 seconds produces no symptoms in the normal hand. (produces numbness and burning in a person with carpal tunnel).
tinels test
tap the median nerve
test for carpal tunnel
allis test
- used to check hip dislocation by comparing leg lengths.
-place baby's feet flat on the table, and flex the knees up.
-knees should be at same elevation
ortolani test
Abduct thighs and apply gentle pressure forward over greater trochanter. Clunking sensation indicates femoral head moving into acetabulum. Hip click may be felt or heard but that is normal. (Butterfly stretch)
sense that allows the brain to be constantly aware of the position and movement of muscles in different parts of the body (without this, coordinated movements with your eyes closed would be impossible)
ability to perceive the form of an object by using the sense of touch
Ability to identify letters, numbers, or shapes drawn on the skin
tactile discrimination
Requires interpretation by the cerebral cortex.
sterognosis, graphesthesia, 2 pt disc, point location
largest part of the brain; responsible for voluntary muscular activity, vision, speech, taste, hearing, thought, and memory
the "little brain" at the rear of the brainstem; functions include processing sensory input and coordinating movement output and balance.
part of the brain nearest the spinal cord which controls breathing, heart rate and blood pressure
extrapyramidal tract
→starts in motor cortex & travels to basal ganglia, brain stem then spinal cord
gross movement, basal ganglia
→problems here cause movement disorders such as:
restless legs
shuffling gait
region of the brain that serves as a relay between the cerebrum, cerebellum, and spinal cord; responsible for breathing, heart rate, and body temperature; the three levels are the mesencephalon (midbrain), pons, and medulla oblongata
the structure of the brain that relays messages from the sense organs to the cerebral cortex
Olfactory nerve -- postsynaptic fibers go to primary olfactory cortex. Lesion associated with loss of sense of smell/taste.
Optic Nerve--visual acuity, visual fields by confrontation, fundoscopic exam; sensory
damage can cause loss of central vision
Oculomotor, Mixed, Motor: most EOM movt, opening of eyelids, PNS: pupil constriction, lens shape
damage can cause blown pupil
Trochlear--corneal light reflection, downward and inward movement of eye, diagnostic position test (cardinal fields); motor
damage causes loss of peripheral vision
motor muscles of mastication
sensory sensation of face scalp cornea
motor lateral movement of the eye
motor facial muscles close eye labial speech close mouth
sensory taste(sweet sour salt bitter) anterior 2/3
sensory hearing and equilibrium
motor pharnyx phonation and swallowing
sensory taste of posterior 1/3 of tongue gag reflex
motor pharnyx talking and swallowing
sensory general sensation from carotis body sinus pharnyx viscera
spinal accessory
motor movement of trapezius and sternomastoid muscle
motor movement of the tongue
glasgow coma scale
objective way of recording the conscious state of a person (3-14)
Generally, brain injury is classified as:
Severe, with GCS ≤ 8
Moderate, GCS 9 - 12
Minor, GCS ≥ 13.
babinski reflex
extension upward of the toes when the sole of the foot is stroked firmly on the outer side from the heel to the front
ex.normal in infants under the age of 2 years but a sign of brain or spinal cord injury in older persons
plantar reflex
flexion of the toes when the sole of the foot is stroked firmly on the outer side from the heel to the front in persons over the age of 2 years
Ex. under 2 years the results should be extension of the toes (Babinski reflex)
romberg test
test for cerebellar dysfunction requiring the patient to stand with feet together, eyes closed and arms extended; inability to maintain the position, with either significant stagger or sway, is a positive test
urethral meatus opens on the VENTRAL side of the glans or shaft . a groove extends from the meatus to the normal location at the tip this is a congential defect that is important to recognize at birth newborn should NOT be circumcised because it can cause further harm
nonretractable foreskin forming a pointy tip with a tiny orifice
may be congital or acquired
carcinoma(p 702)
begins as red raised WARTY GROWTH or as an ulcer with watery discharge
as it grows it may necrose and slough
usually painless
almsot always on glans or inner lip of foreskin and enlarged lymph nodes are common
genital herpes--HSV2 Infection
clusters of small vesicles with surrounding erythema, which are often PAINFUL erupt on the glans or foreskin these RUPTURE to form superficial ulcers a STI lasts 7-10 days. remains dormant indefinitely.
recurrent infections last 3-10 days with milder symptoms
genital warts(701)
soft pointed moist fleshy painless papules may be single or multiple in a CAULIFLOWER like patch
gray yellow pink in white males
black or gray in black males
caused by HPV
syphilitic chancre
begins within 2-4 weeks of infection as small SOLITARY SILVERY papule that erodes into a red round or oval superficial ulcer with YELLOW discharge
nontender; treated with pen G
untreated leads to cardiac and neurologic problems
normal testes
egg-shaped and movable, feels rubbery with a smooth surface, like a peeled hard-boiled egg
left lower than right
Peyronies disease
hard nontender subcutaneous plaques palpated on dorsal or lateral surface of penis
may be single or multiple
painful BENDING of the penis during erection
hegar sign
Softening of the lower uterine segment that allows it to be easily compressed at 6 to 8 weeks of pregnancy.
goodell sign
Softening of the cervix that occurs during the second month(4-6 weeks) of pregnancy.
chadwick sign
bluish discoloration of the mucosa occurs normally in preganany(8-12 weeks )and with any other condition causing hypoxia or venous congestion
Papanicolaou smear
Cytologic study of smears of cervical and endocervical tissue obtained by scrapings to diagnose the presence of abnormal tissue
pelvic inflammatory disease
fallopian tube mass--Acute salpinitis
sudden fever(100.4) subrapubic pain and tenderness
acute rigid boardlike abdomen may have purulent discharge from cervix
cyclic or chronic pelvic pain occurring as dysmenorrhea or dyspareunia low backache
irregular uterine bleeding or hypermenorrhea or may be asymptomatic
may cause infertility from decreased ovarian function
ectopic pregnancy
fallopian tube mass
amenorrhea or irregular vaginal bleeding
softening of the cervix and fundus movement of cervix and uterus causes pain palpable tender pelvic mass, which is solid mobile unilateral
has potential for serious sequelae go to doc immediately bfore mass ruptures!
uterine fibroids
myoma leiomyomas
various symptoms depending on size and location
discomfort bloating heaviness pelvic pressure frequency hypermenorrhea
uterus irregularly enlarged firm mobile and nodular with hard painless nodules in the uterine wall
usually benign most common= 30-45 blacks
pediculosis pubis
crab lice severe perineal itching
excoriations and erthematous areas
may see little dark spots lice are small nits(eggs) adherent to pubic hair near roots usually localized in pubic hair occasionally in eyebrows or eyelashes
symptoms variable vaginal discharge dysuria abnormal uterine bleeding abscess in batholins or skenes glands; the majority of cases are asymp
often no signs present may be purulent vaginal discharge diagnose by positive culture of organism if the condition is untreated it may progress to acute salpingitis(PID)
sexually transmitted infection caused by a spirochete, which may involve any organ or tissue over time; usually manifests first on the skin with the appearance of small, painless papules that erod and form bloodless ulcers called chancres
minimal or no symptoms
may have urinary frequency dysuria or vaginal discharge post coital bleeding
may have yellow green mucopurulent discharge friable cervix cervical motion tenderness
Signs pruitis water and often malaodorous vaginal discharge urinary frequecny terminal dysuria itching
Symptoms are worse during menstration when pH becomes optimal for organism growth
human papilloma virus
a group of viruses that can cause genital warts in males and females and can cause cervical cancer in females
HPV condylomata
virus can appear in various forms when affecting vervical epithelium. here warty growth appears as abnormal thickened white epithelium. visibility of lesion is enhanced by acetic acid wash which dissolves mucus temporarily causes intracellular dehydration and coagulation of protein
situated farthest from point of attachment or origin, as of a limb or bone
closer to the origin of the body part or the point of attachment of a limb to the body trunk
infant exam sequence
• Seize the opportunity with a sleeping baby to listen to heart, lung, and abdomen sounds first.
• Perform least distressing steps first. Save the invasive steps of examination of the eye, ear, nose, and throat until last.
• Elicit the Moro or "startle" reflex at the end of the examination because it may cause the baby to cry
gray stools may be a sign of
malignant melanoma
half arise from preexisitng nevi
ABCDE. may have scaling or oozing legs in women and on plams soles of feet in blacks
menarche occurs in breast development stage
when are the breasts the largest and most tender?
smallest and least tender?
3-4 days before menstration

4th-7th day of menstral cycle
difficulty breathing when supine
Difficulty breathing
breathing problems in babies
respiratory distress syndrome
bacterial infection