229 terms

Nurs 335 Exam 1

Health Assessment Exam 1, includes Jarvis Ch. 1,2,3,4,5,8, & 9
According to the biomedical model, a narrow definition of health is:
the absence of disease.
What type of data base is most appropriate when a rapid collection of data is required and often compiled concurrently with life-saving measures?
A medical diagnosis is used to evaluate:
the cause of disease.
An example of subjective data is:
A) decreased range of motion.
B) crepitation in the left knee joint.
C) left knee has been swollen and hot for the past 3 days.
D) arthritis.
C) left knee has been swollen and hot for the past 3 days.
What type of database is most appropriate for an individual who is admitted to a long-term care facility?
Which of the following is considered an example of objective data?
A) Alert and oriented
B) Dizziness
C) An earache
D) A sore throat
A) Alert and oriented
An example of objective data is:
A) complaints of left knee pain.
B) crepitation in the left knee joint.
C) left knee has been swollen and hot for the past 3 days.
D) report of impaired mobility from left knee pain as evidenced by an inability to walk, swelling, and pain on passive range of motion.
B) crepitation in the left knee joint.
A nursing diagnosis is best described as:
a concise statement of actual or potential health concerns or level of wellness.
A complete data base is:
used to perform a thorough or comprehensive health history and physical examination.
A patient admitted to the hospital with asthma has the following problems identified based on an admission health history and physical assessment. Which problem is a first-level priority?
A) Ineffective self-health management
B) Risk for infection
C) Impaired gas exchange
D) Readiness for enhanced spiritual well-being
C) Impaired gas exchange
Define Assessment
the collection of data about the individual's health state
Define Subjective Data
what the person says about himself or herself during history taking
Define Objective Data
what you as the health professional observe by inspecting, percussing, palpating, and auscultating during the physical examination
What is diagnostic reasoning?
the process of analyzing health data and drawing conclusions to identify diagnoses
What are the 6 phases in the nursing process?
assessment, diagnosis, outcome identification, planning, implementation, and evaluation
What is assessment?
collecting data from clinical record, health history, physical exam, functional assessment, and risk assessment,
What is diagnosis?
Nursing diagnoses are clinical judgments about a person's response to an actual or potential health state.
What is outcome identification?
Individualized goals for each patient that are culturally appropriate and realistic. Needs to be measurable so that goals can be evaluated.
What is planning?
Care planning is setting priorities, develop outcomes, and setting timelines.
What is implementation?
Putting that plan into action, implementing nursing interventions.
What is evaluation?
Make sure that plan is working, that everything is progressing towards the outcomes.
Medical diagnosis vs. Nursing diagnosis
the medical diagnosis is used to evaluate the etiology (cause) of disease. The nursing diagnosis is used to evaluate the response of the whole person to actual or potential health problems. .
First level priorities:
are emergent, life threatening, and immediate, such as establishing an airway or supporting breathing. Airway problems,Breathing problems, Cardiac/circulation problems, & Vital sign concerns (e.g., high fever).
Exception: With cardiopulmonary resuscitation (CPR) for cardiac arrest, begin chest compressions immediately.
Second-level priorities:
next in urgency—those requiring your prompt intervention to forestall further deterioration, for example, mental status change, acute pain, acute urinary elimination problems, untreated medical problems, abnormal laboratory values, risks of infection, or risk to safety or security.
Third level priorities:
are important to the patient's health but can be addressed after more urgent health problems are addressed.
Four Assessment Types:
1) Complete
2)Focused or Problem-Centered
Complete or Total Health Database
a complete health history and a full physical examination. It describes the current and past health state and forms a baseline against which all future changes can be measured.
Focused or Problem Centered database
This is for a limited or short-term problem. Here, you collect a "mini" database, smaller in scope and more targeted than the complete database. It concerns mainly one problem, one cue complex, or one body system.
Follow-up Database
The status of any identified problems should be evaluated at regular and appropriate intervals. What change has occurred? Is the problem getting better or worse? What coping strategies are used? This type of database is used in all settings to follow up short-term or chronic health problems
Emergency Database
This calls for a rapid collection of the data, often compiled concurrently with lifesaving measures. Diagnosis must be swift and sure.
holistic health
views the mind, body, and spirit as interdependent and functioning as a whole within the environment. Health depends on all these factors working together.
Each culture has its own healers who usually:
A) speak at least two languages.
B) own and operate specialty community clinics.
C) cost less than traditional or biomedical providers.
D) recommend folk practices that are dangerous.
C) cost less than traditional or biomedical providers
While evaluating the health history, the nurse determines that the patient subscribes to the hot/cold theory of health. Which of the following will most likely describe this patient's view of wellness?
A) Good is hot.
B) Evil is hot.
C) The humors must be balanced.
D) The phlegm will be replaced with dryness.
C) The humors must be balanced.
Before determining whether cultural practices are helpful, harmful, or neutral, nurses must first understand:
A) the logic of the traditional belief systems.
B) the beliefs of the patients family.
C) their personal belief models.
D) the risk of disease in the patients ethnic group.
A) the logic of the traditional belief systems.
On the basis of median age:
A) the non-Hispanic white population tends to be younger.
B) the Hispanic population tends to be older.
C) the Asian population tends to be younger.
D) minorities tend to be older than non-Hispanic white populations.
C) the Asian population tends to be younger.
Spirituality is defined as:
a personal effort to find meaning and purpose in life.
Which of the following is true regarding language barriers and health care?
A) There are laws addressing language barriers and health care.
B) Limited English proficiency is associated with a higher quality of care.
C) English proficiency is associated with a lower quality of care.
D) Patients with language barriers have a decreased risk of non-adherence to medication regimens.
A) There are laws addressing language barriers and health care.
What is the yin/yang theory of health?
Health exists when all aspects of the person are in perfect balance
Which theory has been expanded in an attempt to study the degree to which a person's lifestyle reflects his or her traditional heritage?
Heritage consistency
What symptom is greatly influenced by a person's cultural heritage?
A) hearing loss
B) pain
C) breast lump
D) food intolerance
B) pain
When considering cultural competence, there are discrete areas that the nurse must develop knowledge of to understand the health care needs of others. These discrete areas include understanding of: (Select all that apply.)
A) his or her own heritage.
B) cultural and ethnic values.
C) the heritage of the nursing profession.
D) the heritage of the patient.
E) the heritage of the health care system.
A) his or her own heritage.
C) the heritage of the nursing profession.
D) the heritage of the patient.
E) the heritage of the health care system.
Title VI of the Civil Rights Act of 1964
when people with limited English proficiency (LEP) seek health care in health care settings such as hospitals, nursing homes, clinics, daycare centers, and mental health centers, services cannot be denied to them.
Religious beliefs and practices influence explanation for:
Cause of illness, perception of severity, choice of healers.
Focuses more on self and includes belief systems other than religion.
Organized system of beliefs and practices in a higher power
Culturally sensitive
implies that caregivers possess some basic knowledge of and constructive attitudes toward the diverse cultural populations found in the setting in which they are practicing.
Culturally appropriate
implies that the caregivers apply the underlying background knowledge that must be possessed to provide a given person with the best possible HEALTH CARE.
Culturally competent
implies that the caregivers understand and attend to the total context of the individual's situation, including awareness of immigration status, stress factors, other social factors, and cultural similarities and differences.
it is the thoughts, communications, actions, beliefs, values, and institutions of racial, ethnic, religious, or social groups.
culture has four basic characteristics
1) learned from birth through the processes of language acquisition and socialization, (2) shared by all members of the same cultural group, (3) adapted to specific conditions related to environmental and technical factors and to the availability of natural resources, and (4) dynamic and ever changing.
pertains to a social group within the social system that claims to possess variable traits such as a common geographic origin, migratory status, religion, race, language, shared values, traditions, or symbols, and food preferences.
process of being raised within a culture and acquiring the characteristics of that group
the process of adapting to and acquiring another culture
the process by which a person develops a new cultural identity and becomes like the members of the dominant culture
dual pattern of identification and often of divided loyalty
biomedical or scientific theory of illness causation
based on the assumption that all events in life have a cause and effect, that the human body functions more or less mechanically (i.e., the functioning of the human body is analogous to the functioning of an automobile), that all life can be reduced or divided into smaller parts (e.g., the reduction of the human person into body, mind, and spirit), and that all of reality can be observed and measured (e.g., intelligence tests and psychometric measures of behavior).
naturalistic or holistic perspective theory of illness causation
believe that human life is only one aspect of nature and a part of the general order of the cosmos. The people may believe that the forces of nature must be kept in natural balance or harmony.
Germ Theory of illness causation
hat microscopic organisms such as bacteria and viruses are responsible for specific disease conditions.
yin/yang theory of illness causation
health is believed to exist when all aspects of the person are in perfect balance. Yin energy represents the female and negative forces, yang forces are male and positive
hot/cold theory of health and illness
The four humors of the body—blood, phlegm, black bile, and yellow bile—regulate basic bodily functions and are described in terms of temperature, dryness, and moisture. The treatment of disease consists of adding or subtracting cold, heat, dryness, or wetness to restore the balance of the humors.
magicoreligious perspective of illness causation
The basic premise is that the world is seen as an arena in which supernatural forces dominate. The fate of the world and those in it depends on the action of supernatural forces for good or evil.
very private, subjective experience that is greatly influenced by cultural heritage
culture-bound syndrome
a condition that is culturally defined
Guide to Cultural Care
Realize that you MUST know and understand your heritage and that of your patient.
Examine the patient within the context of his or her cultural HEALTH and ILLNESS practices.
Select questions that are not complex, and do not ask questions rapidly.
Pace questions throughout the physical examination.
Encourage the patient to discuss the meanings of health and illness with you.
Check for the patient's understanding and acceptance of recommendations, and build on cultural HEALTH practices when indicated.
Touch the patient within the cultural boundaries of his or her heritage—manners are a vital component of the nurse-patient relationship.
When preparing the physical setting for an interview, the interviewer should:
A) set the room temperature between 64 and 66° F.
B) reduce noise by turning the volume on the television or radio down.
C) conduct the interview at eye level and at a distance of 4 to 5 feet.
D) stand next to the patient to convey a professional demeanor.
C) conduct the interview at eye level and at a distance of 4 to 5 feet.
Parents or caretakers accompany children to the health care setting. Starting at ___ years of age, the interviewer asks the child directly about his or her presenting symptoms.
Which of the following statements, if made by the interviewer, would be an appropriate response?
A) "I know just how you feel."
B) "If I were you, I would have the surgery."
C) "Why did you wait so long to make an appointment?"
D) "Tell me what you mean by 'bad blood'."
D) "Tell me what you mean by 'bad blood'."
While discussing the treatment plan, the nurse infers that the patient is uncomfortable asking the physician for a different treatment because of fear of the physician's reaction. In this situation, the nurse's verbal interpretation:
A) affects the nurse-physician relationship.
B) impedes further discussion.
C) helps the patient understand personal feelings in relation to his or her verbal message.
D) helps the nurse understand his or her own feelings in relation to the patient's verbal message.
C) helps the patient understand personal feelings in relation to his or her verbal message.
The use of euphemisms to avoid reality or to hide feelings is known as
avoidance language.
When addressing a toddler during the interview, the health care provider should:
A) ask the child, before the caretaker, about symptoms.
B) use nonverbal communication.
C) use short, simple, concrete sentences.
D) use detailed explanations.
C) use short, simple, concrete sentences.
Nonverbal communication is the primary form of communication for which group of individuals?
Viewing the world from another person's inner frame of reference is called:
An example of an open-ended question or statement is:
A) "Tell me about your pain."
B) "On a scale of 1 to 10, how would you rate your pain?"
C) "I can see that you are quite uncomfortable."
D) "You are upset about the level of pain, right?"
A) "Tell me about your pain."
The most appropriate introduction to use to start an interview with an older adult patient is:
A) "Mr. Jones, I want to ask you some questions about your health so that we can plan your care."
B) "David, I am here to ask you questions about your illness; we want to determine what is wrong."
C) "Mr. Jones, is it okay if I ask you several questions this morning about your health?"
D) "Because so many people have already asked you questions, I will just get the information from the chart."
A) "Mr. Jones, I want to ask you some questions about your health so that we can plan your care."
Results of a successful interview
establish rapport, patient teaching, and health promotion, identify health strengths and problems, and is a bridge to the physical exam
The contract (interview) term include
Time and place of interview and physical exam
Introduction of and explanation of health care provider's role
Purpose of interview
How long it will take
Expectation of participation of each person
Presence of other (family, friends, etc.)
Confidentiality and to what extent it may be limited
Any costs that the patient must pay
all behavior, conscious and unconscious, verbal and nonverbal.
Challenges of note taking:
Breaks eye contact
Shifts attention away from person, diminishing importance
Interrupts patient's narrative flow
Impedes observation of patient's non-verbal behavior
May be threatening to patient's discussion of sensitive issues
open-ended question
asks for narrative information. It states the topic to be discussed but only in general terms
Closed or direct questions
ask for specific information. They elicit a short, one- or two-word answer, a "yes" or "no," or a forced choice.
These responses encourage the patient to say more, to continue with the story ("mm-hmm, go on, continue, uh-huh"). Also called general leads, these responses show the person you are interested and will listen further.
Silence is golden after open-ended questions. Your silent attentiveness communicates that the patient has time to think, to organize what he or she wishes to say without interruption from you. This "thinking silence" is the one health professionals interrupt most often.
This response echoes the patient's words. Reflection is repeating part of what the person has just said. In this example, it focuses further attention on a specific phrase and helps the person continue in his own way
An empathic response recognizes a feeling and puts it into words. It names the feeling and allows the expression of it.
Use this when the person's word choice is ambiguous or confusing, also is used to summarize the person's words, simplify the words to make them clearer, and then ask if you are on the right track.
you have observed a certain action, feeling, or statement and you now focus the person's attention on it. You give your honest feedback about what you see or feel.
This statement is not based on direct observation as with confrontation, but it is based on your inference or conclusion. It links events, makes associations, or implies cause
With these statements, you inform the person. You share factual and objective information.
This is a final review of what you understand the person has said. It condenses the facts and presents a survey of how you perceive the health problem or need. It is a type of validation in that the person can agree with it or correct it. Both you and the patient should participate.
Ten Traps of Interviewing:
1. Providing false assurance or reassurance.
2. Giving unwanted advice.
3. Using authority
4. Using avoidance language
5. Engaging in distancing
6. Using professional jargon
7. Using leading or biased questions
8. Talking too much
9. Interrupting
10. Using "why" questions
Nonverbal skills:
Physical appearance
Facial expressions
Eye contact
telegraphic speech
usually a combination of a noun and a verb and includes only words that have concrete meaning
Cross-cultural communication
refers to the process occurring between a health care professional and a patient, each with different cultural backgrounds, in which both attempt to understand the other's point of view
refers to the conventional code of good manners that governs behavior and varies cross-culturally.
Intimate Zone
0-1 1/2 feet
Personal Zone
1 1/2 - 4 feet
Social distance
4 - 12 feet
Public distance
12+ feet
Which of the following is included in documenting a history source?
A) Appearance, dress, and hygiene
B) Cognition and literacy level
C) Documented relationship of support systems
D) Reliability of informant
D) Reliability of informant
A patient seeks care for "debilitating headaches that cause excessive absences at work." On further exploration, the nurse asks, "What makes the headaches worse?" With this question, the nurse is seeking information about:
aggravating factors.
The CAGE test is a screening questionnaire that helps to identify
excessive or uncontrollable drinking
The "review of systems" in the health history is:
an evaluation of past and present health state of each body system
When recording information for the review of systems, the interviewer must document:
A) physical findings, such as skin appearance, to support historic data.
B) "negative" under the system heading.
C) the presence or absence of all symptoms under the system heading.
D) objective data that supports the history of present illness.
the presence or absence of all symptoms under the system heading.
Assessment of self-esteem and self-concept is part of the functional assessment. Areas covered under self-esteem and self-concept include:
A) education, financial status, and value-belief system.
B) exercise and activity, leisure activities, and level of independence.
C) family role, interpersonal relations, social support, and time spent alone.
D) stressors, coping mechanisms, and change in past year.
education, financial status, and value-belief system.
PQRSTU is a mnemonic that helps the clinician to remember to address characteristics specific to:
The nurse questions the reliability of the history provided by the patient. One method to verify information within the context of the interview is to:
A) review previous medical records.
B) rephrase the same questions later in the interview.
C) ask the patient if there is someone who could verify information.
D) call a family member to confirm information.
B) rephrase the same questions later in the interview.
When taking a health history from an adolescent, the interviewer should:
A) ask about violence and abuse before asking about alcohol and drug use.
B) have at least one parent present during the interview.
C) interview the youth alone with a parent in the waiting area.
D) ask every youth about the use of condoms.
C) interview the youth alone with a parent in the waiting area.
What information is included in greater detail when taking a health history on an infant?
A) nutritional data
B) history of present illness
C) family history
D) environmental hazards
A) nutritional data
Health History Sequence (adult)
1. Biographical data
2. Source of history
3. Reason for seeking care
4. Present health or history of present illness
5. past health
6. Family history
7. Review of systems
8. Functional assessment (ASLs)
subjective sensation that the person feels from the disorder
objective abnormality that you as the examiner could detect on physical examination or in laboratory reports
P: Provocative or Palliative. What brings it on? What were you doing when you first noticed it? What makes it better? Worse?

Q: Quality or Quantity. How does it look, feel, sound? How intense/severe is it?

R: Region or Radiation. Where is it? Does it spread anywhere?

S: Severity Scale. How bad is it (on a scale of 1 to 10)? Is it getting better, worse, staying the same?

T: Timing. Onset—Exactly when did it first occur? Duration—How long did it last? Frequency—How often does it occur?

U: Understand Patient's Perception of the problem. What do you think it means?
pedigree or genogram
a graphic family tree that uses symbols to depict the gender, relationship, and age of immediate blood relatives in at least three generations, such as parents, grandparents, siblings
Purpose of review of systems
(1) to evaluate the past and present health state of each body system, (2) to double-check in case any significant data were omitted in the Present Illness section, and (3) to evaluate health promotion practices.
Functional assessment measures :
a person's self-care ability in the areas of general physical health or absence of illness; ADLs, such as bathing, dressing, toileting, eating, walking; instrumental activities of daily living (IADLs), or those needed for independent living, such as housekeeping, shopping, cooking, doing laundry, using the telephone, managing finances; nutrition; social relationships and resources; self-concept and coping; and home environment.
Have you ever thought you should Cut down your drinking?

Have you ever been Annoyed by criticism of your drinking?

Have you ever felt Guilty about your drinking?

Do you drink in the morning?
interviewing focuses on assessment of the Home environment, Education and employment, Eating, peer-related Activities Drugs, Sexuality, Suicide/depression, and Safety from injury and violence. The tool minimizes adolescent stress because it moves from expected and less-threatening questions to those that are more personal.
A full mental status examination should be completed if the patient:
A) has a change in behavior and the family is concerned.
B) develops dysphagia.
C) is newly diagnosed with type 2 diabetes mellitus.
D) complains of insomnia.
A) has a change in behavior and the family is concerned.
Aphasia is best described as:
a language disturbance in speaking, writing, or understanding.
A patient who was recently diagnosed with a seizure disorder plans to continue a career as a pilot. At this time in the interview, the nurse begins to question the patient's:
A) thought process.
B) judgment.
C) perception.
D) intellect.
B) judgment.
A major characteristic of dementia is:
A) impaired short-term and long-term memory.
B) hallucinations.
C) sudden onset of symptoms.
D) cognitive deficits that are substance-induced.
A) impaired short-term and long-term memory.
Mental status assessment documents:
A) emotional and cognitive functioning.
B) intelligence and educational level.
C) artistic or writing ability in the mentally ill person.
D) schizophrenia and other mental health disorders.
A) emotional and cognitive functioning.
Although a full mental status examination may not be required for every patient, the health care provider must address the four main components during a health history and physical examination. The four components are:
A) memory, attention, thought content, and perceptions.
B) language, orientation, attention, and abstract reasoning.
C) appearance, behavior, cognition, and thought processes.
D) mood, affect, consciousness, and orientation.
C) appearance, behavior, cognition, and thought processes.
An older adult:
A) experiences a 10-point decrease in intelligence.
B) has diminished recent and remote memory recall.
C) has a slower response time.
D) has difficulty with problem solving.
C) has a slower response time.
Which of the following statements about mental status testing of children is correct?
A) The results of the Denver II screening test are valid for white, middle-class children only.
B) The behavioral checklist is useful to assess children who are 3 to 5 years of age.
C) Abnormal findings are usually related to not achieving an expected developmental milestone.
D) Input from parents and caretakers is discouraged when assessing psychosocial development.
C) Abnormal findings are usually related to not achieving an expected developmental milestone.
Which of the following best illustrates an abnormality of thought process?
A) Lability
B) Blocking
C) Compulsion
D) Aphasia
B) Blocking
The mental status examination:
A) should be completed at the end of the physical examination.
B) will not be affected if the patient has a language impairment.
C) is usually not assessed in children younger than 2 years of age.
D) assesses mental health strengths and coping skills and screens for any dysfunction.
D) assesses mental health strengths and coping skills and screens for any dysfunction.
Mental status is:
a person's emotional (feeling) and cognitive (knowing) function.
mental disorder
significant behavioral or psychological pattern that is associated with distress (a painful symptom) or disability (impaired functioning) and has a significant risk of pain, disability, or death or a loss of freedom.
organic disorders
due to brain disease of known specific organic cause [e.g., delirium, dementia, alcohol and drug intoxication and withdrawal]
mental illness
which an organic etiology has not yet been established [e.g., anxiety disorder or schizophrenia
Being aware of one's own existence, feelings, and thoughts and aware of the environment. This is the most elementary of mental status functions.
Using the voice to communicate one's thoughts and feelings. This is a basic tool of humans, and its loss has a heavy social impact on the individual.
Mood and affect
Both of these elements deal with the prevailing feelings; affect is a temporary expression of feelings or state of mind, and mood is more durable, a prolonged display of feelings that color the whole emotional life.
The awareness of the objective world in relation to the self.
The power of concentration, the ability to focus on one specific thing without being distracted by many environmental stimuli.
The ability to lay down and store experiences and perceptions for later recall. Recent memory evokes day-to-day events; remote memory brings up years' worth of experiences.
Abstract reasoning
Pondering a deeper meaning beyond the concrete and literal.
Thought process
The way a person thinks, the logical train of thought.
Thought content
What the person thinks—specific ideas, beliefs, the use of words.
An awareness of objects through the five senses.
full mental status examination
systematic check of emotional and cognitive functioning
necessary to perform a full mental status examination when:
Patients whose initial brief screening suggests an anxiety disorder or depression.
Family members concerned about a person's behavioral changes, such as memory loss, inappropriate social interaction.
Brain lesions (trauma, tumor, brain attack [also known as cerebrovascular accident or stroke]).
Aphasia (the impairment of language ability secondary to brain damage).
Symptoms of psychiatric mental illness, especially with acute onset.
Things that can affect mental health status
Health conditions, medications, educational and behavioral level, and stress
Assess appearance
posture, body movements, dress, and grooming.
Assess behavior
Level of consciousness, facial expression, speech, mood and affect.
Asses cognitive functions
orientation, attention span, recent memory, remote memory, new learning, judgement
Assess thought processes and perceptions
thought processes, though content, perceptions, and suicide screening.
Unilateral neglect
(total inattention to one side of body) occurs following some cerebrovascular accidents.
The Mini-Mental State
simplified scored form of the cognitive functions of the mental status examination (memory, orientation to time and place, naming, reading, copying or visuospatial orientation, writing, and the ability to follow a three-stage command)
Denver II screening
test gives you a chance to interact directly with the young child to assess mental status. The Denver II is designed to detect developmental delays in infants and preschoolers within four functions: gross motor, language, fine motor-adaptive, and personal-social skills.
Behavioral Checklist
For school-age children, ages 7 to 11, who have grown beyond the age when developmental milestones are very useful, It covers five major areas: mood, play, school, friends, and family relations.
an acute confusional change or loss of consciousness and perceptual disturbance, may accompany acute illness (e.g., pneumonia, alcohol/drug intoxication), and is usually resolved when the underlying cause is treated.
gradual progressive process, causing decreased cognitive function, even though the person is fully conscious and awake, and is not reversible.
The Mini-Cog
reliable, quick, and easily available instrument to screen for cognitive impairment in otherwise healthy older adults. consists of a 3-item recall test and a clock-drawing test.
Awake or readily aroused, oriented, fully aware of external and internal stimuli and responds appropriately, conducts meaningful interpersonal interactions.
Lethargic (or Somnolent)
Not fully alert, drifts off to sleep when not stimulated, can be aroused to name when called in normal voice but looks drowsy, responds appropriately to questions or commands but thinking seems slow and fuzzy, inattentive, loses train of thought, spontaneous movements are decreased.
Sleeps most of time, difficult to arouse—needs loud shout or vigorous shake, acts confused when is aroused, converses in monosyllables, speech may be mumbled and incoherent, requires constant stimulation for even marginal cooperation.
Stupor or Semi-Coma
Spontaneously unconscious, responds only to persistent and vigorous shake or pain; has appropriate motor response (i.e., withdraws hand to avoid pain); otherwise can only groan, mumble, or move restlessly; reflex activity persists.
Completely unconscious, no response to pain or to any external or internal stimuli (e.g., when suctioned, does not try to push the catheter away), light coma has some reflex activity but no purposeful movement, deep coma has no motor response.
Acute Confusional State (Delirium)
Clouding of consciousness (dulled cognition, impaired alertness); inattentive; incoherent conversation; impaired recent memory and confabulatory for recent events; often agitated and having visual hallucinations; disoriented, with confusion worse at night when environmental stimuli are decreased.
Difficulty or discomfort in talking, with abnormal pitch or volume, due to laryngeal disease. Voice sounds hoarse or whispered, but articulation and language are intact.
Distorted speech sounds; speech may sound unintelligible; basic language (word choice, grammar, comprehension) intact.
True language disturbance, defect in word choice and grammar or defect in comprehension; defect is in higher integrative language processing.
To examine a toddler, the nurse should:
A) allow the child to sit on the parent's lap.
B) remove the child's clothing at the beginning of the examination.
C) ask the child to decide whether parents or siblings should be present.
D) perform the assessment from head to toes.
A) allow the child to sit on the parent's lap.
Deep palpation is used to:
identify abdominal contents
Amplitude is
the intensity (soft or loud) of sound
The dorsa of the hands are used to determine
Fine tactile discrimination is best achieved with the
A funduscopic examination is an examination of the
internal structures of the eye
Which of the following is considered when preparing to examine an older adult?
A) Base the pace of the examination on the patient's needs and abilities.
B) Avoid physical touch to offset making the older adult uncomfortable.
C) Be aware that loss will result in poor coping mechanisms.
D) Confusion is a normal, expected finding in an older adult.
A) Base the pace of the examination on the patient's needs and abilities.
When performing percussion, the examiner:
A) strikes the flank area with the palm of the hand.
B) strikes the stationary finger at the distal interphalangeal joint.
C) strikes the stationary finger at the proximal interphalangeal joint.
D) taps fingertips over bony processes.
B) strikes the stationary finger at the distal interphalangeal joint.
At the end of the examination, the examiner should:
A) complete documentation before leaving the examination room.
B) have findings confirmed by another provider.
C) compare objective and subjective data for discrepancies.
D) review the findings with the patient.
D) review the findings with the patient.
When should the examiner use hand washing instead of an alcohol-based hand rub?
A) if the patient has an infection with Mycobacterium tuberculosis
B) if the patient has an infection with Clostridium difficile
C) if the patient has an infection with hepatitis B virus
D) if the patient is HIV positive
B) if the patient has an infection with Clostridium difficile
Four skills of the physical examination are:
inspection, palpation, percussion, and auscultation. Always in this order!
concentrated watching. It is close, careful scrutiny, first of the individual as a whole and then of each body system. Inspection begins the moment you first meet the person and develop a "general survey."
follows and often confirms points you noted during inspection. It applies your sense of touch to assess these factors: texture, temperature, moisture, organ location and size, as well as any swelling, vibration or pulsation, rigidity or spasticity, crepitation, presence of lumps or masses, and presence of tenderness or pain.
Grasping action of the fingers and thumb
to detect the position, shape, and consistency of an organ or mass
Base of fingers (metacarpophalangeal joints) or ulnar surface of the hand are::
best for vibration
tapping the person's skin with short, sharp strokes to assess underlying structures. The strokes yield a palpable vibration and a characteristic sound that depicts the location, size, and density of the underlying organ.
Clear and hollow, over normal lung tissue in an adult
Booming, over normal healthy lung tissue in a child
Drumlike, over most of the abdomen, air-filled structure
Muffled thud, over dense organs like the liver and spleen
dead stop of sound, over bone
(or intensity), a loud or soft sound.
(or frequency), the number of vibrations per second.
(timbre), a subjective difference due to a sound's distinctive overtones.
the length of time the note lingers
listening to sounds produced by the body, such as the heart and blood vessels and the lungs and abdomen.
most often because its flat edge is best for high-pitched sounds—breath, bowel, and normal heart sounds
endpiece has a deep, hollow, cuplike shape. It is best for soft, low-pitched sounds such as extra heart sounds or murmurs
funnels light into the ear canal and onto the tympanic membrane.
illuminates the internal eye structures. Its system of lenses and mirrors enables you to look through the pupil at the fundus (background) of the eye, much like looking through a keyhole at a room beyond.
nosocomial infection
an infection acquired during hospitalization
Assessment sequence for infants
Listen to heart, lungs, and abdomen, then ear, nose, mouth, and throat. Last should be the Moro reflex!
The general survey consists of four distinct areas. These areas include:
physical appearance, body structure, mobility, and behavior
A common error in blood pressure measurement includes:
A) taking the blood pressure in an arm that is at the level of the heart.
B) waiting less than 1 to 2 minutes before repeating the blood pressure reading on the same arm.
C) deflating the cuff about 2 mm Hg per heart beat.
D) using a blood pressure cuff whose bladder length is 80% of the arm circumference.
B) waiting less than 1 to 2 minutes before repeating the blood pressure reading on the same arm.
Data collection for the general survey begins:
A) at the first encounter.
B) at the beginning of the physical examination.
C) while taking vital signs.
D) during the mental status examination.
A) at the first encounter.
The Doppler technique:
A) is used to assess the apical pulse.
B) augments Korotkoff sounds during blood pressure measurement.
C) provides an easy and accurate measure of the diastolic pressure.
D) measures arterial oxygenation saturation.
B) augments Korotkoff sounds during blood pressure measurement.
The tympanic membrane thermometer:
A) provides an accurate measurement of core body temperature.
B) senses the infrared emissions of the cerebral cortex.
C) is not used in unconscious patients.
D) accurately measures temperature in 20 to 30 seconds.
A) provides an accurate measurement of core body temperature.
Endogenous obesity is:
A) due to inadequate secretion of cortisol by the adrenal glands.
B) caused by excess adrenocorticotropin production by the pituitary gland.
C) characterized by evenly distributed excess body fat.
D) a result of excessive secretion of growth hormone in adulthood.
B) caused by excess adrenocorticotropin production by the pituitary gland.
To perform an accurate assessment of respirations, the examiner should:
A) inform the person of the procedure and count for 1 minute.
B) count for 15 seconds while keeping fingers on the pulse and then multiply by four.
C) count for 30 seconds after completing a pulse assessment and multiply by two.
D) assess respirations for a full 2 minutes if an abnormality is suspected.
C) count for 30 seconds after completing a pulse assessment and multiply by two.
Physical appearance includes statements that compare appearance with:
A) mood and affect.
B) stated age.
C) gait.
D) nutrition.
B) stated age.
An adult patient's pulse is 46 beats per minute. The term used to describe this rate is:
A) tachycardia.
B) bradycardia.
C) weak and thready.
D) sinus arrhythmia.
B) bradycardia.
The nurse records that the patient's pulse is 3+ or full and bounding. Which of the following could be the cause?
A) Dehydration
B) Shock
C) Bleeding
D) Anxiety
D) Anxiety
Physical Appearance (inspection) includes:
age, sex, level of consciousness, skin color, and facial features.
Body structure includes:
stature, nutrition, symmetry, posture, position, and body build.
Mobility includes:
Gait and range of motion
Behavior includes:
facial expression, mood and affect, speech, dress, and personal hygiene.
Measurement includes:
weight, height, and BMU
Vital Signs include:
temperature, pulse rate, respiration rate, blood pressure, and pain level.
or fever, is caused by pyrogens secreted by toxic bacteria during infections or from tissue breakdown such as that following myocardial infarction, trauma, surgery, or malignancy.
is usually due to accidental, prolonged exposure to cold. It also may be purposefully induced to lower the body's oxygen requirements during heart or peripheral vascular surgery, neurosurgery, amputation, or gastrointestinal hemorrhage.
Stroke volume
amount of blood that is pumped by the left ventricle with each heart beat
systolic pressure
is the maximum pressure felt on the artery during left ventricular contraction
diastolic pressure
is the elastic recoil, or resting, pressure that the blood exerts constantly between each contraction.
pulse pressure
the difference between the systolic and diastolic pressures and reflects the stroke volume
auscultatory gap
is a period when Korotkoff sounds disappear during auscultation
abnormally low BP
abnormally high BP
Orthostatic hypotension
a drop in systolic pressure of more than 20 mm Hg or orthostatic pulse increases of 20 bpm or more occurs with a quick change to a standing position.
Hypopituitary Dwarfism
Deficiency in growth hormone in childhood results in retardation of growth below the 3rd percentile, delayed puberty, hypothyroidism, and adrenal insufficiency.
Excessive secretion of growth hormone by the anterior pituitary resulting in overgrowth of entire body. When this occurs during childhood, before closure of bone epiphyses in puberty, it causes increased height and weight and delayed sexual development.
Acromegaly (Hyperpituitarism)
Excessive secretion of growth hormone in adulthood, after normal completion of body growth, causes overgrowth of bone in the face, head, hands, and feet but no change in height. Internal organs also enlarge (e.g., cardiomegaly), and metabolic disorders (e.g., diabetes mellitus) may be present.
Achondroplastic Dwarfism
A genetic disorder in converting cartilage to bone results in normal trunk size, short arms and legs, and short stature. It is characterized by a relatively large head with frontal bossing and midplace hypoplasia and, often, thoracic kyphosis, prominent lumbar lordosis, and abdominal protrusion.
Anorexia Nervosa
A serious psychological disorder characterized by severe and life-threatening weight loss and amenorrhea in an otherwise healthy adolescent or young woman. Behavior is characterized by fanatic concern about weight, aversion to food, distorted body image (perceives self as fat despite skeletal appearance), starvation diets, frenetic exercise patterns, and striving for perfection.
Marfan's Syndrome
inherited connective tissue disorder, characterized by tall, thin stature (greater than 95th percentile), arachnodactyly (long, thin fingers), hyperextensible joints, arm span greater than height, pubis-to-sole measurement exceeding crown-to-pubis measurement, sternal deformity, high-arched narrow palate, and pes planus. Early morbidity and mortality occur as a result of cardiovascular complications such as mitral regurgitation and aortic dissection.
Endogenous Obesity—Cushing Syndrome
Either administration of adrenocorticotropin (ACTH) or excessive production of ACTH by the pituitary will stimulate the adrenal cortex to secrete excess cortisol. This causes Cushing syndrome, characterized by weight gain and edema with central trunk and cervical obesity (buffalo hump) and round, plethoric face (moon face).