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190 terms

2501

Assessment
STUDY
PLAY
Normal BP
less than 120/ less than 80
Prehypertension
systolic: 120-139 or diastolic: 80-89
High BP, Stage 1
systolic: 140-159 or diastolic: 90-99
High BP, Stage 2
systolic: 160+ or diastolic: 100+
A) allow the child to sit on the parent's lap.
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) identify abdominal contents.
Deep palpation is used to:
A) identify abdominal contents.
B) evaluate surface characteristics.
C) elicit deep tendon reflexes.
D) determine the density of a structure.
A) the intensity (soft or loud) of sound.
Amplitude is:
A) the intensity (soft or loud) of sound.
B) the length of time the note lingers.
C) the number of vibrations per second.
D) the subjective difference in a sound's distinctive overtones.
B) temperature.
The dorsa of the hands are used to determine:
A) vibration.
B) temperature.
C) an organ's position.
D) fine tactile discrimination.
B) fingertips.

The fingertips are best for fine tactile discrimination such as skin texture, swelling, pulsation, and presence of lumps.
Fine tactile discrimination is best achieved with the:
A) opposition of the fingers and thumb.
B) fingertips.
C) back of the hands and fingers.
D) base of the fingers.
C) internal structures of the eye.
A funduscopic examination is an examination of the:
A) inner ear.
B) pharynx.
C) internal structures of the eye.
D) nasal turbinates.
A) Base the pace of the examination on the patient's needs and abilities.
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.
B) strikes the stationary finger at the distal interphalangeal joint.

just behind the nail bed
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.
D) review the findings with the patient.
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.
B) if the patient has an infection with Clostridium difficile
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
D) Reliability of informant
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
C) aggravating factors.
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:
A) the patient's perception of pain.
B) the nature or character of the headache.
C) aggravating factors.
D) relieving factors.
C) excessive or uncontrollable drinking.
The CAGE test is a screening questionnaire that helps to identify:
A) unhealthy lifestyle behaviors.
B) personal response to stress.
C) excessive or uncontrollable drinking.
D) depression.
A) an evaluation of past and present health state of each body system.
The "review of systems" in the health history is:
A) an evaluation of past and present health state of each body system.
B) a documentation of the problem as perceived by the patient.
C) a record of objective findings.
D) a short statement of general health status.
C) the presence or absence of all symptoms under the system heading.
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.
A) education, financial status, and value-belief system.
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.
C) symptoms.
PQRSTU is a mnemonic that helps the clinician to remember to address characteristics specific to:
A) severity of dementia.
B) substance use and abuse.
C) symptoms.
D) the ability to perform activities of daily living (ADLs).
B) rephrase the same questions later in the interview.
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.
C) interview the youth alone with a parent in the waiting area.
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.
A) nutritional data
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) has a change in behavior and the family is concerned.
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) a language disturbance in speaking, writing, or understanding.
Aphasia is best described as:
A) a language disturbance in speaking, writing, or understanding.
B) the impaired ability to carry out motor activities despite intact motor function.
C) the impaired ability to recognize or identify objects despite intact sensory function.
D) a disturbance in executive functioning (planning, organizing, sequencing, abstracting).
B) judgment.
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.
A) impaired short-term and long-term memory.
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) emotional and cognitive functioning.
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.
C) appearance, behavior, cognition, and thought processes.
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) has a slower response time.
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) Abnormal findings are usually related to not achieving an expected developmental milestone.
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.
D) assesses mental health strengths and coping skills and screens for any dysfunction.
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.
B) Blocking

Thought process is defined as the way a person thinks, or as the logical train of thought. Blocking is a sudden interruption in train of thought.
Which of the following best illustrates an abnormality of thought process?
A) Lability
B) Blocking
C) Compulsion
D) Aphasia
C) decreased liver metabolism and kidney functioning.
The nurse would expect an older adult to have higher blood alcohol levels because older adults have:
A) more lean muscle mass.
B) an increased consumption of alcohol.
C) decreased liver metabolism and kidney functioning.
D) increased gastrointestinal motility.
C) needing more than three drinks to feel the effects.
For a patient to meet the criteria for a diagnosis of alcohol abuse, the patient must report that alcohol has repeatedly caused or contributed to:
A) amnesia episodes while drinking.
B) relationship trouble with family or friends.
C) needing more than three drinks to feel the effects.
D) one or more family members complaining about alcohol use.
D) "I believe that you have an alcohol problem and strongly recommend that you quit drinking. I am willing to help."
If the patient has a drinking problem, which statement by the nurse is most appropriate?
A) "Your alcohol consumption is not that bad. You only need to cut down on the amount by only drinking on the weekend."
B) "I want you to record how much you drink over the next 2 to 3 months. This will help you to determine if you have a drinking problem."
C) "If you continue to drink, you might develop serious health problems. It is up to you to find help and the way to quit."
D) "I believe that you have an alcohol problem and strongly recommend that you quit drinking. I am willing to help."
A) elevated gamma-glutamyl transferase (GGT)
A patient denies having a drinking problem. Which of the following laboratory tests is commonly used as a biochemical marker that indicates chronic alcohol use?
A) elevated gamma-glutamyl transferase (GGT)
B) elevated serum aspartate aminotransferase (AST)
C) elevated mean corpuscular volume (MCV)
D) elevated blood alcohol content (BAC)
C) Hypertension
A patient with chronic alcohol use is most at risk for developing which of the following cardiovascular diseases?
A) Bradycardia
B) Deep vein thrombosis
C) Hypertension
D) Acute myocardial infarction
A) oxycodone.
One of the most frequently abused prescription opioid pain medications is:
A) oxycodone.
B) meperidine.
C) morphine.
D) propoxyphene.
B) avoid alcohol before conception and during pregnancy.
A female patient asks the nurse about the safe use of alcohol before and during pregnancy. The best response by the nurse is to instruct the patient to:
A) talk about alcohol use with the physician.
B) avoid alcohol before conception and during pregnancy.
C) reduce alcohol intake before pregnancy and to avoid alcohol after a positive pregnancy test.
D) limit alcoholic beverages to 2 or fewer drinks per week during pregnancy.
B) one drink per day.
Patients should be instructed to consume alcohol in moderation. To consume at a moderate drinking pattern, a female should be instructed to consume no more than:
A) two drinks per day.
B) one drink per day.
C) three drinks per week.
D) six drinks per week.
D) MAST-G (Short Michigan Alcohol Screening Test-Geriatric Version)
Which alcohol screening test is specifically design for use in older adults?
A) CAGE (Cutdown, Annoyed, Guilty, Eye opener)
B) TWEAK (Tolerance, Worry, Eye-opener, Amnesia, and Kut down)
C) AUDIT (Alcohol Use Disorders Identification Test)
D) MAST-G (Short Michigan Alcohol Screening Test-Geriatric Version)
B) alcohol dependence.
If a patient admits to not being able to quit drinking, having to have more drinks to get the same effect, and having withdrawal symptoms, the patient meets criteria for:
A) at-risk drinking.
B) alcohol dependence.
C) hazardous drinking.
D) harmful drinking.
C) neglect
Dehydration and malnutrition can be manifestations of ________________ in the elderly.
A) intimate partner violence
B) physical abuse
C) neglect
D) psychological abuse
C) Ingestion of nonsteroidal antiinflammatory drugs
Increased bruising and bleeding in the elderly may be related to which of the following?
A) Thinning of the skin
B) A reduction in the integrity of blood vessels
C) Ingestion of nonsteroidal antiinflammatory drugs
D) Decreased fluid intake
C) an intimate male partner.
American women are most often killed by:
A) a known sex offender.
B) a male convicted of a serious crime.
C) an intimate male partner.
D) a male with a substance use problem.
A) mental status examination.
An extremely important part of the history and examination in situations of intimate partner violence or elder abuse is the:
A) mental status examination.
B) family genogram.
C) history of the present illness.
D) skin assessment.
B) identifying abuse in the early stages.
The health care system may help abused women by:
A) providing shelter from the abusive individual.
B) identifying abuse in the early stages.
C) providing financial and supportive services.
D) estimating the ages of bruises.
C) chronic pain.

Abused women have been found to have significantly more injuries. Also, abused women have more chronic health problems including neurologic, gastrointestinal, and gynecologic symptoms and chronic pain.
Abused women have been found to have significantly more health problems, including:
A) cardiovascular disease.
B) cancer.
C) chronic pain.
D) chronic anemia.
C) current or former intimate partner.
Women are more likely to be physically or sexually assaulted by a:
A) family member.
B) stranger.
C) current or former intimate partner.
D) friend.
B) incision.
A woman seeks medical attention for a cut made by a knife during a physical assault. The health care provider would document the cut as an:
A) ecchymosis.
B) incision.
C) avulsion.
D) abrasion.
D) disabled child.
Risk factors associated with child maltreatment include:
A) young parents (between 18 and 20 years of age).
B) family with more than four children.
C) a parent with chronic pain.
D) disabled child.
C) Notify the authorities of the suspected elder abuse.
The nurse caring for an older adult suspects elder abuse. Which action is appropriate?
A) Collect proof of abuse before notifying the authorities.
B) Confront the caretakers about the suspicion of abuse.
C) Notify the authorities of the suspected elder abuse.
D) Report the abuse if the older adult gives permission.
C) physical appearance, body structure, mobility, and behavior.
The general survey consists of four distinct areas. These areas include:
A) mental status, speech, behavior, and mood and affect.
B) gait, range of motion, mental status, and behavior.
C) physical appearance, body structure, mobility, and behavior.
D) level of consciousness, personal hygiene, mental status, and physical condition.
B) waiting less than 1 to 2 minutes before repeating the blood pressure reading on the same arm.
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.
A) at the first encounter.
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.
B) augments Korotkoff sounds during blood pressure measurement.
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.
A) provides an accurate measurement of core body temperature.
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.
B) caused by excess adrenocorticotropin production by the pituitary gland.
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.
C) count for 30 seconds after completing a pulse assessment and multiply by two.
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.
B) stated age.
Physical appearance includes statements that compare appearance with:
A) mood and affect.
B) stated age.
C) gait.
D) nutrition.
B) bradycardia.
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.
D) Anxiety
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
B) afferent fibers.
Pain signals are carried to the central nervous system by way of:
A) perception.
B) afferent fibers.
C) modulation.
D) referred pain.
B) Patient self-report
Which of the following is the most reliable indicator for chronic pain?
A) Magnetic resonance imaging (MRI) results
B) Patient self-report
C) Tissue enzyme levels
D) Blood drug levels
A) White individuals receive more analgesic therapy than black or Hispanic individuals with similar symptoms.
Which of the following is true regarding cultural/racial differences in the treatment of pain?
A) White individuals receive more analgesic therapy than black or Hispanic individuals with similar symptoms.
B) Black and Hispanic individuals have been found to have a higher pain tolerance than white individuals.
C) Pain modulation is more highly developed in black and Hispanic individuals.
D) Neurotransmitters are more concentrated in whites individuals than they are in black and Hispanic individuals.
A) Pain signals move from the site of origin to the spinal cord
What occurs during transduction (the first phase of nociceptive pain)?
A) Pain signals move from the site of origin to the spinal cord
B) Pain impulse moves from the spinal cord to the brain
C) Interpretation of the pain signal by the brain
D) Neutralization of chemical mediators to decrease the perception of pain
C) Acute
What type of pain is short and self-limiting and dissipates after the injury heals?
A) Chronic
B) Persistent
C) Acute
D) Breakthrough
B) processing of the pain message.
Neuropathic pain implies an abnormal:
A) degree of pain interpretation.
B) processing of the pain message.
C) transmission of pain signals.
D) modulation of pain signals.
B) Bones and joints

Deep somatic pain comes from sources such as the blood vessels, joints, tendons, muscles, and bones
What is the source of deep somatic pain?
A) Skin and subcutaneous tissues
B) Bones and joints
C) Pancreas
D) Intestine
B) Hormonal changes
Which of the following has been found to influence pain sensitivity in women?
A) Age
B) Hormonal changes
C) Parity
D) Weight
C) nociceptors.
Specialized nerve endings that are designed to detect painful sensations are:
A) synapses.
B) dorsal horns.
C) nociceptors.
D) C fibers.
B) administer prescribed pain medication.

A patient with a pain score of 4 or greater (on the PAINAD scale) should receive pain intervention. Patients with dementia can be given an analgesic trial or option.
An older adult patient with dementia has a pain rating of 5 on the Pain Assessment in Advanced Dementia (PAINAD) Scale. The nurse should:
A) reassess the pain level in 3 to 4 hours.
B) administer prescribed pain medication.
C) ask the patient to verify the pain rating.
D) use only nonpharmacologic pain relief interventions.
C) a body mass index of 30 or greater.
Obesity in adults is defined as:
A) excess body fat placed predominately within the hips and thighs.
B) excessive body fat leading to body weight 5% above ideal.
C) a body mass index of 30 or greater.
D) overnourished.
B) vitamin C deficiency.

Patients with vitamin C deficiency may have the following clinical manifestations: petechiae or ecchymoses, bleeding gums, joint pain, and splinter hemorrhages of the nails.
A patient's complaints include bleeding gums, splinter hemorrhages of the nails, and joint pain. These complaints are symptomatic of:
A) riboflavin deficiency.
B) vitamin C deficiency.
C) vitamin B12 deficiency.
D) iron deficiency.
C) consume 6 ounces of whole-grain products per day.
A patient reports consuming approximately 2000 calories per day. For a healthy diet, the patient should:
A) eat at least 4 cups of fruits and 4½ cups of vegetables per day.
B) consume less than 100 mg per day of cholesterol.
C) consume 6 ounces of whole-grain products per day.
D) keep fat intake to 5% of total calories.
C) Religious
A dietary practice to restrict meat on certain days such as Ash Wednesday and Fridays during Lent is an example of what type of nutritional influence?
A) Ethnic
B) Economic
C) Religious
D) Cultural
C) loss of lean body mass.
Energy requirements for the aging adult decrease as a result of:
A) loss of energy.
B) eating habits.
C) loss of lean body mass.
D) decreasing body fat.
A) serum albumin.

Laboratory testing is required to make an accurate diagnosis of malnutrition. Serum albumin is a common measurement of visceral protein status. Low serum albumin levels occur with protein-calorie malnutrition, altered hydration status, and decreased liver function. A serum albumin level of 2.8 to 3.5 g/dl represents moderate visceral protein depletion, and less than 2.8 g/dl denotes severe depletion.
Nutritional status is best determined by:
A) serum albumin.
B) clinical manifestations.
C) triglycerides.
D) 24-hour diet recall.
C) between 20% and 35% of the total calorie intake.

most from polyunsaturated or monounsaturated fats
Dietary guidelines suggest that overall fat consumption should be:
A) less than 300 mg per day.
B) between 10% and 20% of the total calorie intake.
C) between 20% and 35% of the total calorie intake.
D) mostly trans-fatty acid or saturated fat.
D) Fat
For optimum health, infants and children up to 2 years of age should receive whole milk. What component of whole milk is essential for neurologic development?
A) Lactose
B) Pasteurized protein
C) Fortified vitamin D
D) Fat
A) anthropometric measures.

Anthropometric measures evaluate growth, development, and body composition. Examples include height, weight, waist circumference, derived weight measures (e.g., body mass index, waist to hip ratio, etc.), and triceps skinfold thickness.
A comprehensive nutritional assessment always includes:
A) anthropometric measures.
B) a direct observation of feeding and eating processes.
C) a work history.
D) a comprehensive metabolic panel.
D) android obesity.

Obese persons with most of their fat in the abdomen have android (upper body) obesity. A waist to hip ratio of 1.0 or greater in men or 0.8 or greater in women is indicative of android obesity, which places a person at higher risk for obesity-related diseases and early mortality.
Obese persons with more fat in the upper body, especially the abdomen, have:
A) gastronomic obesity.
B) gynoid obesity.
C) anthropometric obesity.
D) android obesity.
D) Drug reactions
When taking the health history, the patient complains of pruritus. What is a common cause of this symptom?
A) Excessive bruising
B) Hyperpigmentation
C) Cancer
D) Drug reactions
A) purpura.
A flat macular hemorrhage is called a(n):
A) purpura.
B) ecchymosis.
C) petechiae.
D) hemangioma.
D) Newborn infants do not sweat and use compensatory mechanisms to control body temperature.
A student nurse has been assigned to teach fourth graders about hygiene. While preparing, the student nurse adds information about the sweat glands. Which of the following should be included while discussing this topic?
A) There are two types of sweat glands: the eccrine and the sebaceous.
B) The evaporation of sweat, a dilute saline solution, increases body temperature.
C) Eccrine glands produce sweat and are mainly located in the axillae, anogenital area, and navel.
D) Newborn infants do not sweat and use compensatory mechanisms to control body temperature.
B) temperature regulation.
Functions of the skin include:
A) production of vitamin C.
B) temperature regulation.
C) the production of new cells by melanocytes.
D) the secretion of a drying substance called sebum.
C) a lifetime of environmental trauma.
Risk factors that may lead to skin disease and breakdown include:
A) loss of protective cushioning of the dermal skin layer.
B) decreased vascular fragility.
C) a lifetime of environmental trauma.
D) increased thickness of the skin.
A) Zosteriform
What term refers to a linear skin lesion that runs along a nerve route?
A) Zosteriform
B) Annular
C) Dermatome
D) Shingles
A) contour, consistency, and color.
The components of a nail examination include:
A) contour, consistency, and color.
B) shape, surface, and circulation.
C) clubbing, pitting, and grooving.
D) texture, toughness, and translucency.
A) conjunctivae.
To determine if a dark skinned patient is pale, the nurse should assess the color of the:
A) conjunctivae.
B) ear lobes.
C) palms of the hands.
D) skin in the antecubital space.
C) urticaria.
An example of a primary lesion is a(n):
A) erosion.
B) ulcer.
C) urticaria.
D) port-wine stain.
D) erosion.
A scooped out, shallow depression in the skin is called a/an:
A) ulcer.
B) excoriation.
C) fissure.
D) erosion.
the collecting of data about an individual's health state; the starting point of every approach to clinical reasoning, and from it all health care decisions are made based upon the data found during the process.
role of assessment
to collect subjective data- what the person says about him or herself. This history is combined with the objective data- from physical exams and laboratory studies to for the database. The database is then used to make a judgment or diagnosis about the health status of the individual.
purpose of complete health hx
biographic data (name, address,etc)
source of hx (who is giving you the info?)
reason for seeking care
present health or hx of present illness
past health (childhood, accidents, etc)
family hx
review of symptoms
functional assessment (ADLs, self-care)
perception of health
categories of info contained in health hx
1. Location: be specific and ask them to point to the site of pain
2. Character or Quality: specific descriptive terms (ex: burning, sharp, dull, aching, throbbing, etc)
3. Quantity or Severity: quantify the sign or symptom; avoid adjectives and ask how it affects daily activities
4. Timing: onset, duration, and frequency
5. Setting: Where was the person when pain started? What brings it on?
6. Aggravating or Relieving Factors: What makes it worse? What makes it better?
7. Associated Factors: Is this primary symptom associated with any others?
8. Patients Perception: The meaning of the symptom and how it affects daily activities.
8 characteristics of summary of client symptoms
To document a dysfunction and it determines how that dysfunction affects self-care in everyday life. A systematic check of emotional and cognitive functioning.
It cannot be scrutinized directly by skin or heart sounds. Functioning is inferred through assessment of an individual's behavior.
purpose of mental status eval
concentrated watching; it is the use of vision and hearing to distinguish normal from abnormal findings; begins the moment you meet the patient
inspection
should be used to examine all accessible parts of the body; applies your sense of touch to asses factors such as: 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.
palpation
should be used to determine position, texture, size and consistency, masses, fluid, crepitus as well as vibration, rhythm blood vessels such as carotid/femoral artery.
palmar surface of the fingers and finger pads
requires the use of both of your hands to capture certain body parts or organs (ie. kidneys or uterus) for more precise delimitation.
Bi-manual palpation
best for the tactile discrimination of skin texture swelling, pulsation and determining presence of lumps
Fingertips
to measure skin turgor, elasticity and tenderness.
grasping with fingertips
measure swelling, symmetry and mobility of glands such as thyroid and lymph
Pads of fingers
the striking hand directly contacts the body wall. It is used in percussing the infant's thorax or the adult' sinus area. This is do by placing the dominant hand on the skin an raise your forefinger an tap on skin directly.
Direct Percussion
used more often and involves both hands. The striking hand contacts the stationary hand fixed on the person's skin. This is to yield a sound and a subtle vibration. This s one by placing your non-dominant hand on the skin and with your dominant middle finger tap your non-dominant hand
Indirect Percussion
high pitched sounds (breath, bowel, normal heart)
diaphragm of stethoscope best for
soft, low pitched sounds (heart murmur)
bell of stethoscope best for
Clinician asks the patient to answer 8 questions concerning location, duration, quality, intensity and aggravating/relieving factors while also asking about the manner of expressing pain and the effects of pain that impair their quality of life
Initial Pain Assessment
Dry skin
______________occurs as a result of decrease in number and function of the sweat and sebaceous glands
macule
Solely a color change, flat and circumscribed, of less than 1 cm; Freckles, flat nevi, measles, scarlet fever
papule
Something you can feel, solid, elevated; Elevated nevus (mole), wart (verruca)
patch
Macules that are larger than 1 cm; Mongolian spot, café au lait spot, measles rash
nodule
Solid, elevated, hard or soft, larger than 1 cm; Xanthoma, fibroma, intradermal nevi
wheal
Superificial, raised, transient, and erythematous; slightly irregular shape due to edema; Mosquito bite, allergic reaction
tumor
Larger than a few centimeters in diameter, firm or soft, deeper into dermis, may be benign or malignant
Ex. Lipoma, hemangioma
Urticaria (Hives)
Wheals coalesce to form extensive reaction, intensely puritic
Vesicle
Elevated cavity containing free fluid, up to 1 cm; Herpes simplex, early varicella (chicken pox), herpes zoster (shingles)
Bulla
Larger than 1 cm in diameter; Friction blister, burns, contact dermatitis
Cyst
Encapsulated fluid filled cavity in dermis or subcutaneous layer, tensely elevating skin
Ex. Sebaceous cyst
Pustule
Turbid fluid (pus) in the cavity, circumscribed and elevated; Impetigo and acne
Annular, or circular
tinea corporis (ringworm), tinea versicolor
confluent
lesions run together e.g urticaria {hives}
Discrete
skin tags, acne
Gyrate
twisted, coiled spiral, snakelike
grouped
clusters of lesions (e.g vesicles of contact dermatitis)
Linear
a scratch, streak, line or stripe
Target or iris
resembles iris of eye, concentric rings of color in the lesions (e.g erythema multiforme)
Zosteriform
linear arrangement along a unilateral nerve route (e.g herpes zoster)
Polycyclic
annular lesions grown together, e.g lichen planus, psoriasis
Secondary Lesions
when a lesion changes over time or changes because of factors such as scratching or infection
Crust
the thickened dried out exudates left when vesicles/pustules burst or dry up. Color can be red-brown, honey or yellow depending on fluid ingredients (blood serum pus) (Ex: impetigo, weeping eczema)
Scale
compact, desiccated flakes of skin dry or greasy, silvery or white, from shedding of dead excess keratin cells (Ex: scarlet fever or drug reaction)
Fissure
Linear crack with abrupt edges, extends into dermis, dry or moist. (Ex: cheilosis- at corners or mouth due to excess moisture; athletes foot)
Erosion
Scooped out but shallow depression. Superficial; epidermis lost, most but no bleeding, heals without scar because erosion does not extend into dermis.
ulcer
Deeper depression extending into dermis, irregular shape; may bleed; leaves scar when heals. (Ex: stasis, ulcer, pressure sore, chancre)
Excoriation
Self-inflicted abrasion; superficial sometimes crusted; scratches from intense itching (Ex: insect bites, scabies, dermatitis, varicella)
Scar
after skin lesion is repaired; normal tissue is lost and replaced with connective tissue (collagen). (Ex: healed area of surgery or injury, acne)
Atrophic Scar
the resulting skin level is depressed with loss of tissue, a thinning of the epidermis. (Ex: striae)
Lichenification
Prolonged, intense scratching eventually thickens the skin and produces tightly packed sets of papules; looks like surface of moss (or lichen)
Keloid
hypertrophic scar, resulting skin in elevated by excess scar tissue, looks smooth, rubbery and claw-like.
Hemangiomas: port-wine stain, strawberry mark, or cavernous hemangioma
caused by a benign proliferation of blood vessels in the dermis
Telangiectasia: spider or star angioma, venous lake
caused by vascular dilation; permanently enlarged and dilated blood vessels that are visible on the skin surface
Purpuric Lesions: petechiae, ecchymosis, purpura
caused by blood flowing out of breaks in the vessels. Red blood cells and blood pigments are deposited in the tissues (extravascular).
diaper dermatitis, intertrigo (candidiasis), impetigo, atopic dermatitis (eczema), measles (rubeola & rubella), varicella
common childhood skin lesions
primary contact dermatitis, allergic drug rxn, tinea corporis (ringworm of body), tinea pedis (ringworm foot), labial herpes simplex (cold sore), tinea versicolor, herpes zoster (shingles), erthema migraines of Lyme Disease, psoriasis
common skin lesions
basal cell carcinoma (face, ears, scalp, shoulders), squamous cell carcinoma (usually hands, head), malignant melanoma & metastatic melanoma (preexisting nevi)
malignant skin diseases
Resonant; lung
med amp - pitch is low - quality is clear & hollow; moderate duration
Dull; dense organ (liver or spleen)
soft amp - high pitch - muffled thud quality - short duration
96.4-99.1
oral temperature range
most reliable. range .7-1 F higher; 97.4-100.1F; 2-3 cm into rectum
rectal temperature
.7-1 F lower than oral; 95.4-98.1
axillary temperature
If rhythm is regular, count number of beats in 30 seconds & multiply by 2
Assess pulse including 1) rate, 2) rhythm, and 3) force
pulse
3+ full, bounding (increased stroke volume - anxiety, exercise, some abnormal conditions)
2+ is normal
1+ weak, thread (denotes an increased stroke volume - ex: hemorrhagic shock)
0 absent
pulse force
50-90 bpm
pulse rate
bradycardia
HR less than 50bpm; occurs normally in a well-trained athlete
tachycardia
HR over 90bpm; occurs normally w/ anxiety or w/ increased exercise to match body's demand for increased metabolism
10-20bpm
respiratory rates
Peripheral vascular resistance
opposition to blood flow through arteries; when container becomes smaller, pressure needed to push contents becomes greater
Volume of blood circulating blood
volume of circulating blood refers to how tightly blood is packed into arteries; increasing contents in the container increases pressure
Too narrow - result in BP is falsely high
Too loose or uneven - falsely high
cuff sizes
Orthostatic hypotension; occurs w/ prolonged bedrest, older age, hypovolemia, and some drugs
drop in systolic pressure of more than 20mmHg f=
thigh

systolic is usually 10-40 mmHg higher in thigh than in arm & diastolic is same
if bp in arm is excessively high (adolescents & youth), compare with _____ pressure to check for coarction of aorta (congenital form of narrowing)
3
do not take bp on children _____ and younger
children 2 & younger
head circumferences
97-98; range is 90-100
healthy SpO2
doppler technique
used to locate peripheral pulse sites; critically ill individuals w/ low BP, in infants w/ small arms & obsess people when sounds are muffled by layers of fat
brachial until age 8
children pulse sights
Basal Cell Carcinoma
Usually starts as a skin-colored papule (may be pigmented) with a pearly translucent top and overlying telangiectasia (broken blood vessel). 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.
Squamous Cell Carcinoma
Squamous cell cancers arise from actinic keratosis or de novo. Erythematous scaly patch with sharp margins, 1cm or more. Develops central ulcer and surrounding erythema/

Less common than basal cell carcinoma but grows rapidly. Usually on hands or head, areas exposed to UV radiation; above, on habitually sun exposed bald scalp.
Malignant Melanoma and Metastatic Melanoma
Half of these lesions arise from preexisting nevi.

Usually brown; can be tan, black, pink-red, or purple, or mixed pigmentation. Often irregular or notched borders. May have scaling, flaking, oozing texture. Common locations are on the trunk and back in men and women, on the legs in women, and on the palms, soles of feet, and nails in blacks.
Diaper Dermatitis (diaper rash)
Red, moist, maculopapular patch with poorly defined borders in diaper area, extending along inguinal and gluteal folds. History of infrequent diaper changes or occlusive coverings. Inflammatory disease caused by skin irritation from ammonia, heat, moisture, occlusive diapers.
Intertrigo (Candidiasis)
Scalding red, moist patches with sharply demarcated borders, some loose scales. Usually in genital area extending along inguinal and gluteal folds. Aggravated by urine, feces, heat and moisture, the Candida Fungus infects the superficial skin layers.
Impetigo
Moist, thin-roofed vesicles with thin, erythematous base. Rupture to form thick, honey-colored crust. Contagious bacterial infection of skin; most common in infants and children.
Atopic Dermatitis
(Eczema) Erythematous papules and vesicles, with weeping, oozing and crusts. Lesions usually on scalp, forehead, cheeks, forearms and wrists, elbows, back of knees. Paroxysmal and sever pruritus. Family history of allergies.
Measles (Rubeola)
Red-Purple maculopapular blotchy rash. Different Pics in text for light or dark skin. Appears on 3rd or 4th day of illness. Rash appears first behind ears and spreads over face, then over neck, trunk, arms, and legs; looks "Coppery" and does not blanch. Also characterized by Koplik spots in mouth—bluish white, red-based elevations of 1-3 mm.
German Measles (Rubella)
Pink, popular rash (similar to measles but paler) first appears on face, then spreads. Distinguished from measles by presence of neck lymphadenopathy and absence of Koplik spots.
Chickenpox (Varicella)
Small, tight vesicles first appear on trunk, then spread to face, arms, and legs (not on palms or soles). Shiny vesicles on an erythematous base are commonly described as the "dewdrop on a rose petal". Vesicles erupt in succeeding crops over several days, then become pustules, and then crusts. Intensely pruritic.
Primary Contact Dermatitis
Local inflammatory reaction to an irritant in the environment or an allergy. Characteristic location of lesions often gives clue. Often erythema shows up first, followed by swelling, wheals (or urticaria), or maculopapular vesicles, scales. Frequently accompanied by intense pruritus. Ex. Poison Ivy
Allergic drug reaction
Erythematous and symmetric rash, usually generalized. Some drugs produce urticarial rash or vesicles and bullae. History of drug ingestion
Tinea Corporis (Ringworm of the body)
Scales—hyper pigmented in whites, de-pigmented in dark-skinned persons—on chest, abdomen, back of arms forming multiple circular lesions with clear centers.
Tinea Pedis (Ringworm of the foot)
"Athletes Foot" is a fungal infection, first appears as small vesicles between toes, sides of feet, and soles and then grows scaly and hard. Found in chronically warm, moist feet: children after gym activities, athletes, aging adults who cannot dry their feet well.
Labial Herpes Simplex (Cold sores)
Herpes simplex virus (HSV) infection has a prodrome of skin tingling and sensitivity. Lesion then erupts with tight vesicles followed by pustules and then produces acute gingivostomatitis with many shallow painful ulcers. Common location is upper lip, also in oral mucosa and tongue.
Tinea Versicolor
Fine, scaling, round patches of pink, tan, or white that (hence the name) do not tan in sunlight, caused by a superficial fungal infection. Usual distribution is on neck, trunk, and upper arms—a short sleeved turtleneck sweater area. Most common in otherwise healthy young adults. Responds to oral antifungal medication.
Herpes Zoster (Shingles)
Small, grouped vesicles emerge along route of cutaneous sensory nerve, then pustules, then crusts. Caused by the varicella zoster virus (VZV), a reactivation of the dormant virus of chickenpox. Acute appearance, unilateral, does not cross midline. Commonly on trunk, can be anywhere. If on ophthalmic branch of cranial nerve V, it poses risk to eye. Most common in adults older then 50 years. Pain is often severe and long lasting in aging adults, called postherpetic neuralgia.
Erthema Migrans of Lyme Disease
Lyme disease (LD) is not fatal but may have serious arthritic, cardiac, or neurologic sequelae. It is caused by a spirochete bacterium carried by the black or dark brown deer tick. Deer ticks are common in the NE, upper Midwest, and CA (with cases occurring in people who spend time outdoors between May and September. The first stage (early localized LD) has the distinctive bull's eye, red macular or popular rash in 50% of cases. The rash radiates from the site of the tick bite (5 cm or larger), with some central clearing, and is usually located in the axillae, midriff, inguinal, or behind knees, with regional lymphadenopathy. Rash fades in 4 weeks; untreated individuals then may have disseminated disease with fatigue, anorexia, fever chills, joint or muscle aches. Antibiotic treatment shortens symptoms and decreased risk for sequelae.
Psoriasis
Scaly, erythematous patch, with silvery scales on top. Usually on scalp, outside of elbows and knees, low back, and anogenital area.
palliative/provocative: what brings it on, what are you doing when it happens?
quality/quantity: how it looks, feels, sounds?
region/radiation: where it is, does it spread?
severity scale: 1-10, better, worse, same?
timing: onset, duration, frequency
understanding the pt
PQRSTU