Health Assessment EAQ's (JG Orig)

When nurses are conducting health assessment interviews with older clients, what step should be included?

Spend time in several short sessions to elicit more complete information from the client

A congenital condition in which both eyes do not focus on an object simultaneously, these eyes appear crossed. Impairment of the extraocular muscles or their nerve supply cause this

Strabismus

there is an increase in lumbar curvature.

lordosis

lithotomy position

lying on back with legs raised and feet in stirrups Areas Assessed: Female genital and GU Rationale: position provides max exposure of female genitalia and facilities insertion of vag speculum Limitations: Position is embarrassing and uncomfortable, thus examiner min time pt spends in it. Keep pt well draped

supine position

lying on back, facing upward

Sims position

lying on left side with right knee drawn up and with left arm drawn behind, parallel to the back

While measuring _______, _______, and ______the client's body parts should be grasped lightly with the fingertips

position, consistency, and turgor,

The client in the _______ _______ is ready to learn how to adapt to the change in body image through use of prosthesis or changing lifestyles and goals.

rehabilitation stage

Muscular spasms in larger airways or any new growth causing turbulence may produce

rhonchi, which is a loud and low-pitched sound.

Which Korotkoff sound represents the diastolic pressure in children?

the fourth

Lovett scale

0 T P F G N

a congenital condition in which both eyes do not focus on an object simultaneously. In this condition, the eyes appear crossed.

Strabismus is

The nurse administers a pneumococcal vaccine to a 70-year-old client. The client asks "Will I have to get this every year like I do with the flu shot?" How should the nurse respond?

The Centers for Disease Control and Prevention recommend that adults be immunized with pneumococcal vaccine at age 65 years or older with a *single dose* of the vaccine; if the pneumococcal vaccine was received before 65 years of age or if there is the highest risk of fatal pneumococcal infection, revaccination should occur 5 years after the initial vaccination

dorsal recumbent position

Used to assess head & neck, anterior thorax, and lungs, breast, axillae, heart, abdomen Rationale: Position is used for ab assessment b/c it promotes relaxation of abdominal muscles Limitation: Pt with painful disorders are more comfortable with knees flexed

The nurse is caring for a client whose forehead feels warm to the touch. The nurse uses a thermometer and obtains the client's temperature. What is the nurse doing?

Validation The nurse is validating the presence of fever in the client.

Heart and lung abnormalities such as chronic obstructive pulmonary disease cause

clubbing of the nail beds.

Conditions such as syphilis and iron deficiency anemia cause

concavely curved nails, called koilonychia

Maintain strict asepsis during open catheter irrigation to minimize

contamination and subsequent development of a urinary tract infection (UTI).

After losing a limb in a MVA Initially, the client is in a state of shock and

depersonalizes the change. The client talks as if another person is affected by the change.

Wrapping the cuff too loosely will result in

false high systolic and diastolic values.

Repeating the assessment too quickly will result in

false high systolic readings.

Applying the stethoscope too firmly will result in

false low diastolic readings.

Spending time in several short sessions reduces client -

fatigue and compensates for a shortened attention span, which is common in the older adult.

The client with blanched skin, edema of 15.2 cm, cool temperature, and pain at the site of catheterization has symptoms of

grade 2 infiltration.

prone position

lying on abdomen, facing downward (head may be turned to one side)

Semi-Fowler's Position

the head of the bed is raised 30 degrees; or the head of the bed is raised 30 degrees and the knee portion is raised 15 degrees

Phlebitis is an inflammation of

the inner layer of the vein. The findings for this include redness, tenderness, pain, and warmth along the course of the vein starting at the access site.

knee-chest position

the patient is lying face down with the hips bent so that the knees and chest rest on the table This position is embarrassing and uncomfortable. Provides maximum exposure of rectal area. Used to examine the rectum

An accumulation of edematous fluid will result in

the separation of skin and underlying vasculature.

Turgor indicates the elasticity of the skin. The ideal site to assess the skin for turgor in an older adult is back of the forearm or the sternal area. The back of the neck contains redundant skin and may not be reliable. The skin on the back of the hand is normally loose and thin; turgor assessed at that site may not be reliable. The palm of the hand is not an ideal site for the assessment of turgor.

true

The registered nurse is teaching a nursing student about ways to minimize heat radiation. Which statements made by the nursing student indicate effective learning? Select all that apply.

I will apply an ice pack to the client." "I will cover the client with dark clothes." "I will instruct the client to lie in the fetal position." Applying an ice pack will increase conductive heat loss, which results in minimizing heat radiation. Wearing dark clothes and lying in the fetal position will minimize heat radiation. Removing extra clothes will increase heat radiation. Wearing sparsely woven clothes will enhance heat radiation.

The nurse teaching a health awareness class identifies which situation as being the highest risk factor for the development of a deep vein thrombosis (DVT)?

INACTIVITY A DVT, or thrombus, may form as a result of venous stasis. It may lodge in a vein and can cause venous occlusion. Inactivity is a major cause of venous stasis leading to DVT. Pregnancy and tight clothing are also risk factors for DVT secondary to inactivity.

When the abuse is related to an intimate partner, the nurse may observe

strangulation marks on the neck from rope burns or bruises.

SKIN COLOR VARIATIONS: Tan-Brown

increased amt of melanin causes: suntan, preg Assessment location: areas exposed to sun, face, nipples

The Allen's test is

is a medical sign used in physical examination of arterial blood flow to the hands

Staying isolated and not communicating with others are behavioral findings that may be related to: Weight loss and sunken eyes may be a physical finding for:

older adult abuse for both

A barrell shaped chest is a characteristic feature in an

older adult who smokes and has chronic lung disease.

Inflammation of the pleura may produce

pleural friction rubs.

A blowing or swishing sound occurs in the

second Korotkoff sound.

Sitting position

sitting upright provides full expansion of lungs and better visualization of symmetry of upper body parts. Physically weakened pt is sometimes unable to sit. Use supine pos. w/ head of bed elevated

The client with a change in body image following an injury recognizes the reality of the change, becomes anxious, and refuses to discuss it. This client uses ________as an adaptive coping mechanism.

withdrawl

An infant usually doubles his or her birth weight at

4 to 5 months of age.

Norm heart rate for Newborns (0 to 1 month old):

70 to 190 beats per minute.

Lateral Recumbant (recovery) position

Areas Assessed: Heart Position aids in detecting murmurs Pt with respiratory difficultes do not tolerate this postistion well

which part of the hand and fingers is used because it is more sensitive to vibrations

The palmar surface

A client who does not understand English requires an interpreter. Which nursing student action may exacerbate health disparities?

The student talks only to the interpreter about the client A nurse should follow certain strategies while working with an interpreter for a client who does not understand English. The nurse should talk to the client about the client's condition and care and not to the interpreter. The interpreter may act as a client advocate and represent the client's needs to the nurse. The nurse should use a trained medical interpreter who has a health care background. The nurse should maintain eye contact with the client and obtain feedback to be certain that the client understands.

involved in downward and inward eye movements.

The trochlear nerve is *CNIV*(4)

A client complains of difficulty breathing. The nurse auscultates wheezing in the anterior bilateral upper lobes. What could be the possible reason for this sound?

High velocity airflow through an obstructed airway

Research suggests that children who are spanked tend to use aggressive behavior; as they grow older they learn their own behavior through their parents' behavior.

true

Space b/t biceps & triceps at antecubital fossa. Site used to assess circulation to low arm and ausclutate BP.

Brachial Pulse

The nurse is assessing a client who arrived at the healthcare facility for an appointment. Which action by the nurse will be beneficial during the interview?

Asking about the client's current concerns

SKIN COLOR VARIATIONS: Yellow-Orange jaundace

Causes: Liver disease, destruction of RBC's Condtion: increased deposit of bilirubin in tissues Assessment location: sclera, mucus membrane

Turgor is the elasticity of the skin. Poor skin turgor could indicate:

Dehydration

intaocular structural damage resulting from elevated intraocular pressure. Obstruction of the outflow of aqueous humor causes this. Without treatment, leads to blindness

Glaucoma

Which sites would the nurse prefer while assessing for turgor in an older adult? Select all that apply.

On the sternal area Back of the forearm

Sudden reinflation of groups of alveoli may produce

crackling sounds

A registered nurse is teaching a nursing student how to assess for edema. Which statement made by the student indicates the need for further education?

"If the pressure on an edematous site leaves an indentation of 2 mm, a score of 2+ is given.

What is a nurse's most appropriate response, based on current research, when asked about spanking as a disciplinary technique?

"Spanking is strongly suggestive of negative role behavior."

A client complains of rapid, involuntary movement of the eyes after a minor eye injury. A nurse assesses the client and finds that it is a disorder of the cranial nerves. Which condition does the nurse suspect?

*Nystagmus* is a condition defined by rapid, involuntary, rhythmical oscillation of the eyes. This condition is caused by local injury to the eye muscles and supporting structures.

provides sensory and motor innervations for facial expressions.

The facial nerve *CNVII*(7)

While assessing body temperature, the ____ ______of the hand should be used.

dorsal surface (or back)

Edema is classified as pitting if .

the application of pressure on the edematous site will leave an indentation for some time

If the drainage output is less than the amount of irrigation solution infused, or if the patient complains of pain during bladder irrigation, do the following:

1. Examine the drainage tubing for clots, sediment, and kinks. 2. Inspect the urine for the presence of or increase in blood clots and sediment. 3. Evaluate the patient for pain and bladder distention. 4. Notify the health care provider.

The palmar surface of the hand and finger pads Are more sensitive than the fingertips. These should be used to determine .

1. position 2. texture 3. size 4. consistency 5. masses 6. fluid 7. crepitus

The average birth weight of a newborn is

3.2 to 3.4 kg.

prone position

Muscuskeltosystem The position is only for assessing extension of the hip joint, skin, buttocks. Patients w/ respiratory diffulties do not tolerate this position well

The depth of indentation left after applying pressure to an edematous site determines the degree of edema. A 1+ score is given if the depth of indentation is: A 2+ is the score given if the depth of edema indentation is:

2 mm. 4 mm.

Nearsightedness, a refractive error in which rays of light and focus *in front of the retina*. Persons are able to clearly see close objects but not distant objects

Myopia

While performing a physical assessment in a client, the registered nurse (RN) notices reddish linear streaks in the nail bed. Which systemic condition can the registered nurse (RN) suspect in the client based on these assessment findings?

3. Subacute bacterial endocarditis Red or brown linear streaks in the nail bed are caused by minor trauma to nails, subacute bacterial endocarditis, or trichinosis and are called splinter hemorrhages.

A nurse is assessing an older adult male client. Which clinical findings are expected responses to the aging process? Select all that apply

Slowed neurologic responses Forgetfulness about recent events Reduced ability to maintain an erection

Norm HR for todlers - Children 1 to 2 years old:

80 to 140 beats per minute

Norm Heart rate for infants (1 to 11 months old):

80 to 160 beats per minute

Full Fowlers position

90 degree angle

A client who has been admitted to the hospital with chest pain complains of shortness of breath, weakness, and vomiting. The nurse suspects cardiac arrest. Which site is the most appropriate place to check the client's pulse rate?

Femoral A client with chest pain, shortness of breath, weakness, and vomiting may be experiencing cardiac arrest. In a client with cardiac arrest, the most appropriate place to check the pulse rate is the femoral site, because other pulses may not be palpable at this time.

a condition in which the opacity of the lens will be increased; this disorder is commonly related to age.

A cataract is

a visual representation of the connection between the client's many health problems: The first step is to arrange all the cues into clusters that form patterns. This helps the nurse identify specific nursing diagnoses for the client. During the assessment stage, the nurse assesses the client and gathers information. This step is performed before preparing the concept map. After placing all cues into clusters, the nurse begins to identify patterns reflecting the client's problem. The concept map helps the nurse obtain a holistic view of the client's needs. The next step is to identify specific diagnoses so that appropriate nursing interventions can be provided.

A concept map is

Trendelenburg Position (shock position)

A position in which client is supine with the legs below the level of the heart. .

The nurse cares for an unconscious client who underwent head surgery. Which site would be best used to monitor body temperature?

Although the oral route is the most common route for monitoring body temperature, clients who are unconscious should have their temperatures monitored *rectally*.

4th to 5th intercostal space at L midclavicular line. Point of Maximal impulse (PMI)

Apical pulse

supine position

Areas assessed: head, neck, ant thorax, heart, lungs, breast, axilla, abdomen, extremities, pulses Rationale: The most relaxed position. Provides easy access to pulse site Limitations: if pt becomes short of breath easily raise head of the bed

The student nurse prepares a concept map while caring for a client recovering from surgery. What is the first step that the student nurse should take when preparing the concept map?

Arrange cues into clusters that form patterns

The nurse is preparing to teach a client about self-injection of insulin. Which action by the nurse will increase the effectiveness of the teaching session?

Assess clients barriers to learning the new technique

the first step of the nursing process. It involves collecting information from the client and secondary sources.

Assessment is

Along medial edge of sternocleidomastoid muscle in neck. Easily accessible site used durig physologocal shock or cardaic arrest weh other sites are not palpable

Carotid pulse

An increased opacity of the lens, which blocks light rays from entering the eye.sometimes develop slowly and progressively after 35 or sudden trauma. One of the most common eye disorders. Most adults 65 & older have some evidence of visual impairment from this disorder

Cataracts

can occur if intravenous solutions are infused too rapidly or in great amounts.

Circulatory overload

While assessing a client, a nurse finds that the ratio of the anteroposterior diameter and transverse diameter of the chest is 1:1. What is indicated by this finding? Select all that apply.

Client is an older adult Client has a history of smoking. Client has chronic lung disease

SKIN COLOR VARIATIONS: Red Erythema

Condition: Increases visibility of oxyhemoglobin caused by dilation or increased blood flow Causes: Fever, direct trauma, blushing, alcohol intake Assessment location: Face, the area of trauma, etc

SKIN COLOR VARIATIONS: Loss of pigmentation

Condition: Vitiligo Causes: Congenital or autoimmune condition causing lack of pigment Assessment location: Patchy area of skin over the body

Below the inguinal ligament, midway b/t symphysis pubis and anterior superior iliac spine. The site used to assess character of a pulse during physiological shock or cardiac arrest when other pulses are not palpable; used to assess status of circulation to leg

FEMORAL PULSe

Which site should be monitored for a pulse to assess the status of circulation to the foot? Select all that apply.

Dorsalis pedis artery Posterior tibial artery

Along top pf foot, b/t tendons of great and first toe. Site used to assess circ to foot

Dorsalis pedis pulse

a common eye disorder among people over 65. It causes 1. blurred or reduced central vision, due to thinning of the macula 2. symptoms usually develop gradually and without pain. 3. Visual distortions, such as straight lines seeming bent 4. Reduced central vision in one or both eyes 5. The need for brighter light when reading or doing close work 6. Increased difficulty adapting to low light levels, such as when entering a dimly lit restaurant 7. Increased blurriness of printed words 8. Decreased intensity or brightness of colors 9. Difficulty recognizing faces

Dry macular degeneration

A mother is worried about the sudden behavioral changes in her child. The child has suddenly developed a fear of certain people and places. The child's school performance is declining rapidly, and the child has developed poor relationships with his or her peers. After assessing the physical findings of the child, the nurse suspects child abuse. Which physical findings might have led the nurse to this suspicion?

Foreign bodies in the rectum, urethra, or vagina

intraocular structural damage resulting from elevated intraocular pressure.

Glaucoma is

No evidence of muscle contractility

Grade: 0 %: 0 Lovett scale: 0 (zero)

Slight muscle contractility, no movement

Grade: 1 %: 10 Lovett: T (trace)

Full range of motion, gravity eliminated

Grade: 2 %: 25 Lovett scale: P (poor)

Full range of motion with gravity

Grade: 3 %: 50 Lovett: f (fair)

Full range of motion against gravity, some resistance

Grade: 4 %: 75 Lovett: g (good)

Full range of motion against gravity full resistance

Grade: 5 %: 100 Lovett: n (normal)

Common eye/vision problem: farsightedness, a refractive error in which rays of light enter the eye and *focus behind the retina*. Persons are able to clearly see distinct objects but not close objects.

Hyperopia

Allen's test procedure

In the modified Allen test, one hand is examined at a time:[2] The hand is elevated and the patient is asked to clench their fist for about 30 seconds. Pressure is applied over the ulnar and the radial arteries so as to occlude both of them. Still elevated, the hand is then opened. It should appear blanched (pallor may be observed at the finger nails). Ulnar pressure is released while radial pressure is maintained, and the color should return within 5 to 15 seconds. If color returns as described, Allen's test is considered to be normal. If color fails to return, the test is considered abnormal and it suggests that the ulnar artery supply to the hand is not sufficient.[2] This indicates that it may not be safe to cannulate or needle the radial artery.

SKIN COLOR VARIATIONS: Bluish (cyanosis)

Increased amt of deoxygenated hemoglobin (associated w/ hypoxia) Causes: Heart or lung disease, cold environment. Assessment locations: Nail beds, mouth, skin, lips

A nurse is caring for a client who underwent cardiac catheterization. The client's skin was found to be blanched, and there was formation of edema of 15.2 cm (1-6 inches) at the site of catheterization. Upon further assessment, the skin was found to be cool, and the client complains of tenderness. Which condition does the nurse expect?

Infiltration

Which error will result in false high diastolic readings while measuring a client's blood pressure during a physical examination?

Inflating the cuff too slowly Inflating or deflating the cuff too slowly will yield false high diastolic readings.

A registered nurse (RN) is performing a physical assessment of four clients with various medical conditions as shown in the chart. Which client is expected to have concavely curved nails?

Iron deficency aneimia

Blurred central vision, often occurring suddenly caused by progressive degeneration of the retina. Most common visual impairment of Indy over the age of 50 and the most common cause of blindness in adults. There is no cure

Macular degeneration

a systemic skeletal condition in which there is a decreased bone mass and deterioration of bone tissue.

Osteoporosis is

Behind knee in popliteal fossa. Site used to assess stauts of circ in lower leg

Popliteal pulse

The inner side of the ankle, below medial malleolus. the site used to assess status to circulation to foot

Posterior tibal

Impaired near vision in middle-age and older adults, caused by *loss of elasticity of the lens* and is associated with the aging process

Presbyopia

A nurse must establish and maintain an airway in a client who has experienced a near-drowning in the ocean. For which potential danger should the nurse assess the client?

Pulmonary edema Additional fluid from surrounding tissues will be drawn into the lung because of the high osmotic pressure exerted by the salt content of the aspirated ocean water; this results in pulmonary edema. Hypoxia and acidosis may occur after a near-drowning, not alkalosis. Renal failure is not a sequela of near-drowning. Hypovolemia occurs because fluid is drawn into the lungs by the hypertonic saltwater.

Sims position

Rectum & Vag Flexion of hip and knee improves exposure of rectal area Joint deformities hinder patient's ability to ben hip and knee

SKIN COLOR VARIATIONS: Pallor (decrease in color)

Reduced amt of oxyhemoglobin. Reduced visibility of oxyhemoglobin resulting from decreased bl flow. Causes: Anemia, Shock Assessment locations: Face, conjunctivae, nail beds, skin, nail beds

A *non inflammatory* eye disorder resulting from changes in *retinal blood vessels*. It is a *leading cause of blindness*

Retinopathy

A client suspected to have a prostate disorder is encouraged to have a rectal examination. What position of the client will facilitate a rectal examination by the registered nurse (RN)?

Sims position In Sims position, hips and knees are flexed, which results in exposure of the rectal area. Therefore *Sims position is most suitable for performing rectal examinations*. A prone position helps in assessing extension of hips, skin, and buttocks. The dorsal recumbent position is predominantly indicated for abdominal assessment because it promotes abdominal muscle relaxation. The lateral recumbent position is indicated for detecting heart murmurs.

Easily accessible site used to assess pulse in children. Over temporal bone in head, above and lateral to eye

Temporal pulse

While assessing a client who sustained a road traffic accident, a nurse notices that the client is unable to clench his teeth. Which cranial nerve might have been affected?

The *trigeminal nerve* provides sensory innervation to the facial skin and motor innervation to the muscles of the jaw. A client with a damaged trigeminal nerve will be unable to clench his teeth. *CNV*

nerve helps in the eyeball's lateral movement.

The abducens *CNVI*(6)

The nurse is caring for a client who has lost an arm in a motor vehicle accident. Which reaction made by the client leads the nurse to realize that the client is in the withdrawal phase of adjusting to the change in body image?

The client recognizes the reality and becomes anxious.

represents the systolic pressure in children and adults.

The first Korotkoff sound

Avoid open catheter irrigation unless it is needed to relieve or prevent obstruction. The procedure requires breaking or opening the connection between the catheter and drainage bag of a closed urinary drainage system.

True, this leaves greater oppurtunity for infection

Ulnar side of forearm at wrist. Site used to assess status of circulation to hand; also used to preform an Allen's test

Ulnar Pulse

the process of gathering more assessment data. It involves clarifying vague or unclear data.

Validation is

a high-pitched sound that may be caused by a high velocity airflow through an obstructed or narrowed airway.

Wheezing is

The 1:1 ratio of the anteroposterior diameter and transverse diameter of the chest indicates

a barrel-shaped chest.

Edema results from

a direct trauma to the tissue or by impaired venous return.

Glasgow Coma Scale (GCS)

a scale used to assess the consciousness of a patient upon physical examination, typically in patients with neurological concerns or complaints 3 categories 1. Eyes Open Spontaneously - 4pts To speech - 3pts To pain - 2 pts None - 1 pt 2. Best Verbal Response Oriented - 5pts Confused - 4pts Inappropriate words - 3pts Incomprehensible sounds - 2 pts None - 1pt 3. Best Motor Response Obey's Commands 6 pts Localized Pain - 5pts Flexion Withdrawl - 4pts Abnormal Flexion - 3pts Abnormal Extension - 2 pts Flaccid 1 pt Total score - 3 to 15

During the _______ _______, the client and family go through a grieving period as they acknowledge the change in physical appearance.

acknowledgement phase, At the end of the acknowledgement phase, they learn to accept the loss.

The fifth Korotkoff sound represents the diastolic pressure in

adults and adolescents.

An infant has usually tripled his or her birth weight by

around 1 year.