Study sets, textbooks, questions
Upgrade to remove ads
Health Assessment Final Exam
Terms in this set (103)
Priority outcome stage 3 pressure ulcer
Take pressure off the affected area helps ensure it will not worsen. Then cleaning to prevent infection or sepsis
Review types of assessments and when to use each type (Emergency, comprehensive, focused, functional)
- Emergency: AR, quickly assess status, patient is blue, not breathing
- Comprehensive: Health history/ admission into a hospital, long term care, of first-time seeing patient
- Focused: Sprained ankle example, a more detailed assessment that relates to a current medical condition or patient complaint
- Functional: Dizziness, do they need a cane or walker, anything that pertains to functional ability of patient
Breathing posture with labored breathing may indicate what? How might someone with COPD sit to breath more comfortably?
- Indicates COPD
- Tripod, sitting, leaning forward with their hands on their knees or forearms on thighs.
Know bulging and sinking fontanelle and what each can indicate
- Bulging- Occurs when fluid accumulates in the skull cavity or when pressure increases in the brain
- Sinking- Dehydration is the primary cause of a sunken forehead
Know Weber and Rhinne abnormal means what, how to test for low frequency hearing loss and high frequency loss
- Abnormal Weber- Indicates sensorineural loss in the ear which the patient did not hear or has reduced perception of the sound. SNHL on one side may be related to an inner ear disorder such as Meniere disease or vestibular schwannoma.
- Abnormal Rhinne- BC that is longer than or the same as AC is evidence of conductive hearing loss. Conductive hearing loss on one side may indicate external or middle ear disease.
- Low and high frequency hearing loss: Low-frequency and high-frequency hearing loss is typically a sensorineural hearing loss. In which case the Weber test should be used. The base of a gently vibrating tuning fork is placed on the midforhead or the vertex. The patient is asked which ear hears the sound better. Normally, the sound is heard equally in both ears. With unilateral sensorineural hearing loss, sound is heard better in the unaffected ear.
Nursing diagnosis for CVA (Cerebral Vascular Accident/Stroke) patients that cough and choke
- Ineffective Airway Clearance, Impaired Physical Mobility due to decreased motor function, Imbalanced Nutrition, Less than body requirements, related to impaired swallowing and motor deficits.
-Safety of client 1st, airway/ impaired swallowing is priority.
Know age related changes to memory specifically retrieval of facts, vocabulary and general knowledge
Healthy older adults maintain cognitive function, but retrieval speed for information slows. Speed of brain processing on tests of psychomotor performance shows slowing with age
Know how to assess cerebellar functioning
Know how to test CN I
Occlude one nostril, and place vanilla and ask the patient to smell the object and report what it is
Know Kesselbach plexus, Stensen duct, Wharton Duct, Rossenmuller fossa where and what medical conditions assoc with each location
- Kesselbach Plexus- Branches of the internal and external carotid arteries, supply blood to the nose. The anterior portion of the nasal septum has a rich vascular supply. Associated with nosebleeds.
- Stensen Duct- The Stensen (parotid) duct opens into the mouth in the buccal mucosa just opposite the upper and second molar. Associated with stones or growths.
- Wharton Duct- One of the salvatory excretory ducts. Found on each side of the frenulum. Associated with swelling mumps, blockage of a duct, and presence of a stone, abscess, or tumor. Duct obstruction can occur as a result of aging, dehydration, or use of anticholinergic medications.
- Rossenmuller Fossa- Responsible for linking the middle ear with the larynx. A long, deep, shallow and narrow depression found in one of the furthest sections of the nasal cavity, posterior to the torus region. Associated with nasopharyngeal cancers.
Know Macular degeneration and diet interventions
- Macular Degeneration: Gradual process of degeneration, in the macular area of the retina. Affects our vision centrally.
- Diet- High in antioxidants
(green leafy vegetables)
, vitamins (such as C and E) and zinc, healthy unsaturated fats such as olive oil may help prevent vision loss
- Pg 321 in health assessment book
Know female s/s of candida, gonorrhea, bacterial vaginosis and chlamydia (Types of discharge)
- Greyish fishy discharge- bacterial vaginosis
Know what PE tests to do for appendicitis (Rovsing sign)
Iliopsoas muscle test,
positive in question, and psoas sign
Know normal aging findings of breasts
- Saggy, community activities
Know specific and correct medical terminology to chart abnormal exam findings on limbs
- Complete arterial occlusion- Limb- threatening situation. Symptoms: Pain, numbness, coolness, extremity, color change
- Deep vein thrombosis (DVT)- Immediate anticoagulant therapy necessary. Symptoms: Pain, edema, extremity warmth
- Pulmonary embolism: Life-threatening emergency. Signs: Acute dyspnea, chest pain, tachycardia, diaphoresis, anxiety
Behind knee- posterior popliteal
Know what assessment of lifestyle and personal habits associated with risk factors in children- what questions do you ask to assess lifestyle and associated risks
- Lead, TB, immunizations, car safety, poison control, safety at home, fire safety, water safety, water safety, outdoor safety, nutrition and obesity, violence and suicide, contraception and STI
Childproof the home
Know reflex grading (1+, 2+, 3+, 4+ and clonus what these all mean and exam findings assoc)
A grade of 2 indicates normal reflexes. A grade of 3 indicates hyperreflexia; 4 indicates hyperreflexia with clonus.
Know management of pyelonephritis during pregnancy
IV antibiotics immediately to prevent generalized sepsis (not going to the pharmacy and getting a prescription or over the counter meds).
How do male bones differ from female bones
- Teenage boy compared to a teenage female is going to have larger (diameter) and stronger bones
Know what Vertigo, tinnitus, Otalgia, Dizziness are and how might a patient describe
- Dizziness: Inflamed labyrinth causes loss of equilibrium. Described as a whirling sensation
- Vertigo-room spinning
- Tinnitus- ringing in the ear
- Otalgia- ear pain and dizziness
Know familial risk for eye conditions- are there eye conditions that you are more at risk for and if so, what is the risk and who must have the condition to put you at risk- how are they inherited.
- *Macular degeneration- first degree relative (or glaucoma)- may get it if your uncle has it)
- Retinoblastoma-Has to be parent
- Macular degeneration needs green leafy vegetables*
Know considerations for personal hygiene in vision impaired patient
Provide a mirror and adequate lighting when shaving the face
Know education to provide to someone with repeated STI
"Itching and burning in genital area" - Knowledge and understanding of safe sex practices
Know reasons elder abuse may not be reported
- Victims are isolated, some are ashamed, embarrassed, feel guilt and self-blame
What nursing diagnosis may be appropriate for a toddler with tympanostomy tubes (Risk of infection)
- Tympanostomy Tubes- Creates an airway that ventilates the middle ear and prevents the accumulation of fluids behind the eardrum
- Risks- Bleeding and infection, Persistent fluid drainage, blocked tubes from blood, mucus or other secretions, scaring or weakening of the eardrum, tubes falling out too early or staying in too long. Failure of the eardrum to close after the tube falls out or is removed.
What does a neurologic assessment of a newborn consist of
Know how many pairs of spinal nerves
31 pairs of spinal nerves
Know what genu valgum is
- "Knock kneed"
Know diseases associated with jaundice and splenomegaly in African Americans
- Sickle cell anemia
Know risk taking behaviors in teens and counseling to provide
Question is about drinking and driving
Know interventions for someone with genital piercings
- Purulent drainage- Ways to avoid infection, care of the piercing
Know function of testes and know about sperm maturation
- Produce testosterone
- How often is matured sperm generated- every 90 days
Know how the nurse uses critical thinking when accurately assessing vital signs (Used to develop nursing diagnosis)
being able to examine an issue by breaking it down, and evaluating it in a conscious manner, while providing arguments/evidence to support the evaluation.
What LN sign is concerning in adult
- Normally, lymph nodes are nonpalpable. Nodes are palpable when infected or enlarged. Lymph nodes are tender in the presence of infection.
- If they are big, hard, or tender (over 1 centimeter) they're concerning for cancer
Know cultural considerations for pubic hair development and what Tanner Stages are
- Tanner stages how sexually developed a patient is. African American girls can start puberty at the age of 8, different from other ethnicities
- Pubic hair is darker, coarse, curling and spread over mons- stage 3
Know cultural "rites of passage" that we have discussed in class
- Quinceanera- Hispanic, when a girl turns 15 "becomes a woman"
Know tanner staging for pubic hair
Stage 1: Preadolescent- No pubic hair
Stage 2: Long, slightly pigmented, downy hair that is straight or only slightly curled appears chiefly along the labia
Stage 3: Hair is considerably darker, coarser, and more tightly curled. It spreads sparsely over the junction of the mons pubis
Stage 4: Hair is now adult in type, but the area is considerably smaller than most adults, no spread to the medial surface of thighs
Stage 5: Adult hair, spread to the medial surface of thighs
Know Piaget stages of development
: Sensorimotor stage: Birth to 2 years
Preoperational stage: Ages 2 to 7
Concrete operational stage: Ages 7 to 11
Formal operational stage: Ages 12 and up
Stage 1: Trust vs Mistrust
Stage 2: Autonomy vs Shame and Doubt
Stage 3: Initiative vs Guilt
Stage 4: Industry vs Inferiority
Stage 5: Identity vs Role Confusion
Stage 6: Intimacy vs Isolation
Stage 7: Generativity vs. Stagnation
Stage 8: Ego Integrity vs Despair
Objective findings that indicate dehydration
- Poor skin Turgor, pale skin, unable to produce tears or sweat, dry and cracked lips
Know ways to encourage elderly clients to receive adequate nutritional intake when in hospital
Make food accommodations with food preferences
Know secondary circular reactions (4-8 months)
Object permanence- Repeats actions in the environment, such as kicking a mobile to see it move again or picking up a toy to put in his or her mouth
Know subjective information to collect when assessing a client with arterial, venous, and lymphatic disorders
- Plan and educate is not correct, identify cardiovascular list
- Eliminate family history
- Subjective info- smoking, etc
Pain that originates from skeletal muscles, ligaments, or joints.
pain that lasts longer than 6 months
Pain perceived from the skin
Pain perceived at a location other than the site of the stimulus/ origin
Know when PAP tests are performed and why
Cervical cancer screening,
What are the functions of the lymphatic system?
- Maintains fluid and protein balance and functions with the immune system to fight infection
Know developmental development and what might be delay (what age should kids walk, dress, skip etc)
Walk- 11-13 months
Skip- 5 years
Dress- 5-6 years old
Know Subjective information about sleep apnea (What questions to ask)
- Nose, sinuses, mouth, and throat. History relevant to upper respiratory and upper gastrointestinal. Social history including drug and alcohol exposure.
- The family normally says something about their snoring and loud noises. If they don't have a husband or wife, they might say they sleep for 12 hours but they don't feel rested when they wake up
Know what causes coffee ground emesis
- Digested blood
What are modifiable and nonmodifiable risks for breast cancer
Modifiable: Diet, smoking, exercise Nonmodifiable: Genetics, age, asthma
Know religious considerations during labor and delivery for moms and babies
- Jehovas Witness do not accept blood products to save the mother or baby
- In many parts of Africa women are victims of female mutilation
- Under Jewish law, c-sections are permissible but are seen as less natural
- Why assess religious preference, intervene on behalf on mom and behold preferences
The drive to establish and guide the next generation
Older adult has to come to terms with his or her life choices
loss of hope
a discontinuation of development and a desire to recapture the past
Know how to assess motor function of the trigeminal nerve
Clenching teeth/ testing masseter strength
Know breathing patterns and assoc medical diagnosis indicated by each Kussmaul, Cheyne-stokes, Biot, bradypnea
- Kussmaul- Hyperventilation. Diabetic ketoacidosis
- Cheyne-Stokes- Deep and fast then fast to shallow and slow. Normal in children and the elderly and terminal illness, renal failure, drug overdose, increased pressure, and heart failure
- Biot- Irregular. Severe brain damage
- Bradypenea- Slow, shallow and regular. Narcotic overdose, diabetic coma, and increased intracranial pressure
Physical signs of meningeal irritation
- Brudzinski sign, limbs curled, pain with rollie pollie, cannot
- Increased pain with flexion of neck and knees
Know sibilant wheeze, stridor, friction rub, decreased breath sounds and what assoc medical diagnosis for each (we mentioned several in class)
- Sibilant Wheeze- High pitched musical sound heard primarily during inspiration. Asthma, bronchitis, and emphysema.
- Stridor- Loud, high-pitched, crowing or honking sound louder in upper airway. Epiglottitis, croup, partially obstructed airway, can indicate an emergency requiring immediate attention.
- Friction Rub- Loud, coarse, and low-pitched grating or creaking sound similar to a squeaky door during inspiration and expiration; more common in the lower anterolateral thorax. Pleuritis
- Decreased Breath Sounds- May be very soft sounding. Emphysema, atelectasis or pleural effusion.
Know subjective questions to ask about suicide attempt and suicide risk
- Prior suicide attempt
Know what acrocyanosis is, is it normal and what to do if you see it in a newborn
- Cyanosis of hands and feet shortly after birth
- Common finding and usually resolves itself within 24-48 hours
- Intervention- baby warmer
Know what Mongolian spots are and what populations you see them in
- Flat bluish to bluish gray skin markings, found in Asian, Native American, Hispanic, East Indian, and African descent
Cushing Syndrome s/s on physical exam
- Cushing Syndrome- Excessive cortisol production. Signs and symptoms include weight gain, facial roundness, or bruising.
pg 314 in health assessment book
Know NORMAL findings of cranial nerve IX and X on physical exam
- Swallowing, breathing, gag reflex
Know signs of acute arterial occlusion
- Acute pain of the extremities, the 7 Ps Pain, paresthesia, paralysis, polar, pallor, pulse, and perfusion
- Purple is not
Know Whisper pectoriloquy, Tactile Fremitus, Bronchophony, egophony what is it and how to perform, what does it indicate and what is normal vs what is abnormal
Whisper pectoriloquy- Ask patient to whisper 1,2,3 while listening to the chest. Sounds are louder and clearer than the whispered sounds, as if the patient is directly whispering into the stethoscope. Indicates an area of lung consolidation. Negative: Muffled/ undistinguishable words noted indicating normal lung tissue.
-Tactile Fremitus- Assessed by asking an individual to repeat a certain phrase while the examiner places the palms or the bony edge of their hands on the individual's chest wall to feel for sound vibrations. An increase in tactile fremitus indicates denser or inflamed lung tissue, which can be caused by diseases such as pneumonia. A decrease suggests air or fluid in the pleural spaces or a decrease in lung tissue density, which can be caused by diseases such as chronic obstructive pulmonary disease or asthma.
-Bronchophony- The word "ninety-nine" is clear and louder over denser areas. It sounds as if the patient is speaking directly into the stethoscope. Indicates pneumonia.
-Egophony- "c,c,c" sounds like a loud "a,a,a". Indicates consolidation or compression, as with pneumonia and pulmonary edema.
Objective information found when inspecting the neck
- Scars, masses, glandular or nodal enlargement. Inspect the trachea, noting any deviation. Next, inspect the thyroid gland as the patient swallows, noting any enlargement.
Know how to assess strength of upper and lower extremities
- Compare one set of extremities bilaterally, not upper and lower
What are risk factors for developing CVA
- 68-year-old African American male with hypertension
Know when teaching about the ears, the nurse should instruct the client how to clean the ears
- Do not stick cotton swab into ear canal
Cone of light on otoscope exam located where
- On tympanic membrane, anterior inferior
Know anatomy of the breast (acini cells, lactiferous ducts, nipples, lobules, breast sinus)
- Acini cells are in the Lobules
Know anatomy of the penis (shaft, corona, root, corpus spongiosum, glans)
- Corona-base of glands
Know family process and ways to enhance family process
- Have family dinners
Know priority interventions/assessments for acute right pelvic pain in female
Know what pulse difference between upper and lower extremities indicates in a child
- Coarctation of the aorta, cyanosis (expect in newborns)
Know interventions to take if you are not able to elicit patellar reflex in a patient
Know Breast anatomy (Montgomery glands, axillary node locations) and purpose
- Montgomery glands- sebaceous glands that secrete protective lubricant when a women lactate
- Central axillary nodes- high in the axilla in the top of the ribs
Know weight gain during different trimesters of pregnancy
- First trimester- 2-4 lbs
- Second trimester- between a half a pound and 1 pound per week
- Third Trimester- 1 pound per week
- 25-30 lbs total
Know Role of Vitamin A in night vision
- Precursor of rhodopsin, a light absorbing protein in the retina that helps us to see at night. Without vitamin A, "night blindness" occurs
Know most appropriate intervention for constipation related to opioid- this constipation will need more than diet and increased fluids
Know priority intervention when pulse is not palpable with doppler
- Notify the provider
Know how to document specifically the PERRLA/corneal light reflex/extraocular movement eye exam in a child
- PERRLA extraocular movement eye at 180 degrees, corneal light reflexes equal
Know types of assessments and when might each one be used (comprehensive, focused etc)
- Comprehensive- Includes health history and complete physical exam
- Body system- Promotes critical thinking and allows you to analyze findings as you cluster similar fata
- Head-to-toe- Promotes critical thinking and allows you to analyze findings as you cluster similar data
- Emergency-Airway, breathing, circulation, disability, and exposure
Know what types of activities can be delegated to a nursing assistant
- Things that do not require the nursing process (ADPIE), AP can give enemas
Know safety interventions for a client noted to be at risk for falls on admission database
Age, previous fall, medical condition
Know the purpose of collecting subjective and objective admission data- what happens once it is collected (think ADPIE)
- Subjective- How the patient says they feel, symptoms
- Objective-Measurable, what the nurse assesses upon admission signs
- Primary- Patient source
- Secondary- Documentation or family members
Know VS normal and abnormal and what would constitute emergent intervention
Obstructed airway/ turning blue
What is the purpose of a comprehensive health assessment
- Comprehensive- Includes health history and complete physical exam
- Body system- Promotes critical thinking and allows you to analyze findings as you cluster similar data
Know how to chart pulses
1 + indicating a faint, but detectable pulse; 2 + suggesting a slightly more diminished pulse than normal; 3 + is a normal pulse; and 4 + indicating a bounding pulse.
Know some common cultural beliefs for patients we have discussed in class
Muslim- pork and females might request another female to perform exams
Know normal vs abnormal abdominal assessment findings
Normal:Abdomen is soft, symmetric, and non-tender without distention. There are no visible lesions or scars. The aorta is midline without bruit or visible pulsation
Abnormal: hernia, tenderness, hyperactive bowel sounds
Know nursing interventions for a nursing diagnosis of "Diarrhea related to inflammatory changes in the bowel"
Ensure adequate hydration and electrolyte replacements
Other sets by this creator
Mental Health Exam 1
ATI Week 8 Quiz (5,43,44)
BIOL 172 Exam 4