Health Assessment Exam 2, week 8-10 content

palpate the axillae and regional lymph nodes; with woman supine, palpate the breast tissue, including tail of spence, the nipples, and areolae

breast palpation

1) bronchial-high pitched, heard over the trachea and larynx, loud 2) bronchovesicular-moderate pitch, heard over the major bronchi; posterior between the scapulae 3) vesicular-low pitched heard over peripheral lung fields, soft

3 types of breath sounds

1) supplying oxygen to body for energy production 2) removing carbon dioxide as a waste product of energy reactions 3) maintaining homeostasis (acid-base balance) of arterial blood 4) maintaining heat exchange (less important in humans)

4 major functions of the respiratory system

d. Tense posture; restless activity. Clothing clean but inappropriate for the season. Alert and oriented to person, disoriented to time and place.

4. Which finding most accurately describes a patient? a. Alert and orient to time, place, and person. Tearful when discussing diagnosis. Fail to maintain eye contact. b. Laughing inappropriately. Alert and oriented x3. Pacing around the room mumbling unintelligible words. c. Oriented to person and place; confused about time. Sitting rigidly in a start back chair with hands tightly folded in lap. d. Tense posture; restless activity. Clothing clean but inappropriate for the season. Alert and oriented to person, disoriented to time and place. **doesnt make sense?**

C) "Do you have any history of problems with your heart?"

A 45-year-old man is in the clinic for "a routine physical." During the history the patient states he's been having difficulty sleeping. "I'll be sleeping great and then I wake up and feel like I can't get my breath." The nurse's best response to this would be: A) "When was your last electrocardiogram?" B) "It's probably because it's been so hot at night." C) "Do you have any history of problems with your heart?" D) "Have you had a recent sinus infection or upper respiratory infection?"

b) neurological exam

A 50 year-old man is in the clinic complaining of weakness in his left arm and leg for the past week. The nurse performs: a. Cardiac examination b. Neurological examination c. Respiratory examination d. Senile assessment

C) Assess for other signs and symptoms of paroxysmal nocturnal dyspnea

A 65-year-old patient with a history of heart failure comes to the clinic with complaints of "being awakened from sleep with shortness of breath." Which action by the nurse is most appropriate? A) Obtain a detailed history of the patient's allergies and history of asthma B) Tell the patient to sleep on his or her right side to facilitate ease of respirations C) Assess for other signs and symptoms of paroxysmal nocturnal dyspnea D) Assure the patient that this is normal and will probably resolve within the next week.

teach BSE, breast self examination

breast teaching

d) low-sodium food choices when eating out

A health 28 y.o. has BP of 146/94 mmHg; wt. 115 lbs, ht. 5'6". The RN continues w/ the pt.'s health history and discovers: the pt. drinks a glass of wine several times a week and frequently eats fast food. Which topic will the nurse include on the teaching plan for this visit? a) benefits and adverse reactions of beta blockers b) adverse effects of alcohol on BP c) methods of decreasing dietary caloric intake d) low-sodium food choices when eating out

a) obesity

A known risk factor for venous ulcer development is: a) obesity b) being male c) history of hypertension d) daily ASA therapy

B) recognize that these are serious signs and contact the physician

A mother brings her 3-month-old infant to the clinic for evaluation of a cold. She tells the nurse that he had had "a runny nose for a week." When performing the physical assessment, the nurse notes that the child has nasal flaring and sternal and intercostal retractions. The nurse's next action should be to: A) assure the mother that these are normal symptoms of a cold. B) recognize that these are serious signs and contact the physician C) recognize that these are symptoms of rachitic rosary and refer the infant within the week D) perform a complete cardiac assessment because these are probably signs of early heart failure

B) constipation

A patient has hypoactive bowel sounds. The nurse knows that a potential cause of hypoactive bowel sounds is: A) diarrhea. B) Constipation C) laxative use. D) Excessive vomiting

D) distended

A patient's abdomen is bulging and stretched in appearance, although patient is not overweight. The nurse would describe this finding as: A) Concave B) Herniated C) Scaphoid D) Distended

b) protuberant

A patient's abdomen is bulging and stretched, the nurse would describe the finding as: a. herniated b. protuberant c. scaphoid d. undulated

during the heart's pumping phase, systole, to prevent regurgitation of blood back up into the atria

when do the AV valves close?

assess normal breath sounds, note any abnormal breath sounds, if they are present: perform bronchophony, whispered pectoriloquy, egophony, note any adventitious sounds

Thorax and Lung auscultation

confirm symmetric expansion, tactile fremitus, detect any lumps, masses, tenderness

Thorax and Lung palpation

percuss over lung fields, estimate diaphragmatic excursion

Thorax and Lung percussion

during the heart's filling phase, diastole, to allow the ventricles to fill with blood

when do the AV valves open?

b) during ventricular diastole

Atrial Systole occurs: a) during ventricular contraction b) during ventricular diastole c) concurrently with the ventricular systole d) independently of ventricular function

immediately after S2

when does S3 occur

d. understands the cultural context of the patient's situation.

Culturally competent care would best be described as the nurse that: a. applying the proper background knowledge of a culture. b. possess the knowledge of diverse populations. c. speaks the patient's native language. d. understands the cultural context of the patient's situation.

1) inspection 2) palpation 3) teaching

Describe the components of breast examination (3)

the pleurae are thin, slippery, serous membranes that form an envelope between the lungs and chest wall. They are used to prevent friction during respiration

Describe the pleura and it's function.

C) heard right before S1

During a cardiovascular assessment, the nurse knows that an S4 heart sound is: A) heard right after S1 B) usually a normal finding in the elderly C) heard right before S1 D) heard best over the second left intercostal space with the individual sitting upright.

D) Fifth left intercostal space at the midclavicular line

During an assessment of a healthy adult, where would the nurse expect to palpate the apical impulse? A) Third left intercostal space at the midclavicular line B) Fourth left intercostal space at the sternal border C) Fourth left intercostal space at the anterior axillary line D) Fifth left intercostal space at the midclavicular line

B) sternal angle

During an examination of the anterior thorax, the nurse recalls that the trachea bifurcates anteriorly at the: A) costal angle. B) sternal angle C) xiphoid process D) suprasternal notch

d. pressure in right side of the heart has increased

During assessment of a 70 year-old patient the nurse notes swelling of his ankles bilaterally, jugular venous pulsations 5 cm above the sternal angle when the head of the bed if 45 degrees; these findings are indicate: a. decreased fluid volume b. increased cardiac output c. narrowing of the jugular veins d. pressure in right side of the heart has increased

c. symmetry of shoulders and muscles.

During the inspection of the posterior chest, the nurse would assess for: a. diaphragmatic excursion b. egophony c. symmetry of shoulders and muscles. d. tactile fremitus

B) listen with the bell of the stethoscope to assess for bruits.

In assessing the carotid arteries of an older patient with cardiovascular disease, the nurse would: A) palpate the artery in the upper one third of the neck B) listen with the bell of the stethoscope to assess for bruits. C) palpate both arteries simultaneously to compare amplitude D) instruct patient to take slow deep breaths during auscultation.

d) epitrochlear node

Inspection of a person's right hand reveals a swollen, red area; the nurse would palpate which area to assess for infection? a) cervical node b) axillary node c) inguinal node d) epitrochlear noe

mediastinum

Mass of organs and tissues separating the lungs. Contains: Heart, greater vessels, trachea, and esophagus.

gynecomastia

benign growth of male breast tissue, making it distinguishable from the other tissues in the chest wall

d) frequent productive cough

The RN is rounding on assigned patients. Which finding would indicate the pt.'s condition is getting worse? a) barrel-shaped chest b) clubbed finger on both hands c) crackles bilaterally d) frequent productive cough

b) right AV valve

Select the best description of the tricuspid valve: a) left semilunar valve b) right AV valve c) left AV valve d) right semilunar valve

b) 2nd LICS

The examiner wishes to listen to the pulmonic valve area and will place the stethoscope: a) 2nd RICS b) 2nd LICS c) lower left sternal border d) 5 ICS at MCL

D) increased pressure in the right side of his heart.

The findings from an assessment of a 70-year-old patient with swelling in his ankles include jugular venous distention when the head of his bed is elevated 45 degrees. The nurse knows that this finding indicates: A) decreased fluid volume B) increased cardiac output C) narrowing of jugular veins D) increased pressure in the right side of his heart.

d) warm inhaled air

The function of the nasal turbinates is to: a. detect odors as an individual inhales. b. lighten the weight of the facial bones. c. stimulate tear formation. d. warm inhaled air.

True

The heart has a mechanical and an electrical conduction process. True or False

b) radial

The modified Allen's test is used to evaluate the collateral circulation before cannulating the _________ artery. a) brachial b) radial c) ulnar d) dorsalis pedis

c) gastrointestinal bleeding

The nurse empties the bedpan and notes a black tarry stool which is a sign of: a. anal fissures b. esophageal reflux c. gastrointestinal bleeding d. rectal infection

b. proceed with the examination because it is difficult to find the popliteal pulse.

The nurse examines the patient's lower extremities and is unable to palpate the left popliteal pulse; the nurse would: a. contact 911 for an immediate transport to the emergency room. b. proceed with the examination because it is difficult to find the popliteal pulse. c. refer the patient to a vascular surgeon for further evaluation of the left popliteal pulse. d. schedule the patient for a venogram and then an arteriogram.

b) empty their bladder

The nurse has completed the health history and is ready to proceed to the physical exam, but first has the patient: a. completely disrobe b. empty their bladder c. lie down on the exam table. d. walk around the room.

B) decreased peristalsis D) decreased gastric acid secretion

The nurse is aware that a change that may occur in the gastrointestinal system of an aging adult is: (select all that apply): A) increased salivation. B) decreased peristalsis C) increased esophageal emptying D) decreased gastric acid secretion.

C) sounds generated from the larynx.

The nurse is aware that tactile fremitus is produced by: A) moisture in the alveoli. B) air in the subcutaneous tissues. C) sounds generated from the larynx. D) blood flow through the pulmonary arteries

a) dullness

The nurse knows that percussion over an area of atelectasis in the lungs would reveal: a. dullness b. hyperresonance c. resonance d. tympany

a) a mass in the hypogastric region on palpation and dullness during percussion.

The nurse suspects a patient has a distended bladder during abdominal assessment because of which findings: a. a mass in the hypogastric region on palpation and dullness during percussion. b. gurgling upon auscultation in the diaphragmatic area. c. bruit auscultated in the inguinal area. d. tympany percussed in the epigastric region

b) dysphagia

The patient is having trouble swallowing medication and food; in the medical record it is documented as: a. aphasia b. dysphasia c. kyphosis d. myophagia

pericardium

The tough fibrous sac that protects the heart, has 2 layers: Myocardium: muscular wall (needed for pumping) Endocardium: endothelial lining of inner surface of heart chambers and valves

c) pericardium

The sac that surrounds the heart and protects it is called the: a. endocardium b. myocardium c.pericardium d. tricardium

thoracic cage, respirations, skin color and condition, person's position, facial expression, level of consciousness

Thorax and Lung Inspection

d) verbal responses

To assess a hospitalized patient's neurological status, the nurse would pay attention to the patient's: a. blood pressure b. intake and output c. personal hygiene d. verbal responses

c) diaphragm end of stethoscope

To listen to breath sounds the nurse will use the: a) stethoscope with 3 heads b) bell end of stethoscope c) diaphragm end of stethoscope d) stethoscope w/ doppler attachment

hypoxemia

Too little O2 = body says breathe in more O2....but is MUCH LESS EFFECTIVE!!

hypercapnia

Too much CO2 = body says breathe in more O2 = breathe FASTER

inspect breasts as the woman sits, raises arms overhead, pushes hands on hips, leans forward; inspect the supraclavicular and infraclavicular areas

breast inspection

sound should change from resonant to dull on each side, may be somewhat higher on R side bc of liver; diaphragmatic excursion should be equal bilaterally and measure about 3-5 cm in adults, although it may be up to 7-8 cm in well-conditioned people

What are the health expected findings for diaphragmatic excursion?

age, biopsy-confirmed atypical hyperplasia, certain inherited genetic mutations for breast cancer like BRCA1 and BRCA2, lobular carcinoma in situ, mammographically dense breasts, personal history of early onset breast cancer, 2+ first-degree relatives w/ breast cancer diagnosed at early age

What are the high risk factors that increase the risk of breast cancer?

Breast mass Retraction Edema Axillary mass Scaly nipple Tender breast

What does the acronym BREAST stand for?

0-4+

What is the grading scale for pitting edema?

d) femoral pulse

When as ask a patient to bend his or her knees to the side in a froglike position we are assessing: A) popliteal pulse b) temporal pulse c) dorsalis pedis pulse d) femoral pulse

A) consists of two lobes

When assessing a patient's lungs, the nurse recalls that the left lung: A) consists of two lobes B) is divided by the horizontal fissure. C) consists primarily of an upper lobe on the posterior chest. D) is shorter than the right lung because of the underlying stomach.

A) identify S1 and S2

When auscultating the heart, your first step is to: A) Identify S1 and S2 b) listen for S3 and S4 c) listen for murmurs d) listen for the pulmonic closing

b. observe the patient and infer health or dysfunction.

When examining a patient's mental status the nurse would assess: a. examine the patient's electroencephalogram. b. observe the patient and infer health or dysfunction. c. review the patient's I.Q. results. d. state a sequence of words and numbers for the patient to repeat.

C) a normal finding in a health adult

When performing a respiratory assessment on a patient, the nurse notes a costal angle of approximately 90 degrees. This characteristic is: a) seen in patients with kyphosis b) indicative of pectus excavatum. c) a normal finding in a healthy adult. d) an expected finding in a patient with a barrel chest

Heart extends from 2nd to 5th Intercostal Space (ICS) & from Right border of sternum to Left Midclavicular line (MCL).

Where is the heart located?

b. Record the data as soon as possible after the interview and physical exam.

Which statement is the most correct regarding documental of the patient history and physical examination? a. If the information is not documented, it can be assumed that it was done. b. Record the data as soon as possible after the interview and physical exam. c. Talk to any health care provider that examined the patient and summarize your findings. d. Use long descriptive sentences to document the findings.

D) sigmoid colon

Which structure is located in the left lower quadrant of the abdomen? A) Liver B) Duodenum C) Gallbladder D) Sigmoid colon

c) pancreas

Which structure is located in the left upper quadrant? a. Appendix b. Gallbladder c. Pancreas d. Descending colon

C) normal abdominal aortic pulsations.

While examining a patient, the nurse observes abdominal pulsations between the xiphoid and umbilicus. The nurse would suspect that these are: A) pulsations of the renal arteries. B) pulsations of the inferior vena cava. C) normal abdominal aortic pulsations. D) increased peristalsis from a bowel obstruction

crepitus

a course, crackling sensation palpable over the skin surface

inframammary ridge

a firm, transverse ridge of compressed tissue in the lower quadrants, especially noticeable in large breasts

6

a forced expiration of _ seconds or more occurs w/ obstructive lung disease; refer person for more pulmonary function studies

acinus

a functional respiratory unit that consists of the bronchioles, alveolar ducts, alveolar sacs, and alveoli

hyperresonance

a lower-pitched, booming sound found when too much air is present such as in emphysema or pneumothorax

presystole/atrial systole

active filling phase at the end of diastole when atria contract and push last amount of blood into ventricles

precordium

area on anterior chest directly overlying heart and great vessels

surfactant

complex lipid substance needed for sustained inflation of the air sacs, present at 32 weeks gestation

wheezes

continuous musical sounds heard mainly over expiration

crackles

discontinuous popping sounds heard over inspiration

supernumerary nipple

extra nipple

systole

heart contraction, blood is pumped from ventricles and fills the pulmonary and systemic arteries, 1/3 of cardiac cycle

S2, dub

heart sound that is usually loudest at base

S1, lub

heart sound that is usually loudest at the apex

physiologic dyspnea

increased awareness of the need to breathe that develops early in pregnancy

bicuspid/mitral

left AV valve

aortic valves

left semilunar valve

mild: 60-70% moderate: 50-60% severe: <50%

mild obstruction of airflow is an FEV1/FVC ratio of __% to __%; moderate is a measure of __% to __%, severe is ratio of less than __%

forced expiratory time

number of seconds it takes for person to exhale from total lung capacity to residual volume

tricuspid

right AV valve

pulmonic valves

right semilunar valve

6 minute walk test; ask person to stop walking if you measure SPO2 below 85% to 88% or if extreme SOB occurs

safer, simple, inexpensive clinical measure of functional status in aging adults

semilunar valves

set between the ventricles and arteries; open during systole to allow blood to be ejected from the heart

dull

soft, muffled thud that signals abnormal density in the lungs, as with pneumonia, pleural effusion, atelectasis, or tumor

true

true or false: increased breath sounds mean that sounds are louder than they should be

atrioventricular valves

valves that separate the atria and the ventricles

diastole

ventricles relax and fill with blood, 2/3 of the cardiac cycle

bronchophony, egophony, whispered pectoriloquy

voice sounds

pulmonary veins

what return freshly oxygenated blood to left side of heart?